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Full text of "Plain talk about insanity: its causes, forms, symptoms, and the treatment of mental diseases. With remarks on hospitals and asylums, and the medico-legal aspect of insanity"

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T. W. FISHER, M.D., 




Entered according to Act of Congress, in the year i$72, by 


In the Oliice of the Librarian ol Congress, at Wa&nington. 


Popular medical writings are, as a rule, harmful, from the dan- 
gerous self-confidence a superficial knowledge inspires. With re- 
spect to Insanity, much preventible suffering exists, from the tendency 
to experiment with a disease of the brain, requiring, of all others, the 
most patient and skilful attention of the physician. No encourage- 
ment to such experiments on the part of friends, or public officers, 
will be found here. The medical profession alone can furnish suit- 
able guardianship for the insane. 

It seems, however, desirable to exhibit Insanity in its true light, as 
a disease, not only for the sake of encouraging well-directed efforts 
for its cure, but for its prevention. In some of its aspects, it is also 
a legitimate subject of popular interest and inquiry. It is hoped the 
views expressed in the following pages will commend themselves to 
the common-sense of the reader. 

171 Warren Avenue. 
Boston, February, 1872. 




Causes of Insanity 17 

The Forms of Insanity 25 

Symptoms of Insanity 3 1 

Partial Insanity 36 

Monomania 4 1 

Medical Treatment of Insanity 48 

Moral Management of the Insane 54 

Home Treatment of the Insane 59 

Hospital Treatment for the Insane 6sf 

Hospitals and Asylums for the Insane 71 

Medico-Legal Aspect of Insanity 7$ 

" " " " " continued 85 

U U (I (( » '< QI 






INSANITY, of whatever variety, is only a symptom of dis- 
ease of the brain. In its study, we have nothing to do with 
mind apart from its organ, the brain. Our knowledge begins 
and ends in cerebral phenomena. In various ways we may reach a 
belief in something which in part controls them, but we can know 
absolutely nothing of it, and have no right to attribute states of dis- 
ease to a mere abstraction. Speculate as we may, "to this complex- 
ion must we come at last." 

This disease may be functional or organic, in the ordinary sense 
of those terms ; that is, mental disturbance may arise from changes 
in the circulation, nutrition, or nervous action of the brain, which 
may seriously affect its functions without leaving any visible change 
of structure ; or, as is more usual in long-continued disease, certain 
effusions, hardenings, softenings, and other changes of a microscopic 
nature may exist. These structural changes are, however, more 
likely to be the results than the causes of insanity. It is more than 
probable that, in another sense, all insanity is organic. The adult 
brain differs from that of the infant, in that it contains the organized 
results of all past actions, sensations, thoughts and feelings : at any 
rate, as far as these are capable of resuscitation in memory. The 
mental phenomena of insanity are in the same way registered in the 
organic constitution of the nerve-cells. Channels for disordered 
emotions, and tracks for erratic thought, are established there beyond 
a doubt ; but these subtle changes are, of course, beyond demon- 

Not all cerebral diseases produce insanity. The brain being the 
seat of sensation, and the centre of the power of motion, these 
functions are often affected independently, since they have more or 
less definite locations in the cerebral mass. It is not till the rind of 
superficial gray matter is touched, that mental disorder occurs. Here, 
on the surface of the cerebral hemispheres, lie those beautifully con- 



voluted strata of cells, which preside over the highest functions of 
human life ; arranged in patterns of inconceivable intricacy, yet plas- 
tic to every nervous influence, they present an organization suscep- 
tible to the most various harmful influences from within and without. 

Not all mental disturbance, however, is insanity, since, according 
to custom, transient forms of delirium are considered apart, though 
phenomena of the same order. No definition of insanity can be 
in the nature of things exhaustive, though here is one coming very 
near the mark. According to Dr. Ray, insanity is a disease of the 
brain, inducing a prolonged departure from those modes of thought 
and states of feeling natural to the individual in health. 

We will carry our analysis one step farther only, since to consider 
here the various phases of insanity would needlessly confuse and pro- 
tract this paper. The mind, so called, may for practical purposes be 
considered on three sides, making three grand divisions of its powers, 
viz. : the intellect, the emotions, and the will. These are somewhat 
arbitrary distinctions, and it is not certain that these functions have 
each a separate and local habitation. But we may infer an organic 
difference of some kind, from the fact that they may be affected dis- 
proportionately by disease. It is seldom that either is solely dis- 
ordered, although emotional insanity of the most outrageous kind 
may exist, without marked disturbance of the reasoning powers. . So 
the will may be paralyzed, leaving an individual at the mercy of 
chance impulses, unable to restrain himself as reason directs ; more 
commonly these functions are affected in succession, or in different 
degrees, during the same attack. 

Having disposed of these preliminary points, we may go on to 
consider the causes, near and remote, of insanity. First among the 
latter stands Heredity. This term demands explanation, and at 
best is obscurely understood. It must not be taken in too narrow a 
sense, for insanity may be called hereditary, if a tendency to it is 
shown in collateral branches of the family tree. Instances 
of the disease in uncles, aunts, cousins, brothers, or sisters, may 
point to a family tendency as well as if parents and grandparents 
were affected. Many nervous diseases, such as epilepsy, hysteria, 
alcoholism, neuralgia, and the like, should be taken account of in the 
search for hereditary causes. The question does not exclusively con- 
cern the existence of insanity in one's immediate ancestors, but re- 
lates to the prevailing family weakness. Most individuals know 
where the family shoe pinches in this respect. One may be conscious 
of a tendency to " weak lungs," or " torpid liver," or rheumatism, or 
scrofula, while another, ignoring these imperfections, feels all those 
mental perturbations which belong to the insane temperament. 

In this large sense, insanity is notably hereditary. Indeed, it has 
been thought by some to be always a disease of the family, requir- 
ing at least two generations for its full development. In this view, to 
use a homely figure, it may be likened to that style of trowsers, once 
said to be in vogue, which took two men to show the pattern. This 
much we know, that any and all causes which tend to produce a 
degenerate type of nerve-cell in the offspring, are fruitful causes of 


The question of the hereditary transmission of moral and intellectual 
as well as of physical qualities is admirably treated in Dr. Ray's valu- 
able book for the people, on Mental Hygfene. It is at the root of many 
social and theological as well as medical problems, and the importance 
of determining the laws which govern it can hardly be overestimated. 
It is true that a man preserves some of his family characteristics, 
quite as surely as he does those of his species. Which of his im- 
mediate ancestry shall have predominance in him, or whether he 
may resemble several of them by turns, as Dr. Holmes so ingeniously 
suggests in his last story, is beyond our present means of calculation. 
It is a fact that physical and mental diseases, vicious habits and 
tendencies, and local weaknesses, do reappear under various condi- 
tions in the line of family descent. 

The evidence of this truth is especially seen wherever inter- 
marriages are frequent, which, strange to say, is at the two extremes 
of the social scale. Royal families and remote country places are 
noted for high rates of idiocy and insanity. Numerous and illustrious 
examples will readily occur of insanity in high places ; and statistics 
show that this apparent frequency is real. It is not so well known that 
the ratio of insanity to population is greater in farming than in manu- 
facturing towns, in old communities and states rather than in new. 
The same is probably true of idiocy, and it is not improbable that 
one of the causes of the frequency of idiocy and cretinism in moun- 
tainous countries, like Switzerland, is the frequency of inter- 
marriages dependant on the natural isolation of the villages. The 
extent to which intermarriage of cousins prevails may be in- 
ferred in many New England towns, from the statistics of insanity 
and idiocy, as well as from the proportion of certain family names in 
the town register. 

Much of the vice, crime, and insanity which exists is due to this 
breeding in and in of human stock for successive generations. The 
great majority of cases of insanity, at any rate, are traceable to 
hereditary sources of defective organization. This would not be true 
if the statements of friends were always taken without discount, for 
after denial of all hereditary taint it is the rule to find the efficient 
causes of insanity cropping out in the direct line and collateral 
branches of the family. It is not transmitted insanity which should 
be looked for, so much as transmitted cerebral weakness. Now and 
then, we find a case of what may be called " old-fashioned insanity " ; 
when mental disease of distinct character and great severity is trans- 
mitted in kind, from parents to children and grandchildren, with 
frightful certainty ; when suicides, for instance, may be reckoned 
by the dozen in a generation or two. These, however, are excep- 
tional cases. 

Poverty and intemperance, by their debilitating and demoralizing 
influence, in our day at least, help to fill up the measure of a bad inherit- 
ance. These states precede and follow insanity in a vicious round, 
till the stock runs out where unsuitable marriages are common. 
Intemperance in the parents begets mental and nervous disease in 
the children, who, perhaps, cannot bear stimulants, but suffer from 


inefficiency and poverty. Bad living begets scrofula, and here and 
there the vice of intemperance appears again. The combinations 
are various and confusing, but the relations between these vices and 
disorders are intimate. 

It is a better appreciation of such facts as these that has led, in 
many quarters, to a disuse of the old hospital tables of the causes of 
insanity ; as often published even now, they afford little information. 
It is no satisfaction to know that so many have succumbed to domestic 
trouble, and so many to business losses, or disappointed love. This 
is a counting of the " last straws," while the great burden of heredi- 
tary deficiency, which really breaks the camel's back, is disregarded. 
One cannot say, from such tables : Let us avoid business, and 
marriage, and love, and so be safe ; for it matters less what work we 
have to do, than what brains we have to do it with. These second- 
ary causes should take a secondary place. 

When our reformers say intemperance is the one great source of 
poverty, crime and insanity, they commit the same error, and take 
a very superficial view of the matter. What is the cause of this in- 
temperance? Certainly not deliberate and wholesale abuse of 
healthy constitutions by stimulants. It is largely the poor, the 
vicious and the weak, who seek relief for mental or physical distress 
in stimulation. In many cases, knowing a family history, one can 
predict intemperance, insanity, and crime of the children, with great 
certainty; but of each individual career a prison, a hospital, or a 
drunkard's grave seems an equally fitting termination. 

It would seem that man, in spite of his reason, or perhaps on account 
of it, is less protected from sources of deterioration than the lower 
animals. The natural laws of selection are oftener interfered with, 
and though the rule of the " survival of the fittest " may hold good 
for him, the decay and falling out of line of the weakest is more 
marked. The increased complexity of man's organization leads to 
a more easy and decided retrograde in the scale of life. 

The practical inferences to be drawn from these considerations are 
first to keep the individual standard of health and vigor at its highest, 
and to shun, as a high moral duty, all risk of propagating less 
healthy specimens of the race than ourselves, The above facts have 
the most practical bearing on the education of children, the choice of 
occupation, upon marriage, and the general conduct of life. No class 
of facts is so calculated to enforce the divine lesson of charity, for 
the weaknesses and sins of our fellow-men. 

The causes of insanity in the individual may date from birth, 
or depend largely on diseases and accidents of infancy and child- 
hood. One cause, seldom mentioned, is found in a too early ossifica- 
tion of the sutures of the skull, preventing that full and symmetrical 
development of the brain important for its perfect action. This has 
been pointed out by European writers as a constant cause in certain 
forms of cretinism and idiocy, and the fact of important deviations from 
a normal standard in the crania of the insane has also been 

The relations existing between the brain and its bony envelope 



have an importance, aside from the factitious value assigned to them 
by phrenologists. There is an adjustment of the laws of growth in 
each to the other, which, in the progress of normal development, 
prevents the cranium from outgrowing its contents, while it leaves the 
brain free to expand to its proper dimensions. "When such expansion 
has been incomplete, we may look for the cause of the arrest to one 
of two sources, viz. : imperfect development in the brain itself, or 
premature ossification of some of the cranial sutures and cartilages. 

Insanity being largely hereditary, and occurring often in persons 
whose mental development has been deficient or eccentric from birth, 
the cranium might be expected to show certain anomalies among the 
insane. In addition to defects of development, there often occurs in 
chronic insanity a general or partial thickening or thinning of the 
bones of the skull, due to nutritive changes concurrent with different 
phases of the cerebral disease. 

It occurred to the writer, not long since, to utilize the outline pat- 
terns, taken by hatters, with the formateur, and to obtain from them 
a standard of comparison for certain dimensions of the head. One 
hundred of these miniature outlines were taken, giving the exact 
shape of the human head at its greatest horizontal section, and repre- 
senting one hundred male adult heads of the class of men who 
usually have hats made to order. The greatest transverse and 
longitudinal diameters being taken, careful averages of areas and 
lines were made. 

Next eighty-five male adult heads were measured, by permission 
of Dr. Walker, at the Boston Hospital for the Insane, and similar 
averages taken. The following table shows the comparative dimen- 
sions of this section of the cranium in the sane and insane : — 


Long diameter 



Anterior Segment 
Posterior " 
Right Half 

35- 2 5 

35 -oo 




Right Anterior Quarter 
" Posterior " 

Left " " 

" Anterior " 

Anterior Segment 

Posterior " 

Right Half 

Left Half 

Whole Area 








- 28.85 27.18. 

- i9- 8 5 I 7-23- 

- 20.50 I7-32. 

- 29.9O 25.60. 

" 57-05 50-94- 

- 4O.4O 33.I9. 

- 50-90 4 2 -94- 

- 50-4° 4 J -29- 

- 99.25 82.84. 

The diameters are in sixteenth inches, and the areas in square 
quarter inches. 

It is evident, from the above figures, that the average insane head 


is smaller in all the dimensions of this section than the sane. There 
were, in fact, of eighty-five insane ones, four too narrow to be accu- 
rately measured by the forma tenr. The extremes of size are shown 
in the following table : — 


Whole Area - 155 and 63 119 and 61. 

Long Diameter - - 73 an d 42 63 and 45. 

Short Diameter - 43 and 28 39 and 24. 

The differences in shape presented by these outlines are as re- 
markable as the differences in size. In the sane heads four princi- 
pal forms were noticed in the following order of frequency, viz. : 
ovoid, ellipsoid, round and rectangular. Of course these forms 
were only approximated while their modifications gave figures pear- 
shaped, shoe-shaped, and coffin-shaped, or in their outlines remotely 
suggesting these terms. The same forms were observed in the in- 
sane heads, but with smaller dimensions, and a greater frequency of 
irregular outline ; while in the sane heads ovoid shapes were most 
frequent, in the insane ones two-thirds were ellipsoidal. 

The want of symmetry between the two sides was noticeable. In 
the sane heads the area of the left anterior quarter averaged a trifle 
larger than the right ; while the opposite is true of the insane ones. 
In many heads this difference was accompanied by a decided pro- 
jection in the right frontal region. 

The plates at the beginning of this chapter will give an idea of 
some of the points mentioned above. Fig. 1 represents the largest 
sane head, that of Judge X — , and is rectangular in the anterior part. 
Fig. 2 represents the smallest among the sane heads, is asymme- 
trical, and one of the few specimens of the round type ; mental 
capacity of individual unknown. Figs. 3 and 4 represent sane heads 
of the ovoid and ellipsoid variety. The remaining four outlines are 
from the heads of insane persons, and exhibit marked peculiarities 
and irregularities of shape ; especially the projection of the right 
frontal region. They represent chronic cases, and are more curious 
than instructive at present. 

The defect in the above method of measurement consists in its 
partial character, taking no account of the dimensions of the arch of 
the cranium. This defect, however, is common to both classes of 
heads compared, and may be expected to affect the result similarly 
in each class. It was hoped some subordinate distinctions might be 
made between the heads of those intellectually and those emotion- 
ally insane, for instance : Bucknill and Tuke, in their text-book on 
insanity, speak of the connection noticed between hio-h vertical 
skulls, asymmetrical skulls, and melancholia. They remark that in 
mania the anterior region of the cranium is generally well developed, 
with sometimes a square outline. The attempt to draw any satis- 
factory conclusions of this kind would require a much larger number of 
observations than the preceding. They, however, confirm the state- 
ments of Bucknill and Tuke, that in the insane the cranial dimen- 


sions are smaller in the average, irregularities and asymmetry more 
frequent, and long and narrow heads more common than among the 
sane. Similar observations among the criminal classes might prove 
interesting. {See Med. and Stir g. Jour., May 18, 1871.) 

Given, then, an enfeebled cerebral organization, what other causes 
predispose to insanity in the individual? Evidently any and all which 
tend still further to deterioration of the nerve-cells. And here it 
may be well for the peace of mind of sundry "nervous" people, to 
discriminate between constitutional nervous debility, and the insane 
temperament. Through lack of original vitality, many persons go 
through life with a nervous system constantly on the verge of bank- 
ruptcy. Their daily accumulations of strength serve barely to meet 
the daily organic demands of the body, and no surplus remains for 
the struggle with the active duties of life. Any unusual demand 
upon their energies leaves them stranded, with now this, and now 
that form of nervous disorder, but with no necessary tendency to 
insanity." The mind, barring its lack of energy, may be free from 
any disturbance. On the other hand, when there is some hereditary 
defect in the organization of the superficial gray matter, slight causes 
will disturb its functions, although the lower cerebral operations may 
be carried on properly enough. 

The most frequent predisposing causes are exhaustion from over- 
work, the various moral sources, such as grief, anxiety, disappoint- 
ment, fear, ennui, the abuse of stimulants, and excesses of all kinds. 
These causes may so act as to induce insanity in a healthy individ- 
ual, but they are undoubtedly most efficient in the presence of an 
insane temperament. Upon this point of the predisposing, and also 
upon the exciting, causes of insanity, Dr. Ray's book on Mental Hy- 
giene is most complete and exhaustive. It should be read by every 
one, since it is unique in character and treats plainly and practically 
of topics of the most vital interest. It would be in vain to attempt 
here to cover similar ground, and we have only enumerated some of the 
causes of which it treats at length. 

A few examples of injury from continued study will show how 
mental strain affects the health, of young girls particularly. Every 
physician could, no doubt, furnish many similar ones . 

Miss A — graduated with honor at the normal school after several 
years of close study, much of the time out of school ; never attended 
balls and parties; sank into a low state of health at once, with de- 
pression. Was very absurdly allowed to marry while in this state, 
and soon after became violently insane, and is likely to remain so. 

Miss B — graduated at the grammar school, not only first, but per- 
fect, and at once entered the normal school ; was very ambitious to 
sustain her reputation, and studied hard out of school ; was slow to 
learn, but had a retentive memory; could seldom be induced to go to 
parties, and when she did go, studied while dressing, and on the way ; 
was assigned extra tasks at school, because she performed them so 
well ; was a fine healthy girl in appearance, but broke down per- 
manently at end of second year, and is now a victim of hysteria and 

Miss C — , of a nervous organization and quick to learn ; her health 

2 4 


suffered in normal school so that her physician predicted insanity if 
her studies were not discontinued. She persevered, however, and is 
now an inmate of an hospital with hysteria and depression. 

A certain proportion of girls are predisposed to mental or nervous 
derangement. The same girls are apt to be quick, brilliant, ambi- 
tious, and persistent at study, and need not stimulation, but repression. 
For the sake of a temporary reputation for scholarship they risk their 
health at the most susceptible period of their lives, and break down 
after the excitement of school-life has passed away. For sexual 
reasons they cannot compete with boys, whose out-door habits still 
further increase the difference in their favor. If it was a question of 
school teachers instead of school girls, the list would be long of "young 
women whose health of mind has become bankrupt by a continuation 
of the mental strain commenced at school. Any method of relief in 
our school system to these over-susceptible minds should be wel- 
comed, even at the cost of the intellectual supremacy of woman in 
the next generation. 

Mental exercise is as favorable to mental health as physical exer- 
cise to physical health, and only its excess and irregularity is harm- 
ful. In the adult male American, it is often the excessive demands 
of business, leading to a neglect of all the laws of life, which ruins 
mental health. Our climate is partly answerable for the excitable 
temperament of the people, and our sterile soil turns attention largely 
to lines of activity, which create competition and tax the energies to 
the utmost. In the great towns and cities over-stimulation is added 
to keep up the flagging powers to their unnatural strain. For in- 
stance, a young man of thirty, otherwise healthy, carries up his in- 
come by salary, and commissions for new customers, to six or eight 
thousand dollars a year. To do this requires an exertion of his social 
powers by night, as well as legitimate labors by day. Fast driving, 
champagne suppers and theatres, induce indigestion, loss of sleep, 
and a super-excited brain, which end in acute mania of the most 
violent form. 

The excitement of politics or religion is responsible for unsettling 
many unstable minds. Those topics which take such deep hold on 
the minds of men and women respectively, cannot fail to prove 
efficient causes of mental disorder. They are, however, superficial 
compared with those elements of weakness which exist in the brain 
itself. It is quite often this weakness which leads to unnatural 
excitement upon topics which do not disturb the ordinary mind. 
When insanity is said to have been caused by mesmerism, spiritual- 
ism, and the like, it is quite as probable that an interest in these 
matters is the first symptom, rather than the cause of it. 

The causes of insanity we have briefty mentioned will serve to 
indicate those directions in which care should be exercised. It is in 
the power of an individual predisposed to insanity to prevent it, in 
most cases, by avoiding all those excesses and excitements which 
are known to be harmful. All which tends to impair health, to per- 
vert nutrition, and prevent reparation of the nervous waste, will have 
its effect on the mind, preparing the way for downright insanity, 
when some unexpected draft is made. 



IN a preceding paper the forms of insanity were only briefly 
noticed. We propose to consider a few of them here. In the 
minds of many, to be insane is simply to be " mad " ; and the typ- 
ical madman is one who raves, threatens, destroys, or adorns him- 
self fantastically, cutting strange antics before high heaven. If a 
woman, to be mad implies singing, tears and laughter, dishevelled 
locks, and the strewing of flowers on imaginary graves. The ideal 
maniac of the stage has long filled the public mind to the exclusion 
of those more common, but less dramatic, forms of disease which 
now seem so prevalent. 

One of a large party of insane ladies which had just returned 
from seeing the " Ophelia " of Miss Leclercq, at the " Globe," re- 
marked, after complimenting the performance generally : " But we 
don't strew flowers, and sing in that way, at our house." 

The usual remark of visitors to a hospital for the insane, after an 
inspection of the whole premises, is, "Are these all crazy?" fol- 
lowed by the suspicious inquiry, "Where do you keep the raving 
ones?" In a well-regulated hospital, not more than two or three 
per cent, would answer the popular requirements. 

The observer who comes to the study of insanity with a belief in 
the sufficiency of the old method of classification, will find himself 
constantly at a loss. Mania, melancholia, and dementia, do, indeed, 
express three prominent forms under which many cases easily fall ; 
but in many more instances there will occur dementia, with mani- 
acal paroxysms, melancholia, with manical excitement, mania, with 
alternations of depression, melancholia, bordering on dementia, with 
other complications, which set at defiance the simple rule of three 
with which the student attempts to solve his problem. The defect 
in this method lies in the use of symptoms which are unstable and 
fluctuating, and may succeed each other, or coexist and combine in 
new proportions while under observation. The necessity for its use 
arises from our ignorance of the exact character of the hidden con- 
ditions on which these symptoms depend. 

A pathological classification of insanity is greatly to be desired, 
but our means of diagnosis in this direction must be limited, in the 
nature of things. Great advances are being made even here, and 
the whole scientific world seems earnestly bent on a better understand- 
ing of mental and nervous phenomena. The following provisional 
classification has been recently published by Dr. Skae ( Edinburgh 
Medical "Journal, November, 1870). It has defects and limitations, 
but it is easier to criticise than to make a perfect one, and it would 
be impossible to assign every case of insanity its place in it : 

Idiocy, ) Moral and 
Imbecility, $ Intellectual. 
Insanity with Epilepsy. 
Insanity of Masturbation. 
Insanity of Pubescence. 




Hysterical Mania. 

Amenorrhceal Mania. 

Post-Connubial Mania. 

Mania of Pregnancy. 

Puerperal Mania. 

Mania of Lactation. 

Climacteric Mania. 

Ovario, Mania. 

Senile Mania. 

Phthisical Mania. 

Metastatic Mania. 

Traumatic Mania. 

Syphilitic Mania. 

Delirium Tremens. 


Mania of Alcoholism. 

Post-Febrile Mania. 

Mania of Oxaluria, etc. 

General Paralysis, with Insanity. 

Epidemic Mania. 

tj- iu- t\/t ■ ^ Sthenic. 
Idiopathic Mama, < . , 

The attempt is made in the above table to assign a name for each 
form of insanity in accordance with its physical origin or cause, 
often to be found in some disease or irritation distant from the brain, 
which affects its nerve-cells sympathetically . Those cases which 
depend primarily on disease of the gray matter, are called idio- 

It may be instructive, as well as convenient, to glance at some of 
the forms given above. Idiocy and imbecility, or dementia, are 
forms of mental weakness. The brain may be abnormally developed 
at birth, or be subsequently damaged by infantile disease, or, later 
in life, be reduced by various causes to any grade of dementia. 
Most forms of insanity tend to dementia, and our hospitals are full 
of the "ruins" of minds once useful, if not "noble." 

