Observations on the deranged manifestations of the mind, or insanity

1barvar& TUnivereit^

Xtbrari? ot

XTbe /iDeMcal Scbool

XTbe em ot

i^^.i.e. \j^i.T<.

Vy

OBSERVATIONS

ON THE

DERANGED MANIFESTATIONS

OP

THE MIND,

OR

INSANITY.

BY J. G. SPURZHEIM, M. D.

LICENCIA.TE OF THE COLLEGE OF PHYSICIANS OF LONDON, AND OF THE
UNIVERSITIES OF VIENNA AND PARIS.

FIRST AMERICAN EDITION, WITH NOTES, IMPROVEMENTS,

AND PLATES.

WITH AN APPENDIX,
BY A. BRIGHAM, M. D.

Author of ' Remarks on the^nfluence of Mental Cultivation on Health.'

' NOTHINQ TENDS MORE TO THE CORRUPTION OF SCIENCE THAN TO SUFFER
IT TO STAGNATE.'

BOSTON:

MARSH, CAPEN & LYON.

1833.

^^0r?5^'^'n/l^

J'^i-'UAr^Y 2, 1329

'^^Vi^A^^O^

Entered according to Act of Congress, in the year 1833, by

Marsh, Capen & Lyon,
in the Clerk's office of the District Court of Massachusetts.

boston;
Kane k Co 127 Washington Street.

PREFACE.

Anatomy, Physiology, and Pathology are most in-
timately connected with each other; accordingly,
these three branches of medical knowledge are to
be cultivated together. Our investigations into the
structure and functions of the nervous system in gen-
eral, and the brain in particular, or into the depend-
ence of the manifestations of the mind on the organ-
ization in the state of health, have been published
some time ago. I now intend to communicate to the
pubhc my manner of considering the state of de-
rangement of the mental operations.

In anatomy and physiology, divisions may be esta-
blished according to the structure and functions of
similar organs, as of bones, muscles, blood vessels,
nerves ; or of single and individual parts, as of the
eye, teeth, liver, &c. With respect to the state of
disease, it is to be lamented that we must be too

IV^ PREFACE.

often satisfied with mere nosographical divisions, ac-
cording to the deranged functions of the different
parts, and that we have no true and satisfactory pa-
thogeny, that is, a doctrine of the nature of diseases,
which ought to be founded on the whole of the human
frame, and not on the morbid appearances of single
parts, which, being affected by the same disease, on
account of their different structure and functions,
must produce different symptoms.

The knowledge of man is divided into that of au-
tomatic and animal life. As automatic life is pro-
vided with nerves, it is also subjected to nervous
complaints, such as dysphagia, cardialgia, dyspepsia,
colica, asthma, &c. These disorders, however, do
not at all enter into the considerations of this work ;
nor shall I speak, with Cullen, Alusgrave, Fr. HofT-
man, Tissot, and others, of nervous disease, whenever
nerves are affected ; for in that acceptation every
disease should be called nervous ; nor with Whytt,
where sensibility is increased, because, according to
that definition, palsy should not belong to the ner-
vous disorders. Moreover, as the nerves of animal
life and the brain are not only in relation to, and

PREFACE.

dependent on, each other, but also to and on the
organization of automatic hfe, 1 cannot treat of the
derangements of the nervous system in general, and
of the brain in particular. Thus, 1 shall examine
only the derangements of the mental functions. These
are voluntary motion, the five senses, feelings, and
intellectual faculties. With respect to the mental
operations in the healthy state, I refer the reader to
my other v^^orks.

CONTENTS.

Preface
Introduction

PART 1.

DERANGEMENTS OP THE EXTERNAL FUNCTIONS OF THE MIND.

CHAPTER I.

DISORDERS OP VOLUNTARY MOTION

Convulsions ....
Epilepsy .....
Catalepsy ....
Palsy

CHAPTER n.

DISEASES OP THE FIVE SENSES .....

PART II.

DERANGEMENTS OF THE INTERNAL FUNCTIONS OF THE MIND

CHAPTER I.

DISEASES OF THE BRAIN . .

Cephalalgia, vertigo, and lethargic affections
Apoplexy ......

Phrenitis ......

Hydrocephalus acutus ....

CHAPTER n.

ll-^iSAltlXi. X «

SECTION I.

Definition

SECTION II.

Symptoms

SECTION HI.

Division

SECTION IV.

Causes

Page.

iii
I

15

The proximate'cause of insanity is corporeal
It resides in the brain . .

12

12
14
17
18

25

29

31
32

38
39

49

49

58
66

75

ib.
86

Vlll

CONTENTS.

On the nature of the causes of insanity
Idiopathic connate idiotism
Idiopathic occasional idiotism
Fatuity ......

Idiopathic mechanical causes of insanity
Is the shape of the head a cause of insanity
Idiopathic dynamic causes of insanity
Sympathic causes of insanity
Insanity is frequent in England

Forms of insanity
Fits of insanity

SECTION V.

SECTION VI.

Prognosis .......

SECTION VII.
Treatment of insanity .....

Moral treatment ......

Architectural requisites of a hospital for curable insane
Department for convalescents ....

Reception of patients .....

Cleanliness, air, and light . . . .

Temperature .......

Diet

Coercion .......

Treatment of the feelings .....

Treatment of the intellectual faculties
Occupations of the insane ....

Inspection and visitation . .

Medical treatment ......

APPENDIX.

Insanity ....

Epilepsy ....

Palsy ....

Apoplexy

Phrenitis

Hydrocephalus acutus

Idiots ....

Hallucinations, suicide

Monomania

Age has an influence on insanity

Hereditary insanity

Pathological appearances

Paj,'e.
88

90
100
103

ib.
105
110
119
123

129
142

147

156
157
161
169
170
175
176
177
180
184
186
191
194
202

233
238
240

ib.
242

ib.
243
245
246

247

248

ib.

INTRODUCTION.

Inquiries into the deranged manifestations of the mind, interest
mankind in general, and ought particularly to engage the attention
of physicians in Great Britain, where this affliction may be con-
sidered as almost endemical. Every one who has observed the
deplorable condition of insane people ; — who has witnessed the
disorders which take place in their feelings and intellectual mani-
festations ; — who, for instance, has seen that some individuals feel
the most distressing anxiety, and fancy themselves objects of hu-
man persecution or victims of Divine vengeance ; — who has re-
marked that ' often all the best principles of the human mind are
perverted, and a pious Christian changed into a drunkard and
abandoned felon ; ' * — that others, naturally of mild and pacific
dispositions, appear, during their attacks, to be inspired by the
demon of mischief ; — that some of known probity feel a blind pro-
pensity to steal ; — that others feel a ferocious inclination to com-
mit to the flames every thing of a combustible nature, or to imbrue
their hands in human blood ; — that modest females are seized
with the feelings of a loose libertine ; — that wretched persons
think themselves bishops, popes, lords, ministers, kings, emperors ;
— in short, every one who has observed that insane people often
lose, not only bodily health, but also their moral and intellec-
tual character, and, in consequence, their personal liberty ; and
that sometimes the figure of the human species is all that remains,
— must wish for the improvement of that branch of medicine.
Moreover, if we reflect that no one is secure from it ; that rich

** Dr. Parry. Elements of Pathology, vol. i. p. 331.
I

2 INTRODUCTION.

and poor, the laborious and sober laborer, and his master who in-
dulges in scenes of luxury, are all equally liable to this affliction,
humanity renders it a point of duty to contribute to the elucidation
of this subject.

It is generally admitted that insanity, and the method of curing
it, are not sufficiently understood. This study, indeed, has been
too much neglected. Physicians constantly make improvements
in the treatment of other diseases, but they have done very little
with respect to insanity. Theie exists no work of Hippocrates on
this complaint. It is uncertain whether he has written one, or
whether the work has been lost. In his treatise on Epilepsy, he
considers the bile, mixed with the blood and carried to the brain,
as the cause of mental derangement. The black bile, for instance,
was cause of dark passions, such as suspicion, jealousy, hatred,
and revenge ; while the yellow bile produced great irritability, high
spirits, and extravagance. He supposed pituita to operate as a
sedative principle to diminish the operations of the mind, and to
produce great depression of spirits, fear, anxiety, and despair.- —
Aretaeus, Celsus, Aurelianus, and Trallianus, may be considered
as the principal ancient writers on insanity. The Arabian physi-
cians adopted the speculations of their Greek and Roman prede-
cessors, modifying them according to circumstances and their own
prejudices.

* Medical writers of more recent dates,' says Dr. Davis, the
translator of the work of Pinel, ' neglected the study of individual
disorders of the mind. The unhappy lunatic was permitted to
subsist on his bread and water, to lie on his bed of straw, chained
to the wall of a dark and solitary cell, a being unworthy of solici-
tude in his fate, and a victim of our idle and interested maxim,
that insanity is an incurable malady. Of all the disorders to which
the human frame is unfortunately subject, it is remarkable that this
interesting malady has been most neglected. The treatises which
have been professedly written upon it, since the revival of litera-
ture in Europe, are all of late publication, and with a few excep-
tions, are mere advertisements of lunatic establishments under the

INTRODUCTION. 3

superintendence of their respective authors. These essays, with-
out being contemptible, have not contributed, in a great measure,
towards the elucidation of the theory, nor towards the successful
treatment of mental indispositions. They have seldom exhibited
those nice delineations of the peculiar varieties of insanity, depend-
ing on diversities of temperament, habits, intellectual abilities, the
faculties principally affected, and other causes, the knowledge of
which would be highly advantageous in practice ; — without clear
views of the nosology of the disease on which to establish their in-
dication, the professors of this department of the healing art, have
generally indulged in a blind routine of treatment, which has been
more cultivated to throw discredit upon its pretensions, than to ad-
vance our knowledge upon certain and unquestionable principles.'

In the time of Locke, madness was spoken of as an ungrateful
imputation. Until very lately, lunatics were not considered, in
several countries, as beings worthy of the public care ; they were,
and still are, permitted to wander about the streets, to the terror
of the timid, and to the horror of the charitable.* Even intelli-
gent practitioners either wholly neglect the victims of insanity, or
hastily consign them, as loathsome or terrific objects, to confine*
ment ; which was, and often still is, the only object of institutions
for insane persons, whether of a public or private description.
Every other treatment was, and mostly still is, overlooked.

The causes of our ignorance in insanity are numerous. First,
the examination of this subject is extremely difficult, and often
considered as beyond the medical profession. Instead of multi-
plying the observations, and making use of every opportunity,
medical people are, in a great measure, excluded from this branch
of practice ; and in general, they make the treatment of insanity,
not a leading part of their professional acquirements. Those who
have opportunity are often engaged in another line, and from want

* This neglect of the insane is a reproach to hximanity — and although Ameri-
ca may justly claim great credit for her benevolent institutions — yet in this re-
spect, her citizens have been too often regardless of their duty.

4 INTRODUCTION.

of time do not pay the due attention to this object. Others fear
any innovation, and, from want of courage to exercise their own
powers of reflection, follow the doctrines of their predecessors or
of titled contemporaries. It is, indeed, to be lamented, that from
public institutions and from private establishments, where opportu-
nity of inquiring into this disease occurs, no more medical com-
munications are made. 1 think with Pinelthat * he who cultivates
medicine ought to pursue a frank and open system of conduct, and
not seek to conceal the obstacles which he meets with in his course.
He ought to feel no reluctance to show what he discovers.' The
contrary, however, often happens. Indeed I have met with sev-
eral medical men who prevent others from inspecting their estab-
lishments, and who, as Pinel says, ' under the veil of secrecy, in-
tend to give a sanction to pretensions to which they have no just
nor exclusive claims.'

Moreover, nothing is done to teach medical pupils that which is
known. The notion of insanity, which any one acquires, depends
on his own application. There are no lectures on this important
branch of medical knowledge, while, at certain universities, medi-
cal students are obliged to attend lectures on the diseases of ani-
mals and on the veterinary art. I however think with Dr. Rush,*
that the knowledge of the human mind is so important even in
the general practice of medicine, that it should be the Vade-Me-
cum of every physician. Finally, it was quite impossible to im-
prove the doctrine of the deranged manifestations of the mind, be-
cause their healthy state was not understood.

The history of insanity is necessarily connected with that of the
human mind. Hence the different opinions of it are always con-
formable to the prevailing doctrines of philosophy. Those of the
ancient philosophers, who believed in the soul of the world, and
considered the soul of man as an emanation, the matter as inert,
and every activity as the effect of some spirit ; — those who ascrib-

* Sixteen Introductory Lectures, Philadelphia, 1811, p. 266. Lecture on the
Utility of a Knowledge of the Faculties of the Human Mind.

