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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TRANSFERRED TO
YALE MEDICAL LIBRARY

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.

BY

T. W. FISHER, M.D.,

LATE OF THE BOSTON HOSPITAL FOR THE INSANE.

BOSTON :
ALEXANDER MOORE

1872.

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

ALEXANDER MOORE,

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

PREFACE.

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.

T. W. FISHER.
171 Warren Avenue.
Boston, February, 1872.

(V)

CONTENTS.

TAGE

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

(vii)

•

PLAIN TALK

ABOUT INSANITY.

CAUSES OF INSANITY.

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-
stration.

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-

(i7)

:t8 CAUSES OF INSANITY.

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
insanity.

CAUSES OF INSANITY. I9

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

2o CAUSES OF INSANITT.

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
observed.

The relations existing between the brain and its bony envelope

CAUSES OF INSANITY.

21

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 : —

DIAMETERS.

Long diameter

Short

Diam.

Anterior Segment
Posterior "
Right Half
Left

SANE.
58.20
35- 2 5

35 -oo

25.20

17-35
17.80

AREAS.

Right Anterior Quarter
" Posterior "

Left " "

" Anterior "

Anterior Segment

Posterior "

Right Half

Left Half

Whole Area

INSANE.

55-08.

31.21.

33-57-

21.79.

I5-83-
15.08.

SANE. INSANE.

- 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

22 CAUSES OF 1NSANITT.

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 : —

SANE. INSANE.

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-

CAUSES OF INSANITY. 23

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
depression.

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

2 4

CAUSES OF INSANITY.

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.

THE FORMS OF INSANITY. 25

THE FORMS OF INSANITY.

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.

26 THE FORMS OF INSANITY.

Satyriasis.

Nymphomania.

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.

Dipsomania.

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-
pathic.

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

THE FORMS OF INSANITT. 27

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

28 THE FORMS OF INSANITT.

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
exhaustion.

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

THE FORMS OF INSANITT. 2 p

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

3°

THE FORMS OF INSANITY.

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 ! " ?

STMPTOMS OF INSANITT. »l

SYMPTOMS OF INSANITY.

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

32 SYMPTOMS OF INSANITT.

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

SYMPTOMS OF INSANITY. 33

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
agency.

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.

34 SYMPTOMS OF INSANITY.

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-

SYMPTOMS OF INSANITY. 35

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.

3 6 PARTIAL INSANITr.

PARTIAL 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-
ference.

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
plums.

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.

PARTIAL INSANITY. 37

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
consent.

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
witted.

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

3S PARTIAL INSANITY.

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

PARTIAL INSANITY. 39

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

40 PARTIAL INSANITY.

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,
witnesses.

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. , t

MONOMANIA.

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

4.3 MONOMANIA.

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
action.

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

MONOMANIA. 43

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
extravagances.

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

44 MONOMANIA.

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
projects.

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-

MONOMANIA.

45

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-

46 MONOMANIA.

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

MONOMANIA. 47

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 *

48 MEDICAL TREATMENT OF JNSANITT.

MEDICAL TREATMENT OF INSANITY.

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
unnoticed.

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

MEDICAL TREATMENT OF INSANITY.

49

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-

5° MEDICAL TREATMENT OF INS AN ITT.

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

MEDICAL TREATMENT OF INSANITT.

51

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

52 MEDICAL TREATMENT OF INSANITT.

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
action.

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

MEDICAL TREATMENT OF IN SAN ITT. 53

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.

54 MORAL MANAGEMENT OF THE INSANE.

MORAL MANAGEMENT OF THE INSANE.

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
question.

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,

MORAL MANAGEMENT OF THE INSANE. 55

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-

56 MORAL MANAGEMENT OF THE INSANE.

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

MORAL MANAGEMENT OF THE INSANE. 57

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
habitual.

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
requires.

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
answer.

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.

58 MORAL MANAGEMENT OF THE INSANE.

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."

HOME TREATMENT OF IN SAN ITT. 59

HOME TREATMENT OF INSANITY.

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

Co HOME TREATMENT OF INSANITY.

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
easy.

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
hospital.

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

HOME TREATMENT OF INSANITY. 6 1

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.

62 HOME TREATMENT OF INS AN ITT.

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
friends.

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
friends.

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
mania.

HOME TREATMENT OF INSANITY. 63

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-
sion.

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

64 HOME TREATMENT OF INSANITY.

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

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.

HOSPITAL TREATMENT FOR THE INSANE. 6$

HOSPITAL TREATMENT FOR THE INSANE.

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
discharges.

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

66 HOSPITAL TREATMENT FOR THE INSANE.

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

HOSPITAL TREATMENT FOR THE INSANE. 6j

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
diminished.

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

68 HOSPITAL TREATMENT FOR THE INSANE.

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

HOSPITAL TREATMENT FOR THE INSANE. 69

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
years.

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

70 HOSPITAL TREATMENT FOR THE INSANE.

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.

HOSPITALS AND ASTLUMS FOR THE INSANE. p

HOSPITALS AND ASYLUMS FOR THE INSANE.

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

73 HOSPITALS AND ASTLUMS FOR THE INSANE.

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
detention.

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
provided.

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

HOSPITALS AND ASYLUMS FOR THE INSANE.

n

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

74 HOSPITALS AND ASYLUMS FOR THE INSANE.

i
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,

HOSPITALS AND ASYLUMS FOR THE INSANE.

75

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.

76 HOSPITALS AND ASYLUMS FOR THE INSANE.

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

HOSPITALS AND ASYLUMS FOR THE INSANE.

n

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
State.

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.

78 MEDICO-LEGAL ASPECT OF INSANITY.

MEDICO-LEGAL ASPECT OF INSANITY.

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

MEDICO-LEGAL ASPECT OF INSANITT.

79

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

80 MEDICO-LEGAL ASPECT OF INSANJTT.

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
disease.

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

MEDICO-LEGAL ASPECT OF INS AN ITT. Si

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
example.

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-
6

«
83 MEDICO-LEGAL ASPECT OF INSANITY.

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

MEDICO-LEGAL ASPECT OF INSANITY. 83

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-
monwealth."

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.

84 MEDICO-LEGAL ASPECT OF INSANITY.

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.

MEDICO-LEGAL ASPECT OF INSANITT.

85

MEDICO-LEGAL ASPECT OF INSANITY.— Cent.

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.

86 MEDICO-LEGAL ASPECT OF INSANITT.

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
sensation.

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

MEDICO-LEGAL ASPECT OF INSANITT. 87

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.

SS MEDICO-LEGAL ASPECT OF JNSANITT.

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
cases.

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.

MEDICO-LEGAL ASPECT OF INSANITT. 89

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
relish.

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-

9°

MEDICO-LEGAL ASPECT OF INSANITY.

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.

MEDICO-LEGAL ASPECT OF INSANITT. gl

MEDICO-LEGAL ASPECT OF INSANITY— Concluded.

"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
unreliable.

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

MEDICO-LEGAL ASPECT OF INSANITY.

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

MEDICO-LEGAL ASPECT OF INS AN ITT. g3

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.

94

MEDICO-LEGAL ASPECT OF INSANITY.

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

MEDICO-LEGAL ASPECT OF JNSANITT. q e

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
parties.

" 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

96 MEDICO-LEGAL ASPECT OF JNSANTTT.

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

MEDICO-LEGAL ASPECT OF WSANITr. Q »

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-
sane.

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
proper.

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.

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