The term moral, in this connection, has been often objected to. 
A moral idiot, however, is not so rare a specimen as to render his 
existence in the least doubtful. The type is familiar to every alien- 
ist, and every few months we are called on to listen to the well- 
known story. These patients are most troublesome between the 
ages of twelve and twenty -five. There is often a history of mental 
aberration from the cradle. Many have queer-shaped heads, or 
have had St. Vitus's dance. They are often bright at school, with a 
fitful brilliancy ; but are better at games of skill. They are inge- 
nious at mischief, preternaturally sharp in the ways of the world, and 
yet always in trouble. Their defects are largely of a moral, and 
not intellectual, character. They have little natural affection, little 


sense of right and wrong, little regard for the feelings of others, or 
for the consequences of their own impulsive acts. They lie, steal, 
run away from home, travel on the "confidence" plan, set fires, and 
kill — never profit by punishment, never regret their acts, but merely 
the consequences. They usually go from bad to worse, but may, 
by long-continued and judicious restraint, learn, in adult life, to 
avoid the greater dangers to which their conduct exposes them. 

Epilepsy gives rise to many exceedingly interesting mental phe- 
nomena. Its tendency, in ordinary cases, is, in the long run, to 
loss of memory and imbecility. It often, at the time of the fits, 
gives rise to a form of mania of all others the most dangerous. The 
patient may be suddenly seized with a blind fury, leading him 
to the most terrible acts of violence and homicide. The frenzy may 
last five minutes, or a week. It may come with the first fit, or only 
after years of epileptic attacks. Still more strange, it may take the 
place of the ordinary convulsive attack at any time. 

Epileptic vertigo, or -petit mal., which a person may have had for 
years without a suspicion of its true nature on the part of himself or 
his friends, is very fruitful of mental disturbance. In these cases 
there is no spasm, simply a momentary dizziness, and all is as be- 
fore. The irritation, we will call it, may at any time seize the 
higher centres of the brain, instead of the lower, producing delirium 
as transient as the vertigo. In this transitory mania — for it is such — 
an act of violence may be done for which the patient is utterly 
irresponsible. This state of delirium may last ti few hours, as in 
wandering epilepsy, and the patient come to himself miles away 
from home. 

The next dozen forms come under the head of sympathetic or re- 
flex insanity, and may be mentioned together. The comparative 
frequency of insanity from irritation of the sexual organs need not 
be inferred from the number of this author's subdivisions. No doubt 
such irritation may produce insanity, if extreme or habitual, but 
without a special susceptibility in the superficial gray matter, it more 
frequently gives rise to nervous disorder, and states of mind which 
fall short of actual insanity. It is a mistake to suppose that be- 
cause uterine irritation almost produces insanity in many women, 
that most cases of insanity in women depend on uterine irritation. 
It is often a predisposing cause, through the disorder of the general 
health to which it gives rise, but events still more remote, of an her- 
editary nature, will be found to have generally prepared the way. 

Uterine irritation very frequently affects the morale, or the emo- 
tional status of the patient, for a long time before giving rise to intel- 
lectual disturbance. Delusion and dementia may be indefinitely 
postponed. The most conscientious become deceitful, the affection- 
ate learn to hate most easily, the pious lie, swear, steal, perhaps, and 
are at the mercy of their disordered emotions and impulses. These 
habitual peculiarities may at times become intensified to a frenzy, 
which sweeps the reason before it, resulting in a paroxysm of 
hysterical mania. These attacks may last for weeks, but are often 
transitory ; and none but the immediate family can discover insanity 


in the amiable, intelligent, lady-like person who does the honors of 
her parlor with accustomed grace. 

The next four forms need not detain us ; but the three after them, 
which constitute what, in medico-legal slang, have been called "rum 
cases," are interesting, from their frequency and practical importance. 
Delirium tremens is not usually considered an insanity, and does 
not, by right, find admittance to hospitals for the insane. It is a 
self-limited disease, and seldom runs more than seventy-two or 
ninety-six hours. It is not, therefore, a -prolonged departure from 
mental soundness. Dipsomania I take to mean a passion for stim- 
ulants, inherited or acquired, in which the will is powerless to resist 
a certain periodical craving for liquor. Mania from alcoholism is a 
condition of insanity induced by the prolonged or excessive use of 
alcohol, and is due to the irritation and probably organic change 
which that poison induces. The latter disease is as appropriate for 
treatment in a hospital as any other form of mental disease. 

Special legislation, and special institutions, are needed to meet the 
peculiar requirements of cases complicated with or caused by habit- 
ual intemperance. It is worse than folly to go on punishing the habit- 
ual drunkard by fines, and short sentences. He is nearly, or quite, 
irresponsible for the continuance of a habit which he may have a 
right to by inheritance, or may have acquired under pressure of ex- 
traordinary circumstances. He should be restrained indefinitely, 
but not punished at all. The best case of Dipsomania I can call to 
mind, is a man whose mother was insane, and who for years has 
had periodical cravings for liquor, which he indulges in freely at 
such times, becoming slightly maniacal. In the intervals he is 
sober, intelligent, and successful in business. He has been repeat- 
edly treated both in an insane hospital, and in penal institutions. 
One of his attacks was replaced after months of abstinence, by a 
long siege of melancholia, in which he nearly lost his life from 

I will only speak of General Paralysis with insanity, to conclude 
this paper, leaving the symptoms of insanity for another time. This 
disease is quite common, and having been of late much discussed, 
like neuralgia and diphtheria, when they were popular medical 
novelties, it is often suspected when it does not exist. All sorts of 
mental diseases are attributed to softening of the brain, which is 
used as a synonymous term. It is often difficult, in its earlier stages, 
to be sure of a correct diagnosis, and an utterly incurable and fatal 
disease should not be hastily affirmed of any case. As the disease 
progresses, however, there can be no mistaking its true nature. 

General Paresis is, perhaps, the best term for this disease, as it 
signifies weakness, rather than absolute loss of function, and better 
expresses that gradual impairment of physical and mental power, 
which may exist for months before it is recognized for what it is. 
The speech is early affected, becoming, at last, clumsy, thick, and 
hesitating. The gait grows feeble, and occasional attacks of vertigo 
induce staggering, which often leads to the belief that the patient is 
intoxicated. The memory fails by degrees, as the mind becomes 


affected by this creeping death, and the cohesion of ideas is par- 
tially lost. The mind which in health is moored to its surroundings, 
goes adrift, and runs into all kinds of unrealities. Mania is often a 
symptom of the earlier stages, and it usually assumes a peculiar 
type, in which what the French call " delire des grandeurs " is 
prominent. The patient has vast ideas of his wealth, amount of 
business done, increase of physical strength, and the like. If these 
notions do not assert themselves, there is at least a pervading feeling 
of well-being and content, interrupted, perhaps, by occasional 
glimpses of the real state of things, which affect the patient very 
painfully. The mind for the most, however, is busy with schemes 
of business or pleasure, and while really helpless, and perhaps bed- 
ridden, the patient will talk of his daily business excursions with 
great satisfaction. Often his plans for "to-morrow, and to-morrow, 
and to-morrow," occupy his mind; but he does not grow more im- 
portunate that to-morrow does not come, as there is little cumulative 
power in his memory. 

All this tends slowly and surely to death — first of the mind, and 
then of the body. Sensation and motion are impaired from the first; 
and in hospital, while the patient's delusions of strength and self-im- 
portance invite quarrels with his more able-bodied companions, his real 
weakness prevents successful resistance, and insures frequent falls, the 
loss of sensation prevents any complaint of pain from injuries received, 
and the loss of memory makes him forget the circumstances of an acci- 
dent almost as soon as received. As if this state of things was not 
sufficiently disastrous, it has been demonstrated that the nutrition of 
the bones, especially of the ribs, is, in many cases, so perverted as 
to allow of fractures from very slight pressure. This has been 
proved, of late, by autopsies upon cases of fractured ribs, occurring 
in and out of hospitals, in these patients. 

The pathology of this disease cannot be adequately described 
here. It will suffice to say, that it is a subtile and general change, 
which slowly affects the central nervous system, accompanied by 
congestions in the early stages, and leading to destruction, cell by 
cell, of the gray matter of the brain. 

The causes of general paresis are found to prevail most among 
men, and at the most active time of life, from thirty-five to forty, in 
the majority of cases. Habitual intemperance, sexual excesses, 
overstrain in business, in fact, all those habits which tend to keep up 
too rapid cerebral action, are supposed to induce this form of disease. 
It is especially a disease of fast life, and fast business life, in large 
cities. It is preventible, in many cases, without doubt ; since, if it 
was hereditary in its own form, and not dependent on causes to 
which the male sex is more exposed, the proportion of cases would 
be more nearly equal in the two sexes. 

General paresis, unlike the apoplexy and paralysis of advanced 
life, steals upon its victims in the early prime of life. The latter, 
often due to the natural decay of the blood-vessels of the brain, in 
old age, are not, necessarily, evidences of the physical degeneracy 
of our days. The former is certainly to be dreaded, and avoided by 



every means of correct living in our power. But what is more de- 
sirable, when our work is nearly done, than sudden and painless 
death? It is merely another veteran fallen in the ranks ; the gap is 
instantly filled, and the army moves on. Why pray, "From battle, 
murder, and sudden death, good Lord deliver us ! " ? 



DR. SKAE'S classification of the forms of insanity given in my 
last paper, and based on special physical conditions, is by no 
means in general use. Most of these conditions are recognized, and 
many of the terms are employed, but mental disorder being the 
striking feature of each case, while its cause is often mere matter 
of conjecture, it must continue to form a basis of classification. In 
a large class of cases, insanity is purely idiopathic ; we can assign 
no cause outside the brain. In these, the mental symptoms differ-; 
not only in the degree of underlying constitutional vigor or debility 
(sthenic and asthenic), but in various other ways, tolerably distinct 
and well recognized. Sympathetic insanity, too, always presup- 
poses disease of the superficial gray matter, secondary, it is true, to 
some distant source of irritation, but presenting similar phases of 
mental disturbance. 

To illustrate the principal modes of diseased mental action, let us 
take, or rather make, a few typical cases. A man thirty years old, 
whose maternal uncle was insane, whose father is intemperate, and 
his mother consumptive, for instance, inherits, in consequence, a sus- 
ceptible cerebral organization. He is in active business, and over- 
working himself. His wife dies after a few weeks' sickness, leaving 
him worn with watching and anxiety, and overwhelmed with grief. 
Here are all the elements for the development of insanity, viz., her- 
edity, over-work, loss of sleep, and the shock of intense grief. 
Take away either, and the crisis might pass safely ; as it is the mind 
gives way. 

What is to determine whether this man shall become maniacal, 
melancholic, or demented? To the best of my knowledge and 
belief, it is a question of temperament and original mental constitu- 
tion, influenced, perhaps, by the comparative suddenness and sever- 
ity of the exciting causes. I think acute mania would oftenest 
occur in a person of excitable, sanguine temperament, in whose 
brain the normal rate of nervous action was rapid ; while in a 
person of slower mould, with a constitutional tendency to depression, 
melancholia might arise. Dementia, as a primary affection, is more 
rare, but sometimes follows a sudden shock, or a fever, in a naturally 
weak brain. These hints are not to be taken as sure guides to the 
prediction of the special form of mental disease to be expected, as 
exceptions are very numerous, and it would hardly do to elevate 
them into rules. 

If mania is to occur, it may develop rapidly. The man who slept 
little before his wife's death, now sleeps none at all. He moves 
about silent and abstracted, or bustles about with over-officiousness, 
or goes calmly on the business of the day, according to his habits 
of self-control, but he does not sleep. His brain is congested, or the 
circulation is too rapid, and the physiological condition of sleep, 
which requires a diminution of blood, is an impossibility. 

Another question occurs : What is to determine whether the 


emotions, the intellect, or the will, shall be first affected? These 
divisions of the mind are somewhat arbitrary, though better founded 
than most of the metaphysical and phrenological subtleties and 
absurdities, which true science has now discarded. According to 
the best and latest authorities, they have no separate local habitation 
in the brain. Emotion is but the way our ideas feci to us. Each 
idea, or group of ideas, excites its natural feeling in the brain. The 
will is the result merely of a train of ideas ; — whether the train stops 
or goes on, whether we refrain from action, or whether we act, there 
is no need of a distinct organ, or nervous centre to determine it. 
Each idea fades out, by changing to another, or runs on to the cen- 
tres of motion, according to organic necessities for the most part, 
inherent in the nerve-cells through which it passes. 

The long and the short of this profundity is, that insanity always 
affects the whole mind more or less, however partial the affection 
may seem, judged from the speech and action. If the emotions 
predominate, be sure that the corresponding ideas prevail in the 
mind, however contradictory the speech may be. Incoherence and 
delusion are not necessary to intellectual disturbance, since a fixed 
predominance of gloomy or exhilarating ideas is equally unnatural. 
So when we say the will is intensified, or the will is paralyzed, it 
means not that a separate organ or faculty is affected, but that the 
nerve-cells hold their ideas well in hand, or let them go by the run, 
through sheer weakness. 

Emotional disturbance may exist, however, for a long time, and 
to great excess, without incoherence or delusion. The brain may 
be as sensitive to the feeling of ideas, as an inflamed eye to dust or 
light. The reaction upon irritating thoughts may be as instinctive 
and sudden as the spasmodic closure of the eyelids, or as the cough 
which follows irritation of the windpipe. 

In the case of our patient, the usual premonitory emotional dis- 
order is merged in the grief natural to a distressing event, and the 
first sign of insanity is an outbreak of maniacal delirium. The 
whole mind is in commotion, and the body too, for that matter. 
The least thing provokes an emotional explosion. The ideas follow 
each other too fast for utterrance, and appear in speech as a broken 
torrent of words, with only a chance association of sense and sound. 
The mental machinery runs rattling down like a crazy clock, with 
all its checks and balances destroyed. Like the clock, too, its hands 
move aimlessly, and it strikes frantically till restrained. This is 
mania of the most active sort. 

Mania is still but a symptom of changes in the circulation, nutri- 
tion, and nervous action of the superficial gray matter. Its various 
forms depend on the kind and degree of those changes, plus the 
individual's mental peculiarities. The maniacal paroxysm must be 
distinguished from the general state we call mania. The brain may 
be in a condition of latent or potential excitement, ready, like powder*^ 
to explode on the slightest provocation. The paroxysm must in the 
nature of things be brief, but the explosive tendency may be per- 
sistent for life even. The former may last a few seconds, as we saw 


in epileptics, or it may endure a week or two. Our patient may die 
exhausted by his frenzy, may recover entirely in a month or two, 
may set up the bad habit of recurrent mania with lucid intervals, 
may lapse into a state of chronic, sub-acute mania, may alternate 
mania with melancholia, through a long period, or, as is more com- 
mon, sink into partial or complete dementia, the final goal of all 
forms of insanity not cut short by death. 

Mania under all its variations, supposes an excessive and expan- 
sive activity of the mind. The disordered feelings and ideas tend 
to express themselves at once in action. The mental state in mania 
may be best described by words beginning with the Latin prefix ex, 
signifying a tendency from within outwards, such as exhilaration, 
extravagance, exaltation, expansion, exaggeration, explosion. 

Melancholia, on the other hand, is accompanied by depression, 
dejection, despondency, and despair. The same causes may lead 
to it, as in our case of mania, but the symptoms are usually devel- 
oped more slowly. There is oftener a history of debility and ill- 
health preceding them. The natural grief for the loss of a wife 
may deepen into gloom, and extend, by degrees, to the patient's busi- 
ness prospects, and to his estimate of his own health. He can fore- 
see nothing but financial ruin, sickness, and mental distress. He 
broods over his miserable condition, dragging himself on his daily 
round of duty, till dejection becomes despair. Reason is slowly 
eclipsed, and he seeks unreal causes for his misery, in the frown of 
God, or the machinations of his enemies. He attributes his bodily 
discomfort to magnetism, or spiritualism, or other forms of unseen 

Many cases stop short of active delusion. There is simply a 
settled state of gloom, which makes the patient miserable. In this 
condition the impulse to suicide as the most natural means of relief 
is common. This is really the quickest way out of trouble, and it 
is not strange that the instinct of self-preservation, and the restraints 
of religion, are overborne by the tide of mental distress. The un- 
happy victim of this cerebral condition has but one wish, one long- 
ing, quick — 

"To be hurled 
Anywhere, anywhere, out of the world ! " 

Homicide may result from pure insane impulse, or depend on a 
definite delusion. It is not uncommon in melancholia, and the impulse 
is confessed to, by many patients whose friends little suspect the 
danger they have been in. A parent, for instance, sees nothing but 
ruin and starvation before his children, and illogically kills them to 
avoid a possible calamity. Melancholic females are often possessed 
by a horrible longing to destroy children in their charge, but fortu- 
nately the frequency of the act bears a small proportion to the fre- 
quency of the impulse. Homicide may be committed in such an 
agony of mind, and in such a state of the brain, as to leave no trace 
in memory of the circumstances of the act. This merciful oblivion 
renders the convalescence free from those haunting recollections 
which retard recovery in other cases. 


Melancholia often borders closely on dementia. It may, for 
months, prevent speech, or voluntary action. The patient is help- 
less, and either passive or obstinate, giving no sign of intelligence, 
unless a countenance gloomy rather than vacant is one. He would 
die of starvation without forcible feeding, and yet, after months, may 
recover, and remember much which occurred in his presence. 

Actual dementia may assume an apathetic character, but differs 
from the last described condition considerably. There is, in the 
former, an air of vacuity and a general passivity, from which the 
patient may be partially roused ; in the latter, more often resistance 
to all kindly interference, and an evident absorption in gloomy and 
painful thought. Acute dementia, from overwhelming shock to a 
weak brain^ may assume the apathetic form; but in spite of their 
hopeless appearance, such cases may speedily recover, Dementia, 
secondary to other forms of insanity, is characterized by incapacity 
for deep emotion, for natural feeling, or for earnest thought. The 
mental activity is superficial and irregular. There may be fixed 
ideas, systematized delirium, or delusions, as they are called, as well 
as in chronic mania. There may also be outbreaks of brief excite- 
ment and violence, but they are not expressive of the ruling state of 
mind, as in the latter disease. Dementia may also be the result of 
long-continued vicious habits, or of premature decay in old age. 

I have said nothing of the -physical symptoms which accompany 
insanity, as they do not in themselves necessarily indicate mental 
disease. They do, however, in connection with the mental signs, 
serve to show the stage and degree of insanity. In writing upon this 
subject the mental peculiarities are largely dwelt upon ; but the 
physician, in dealing with it practically, is concerned most with the 
patient's physical state, and, contrary to popular notions, finds in every 
recent case, at least, ample indications for physical treatment. 
After a careful examination of the whole case, he takes little interest 
in, or notice of, those mental vagaries which so excite the curiosity 
of strangers, except as they indicate the effects of treatment or the 
progress of the disease. 

The patient's aspect, manner, and actions, are of course a direct 
reflex of his mental state, and should be studied with care. Some- 
times a mere peculiarity in some article of dress may satisfy an 
experienced eye of something wrong in the wearer. The strictly 
physical symptoms relate to sleep, appetite, digestion, circulation, 
temperature, respiration, strength, and the like. The bodily func- 
tions in acute insanity are always deranged ; strange sensations in 
the head and stomach are common ; sometimes there is intense head- 
ache, with great heat of the head, quick pulse, restlessness, fever, 
dry and red or brown tongue. Extreme constipation, or menstrual 
irregularity, usually exists. 

A careful examination of all the organs of the body is necessary 
to discover whether some local disease is not concealed by the men- 
tal state. Disease of the heart, consumption, Bright's disease of the 
kidneys, and local or partial paralysis, should be especially looked 
for. In fact there is no safety in undertaking to treat insanity with- 


out a thorough examination of all the functions of the body. But 
this subject will be enlarged upon when we come to speak of the 
treatment of insanity. 



THE term partial insanity may be used to cover all those cases 
in which the mind is affected so slightly, or so one-sidedly, as 
to contrast with a condition of marked general disorder. A mild 
case of mental disease affecting both the moral and intellectual 
powers slightly, may be considered partial, because limited in degree, 
while moral or intellectual insanity is partial in the extent to which 
the mind is disordered. This latter division is based on the obser- 
vation of cases in which either moral or intellectual disturbance 
exists, each independent of the other, as far as can be well demon- 
strated, the patient being manifestly insane, and unfit to be at large. 

This distinction should not be too much insisted on, since, in most 
cases of moral insanity, a relative intellectual weakness may be in- 
ferred, if not proved ; that is, either the control of the reflective 
.faculties over the feelings has been weakened by disease, or the 
feelings are so aroused and intensified by disease as to overcome all 
intellectual restraint. So when the insanity consists of a mere delu- 
sion, there is generally an undercurrent of perverted feeling, though 
the actions may be quite sane and correct. Practically there are 
many cases of extreme insanity without delusion, and of delusion 
without such disturbance of feeling or conduct as to call for inter- 

In examining a case of suspected insanity, the physician does not 
rely so much on intellectual aberration, as upon alteration of the nat- 
ural state of the patient's feelings towards his family and friends, and 
changes in his conduct consequent upon cerebral disease. Actions 
here, as elsewhere, speak louder than words, and the case is often 
clearly made out before any evidence of delusion is reached. Delu- 
sions are generally secondary, and arise in the patient's mind to 
account for his changed feelings. They crystallize out of the 
unsettled state of his relations to external things, and are a sort of 
attempt at readjustment, after a period of excitement and confusion. 
The patient ma}' come under observation before they are fully formed, 
or they may never assume fixed and definite proportions. In a case 
which is to undergo legal scrutiny, it is always necessary to brine 
them to the surface, if they exist. Like plums in a pudding, they 
make a case go down better; but a pudding is a puddino- without 

Insanity may be limited in degree in all its forms. We may have 
mania, melancholia, or dementia, of so mild a type as to call for no 
restraint, the patient hovering, as it were, over the border line; too 
sensible to be called insane, and yet so altered or peculiar as to be 
really unsound in mind. I might name many men in public life, 
who present all the essentials of mania in their conduct, opinions, 
and feelings. They are called "cracked brained," or "fanatical,' - or 
"eccentric," and are said to have "a bee in the bonnet." They <>-en- 
erally exhibit those exalted, extravagant, self-sufficient, meddlesome, 
erratic, and violent traits, which characterize the true maniac. 


These men seem always on the point of becoming, what they some- 
how always manage to escape being, really mad. 

Partial insanity of another kind is seen in persons whose nervous 
energy is insufficient for their organic wants, and whose mental 
vigor suffers in consequence. They are "blue," dyspeptic, hypo- 
chondriacal, suspicious, whimsical, irritable, notional, to the perpetual 
disgust of all healthy minds. These sufferers are to be pitied, and 
may be helped, though the patience of Job, and the wisdom of 
Solomon, seem requisite to deal with their fancied ills and mental 
vagaries. They are not all repellant, however, as many are able to 
conceal the intense selfishness common to melancholia. The lips 
may disavow all suffering, or may persistently dwell on the hopes, 
plans, and interests of others, and the most amiable traits of char- 
acter appear, in spite of evident and constant mental anguish. 

A lady of superior intellect and refinement of feeling lately con- 
fessed to me her liability to transient attacks of depression, lasting 
a few hours only, in which a suspicious state of mind is developed. 
Her relations to her surroundings become disjointed, as it were, and, 
without any change in her friends, she feels she is not appreciated, and 
still farther, that she is ill-treated and abused. Fully recognizing the 
morbid nature of this condition, she seldom allows a word to escape 
which would reveal her true feelings. In a physically weak condi- 
tion from special illness, she once suspected her physician of a plan 
to perform a painful operation upon her without her knowledge and 

I have known this morbid feeling to seize upon a whole officers' 
mess, after a period of prolonged excitement and fatigue, producing 
a state" of irritability worthy of sick children, and ludicrous to think 
of, when the soup, which had been well quarrelled over, had done its 
work on the inner man. 