INTRODUCTION. 5

ed the efficient cause of all operations of man to the mixture of
the, elements of his body ; — others who admitted two principles, a
good and an evil one ; — or who maintained the existence of spirits
of different orders, and an intercourse between the spiritual and
material worlds, and who supposed invisible spirits to molest the
human soul ; — or who considered the soul as essentially pure, in-
corruptible, and the grossness of matter as the cause of the disturb-
ances of the soul ; — naturally, according to their theoretical opin-
ions, contended for different causes of the deranged manifesta-
tions of the mind, and modified their curative plan accordingly.

The earliest metaphysicians of Egypt, detached the history of
the mind, from the pursuits of natural philosophers, and ascribed
its deranged manifestations to the agent as independent of organ-
ization. This opinion has been propagated to future centuries.
During the period when the derangements of the mind were con-
sidered as the effect of malignant spirits, the priests pretended to
have more influence on such diseases, and more power over the
invisible cause, than the rest of mankind. They maintained that
they were able to drive out the evil spirits. Accordingly, the
treatment of mental alienations has been associated with the other
duties of the sacerdotal office.

In later ages the influence of the organization on the manifesta-
tions of the mind has been examined with more attention, and the
brain and nerves have acquired a degree of importance which they
did not possess in the estimation of ancient physiologists. Indeed,
it cannot be doubted that a perfect knowledge of the faculties of
the mind, and of the conditions under which they are manifested,
must lead to a better knowledge of their deranged functions.
Thus, we flatter ourselves that our anatomical and physiological
investigations will become the basis of a new doctrine on insanity.
Every one must agree with Haslam,* that ' whenever the functions
of the brain shall be fully understood, and the use of its different
parts ascertained, we may then be enabled to judge how far dis-

* Observations on Madness, 2d edit. p. 237.

6 INTRODUCTION.

ease, attacking any of these parts, may increase, diminish, or oth-
erwise alter its functions.'

There are general considerations of pathology which are over-
looked in the treatment of the deranged manifestation of the mind.
As, however, the diseased state of animal life, in many respects,
is to be treated in the same way as that of automatic life, and as
medical practitioners never ought to lose sight of these considera-
tions, I shall mention them succinctly.*

In medicine, the first notion to be acquired, is that of the differ-
ence between symptoms and disease. If the functions of the body
or its parts be disturbed, not the disturbance of any functions, but
the cause of this disturbance, is the disease. Hence, by far the
greater number of the pretended diseases are mere symptoms.

In every patient, a peculiar attention is to be paid to his bodily
constitution. Its influence on the susceptibility of diseases, and on
their curability, may be observed in whole nations, and in different
individuals of die same nation. Civilized people suffer many com-
plaints which are quite unknown to savages ; and these overcome
injuries and diseases, the tenth part of which would kill delicate
citizens. The greatest practitioners consider it as a maxim, that
weak and cachetic persons are easily and often affected, and that
their functions suffer the greatest disorders by insignificant causes,
which have not the least influence on strong and robust individu-
als. Moreover, not only general, but also local weakness is to be
considered. There are few persons who have not one part of the
body weaker than the rest. In many families the weakness of
various parts is even hereditary. On this account, the same dis-
ease often produces different symptoms in different individuals,
and affects in one patient the head, in another the thorax, in a

* Dr. Gall has examined this important subject of medical knowledge in a
work entitled, Philosophish Medicinische Untersuchungen ueber Natur und
Kunst im gesumden und kranken Zustande des Menschen : Wien, 1791.
Those who have perused with attention the first two chapters must regret that
the work has not been continued, and they certainly wish for a new improved
edition of the first two chapters, and for the completion of the whole.

INTRODUCTION. 7

third the abdomen, he, so that sometimes physicians are mistaken,
and declare the different symptoms to be different diseases.

Another consideration to be made in any disease is the relation
of the bodily constitution to the disease. It is known that epi-
demic diseases sometimes attack one species of animals rather
than another ; and in mankind robust persons sooner than weak.
Inflammatory diseases, for instance, are more dangerous to cer-
tain individuals than others. The susceptibility of diseases appears
different according to the sex, temperament, and age of the patient ;
to climate, season, weather, the nature of the disease, and its pe-
riods. The same disease, indeed, affects one system rather than
another, or in its different stages appears in different systems.
Even in the same individual, during the state of health or disease,
his excitability differs, and no exact inference can be drawn from
either of these states with respect to the other.

In the attempt to cure, it is necessary to distinguish the heal-
ing power of nature and that of art; to be acquainted with the
conditions which are indispensably necessary to nature ; with her
proceeding, and the means she employs, with her efficacy or im-
potence. It is only when provided with such a knowledge, that
we can imitate, support, weaken or direct her proceeding. It is
nature which preserves the healthy state, and nature is the princi-
pal agent in curing derangements of the system. There are,
indeed, an infinite number of cases where nature alone cures.
Her strong healing power is obvious, because health is restored
under quite different, nay opposite treatments. It is for that rea-
son that the greatest physicians do not agree with respect to the
most efficacious remedies. Every one attributes to his proceed-
ing the good success which he observes, while the patient owes his
recovery to nature alone. Van Helmont, therefore, said, ' Omnes
academiarum potestates connexse tantum non possunt qeam natura
absque illis sua sponte potest atque facit.' It is certain that, in
many cases, we rather should let nature be the chief physician.

The means of cure which nature employs are various. In this
respect, the symptoms, particularly the periods of diseases and the

8 INTRODUCTION.

crises, are to be considered. Moreover, the affected parts, their
irritability, their sympathy with other parts, the habit, and in a
certain degree the instinct of the patient, are to be examined.

There are, however, cases where the power of nature is not
sufficient, and where a rational proceeding will restore health,
while the impotent nature would sink under dissolution. Hippo-
crates, who observed nature, found many diseases mortal which are
cured in our days. For that very reason, Asclepiades was au-
thorized to call the proceeding of Hippocrates a contemplation of
death. — Nature, for instance, is for the most part insufficient in
cachexy, scurvy, scrofula, obstructions, indurations, dropsies, invet-
erate diarrhoea, dysentery, &ic. Yet we must admit that sometimes
nature cures even some of these diseases ; but if supported by
art she will produce the same effect in a shorter time, for which, if
let alone, she will require years.

In the medical treatment of any disease, it is of the highest im-
portance to consider the bodily strength, or, as it is commonly
termed, the vital power. Its influence is perceptible not only in
the origin, but also in the progress and issue of any disease, in its
convalescence and relapse. Without vital power, medical art is at
a loss. Weak patients then are not only subject to a greater num-
ber of disorders, but their diseases are also more dangerous. In
exhausted or worn-out patients diseases easily degenerate, and
show a less regular course. For the same reason, if in less dan-
gerous diseases the bodily power be too much diminished by art,
dreadful symptoms and incurable consequences take place. — The
convalescence also entirely depends on the preservation or restor-
ation of bodily strength, and the relapses are more or less frequent
according to the state of convalescence. Hippocrates, who neg-
lected to support the vital power, observed a great number of
relapses.

As bodily strength is of such importance, it is a pity that its
estimation is so difficult. Every disease and every individual pre-
sent particularities. The same symptoms, indifferent in one dis-
ease, indicate imminent danger in another, and in other mortal

INTRODUCTION. \)

diseases they are not at all observed. Hence it is necessary to
be acquainted with the whole course of any disease, and the ap-
pearances which happen under all circumstances.

The state of weakness deserves a particular attention of practi-
tioners. It seems to me that the division which Dr. Gall has
established in the above-mentioned work is the most practical.
He shows the importance of distinguishing suppression, fatigue,
and exhaustion of the vital power. Sanguine and robust persons,
for instance, at the beginning of an inflammatory disease feel very
weak ; even the pulse is sometimes suppressed. Bleeding, how-
ever, and the debihtating apparatus lake away the sensation of
weakness. A feeling of weakness from suppression may be pro-
duced from blood, saburra in the intestines, from contagious dis-
eases ; and it may always be suspected, if neither chronic diseases
nor any debilitating cause have preceded, if the bodily strength
sink suddenly, and if stimulating remedies increase the symptoms.
It may also be suspected, and often exists, if symptoms of exces-
sive weakness and great strength alternate or suddenly change.

In other cases, the feeling of weakness is the result only of fa-
tigue, and rest is the principal indication. This happens after
convulsive, hysteric, and hypochondriac fits, after a long continu-
ation of the same function, as of walking, standing, swimming,
speaking, watching, thinking. This sort of weakness is often
illusory, since it presents the same symptoms as exhaustion does.
The face, for instance, is sometimes pale, the eyes are staring,
the pulse weak and intermittent, and the patient seems almost
dead ; but this weakness soon disappears. Only if the cause of
fatigue continue too long, and act with excessive violence, real
exhaustion succeeds, and the plan to cure must be adapted
to it.

The third sort of weakness is founded on exhaustion, and ad-
mits various degrees. The causes are numerous ; such as, violent
diseases, chronic complaints, copious evacuations of blood, of
semen, continued vomiting and purging, want of food, protracted

o

IQ INTRODUCTION.

watching, painful affections, internal diseases which prevent nutri-
tion, &c. .

All these considerations are applicable to the diseases of animal
life, and it is my intention to show that the doctrine of its
derangedfunctions must be reduced to the general principles of

pathology.

PART I.

DERANGEMENTS OF THE EXTERNAL FUNCTIONS OF THE MIND.

The derangements of these functions, as to their definition, are
easily understood. Wherever voluntary motion, or the functions
of the five senses, deviate from their healthy state ; if, for instance,
the will has no influence on the muscles, or if the sensations of the
five senses be too acute, too weak, or irregular, they are said to
be diseased, just as any other part of the body. These diseases
are commonly treated in pathology under the class of nevroses,
and are arranged together with the nervous affections of the thorax
and abdomen, such as tussis convulsiva, asthma, dyspnoea, cardi-
algia, colica, he. As the functions of automatic and animal life
are essentially different, the former the result of organization, the
latter of the mind, I wish to separate the treatises on their derange-
ment. It is, however, to be observed that the causes of the disorders
of both sorts of functions must be reduced to the same principles,
as far as they always affect the organization. Hence he who
treats the derangements of animal life must be acquainted with
pathology in general. I shall give only outlines of the disorders
of the external functions of the mind, because they are examined
in many nosological works ; though I think that our knowledge
of them still admits great improvement. They are only a secon-
dary object of this work. I shall not, however, pass them over in
silence, partly for the sake of connexion, but particularly because
we shall find that the derangements of the internal functions of
the mind must be explained in the same manner as those of the
external senses. With this view only I wish my considerations
on the external senses to be read.

CHAPTER I.

DISORDERS OF VOLUNTARY MOTION.

In my opinion there are no peculiar diseases of the muscles.
These are only affected by various diseases or morbific causes,
such as inflammation, syphilis, contagious fevers, he. : their func-
tions then are deranged, and these derangements must appear
differently from those of other parts on account of their peculiar
structure and function. Convulsions therefore, as chorea, tetanus,
trismus, epilepsy, &ic. cannot be considered as diseases of the
muscles, but as symptoms which are produced by different causes.
This idea is the more plausible, that the same cause produces in
one individual convulsions in general, in another chorea, in a third
epilepsy, or tetanus, or trismus, &ic.

CONVULSION AND SPASM.

Every involuntary contraction and relaxation of muscular fibres
is called convulsion, while the mere contraction is termed spasm.
Convulsions are not necessarily accompanied with pain, and they
admit various modifications : they may affect single parts or the
whole body ; they may be of short or long duration, continual or
intermittent, periodical or of irregular appearance ; they are
accompanied with fever, or are not.

Different names are given to the spasmodic and convulsive affec-
tions, according to the affected parts and their external appear-
ances. Chorea means involuntary motions and gesticulations
over the whole body, or on one side, or in single parts, continual
or intermittent particularly during sleep, without pain, and with
preservation of consciousness. Tetanus is a continual cramp of

DISORDERS OF VOLUNTARY MOTION. 13

muscles, with immobility and rigidity of any part. That name,
however, is mostly applied to such a state of the whole body, that
is, if the whole body be extended and rigid like a statue. It is
called emjfjrostotanus, if the head be drawn forward and down-
ward ; in opistotanus the head is drawn backward and downward ;
and in pleurostotaniis it is drawn to one side. Trismus designates
the mouth shut, and the jaw-bone immovable ; in antitrismus the
mouth is open, and the jaw-bone stiff; in risus sardonicus the
muscles of the face are drawn as in laughter.