Dementia of all grades maybe found, both in and out of hospital. 
Every community furnishes examples of amiable imbecility. People 
for whom allowances must be made, who are instinctively treated as 
children, though advanced in years, and whom everybody calls by 
the first name. They may be shrewd, handy, and cunning, in cer- 
tain directions, and in their own sphere useful members of society, 
but a faulty organization prevents any hope of development ; on the 
other hand, they may be morose, irritable, and at times dangerous, 
or gay, dissipated, deceitful, malicious, given over to drunkenness 
and vice, swelling the criminal class, filling jails and prisons, and a 
scandal to the law which makes no provision for the three-quarters 

I am convinced, from continued personal observation of both the 
insane and the criminal class, that both are largely recruited from 
individuals of defective mental organization. This belief is shared 
by many physicians whose opportunities for observation have been 
ample. In certain youth, it is safe to predict either habitual intem- 
perance, crime, or insanity, as a result of hereditary disease. Many 
persons alternate between a prison and a hospital. There are 
patients in every hospital whose career would seem rather to justify 


punishment, and it is certain that many in every prison are in no 
true sense morally responsible for their offences. The condition of 
the habitual drunkard, for instance, is either one of acquired partial 
dementia, or of inherited mental weakness, in respect of his one 
vicious habit at least. The short and repeated sentences of our 
courts for drunkenness are worse than useless, for a disease of this 
chronic nature demands prolonged restraint, and humane and lib- 
eral treatment. In no other way can the well-being of the individual 
be secured, societyprotected, transmission of vice, crime, and insanity 
prevented, and the labor which this class owes to society utilized. 

Intellectual disorder without marked and obvious effect on the 
general conduct is sometimes observed. The usual morbid change 
of feeling may have passed off unnoticed, or have been brought 
about so gradually, as not to be recognized as part of the disease. 
Delusions may exist so disconnected from the ordinary mental oper- 
ations, as to produce no change of character or conduct. Some 
transient period of mental exaltation may have been accompanied by 
hallucination of the senses, entailing a life-long delusion concerning 
it, as a supernatural event. This is the explanation of many a sup- 
posed revelation, divine mission, apparition of angel or devil, in 
which the individual steadfastly believes. 

The unsettled condition of puberty is especially favorable to th<e 
development of religious delusion. The child's mind may have been 
injudiciously stored with religious fables, legends, miracles, or otta;:r 
spiritual machinery. He may have been led to expect, in his own 
case, some great and supernatural change, which will save hiin 
from everlasting torment, and bestow a mysterious peace and ecstasy 
of happiness. In some unstable minds at puberty, by continual- 
thinking, and loss of sleep, from religious excitement, a condition 
of temporary delirium results. A distinct physical crisis occurs, 
prayers seem to be answered, an angel appears in the still watchea 
of the night, announces that all is well, and gives some divine com- 
mission. A reaction from the state of gloom and depression follows, 
and peace results. A belief in the supernatural may, and often does, 
in some form, arise out of this condition, remaining as a permanent 
delusion after all undue excitement has passed away. 

However formed, we do find delusions, the result of disease of 
a partial character, affecting the greatest and best minds. Joan of 
Arc, Swedenborg, Martin Luther, Napoleon, Sam. Johnson, and 
others, were in this sense insane. But instead of a single delusion, 
standing more or less apart, and disturbing but slightly the conduct 
and feelings, we may have a series of fixed ideas, constituting a 
system of delusive belief. 

A general delusive idea of vast self-importance takes possession 
of the mind in most co-called monomaniacs. Out of this grand 
primary delusion arises a belief in some special extraordinary gift, 
or mission. As a rule, the greater the claims of the monomaniac, 
the more inadequate his power of performance. He believes him- 
self destined to heal the world, and his means consist in an incoherent 
advocacy of the use of the syringe. He believes himself capable of 


reforming the language, and his instrument is a tract, containing a 
crazy jumble of words and phrases. Such cases, however, afford 
examples of general insanity, partial only in the sense that consid- 
erable reasoning power, in certain directions, remains. The con- 
duct, except when under restraint, moral or personal, is always 
radically affected, and the feelings deeply perverted. 

Partial insanity of the moral or affective faculties is not uncom- 
mon, and is more clearly a distinct form than intellectual insanity, 
for this reason : in all forms of insanity the morale is first affected. 
The feelings, emotions, affections, and passions are altered, and the 
conduct correspondingly changed, before the intellect is much dis- 
turbed, or at any rate, in many cases, long before delusions are 
formed. This stage may be permanent, ending in dementia with 
delusions only after many years. It may take the form of depres- 
sion, with suicidal and homicidal impulses, and no delusions. It 
may take the form of instinctive or transitory mania, with impulses 
to violence, vice, or crime, as in cases where there is an irresistible 
desire to drink, to steal, to ravish, burn, or kill, regardless of time, 
place, or consequences. 

Chronic moral insanity is a comparatively frequent condition. No 
expression is adequate to describe the chronic misery which its pres- 
ence inflicts on many a family. It remains unrecognized, oftentimes, 
even by the nearest friends, for what it really is — a subtile form of 
mania. In the wife, outrageous and unfounded jealousy is common ; 
and the delusions, if any exist, relate to that which may be true, and 
which the world is ready enough to believe, especially on the asser- 
tion or insinuation of a wife apparently sane. Outrageous temper, 
the result of mental disease, confined to the family circle, is com- 
mon to both sexes. In men, a fondness for litigation sometimes ac- 
companies it. Not every case of bad temper or jealousy is insanity ; 
but, oftener than might be supposed, there is a constitutional or 
pathological foundation for it which should be taken into account. 
It is the incipient form which the physician sees and helplessly de- 
plores ; while only after years of suffering does the confirmed dis- 
ease bring its victim into court. It is to the credit of human nature, 
that, when recognized as disease, it is only in the last extremity of 
endurance that friends seek legal relief. 

Take, for instance, a man who, up to middle life, has been tem- 
perate, industrious, a kind father and husband, and a successful 
business man. By degrees a naturally quick temper becomes 
uncontrollable. It involves him in difficulties which react upon him, 
and increase and develop an hereditary tendency to disease. In a 
few years his character has decidedly changed — his amiable traits 
have disappeared, and all his bad qualities have grown upon him. 
He may, or may not, have taken to drink. His abuse has driven 
away his children, alienated his friends, and made his wife sick and 
wretched. His home is ruined, his property melted away in fruitless 
lawsuits and damages for assaults. At last, in sheer self-defence, 
his wife attempts to secure his custody in a hospital for the insane. 
A. few business friends, his lawyer, and others, in a meddlesome 


spirit of philanthropy, rally round him, and denounce the attempt as 
an outrage. He has money, self-control, influence, business mo- 
mentum to carry him on ; his wife, nothing ; and, still worse, has to 
contend with a real love for her husband as he was, and a fear of 
his often-threatened revenge if she is successful. Physicians bold 
enough to help her, doit at the risk of prosecution, and without hope 
of reward. His wife and children, before whom alone his insanity 
displays itself unrestrained, are incompetent, or, at least, suspected, 

This is no fanciful picture, but a correct likeness of an actual case, 
which has its fellows in every community. The conduct in such 
cases, whether occurring in male or female, if they find permanent 
lodgment in a hospital, is the same from beginning to end. Pur- 
poseless lying, thieving, quarrelling, mischief of all kinds, setting 
patients by the ears, plans of escape, and the like moral offences, 
fill up the whole time, through a long series of years. Often under 
discipline, seldom profiting long by it, with the plausibility of angels 
of light, they sink slowly into partial dementia, with now and then 
a delusion, or, as in one case I have in mind, die of some fortunate 
intercurrent disease, with oaths and cursing in their latest breath. 

These, and other forms of moral mania, especially where crimes 
have been committed, involve all concerned in dealing with them in 
the heaviest responsibilities. The greatest caution is required lest 
one side or the other, in a legal inquiry, should suffer injustice ; but 
it will not answer to close the eyes to the existence of forms of dis- 
ease, just as evident to alienists as small-pox is to all observers. 
The plausible appearance of the patient under prolonged examina- 
tion should not have the slighest weight against clear and positive 
evidence of disease at home, before the moral restraint of a legal 
proceeding existed. These patients not only may have a habit of 
self-restraint before the world, but may carry out an assumed char- 
acter of amiability and injured innocence for years, with a skill and 
persistency which would be impossible to any but an insane mind. 
They often deceive the " very elect." And this is not strange, since 
nothing but actual observation of them, when off their o- U ard in the 
privacy of home, or during a prolonged residence in hospital, can 
give any adequate idea of the subtle, yet deep-seated, nature of this 
form of insanity. 

The moral of this subject is, be charitable, and don't "take sides" 
hastily where insanity is suspected or alleced. 



MONOMANIA is a term which has become established by usage, 
but which conveys an incorrect idea of the disease so called. 
It is objectionable, but as it can hardly be gotten rid of, I wish to 
speak of this form of insanity by itself. The disease monomania is 
merely one form of general mania. The expansive emotions, the 
exalted self-feeling, and the disordered ideas, which tend so strongly 
to eventuate in action in mania, are all present in monomania. The 
difference is in the degree of explosive energy, and in the range of 
the delirious ideas. Instead of an immediate and irregular outbreak 
of insane violence, the maniacal tendency is restrained. It smould- 
ers for years, blazing up now and then when some special series of 
associated ideas is touched, but giving its character to the whole life. 
It is mania, latent or suppressed, and turned to service in some all- 
absorbing, but narrow, sphere of action. 

In common terms, a monomaniac is one who is " insane on one 
subject" only, being in all other respects perfectly rational. This 
condition does not accord with our ideas of the unity of the mind. 
It is hard to believe that the secret relations of ideas are not deranged 
when so decided a symptom as insanity exists, if it is limited in its 
manifestations. Evidence of the separate localization of the so- 
called mental faculties is wanting, and still less can a definite loca- 
tion be asserted for each group of ideas. It is more reasonable to 
suppose a general cerebral affection, with a limited expression, in 
the region of ideas, determined by circumstance and perpetuated by 
habit, while the stress of disease falls on emotion and volition. 

This view is supported by the fact that monomania, in the narrow 
sense of a single delusion, is very rare, and occurs oftenest in cases 
of hypochondria. The underlying disease is melancholia, with ex- 
aggeration of certain physical symptoms, some of which becomes 
in the patient's mind the basis of a delusion. He fancies his legs 
are of glass, or his head a diamond, and the like. Or he has a 
snake in his stomach ; or he is a lobster, because his body turns red 
after a hot bath. The term monomania was perhaps well enough 
suited to these cases when insanity was considered an exclusively 
intellectual phenomenon ; when . the inexact observation of former 
times perceived in a single prominent delusion the whole disease. 
The term is, however, now often used carelessly to designate serious 
and deep-seated insanity, if the prominent symptom is disorder in 
some special group of ideas. 

The definition of Griesinger does not convey the usual insufficient 
conception of this form of mental disease. He says : " Under the 
term monomania are comprehended those states of exaltation which 
are characterized by affirmative, expansive emotions, accompanied 
by persistent overestimation of self, and the extravagant, fixed, de- 
lirious conceptions which proceed therefrom." 

The all-comprehending nature of monomania is shown at once in 


the central symptom of self-exaltation, which manifests itself in 
vanity, pride, haughtiness, presumption, or audacity. This affirm- 
ative disposition is persistent, and will not brook opposition. 

The power of volition is correspondingly exalted, and manifests 
itself, not in immediate action, as in mania, but in extravagant 
projects, which seem feasible to the patient, who thinks himself 
capable of anything. The desire for the manifestation of power, 
common to all forms of mania, is here controlled and kept in check 
by the series of fixed morbid ideas which preside over the will. 

The intellect, as well as the emotions and the will, suffers in 
monomania. Out of the numerous trains of exalted thought which 
at the outset present themselves, the mind naturally fixes upon some 
one appropriate channel for its expansive tendencies. This may be 
determined by chance, or by previous tastes and habits ; but once 
chosen, the delirious ideas maintain considerable independence, and 
tend to develop and express themselves in their own sphere of 

The conduct is what logically would result from the above-stated 
condition of the intellect, emotions, and will. The patient generally 
assumes some exalted office or mission, which absorbs, sooner or 
later, his whole mental and physical activity. His relations with 
his family and with society are disturbed and broken up, and he be- 
comes the slave of his delusions. By force of a diseased will, he 
tries to bend everything to the accomplishment of his insane plans. 
From choice, and for a purpose, such a patient may, however, fulfil 
the ordinary requirements of society, and even prove expert in con- 
cealing or explaining away his insane schemes if they are in danger. 
Opposition, when not too formidable, is sure to excite to acts of vio- 
lence, as the most ready means of repelling interference. The 
restraints of the family and intimate friends are quite likely to be 
resented forcibly. 

Monomania, therefore, instead of being a partial insanity, super- 
ficial, trivial, and unimportant, is really of extreme gravity, since it 
profoundly involves those organic centres controlling the emotions, 
the intellect, and the will. Griesinger says, in so many words, that 
"it is to be considered a much more serious affection than mania." 
Mania is a storm which soon expends its fury, while monomania is 
a current, deep, dark, and often dangerous. I will put the following 
case to the test of Griesinger's definition : 

A gentleman, seventy-two years old, originally of eccentric habits 
and insane tendencies, was, thirty years ago, cured, as he thought, 
of acute rheumatism, by Thomsonian remedies. On his recovery, 
he determined to do something, sooner or later, for this system of 
practice, at that time somewhat in vogue. To that end he began to 
collect newspaper items, and to read books bearing on this subject, 
and finally to prescribe for his friends. 

Ten years ago, after retiring from business, he began to devote 
more time to his queer researches. The copperplates of Thomson's 
portrait, an ancient medical dictionary, and other now obsolete 
books, were his most valued possessions. He published, about this 


time, two pamphlets, which he regarded with great satisfaction. 
One of them, singularly enough, was not in the line of his medical 
inquiries, but purported to be a new plan for reforming the language. 
Under the two captions, "Age of Words and Phrases," and "Gram- 
mar," were assembled nearly thirty pages of disconnected and 
incoherent sentences, made more confusing still by the constant in- 
terpolation of synonyms, abbreviations without method, and other 

The second pamphlet, entitled "Track No. 1," is more readable, 
from the absence of the fantastic and distracting verbal construction 
of the former. It is still a good specimen, from beginning to end, 
of incoherency of ideas. There is also occasional verbal inco- 
herence, and, throughout, the most absurd ideas are expressed with 
a gravity and earnestness born only of an insane conviction. The 
writer says, "We have been so excited with joy, when, after twenty, 
hours' study, followed day after day, we found we could discover no 
failure in these frinciflcs ( !) that our body, and our voice, too, has 
shaken for days afterwards like a dry leaf in the wind." 

The central idea in this so-called system is the use of the syringe, 
of which the writer makes himself the champion, offering rewards 
to clergymen who will advocate its use from the pulpit, and to the 
city fathers, if they will provide facilities for its public use, and urg- 
ing all hotels to provide injections for guests on arrival. It is un- 
necessary to particularize further, when all is so absurd. Suffice it 
to say, that under the guise of a system which was to restore man- 
kind to health and happiness, and prove its author the benefactor of 
his race, is found a mere tissue of incoherent nonsense. 

Six years ago, in further pursuance of his schemes, he added to 
his brick house, situated in the heart of the city, a story and a half, 
and built against its rear windows a wooden structure, quite filling 
up his back-yard. These additions, fitted up with steam 
boxes, water-closets, and bath-tubs, in each room, he called his 
hospital. To sustain this impracticable and expensive institution, 
he, from time to time, drafted, and attempted to execute, wills, leav- 
ing large bequests to it. These were so absurd that he was unable 
to prevail upon his legal adviser to complete them. He never suc- 
ceeded in getting his hospital officered, even, and it is, in fact, 
wholly unfit for any hospital purpose whatever, and is, moreover, a 
damage to the estate. 

Three years ago he withdrew more and more from his family 
and society, living, night and day, in an attic room, surrounded by 
his literary scraps, and devoting his time, far into the night, to the 
preparation of a more elaborate exposition of his medical system. 
This new work, of which he published a dozen pages, is entitled 
" The Herbal Physician," and is in the form of a drama, cut short at 
the twelfth page. Its style is tolerably coherent, being largely the 
work of hired amanuenses, who were constantly in his employ. 
Under these circumstances, his health was rapidly failing. Want 
of a proper amount of sleep and nourishment, with the naturally 
progressive nature of the last stages of his disease, had so seriously 


impaired his health, that he expressed his fear of dying before finish- 
ing his last great work. 

He had proved violent in several instances, and kept his family in 
constant fear and subjection to his least whim. He confessed his 
suspicions of the sanity of his family, and his belief in their intent 
to kill him, and showed, on several ocasions, by his conduct, that 
these suspicions and this belief were genuine, and not assumed. 
Furthermore, his management of his property was entirely controlled 
by his delirious ideas, and his purse and estate were literally at 
the disposal of anyone who should set himself about deceiving him. 
His credulity in the direction of his delusions was great. 

His disease proved fatal in a few months. 

The first and essential feature in Griesinger's definition of mono- 
mania was strongly marked in this case. It is seen in the disparity 
between his extravagant claims and his utterly inadequate perform- 
ances. Nothing short of an insane conviction of infallibility could 
bridge over such a gulf. It is shown in his pretentions as a medical 
reformer, and in his scheme for renovating the language, based on 
a chaos of unreadable sentences. It was further shown in the acts 
of petty household tyranny by which his morbid will continually 
enforced itself. It found expression in such words as these : "/am 
my family ! " and, " This hat covers my family." The fact that this 
patient was allowed, for years, to go on unrestrained in his exactions 
and expenditures, exhibits the power of this diseased self-assertion 
over ordinary minds. 

Emotional disorder was shown in irascibility, resulting at times in 
personal violence ; also by fears and suspicions of danger, leading 
to strange defensive precautions, based on the expressed belief in 
the insanity of those about him, and upon alleged attempts on his 
life. The disposition, amiable at times, was subject to sudden vari- 
ations and contradictions ; extreme harshness and severity following 
kindness, without warning. There was parsimony in household 
expenditures, while no expense was spared to further his insane 

The intellectual disorder showed the usual one-sided development 
which alone gives pertinency to the term monomania, while the 
judgment was fatally impaired with reference to the value of his 
delirious ideas. Upon matters of business routine, he retained a 
fair amount of reasoning power. Under the stimulus of legal pro- 
ceedings, and aided by able counsel, he made a very efficient 
defence against the charge of mental disease. He used, in conver- 
sation, the stereotyped arguments, with a certain shrewdness com- 
mon enough among the insane. There was a display of cunning 
which sometimes overleaped its object, and was far removed from 
the defensive action of a healthy mind. Technical skill and a 
knowledge of affairs are often found in cases of general insanity, 
and should excite no astonishment in a case like the above. 

With such evidence of incoherence as the pamphlets alluded to 
afford, with hundreds of still more fantastic scraps in manuscript, to 
say nothing of the abortive wills, and the standing proof of his so- 



called hospital, no question of profound intellectual aberration can 
be entertained. In fact, as is so often the case, this patient had a 
half-suspicion of his own sanity ; for he asks, in one of his man- 
uscript scraps, "Am I insane, or is all the world becoming so?" 

His conduct, from first to last, was logically consistent with his 
delusions, and with the form of mania above described. As his 
writings were the organic outgrowth of his disease, so his actions 
were the necessary expressions of his disordered ideas and feelings. 

And, finally, his persistent use of his own exhausting remedies, 
his last business acts, and testamentary disposition of his property, 
proved his disease to be strong in death. 

The case of Lady Hester Stanhope is illustrative of this form of 
mental disease. The account of a visit to her, given by Lamartine 
in his " Voyage en Orient" is fortunately so detailed and circum- 
stantial as to afford ample grounds for an opinion as to her mental 
condition. This is the more remarkable as he himself, with a poet's 
appreciation of the picturesque in character, as well as in nature, 
is unwilling to admit her insanity. Perhaps also with a Frenchman's 
politeness and sense of honor, he is willing to excuse to the world 
the eccentricities of his hostess, while unwilling to lose so interesting 
an episode for his book of travel. 

Lady Hester Stanhope, after the death of her uncle, the illustrious 
statesman Pitt, set out on an extended tour of Europe, and for several 
years was at home in the various capitals, where her rank, fortune, 
wit and beauty brought her many admirers. Her motive for refusing 
all offers was attributed by some to the death of an English general 
in Spain, to whom she was attached, by others simply to her love of 
an adventurous and independent career. She visited Constantinople 
at last with a numerous suite, and, after remaining some years, em- 
barked with the greater part of her property, in the shape of jewels 
and rich presents, for Syria. 

Suffering shipwreck, with loss of all her treasure, she returned to 
England, collected the remnant of her fortune, and, freighting 
another ship, departed once more for Syria. This voyage proving 
a happy one, she established herself at Latakia, and prepared, by 
learning Syriac, and making the acquaintance of Arabs, Druzes, 
Maronites, and natives of other distant tribes, to explore the most 
inaccessible regions of the country. 

Her travels were extensive and prolonged. She moved with a numer- 
ous train, richly appointed, and distributed he'r gold and presents with 
a lavish hand. Her almost royal progress, her beauty, and grace, and 
magnificent generosity, so impressed the wandering tribes, that they 
surrounded her tent in great numbers on one occasion, and pro- 
claimed her Queen of Palmyra. They presented her with firmans, 
offering safe conduct to any European who should visit the desert 
under the protection of her name, and promising tribute-money to 
the amount of a thousand piastres. 

After a nomadic life of years, Lady Hester took up her abode in 
an almost inaccessible solitude of the mountains of Lebanon. She 
built many houses, surrounded them with walls, and established her- 


self with a suite of followers in the midst of Oriental luxury. She 
held, for a time, a sort of court, in friendly, if not political, relations 
with the various native authorities. Her fortune soon melted away, 
and with it most of her followers vanished, until, at the time of Lam- 
artine's visit, she was almost alone, without books, papers, or letters 
from Europe, without friends or white servants even. Refusing the 
society of her travelling countrymen, she lived, as it was said, a life 
of religious exaltation, only varied by the study of astrology. 

In reply to a very ingenious and flattering letter, Lamartine, more 
fortunate than others, received permission to visit her. After describ- 
ing her still attractive features and figure at the age of fifty years, 
her Turkish costume and her graceful reception of him, the poet 
details at length his prolonged interview. Lady Hester informs him 
that she perceived, beforehand, that their "stars were friendly," and 
is pleased to find her presentiments confirmed. She knew by his 
step in the corridor, he would be welcome. Surprised at this 
sudden proffer of friendship, he confirms his presumption that he is 
a stranger to her. She denies all knowledge of his wordly identity, 
but has at once perceived his spiritual character. " Do not consider 
me mad, as the world often does," she says, "for I cannot resist the 
necessity of speaking to you frankly." 

Then follows her affirmation of the truth of astrology. She says 
the influence of our natal planet is written in every movement and 
in every feature. Lamartine, she says, (without, as it seems, any 
calculation of his nativity,) was born under three stars, happy, pow- 
erful, and good. God has led him to her to be the instrument of her 
power at the second coming of Christ, which was near at hand. As 
she warms with her theme, she sees more than three stars, even four 
and five, " ct qui sait plus encore!" "You should be a poet; this I 
see in your eyes, and the upper part of your figure ; below you are 
under the control of different stars almost opposed," etc. 

Suddenly she asks his name, and predicts his return to the East 
after great deeds in Europe. The East, she says, is the home of his 
fathers, since he has an Arab foot under which water can run. She 
expounds her religious views, which seemed a mixture of beliefs 
gathered from the tribes among which she had lived. She took him 
mysteriously to the stables, where was a bay colt born ready saddled; 
that is, through a deformity of the spine, his back presented a curve 
like that of a Turkish saddle. This colt, it had been foretold for 
centuries in prophecy, would carry the Messiah at His next coming. 
No one was permitted to mount him, and he received the tenderest 
care, as did also a white colt, which Lady Stanhope had reserved to 
bear her into Jerusalem, by the side of the Saviour. 

Lamartine's opinions upon this case are a poet's apology for the 
eccentricities of his hostess, and are more ingenious than plausible. 
He talks of " the fantastic coloring and supernatural dreams of an 
Oriental imagination, heated by solitude and meditation." In speak- 
ing of her remarkable memory, he says, "Solitude concentrates and 
fortifies all the faculties of the soul." So does monomania concen- 
trate the faculties into a narrow channel, and the strength of the 


current is in proportion to its width. Memory is a strong point with 
the insane of this class. He also does justice to her generally sound 
intellect, but attributes to solitude again the " false tone of the met- 
aphysical chord strained to a pitch too high for mortal intelligence." 

It is unnecessary to analyze here this exceedingly interesting case 
of mingled genius, eccentricity, and disease of mind. Its resem- 
blance to less illustrious examples will be none the less apparent for 
its romantic setting. It is one of a class, having marked general 
traits with great variety in detail. The truth aimed at in the begin- 
ning, is exemplified in it as far as the narrative has been presented, 
and is indicated in many hints which cannot well be reproduced. 

I cannot omit to offset the opinion of one poet with that of another 
here, since it will call attention to a most interesting episode in .the 
life of Lady Hester Stanhope, which I have not space to enlarge 
upon. In Whittier's Snow-Bound will be found a beautiful descrip- 
tion of another character, " strong, self-concentred, passionate, and 
bold," a half-unwelcome guest at that famous fireside. "A vixen 
and a devotee," whose rounded wrist " had facile power to form a 
fish " ; whose " sweet voice had notes more high and shrill for 
social battle cry." 

" Since then what old cathedral town 
Has missed her pilgrim staff and gown ; 
What convent gate has held its lock, 
Against the challenge of her knock! 
Through Smyrna's plague hushed thoroughfares, 
Up sea-set Malta's rocky stairs, 
Gray olive slopes of hills that hem 
Thy tombs and shrines, Jerusalem, 
Or startling on her desert throne, 
The crazy Queen of Lebanon, 

With claims fantastic as her own, < 

Her tireless feet have held their way; 
And still, un restful, bowed, and gray, 
She watches under Eastern skies, 
With hope each day renewed and fresh, 
The Lord's quick coming in the flesh, 
Whereof she dreams and prophecies I * 



THE treatment of insanity consists in the medical and moral man- 
agement of the patient, either at home or in hospital. It 
differs from the treatment of other diseases, chiefly on account of the 
fact that every insane person having lost, in some measure, his rea- 
son, depends on others for guidance and control. This radical dif- 
ference between an insane patient and a sane one, arising from the 
peculiar functions of the organ affected, will always necessitate re- 
straint in some form, for the sake of treatment, if not for safety. 

It is a popular notion, shared sometimes by members of the pro- 
fession, that medical treatment is of little use in cases of insanity. 
The public is naturally at fault on this subject. Insanity has been, 
and still is, too often regarded as a mysterious affliction of the im- 
material spirit ; a dispensation of Providence of an obscure and aw- 
ful character, quite removed from the ordinary category of disease. 
Physicians have been led into a similar error, partly from want of 
experience, and partly from the failure in their hands of such irreg- 
ular and inadequate treatment as could be administered at home. 

Insanity is more amenable to treatment than most chronic diseases. 
It is functional in its character in a large number of cases. At the 
outset it consists in slight changes in the circulation and nutrition of 
the brain, and does not necessarily entail any visible change of struc- 
ture. The cerebral machinery is so delicate as to be easily disar- 
ranged by slight causes, and as easily restored to healthy action, by 
early and judicious treatment. The actual disease is not commen- 
surate with the gravity of the mental symptoms. The same amount 
of disturbance in some other organ whose functions do not so imme- 
diately concern our relations to the world outside of us, might pass 

For another reason medical treatment is especially efficacious in 
mental diseases. No other organ is so quickly and easily affected by 
remedies. It is to the brain through the blood, that almost all rem- 
edies are addressed. In diseases of all the organs we use medicines 
to modify the nervous action of the brain ; by which means we reg- 
ulate the circulation generally, increase or diminish nutrition and se- 
cretion, control muscular action, promote appetite, and eliminate 
morbific elements from the system. By means of medicine we can 
annul pain and induce sleep, surely and safely extinguishing one func- 
tion of the brain after another, until the nervous apparatus runs at its 
lowest speed, and barely suffices to keep life going ; or we can so 
feed and stimulate the cerebral engine as to carry life safely at high 
pressure, over many dangerous obstructions. 

The medicines directly affecting the brain increase every year in 
variety and usefulness. Opium, the chief reliance of our medical 
fathers, finds itself in the company of formidable rivals. The im- 
proved use of the old vegetable neurotics — belladonna, hyoscyamous, 
conium, and stramonium — the discovery of ether and chloroform, 
the subcutaneous use of morphine and other remedies, the bromides 



and iodides, lastly, chloral hydrate, have revolutionized the medical 
treatment of insanity. Our increased knowledge of the proper use of 
stimulants, high feeding, and the various tonics, has increased our means 
of dealing with a disease formerly allowed to pursue its course unre- 
strained. If any one fact is plain to physicians conversant with in- 
sanity, it is that cases eminently curable are rendered hopeless by 
the neglect of friends to enforce proper medical treatment. 

The great importance of early treatment cannot be too much dwelt 
upon. The observance of this simple rule, would increase recoveries 
from fifty per cent., the average hospital rate, to at least eighty per 
cent, for recent cases. The difficulties in the way of early treatment 
are peculiar, but not insurmountable. The patient often conceals his 
disease as long as possible, instead of seeking relief of his physician, 
as he would in case of some physical ailment. He may be unaware 
of his danger, or dread exposure, and so wastes the precious days 
in which the impending attack might be prevented. If his friends 
observe the approach of mental disease, they are unable to influence 
the patient, misapprehend the danger, dread exposure, hope against 
hope, and throw away his best chances in useless experiments, until 
the case becomes hopeless, or some public outbreak compels action. 

For these reasons the second attack is sometimes less to be 
dreaded than the first. The patient, instructed by sad experience, 
takes his own. precautions, consults some physician who knows his 
history, or goes directly to the hospital where he was formerly cured. 
Such cases are of frequent occurrence — I have repeatedly seen 
a threatened attack of insanity prevented by a timely prescrip- 
tion, and am morally sure that, without such early interference, 
months of suffering would have ensued. For instance, an intelli- 
gent mechanic who had twice been an inmate of an insane hospital, 
on his own application, suddenly gave up work on account of another 
attack which he felt to be impending. He was sleepless and de- 
pressed ; was ashamed of his condition, and had determined to start 
at once for the West, without informing his friends of his mental 
state. He fortunately applied to his physician at the last moment, 
was prescribed for, slept, gave up his scheme of emigration, returned 
to his work in two or three days, became well and cheerful, and 
has remained so. 

The importance of securing regular and sufficient sleef, in this 
early stage of insanity, by means of medicines skilfully varied to 
meet the requirements of the case, cannot be too much insisted on. 
The proper amount of sleep, the kind of medicine, the size of the 
dose, and the times of giving it, should be determined only upon the 
best obtainable medical advice. Nothing is so pernicious as to leave 
the treatment at such times to the judgment of the patient or his 
friends. Success and failure depend entirely upon the manner in 
which treatment is carried out at this critical period. Patients have 
often been stupefied with bromide of potassium, in the attempt to 
force sleep with a drug only adapted to quiet and relieve them, until 
it was hard to distinguish stupor from depression or dementia. 
Chloral hydrate has been given till exhaustion and threatened col- 


lapse followed what should have been refreshing sleep ; on the other 
hand, over-cautious doses, domestic herbs, and infinitesimals, are 
relied on, till the incipient stage goes on to confirmed insanity. This 
sliding scale of domestic practice descends, in my experience, from 
six pounds of chloroform, in twenty-four hours, to hop pillows, and 
decillionth grain doses of belladonna, tri-daily. 

Constipation is a frequent accompaniment of incipient insanity, as 
well as a troublesome complication in all its stages. The necessity 
of attention to this exceedingly harmful condition is not sufficiently 
recognized. It is a matter which requires advice, and should never 
be left to the judgment of patient or friends. It may make all the 
difference between suicidal impulse and its absence in cases of mel- 
ancholia. It is a matter of life and death, literally. It is responsible 
for many an outbreak of excitement. Coma, paralysis, and ap- 
proaching death, disappear sometimes before a timely cathartic. 
The ways and means of relieving this condition are not to be lightly 
chosen. The thousand pills which flesh is heir to, in these latter 
days, may or may not contain useful and wholesome drugs, but the 
patient who puts his trust in them deserves to suffer. 

The feeding an insane patient is strictly a part of his medical 
treatment, and the most important part, too. Food is tonic, sleep- 
producing, and directly curative, when properly used, in cases of 
insanity. It should not be left to be given or taken at hap-hazard. 
The physician who feeds most skilfully will succeed best. In the 
acute stages of all forms of mental disease, there is a disturbance of 
the appetite. It is wanting entirely, or is fickle and irregular, or, 
rarely, inordinate. The patient's mind may be so preoccupied by 
excited or delusive ideas, that he will not take time to eat. Some 
patients refuse to eat as a result of concealed delusion, or openly 
insist that their food is poisoned, their throat grown up, or attempt 
starvation as a means of suicide. 

In all these cases the most unremitting attention must be paid 
to the amount, and kind of food taken, as well as to the times of 
taking it. There is always great nervous waste, from the rapid or 
painful cerebration constantly going on, to which is often added the 
waste attending great muscular activity. The patient, thinking he 
is sick, may abstain from meat and other strong food, or, thinking he 
is well, and being naturally a small eater of meat, cannot be induced 
to take the increased quantity the exigencies of his case demand. 
With some patients, double the usual amount may be required to 
sustain the exhaustive tendency of the disease, and this change 
seems unnecessary, and hurtful to them. 

Animal food must be prescribed in concentrated form, in the 
shape of beef extract, soups, oysters, eggs, milk, custards, jellies, 
etc., in such quantities, and at such frequent intervals of clay and 
night, as shall insure a very generous diet of known quantity. Its 
administration must be enforced regularly and persistently in all 
cases where the exhaustive tendency is strong, and this will tax the 
skill and energy of the nurse and physician to the utmost. Feeding, 
however, is the one thing needful, and must be carried on peaceably 



or forcibly, as the case requires. Solid food, rich in nourishment, is 
best, but beef tea has come to be the main stay in hospital practice, 
from its concentration, its easy administration, and digestion. 

I cannot help quoting here the experience of Dr. Blandford, the 
latest English authority on insanity, since it accords with what every 
asylum physician sees daily. He prescribes, in some cases of mel- 
' ancholia with supposed dyspepsia-, the following diet : " Before get- 
ting out of bed in the morning, rum and milk, or eggs and sherry ; 
breakfast of meat, eggs, and cafe an lait, or cocoa ; beef tea, with a 
glass of port, at eleven o'clock, and a good dinner or lunch at two, 
with a couple of glasses of sherry ; at four, some more beef tea or 
an equivalent ; at seven, dinner or supper, with stout and port wine ; 
and at bed-time stout or ale, with the chloral, or morphia. This al- 
lowance I have given to patients who were said to be suffering from 
aggravated dyspepsia ; who, I was told, had suffered from it all their 
lives ; who had never been able to take malt liquor, or eat more than 
the smallest quantity at a time ; who, in fact, had been living on 
about half the quantity requisite for their support, and through 
chronic starvation had come to this depressed condition. I hardly 
need tell you, that the patients and their friends were aghast at the 
quantity ordered to be taken ; but improvement has taken place 
immediately, the tongue cleaned, the constipation given way, and 
the depression diminished." A modification of this treatment would 
suit many cases of " dyspepsia " without insanity. 

It is a mistake to suppose that, with the insane, "good digestion 
waits on appetite." It only waits for food, and soon disposes of it, to 
the advantage of the patient. The appetite comes with eating. It 
is also an error to suppose that forcible feeding does no good ; in 
the few cases where it is required, it often proves the salvation of the 
patient, as many persons now sane and well can testify. Tri-daily 
feeding with a stomach-pump, kept up for three, six, or nine months, 
is heroic practice, at least as regards the operator, but it has the 
advantage of saving life, and restoring reason. More commonly, 
howeer, a resolute use of moral suasion, backed up by an occa- 
siona. appeal to force, will overcome a patient's morbid obstinacy. 
The kood effects, too, are often so immediate and obvious to the pa- 
tient, that he yields at discretion. It is not only while the patient is 
master of himself, and able to resist advice, that mischief results 
from insufficient food. Too many, helplessly sick, have been al- 
lowed to die of sheer starvation through ignorance and supineness. 

The use of stimulants forms a part of the food question. Without 
entering upon the discussion whether alchohol is assimilable as food 
is, it suffices to know that it does of itself support life, and in com- 
bination with milk and eggs, or as an adjunct to ordinary diet, it is 
indispensable in the exhaustive forms of insanity. Its use should be 
regulated by the effect produced, without regard to theoretical no- 
tions of its chemico-vital reactions in the body, or of the quantity a 
person in health might safely use. To keep within the limits of 
purely stimulant action, and to avoid its narcotic effect, should be the 
rule, whether half-ounce or half-pint doses are required. A layman 


is no more competent to prescribe alchohol than other medicines, 
since much harm may be done by its improper use. 

I might speak further of the use of tonics, when failing strength 
is the precursor of mental disturbance ; of alteratives and other rem- 
edies for the underlying constitutional affections of scrofula, rheum- 
atism, syphilis, and the like, upon which insanity sometimes depends ; 
of the treatment of local diseases which affect the brain sympathet- 
ically ; but these are matters which are not susceptible of popular 
treatment. In fact, discussing the question' of the medical treatment 
of insanity in a family journal of health at all, needs a word of 
apology. The only safe direction to give the friends of a person be- 
coming insane, is to send at once for a competent physician. Better 
in this, and all other diseases, an experienced physician without 
medicines, than the best remedies without a physician. 

I have intended to say only enough to enforce the idea that insan- 
ity is curable ; that medical treatment is even more efficient than in 
othei diseases, and that early treatment is essential to speedy recov- 
ery. A vacillating and expectant course, which is safe in the ordi- 
nary sicknesses which may tend of themselves to recovery, is fatal 
in a disease which, like insanity, almost invariably progresses from 
bad to worse unless interfered with. Prompt and well-directed 
treatment in those cases which promise success, is equally removed 
from the weakly-expectant on the one hand, and the rashly-heroic 
on the other. 

Lest from zeal to inculcate one truth we lose sight of another, and 
thereby convey a partial view of the subject, it should be remembered 
here, that many cases are obviously incurable from the beginning ; 
those depending on epilepsy, general or local paralysis, or other or- 
ganic diseases, for instance. Some cases which promise well at the 
outset, prove most intractable. There comes a stage in every form 
of insanity which is practically incurable, and this may have arrived 
insidiously, before treatment has been deemed necessary at all. It 
is because insanity, although generally curable, so often becomes 
fixed and permanent, that no time should be lost in taking measures 
to arrest its progress. The structure of the brain, so susceptible to 
morbid impressions, quickly assumes the vicious habit of diseased 

When incurable, much may be done to relieve and modify the 
worst symptoms, and many cases which only seem incurable from 
their duration may, by persistent endeavors, be relieved.. It not only 
requires experience and discrimination to decide what to do and 
when to do it, but to determine how long treatment may be usefully 
continued. Next to delay, a frequent change of treatment is per- 
nicious with a disabled brain ; trying this and trying that is not a 
safe policy. As many patients become permanently insane through 
the interference of friends in the stage of convalescence, as from their 
neglect at the outset. 

Certain cases of melancholia particularly require long-continued 
treatment. The disease may have been of slow formation and mod- 
erate intensity, extending over years, and requiring from one to 


three years more of steady effort to change and improve the nutrition 
of the brain, to break up morbid cerebral habits, and to establish 
healthy action. This, it is needless to add, requires hospital oppor- 
tunities, for the sake of rest, seclusion, constant observation, and 
the carrying out of systematic medical treatment. It also requires 
an amount of faith and patience on the part of patient and friends, 
which merits, and often obtains, its reward. 



IT is not the insane alone, among the sick, who need other than 
drug treatment. The student of medicine is taught the use not 
only of ingesta and medicaments, diet and medicine, but of subjecta 
and circumfusa, which include moral forces, and the effect of sur- 
roundings. These classic elements of treatment apply in varying 
proportions to all forms of disease, and failure quite as often results 
from neglect of the last two, as from misuse of the first two. The 
homceopathist practically ignores the medicamenta, if he honestly 
adheres to the infinitesimal theory, and succeeds, when he is 
successful, by treating the patient, and letting the disease take its 
own course. All forms of quackery thrive by force of the subjecta, 
in spite of improper and useless medication. The vice of all kinds 
of irregular and exclusive systems of practice is not in appealing 
strongly to the mind of the patient, but in deceiving the imagination 
with illusive hopes and fallacious theories, which react unfavorably, 
and produce a harmful scepticism, when discovered to be ground- 
less. In this way, positive medical science is made to share in the 
disrepute which should attach only to the special form of error in 

There is a way of reaching disease through the mind which does 
not sacrifice the requirements of scientific truth. By quick sym- 
pathy, and a lively interest in the patient as a member of the great 
human family, whose fate is important to all as well as to himself, 
by showing a critical knowledge of his disease, by an active use of 
remedies when they are indicated, and a masterly inactivity when 
they are not, his confidence, respect, and affection may be secured, 
and ought to prove a better foundation for treatment than the ever- 
shifting promises and subterfuges of quackery. 

With the insane, the moral management of the case assumes a 
greater relative importance. We here see mental states reacting 
upon the physical condition in a remarkable manner. Although 
cerebral disturbance affects the mind from below upwards, moral 
causes as certainly originate cerebral disease, acting, as it were, from 
above downwards. Given a brain predisposed by hereditary weak- 
ness to take on morbid action in that part responsible for the mental 
manifestations, and it is apparently a matter of chance whether the 
exciting cause of insanity shall come from within or from without ; 
whether the train already laid shall be fired by physical irritation or 
some painful moral impression. In fact, a series of the latter may 
lay the train as well as a continuation of the former ; or a powerful 
mental shock may overcome reason at once, when no special pro- 
clivity to disease exists. 

Since the moral forces have such a causative influence, they may 
be expected to have a peculiar curative power. But because a 
mental shock may induce insanity, it does not follow that a shock of 
another, or of the same kind, will cure it. Such a belief was, 
however, once honestly entertained and acted on, and will account 
for some of the cruelties practised upon the insane in former times, 


which are too often attributed wholly to neglect or barbarity. It is 
one thing for sudden grief, or fright, or other depressing emotion to 
disable or paralyze the delicate functions of the cerebral nerve-cells, 
and, by reactionary excitement, cause permanent insanity, and quite 
another for any shock, whatever to restore healthy action. A refrac- 
tory watch or clock may possibly be started by a lucky blow, the 
machinery beiug already in running order ; and so, in some rare in- 
stances, the mental faculties, suspended rather than disordered, 
stand ready, like an- engine-beam "on the centre," to act upon any 
chance impulse. 

In this way, if the legend can be trusted, was St. Dymphna, the 
patroness of Gheel, the means of curing, by her violent death, a 
poor lunatic. This saint, as the story goes, was an Irish princess, 
and an early convert from paganism to Christianity. Fleeing from 
the rage of her father to Belgium, she was there overtaken by him 
and brutally murdered. The cure effected by this frightful occur- 
rence upon an insane bystander, has made her shrine the resort of 
lunatics for many centuries ; but it is not recorded that any other of 
the thousands visiting it has been cured in so sudden a manner. 

The prolonged effect of the depressing emotions is a more frequent 
cause of insanity, and a prolonged and habitual use of moral agen- 
cies, thereby regulating the modes of life and thought, is more 
efficient in its cure. There is nothing mysterious in the influence 
which some persons have over the insane. It is founded in those 
qualities which prevail everywhere, and which are felt to be influen- 
tial by all. It often happens that immediately a person becomes 
insane, those about him take leave of their senses also. They look 
upon their former friend as suddenly transformed into some new and 
strange kind of being, upon whom ordinary motives and methods of 
dealing will be thrown away. If he is violent and deluded, they 
plan deceptions, or spring ingenious traps on him, or attempt to look 
him into submission, as if he were a wild beast. If he is abstracted, 
they think he knows nothing, and will remember nothing, and are 
astonished at acts the result of their own imprudence. All this 
misunderstanding aggravates the patient's suspicions, and increases 
his hostility and violence. In this state of things, some physician, 
or other experienced person, beards the maniac in his den, and, 
after a little, quietly drives away with him to the hospital. The one 
thing which it was supposed would excite the patient's utmost frenzy, 
has been quietly and speedily accomplished. 

To many persons this would seem the result of personal magne- 
tism, or great will-power ; but does not necessarily imply that, being 
simply that influence which an intimate knowledge of the patient's 
state of mind gives to one possessing it. To say the right thing, in 
the right way and at the right time, or to present the one adequate 
motive, is to control the patient for the time. 

No deception is allowable or necessary under the circumstances 
we have supposed. If the patient is absolutely beyond the reach 
of motive, words maybe spared, but the only basis of communication 
should still be the truth. This, properly presented, is a powerful 
lever for moving even the insane mind ; but if it fails, let the alterna- 


tive be force, and not deception. Force, kindly exercised, leaves 
no sting behind; deception is always a mistake, and destroys all 
influence at once and forever, when discovered. The truth first, 
last, and always should be the rule. An exception to this rule is 
found in some cases of emergency, as when relapse or death is quite 
sure to result from the communication of disastrous news. Here the 
truth may be withheld, but if it cannot be easily done, let the lie be 
sound and plump enough to accomplish its purpose, to be confessed 
and justified afterwards. It is needless to say this direction will not 
be found in the text-books on moral philosophy. 

Next to truth stands sympathy, in its influence over the insane 
mind. This should be a deep and real interest, shown rather in 
manner than in words, and pervading all which is said or done. If 
obtruded, it would in some cases excite resentment ; if lavished in 
others, it would stimulate emotion which should rather be allayed. 
This feeling in excess, is one thing in the way of home treatment. 
Friends and relatives are often so sympathetic and emotional as to 
excite unnecessary feeling in the patient. Their own excited feel- 
ings prevent that cool and deliberate action which is not incompatible 
with the warmest interest in his welfare. They magnify trifles into 
cause of grief or anger, embarrass and fret the patient by unneces°a- 
rily assiduous attentions, and instead of seeking to remove the phy- 
sical causes of excitement, attempt, by appeals to his affection, and 
arguments from their past relations, to suppress it. A misdirected 
sympathy is worse than none at all ; just as a heartless but skilful 
surgeon is better than a bungler running over with the milk of hu- 
man kindness. But in the long run, a genuine feeling of unobtru- 
sive sympathy will have its due effect, and is necessary to continued 
personal influence over the insane. 

A knotvledge of the case in hand, and of similar forms of mental 
disease, is a requisite which only results from long experience, but 
which is the one element most essential in the treatment of the in- 
sane. It is here that the trained physician has an advantage over 
all comers. To frankness, which disarms suspicion, and to a sym- 
pathy which attracts, he can add the power to touch those chords of 
the mind which shall respond most healthily ; or if his purpose is to 
test and display a concealed state of feeling or delusion, he can bring 
it to light in the most easy and natural way. Knowing the history 
of the case before him, or getting a hint of the form of the mental 
disorder from the aspect of the patient, he has the key in his knowl- 
edge of the class to which it belongs, with which to unlock this 
individual case. Though he cannot play the flute of Hamlet, he 
can play upon Hamlet himself. 

A more valuable use of his knowledge consists in his power in 
many cases to gain the confidence of his patient, and to impress 
upon him the necessity of treatment, and of his ability to relieve him, 
if not of his insanity, which he will not acknowledge, at least of 
some of its physical symptoms. Comparatively few patients are be- 
yond the reach of such influence at some stage "of their disorder. 

To the above qualities must be added firmness, persistency, and 
tact. It is noticeable that the insane are often found more docile in 


the hands of some one person, oftener a nurse or neighbor than a 
near relative. It is generally because this person, without theoriz- 
ing about it, has some of the qualities we have mentioned strongly- 
marked. His will is judiciously exercised, but may be relied on in 
emergency, and the patient knows it. He does not venture on ex- 
periments with this one. He does not find his harmless vagaries 
checked, he is more trusted, and has more scope than with others, 
but he finds the limits to his action firmly and quietly maintained. 
He is not tempted to try their strength a. second time. 

This firmness persistently maintained, it is which in hospital or 
home practice affords such support to the wavering mind. It is the 
best of tonics to an enfeebled will. It allows its free exercise in 
healthy directions, and takes away all inducement to its use in others. 
It supplements it when feeble, till habit takes the place of self-con- 
trol, and stimulates self-restraint as fast and as far as it can be safely 
exercised. This one man -power, or woman power, as the case 
may be, resembles in some respects parental authority, just as the 
behavior of the insane often resembles that of children. Similar 
motives affect both, and each may, by firm and persistent treatment, 
be encouraged in well-doing until healthy mental action becomes 

It is useless to say much of tact, for if it does not grow with ex- 
perience it is because the individual was born without its germ. It 
seems to be a partly instinctive, and partly cultivated quality. It 
consists in a feeling of the exact requirements of time, place, and 
circumstance. It admits of yielding in non-essentials to accomplish 
quietly a desired result. It is not deception so much as indirection. 
It may be used to divert the patient's mind from painful and trouble- 
some thoughts, or to lead him to disclose them, if it is important that 
he should do so. It is, above all, useful in inducing him to pursue 
such a line of conduct, and to accept such treatment as his case 

Its exceptional use is demanded in circumstances of danger from 
insane violence. It is not likely any reader will ever find himself 
in the situation of the gentleman in the following story. If he does, 
it is to be hoped, his tact will serve him as good a turn : Finding 
himself on a tower with a madman, who said to him, "Sir, we must 
jump down together," he replied, jokingly, "Any fool could jump 
down; lets go to the bottom and jump up!" If this story be true, 
it was probably the wit of the reply which diverted the maniac from 
his purpose, and not his acceptance of the absurdity involved in the 

The elements of character essential to successful dealing with the 
insane, are in no sense peculiar in themselves, and there is no pecu- 
liarity in their application to insanity except that arising from the 
various mental states, which render the patient sometimes more, and 
sometimes less, susceptible to them. It will be seen how important 
it is to unite them in a single person, and to place that person in 
intimate relations to the patient. The practical difficulties in the 
way of accomplishing this result without combining with the moral 
a certain degree of personal restraint also, will be considered hereafter. 