Wi^h several other writers, I consider these affections, not only
in acute but also in chronic diseases, as mere symptoms or conse-
quences, and not as the disease or cause. They are produced
by various causes, and these are the diseases. The proximate
cause must remain unknown as long as we do not understand that
which really happens in involuntary and voluntary motion. We
can only endeavor to point out the remote causes, and modify the
curative proceeding accordingly. The cause may be idiopathic,
that is, affect immediately the muscular apparatus itself; or sym-
pathetic, viz. the cause may reside elsewhere and influence the
muscles by sympathy. Moreover, the cause may be local, that
is, reside in one particular part ; or general, viz. extended over
the whole body. Local causes, for instance, are meconium,
saburra, worms, poisons in the intestines, difficult dentition ;
wounds, particularly of the soles of the feet, in the palms of the
hand, and under the nails ; painful surgical operations, such as
amputations, extirpation of a schirrus, extraction of a tooth, cas-
tration, cutting a nail too closely ; injuring a toe by stumbling in
walking ; calculi, bony excrescences which injure the nervous
system, repercussion of cutaneous affections, parturition, &:c.
General causes are, too great irritation of exanthemata, strong
painful emotions of the mind, as violent terror, a too great loss of
blood or semen, general weakness, a sudden refrigeration. Teta-
nus is easily produced by sudden application of cold to the body,
which was exposed to intense heat, as by sleeping on the ground
after a warm day, in the same way as exposure to a stream of

14 DERANGEMENTS OF THE EXTERNAL SENSES.

cold air produces a stiff neck. Now according to the remote
cause the treatment must be modified ; and the more easily the
former can be discovered and removed, the better is the prognosis
and the more easy the cure.

EPILEPSY.

The name epilepsy is given to convulsive motions of the whole
body or of several parts, accompanied mostly with suppression of
the external senses and the internal faculties. I say mostly, because
sometimes in slight fits, epileptic persons do preserve some kind
of consciousness, and the iris is contracted by the impression of
light. In strong fits, however, all sensation is lost, and the iris
immovable. Sometimes the fits take place suddenly ; sometimes
they are preceded by various symptoms, such as lassitude, anxiety,
difficulty of breathing, bad digestion, cardialgia, excretion of
copious pale urine, tinkling in the ears, deranged sensibility of the
five senses, overflowing of tears, giddiness, red face, aura epilep-
tica, &ic.

The fits themselves are accompanied with various symptoms.
Sometimes the epileptic person falls where he is ; sometimes he
walks without consciousness several steps, and sinks down, or he
is drawn by a rotary motion ; sometimes he continues to walk, but
without consciousness, till the fit ceases ; sometimes he is silent,
sometimes noisy and vociferous. He commonly, but not always,
contracts the fingers, particularly the thumb, suffers various con-
tractions and contortions ; there are often evacuation of saliva,
urine, or semen ; many gnash their teeth : the pulse is commonly
irregular, small, contracted, sometimes scarcely perceptible;
sometimes, however, it is large and full : sometimes there is a vio-
lent hiccough, &c.

The number of fits and their duration vary extremely. Some

individuals are attacked once in a year, others once a month, a

fortnight, a week, a day, or many times a day. After strong fits they

feel very weak, fall asleep, and sometimes he down for several hours,

*like apoplectic persons ; but the frequent pulse, the soft and per-

DISORDERS OF VOLUNTARY MOTION. 15

spiring skin, and the less deep and more natural respiration, remove
such an apprehension. When they awake they have not the least
consciousness of anything which happened to them during the fit.

Epilepsy, as I have mentioned, is a symptom ; the remote causes
are local or general. The former are often in the brain, and
often in the abdomen. Wounds of the head, fractures and de-
pression of the skull, bony excrescences, induration or osifications
of the blood-vessels or of the membranes, tumors, hydatid, or a
collection of any fluid in the head, may produce epilepsy. The in-
fluence of the peculiar irritability of the patient is evident, because
all these morbid phenomena have been detected after death without
previous epilepsy. Many persons subject to epilepsy have small
foreheads, and the upper posterior part of the head across the
summit, or across the midst of both parietal bones, elevated.
This configuration, however, is not observed in all who are subject
to this complaint, and it often exists without epilepsy: hence it
cannot be considered as a cause. The local affection of ihe brain
in many cases is obvious by the observation, that idiotism, insanity,
and epilepsy, often accompany or succeed each other. I think
with Dr. Parry* that it is scarcely necessary to advert to the
theory of the brothers Wenzel, who attribute idiophatic epilepsy
to a change produced on the pituitary gland. Ihave seen several
times that part disorganized by suppuration without preceding
epilepsy. Also at Bath, I opened, in presence of Mr. Normon
and Mr. Kitson, the head of a man who had been observed for a
long time by Mr. Norman. He had never suffered from epilepsy ;
the pituitary gland, however, and the neighboring parts, were
destroyed by suppuration.

Local affections of the abdomen, which sometimes produce
epilepsy, are sordes, acids, worms, poisons, calculi, pregnancy,
obstructions of the abdominal viscera ; other local causes are those
which I have quoted as producing convulsions. Epilepsy is
sometimes the result of a general cause. It is, however, seldom

Elements of Pathology, vol. i. p. 312.

16 DERANGEMENTS OF THE EXTERNAL SENSES.

a symptom of plethora ; it is more commonly the effect of general
debilitating causes, such as great and continual evacuations of all
sorts, onania, diarrhoea, hemorrhages; of continual night-watching ;
studying ; of disagreeable affections of the mind, as terror, anger,
hatred ; drunkards are subject to this malady. Finally, this dis-
ease is notoriously hereditary, like various convulsive complaints,
and many other disorders. For that reason, in families where it
prevails, it is carefully concealed ; whilst others feel justly disin-
clined to be allied by marriage to such families.

In ancient times, epilepsy was considered as the effect of evil
spirits, or as a punishment of angry divinities. It is known that,
among the Romans, epilepsy produced such a consternation, that
the popular assemblies were dissolved, and the afHicted relinquished
to their misery by their friends, as if they were objects of guilt.
They were considered as having offended divinities, and being
punished by them.

From the examination of the cause of epilepsy, it results that
there cannot be a general anti-epileptical remedy, or a general and
always uniform method of proceeding. If I am simply asked by
medical men for a remedy against any symptom termed disease,
I do not know whether I shall pity more the patient or the physi-
cian. Does not daily experience prove that there is not one
general remedy against any symptom ? The observation, that the
same remedies used against the same symptoms are praised and
blamed, can be explained only because the symptoms were either
produced by different causes, or the individual irritability and
strength of the patients were different. And in case of cure, are
we always certain whether nature or art has cured ?

Epilepsy is curable or incurable according to the cause and the
possibility of removing it. If the cause reside in a bad configu-
ration of the brain, or in an internal tumor, or in a collection of
any fluid, in a hydatid, or m any organic cause of that kind, no
remedy can be thought of. From ancient times it has been
observed that epilepsy often disappears at the climacteric years,
and that after puberty, if it be chronic, it is rarely or difficultly

DISORDERS OF VOLUNTARY MOTION. 17

cured. In these cases the cause is evidently constitutional ; and
at these periods of development a greater natural change takes place
in the organization, or is more easily produced by art than at other
periods of life. Hereditary epilepsy, as to cure, is of the most
difficult kind. Noxious things in the stomach or intestines must
be evacuated. Dr. Prichard has successfully treated several
epileptics with evacuants : in other cases he has not succeeded.
Every practitioner will find a sound judgment in his observations
how far cathartic remedies are serviceable, viz. by removing sordes,
by determining the fluids from the head, by setting up a new action
in the intestinal canal, by stimulating the absorbent system, and
invigorating the digestive organs."^ Sometimes zinc or nitrate
of silver has produced the desired effect. If pregnancy is the
cause of epileptic symptoms, the disease cannot disappear before
the cause be removed. If plethora produce epilepsy, bleeding
will cure; but what shall we think of those symptomatica!
physicians, who attack with bleeding every epilepsy, even those
which positively succeed debilitating causes ? In short, the
remedies and plan of cure are indicated by the cause : before this
is discovered, our proceeding is merely experimental.

CATALEPSY.

Catalepsy is that state of the muscular system, in which the
patients, without fever, lose voluntary motion, and commonly the
functions of the five senses, but preserve the mobility of the mus-
cles, and keep every position wherein they are attacked or arbi-
trarily placed by other persons. The duration of the fits varies ;
sometimes they last several minutes, sometimes several hours.

The causes of catalepsy seem to be seldom local, but mosdy
general. There have been examples where plethora has pro-
duced this singular disorder, and where it has been cured by a
spontaneous hemorrhage. This may be the case in suppressed
catamenia, though the suppression of the catamenia and catalepsy

Edin. Medical and Surgical Journal, Oct. 1815.

3

IB DERANGEMENTS OF THE EXTERNAL SENSES.

may result from the same cause. Dr. Parry of Bath,* in a violent
case with total insensibility, by pressure on both carotids, uniformly
suspended the symptoms and restored the patient's senses, while
pressure on one carotid only had no perceptible effect. Mostly,
however, the causes are of a debilitating nature, and painful emo-
tions of the mind, as unfortunate love, terror, grief, anger, &xj.
These affections certainly will produce a greater determination of
blood to the head, while the bodily strength is diminished. The
plan of cure must be modified accordingly.

PALSY.

Palsy is the deprivation of the power to move. In most cases
the sense of feeling is destroyed at the same time. Palsy may
also be partial, such as of the lower or upper extremities, or of
one limb ; of the muscles necessary to respiration, to mastication,
deglutition, to language ; or of internal parts, as of the stomach,
intestines, anus, bladder, uterus. Or it is general over the whole
body, or on one side. This latter case is termed hemiplegia.
Palsy may take place suddenly or by degrees.

The observation that sometimes both voluntary motion and the
sense of feeling are destroyed, and sometimes only one, while the
other continues, is very ancient ; and from it the inference was
drawn that there must be two sorts of nerves, those of motion and
those of feeling. In my work on the Anatomy of the Brain I
have mentioned several other reasons, which convince me of the
existence of these two sorts of nerves.

In palsy, as in any other disorder, the first examination to be
made concerns the parts which are affected, and the functions
which are disturbed. Then the cause of the disturbance is to be
discovered. In palsy, the disorder may reside in the brain, in the
nervous cord of the spine, in the abdominal viscera, or in the
paralytic parts themselves. Hemiplegia originates from various
injuries of the brain. By our anatomical investigations we have

"* Lib. cit. p. 349.

DISORDERS OF VOLUNTARY MOTION. 19

pointed out the cause, why the injuries of the brain on one side
of the head produce sometimes morbid symptoms on the other
side of the body, sometimes affect the same side, and sometimes
excite morbid appearances on both sides. One side, for instance,
may be paralytic, while the other is attacked with convulsions ;
one side may lose voluntary motion, and the other the sense of
feeling. These different phenomena are founded on the commu-
nication of the cerebral parts with the nerves of the body. The
pyramidal bundles of what is called the medulla oblongata form a
decussation, the fibres of each bundle arising from the opposite
side and crossing each other. Hence all cerebral parts which are
in connexion with these pyramidal bundles are in communication
with the nerves of the opposite side, while the other cerebral parts
communicate with the nerves of the same side. As to farther
anatomical details, I refer the reader to my work on the Anatomy
of the Brain. Thus, if the cerebral parts connected with the
pyramids be injured, their influence is propagated to the opposite
side, while the injuries of the other cerebral parts have an influence
on any part of the same side Moreover, the observation that the
parts of the face provided with the fifth and sixth pairs of the sup-
posed cerebral nerves, and the facialis, are affected on the same side
of the body, finds also its explanation in the anatomical structure ;
that is, the supposed cerebral nerves of voluntary motion communi-
cate with the nervous apparatus of that side of the body which is
affected by hemiplegia. Hence the influence of the injury of the
brain on the opposite side may be propagated upward as well as
downward, that is, to all similar parts which are in communication
with each other. Finally, anatomy explains not onlj^ some cases
in which the eye of the side opposite to the injury of the brain,
but sometimes the eye of the injured side is morbidly affected ;
that is, only a part of the optic nerve forms a decussation, and an
injury which affects the part of the optic nerve anterior to its
decussation, or the upper external ridge of the optic nerve, from
the decussauon to the corpus geniculatum externum, will disturb
the sense of vision on the same side of the injury.

20 DERANGEMENTS OF THE EXTERNAL SENSES.

The cause of almost every hemiplegia exists in the brain ; and
and this mjiy be particularly supposed, if any functions of the head
be diseased at the same time. The causes of hemiplegia residing
in the brain are various. Besides violent injuries from without,
such as blows, fractures, depression of the skull, violent concus-
sion, there may be a collection of fluid matter, as of blood or of
serum, tumors, suppuration, or other morbid affections, such as
indurations, ossifications of the blood-vessels, &,c. All these
causes may be called local.