There are many extreme cases of all forms of insanity, in which 
moral influence is of little avail. In complete dementia, those facul- 
ties are wanting to which motives can be addressed. In acute 
mania, at its height, their normal relations are so broken up by rapid 
and disordered cerebral action, that all impressions are effaced as 
soon as made. In the less rapid action of melancholia, when 
the mind is painfully absorbed, and the attention turned inwards and 
immovably fixed, no influence from without seems to reach it. The 
most powerful arguments, the strongest appeals to the natural affec- 
tions and instincts, are powerless, and even hope, which 

" Springs eternal in the human breast," 

finds no expression, and gives no sign of existence. Even in these 
cases the same qualities should be persistently exercised, surround- 
ing the patient with an atmosphere of influence, which, at favorable 
moments, may insensibly penetrate the defences of the mind, and 
accomplish its proper work. The hope of recovery should be con- 
stantly held out to those who seem insensible to it, as well as to 
those who take daily encouragement only to lose it again. 

When, from disease, the moral sense is perverted or wanting, it 
seems hopeless to appeal to it. When the feeling of the natural 
relations of right and wrong is wanting, when the instincts and 
affections are absent or changed, moral appliances lose their power, 
or at least degenerate into an appeal to the lower motives of reward 
and punishment. By invariably connecting good behavior with 
privileges and favors, and bad conduct with a deprivation of them, 
the intellect associates them, and serves as a tolerable check upon 
the prevailing tendency to mischief. 

The limitations to strictly moral management of the insane are at 
best numerous, and too much should not be expected of it, espe- 
cially when uncombined with hospital restraint. In hospital the 
patient is more immediately and constantly dependent on the phys- 
ician for daily advice and kindnesses. The relations established in 
this way are often, in the cases most unpromising at the outset, 
pleasant and useful. It needs time and opportunity to effect what is 
really an education of the patient in the causes and consequences of 
his new state of thought and feeling ; and in convalescence he must 
be shown how groundless have been his disordered ideas. In a 
curable case, the patient's mind passes through several stages of feel- 
ing toward those in authority over him. From active opposition, at 
the outset, to acquiesence in what he finds to be inevitable, is the 
usual experience. Then, as convalescence begins, another stage, 
of home-sickness, irritation, and impatience, based on a weak brain, 
which begins to admit the insanity of its former condition, but can- 
not see the need of further treatment ; and finally, as strength and 
reason are fully restored, a cheerful acceptance of advice, a reluc- 
tance to risk even the pleasant change of home for hospital, and 
often a refusal to do so without the fullest approbation of the phys- 
ician in charge. The above series of events in the mental history 
of hospital patients is of frequent occurrence. But, as they say in 
dramatic phrase, "more of this anon." 



UPON the question of the advisability of home treatment in cases 
of insanity, there must always be a struggle between prudence 
and affection, between judgment and feeling. The almost universal 
opinion of the medical profession is in favor of hospital treatment, 
as a rule, for all recent cases of insanity. The feelings and affec- 
tions, however, shrink from such a painful separation of the patient 
from home and friends just when the assiduous care which love inspires 
seems most needed. From this struggle between the dictates of 
experience and the promptings of the heart, arises delay, contro- 
versy, and hard feeling, which often ruin, at the same time, the 
patient's chances of recovery, and the peace of the family. 

In former times, when insanity was regarded as a "visitation from 
God," or as a state in which the patient was "possessed of the devil," 
or was "moon-struck," or "love-cracked," or anything but sick, 
home treatment was common. The unfortunate lunatic was allowed 
to wander from place to place, the sport or the terror of children, no 
attempt ever having been made to restore his reason. If evidently 
dangerous, or otherwise a nuisance, he was treated, at home, to a 
cage and a bunch of straw, or, being "furiously mad," was com- 
mitted to the poor-house, jail, or asylum. But, thanks to Pinel, and 
Connolly, and other hospital superintendents, to whom, from first to 
last, we owe nearly all the progress made in the knowledge and hu- 
mane treatment of insanity, this state of things is entirely changed. 
Hospitals for the medical and moral treatment of the disease in- 
sanity are numerous in every civilized country, and, though still ful- 
filling the function of asylums for the chronic insane, and affording 
protection to the community from insane violence, their new and 
crowning glory is the humane and efficient treatment they afford. 

In view, however, of a natural reluctance to consigning the near- 
est and dearest objects of our affection to prolonged absence and the 
care of strangers under the most painful circumstances which can 
afflict a family, it becomes of the utmost importance to determine 
what exceptions, if any, exist to the rule requiring hospital treat- 
ment. This embarrassing question will often present itself to 
every practising physician, and upon him will fall the respon- 
sibility of his advice. It is not strange that at such times special 
advice should be found desirable by all parties, or that the law 
should require the certificate of a second physician for admission 
to hospital. 

If insanity was a trifling or a transient ailment, if it did not sub- 
ject the patient to unpleasant suspicion, even after recovery, if the 
hospital could be as freely resorted to as in surgical cases, for in- 
stance, without exciting painful comment, this question would be 
less perplexing ; the desire to conceal the fact of insanity, or to 
call it by some softer name, and to explain it away, as if it were 
something of which to be ashamed, would be less frequent. 

Feeling should always hold a subordinate place, since the patient, 
having lost the use of his own reason, has a right to, and humanity 


demands he should have, such treatment as the best judgment of 
the most experienced physicians of his time and place shall advise. 
For whatever may be said of the individual's right, in his senses, to 
choose what is harmful, to reject the useful, and, by neglect of the 
only means of cure, to commit slow suicide, there is but one course 
open to his friends and physician, when the responsibility falls on 
them, viz. : to enforce the use of those means best adapted to 
save life and restore reason. Neglect to do so is criminal neglect, 
and cannot be excused by any unprofessional opinion of the neces- 
sities of the case, nor by the aversion of the patient himself, nor by 
the legal opposition to which he sometimes resorts. The question is 
purely a medical one, and the immense superiority of hospital over 
home treatment, in most cases, renders its solution comparatively 

There is a varying period at the outset of mental diseases, during 
which the experiment of home treatment may be tried, under com- 
petent medical advice ; but this period should not be improperly pro- 
longed. It may be availed of to satisfy both the patient and his 
friends that hospital treatment is demanded, and it is quite common 
to find a household, strongly opposed to it at first, yielding in a few 
days to the inexorable logic of events. In cases manifestly incur- 
able from the first, home treatment may be pursued as long as safety 
will permit, or the patient's means allow, remembering that an im- 
proved condition and increased comfort may often be obtained in 

General Paralysis with insanity is a form in which this may be 
attempted. It is incurable, and recovery is not to be looked for in 
any case. There is also a feeling of content and well-being pecu- 
liar to this disease in part of its course, which hospital treatment 
would not essentially increase. The impaired memory and blunted 
perception shield the patient from many sources of annoyance 
which, in more susceptible cases, require a removal from home. A 
man who believes himself possessed of immense wealth, who thinks 
his health never was so good before, who, without strength to leave 
his room or his bed, tells of daily excursions upon business or 
pleasure, is, in a great measure, independent of his surroundings, 
and may as well be at home as elsewhere. This reasoning will also 
work the other way. If it is found difficult to prevent attempted 
excursions into the street, if he is violent and noisy, or the means 
at his command will not furnish the constant attendance he requires, 
then, for the same reasons, he is as well off in hospital as at home. 
The effect of medical treatment is very uncertain with general 
paralytics, the susceptibility of the whole brain being so impaired as" 
to be very slowly and feebly impressed. 

Efilcftic Mania may, in some cases, be treated at home, but always 
under proper advice, since no form of insanity is more dangerous. 
The disease on which the maniacal excitement depends is practically 
incurable, and the mania, though likely to recur, is transient. It is 
also quite amenable to medical treatment. For these reasons, the 
patient may be cared for at home, under suitable restraint, until it is 


found that mania accompanies the convulsive attacks as a rule, or is 
of so dangerous and outrageous a type as to demand seclusion in 
hospital. There is always more or less danger in a case of confirmed 
epilepsy that mania may unexpectedly ensue, and its victim is often 
possessed, for the time, by a blind fury, which attacks friend or foe 
indiscriminately. This mania, as we have before remarked, may 
occur suddenly, and independently of any known, or at least of 
any recent, convulsive attack, constituting the most common form of 
transitory mania. It is important to distinguish the epileptic 
element, when it exists, either as petit mal, or masked, or wander- 
ing, epilepsy. 

Senile Insanity, being incurable, may be treated at home, but it 
is important to distinguish it from other forms of insanity occurring 
in old people, and which may sometimes be recovered from. It is 
desirable to be spared the affliction of leaving an aged and insane 
relative in the hands of strangers, and yet hospital treatment may 
be demanded for the comfort and relief of the oldest person, as well 
as for the safety and peace of the family and the community. Each 
case should be decided on its own merits, after careful consideration 
of all its bearings. 

Imbecility, moral and intellectual, and dementia, secondary to 
acute forms of insanity, being permanent states, and the chronic 
insane of all classes having had a thorough trial of hospital treat- 
ment, and being manifestly incurable, may be treated in private 
when circumstances permit. How seldom they do permit, and how 
much more suitable, satisfactory, and safe, hospital treatment is for 
all the above classes, will be considered hereafter. 

Of the curable forms which justify attempted home treatment, the 
following are most common : Insanity of Pubescence, in the female, 
especially, depending on retarded menstruation, is often transient. 
It is sometimes marked by hallucinations, delusions, and strange 
behavior, which yield to proper treatment readily, or at least dis- 
appear when the sexual evolution is accomplished. Epilepsy, even, 
may occur without becoming habitual. The youth and sex of such 
patients make it peculiarly desirable to avoid hospital treatment if 
possible. Under judicious management in adapting the patient's 
surroundings, as much as possible, to the requirements of the case, 
regulating the moral influences to which she is exposed, and a 
patient use of the proper remedies, this may be accomplished. 

Hysterical Mania may sometimes be treated at home. It gener- 
ally occurs in females who have been subject, for years, to the ner- 
vous phenomena-embraced in the term hysteria. There is generally 
a history of changeable and perverted states of feeling, disordered 
emotions, and obscure nervous symptoms, such as spasms, pains, 
tenderness of the spine, strange sensations in throat and chest, dys- 
pepsia, etc., sometimes, though not always, dependant on local 
uterine disease and disordered menstruation. These symptoms may 
be complicated by an occasional abuse of stimulants, which the 
patient uses to the extent of narcotism to allay her distress, thereby 
aggravating the condition on which it depends. 


In the course of such a train of symptoms there may occur an 
attack of distinct insanity — a mania, largely emotional, but accom- 
panied, for a time, by hallucinations, delirium, and violence. The 
hysterical irritation (whatever that may be) expends itself on the 
higher nerve centres, by a sort of transference, as in cases of 
epileptic mania, and other transformed neuroses — mental symptoms 
either replacing or accompanying those of ordinary hysteria. Such 
cases resemble, so much, other forms of mania, as to deceive those 
unfamiliar with them. I have seen recovery, as far as the mania 
was concerned, in from three days to six weeks, while the same 
severity of symptoms, not founded upon hysteria, would entail sev- 
eral months of mental disturbance. 

Not all these cases recover thus speedily, but since they often do, 
when the necessary moral influences can be brought to bear upon 
them, the attempt may be made to keep them at home. These 
patients, particularly, should be given up to the physician wholly 
and without reserve, their surroundings to be regulated according to 
the exigencies of the case. The great and almost insurmountable 
difficulty in the home treatment of this and other forms of insanity, 
arises from the well-meant, but harmful, influence of the family and 

Hysterical mania profoundly affects the emotional and moral 
nature, leading to all sorts of strange manifestations of mind, just as 
hysteria affects the body, with strange sensations and symptoms. 
There is a tendency to exaggeration, and an intense craving for 
■sympathy, which leads the patient to rehearse the story of her suf- 
fering with new embellishments and demonstrations to each new- 
comer. A change of nurses or physician is equivalent to a relapse 
simply for this reason. Emotion, especially when disordered and 
unhealthy, feeds on sympathy, and grows by what it feeds on ; 
hence the need of restrictions in the matter of intercourse with 

The physician who undertakes to contend with this disease should 
not be hampered by the experimental intrusion of kind, but mis- 
taken, sympathizers. He should not be destitute of sympathy him- 
self for so terrible an infliction, but he should be allowed to regulate 
this most powerful moral element in the treatment according to his 
own judgment, otherwise he will utterly fail. He himself needs the 
moral support of the family, or he will be unable to control the 
patient. By disuse, the emotions subside into normal channels, self- 
control is re-established, and reason resumes its interrupted sway ; 
not always completely, as there may remain a condition of calm- 
ness, with permanent moral obliquity, in which the patient denies 
her previous insanity, puts a false construction and coloring on the 
facts of her sickness, or even lies outright, resents the constraint put 
upon her actions, and prejudices her friends and family against those 
who may have excited her ill-will by necessary opposition to her 
wishes. In such cases, virtue must be its own reward. Friends too 
often lend a willing ear to her misrepresentations, and the physician 
becomes resolved never to undertake another case of hysterical 


Mild forms of Puerperal' Mania are sometimes treated at home 
with success. They depend on a condition of debility and exhaus- 
tion which may be removed by careful treatment when no strong 
hereditary tendency exists. There is, however, great danger of re- 
lapse, and, in the convalescent stage, such patients need most the 
protection of hospital surroundings. Some imprudence is sure to be 
committed, by which months of mental suffering, if not permanent 
insanity, is induced. 

Simple Melancholia, of a mild type, due to nervous exhaustion, 
may sometimes be carried through at home, especially if the re- 
sources afforded by change of scene be added. In well-selected 
cases, travel is a valuable adjuvant to treatment ; it affords mental 
refreshment of a useful character when the patient is not too de- 
pressed to respond to this kind of stimulation. It corrects bad states 
of bodily health, which may be at the foundation of the mental 
trouble. Fresh air, exercise, new and varied diet, promote sleep 
and improve the physical condition, while the mind is pleasantly 
excited by new interests, and the thoughts directed from the well- 
worn and painfully sensitive ruts of business or domestic cares, into 
new and healthy channels. 

Travel is, however, too often recommended indiscriminately in all 
forms and every stage of mental disease. It is advised when the 
patient is unable to respond to its pleasant excitation, by reason of 
his mental preoccupation, and when he needs, rather, quiet, and 
medical attention. Nothing is more sad than to see a forlorn and 
dispirited patient dragged from city to city, or crossing the sea, and 
enduring all the fatigue and annoyance of foreign sight-seeing, in 
search of that rest and peace of mind which he could have found in 
a few weeks at the nearest hospital. 

Another fashionable prescription is "quiet, and country air"; 
which, being good things in their way, are too often thought to have 
a specific influence in the cure of 'mental disease. Here everything 
depends on a proper selection of cases. When rest alone is needed 
to restore the mental tone, when there is a resiliency in the brain 
sufficient to restore, at once, its healthy action, when the weight of 
business or domestic care is removed, the patient may be benefited 
in this way. But too often the patient takes the responsibility of his own 
case with him, is thrown on his own resources, and lacks the moral 
support he might find in other surroundings. The ennui of country 
life is often insupportable, and tends to increase the existing' depres- 

In hospital, the consciousness of a sustained attempt at cure, the 
daily medical supervision and encouragement, the presence of 
similar cases happily progressing towards recovery, the adaptation 
of the daily life to the patient's varying necessities, the rational 
treatment or explanation of trivial symptoms which alarm the 
patient as they arise, all tend unconsciously to sustain hope and 
keep alive the, patient's feeble and irregular struggle towards re- 
covery. I have often had occasion to say of these mild cases of 
depression, "Tis a pity this patient is not worse, for she would then 


be sent to hospital, and would certainly recover." The danger of 
suicide, in the mildest cases, is another argument for hospital treat- 

Climacteric Insanity in females, if distinctly dependant on the 
"turn of life," may sometimes prove transient, and pass away, under 
suitable treatment, at home. It often happens, however, that a per- 
manent failure of the mental powers begins at this time, and it is un- 
safe, without the most careful consideration, to predict a recovery at 
the close of this period. In men, an indefinite term of ill-health and 
depression often occurs about the age of sixty, depending on a vari- 
ety of causes. The waning powers of life, disappointed ambition 
or business losses, the reaction from that overstrain which men in 
active life endure, till, warned by advancing years, they retire too 
suddenly, concur in producing a state of depression and ennui, 
which may amount to actual insanity. Men who have lived and 
worked as if life had no end, on its near approach cannot conform 
their mental habits to its calm anticipation. A period of mental 
disturbance at this time may be the precursor of senile dementia in 
persons predisposed to insanity. On the other hand, after a longer 
or shorter interval the exhausted mental powers are recruited, and 
their operations gradually readjusted to new interests and occupa- 
tions, and the patient lives out his days in cheerfulness and comfort. 



SOCIAL Science, or the "philosophy of philanthropy," as some 
of its cultivators choose to call it, comprises a few truths, and 
many crude theories, and unsolved problems, relating to the com- 
plex civilization of our day. It has, of course, busied itself with 
the question of the proper disposition of the insane. This subject 
has been discussed in the large way, and at arm's length, by profes- 
sional philanthropists, and by amateurs. But however valuable 
such discussion of this many-sided subject may eventually prove, 
the facts so far elicited do not warrant a reversal of former methods, 
by the abolition of hospitals, or experiments on the grand scale, in 
the treatment of recent insanity. However safe such experiments 
might be with a few of the harmless chronic insane, they could not 
but prove hazardous in the majority of cases. 

The interests of the insane in this vicinity have suffered, and still 
suffer, cruelly, from the theorizing tendency of certain well-meaning 
gentlemen, whose views have been used to prevent much-needed 
hospital improvements. Their conclusions are drawn too much 
from observations made in mass, in asylums containing many 
chronic insane. A practical knowledge of insanity as a disease 
of the brain, with its prospects of cure under different methods of 
treatment, is absolutely essential to correct conclusions. And this 
practical knowledge must be acquired by a large experience in the 
actual care of the insane. Nothing short of this is of much value. 
Nor this, unless continued through what may be termed the soph- 
omore stage, where some hopelessly remain for life. The observa- 
tion of a single case from onset to complete recovery often requires 
several years. It is beyond question that. the insane, both here and 
in England especially, have suffered much from delayed treatment, 
due to pseudo-scientific doubts and theories, which have led to popular 
misunderstanding, prevented hospital improvements, and induced 
overcrowding, increased difficulties of admission, and premature 

The standpoint proper to us, as friends to the insane individual ', 
should command a nearer view. We wish to know what to do with 
our insane parent, wife, husband, brother, or sister. Social Science 
may inform us that the congregate system is bad ; that dissemination 
should be the rule; that they do these things better at Gheel, or 
Jamaica; that " free air " and family influences are the panacea for 
insanity. It is forgotten that the disease has made its appearance in 
the midst of the usual social surroundings. Each patient has had 
free air and the benefit of family influences up to the time of becom- 
ing insane, and they have exerted no preventive tendency. It is 
found that congregation for a time, at least, is beneficial to the blind, 
the deaf and dumb, and the feeble-minded, who are not the subjects 
of a disease requiring treatment, but simply of a permanent defect. 
Dissemination does not cure intemperance, or prevent insanity, pau- 
perism, or crime. There is no resource upon this theory but to con- 
clude that some change to freer air and new domestic surroundings 


will prove useful. Hence one source of the current belief in the 
efficacy of "quiet and country air," which, however desirable for the 
general health, has no specific effect upon insanity. 

Prejudice against hospitals arises from a less reputable source, 
when it is the offspring of ignorance, suspicion, jealousy, and love 
of sensation. The ignorance of what constitutes insanity, and of 
its subtile ways, leads many to believe the plausible stories of those 
who have been, and still are, insane and unreliable, and who find a 
ready market for their distorted recollections, exaggerations, and 
lies. It is inconceivable by many who know nothing of insane 
delusion, or of that form of mental disorder, often purely emotional, 
which. dulls the fine edge of the moral sense, that the deliberate 
statement of an apparently sane and conscientious person may be a 
tissue of falsehood. But the physician who deals with mental and 
nervous disorders often meets this kind of lying in unsuspected 
quarters, and, strange to say, most frequently in naturally conscien- 
tious persons of the more scrupulous sex. It is a curious fact, that 
the public are ready to believe the most improbable stories of corrup- 
tion, conspiracy, and crime against parties in good standing and 
responsible positions, rather than doubt the accuracy or veracity of 
some insane pamphleteer. 

The public being very properly excluded from hospitals devoted 
to the care of the insane, and much that is out of the common course 
occurring therein, suspicion breeds out of ignorance a thousand hor- 
rors. In one particular it is easy to show how mistaken public 
opinion is. In the matter of visiting patients, it is generally sup- 
posed that the majority receive no visitors, while the facts are, in 
respect to the hospitals in this vicinity at least, that seldom more 
than from three to five per cent, are so restricted, and often, for a 
time, no patient is prohibited from seeing some friend or relative. 
Jealousy, however, on the part of some members of a family, aris- 
ing from their necessary exclusion from the care of one dear to them, 
or hard feeling due to differences of opinion concerning the neces- 
sity for hospital restraint, is quite common. These causes, and the 
irksome regulations incident to hospital life, in the matter of times 
and seasons for visiting, and the like, create in some ill-balanced 
minds a strong tendency to fault-finding and abuse. 

Sensationalism, too, is largely answerable for the current prejudice 
against hospitals. Out of such rare accidents as sometimes happen 
in the attempt to control the violently insane ; instances equally rare 
of severity at the hands of some unsuitable nurse ; traditions of the 
cruelties of a past generation ; unfounded tales of sane persons 
shut up as insane for a wicked purpose ; with a large allowance of 
pure invention, Charles Reade, and other reportorial novelists, have 
succeeded in making a sensation — and money thereby. A distin- 
guished alienist, when asked if he had read a certain book of the 
above character, innocently asked : "Is it a scientific book? " 

Such suspicions and prejudices as we have mentioned are most 
current among inexperienced and irresponsible lookers-on and 
advisers. Responsibility for the proper disposal of a case in hand 


stimulates common sense to the extent of an appeal to some one 
practically acquainted with the various phases of mental disease. 
The right thing is done tardily and under protest, but, in most 
cases, the necessities of the case prevail, and the patient is com- 
mitted to a suitable hospital. In chronic, or incurable, cases, the 
circumstances of the family determine the question, since the pres- 
ence of an insane member involves an outlay of time or expense, 
which interferes with its capacity for self-support. 

Insanity differs from ordinary diseases in the fact that it affects, 
permanently, that part of the brain responsible for judgment, feel- 
ing, and action. The self-control is impaired, or the reason dis- 
torted, in every case, and a skilfully-regulated restraint is the first 
essential for treatment. This may, in favorable cases, be exercised 
at home, but is most easily applied and adapted to the wants of each 
patient in a well-arranged hospital. Here are combined the re- 
straining influences of new surroundings, new acquaintances, and' 
modes of life. A habit of acquiescence in the physician's authority 
on the part of all, sane and insane, and a routine which carries the 
patient along insensibty in a prescribed course. It is easy to submit 
to regulations seen to be necessary, or at least inevitable ; and there 
is less temptation than at home to experiment upon the good-nature 
and yielding disposition of inexperienced nurses and friends. The 
risk of relafse, in the stage of convalescence, is, above all, greatly 

The brain, in insanity, needs rest, as much as a broken limb. 
Sometimes it needs rest as a whole, sometimes only in those parts 
most susceptible to painful activity. To some, the hospital is, for the 
time, a mental fracture-box and splint. The problem is to diminish 
the cerebral waste to a minimum, and to carry cerebral nutrition to 
a maximum. To others, and at times to all, it should be a men- 
tal gymnasium, affording regulated exercise to the mind in direc- 
tions where strength and development are required, and resting those 
faculties which, having been overworked, should lie fallow for a 
time. The manifestations of insanity usually concern the affairs of 
every-day life, of business or the family. The disturbed feelings 
and the delusions are in intimate relation with the persons and 
things the patient has been daily accustomed to see. The brain has 
literally been worn into ruts, and the ideas run in tender channels. 
Certain series of nerve-cells have been overused and are exhausted, 
while others have been disused. Here the first and only thing to 
do is to remove the patient from all association with those things 
which excite mental activity in these accustomed directions. " Out 
of sight, out of mind," is true in a physiological, though partial, 
sense, and absence will prove, in almost every instance, the first 
step to recovery. This absence from customary scenes, and non- 
intercourse with familiar persons, must be more or less protracted 
and complete, according to the necessities of the individual case. 

In acute general insanity, the patient must often be for a time 
isolated from all society, conversation prohibited, and only the occa- 
sional and necessary attendance of the nurse allowed. The action 


of sleep-producing medicines is thus aided, and exhaustion from 
constant talking and motion prevented. The mind will act in soli- 
tude, but less harmfully in this stage, than if excited by the presence 
of others. After a varying period of cerebral rest and nourishment, 
the mind may be safely led into new regions of activity, and new 
sights, sounds, and interests presented, as the strength permits, 
until convalescence ensues. The brain is thus gradually strength- 
ened to bear a return to the old and formerly exciting associations 
of home and business relations. Nothing in the treatment of the 
insane requires so much experience and skill as this sort of moral 
management, and it is needless to observe how difficult it is to carry 
it on outside of a hospital, since the danger is greatest in the conva- 
lescent stage, just when the apparently rational patient is most 
self-confident, and his friends most importunate. If, for instance, a 
shocking piece of news is to be communicated, it is wiser to do it in 
the earlier stages, than to wait till later, when a relapse would very 
likely be induced. If physicians in charge of the insane sometimes 
err from excess of caution, it is to be commended, since the real 
danger lies in the other direction. 

It is a common mistake to attribute the discontent of certain pa- 
tients to the nature of their surroundings, — to the horrible sights and 
sounds they are supposed constantly to experience, and above all, 
to the bolts and bars, of which one hears vastly more outside of the 
hospital than inside. There is a natural discontent, which does not 
surpass the bounds of reason ; but it is a very different thing from 
that fretful impatience at continued restraint, which accompanies the 
early convalescent stage, in most cases, or which may be present 
from the first. -The patient was no happier or better contented at 
home, and was under more irksome restraint; it may be, a prisoner 
in his own house. He was irritable, restless, impatient and un- 
happy, as the result of his disease, and it is not to be expected he 
will become at once, resigned to a position which affords him such 
an admirable pretence of grievance. To grumble is human, and 
this trait of humanity, is liable to be exaggerated by mental disease. 

If too excited or depressed to care much for his surroundings at 
first, as convalescence begins it is natural for him to think himself 
well, as soon as he becomes conscious of returning reason. He 
cannot estimate his own mental strength, nor the dangers of testing 
it too soon, any better than, nor as well as, the fever patient his 
physical strength. If the discontent at this period were not due to 
weakness and want of judgment, we should expect it to continue, 
and strengthen with continued detention ; whereas, the constant ex- 
perience in every hospital is that patients, as they grow better and 
stronger, take more rational views of their situation, realize the 
state they have been in, and know that their whole future depends 
on caution at this period. A natural desire to be at home re- 
mains, but above all things they hope for a permanent recovery, 
and, to the surprise of friends, cease to importune them, or even 
refuse to be removed against advice. 

Insanity is essentially a chronic disease, and, like all such, does 


not tend to recovery without patient and continued treatment. In 
cases of long standing the rate of progress is slow, and the irritable 
stage may last for months. How hard it is for friends to understand 
this, in some cases, every hospital physician can testify. It seems 
to them as if the only obstacle to the patient's complete recovery was 
the hospital itself! 

Take a case, unusual in point of duration, but of very common 
occurrence, in respect to the succession of events, as an illustra- 
tion : A lady gradually sinks into a state of settled melancholy, 
and, after a year wasted in experiments, is sent to a hospital in as 
miserable a plight as is possible in this fearful disease. There is no 
cessation while waking from the terrible gnawing anguish at the 
heart, and the time is passed in tears and groaning, until dress 
after dress is worn away in constant chafing at the seat of distress. 
A year and a half also wears away, and, under continued medical 
treatment, the brain begins to resume its healthy action. The fan- 
cied ills vanish, the clouds lift, the load lightens, and convalescence 
is established. Now is certainly the time, think her friends, to has- 
ten returning health by the cheering influences of home. Forget- 
ting the disease on which all this misery depended, and disregard- 
ing advice, she is removed, and at once sinks into her old condition 
of constant mental agony, and to her despair is added the sense of 
opportunity wasted, and time lost never to be regained. A year 
or two passes, and hospital treatment is again resorted to, with a 
promise to pursue it steadily, if it takes five years for recovery. 
Under constant medical treatment the uphill road is again climbed, 
and, in a year and a half more, the stage of convalescence is re- 
gained. Again comes impatience at further detention, and it is only 
with difficulty that the formerly well-nigh fatal mistake is prevented. 
At the end of two years, however, and five years after the first at- 
tempt at treatment, this patient goes home cured. She is well, and 
grateful, and 'happy, taking her place in her family and in society, 
so long vacant, and still retaining ifc after the lapse of four or five 

In some unfortunate cases the irritable stage is never passed. 
The mind does not recover sufficient tone to take a healthy view of 
its past condition, or. its true relations to hospital surroundings. 
This may be due to its original constitution, since certain temper- 
aments lead unconsciously to an exaggeration of annoyances, and 
an uncomfortable or dark view of things in general. More com- 
monly this stage becomes chronic from a suspension of treatment, 
and premature discharge. The patient leaves hospital before he 
has had time to establish healthy relations, and ever after reviews 
his experience with distempered vision. His recollections are but 
the revival of impressions made when his mind was unfitted for dis- 
crimination, by emotional or intellectual disease. Hence he is un- 
consciously an unsafe, unreliable, and often very unjust witness, 
however honest and well-meaning he may appear. • 

If, in addition, as occasionally happens, the patient has not been 
able to realize fully the fact of his own insanity, and feels aggrieved 


at his restraint, or assumes a philanthropic mission in behalf of 
his companions, there are few lengths of misstatement and plausible 
misrepresentation to which he may not go. Scandalous newspaper 
articles may be written, courts appealed to, and legislatures lobbied 
in the interests of the oppressed insane. Such appeals catch the 
public ear, and create a sentiment very harmful to the true interests 
of the class they are intended to benefit. 



TWO functions are fulfilled by most institutions for the insane, 
viz. : that of an hospital for the relief or cure of insanity, and 
of an asylum for the care and custody of the incurable, helpless and 
dangerous. It has so far been generally found expedient to unite 
these functions, which are after all not so essentially different, since 
it is very difficult to draw the line between the curable and the incur- 
able, the harmless and the dangerous. Most cases, too, of confirmed 
and hopeless insanity, are relieved and improved by proper treat- 
ment, medical and moral. The relief and cure of disease being 
of the first importance, the hospital idea should predominate. How 
far it is advisable to separate the curable from the chronic insane, is 
a question of much importance, which has been carefully considered 
of late years. 

What, in the first place, does experience and common sense prove 
to be essential to hospital treatment? That most cases of insanity 
must continue to be treated away from home, and in some special in- 
stitution fitted for the purpose, does not admit of question. This 
special residence should have, as a matter of course, all the ordinary 
requisites for the promotion and preservation of health : such as quiet, 
cheerful surroundings, good drainage, plenty of air and sunlight, 
water, an equable temperature, and at least one thousand cubic 
feet of air hourly to a patient. These the commonest humanity 
demand as essential, and the public is bound in justice, if not by 
law, to supply. 

In all civilized countries, each county, district, province, and large 
city has its hospital in some central and convenient location. It is 
generally to be found in the midst of an enclosure of cultivated land, 
of from one hundred to five hundred or more acres. Here the 
facilities for walking, driving, working and living in the midst of 
those rural surroundings, supposed to be most healthful and natural, 
are provided. The farm, moreover, furnishes those fresh supplies 
which give relish to a routine diet, and utilizes the labor of patients, 
to their own and the public advantage. , 

Such hospital farms in New England have generally proved re- 
munerative, both directly and indirectly. In Massachusetts, the 
three State hospitals have large farms attached. The McLean 
Asylum at Somerville has found its small one profitable on paid 
labor entirely, while the Boston Hospital for the Insane, at South Bos- 
ton, makes the most of its three acres, and would cease to exist as an 
hospital without them. If its two hundred and fifty patients were 
trees, there would not be room in the grounds to set them out ! 

The first special and peculiar requisite for a hospital for the insane, 
is some method of security against escape and accident ; and as con- 
stant superversion is manifestly impossible, window bars and locked 
doors are a necessity. Not that "all patients are considered suici- 
dal " or dangerous, or likely to escape. To many the cordon of moral 


influences is more efficient restraint than bolts or bars. It is the 
knowledge that their condition necessitates, or will certainly result in 
recommitment, which restrains the reasoning portion of the insane ; 
while with the more deluded and demented, if they complain at all, 
it is of their wicked relatives, and the corrupt physicians or judge, 
and not of the material means of restraint. There may be a patient, 
now and then, sentimental enough to arraign the innocent locks and 
window bars, but most are too sensible or too dull for that. The novelty 
of hospital surroundings in this respect soon wears off, and those most 
likely to be disturbed by these physical evidences of restraint are well 
enough aware that something beyond them is the cause of their 

The second requisite peculiar and essential to an hospital for the in- 
sane consists in facilities for distinct and independent classification. 
Every hospital requires from six to eight wards for each sex ; each 
ward consisting in a suite of apartments separate from all others. Its 
inmates, from fifteen to twenty in number, should constitute a family, 
having sleeping, dining, bathing and parlor accommodations of its 
own. It has been customary to unite these families under one large 
roof, for the sake of economy and convenience. It is getting to be 
thought proper in some quarters to provide a few detached wards, in 
the shape of cottages, in the asylum grounds. The farm-houses 
found on the new hospital site at Worcester have been utilized in 
this way, and there is no harm in it. Perhaps a certain good moral 
effect may be gained, in some cases. There is, however, no new 
principle involved, and the advantages and economy of the arrange- 
ment are still matter of experiment. 

Classification in the democratic public hospitals of our ' country 
does not follow the lines of social caste or financial standing to any 
great extent. All hospitals contain the rich and the poor, the intelligent 
and ignorant. In the Western States, the hospitals are free to all. 
When, as is seldom the case, an incorporated asylum, like the 
McLean, at Somerville, exists, it is made the resort of the more 
wealthy classes. There are in some States distinct establishments 
for the criminal insane, for the chronic insane, and for inebriates. 
Hospitals also vary in character with their constituencies, and 
natives or foreigners, country people or city people, may preponderate. 

Neither does classification follow the special forms of disease, ex- 
cept in a general way. A patient's position in the scale of hospital 
life is an arbitrary matter, often changing with the fluctuations of 
disease, and to be determined at the time, and for each case, by the 
judgment of the physician. The noisy and disorderly insane are 
usually assigned to special wards, at a distance from those they 
would be likely to disturb. For light, air, neatness and sweetness, 
these " worst " or " excited " wards should be tbe best in the house. 
Here the acute stage of mania is to be passed, and facilities for the 
care of the very sick and excited, but curable cases, must here be 

At the McLean Asylum, for instance, these wards are quite new, 
and are therefore the pleasantest, best ventilated, and have the most 



complete appliances for treatment. At the Boston Hospital for the 
Insane, at South Boston, the two hundred and fifty patients are dis- 
tributed in six wards ; three for each sex only. The lowest and 
darkest of these wards is necessarily allotted to the above class, and 
contains about fifty insane inmates. These noisy and sometimes turbu- 
lent patients are here obliged to live, eat and sleep, in quarters so 
crowded as to peril health and life. How, then, can the curable in- 
sane be expected to recover? I allude to the deficiencies of this 
institution with a feeling of indignation at the apathy which exists 
regarding its necessities. 

The more quiet and demented patients are properly classed to- 
gether, and different grades of dementia find different levels Cer- 
tain cases of mild or chronic mania, and the epileptic or paralytic, 
may furnish a basis for other classes. The sick need an infirmary ; 
the weak, nervous and depressed, a quiet retreat, and convalescents a 
temporary home. A hospital which does not provide accommoda- 
tions for all these classes, with room enough to allow for the temporary 
excess of one class over another, is fatally deficient. If, with only 
six wards containing from thirty to fifty patients each, no provision 
for separate dining rooms, or reception rooms for visitors, is made, it 
is easy to see how little semblance of classification remains. 

Fifteen to twenty in a ward gives variety enough to favor a choice 
of companionship, and larger numbers create confusion, and are 
more likely to bring together objectionable associates. The favor- 
able influence of promotion in the hospital scale, is one of the most 
powerful moral aids to treatment. The sight of others with the 
same form of disease, progressing favorably towards recovery 
through its various stages, demonstrates to a new-comer the possi- 
bility of his own cure. 

The necessity for classification is also shown when some objection- 
able patient spoils all chance of harmony by a persistently irritable, 
malicious, and fault-finding disposition. A removal to wards less 
agreeable, where such conduct will annoy no one, is a necessary 
mode of discipline. Upon this alone the physician depends to keep 
his numerous family in order. The patient is made to feel his de- 
pendence, for special advantages and privileges, upon his own good 
behavior, and this proves an incentive to the very dullest minds. 
The gradations should, however, not be too abrupt, since each 
patient seems to do best in society not too much above his own men- 
tal level. Attempts to force improvement by too sudden and 
radical changes, are very apt to end in relapse. For a convalescent 
patient, the self-restraint and propriety of conduct which the society 
of the best ward imposes, is sometimes as bad, and has the same 
effect, as a premature discharge. 

On account of the necessity for prolonged residence of the insane 
in hospitals, and their partial capacity for work and recreation, 
various forms of employment, amusement, and exercise are essential. 
These advantages are furnished to some extent in all hospitals, and 
their importance is recognized by all who have to deal practically with 
the insane. For males, the varied duties of the farm and garden 


are best suited to the needs and capacities of the majority. In most 
public hospitals a few skilled persons are found, who make them- 
selves useful in the paint shop, or the carpenter's shop, and who in 
their leisure hours produce fine specimens of wood-carving, nice 
joinery, or turned ware. Now and then, an artist or photographer, 
or writer, turns out articles of value. In large hospitals abroad, the 
Glasgow Royal, for instance, workshops of various kinds furnish 
employment to the patients, who supply the institution with clothing, 
shoes, bread, brooms, mats, etc. 

Female patients, as a rule, have fewer resources for occupation 
than males, but are more accustomed to the quiet of an in-door life. 
For those whose prejudices and social position do not interfere, 
household duties in the wards, sewing-room, laundry or kitchen,, 
furnish partial employment. Needlework is always at hand, and 
can generally be availed of. In some hospitals, the McLean Asy- 
lum, for instance, systematic instruction is given in music and the 
modern languages. In the Dublin Asylum is found a school-room, 
with a corps of teachers and regular sessions. Much attention is 
paid to object-teaching, for the ignorant or demented. 

Amusements are everywhere considered essential to enliven the 
mind, and divert the morbid currents of thought into healthy channels. 
In most hospitals are found organs, pianos, books, birds, flowers, 
pictures, billiard tables, bowling alleys, chess tables, and all the 
minor games ; libraries, magazines, papers, lectures, cabinets, and 
magic lanterns are common. An amusement-room, with a small stage 
for theatricals, concerts, lectures and parties, is now thought to be 
almost as essential as a chapel ; and when it cannot be had, our 
liberal notions in this country do not forbid putting the latter to secu- 
lar uses. In England, when the chapel is sometimes a church, cost- 
ing forty thousand dollars, this is not allowed. 

These measures for the moral treatment of insanity are coming 
to be more and more valued and appreciated. Take, for a familiar 
instance, the hospital at South Boston, already alluded to. Having 
no farm, no grounds for walking and driving, no conveniences for 
work in-doors, being over-crowded and uncomfortable, amusements 
have been more and more resorted to as a means of relief and offset 
to these serious defects. In this hospital are to be found all the 
resources for amusement mentioned, but with little room for their 
proper use and enjoyment. Parties for the more rational of each 
sex are given on every day which can possibly be construed into a 
holiday. The festivities on Christmas and Fourth of July are un- 
usually elaborate, and on a very generous scale, — thanks to an 
enlightened board of trustees. Excellent music is provided for these 
parties, and the programme includes, at different times, concerts by 
gentlemen and ladies from town, who volunteer their services ; pri- 
vate theatricals and tableaux, by inmates and interested friends; 
magic lantern exhibitions, legerdemain, Punch and Judy, and usually 
dancing and refreshments. 

On Washington's Birthday occurs a reunion of former patients, 
who are present in considerable numbers. During the winter, 



tickets to the various courses of lectures, to concerts, theatres, 
and fairs, are provided, and parties attend regularly. In summer, 
by great good fortune, the city steamer is available for excursions, 
and frequent trips are made to all points of interest in the harbor and 
bay. A band of music usually attends. Former patients or inmates 
of the McLean or Blind Asylums are invited, and refreshments 
provided. More than half the inmates of the hospital are sometimes 
on board at once. These special advantages, however valuable in 
promoting a healthy tone of feeling, and restoring mental health, do 
not, and cannot, be made to compensate for the absence of other 
essentials for hospital treatment. 

The increase of insanity, from growth of population and other 
causes, has of late years suggested the possibility of more econom- 
ical provision for the chronic insane. In this State, at Tewksbury, 
is to be found an asylum for this class of incurables, to which 
patients are transferred from the State hospitals. While deprecating 
that economy which consists in depriving the insane of any possible 
comfort, it must be admitted that something may be saved in this way, 
without serious danger to the patient's life. This plan has, how- 
ever, some objections, which arise from the difficulty of deciding in 
every case who are incurable, and there is danger that a patient 
may now and then lose his chance of recovery through a cessation 
of effort. The moral effect on some patients of a transfer which 
stamps their condition as hopeless, must be more or less harmful and 
depressing. There is in such an asylum a tendency to mental 
deterioration, which is to some extent resisted in a properly equipped 
hospital, where the classification does not so much take into account 
the curability of the patient as his capacity to appreciate his 
surroundings, and his ability to conduct himself with propriety in 
the society in which he is placed. These are weighty objections in 
the minds of all alienists ; but if the State cannot afford hospital 
privileges to all, the curable and the recent cases must, of course, 
take precedence. If such institutions must exist, it would be better 
to build them within the grounds of some hospital. 

Another method has been in practice for several years in Scotland, 
for the disposition of this class. About fifteen hundred insane are 
boarded at low rates, with the peasantry of small villages. The re- 
sults of this experiment are not brilliant, from a financial point of 
view even, and the saving that is thus effected is at the expense of 
those advantages which give the hospital its character. The system 
differs but little from the one formerly in vogue here, of "/arming 
out " the poor to the lowest bidder. The price is fixed, but at so low a 
figure that the patient's labor is necessary to make his employer whole. 
The inefficiency of the insane laborer must, at times of sickness 
especially, lead to scanty fare, neglect, or rough usuage. It is im- 
possible that the ignorant or shiftless peasantry, who would be most 
likely to consent to eke out a living by insane boarders, should 
exercise a control always kind and judicious. The certain tendency 
is to save as much from his board, and get as much work from the 
patient, as possible. 


As an actual fact, the patients themselves prefer the hospital. 
The society and variety of hospital life, dull as it may seem to 
lookers-on, is less wearisome than the monotony of existence in a 
distant hamlet, with no resources for amusement or mental recreation. 
The "free air'' has no more oxygen v than the air of the hospital 
grounds, and is a poor offset to the loss of hospital advantages, 
since most patients know well enough that they are kept in the vil- 
lage as in the asylum. It is the moral restraint which is felt, after 
all. Abuses have been found to exist, growing out of the low rate 
of board, the enforced labor, the ignorance or selfishness of 
guardians, the absence of adequate supervision and skilled medical 
observation. The freedom of association between the two sexes has 
also its dangers. Recent and curable cases sometimes find their way 
to these colonies, where they lapse into chronic insanity, or are sent 
to hospital with diminished chances of recovery. 

The colony system, however, finds its great ante-type in Gheel. 
To this remote village, in Belgium, have been sent for centuries the 
insane of various kinds, in accordance with the superstition that a 
certain shrine was efficient in the cure of mental diseases. The 
history of this unique colony does not encourage the attempt to imi- 
tate it, although the abuses, which had formerly been so flagrant, 
have been diminished by the recent interference of the Belgian 
Government. Now, by carefully excluding all objectionable cases, 
establishing a central hospital, extending and improving the police 
department, and providing for regular medical visitations, it is kept 
in tolerable order. The condition of the patients is such, however, 
as would not be tolerated in a well-managed hospital, either by its 
officers or the public. Take the free use of leg-fetters which pre- 
vails, to keep the men and women in the fields from running away, 
or the entire absence of bathing facilities, and fancy the storm of in- 
dignation from the press which would, in New England, deluge a 
hospital so situated. 

Want of proper medical supervision is a defect almost necessarily 
incident to the colony system. Chronic insanity is a disease which 
is seldom stationary, though its rate of progress ma)' be slow. It is 
subject to fluctuations and changes, which in the interest of the 
patient should be foreseen, and prevented or controlled. Dangerous 
attacks often occur which watchfulness would easily prevent. A patient, 
sent as harmless and incurable to the asylum at Tewksbury, and 
from thence to the almshouse, on account of overcrowding, two 
years ago, stabbed an officer, inflicting serious and permanent in- 
jury. The horrible murders by insane people, at which the public 
are momentarily astonished, are often committed by the inoffensive 
chronic insane under a transient excitement, which might have been 
easily warded off. Every physician in an asylum knows how much 
of his attention is required in the management of the chronic insane. 
They need constant and skilful supervision. In hospital, they may 
be kept in a state of tolerable order and comfort ; but left to them- 
selves, they almost invariably get into trouble. 

As soon as the condition of colony patients is made to approximate 



the hospital standard of comfort, the expense rises, and defeats the 
most valuable feature of this system. There is little danger of its 
taking root here. It may hold its own in Belgium, by right of long 
possession, but it is an experiment at the expense of the patient in 
Scotland. The country people of New England would not take 
kindly to it, and Yankee legislators would be unable to see how one 
hundred men could be fed, warmed, and lodged under fifty roofs so 
cheaply as under one. They would also fail to see how insane labor 
could be utilized to any better advantage by individuals than by the 

It is possible, however, the cottage system may become more or 
less fashionable. Cottages, constituting small detached wards, 
situated in the grounds of the hospital, near enough for convenient 
daily visitation, may be found useful for certain mild or convalescent 
cases. The air of freedom which such cottages might be made to 
show would certainly please the friends of patients, and prove attrac- 
tive at the outset to the patients themselves. No doubt many of the 
insane could be taken care of in this way, but it is doubtful if the ex- 
pense would be much diminished, or the proportion of recoveries 
visiblv increased. 



INSANITY is many-sided, and so more fruitful of disputes than 
the fabled shield of gold and silver. It as surely incites to strife 
those who approach it from opposite directions. Its social bearings 
interest particularly the philanthropist, and its purely mental phe- 
nomena the metaphysician. To the alienist it is a disease of the 
brain, to the lawyer a convenient plea, and to court and jury, 
too often, a stumbling-block and rock of offence. To the family 
smitten by it, insanity is a mysterious infliction, a source of distress 
and despair, a terror by night, a skeleton in the closet, a heartache, 
a bone of contention, and a disgrace. In the eyes of the general 
public it is equally mysterious and misunderstood. To the sensa- 
tional reporter, a fit theme to conjure his thousand and one tales 
upon, whereby to save his neck from the editorial bow-string. 

Each observer is too apt to look at this subject from his own point 
of view alone ; to build theories only on what he sees ; to discard 
the experience which has taken time to walk around the shield, and 
to hotly contend for the absolute truth of his particular opinions. 
The reader will probably say, "Who can we trust in this matter?" 
I reply, unhesitatingly, "Those who have been the most intimately 
associated with the largest number of the insane, and for the long- 
est time." I set these men above all theorists whatever. Medical 
experience is just as valuable here as elsewhere, and there is no 
occasion for suspicion or jealousy, because, in the nature of things, 
this intimate acquaintance with insanity falls to the lot of a few. 
Common sense and common honesty are as frequent among prac- 
tical alienists as among other classes of men. Their opportunities 
are not so partial and one-sided as they seem. They become thor- 
oughly acquainted with the life-history of each patient, and of his 
ancestors. They follow the careers of all kinds of men, from the 
genius to the criminal, which afford points of psychological interest. 
They experiment continually in home treatment, in travel, in "free 
air** and early discharges. The plans which social science has just 
evolved from its inner consciousness they have tried, and have seen 
tried, in two-thirds of their patients. 

But the legal point of view lacks all such advantages. The fact 
of the existence of mental disease must be obtained at second-hand in 
most cases, the time and chance of becoming acquainted with insanity 
in court being of small value. The law touches a patient here and 
there only, and, by the light of partial evidence, shows his acts in 
bold relief, but leaves the disease from which they spring in shadow. 
The evidence which satisfies the experienced physician of disease is 
not legal evidence, any more than the latter is mathematical evidence ; 
and yet the physician, the judge, and the mathematician may be 
equally convinced, each in his own way. 