The general causes which may produce palsy are violent
affections of the mind, as terror, grief, anger, abuse of physical
love, general weakness, and exhaustion from any debilitating cause,
such as too large and continued evacuations, refrigeration in
bathing, suppression of habitual evacuations and repercussion of
cutaneous eruptions. Sometimes palsy is a symptom of the ague
or of tooth ache ; it may be also the effect of mercury, lead, or
arsenic, as it often attacks those who work in mines and factories.
That it may be the result of lead, we learn by the history of the
colica pictonum, and because it sometimes originates from the use
of wine adullered with lead.

Palsy of the whole body or of one whole side is less common
than that of the upper or lower extremities, or of single parts. I
doubt whether palsy of the lower extremities alone, or of one single
part, has so often its cause in the brain as it is said. Formerly
such an idea could have been adopted and supported by the
erroneous opinion that all nerves originate in the brain. But as
the contrary is anatomically proved, I think that, in many cases,
the cause may also reside either in the nervous cord of the spine,
or in the abdominal viscera, or in the affected limbs themselves.

The morbid affections of the nervous cord of the spine are far
more frequent than it is commonly believed. It is too seldom ex-
amined after death. The dissection of the vertebral canal is too
difficult, and discourages the anatomists. If there be no external
morbid appearance of the vertebrae, physicians do not think of
dissecting this important part. Dr. Sanders of Edinburgh, how-

DISORDERS OF VOLUNTARY MOTION. 21

ever, is to be excepted from this reproach. In him I have wit-
nessed the greatest ardor to investigate the morbid affections of
spinal cord. There is no trouble which prevents him from open-
ing this part of the body. His labor has already been rewarded
by new observations of morbid appearances, especially by point-
ing out the congestion of the blood-vessels after convulsions ; an-d
his continued investigations may throw still much more light on
this hitherto neglected object. Dr. Parry judiciously remarks,*
* The effect of a blow on the ulnar nerve in the elbow, which
produces a tingling in the little finger, shows that a disorder may
be almost equally perceived in that part of a nerve which is con-
siderably more distant from its origin than the spot on which the
irritation was made. This is indeed an illustration of the symp-
toms of paraplegia, which, though usually situated in the spinal
marrow, is chiefly perceived in the limbs.' He adds,f ' In scia-
tica the pain is, by the patient, often referred chiefly to the ram-
ifications of that nerve on the outside of the knee, leg, and ancle.
One may, however, often discover the origin of the complaint by
pressure behind the great trochanter, in which case the patient
will not only feel that part tender, but the pain of the knee and
ancle will be much aggravated.' The spinal cord is composed of
a nervous mass, has the same membranes as the brain ; hence it
may be affected by the same diseases as the brain, such as inflam-
mation, suppuration, induration, tumors, congestion, or ossification of
the blood vessels, collection of any fluid, by irritation, weakness, or
exhaustion of the nervous mass. The spinal cord may also be
injured or compressed by the deviation of the vertebrae.

PottjJ however, has proved that, in the disease termed incurva-
tion of the spine, there is no unnatural pressure, though the use of
the limbs is lost. He therefore separates entirely this distemper
from palsy. * In true palsy,' says he, ' from whatever cause, the

* Lib. cit. p. 3G2. tLib. cit. p. 364.

t Pott's Chirurgical Works, by Sir James Earle, vol. ill. Art. on Palsy of the
Lower Limbs.

22 DERANGEMENTS OF THE EXTERNAL SENSES. •

muscles of the affected limb are soft, flabby, unresisting ; the limb
may be placed in almost any position or posture. If it be lifted
up and then let go, it falls down ; and it is not in the power of the
patient to prevent or to retard its fall. The joints are easily and
perfectly moveable in any direction. In the other disease the
muscles are rigid ; knees and ancles acquire a stiffness not very
easy to overcome.' He shows that there is never a real disloca-
tion of the vertebras, but always caries ; that without erosion and
destruction of the substance of vertebrae there is no curvature,
and therefore the curve is from within outward ; that the curva-
ture accompanies the caries of the substance of the cervical and
dorsal vertebrae, while the same disease of the lumbar vertebrae
commonly exists without curve. Moreover, he proves that the
curvature is not the cause of the useless state of the limbs, since
it remains, though the patient recovers health and the use of the
limbs. He ascertains that many complaints of the thorax and ab-
domen are the consequence of the same disease which causes the
curvature of the spine ; that a morbid state of health is previous to
the deformity, such as pain and tightness about the stomach, indi-
gestion, want of appetite, disturbed sleep. Pott considers this
disease as the same scrofulous disorder which occasions the thick
upper lip, the ophthalmia, the indurated glands on the neck and un-
der the, chin, the obstructed mesentery, the glairy swellings of the
wrist and ancles, and the enlargement and caries of other bones.
Sometimes the vertebrae are attacked in various degrees ; the sub-
stance, for instance, is sometimes eroded. Finally, in the same
way as the general complaints exist previous to the deformity, the
general complaints disappear gradually before the • limbs recover
the smallest degree of their power of moving.

Paralytic affections of the lower limbs are often an effect of dis-
order of the digestive organs. Mr. Abernethy quotes several facts
which he has observed.* Finally, in palsy the muscles them-
selves may be idiopathically affected" by compression of the nerves

* Surgical Observations on Local Diseases,

DISORDERS OF VOLUNTARY MOTION. 23

in their course, or by ossified blood-vessels in the limbs, where
the ossified arteries prevent the blood from going to the parts,
and the ossified veins oppose its reflux. Refi-Igeration seems to
be not an unfi-equent cause of this partial palsy. By the kindness of
Baron Larrey at Paris, I have seen several soldiers who, during
night, were exposed to cold and wet weather, and who in the
morning felt stiffness in one or the other lower limb, which by de-
grees diminished, attacked the whole body, and was succeeded
by death.

According to all these different causes the plan of cure must
be modified. If a local disorganization of the brain, or a collec-
tion of any fluid in the brain, be the cause, the disease is incura-
ble. If it originate from a depression of the skull by violence,
the operation of trepanning must be performed, and the broken
portions removed. If it be a symptom of a general disease, as of
gout, fever, inanition, the plan must be adapted to the general
disease. If it result from repercussion of cutaneous eruptions, or
from drying up habitual drains, then issues, blisters, setons, artifi-
cial eruptions of the skin, and remedies acting on the skin, are to
be administered. If it have been produced by lead, the reme-
dies against the colica pictonum in general are also indicated
against this symptom.

If the cause reside in the spine, it may be in the nervous sub-
stance, in the membranes, or in the vertebrae injuring the nervous
mass. I have already mentioned that Pott has ascertained that,
in the disease called curvature of the spine, the deformity alone
does not produce palsy, but that the general disease affects par-
ticularly the spine. Nobody, however, will object that at the same
time, the body may be brought into a suitable horizontal position,
and supported by convenient machines, as is done with a broken
limb. But after the considerations of Pott it is by no means rea-
sonable to consider every palsy of the lower extremities as the
result of weakness and softness of the spinal vertebrae, even where
there is no external appearance. Indeed it seems unpardonable

24 DERANGEMENTS OF THE EXTERNAL SENSES.

to condemn every patient with palsy of the lower extremities for
months, nay years, to a horizontal position, because there are a
few cases where such a treatment is indicated. Such a proceed-
ing must be injurious to the general state of health, and I know
positively that the cases where it has succeeded are less numer-
ous than those where it has failed. It is beyond doubt that Pott's,
or the Arabian method of treating palsy of the lower limbs, even
where there is no curvature, has cured a greater number of patients
than the horizontal position without issues.

If weakness of the abdominal viscera produce palsy, the object
of the plan of cure is to restore the digestive power by means
adapted to the individual irritability of the patient, such as evac-
uants in small doses, bitters, bark, iron, and tonics in general.

From the preceding considerations it results that, in the state of
involuntary motions of the muscles, or in the state of impossibility
to move them by the will, the cause may be idiopathic or sympa-
thetic, and that the latter case is the most common ; that the de-
ranged manifestations are mere symptoms, and that, as to the
method of cure, the remote cause must be discovered and re-
moved.

CHAPTER II.

DISEASES OF THE FIVE SENSES.

The natural order leads us to the examination of the disorders
of the five senses. I have mentioned why I give outlines, and
merely outlines, of the disturbances of the external functions of the
mind. The organs of the five senses are subject to various affect-
ions. Several of them form the object of the peculiar study of
certain individuals. There are, for instance, oculists, while others
investigate particularly the disorders of the skin. The disturbances
of these parts, however, are not always local : hence those who
examine the diseases of the eyes or skin must possess a knowledge
of the functions and disturbances of the body in general, and of
the mutual influence of the difierent parts on each other. It is
known, for instance, that tooth-ache is sometimes merely a symp-
tom of pregnancy, or of a general nervous irritation. Its treat-
ment then must be conformable to the general state of the body,
and not merely confined to the teeth. Blindness is sometimes
merely a symptom of another disease, and will be cured along with
the other disease, if no part of the organization have been de-
stroyed. The operative part of oculists, like operative surgery
in general, may be learned by itself; but the dynamic laws of
physiology and pathology are essentially the same throughout the
whole organization, and their study is necessary to every one who
practises the healing art.

The sense of feehng may be increased, diminished, or perverted.

Sometimes the least touch is painful to gouty patients. In plica

polonica patients sometimes feel great pain from their hair being

cut. On the other hand, there occur individuals who are quite

4

26 DERANGEMENTS OF THE EXTERNAL SENSES.

insensible to pinching or piercing the skin with a needle. Other
patients feel cold or heat in opposition to the indication of the
thermometer. Some feel a burning heat when nothing is to be
seen on the skin. These and various other morbid affections of
the nerves of feeling are mostly symptomatical, and are to be
treated in connexion with the general complaint. External applica-
tions to the skin, however, such as bathing, anointing, blistering,
fomenting, rubbing, setons, moxa, issues, often greatly assist the
internal treatment.

The same observations may be made with respect to smell,
taste, hearing, and seeing. Their sensibility is increased, dimin-
ished, or perverted. Some patients distinguish odors and savors
with greater accuracy than in the state of health. Too strong
impressions from without, or often general diseases, blunt their
power. Sometimes patients like the taste of things which would
be disgusting to them in health. Sometimes hearing is extremely
acute ; sometimes the irritability of the eyes is so great that they
cannot bear day-h'ght, and see at night. In others, hearing and
seeing are weakened, or quite destroyed. Others smell odors,
see colors, hear voices, in short, perceive impressions, which do
not come from without ; others see single objects double, hear
music half a tone too low, he. These and various other disorders
exist with or without pain.

As to the causes of the deranged functions of the five senses,
the same general considerations obtain. The individual nerves
may be affected for themselves ; they may, for instance, be in-
flamed or affected by a greater vascular action, or diminished in
size, disorganized, or morbidly affected by general diseases, like
every organic part ; or their functions may be deranged on ac-
count of a diseased brain, or on account of disorders of the abdo-
minal viscera. Worms in the intestines, for instance, may affect
all the senses ; they may produce pain in the limbs, tickling in the
nose, cough, grinding of the teeth, disagreeable smell, blindness,
deafness, and other symptoms. Derangements of the five senses
are often precursory symptoms of apoplexy.

DISEASES OF THE FIVE SENSES. 27

Thus, the disorders of the five senses are to be considered ac-
cording to the general piinciples of pathology. The nature of the
disease or its cause require our principal attention. Amaurosis,
or deafness from rheumatism, or from repelled cutaneous affec-
tions, must be treated differently from the same morbid appearance
when it is the result of spasmodic affections. In general diseases,
the functions of the five senses are mostly disturbed, but in
curing the general disease all individual symptoms disappear. —
After the nature of the disease, the individualities of the patient
are to be considered. In scrofulous subjects, or in persons of
robust constitution and sanguine temperament, the disorders of
the eyes and ears require a modified, though essentially similar
treatment. The farther details belong to the general pathology.
I have considered the object only in a general view, since I
intend to show the analogy between the disorders of automatic life,
and those of the external and internal senses.

PART II.

DERANGEMENTS OF THE INTERNAL FUNCTIONS OF THE MIND.

From the preceding considerations it results that the external
functions of the mind, viz. voluntary motion and the five senses,
are disturbed and cured according to the general principles of
pathology. They are sympathically aiFected in various diseases,
and suffer often idiopathically. Moreover, sometimes a morbid
appearance is perceptible in the organization, and sometimes no
organic change can be detected. We shall find that all these ob-
servations may be made with respect to the internal functions of
the mind.