In the region of acts and motives, as they are related in the sane 
mind, the legal profession has the advantage, perhaps, at least as 
far as such acts are criminal, but the practical alienist deals no less 



with the same acts performed from insane motives. A man steals 
cunningly, and hides the theft. He steals what profits him, perhaps, 
and yet the inferred motive of the court may do him injustice. His 
physician knows he is as irresponsible as a child. Insanity presents 
many difficult problems, and modesty is becoming in all who d'eal 
with a subject so obscure and perplexing. But it is too often the 
fashion to sneer at medical evidence in questions of insanity. It 
may sometimes be contradictory, as the decisions of courts so often 
are. Even doctors of the same amount of experience may differ, 
but more seldom than is often supposed. The kind of experience is 
of importance. One expert may never have seen a satisfactory case 
of transitory mania, or he may doubt its existence on theoretical 
grounds, but truth and safety may come out of honest evidence, 
however inconsistent. A sincere conviction, decently expressed, 
founded on experience, is entitled to respect. If medical evidence 
is valueless, none other is of much worth. 

The law is pre-eminently conservative ; it crystallizes slowly out 
of the solution of public opinion, and redissolves still more slowly 
under new solvents. The law suits best the strongly-marked and 
typical cases of general insanity, and does not fit certain newly-dis- 
tinguished, but well-marked, forms of partial insanity. Like armor, 
it is too inflexible to adapt itself to the nicer gradations which exist 
in nature. It is a thing of joints and hinges, a mechanical and arbi- 
trary appliance, while each case of insanity is a living growth. 

English law does not, and until recently English courts have not, 
recognized the existence of moral insanity. The presence of delusion 
even has been allowed little weight unless its bearing upon the crime 
could be shown. If the prisoner knew abstractly right from wrong 
at the time of the act, he was, and generally is, held responsible, 
both here and in England. In isolated cases, however, account is 
now made of partial or modified responsibility, and of moral or 
emotional insanity. Transitory mania, even, is sometimes allowed 
to excuse the criminal, though its existence is still questioned by 
some alienists. 

The term moral insanity was used by Pritchard to designate all 
cases of insanity affecting the emotional, in contradistinction from 
the intellectual, nature. By abuse it has been limited to such as are 
characterized by perversity, vicious propensities, or criminal im- 
pulses, and in this sense it has been denounced as a fiction of the 
medical brain, unfounded in fact, and pernicious in tendency. The 
term is objectionable, since it is not an equivalent in its common ac- 
ceptation for disorders of the emotional nature. A better name, 
and one in use, is Affective Insanity. 

Still, all reluctance to recognize these forms of mental disorder 
not directly affecting the intellect, is not dependent on the name. 
That a man of calm exterior, in full possession of his usual conver- 
sational powers, of sound memory, his capacity for business appar- 
ently unaffected, and, to a superficial observer, in his usual frame 
and disposition of mind, may not be responsible for a crime he has 


committed, is a startling proposition. It is hard to acknowledge the 
existence of disease whose manifestations so closely resemble crime. 

When the sympathies of court, lawyers, and jury are strongly 
appealed to, as in the well-known Mary Harris case, acquittal is 
easy. But let the defendant be poor, unknown, or perhaps vicious 
and repulsive, and his life depends on such weight as may be allowed 
to medical evidence, founded, too often, on insufficient opportunity 
for examination. It is noticeable, too, how differently public sym- 
pathy runs in different cases. If the diseased impulse results in sui- 
cide, apologists are numerous. It is then seen how much may be 
stirring under the surface, and how hard it is to fathom the under- 
currents of the individual mind. It is seen how superficial are those 
social disguises which veil the real feelings and deceive the nearest 
friends. It is seen with what power the semi-conscious automatic 
operations of mind assert themselves when its balance is disturbed by 

If, however, the same train of hidden causes eventuate in some act 
of violence or murder, public prejudice is sure to set the other way. 

It is to be regretted that in the examination of obscure cases we 
have no crucial tests, but must depend for our knowledge of insan- 
ity, at the time of the outbreak, upon ignorant and unobserving wit- 
nesses. As to the actual condition at the time of examination, many 
things tend to obscure the truth. Under close examination some 
cases of seemingly pure insane impulses prove dependent on a latent 
insanity of long standing. It is this fact which makes it seem prob- 
able to some that all cases of impulsive insane acts depend on dis- 
ease of considerable duration. Practically the law has often to deal 
with isolated acts of impulsive insanity, the evidence of underlying 
disease being matter of inference rather than of evidence. 

There is a form of moral insanity occurring in the young, and 
dependent on hereditary weakness or infantile disease. It is man- 
ifested by a tendency to mischievous, cruel, vicious, or criminal acts, 
with a lack of feeling for their true nature. These acts in themselves 
do not constitute the disease, since temptation may lead to the same 
crimes a young and healthy mind. When repeatedly observed in a 
young person without adequate motive, and without compunction or 
remorse, they point to some fault of the cerebral organization. 

The term "moral idiocy " is perhaps too strong, since the sense of 
right and wrong may not be wholly wanting. There is apt to be an 
aversion to study and a lack of intellectual strength, though these 
patients get much credit for ability in certain directions. They are 
quick at games and ingenious at mischief. Their observation of char- 
acter is keen, and may be sometimes put to good use in the further- 
ance of their various schemes. They are cunning in disguises and 
excuses, feigning emotions they do not feel, and controlling their 
impulses for a time for a purpose, or to avoid punishment. 

This class of cases is specially mentioned, because the evidence is 
generally satisfactory, while the contrast between the youth of the 
patient, and the acts which indicate affective disease, is great. In 
adult years it is more difficult to distinguish the same individuals 


from ordinary criminals. In youth they are sheltered from the law, 
except in extreme cases of crime, but in later life they are sure to 
fall into the hands of justice. A few cases will be cited by way of 

A. B. Family history unknown. Previous to age of eleven, gave 
his parents much trouble by his mischievous propensities : stole jew- 
elry from a pedler's wagon ; threw stones on the railroad track ; would 
leave home to avoid punishment, and wander about, sleeping in 
barns and outhouses. Had a "wild look" at times, and a head 
" small at the top." Was a dull scholar. At the age of eleven he 
drowned, without provocation, a schoolmate five years of age, sim- 
ply, as he said, "to see the little devil kick in the water." He was 
arrested and convicted of murder, but his age would not allow of 
capital punishment under the law, and he was sent to the Reform 
School. He expressed no regret for the murder, and talked of it 
with indifference. Is constantly under discipline at the School. 

C. D. was the son of parents and grandparents of marked intel- 
lectual ability and piety. His brothers and sisters inherited these 
qualities in different degrees, with a large share of nervous suscepti- 
bility, in two cases amounting to disease. At an early age he gave 
proof of mischievous tendencies, for which, during minority, he be- 
came notorious. Before puberty he set fire to a building ; was skil- 
ful in obtaining money by ingenious devices, as well as by thieving ; 
was careless of exposure, and showed little remorse for his misdeeds ; 
was an indifferent scholar, and always in trouble at school ; ran away 
at last, became an adventurer, led a life of vice, and died in battle. 

Other examples more striking might be given, perhaps, but it is 
difficult adequately to describe cases like the preceding, although 
the observer has no room for a shadow of doubt in the existence of 
defect or disease. From such cases, and the other forms of partial 
insanity, a belief in a modified responsibility arises, and has become 
an established doctrine with all alienists. It follows naturally upon 
that of the hereditary transmission of mental qualities, so ably ex- 
pounded from time to time by Dr. Ray, and of late by Dr. Holmes. 
If the disciples of this doctrine have erred by too great leniency for 
crime and sin, both law and theology are guilty of the opposite error. 
Both, too often, stretch each individual on a Procrustean bed of their 
own making, regardless of his real mental stature. 

The case of Green, the Maiden murderer, is in point. The plea 
of insanity could not be sustained, but the signs of defective cerebral 
organization were patent to every careful observer. His family his- 
tory furnished abundant evidence of transmitted imperfections, both 
physical and mental, affording a dreary catalogue of insanity, idiocy, 
intemperance and scrofula, which could not but propagate themselves 
in some form. These points, with an individual history in perfect 
harmony with them, up to the time of the murder, satisfied the experts 
who examined him of" his limited responsibility. It is needless to 
recall the noble action of Governor Andrew in this case, and the 
evidence he often gave of an appreciation of the true nature of in- 


sanity, as well as of a mind above mere technicalities, and dwelling 
habitually in the higher domain of truth. 

It is easy to call emotional or moral insanity a "medical subtlety," 
and to deny that partial insanity should limit responsibility for crime, 
but it cannot be denied that the brain is the organ of the whole mind, 
of its moral as well as intellectual faculties. Disease cannot be con- 
fined to one part and excluded from another part of its structure. 
How then can any of its functions be excluded from all chance of 
disorder? In any case, under actual examination, the most severe 
scrutiny and prolonged observation should be made, in order to 
approximate the true limit of responsibility. The canons of the law, 
however, will prove less useful in this research than large practical 
knowledge of the disease insanity in all its phases. 

This chapter is not intended as a comprehensive view of the juris- 
prudence of insanity, but rather as a place for such suggestions on 
the subject as may be of popular interest. A hasty glance, from a 
professional point of view, at some of the contested cases of insan- 
ity which have exercised the public mind of late years, may not be 
out of place. The discussion of rules of law would be tedious and 
useless. Frorn time to time the public mind is exercised with refer- 
ence to the plea of insanity set up in defence of a criminal, sometimes 
with and sometimes without reason, or at tales of false imprisonment 
of the sane in some well known and well conducted asylum. The 
press, resting firmly in certain judicial decisions or verdicts, as if 
courts possessed an infallible touchstone for testing insanity, stretches 
out, from time to time, a threatening hand, as if to sweep from the 
earth those strongholds of crime and corruption known as hospitals 
for the insane. No distinctions are made, and the characters of ex- 
perienced and honored members of our profession are assailed with- 
out mercy. 

The public naturally suppose there must be fire under so much 
smoke, and at best are not disposed to be charitable in this direction. 
Every jail, hospital, nunnery, or close establishment of any kind, 
must, sooner or later, pass under public suspicion, because it is close. 
The cases, however, which usually kindle this blaze of indignation, 
and gain a brief notoriety in the courts, are not of the class which 
may be called obscure. On the contrary, they are, in most instances, 
clear cases of insanity, and recognizable even through the cloudy 
medium of a newspaper report. 

Take the case of Haskell, said to be improperly confined at the 
Pennsylvania Hospital for the Insane in Philadelphia. Dr. Ray, 
whose testimony is unimpeached and unimpeachable, who resided 
in Philadelphia, with every means of information at hand, says : 
"The evidence showed, beyond the reach of doubt, that Haskell en- 
tertained delusions ; that he believed he had been poisoned ; that his 
eldest son was a changeling ; that his wife, whom the slightest breath 
of suspicion had never reached, had been unfaithful ; that he pos- 
sessed certain property, to which he had not the shadow of a title; 
that his wife was a negress, etc. With scarcely a dollar at com- 
mand he projected enterprises which would have required hundreds 


of thousands. His character changed completely. He became 
noisy and quarrelsome, carrying fire-arms and threatening to use 
them. He made a will so absurd that the court, with all its leaning 
to his side, could not explain it on any theory of sanity. How could 
any case be clearer? What single ingredient of the disease was 
wanting? What criterion or test did it fail to meet? If not insanity, 
what was it?" The jury found a verdict of sanity. 

The testimony, in this case, concerning the gloomy and loathsome 
character of the " cells " at the Pennsylvania Hospital, was given by a 
former patient, who had occupied one of them during an attack of 
delirium tremens, and whose diseased imagination transformed a 
room, large, light, warmed, and ventilated, and wholly above 
ground, to a vile dungeon ! This witness, after the trial, was found 
dead drunk and asleep in the reception room of this very hospital, 
whither he had voluntarily returned, and had to be put out at the 
gate by force. 

Dr. Ray takes occasion to compliment the charge of the judge in 
this case, as follows : "We cannot forego the opportunity of noticing 
with the strongest expressions of commendation, the criterion or test 
of insanity adopted by the court in this case. ' The true test in all 
these cases,' said the court, ' lies in the word power. Has the defen- 
dant in a criminal case the power to distinguish right from wrong, 
and the power to adhere to the right and avoid the wrong?' No 
greater advance in the law of insanity has ever been made at one 
step than this. To recognize the power not only of knowing right 
and wrong, but of pursuing the one and avoiding the other, as an 
element of legal responsibility, is also to recognize, in the most 
decided manner, the doctrine of moral insanity — that kind of insan- 
ity which, while it leaves the intellect, the perceiving, discerning, 
and judging faculties untouched, deranges and perverts the propen- 
sities, sentiments, and emotions. Unfortunately this test had no 
applicability to the case in hand. That person was supposed to be 
intellectually as well as morally insane. We are none the less, how- 
ever, under a weight of obligation to the court for this admirable 
test, which we hope will evermore be the rule of law in this Com- 

In the Commodore Meade case, on one side was the negative evi- 
dence of sundry persons, who could see no insanity in him at the day 
of hearing. On the other hand, his relations, without dissent, affirm 
his insanity and its dangerous character. They testify to an attack 
of apoplexy, confining him to his bed for a month, the paralysis ac- 
companying which still existed ; to his marked change of character 
after the event ; to his aversion to his relations, and his deadly hos- 
tility toward several friends of his family, leading to his carrying 
fire-arms with the avowed purpose of killing them. Surgeon Bache, 
of the U. S. Navy, who had known him a long time, testified to his 
insanity. Dr. Brown-Sequard gave the family a written opinion 
that his mind was affected by an unabsorbed apoplectic clot. Dr. 
Brown, of Bloomingdale, had not the slightest doubt of his insanity. 
He was discharged by order of the court. 


The acquittal of Gen. Cole exhibited as great eagerness to find 
insanity as the other two cases to ignore it. The same may be said 
of McFarland, the murderer of Richardson. The bias of the court 
and jury was as strongly in favor of the prisoner as in the Mary 
Harris case, and the defence was the same — that of impulsive hom- 
icidal insanity. In the McFarland and Harris cases the evidence 
sustained the plea of insanity, though the motive for killing was 
strong. In the Gen. Cole case it was less satisfactory, and the 
motive was the same. The following return of the jury will show 
how ready they were, from sympathy, to take a stand with the most 
radical alienists : 

" The foreman stated that they found the prisoner to be sane at 
the moment before and the moment after the killing, but they were 
in doubt as to his sanity at the instant of the homicide. The judge 
said they must give the prisoner the benefit of the doubt, and thus 
instructed, they rendered a verdict of acquittal." 

If Gen. Cole and McFarland were liable to such a dangerous form 
of insanity, why were they allowed to go at large? Moral insanity is 
not a disease which begins and ends, except in rare instances, in the 
same act of outrage and crime. The catastrophe may come like an 
avalanche, which has been preparing under the accumulated snows 
of years, but which an echo lets loose to thunder a moment and dis- 
appear. Such cases are not common, but they do exist. A man 
may go through life maintaining an even contest with the hereditary 
gift of an insane temperament. Circumstances are favorable, and 
the will keeps watch and ward to prevent any public display of 
emotion. But a crisis comes when the will sleeps, or is overpowered, 
and the fair fabric of a life goes down in ruins. Yet the disease was 
there before, and remains after, the downfall, ingrained into the 
most intimate texture of the brain. 

These are the obscure cases which puzzle not only the legal brain, 
accustomed to deal with outward facts and ordinary motives, but 
those who are, by study and experience, best trained to appreciate 
the disordered workings of the delicate machinery of mind. All the 
medical expert asks, in such cases, is that justice should withhold 
her hand while the victim of -suspected disease awaits, in some secure 
place, its further development. 




OINCE the disputed points relating to insanity have most popular 
^ interest, it may be well to consider this subject of Transitory 
Mania a little further. Dr. Jarvis says, in a long and interesting ar- 
ticle in the Medical and Surgical Journal, of Boston, for June 10, 
1869 : " This is not exclusively a new or an old doctrine, but has 
been taught in France and Germany for many years by the managers 
of the insane, and writers on these topics. It is recognized by psycho- 
logical authorities in Great Britain. It is admitted and established 
by jurists and courts in Europe, in their management of persons who 
have committed acts which would otherwise have been considered as 
crimes, and for which they would have otherwise been doomed to 
death on the scaffold." 

The authorities and cases he quotes are very numerous and con- 
clusive ; so entirely so, it isuseless to review them. The attack of 
transitory mania is characterized by its sudden outbreak, its short 
duration, the sudden restoration of the patient to sanity, calmness 
after the act of violence, absence of motive, absence of remorse, and 
want of consciousness during the act, and of recollection afterwards. 
That such cases occur, is settled beyond a doubt. That they are 
comparatively rare, and that the defence of transitory mania is often 
made without a warrant, is also true. There is very often, in cases sus- 
pected of this form of insanity, a lack of evidence sufficient to satisfy 
the law, while it may furnish the physician strong reasons for his 
suspicion. The patient's own statements, which are the most val- 
uable, and often the only evidence of his state of mind, are ruled out, 
or are disbelieved, because of his supposed crime. So in the An- 
drews case, accepting the prisoner's statements, there is a stronrr 
case of transitory mania made out. How far circumstances corrob- 
orated and confirmed those statements may be gathered from the 
published account of the trial, and from Dr. Jarvis's resume of the 
evidence in the journal above mentioned for November 4, 1869. 

There is nothing in the nature of things to make an attack of 
transitory mania improbable, but, on the other hand, much to render 
it likely to occur. We are not astonished at the suddenness or brev- 
ity of other nervous attacks. A person may faint but once in his 
life, or have but one fit, or walk in his sleep but once. He may be 
delirious but for one night of his life. How can he be sure that the 
part of his brain which controls his acts may not be suddenly affected, 
so as to lead to an act of involuntary violence ? That such is very 
often the case with epileptics, no one can doubt. The seizure may 
be of the kind known as -petit mal, a mere transient suspension 
of consciousness so brief, as not to allow the body time to fall ; a 
mere vertigo. Or, in place of this may occur a delirium of a min- 
ute's duration. Some strange thing is said or done, which attracts 
notice, but of which the person is unconscious, being only aware 
of a sensation of giddiness on coming to himself. These phenom- 
ena are seen frequently. 


This period of unconscious delirium is often seen to extend over a 
longer time, allowing the victim of it to make long walks, and to do 
many strange things, of which he remembers nothing. These cases 
pass under the eye of the alienist, when there is nothing to impeach 
the testimony of the parties themselves, or to throw doubt upon their 
acts. Epileptics are also known to be subject to attacks of frenzy, 
or short-lived fury, in which, though not fully unconscious, they 
commit the most outrageous acts of violence from blind impulse, or 
upon the spur of some sudden delusion. The knowledge of these 
facts make physicians careful, in cases of unexplained violence, to 
search for some trace of epilepsy, vertigo, or -petit rnal, in the pre- 
vious history of the suspected person, and it is often found. 

The latest discussion of this subject will be found in a German 
work on Transitory Mania, by Dr. Krafft-Ebing, for the use of phy- 
sicians, judges, and lawyers, published in Erlangen, 1868. The 
author presents a succinct account of all the psychological states in 
which, from one cause and another, a man, losing momentarily the 
knowledge of his acts, and of his own existence, enjoys no longer a 
free agency, and is not, in any degree, responsible for the acts he 
may commit. These acts are usually of extreme violence, but their 
character is difficult to estimate, from the fact that the insanity, under 
which they are committed, is over when the physician is called to 
give his opinion. 

Besides his personal experience, the author has carefully studied 
the literature on this subject. Dr. Krafft-Ebing distinguishes seven 
different groups of conditions, under any of which transitory mania 
may occur : 

1. The state of dreaming. 

2. Different kinds of intoxication. 

3. The delirium of febrile maladies. 

4. The transformation of neuroses. 

5. The transitory psychoses. 

6. Pathological passion. 

7. Transitory intellectual troubles at childbirth. 

The first three will be readily understood. The fourth form is 
the one of which we have spoken in connection with epilepsy, and 
is, perhaps, the most common. The transformation of epilepsy, 
hysteria, and neuralgia simply means that, instead of the customary 
seizure, a transient delirium occurs, in which any violent act may 
be committed. The irritation seizes the intellectual or emotional 
nerve-centres in the brain, instead of those regulating motion and 

To the fifth form, transitory mania, properly so called, belongs, and 
is distinguished, with some difficulty, from epileptic mania. It con- 
sists in an aberration of mind, which may last from twenty minutes 
to six hours ; it appears suddenly, without warning, differing in this 
from the preceding forms, in individuals, generally men, perfectly 
well-behaved, both before and after the attack. The loss of con- 
sciousness and of recollection afterwards is complete. The attack 
has the character of fury, or acute delirium, with hallucinations and 


illusions, and terminates in a profound sleep. The attack is gener- 
ally unique, and recurrences very rare. It is probably due to con- 
gestion of the nervous centres. 

Sometimes this transient delirium takes the character of melan- 
cholia, and is accompanied by a mental distress, which irresistibly 
drives the individual to commit acts of violence in order to relieve it. 
Usually, the act being committed, he is calm until consciousness 
brings a recollection of it. 

The sixth form consists in what the author calls pathological pas- 
sion, or delirium of the senses. Every man has passions which he 
can conquer and control, if in his normal psychological state ; but 
there exists an unfortunate class whose physical and mental organ- 
ization is defective, either temporarily or permanently, and with 
whom violent passions or emotions produce a reaction, of which they 
are not masters, and which too often brings them to the bar of jus- 
tice. They are not responsible in the same degree as those of firmer 
moral and physical fibre. The paroxysm of passion may go on to 
complete delirium, and produce a true access of transitory mania, 
during which the senses may be led into error, and the perception 
of exterior objects distorted. The limit of responsibility is here 
difficult to trace, and it is necessary carefully to individualize. 

Of the seventh form it is only necessary to say here that it is an- 
swerable for many infanticides, and is a form shared by the lower 
animals, who, to the full extent of their mental development, are 
liable to insanity. 

All these conditions of transitory disorder may prove very difficult 
to estimate when the question of responsibility is raised, because the 
direct examination of the accused person affords only negative re- 
sults. His physical, moral, and intellectual antecedents, both per- 
sonal and hereditary, and his condition preceding the act in relation 
to fatigue, emotions, nervous accidents, etc., may furnish valuable 
indications. Next, one should study the character of the act itself, 
which is always violent, sudden, without plausible motive or con- 
scious aim, absurd, illogical, the patient breaking, killing, destroying 
indiscriminately all which comes to hand, and often to the detriment 
of his own best interests, or of his dearest affections. There is no 
concealment and no calculation. It is a blind, brutal, irresistible 
force which acts in the individual. He acts openly, and does not 
secrete himself. He acts often with noise and violence. Nothing 
can withhold him in his blind fury. 

Somnambulism furnishes an exception to this rule, not presenting 
all these characters, the acts often appearing the result of forethought 
and calculation. The manner of the accused will, however, gener- 
ally be a guide to his mental state. He has usually no knowledge 
of what has passed, and does not understand why he has been ac- 
cused ; he is calm and tranquil, having no fear of consequences, for 
the same reason. 

In the state called rapttcs melancholicus, it may happen that the 
patient has a knowledge and recollection of what has passed, for 
when the attack is over he often goes to denounce himself to justice. 


This form of transitory mania is also distinguished from others by 
the fact that the individual seems to calculate his acts, or at least to 
be more or less conscious of them at the time of commission. Their 
irresistible character excludes responsibility, nevertheless. 

We might add instances illustrating some of the conditions described 
above, but have dwelt too long already on this subject. Cases of 
pure mania transitoria are rare, but the melancholy form is more 
common. When we remember the large numbers of unaccountable 
suicides, we may properly infer that transient aberration is often the 
cause of them. That the attack is sudden, in such cases, all know, 
but the death of the individual afflicted prevents any estimate of its 
likelihood of duration. 

Investigation, judicial or otherwise, is sometimes required in case 
of violence inflicted upon the insane. Cases of this sort have oc- 
curred in England and elsewhere, attracting much attention, and 
exciting much natural indignation. It is, however, to be expected 
that accidents, and even malicious violence, will happen to the in- 
sane now and then. The wonder, all things considered, is, that they 
are not more frequent in hospitals, since they occur often enough 
outside. Violence requires, at times, vigorous restraint, and abuse 
meets with sudden punishment at the hands of a fellow-patient or an 
unsuitable attendant. The law is very properly appealed to in such 

An advance in pathological knowledge has recently been made 
which has a bearing upon these cases. It was noticed that injuries 
to the insane most frequently occurred to general paralytics, and 
usually consisted of broken ribs. The investigation of such cases 
has led to observation of the fact that the ribs, in certain cases of 
insanity, become softened, so as to bend or break with great facility. 
This has been proved in many instances by autopsies upon the in- 
sane. A fall, a quarrel with another patient, or a forcible handling 
of such a person, would lead to numerous fractures. In general 
paralytics, the delusions of importance and power lead to displays 
of strength, and invite assaults from other patients. Their weakness, 
and tendency to fits, lead to frequent falls, while the entire loss of 
memory prevents the recollection of any such occurrences. 