It is known that the internal operations of the mind are often
deranged in general diseases, such as in fevers, inflammations,
gout, &c. ; and every one admits that delirium, stupor, vertigo,
lethargic affections, even apoplexy, depend on the cerebral organi-
zation. But, by our ignorance with respect to the functions of the
brain, far the greater number of the deranged manifestations of the
mind have not yet been generally considered as disorders of the
cerebral organization. I think, however, that, as in the disorders of
any oiher organic part we always consider at the same time its de-
ranged functions, and in observing the deranged functions we think
of its disturbed organization, our proceeding in regard to the brain
ought to be the same. Those who speak of diseases of the mind
alone may speak with the same reason of diseases of the mere
vital principle in liver complaints, or in disturbed digestion, or in
its idiosyncrasies. Such physicians may confine their plan of

30 DERANGEMENTS OF THE INTERNAL FUNCTIONS, &C.

cure to a moral treatment of the archeus, in cases where a person
cannot digest mutton or cauliflower.

Meanwhile I am obliged, in a certain degree, to render my con-
siderations comformable to the general division of nosography; but
the time may come when the derangements of the mental opera-
tions, and the disorders of the brain, will be classed in the same
order, ajid only the different disorders of the brain will be spoken
of, as is actually the case with the five senses and their organs ;
when it will be admitted that the deranged functions of the mind
are sympathic or idiopathic affections of the cerebral organs ;
finally, when it will be believed that what happens in all other
bodily parts occurs in the brain, viz. that every perceptible de-
rangement of the organization does not visibly affect the function,
and that every disturbance of function is not accompanied with a
visible alteration in the organization. Accelerated circulation of
blood does not always derange the function of the stomach, nor
that of the brain. There are cases on record where a considera-
ble disorganization of the lungs had not disturbed respiration, and
was detected only after death. More details of this kind are men-
tioned in my work on Phrenology, where I answer the objection,
founded on the injuries of the brain, against the proposition that
the brain is the organ of the mind.

I shall, therefore, first treat of those disorders which are gener-
ally admitted as diseases of the brain, and then examine the prin-
cipal object of this work, viz. Insanity.

CHAPTER I.

DISEASES OF THE BRAIN.

Cephalalgia^ Vertigo, and Lethargic Affections,

In animal life there are various morbid appearances which
have received individual names, and are often considered as pe-
culiar diseases. They are, however, mere symptoms, which may
originate each from the same or from various remote causes.
Such as Cephalalgia, or head-ache : Vertigo, or giddiness,
that is, an illusory rotation of all objects around us, and of our-
selves, with a fear of falling : Lethargy, coma or drowsiness,
with its different degrees ; Cataphora, for instance, when the pa-
tient sleeps much and is roused with difficulty, when he looks up or
answers, and again relapses into profound sleep ; or Cams, when
the patient is not to be excited by noise, shaking, nor even
by pinching the skin : Lipothymy or fainting, that is, a less or
greater degree of suppression of animal life, while respiration and
circulation continue : finally, Syncope, when all powers of the
mind are suppressed, and pulse and respiration diminished.

The proximate cause of these morbid appearances is not known ;
it affects particularly the senses and the brain, and for that reason
I mention these disorders. The remote causes are multifarious,
such as injuries of the head ; pressure on the brain by a conges-
lion of blood, by a collection of water or serous matter, by exojs-
toses ; inflammation; strong mental affections, as love, fear, grief,
joy, anger ; complaints of the intestinal canal, as indigestion,
flatulency, worms ; intemperance, or abuse of spirituous liquors ;
protracted studies ; busy days and resdess nights ; diseases of

32 DISEASES OF THE BRAIN.

the heart ; pregnancy ; hysteric and hypochondriac disorders ;
inanition from fasting, too violent exercise, evacuations of blood,
of semen, or sweat ; epidemic and all debilitating diseases ;
erect position in weakness ; repelled cutaneous eruptions ;
vitiated atmosphere in playhouses or in crowds ; the smoke of
various poisonous objects, as of sulphur, arsenic, he. ; various idi-
osyncrasies, if, for instance, a person cannot bear the smell of flow-
ers, of a cat, the sight of a frog, &:c. ; sometimes merely old age.
The prognosis and cure vary according to the remote cause,
which can be removed or not. In mechanical injuries burgical
operations are often required ; in saburra, an emetic ; in plethora,
phlebotomy; in spasmodic affections, nervina; in weakness, tonics.
Every thing that stimulates the brain is to be avoided; the
scalp may be washed with spirits, and so on. The nature of the
disease and the whole constitution, and not the individual symp-
toms, are to be kept in view. Thus, the deranged functions of
the brain, such as delirium, stupor, lethargic affections, &c. cannot
always be treated in the same way, since they may be produced
by various causes. If rheumatismus vagus, or the gbut, be the
cause, or a congestion from inflammation or from weakness, the
treatment must be different. Bleeding in one case will do no harm,
while in the other it will relieve. In short, in the brain, as in any
other organic part, all general principles of pathology are to be
considered and applied.

APOPLEXY.

Apoplexy is a more or less sudden suspension of the functions
of animal life. The name has arisen from the particular appear-
ance of instantaneous death. It is, however, to be remarked that
the apoplectic attack is not always instantaneous or general, but
often gradual and partial. The symptoms of this disease are
much modified. Sometimes a person seems to be in good health,
cheerful in society, and instantaneously sinks dead on the ground,
without a sigh or a groan. Often there are precursory symp-

APOPLEXY. 33

toms, such as tinnitus aurium, muscae volitantes, temporary fits of
blindness, heaviness of the eyes, head-ache, tightness across the
forehead, confusion of ideas, drowsiness, vertigo, loss of clear
consciousness, of speech, of voluntary motion, of the five senses;
inactivity of the mind ; convulsions, epilepsy, flushed or livid coun-
tenance, restless nights, anxiety, palpitations of the heart, forget-
fulness ; slow, difficult and interrupted respiration ; slow and full
pulse ; inactive secretions, relaxations of the sphincters, inaptitude
to swallow : partial palsy, or even hemiplegia, is a frequent symp-
tom of apoplexy.

Apoplexia belongs to the complaints which are hereditary, and
certain constitutions, such as plethoric temperaments with a short
neck and large head, or pituitary temperaments with a dropsical
state of the cellular membrane, are the most liable to it.

The proximate cause of apoplexy is connected with changes of
the brain, which may go on for a considerable time. This opin-
ion is founded on the previous disorders of its functions, and on the
various organic changes detected on dissection. Undoubtedly the
scalpel in the hand, or dissection after death, is the best way of
investigating the seat of the proximate cause of diseases. In divid-
ing the scalp there is often a great flow of blood from the frontal
and occipital veins ; the membranes of the brain are often thick-
ened, the arachnoidea is sometimes opaque, the veins turgid with
dark blood; in general a great congestion or determination of
blood to the head is observed. The consistency of the brain is dif-
ferent, as is the case in other individuals who do not die apoplec-
tic. Three appearances are particularly remarked, viz. there is
an extravasation of blood in the ventricles, or at the basis of the
brain and cerebellum ; or there is a serous effusion, sometimes
accompanied with suppuration or tumors; or there is no extra-
vasation at all. Accordingly, long ago, apoplexy has been divid-
ed into sanguineous, serous, and nervous.

With respect to sanguineous apoplexy it may be asked, on what
sort of laceration the effusion of blood depends, whether on dila-
tation and weakness ; or on erosion and suppuration ; whether on

34 DISEASES OF THE BRAIN.

the large or small vessels ; and in what part of the brain ? The
blood-vessels may break at all parts of the brain and cerebellum,
in the cavities and at the surface, in the same way as in other
parts, on the legs, for instance, in the abdomen or thorax. An
effusion, however, at the basis, towards the medulla oblongata,
produces the most certain and sudden death.

It seems to me that anatomists, in dissecting the brain, are not
sufficiently attentive to the different degrees of density of the blood-
vessels. In the inflammatory state of the brain I have found them
very firm ; in chronic dropsical affections, in flaccid and pituitary
temperaments, weak and fragile. Dr, Cheyne, in his Treatise on
Apoplexy,* relates the history of a man who, by beating his wife,
killed her, while she was in a state of intoxication. A ruptured
vessel and effusion of blood was the cause of her death. Mr.
Charles Bell, who made the dissection, declared that there was a
state of the blood-vessels in which an external injury or shock is
more apt to produce rupture, and that drunkenness may be supposed
the artificial excitement which produced this state of the vessels.
When I was at Liverpool, a sailor received from another man a
blow on the head, and fell dead to the ground. A large effusion
of blood at the basis of the brain was the cause of his death. The
substance of his brain was soft, and the blood-vessels extremely
delicate. Intoxication, indeed, predisposes to such an event for
two reasons ; it increases the determination of blood to the head,
and also weakens the texture of the blood-vessels, so that a less
violent blow may produce rupture than what in other circumstan-
ces would have proved fatal.

Among the remote or occasional causes of sanguineous apoplexy,
the first to be considered is the hereditary and constitutional dis-
position. Other such causes are intoxication, repletion of the
stomach,! intemperance, and a luxurious life, violent exercise in

* Page 218.

t Mach, and perhaps justly, is said with respect to intemperance ; but the
terra seems to be fixed by usage only with reference to an imprudent use of ar-
dent spirit. It should be remembered by those who are active in the cause of

APOPLEXY. 35

hot weather, a great muscular effort after a full inspiration, violent
exertion during child-bed, stooping, tight constriction of the blood-
vessels of the neck by cravats, costiveness, vomiting, and every
thing which produces an accumulation of blood in the head, and
weakness of the blood-vessels.

A serous apoplexy is observed in adults under circumstances
which in children produce hydrocephalus acutus ; that is, in indi-
viduals with an inflammatory diathesis of the brain, where the
great determination of blood to the head produces a serous effu-
sion. In strong individuals it may appear as phrenitis. In weak
persons its progress is slow, and the modified appearances induce
those physicians, who consider merely symptoms and not the na-
ture of the diseases, to speak of different diseases. There are,
however, acute and chronic inflammations in the brain as in any
other part of the body, and every where the same morbid changes
may be observed.

Serous effusion is not so unusual in adults as is believed. It is
often found in those who die of chronic mania, or who had be-
come idiotic from that disease. This view coincides with that of
Dr. Rush,* and with the observations of Dr. Cheyne,f when he
says, ' I have in my possession two dissections of very young sub-
jects, whose brains presented the appearances which belong to
lethargy. Before death they were both comatous. In both chil-
dren the surface of the brain was hid by a large deposition of serum
between the tunica arachnoidea and pia mater. The substance
of the brain was soft and moist, and in the ventricles there was
scarcely any fluid.' If such patients suddenly die they are said to
die apoplectic, a mere name to express the mode of dying. It is,

temperance — that intemperate eating is an evil of no small magnitude in so-
ciety, and often quite as fatal in its consequences as that of excessive drinking.
We see it at the private table, at the public feast, and even in the nursery of
children. There is no consistency in refusins^ a glass of wine for the cause of
temperance, and at the same time load the stomach to excess with food. To
be truly temperate is to be so in all things.

* Medical Inquiries, vol. ii. p. 206. t On Apoplexy, p. 209.

36 DISEASES OF THE BRAIN.

however, very common that lethargic and other symptoms precede
death. More details will be found in the considerations which I
shall make on hydrocephalus acutus.

In nervous apoplexy no effusion at all is detected on dissection.
This will be the case if persons die of strong mental affections, of
extreme and sudden joy, fear, anger ; quidam sub coitu periere.
Asphyxia in carbonic gas is a kind of apoplexy. The nervous
apoplexy sometimes occurs in delicate, hysteric, and hypochon-
driac subjects, but it is not to be confounded with asphyxia, or
apparent death, where all the powers are only suppressed, while
their excitability remains. In such cases, indeed, it is literally
true that we cannot have confidence even in death. Then putre-
faction alone is a positive sign of dissolution.

It is to be remarked that, in apoplectic persons, sometimes va-
rious parts, such as the Hver, or other viscera, are found diseased.
Now it may be, that the disease has begun in the liver, or in any
other viscus, and has been propagated to the brain : on the other
hand, the liver complaint may be the effect of the diseased brain,
or the liver complaint, and all morbid appearances of apoplectic
patients, may be the result of the same cause. Sometimes apo-
plexy is a mere symptom of epidemic diseases, sometimes of the
ague.

The prognosis naturally varies according to the cause and re-
lapses. The danger is greater, if the disposition is hereditary.
The more the functions of animal and automatic life are deranged,
and the greater the disorders are, the more dangerous is the event.

The treatment depends on the cause. Some practitioners re-
commend emetics. But wherever there is a determination of
blood to the head, emetics are contra-indicated. Vomiting is ad-
missible only where apoplexy is connected with an overloaded
state of the stomach, and then we ought to have recourse only to
tickling of the fauces. If the patient is insensible and cannot
swallow, there is danger of suffocating him by introducing any
liquid into the mouth. Vomiting always increases the vascular

APOPLEXY. 37

action ; the face becomes turgid and suffused ; it gives headache,
which can be explained only by the congestion of blood in the
vessels. Indeed, there is every reason to think that vomiting will
rather bring on apoplexy, and convert a slight attack into a hope-
less case, than cure it.

If the individual be not subject to spasmodic fits, to rheuma-
tismus vagus, or the gout, or if there be no reason to suspect any
strong emotion of the mind, as an extreme joy, anger, fear, I
think with the best practitioners, that blood-letting is more effec-
tual than all the other remedies in use. I say with Dr. Cheyne,*"
* If the display of the brain destroyed by apoplexy does not
prove how indispensable V. S. is, every other argument in favor
of it must be accounted weak.' It is obvious that, in the sanguin-
eous and serous apoplexy, that is, where the extravasations are
made, nothing will cure, but the patient may be kept ahve for a
longer period. Besides a large blood-letting on the head, every
thing which determinates the blood to the brain, or prevents its
free circulation, must be avoided. If a congestion of blood by an
inflammatory diathesis be suspected, or in congestion from mere
weakness, the patient is to be brought into an airy place, the head
to be shaved, and exposed without covering to cool air ; the ap-
plication of cold water or ice will be of advantage. But if
rheumatismus vagus or the gout be the cause of apoplectic symp-
toms, blood-letting and cold applications on the head will rather do
harm than be useful. Then it is not a mere determination of blood
to the brain but the cerebral mass is affected by the specific dis-
eases ; and this requires a modified plan of cure. It is easy to
mention these differences, but it is sometimes extremely difficult to
distinguish them in practice. The symptoms are often so tumul-
tuous, the situation of the patient so urgent, that there is scarcely
time for deliberation ; and, as it is said, periculum in mora. In
nervous temperaments with spasmodic fits, there is less danger,
and antispasmodics are indicated. The same remedies are to be

* On Apoplexy, p. 52.

38 DISEASES OF THE BRAIN.

employed in strong emotions of the mind. In the gout of the
head, opium, wine and diaphoretics have been found useful ; if
apoplexy is a symptom of the ague, bark in a large dose is requir-
ed. But in the genuine apoplexy, sanguineous and serous, if any
relief can be expected, it is from blood-letting.

PHRENITIS.

I am astonished that the inflammation of the brain is so seldom
spoken of; and I am convinced that it is often overlooked on ac-
count of the erroneous idea, that it takes place only when accom-
panied with violent delirium. Dr. Cheyne, in his first essay on
hydrocephalus acutus,* says that phrenitis is a disease scarcely
seen in Scotland. Repeated observations and dissections after
death, however, induce me to think with Dr. Powell, f that " in-
flammation of the brain is by no means unfrequent, while we rarely
find it accompanied by the symptoms which " (according to the
theoretical opinions of the schools) " should designate phrenitis.
The symptoms are referable rather to oppression of nervous power
than to increased activity of the blood-vessels." I have dissected
several young individuals, who by their physicians were treated as
affected with a typhus or nervous, or brain fever, who appeared
comatous, and whose cerebral functions were entirely suppressed,
but whose brains, on dissection, offered the most unequivocal ap-
pearances of true inflammation. Another not uncommon error is,
that phrenitis takes place only in adults. Children, however, are
liable to it, and perhaps still more than adults ; and it is often the
cause of hydrocephalus acutus.

The causes of phrenitis are multifarious, such as violent blows ;
INSOLATION ; hard work in hot weather : intense application of
the mind ; sudden refrigeration ; abuse of spirituous liquors ;
in short, all the causes which produce inflammation of other parts.
The treatment must be debilitating or lowering, and consists in

* Page 69.

t Some Cases illustrative of the Pathology of the Brain, read at the College
of Physicians. London Medical Transactions, vol. v. p 198,

HYDROCEPHALUS ACUTUS. 39

bleeding, cold applications to the head ; in certain cases, tepid
bathing of the body ; low diet, and in all, anti-inflammatory reme-
dies. All other details must be understood by the general princi-
ples of pathology.

HYDROCEPHALUS ACUTUS.

This name ought not to be considered as indicating a peculiar
disease, but the effect of various diseases ; for it designates only a
collection of water, formed and becoming destructive in a short
period. This morbid appearance had been too long neglected,
and, notwithstanding the careful attention of great and very intelli-
gent practitioners, our knowledge of it is still imperfect. Accord-
ing to the common notion, founded on symptoms, it is impossible to
give a definition of this disorder. Sometimes all appearances
which accompany a serous effusion in the cerebral cavities take
place, and no effusion is found after death. Such cases are men-
tioned by Quin, Rush, Cheyne, Abernethy, and others. I have
witnessed several examples. On account of the importance of
this disorder, I shall treat of it with some details. I shall first
mention the different sorts of hydrocephalus, and consider the
individuals liable to them ; then I shall examine the symptoms
which occur, afterwards the causes, and finally the curative
proceeding.

The first consideration to be made is to distinguish hydroce-
phalus, or dropsy of the brain, from hydrocephalus acutus. The
former is of a slow character; it may originate from accidental
causes, such as violent blows ; but generally it takes place in scro-
fulous and weak children, who sometimes are born with it ; and
sometimes have scrofulous tumors in the brain. The quantity
of water collected in the cavities of the brain is commonly very
considerable, and sometimes amounts to fourteen pounds and
more. The ossification of the skull is generally slow ; but those
are wrong, who think that the fontanel remains always open in
such children. I have seen many cases which show the contrary.
The too great size of the head is a more characteristic sign.

40 DISEASES OF THE BRAIN.

Sometimes it is distinguished by the configuration of the orbits,
and the appearance of the eyeballs, which are pushed out and
downward by the water collected in the anterior part of the lateral
cavities. At other times the size of the forehead and the situation
of the eyes are as usual; but the parietal bones protrude ex-
tremely by the water which has distended the middle and poste-
rior lobes of the brain. The limbs of such patients are weak and
meager ; the functions of the alimentary canal mostly tardy; the
gait is wavering and uncertain ; the functions of the five senses and
of the brain are more or less deranged, sometimes, however, in-
tact ; these unhappy beings often complain of headache, vertigo,
drowsiness, or watchfulness, convulsions, even epilepsy. In rainy,
stormy, and changeable weather they generally suffer most. The
scalp is often covered with a scaly or brawny eruption. It seems
that more girls than boys suffer from this complaint. Other con-
siderations relative to this disease may be looked for in my other
works, where I answer the objection founded on hydrocephalus
against the assertion that the brain is the organ of the mind.
With respect to the medical art it is incurable, and it is wrong to
torment such children with blisters, fonticuli, or issues, with mer-
cury, digitalis, and so on.

In hydrocephalus acutus the quantity of secreted serum is never
considerable. This effusion, then, ought not, with Whytt and
Fothergill, to be called dropsy of the brain. It is mostly observed
during the time from birth to the perfect development of the brain,
and is the most frequent in children from two to ten years of age.
A serous effusion, however, may also occur in adults, ' who have
been accustomed to headache, especially to the sick headache of
authors.'* As in any other part, so in the brain, the frequency of
its diseases coincides with the greatest energy of its development.

Scrofulous, weak, delicate, and also stout and strong children
of a fair complexion, are subject to this disorder. Those whose
brain is developed early and rapidly, and whose mental powers

^^ Dr. Parry, lib. cit. p. 352,

HYDROCEPHALUS ACUTUS. 41

show a great and premature energy, are most liable to be affected
with it. In such children, the activity of the brain is greater, and
a larger quantity of blood is determinated to it. Those who think
that round heads are more subject to this complaint are mistaken.
The most beautiful configurations of head are no security against
this evil. The children of families, where other individuals have
been carried off by the same affection, are exposed to the greatest
danger.

The progress of the complaint is sometimes more or less slow,
sometimes extremely rapid. It is generally slower in scrofulous
and sickly children with smaller heads, and in those who have
been debilitated by other diseases, such as intermittent fever,
scarlet fever, copious and repeated bleeding, measles, hooping
cough, cutaneous sores, or other chronic complaints. Children
of general weakness are often for days or weeks feverish, without
appetite, and complaining of deranged functions of the abdomen,
and of headache. At the beginning the symptoms are not at all
alarming ; but gradually they increase ; the headache, chiefly
about the forehead, becomes severe ; dulness, frequent sighs and
deep inspirations, vomiting, white tongue, and quick pulse, are
observed. In such children there are scarcely any acute symp-
toms ; the morbid appearances commonly occur in proportion as
the effusion takes place. This is sometimes the case with appa-
rently healthy children who suffer for months from headache,
which comes and disappears from time to time, and is often ac-
companied with vomiting. In the intervals the children run about
and attend their lessons. Their morbid symptoms then are over-
looked, because medical men do not know that, in children, a
chronic and superficial inflammatory state of the brain often takes
place which too frequently terminates in a fatal manner. Relief
is scarcely looked for till organic changes are already produced,
and the disease is become incurable. In stout and in weak irrita-
ble children, with large heads and premature dispositions of the
mind, the progress of the disease is commonly rapid. A sudden
change, increased sensibility, fever, a flushing face, brilliancy of
6

42 DISEASES OF THE BRAIN.

of the eyes, severe headache, stupor, retching, vomiting, dejec-
tion in the countenance, rapidly succeed. The diseased state
sometimes begins directly with convulsions, and the first stage is
scarcely distinguishable from the second.

In proportion as the disease increases, the child cannot longer
sit up, is subjected to fits of starting, or crying, and sighing ; the
headache is less felt, the stupor increases, the pupil of one or both
eyes dilated; copious alvine evacuations of foetid greenish matter,
and vomiting, often continue.

In the third stage, the child rolls the head on the pillov^^, or
throws it back j the hands are involuntarily carried to the eyes or
face, and moved before them as if some object were to be remov-
ed ; the eyelids are half closed, the pupil is dilated, and the iris
has sometimes lost all irritability ; there are commonly long sighs,
fits of convulsions, frequent grinding of the teeth, and a complete
insensibility. Where the progress is rapid, the skin is often burn-
ing, or an extreme perspiration, particularly on the head, occurs.

The proximate cause of this morbid appearance affects the
brain, and consists in a greater determination of blood to the head,
often combined with an inflammatory state. Dr. Rush* calls it
phrenicula. As to the occasional cause, the opinions of diiFerent
authors vary. Dr. Cheynef and others consider the irritation of
the abdominal viscera as the principal occasional cause. There
is no doubt that often the first disorders take place in the abdo-
men, and the greater determination of blood to the brain is the
result. Yet anatomical dissections have convinced me that, in the
greater number of cases, the morbid appearances of the abdomen
are secondary symptoms of the affection of the head. Every
cause which produces a morbid accumulation of blood in the
vessels of the brain may become a cause of hydrocephalus acutus ;
such as the irritation of the abdominal viscera ; abuse of spiritu-

* Medical Inquiries, vol. ii. p. 193.

t On Hydrocephalus Acutus. First Essay, Edin. 1808. Second Essay,
Dublin, 1815.

HYDROCEPHALUS ACUTUS. 43

ous drinks ; insolation, that is, when the child with his naked head
is exposed to the heat of the sun ; running and playing in hot
weather, and sudden refrigeration ; and particularly dentition. I
have seen examples of every sort. I shall copy the description of
one case related by Dr. Cheyne in his work on Apoplexy,* and
communicated to him by Dr. Kellie. ' Thomas Clarke's child, a
boy about two or three years of age. On visiting this child,
(October 6th, 1807,) I found him torpid and drowsy, his face
flushed and tumid, his body hot, and the feet cold, and the pulse
frequent. I was told that, on the preceding evening, he had in-
advertently been given, by a careless neighbor, a quantity of
whisky estimated from a glass to half a gill, and that he had been
brought home in a state of torpor, and had vomited almost inces-
santly during the night, and even now whatever he swallows is
almost instantly rejected by vomiting ; he retched also when raised
from bed. The belly was not swollen, nor did he express pain
when the abdomen was pressed. An emetic was prescribed ; and in
the evening, after an exhibition of a glister, a blister was applied
over the epigastrium. October 6th, the drowsiness, vomiting, and
moaning, continued ; the bowels costive, skin hot, pulse very fre-
quent, but softer ; the eyes looked watery and suffused. Leeches
were applied to the temples, and four grains of calomel were
ordered to be given every three hours^ till the belly should be
freely opened. October 7th, the pulse was much reduced in
frequency ; several greenish slimy stools had been passed, the
stomach was less irritable, and the inclination to vomit less fre-
quent. He continued oppressed, moaned much, and the pupils
seemed dilated. In the evening he had a severe convulsive fit ;
a blister was applied to the head, and the calomel continued.
The pulse was again very frequent, the vomiting had ceased,
there had been two returns of the convulsions. Leeches were
again applied to the temples, and a blister to the back. On the
9th the child died. In the brain the veins of the pia mater were

* Page 123.