Another interesting fact has often been noticed in this connection, 
that of the insensibility of the insane to pain, whereby the usual 
signs of injury are concealed. This immunity from pain, by reason 
of mental disease in many of its forms, is a well-known fact, and 
matter of record. Probably no psychological fact is capable of such 
complete and startling illustration. From the time of Hippocrates, 
who first recorded insensibility to pain as a symptom of insanity, to 
the present, medical literature contains frequent examples of it. 
This fact makes it important to look beyond the last possible source 
for an injury which may have lasted for weeks. In a case within 
the writer's knowledge, it was matter of doubt whether certain inju- 
ries occurred in hospital or just previous to admission. It is there- 
fore important to analyze the various causes from which insensibility 
to pain may arise. 


For instance, there may be actual paralysis of sensation — a con- 
dition of true anaesthesia ; or, sensation being perfect, the seeming 
t insensibility may be due to a careful repression of all signs of pain, 
as in some cases of hysterical paralysis. Between these extremes 
come various degrees of indifference to pain, the result of mental 
preoccupation in some morbid train of thought. There may also be 
the indifference of frenzy, the current of emotion admitting of no 
interruption, and the indifference of stupidity and dementia. The 
pain may be felt, but misinterpreted by the diseased mind, being re- 
ferred to some fanciful source, and so discredited or undiscovered. 

In these ways, the exhibition of suffering among the insane is, to 
a large extent, prevented, and the utmost watchfulness is required on 
the. part of medical attendants to discover the actual condition of 
parts and organs, to which, among the sane, the sense of pain is 
such a valuable index. Painful diseases may run their course with 
few of the ordinary signs. Consumption is usually a masked disease 
with the insane, being unaccompanied, from first to last, by cough or 
pain. Many of the insane, however, feel pain very acutely. 

The most common cause of actual anaesthesia is general paralysis. 
In the early stages of this disease, before the loss of motion is very 
well marked, it may be observable. It renders the patient regardless 
of exposure to cold, to burns, injuries, and minor surgical operations. 
If under the influence of delusion at this time, self-mutilation may be 
deliberately inflicted. Pulling out of the intestines, gouging out an 
eye, or sawing off the tongue, are a few of the eccentricities in 
which such patients may indulge. 

Anaesthesia may likewise affect the melancholy, being shown by 
indifference to cold, to the pangs of starvation, or the fatigue of 
standing motionless, or lying naked on a hard floor, for days. 
Melancholiacs sometimes resort to painful methods of suicide. 
Forbes Winslow relates a case of experimental suicide, in which the 
patient tried various plans up to the point of unconsciousness, with 
the humane intention of recommending the least painful to his more 
sensitive fellow-sufferers ! In dementia, the indifference to pain de- 
pends upon the extent of mental obscuration. 

In mania, the condition bears less resemblance to anaesthesia ; or, 
if it is of this nature, the state is transitory and fluctuating, accord- 
ing to the rate and direction of the cerebral currents. Motor activ- 
ity, however, is not a safe index to the degree of activity in the mind. 
The maniac may be outwardly calm, and perhaps coherent, at the 
moment when his mind is at its intensest point of activity. In this 
state there is no room for the consciousness of pain, and the patient, 
under this suppressed excitement, may disregard the existence of 
severe injuries with a sang- froid truly deceptive. I have seen such 
an one chew the ends of a burning card of matches with apparent 

As we have digressed so far upon this subject, we may be allowed 
to carry it a little farther, especially as the question of insensibility 
to pain has a general interest. Indifference to suffering is not solely 
characteristic of the insane, but is seen in states of mind not consid- 



ered wholly abnormal. The convulsionists of St. Medard were 
victims of one of those moral epidemics of the middle ages, in which 
religious ecstasy produced an abolition of pain, and a wonderful 
power of endurance. The Book of Martyrs furnishes many similar 
examples. A like condition obtains among those heathen and sav- 
ages who practise self-torture as a propitiatory exercise. There is a 
state of anaesthesia resulting from extreme peril, which Dr. Living- 
stone experienced when in the jaws of a lion. 

War furnishes, t>n a large scale, fine examples of endurance and 
disregard of suffering. The emotions developed during a battle are 
various. In a few constitutionally timid natures, they are of the 
most depressing nature. Fear is imprinted on every feature, and 
each limb is a tell-tale. The term demoralized is strictly and scien- 
tifically correct. In one instance, under my own observation, an 
attack of mania was induced. A soldier, under unexpected fire for 
the first time, suddenly clubbed his musket and struck out furiously 
among his comrades, yelling as if in the midst of enemies. On be- 
ing led out of the fight the delirium subsided, leaving a condition of 
stupor, which lasted several hours. He subsequently became a 
good soldier. 

In the mass, the excitement does not exceed the limits of self- 
control, but serves to keep each man up to his duty, and makes him 
more or less careless of danger, and regardless of ordinary wounds. 
This is especially the case if the fight goes well. For instance, a 
soldier lies in an ambulance with a bullet in his foot, shouting, " Dig 
away, doctor, and damn the pain ! we've licked 'em ! " Or a del- 
icate drummer-boy, with a large flap of skin torn away from his 
knee by a shell, requiring tedious dressing and many stitches, asks 
for a pencil, meanwhile, to make notes in his diary of the occur- 
rence. On the other hand, a fellow comes up with his right fore- 
finger shot off, and an empty gun-barrel. A self-inflicted wound is 
diagnosed, and amputation at the joint proceeds amid contortions 
and frantic exclamations of pain, while all around lie the severely 
wounded, with scarce a groan among them. 

Such strong contrasts forcibly illustrate the influence of mental 
conditions upon sensibility to pain. Pain is a sensation which, in 
ordinary states of mind, has an intensity sufficient to excite the at- 
tention powerfully ; but in certain unusual conditions, the perceptive 
\faculties are under the absorbing control of central agencies in the 
brain. Whatever these agencies are, whether changes in the cir- 
culation, the cell nutrition, or the nervous currents, the results re- 
semble artificial anaesthesia. Nature, however, more skilful than 
man, applies her anaesthetics so delicately as to produce more exact 
localizations of effect. In the more permanent anaesthesia of insan- 
ity, we look for more visible and lasting changes in the structure of 
the brain. 



"jVTOT only in criminal processes must nice discrimination be made 
-L ^ when insanity is suspected, but in all civil suits, will cases, appli- 
cations for guardianship, or for commitment to hospital. It is hardly 
necessary to discuss here the various points of law involved, but 
only to insist that each case should be carefully examined on its own 
merits, not only on the abstract question of insanity, but upon the 
necessity of the action applied for. The insane are in part respon- 
sible for their acts, are often reliable witnesses, may make valid 
wills, do not always need guardianship or hospital treatment. 
Hence the necessity for careful individualizing. 

The existence of any form of insanity, however, should render the 
testimony of the person so afflicted questionable. A slight defect of 
memory ; a recollection of events as distorted by past emotions ; the 
intermingling, in the patient's mind, of things narrated with actual 
occurrences, as happens in our recollections of early childhood ; the 
influence of some obscurely related delusion ; the insensible ex- 
aggeration of diseased feeling, and the dulling of the moral tone, so 
frequent in certain forms of partial insanity, are so many different 
ways in which the testimony of the partially insane may be rendered 

Their capacity for other acts, in law, may be similarly affected. 
Many an unjust will has been the product of a mental disorder but 
partially recognized, or in fact denied, by the parties benefited. 
Many an estate has been in this way alienated from the testator's 
family and natural heirs, against his life-long intentions. This may 
happen by transactions before death, which could not have been 
brought about except through mental disease, unprovable, save by 
the acts themselves. In several cases, in my own knowledge, the 
property of old men, becoming demented, has been purchased at 
cheap rates by over-persuasion and moral pressure, which wrong 
could not be righted, because, with a country jury, " a deed is a 
deed"; while insanity of the partial and obscure kind is, as Flute, 
the bellows-mender, would say, " a thing of nought ! " 

Nice discrimination is also needed in the matter of guardianship 
of the insane. It is an injustice, as well as an indignity, to put the 
property of a person of sane mind and sober habits under the control 
of another ; but the first and only prominent sign of insanity, may 
be a reckless expenditure of money. This is an early symptom of 
some forms of mania, and of general paralysis. In cases of melan- 
cholia, the chief and only marked symptom, besides depression of 
spirits, may be an unreasonable dread of poverty ; or, perhaps, a 
present sense of being poor, leading to extreme economy. So, in 
commencing mania, the opposite is often seen ; an exhilaration of 
spirits, and sense of well-being, taking the place of depression, and 
extravagance that of parsimony. The patient is careless of expense, 
lives luxuriously, is over-generous, makes valuable presents to 
chance acquaintances, and has a confidence in the prospect of near 

9 3 


and great wealth, which leads him to set a'small value on his trifling 
possessions. In his unlimited faith in the future, he beggars himself 
and his family in the present. 

All this may be done before legal restraint can be secured. It 
may be done in the way of business, and unknown to all except those 
immediately concerned. The prospect of wealth maybe founded on 
investments or patents, whose future value is uncertain, but which 
may justify the patient's hopes. How then, can these hopes be 
called insane delusions, and be made the basis of legal action? 
Many a wife has seen the small dependence of herself and children 
melt away in a few months, unable to resist, until the dreaded relief 
of the insane hospital at last becomes possible and welcome. She 
then appreciates a public charity, which, perhaps, had little of her 
sympathy before. If she reads the respectable dailies, she may have 
the pleasure of seeing her husband classed with scores of other 
gentlemen and ladies as " faupcr lunatics ," — an outrageous abuse 
of language. Gentlemen in high positions will labor to show how 
cheaply the State can take care of such ; and she may wonder that 
the law which could not save her property is now so easily availed 
of, to cut down her claims on the public purse. 

The law, however, is not a panacea which can be applied to all 
the cases of hardship and injustice in the community, and should 
not be railed against. Rather should we strive to cultivate such a 
public sentiment as will recognize the rights of the families of the 
insane as equally sacred with those of the insane person himself. 
Protection to life and property from insane persons may be secured 
under existing laws, when liberally interpreted, and seconded by 
medical skill and sound public feeling. 

It is a common charge, that the friends of an insane person wish 
to put him under guardianship, so as to obtain his property. How 
this is to be brought about, they do not stop to inquire. One would 
suppose a guardian, whose accounts are open to inspection, and who 
acts only under supervision of the court, most intimately concerned 
with family affairs, would be the best safeguard of the law to prevent 
foul play. 

A mistaken sentiment also exists with reference to commitments to 
hospital. It is not that the public mind is so very unhealthy in its 
operations, but that the facts cannot be adequately presented. They 
do not always lie on the surface ; and patient investigation is not a 
popular virtue. However it has grown up, there exists a somewhat 
wide-spread feeling, which shrinks from early commitments, and 
which resents interference with the personal liberty of any insane 
person who can sustain tolerably safe and fair public relations. 
The family is no longer able, uncriticised, to manage its insane mem- 
bers under medical advice. The public is suspicious of disease, which 
is limited in its expression to the domestic relations, and the press will 
utter whatever the public thinks. 

Perhaps this publicity is for the general good, but it certainly does 
great harm and injustice in individual instances. It not only ex- 
poses to hostile criticism the motives of those naturally most deeply 


interested in the patient's welfare, but prevents an early and free re- 
sort to measures necessary for hopeful treatment. For instance, a 
gentlemen of large property, — say half-a-million, — loses a hundred 
thousand by the Chicago Fire. This and other causes combine to 
produce a state of moderate depression, with fear of coming poverty. 
He is able to travel, to conduct himself well in public, reads the 
news in the hotel parlors, and sits at the general table. His wife 
seeks the best medical advice obtainable, and hospital treatment is 
suggested. Friends and relatives are consulted, and the usual aver- 
sion to this resort, except in cases of extremity, prevents their assent. 
The utmost watchfulness is enjoined, and all precautions possible in 
hotel life are taken. Meanwhile, the patient seems to improve under 
medical treatment, and the opinion is given that he will recover, if 
no accident occurs ; but not as quickly or as safely as in hospital. 
In this hopeful state of affairs, the patient suddenly leaps from an 
upper window, and is killed. For twenty-four hours the public is 
shocked that an insane man was allowed to be at large, and the next 
day the incident is forgotten. 

In another case, a lady has been subject to slight attacks of 
depression, lasting a few weeks only. In the last she has shown 
some slight suicidal propensity. The family will not listen to the 
suggestion of hospital treatment, and it is not urged, on account of 
the probability of recovery at home as before. A suitable treatment 
is prescribed, and the patient is promised a speedy cure ; but before 
the physician has reached home, his patient has put herself beyond 
the reach of human aid. 

A lady who had been moderately depressed for a few weeks, 
whose friends had been warned to watch her narrowly, while going 
quietly about her household duties, seized a hammer and killed her 
only son in the presence of the family. Being sent at once to 
hospital, she showed no recollection whatever of the act, and after 
the first few days, no signs of insanity which would have convinced 
a captious public, in the absence of any preceding act of violence. 
For two years she remained in hospital, apparently sane, was then 
discharged, and remains sane and well to the present day. Her 
husband, meanwhile, has twice insisted on admission to the same 
hospital, as insane, while presenting no evidence of intellectual aber- 
ration whatever. He, too, has recovered his mental equilibrium. 
In neither of these cases could a writ of habeas corpus have been 
successfully opposed, save for the homicide in the former, and the 
patient's admission of his mental disability in the latter. 

A gentleman goes home from business, and, having been troubled 
by recent losses, rises in the night, kills his children, and escapes to 
the water to drown himself. 

Another goes down to business in the morning, perplexed and 
discouraged, but apparently sane. At ten o'clock his wife receives 
a note, saying, "If you wish to see me alive, take the next train to 
B 1_." f n terror she starts for his boyhood's home in the coun- 
try, arrives, inquires for him in vain, searches, and finds him hang- 
ing in the barn. 



A man calls on a physician for advice for some nervous trouble, 
is sent to another for his opinion, meets this one's child playing near 
his father's door, and kills him on the spot. 

There is no end to such dreadful occurrences. Scores of cases 
happen within the personal knowledge of every man whose atten- 
tion is called to this subject. The newspapers, day after day, and 
year after year, teem with insane murders and suicides — almost in- 
variably by persons not thought to be in the least dangerous. Mel- 
ancholia of the mildest form, chronic mania, and dementia of a 
generally harmless type, and mania from drink, account for most 
of these deeds of violence. The writer once undertook to make a 
scrap-book of these pleasant items, but the material was so abundant, 
and the circumstances were so stereotyped, as to make it a tedious 
and profitless task. 

But the impression made on the public mind by these startling 
events seems to be very slight and transient ; and when a physician 
testifies to the possibly dangerous character of one of these tolerably 
sane persons, he will find plenty of opinions, ready formed, on the 
part of irresponsible persons, that there is no danger, or even no 
insanity. The physician and the judge feel the weight of responsi- 
bility for their opinions ; and the family know the pressure of a 
secret anxiety, which has been a constant companion by day and 
night. These outside parties, whose flippant opinions are so freely 
volunteered, are apt to forget their inconsistency when a catastrophe 
occurs, and to say, " I told you so." 

There is an impression in some minds that persons not insane are 
sometimes committed to hospital by conspiracy between interested 
relatives and corrupt physicians. That insane people who could be 
well enough managed, under favorable circumstances, outside, are 
sometimes committed, there is no doubt. The poverty of the indi- 
vidual, or the reluctance of relatives not legally bound for his sup- 
port, to interest themselves in his behalf, may keep an insane person 
unnecessarily in hospital. Under all the circumstances, however, 
it is the best and only place for him. But of sane persons confined 
in hospital as insane, the instances are extremely rare. The Com- 
missioners of Lunacy, for England, appointed ten or twelve years ago 
to examine into abuses, and prevent improper commitments, have not 
found a single case. I have known one case where there is reason 
to believe a mistake of this sort was made. 

A man of fair intelligence, and average social position, quarrelled 
with his mother-in-law, and, on one occasion, was so overcome by 
passion as to use personal violence toward her. His father-in-law, 
being of a peculiar turn of mind, assumed that this was the culmi- 
nation of sundry acts which, together, betokened insanity. A phy- 
sician was summoned at once, the case heard, and an attempt made 
to examine the supposed patient, who preserved an obstinate silence. 
Thinking this the freak of an insane man, the certificate was signed, 
and the patient taken to hospital. On arrival he had become cool 
enough to explain the situation, and to confess his hasty temper and 
unjustifiable violence. He quietly denied his insanity, and requested 


a thorough examination of all his acts. He moreover insisted upon 
staying in hospital till the question should be settled beyond a doubt. 
In three or four days it was possible to come to the conclusion that 
he was not insane. He was therefore discharged, thankful for the 
consideration his case had received, and determined to avoid future 
collision with his mother-in-law. 

The cases which, from time to time, vex the community, are not 
generally such as give rise to doubt in the minds of experienced 
alienists. The evidence of such is generally unanimous as to the 
existence or non-existence of insanity, when equally sufficient oppor- 
tunities for examination of the patient have been afforded. " A 
case which has for many years disturbed the courts and the com- 
munity, has recently been disposed of. It never gave rise to doubt 
or difference of opinion among competent medical observers as to 
the fact of insanity, but has unnecessarily excited passion and prej- 
udice in the minds of many not properly concerned in it. The 
following is an abstract of the last decision in the Phelps case : 

" His Honor Judge Ames, of the Probate Court for Suffolk County, 
reviewed the history of the respondent briefly up to the time of the 
present application for commitment, the hearing upon which had ex- 
tended over six months. Thirty days had been consumed in the 
examination of witnesses, eight of which the respondent, with 
scarcely any interruption, had occupied in giving her evidence. 
The fullest latitude had been allowed to both sides, and no evidence 
ruled out unless widely irrelevant. The decision had been carefully 
considered, and delayed for several months, in hopes some disposi- 
tion could have been made of the respondent satisfactory to all 

" Two questions were to be considered, viz. : ' Is the party insane ? ' 
and ' Is hospital treatment necessary? ' Upon the first there was evi- 
dently a division of opinion among the witnesses, which produced an 
insensible bias, though the testimony to facts was in the main fair and 
honest. The immediate family, and all the respondent's relatives, 
with the exception of one, whose position had not been clearly de- 
fined, had adopted and acted upon the theory of insanity. Upon 
that theory, their proceedings generally had been such as the case 
seemed to require ; and there was no evidence to justify any con- 
clusion, but that those whose duty it was to look after the best interests 
of the respondent acted in good faith, under competent medical ad- 
vice, and did what they believed, under the circumstances, it was 
their highest obligation to do. In such a case as this, under prov- 
ocation occasioned by interference from one quarter and another, it 
could hardly be expected that they would always act judiciously ; 
and upon any other theory than insanity, their treatment, in some 
instances, would not have been justifiable. 

"On the other hand, the respondent, being a lady of culture, and 
having naturally a good mind, with a strong will, perhaps intensified 
by disease, had made numerous friends, who espoused her cause, 
and could see no insanity in her. His Honor did not regard the 
testimony of these persons as negative, but as positive, as far as it 


went. He quoted cases from Dr. Ray's book on 'The Jurispru- 
dence of Insanity,' and mentioned others in his own experience, 
where the exhibitions of mental disease were limited entirely to 
the domestic circle, or only became apparent under opposition. He 
was astonished at the readiness with which even intelligent persons 
formed and expressed opinions in such cases, and firmly adhered to 
them, without taking any pains to inform themselves thoroughly of 
all the facts, upon both sides ; and at the amazing indifference with 
which the public regarded the frequent cases of homicide and suicide, 
by persons supposed to be harmlessly insane. 

" The opinions of the medical experts in this case were very de- 
cided. (The physicians called by the petitioner were Drs. Ray, 
Walker, Fisher, and Chase.) Although sharing the views of the 
legal profession upon expert testimony in general, he believed the 
evidence of experienced and respectable physicians the best that 
could be obtained in these cases. As in legal matters well-educated 
lawyers are the proper persons to be consulted, so well-educated 
physicians are to be consulted in medical matters, and medical wit- 
nesses who have been called for the petitioner stand at the very head 
of this most difficult department of medicine, and are men of intel- 
ligence, of very large experience in insane cases, and their testimony 
on this point seemed entirely fair, and without special bias. They 
are men whose professional aid in mental disease is eagerly sought. 
Their testimony was unanimous that the respondent was insane, and 
that hospital treatment, or its equivalent, was absolutely necessary, 
both for the respondent's sake and the good of her children. 

" Their opinion as to insanity was also sustained by the other evi- 
dence and his own observation. Upon all the facts in the case he 
could see no room for doubt, and was clearly of the opinion that the 
respondent was insane. 

" Upon the second point, the propriety of hospital treatment, he 
had little to say. He did not think the case required absolute re- 
straint, but it did require the constant supervision of some suitable 
person, satisfactory to the patient, if possible. He considered it out 
of the province of any judge, of his own legal knowledge, and inde- 
pendent of medical testimony, to determine what was the best treat- 
ment for a case of insanity like this. It was a medical matter, as 
much as the treatment of typhoid fever. In the absence of any tes- 
timony upon this point controlling that of the physicians alluded to, 
there was but one conclusion : that the respondent is a proper subject 
for hospital treatment, and is to be committed to some institution for 
that purpose. 

"He would give the respondent her choice of hospitals. In regard 
to the one at South Boston, he could say, from long expei-ience as one 
of its inspectors, that it was under most admirable management ; but 
as the accommodations for the insane in the matter of buildings and 
grounds entirely failed to furnish what such cases imperatively need, 
he should not designate that one for the treatment of this case." 

The laws relating to insanity in many of the States are rudi- 
mentary. It was formerly supposed that the family was to be 
trusted with the disposal of its own insane members, as in any other 


form of sickness. This confidence has declined of late years, and 
has led the American Association of Medical Superintendents to 
draft laws, applicable to all the States, for the protection of the in- 
sane and those to whose care they are intrusted. These proposed 
laws have been adopted in some States, but not in the majority. 
The problem is to prevent the possibility of abuse, and, at the same 
time, not to render the hospital difficult of access to the curable in- 

The laws in Massachusetts are well adapted to insure this result, 
without further change. The best security the public can have is in 
the character of its hospital superintendents, and here this State is 
also fortunate. For admissions to hospital, the laws of Massachu- 
setts require the certificates of two respectable physicians, given 
within one week after " due inquiry and personal examination " of 
the insane person. One of these must, if possible, be the patient's 
family physician. Notice must be given to the mayor or selectmen 
of the place where the patient resides, and a full written statement 
of the history and character of the patient's disease must be sent to 
the hospital for preservation. 

Patients may also be committed to the State or the Boston hos- 
pitals by any judge of the Supreme, Superior, Probate, or Munic- 
ipal Courts. Practically, this business falls into the hands of the 
Judges of Probate, the most fitting place for it. The judge may 
appoint a hearing at such place as he sees fit, and require or dis"- 
pense with the presence of the patient. He may summon a jury of 
six to determine the question of sanity ; but this proceeding is ex- 
ceedingly rare. A jury might as well be called to sit on a case of 
Bright's disease, or a cataract, as far as determinining the exist- 
ence of insanity is concerned. And for the protection of the pa- 
tient's rights, the presence of the judge is sufficient. 

Patients in hospital may be discharged by its trustees, or by any 
of the judges above named. The following provision is in addition 
to the writ of habeas corpus, which may be used for the insane : 
Upon petition, under oath, setting forth belief that a certain person 
is unjustly confined as a lunatic, made to a judge of the Supreme 
Judicial Court, the judge may appoint a commission of three to 
make inquiry. This body shall be sworn, and shall give notice to 
the petitioner or his counsel, and to the authorities of the hospital, 
shall summon and swear witnesses, hear evidence, and make per- 
sonal examination. No notice is to be served on the patient, nor is 
he to have counsel or be present at the inquiry. He is not to be ex- 
amined by petitioner or counsel unless by permission of his physi- 
cian, or by special order of the judge. The commission are to visit 
the patient at the hospital, and not to remove him. Report of com- 
mission being made, the judge takes such action as he deems 

In application for guardianship, the patient must be notified. An 
abstract of the laws relating to insanity in each State, by Dr. Ray, 
will be found in an Appendix to Dr. Blandford's recent work on 
Insanity and its Treatment. 

ALEXANDER MOORE, 2 Hamilton Place, Boston. 

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«♦» — 

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ALEXANDER MOORE, 2 Hamilton Place, Boston. 


.61 a- 

Date Issued ?>73. T 










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