44 DISEASES OF THE BRAIN.

turgid and black. A very small quantity of serous fluid, not ex-
ceeding six or eight drachms, was effused into the lateral ventri-
cles. The thorax was natural, the liver of a florid vermilion
color, stomach and intestines perfectly sound.'

In speaking of phrenitis, I have mentioned that the inflamma-
tory state of the brain is not so rare as it is commonly believed,
particularly in children and in young persons. In them it is even
the most dangerous, because the structure of the brain is still very
delicate. It is known, that in children the brain increases rapidly ;
hence there is naturally a great determination of blood to the head,
and any febrile affection will increase that determination. This
is very often the case by dentition, the irritation of which is pro-
pagated to the bowels and to the brain. The fifth pair of nerves
takes its origin at the same spot with the vagus, and is in com-
ri?unication with the cerebral parts.

The symptoms of this disease in general are treacherous ; the
pulse is sometimes small and contracted ; the bodily strength
seems to be suddenly diminished, or even exhausted ; this appa-
rent weakness is sometimes accompanied with numbness, coldness,
paleness, and convulsions. On dissection, however, the effects
of inflammation abundantly appear. The tissue of minute or florid
vessels indicates the increased arterial action ; the veins of the
brain, or particularly of the membranes, are gorged with dark col-
ored blood ; there are sometimes considerable adhesions between
the membranes ; the membranes are often thickened, and serous
effusions exist in the cavities, and in a small quantity under the
tunica arachnoidea ; innumerable little yellowish spots are spread
over the arachnoidea, &c. In short, it happens with the inflam-
mation of the brain as with that of the liver, or any other part.
If it be not resolved, or mortal, in a short time, serous secretions
commonly take place. In the brain the serosity is sometimes clear
and transparent, sometimes thick and yellowish, and sometimes
flakes of coagulated lymph swim in it.

In sickly children with small heads the disease lasts longer be-
fore any effusion takes place, and the symptoms of its appearance

HYDROCEPHALUS ACUTUS. 45

are less deceitful. But in stout children, particularly in children
with large heads, irritable temperament, and premature capa-
cities, the progress of the disease is often so rapid, that it produces
all the symptoms of effusion, but kills the patient before an effu-
sion takes place.

There are physicians who flatter themselves to have cured hy-
drocephalus acutus ; others deny its possibility. I am of the opin-*
ion of the latter. 1 have already mentioned that, often, all the
symptoms which accompany an effusion in the brain are observed,
and no serosity is detected on dissection. This is the case in chil-
dren who die in a few days under perfect insensibility, strabismus,
dilatation of the pupil, deep sighing, grinding the teeth, convul-
sions. Such cases may be treated with success : 1 have seen it
done by Dr. Gall, and have done it myself; but we think we have
only prevented the effusion. Cures of that kind happen in the
first days, while the morbid action of the blood-vessels, and not
effusion, produces the alarming appearances. I do not know any
case of cure, when the progress of the disease was slow, and all
symptoms of the third stage had appeared.

It results that we consider hydrocephalus acutus itself as incu-
rable ; it can only be prevented. The treatment then depends
on the causes which can produce that effect. Dr Cheyne* says,
" The chance of cure is nearly in proportion to the duration of
the symptoms. The disease yields to different methods of treat-
ment." He addsjf " I know no disease which is so much influ-
enced by the age, constitution, and temperament of the patient."
Undoubtedly the organic state of the brain is different according
to age and temperament ; the treatment, in consequence, must
be proportionate : but it seems to me that the treatment ought to
be essentially different only when the nature of the cerebral affec-
tion is different. If in the same appearances different methods
succeed, either nature cures, or the disease was not the same, but
only the symptoms*

^ First Essay, p. 29. t Ibid. p. 93.

46 DISEASES OF THE BRAIN.

Many practitioners in this disease direct their first attention tb the
state of the abdomen, and prescribe purgatives. Mi'd evacuations
certainly are of use ; but a great irritation of the intestinal canal
will rather increase than diminish the affection of the head.* Par-
ticularly emetics produce a greater determination of blood to the
brain ; and the disease, which at the first period might be cured,
soon becomes incurable. As some physicians are deceived by
greenish evacuations, nausea, and vomiting, end prescribe purga*
tives or emetics, so others are mistaken by the apparent weak-
ness, and employ blisters and stimulating medicines. In chil-
dren, however, every thing that irritates will increase their natu-
rally great determination of blood to the head. Drastics seldom
reestablish the natural secretions, and no liver complaint is cured
by drastics alone ; hence, even in cases where the first irritation
begins in the abdomen, they ought to be carefully administered.

The most inconsistent treatment certainly is when, as it is said^
every thing is done ; that is, they draw blood, and at the same
time excite the circulation by blisters, emetics, drastic purges, or
stimulating medicines. A child has this disease from having taken
too much spirits, and vomits ; notwithstanding they give emetics,
and apply a blister. In a healthy, and little irritable child, treat-
ed by blisters and emetics, fever and headache will be produced*
Notwithstanding they continue, as they have been taught^ to pre-
scribe blisters, emetics, and drastics; and if the patient die they
declare the disease incurable. I say here with Dr. Cheyne,f
' Every disease, whose natural tendency is to destroy a vital
organ, becomes in unskilful hands an incurable disease.

We have paid particular attention to this disorder, and the dif-
ferent treatment in different countries, and are convinced from
experience that the most successful treatment consists in tepid

* This is an important truth, and should be generally known— for the reason
that some physicians make it an invariable rule to prescribe purgatives for al-
most every species of insanity. This may appear strange to some — but such
is the fact.

\ Second Essay on Hydrocephalus acutus, p. 12. Dublin, 1815.

HYDROCEPHALUS ACUTUS. 47

bathing of the temperature of the child's skin, repeated every
second hour for ten or fifteen minutes ; in wrapping hira up in
tepid linen (when a large perspiration succeeds we do not interrupt
it by the bath) ; in putting leeches at the temples and behind the
ears, or in V. S. ; in mild opening glisters ; in mild diaphoretics ;
and particularly in avoiding every stimulous, as blisters, emetics,
drastics. The good effect of such a treatment will be the most
obvious in strong or in premature delicate children with large
heads, where the disease is of the most rapid character. Such
children, if nature be supported from the beginning, sometimes in
a few days play again and run about. We have saved children
who were considered as lost ; but 1 repeat that we do not think
we have cured the effusion, but only prevented it. In children of
general weakness, or of chronic complaints, where the progress of
the diseased state is slow, the treatment must be modified ; every
irritation of the brain must be avoided, but the body in general
is to be strengthened, while in the other the whole proceeding is
rather debilitating. If in such children, after long sufferings, we
observe symptoms of extravasation, such as stupor, dejection in
countenance, dilatation of the pupils, grinding of the teeth, com-
plete insensibility, strabismus, rolling the head on the pillow, or
drawing it back, there is scarcely any hope of recovery. I am
not acquainted with any successful case.

I know cases where, in children, the inflammatory state of the
brain was not mortal ; the patients escape the first accidents, but
lost the promising dispositions which they had manifested before
the disease, and became idiotic. Sometimes in such patients the
bodily strength seems to improve, but in a slow and incomplete
manner ; the intellectual faculties continue their manifestations,
but in a weak degree, while in others they are entirely blunted or
deranged. If the state of apathy or alteration be accompanied
with palsy of the tongue, or of other single parts, it is a sign that
the improvement is only apparent, that the danger still exists, and
that in a shorter or longer interval the disease will terminate in a
fatal way. Indeed, such patients are miserable ; they are Ian-

48 DISEASES OF THE BRAIN.

guishing, sorrowful, morose, and indifferent to all external impres-
sions. After a long while commonly head-ache and a slow fever
take place. This slow fever then is often confounded with a
worm fever, but at last convulsions arise, and the whole position
becomes insupportable ; the patients commonly lie on the back,
and throw the head backward even when asleep. A long series
of distressing accidents, and of more or less painful symptoms, is
terminated by death, sometimes after several years.

Before I finish this chapter I repeat, that, though the preced-
ing diseases are considered in the general pathology, 1 have men-
tioned them because they belong to animal life, and have exam-
ined them only in a general view, in order to show that the other
diseases of animal life, which are commonly termed mental de-
rangements, are to be ti:eated according to the same principles.

CHAPTER II.

INSANITY, OR MENTAL DERANGEMENTS.

SECTION I.

Definition arid JVame.

An exact definition of insanity is of the highest importance for
the art of medicine, as well as for medical jurisprudence. Insan-
ity deprives an individual of the rights of society, and often in-
volves property, conjugal, and^ other relations ; it is subject to
various inconveniences of the greatest consequence, which cer-
tainly are sufficient motives to examine it with more accuracy
than hitherto has been done. Insanity might be defined an
aberration of the manifestations of the mind from their state of
health ; that definition, however, could have a determinate mean-
ing only for those who have a previous knowledge of the opera-
tions of the mind in the healthy state. Artificial signs and ideas,
definition and knowledge, are in the most intimate relation.
Where information is deficient, nomenclature will be vague ;
where there is no exact knowledge of the nature and properties
of anything to be described, an exact definition is impossible.

Various definitions of insanity have been given ; all are found-
ed on the opinions of the schools with respect to the mind, its pro-
perties, and the conditions of its manifestations. In the Intro-
duction, I have mentioned that no branch of medicine is so inti-
mately connected with the philosophy of the human mind as in-
sanity. Mr. Haslam says,* ' The difficulty of proposing a satis-

** Obeervations on Madness, 2d edition, p. 6.

7

60 INSANITY.

factory theory of the human mind must have been felt by every
person who has touched this delicate string since the days of Aris-
totle It is therefore not astonishing that the knowledge

of the derangement of the mind is so little understood »' Physi-
ology naturally must always precede pathology.

As, in the prevailing philosophical opinions of the schools, the
activity of the mind was looked for in the intellectual powers ;
as, according to an axiom, its whole activity began with sensation,
so that there was nothing in the mind which did not come into it
by the senses ; it was very natural to think always of the intellect-
ual powers, if derangements of the mind were spoken of. More-
over, the intellectual derangements are the most obvious. It is,
for instance, easily observed, if any reject what is excellent,
hate what is useful, fear where there is no reason to fear, suppose
perceptions of external impressions which do not exist, he.

Among the derangements of the mind, memory, judgment and
imagination, were particularly attended to, and for a long time it
was believed that deranged judgment is the basis of insanity. It is
true, as long as judgment exists and corrects erroneous percep-
tions, the morbid affections of the five senses are not considered
as insanity. The mind, for instance, may be deprived of volun-
tary motion, or of any other sense ; the senses may be morbidly
affected ; we may feel burning heat on the skin ; may see flames,
the external objects double, reversed, or red-colored ; we may
hear noise, perceive various odors or savors ; as long as we know
the incorrectness of our perceptions, such diseases are not called
insanity : but a patient is styled insane, if he believe in such per-
ceptions from external impressions w^hich do not exist. He, for
instance, who thinks he has a frog in his stomach, or that he has
feet of glass or straw, will be called insane.

In common language, the meaning of insanity is very relative ;
it depends on the manner of thinking and feeling of each individ-
ual. Common people consider every thing that is above their
conception either as foolish or spiritual. Several authors think
Jthat insanity is always a chronic disorder, and excludes any other

DEFlNlTIONo 51

bodily disease. Experience^ however^ shows that all those con-
siderations are incorrect.

At the present time it is well ascertained that, in insanity, the
power of judging is not always derarged. Many insane persons, if
we grant their premises, reason with perfect consistency ; nay, in
many, that power is increased. For that reason one sort of in-
sanity is designated by the name reasoning foolishness {follie rai-
sonnante). This truth might be illustrated by many cases ; but it
is superfluous to mention them, since every one who takes care
of insane persons must have had occasion to make observations
of that kind. I shall only extract from Dr. Cox's work on Insan-
ity* that passage where he refers to a part of the speech of Lord
Erskine, when at the bar, in the defence of Hadfield. ' I remem-
ber,' said the advocate, ' the case of a man who indicted another
for imprisoning him ; and in ihe course of the trial, though I
endeavored by every means in my power, by every question I
could put, to draw from bim some proof of the real state of his
mind, yet such was his subtlety, and such his caution, that he baf-
fled me at every point ; and it was only by Dr. Sims's appear-
ing in court that he discovered himself; for he no sooner saw the
doctor, than he addressed him as the Lord and Saviour of man-
kind. The person indicted was therefore acquitted. But such
was the subdety and perseverance of this man, that, recollecting
the doctor had one day confined him in his house in town, he in-
dicted him for the same offence, and so well did he remember
what it was that lost him his cause in Middlesex, that nothing
could extort from him the same behavior ; and yet there was not
the smallest doubt in the mind of any one who knew him, that he
was really and truly a lunatic' I have chosen this example as a
proof, that such cases do not fall within the observation of medi-
cal practitioners only.

Sometimes it happens that the manifestations of all intellectual
powers, as perception, memory, judgment and imagination, are

'*Thirdedition,p. 195.

62 INSANITY.

perfect, nay, improved, while, however, the patients are decidedly
insane. At Vienna, a melancholy person having seen the execution
of a criminal, the spectacle produced in him so violent an emo-
tion, that he was suddenly seized with a propensity to kill. At
the same time he had clear consciousness of his situation, and
preserved the strongest aversion to such a crime. Weeping bit-
terly he described his deplorable situation with an extreme con-
fusion ; he struck his head, wrung his hands, exhorted himself,
and cried to his friends to take care, and to fly, and he thanked
them if they resisted and menaced him. Pinel speaks of a mad-
man who did not show any mark of alienation in respect to memo-
ry, imagination, and judgment, but who confessed that, in his nar-
row seclusion, his propensity to murder was quite involuntary,
and that his wife, notwithstanding his tenderness for her, was
near being immolated 5 he having time only to warn her to fly. In
bis lucid intervals he made the same melancholy reflections, he
expressed the same remorse, and he was disgusted with life to
such a degree, that he several times attempted to put an end to
its existence. 1 have quoted more examples in my work on
Phrenology. Hence there can be no doubt that insanity embraces
more than the derangement of intellectual powers.

I have divided the functions of the mind into feelings and intel-
lectual powers. Now froni what I have said it follows that the
derangements of the five senses only do not constitute insanity,
and that there may be insanity without derangement of the intel-
lectual faculties, as they are commonly spoken of. Lt is also
certain that the diseased functions of the feelings, are not always
insanity. Our appetite may be deranged, and we may be fond
«of unusual savors, as of coals, chalk, &ic. ; physical love may
foe subject to various aberrations, as in unnatural desires ; various
idiosyncrasies may occur in other feelings ; the individuals, how-
ever, as long as they preserve a power over their actions, are not
43onsidered as insane, just as memory, judgment, and imagination,
may be extremely weak and incorrect, and may commit continual
errors withouj: being cpnsidered as insanity. Yet there is insanity

ITEFINITION. 53

with respect to the feelings and intellectual faculties. In what
then does insanity consist'?

With respect to the morbid affections of the senses, and to the
errors of the intellectual powers, we are insane, if we cannot dis-
tinguish the diseased functions, and do consider them as regular ;
and in the derangement of any feeling we are insane, either if we
cannot distinguish the disordered feeling, if, for instance, we really
think we are an emperor, king, minister, general, he. or if we
distinguish the deranged feeling, but have lost the influence of
the will on our actions, for instance, in a morbid activity of the
propensity to destroy. Thus, insanity, in my opinion, is an
aberration of any sensation or intellectual power from the healthy
state, without being able to distinguish the diseased state ; and
the aberration of any feeling from the state of health, without being
able to distinguish it, or without the influence of the will on the
actions of the feeling. In other words, ^^e incapacity of distin-
guishing the diseased functions of the mind, and the irresistibility
of our actions, constitute insanity.

As medical jurisprudence is highly interested in a clear idea of
insanity, I will make a few remarks to this purpose. Insanity, in
many cases, is too little understood ; but the greatest error is
committed in considering the mind as one single power, or in
deriving the feelings from the intellectual faculties. The mind is
an aggregation of powers, which may act and be disturbed indi-
vidually, as is the case with the external senses and voluntary
motion. Every disturbance, however, of any faculty is not
insanity, but merely the want of the faculties which constitute
liberty.*

In medical jurisprudence, with respect to insanity, two consid-
erations are of the highest importance, viz. partial and intermittent
insanity. Numerous facts prove the existence of both kinds.
Persons may lose their intelligence with respect to any sensation,

* With respect to my considerations on liberty, I refer the reader to my work
on Phrenology.

54 INSANITY.

idea, or feeling, or they may lose the influence of the will with
respect to the action of any feeling, while they preserve intelli-
gence and will with respect to all other special faculties. Hence
there are as many sorts of partial insanities as individual powers of
the mind. Now it is the duty of the legislator, or of those who
interpret the laws, to be acquainted with those powers, in order
to conform their judgment to nature. The intermittent nature
of insanity presents still greater difficulties : that state is commonly
designated by lucid intervals. This term, however, is of great
latitude, and ought to be explained in a more accurate manner.
Every one admits that insanity is liable to intervals, but not every
one understands the nature of intervals.

Every part of our body may be affected from time to time, and
free at intervals. The eyes, for instance, may be inflamed at
certain periods, and healthy at others. Many other complaints,
such as gout, rheumatism, catarrhal affections, may from time to
time disturb our health, and cease at intervals. Why should the
organization of the brain not be liable to undergo, at certain peri-
ods, morbid changes, whix^h disappear and return again? The
temporary derangements of the mind can be explained only by
the temporary excitement, weakness, or disease of the brain.
The brain, once affected, may be disposed to relapses as well as
any other part of the body : moreover, the morbid appearances
and disappearances may not only be temporary, but of an inter-
mittent nature ; as, for instance, is generally known with respect
to the ague : finally, diseases are liable to exacerbations and re-
missions. All these phenomena then may take place in the de-
ranged functions of the brain.

Now as insanity is partial or intermittent, or partial and intermit-
tent at the same time, what shall we call interval ? The answer
is obvious, that the interruption or intermittence is the interval.
But what are lucid intervals ? The expression lucid is not suffi-
ciently determined. It cannot mean understanding and judgment,,
as Locke thought, because experience shows that, in insanity, th&
intellectual powers may increase. Van Swieten, for instance^ re-

DEFINITION. 55

lates that a female, whose understanding had not been cultivated,
and who before was employed only in manual labor, durmg her
fits of insanity, displayed a rare facility of versification. Pinel
speaks of a madman who, during his long intervals, was a man of
very ordinary gifts, but who, during his fits, reasoned on the
events of the revolution with dignity, purity of language, and all
the strength of reason which could have been expected from the
most learned and most intelligent man in a state of health. Cor-
rect judgment, indeed, is not a sign of lucidity with respect to
insanity of the feelings. It is only applicable to insanity of the
senses and internal intellectual faculties ; even in their partial
insanity there may be lucidity with respect to the other senses
and intellectual faculties. Some persons cannot distinguish col-
ors, and take red for green ; but they see perfectly well the size,
form, and distance of the external objects : hence their judgment
at the same time, is defective and lucid, or, if 1 may say so,
insane and sane. Thus, lucidity may be partial or general ; it
is characterized by clear inteUigence with respect to sensations
and ideas, and the free-will with respect to the feelings.

I shall now examine the question, whether, in partial insanity
or in intervals, the patients are to be considered as incapable of
transacting their own concerns, and as free from all responsibility
for their actions ? As to partial insanity, shall we say that the
loss of one faculty makes us incapable to manifest any other pow-
er ? Can a blind man not witness what he has heard ? When
old persons lose their memory, and preserve a weak judgment,
are they unfit to make a lawful will ? As the manifestations of
the difierent faculties of the mind depend on the different parts of
the brain, any instrument may be disturbed, while the others per-
form their functions in the healthy state ; and the patient may be
deceived in one respect by the impressions of the instrument, and
manifest all other powers in perfect health. If a man be insane
by a feeling, but calm and perfectly composed ; if he can reason
on other subjects with strict propriety, and think like the majority
of mankind ; if he can converse with philosophic coolness and

56 INSANITY.

correctness on the nature and effects of his disease, have we the
right to condemn such a patient to continual incapacity of trans-
acting his own concerns ? It seems to me, that it ought to be still
less the case when insanity is intermittent. In certain diseases
the faculties of the mind are extremely weakened, or even sup-
pressed ; but at certain moments the patient distinguishes those
around him, and recollects certain facts ; is he therefore entitled
to legal indulgence ? If a poet be insane, but during intervals his
imagination be unclouded, and he compose beautiful verses, shall
we reject them ? Habitual intoxication frequently debilitates the
faculties of the mind ; shall we therefore not allow an interval in
which the ordinary business of common life can be performed
with certainty and propriety ?

From the preceding considerations on the complicated nature
of the human mind, the various conditions of its manifestations,
and our imperfect knowledge as to its operations, it results that
the examination of its deranged manifestations is extremely diffi-
cult. The decision upon certain cases, required in courts of jus-
tice, is sometimes almost impossible. In other cases it is as difficult
to say where it is not, as where it is. Indeed it is sometimes
counterfeited by criminals, in order to escape punishment. In
such cases, then, the individual disease which is imitated, as ma-
nia, melancholia, or idiotism, must be well understood ; and all
phenomena, which occur in automatic and animal life must be
compared together, in order to distinguish whether there is con-
cordance in the whole or not. In mania furibunda, for instance,
the sleep is deranged. If a criminal imitate it, let him be obser-
ved day and night, and he will soon betray himself Impostors
in the streets, who imitate epilepsy or convulsion, sometimes are
detected by proposing painful operations, such as actual cautery,
trepanning, &c. as curative means* It is understood, that the ex-
amination of such cases requires the greatest caution.

A practical reflection is obvious^ and must have been felt by all
those who are somewhat acquainted with insanity 5 I mean, the
abolition of a regulation which invests every member of the medi-

DEFLNITION, 57

cal profession with the power of depriving any individual of his
liberty, and of exposing him to all the inconveniences and disad-
vantages to which insanity is subject. Few medical men pay at-
tention to that branch of the art. Moreover, in any profession
there are individuals without a sufficient degree of skill ; 1 will not
hesitate even to say, without probity and moral principles. Now
as sometimes the most experienced and most able men are at a
loss, and find it impossible to decide whether there is insanity or
not, it must be obvious that not every one who knows how to com-
pose some prescriptions ought to be trusted with the privilege to
dispose of the liberty of his fellow:-citizens.

It remains to examine what name is preferable to designate the
deranged manifestations of the mind. Various appellations are
used, such as madness, lunacy, mental derangement, or insanity.
Madness indicates mania, or a wild and furious, state of the
mind, and not its deranged manifestations in general. Lunacy
is quite improper, because the moon does not at all pro-
duce such complaints. Mental derangements embrace only those
of the intellectual powers. 1 prefer that of insanity as a quite
general expression, and repeat, that either the incapacity of distin-.
guishing the diseased functions of the mind, or the irresisdbility
of our actions, or both together, characterize insanity.

RECAPITULA.TION.

In this section I have endeavored to give a better definition of
insanity. I have spoken of the difficulties which we meet in ex-
amining that disorder, and have considered its pardal and inter-
mittent nature with respect to medical jurisprudence.

8

58 INSANITY.

SECTION II.

Symptoms of Insanity.

A description of morbid phenomena, which are observed in
insanity, will guide our power of distinguishing the diseases, or the
causes of the morbid appearances. It is certain that the majority
of medical men have a too great tendency to consider the symp-
tom as the disease, and it is particularly the case in insanity.
Symptoms, however, are only deranged functions. Now the same
function can be deranged by various causes, and the same cause
may derange various functions, and hence produce various symp-
toms. Fever alone is not the disease, but merely a morbid phe-
nomenon ; and the circulation of blood may be accelerated by
different morbific causes. In the same way, inflammation will
produce various symptoms according to the functions of the parts
which are affected. Refrigeration may produce headache, sore
eye, sore throat, toothache, cough, vomiting, diarrhoea, &c. Dr.
Parry, in speaking of the relation of the diseases, asserts well,*
that ' various maladies are apt in one set of persons to extend, in
different forms, and therefore often under different names, to dif-
ferent parts nearly at the same time ; in another set, to affect one
part in one form at one time, and, having ceased, to affect another
part in another form at a subsequent time ; and, lastly, in a third
set, to leave one part or texture, and at the same time, or nearly
the same time, to appear in the same or some other form in another
part or texture.' As in pathology in general, so in insanity in
particular, this consideration is of the highest importance. Hence
the enarration of symptoms is not the essential point in considering
insanity ; it is only of secondary use, and conducive to the dis-
tinction of its nature.

In insane people the functions of automatic life, such as diges-
tion, circulation, respiration, nutrition, secretions and excretions,

^ Lib. cit. p. 370.

SYMPTOMS. 69

may or may not be disturbed ; their disorders may take place in
various degrees ; and on account of the absence or existence of
such symptoms, the elucidation of insanity will only become more
simple or complex. Their detailed consideration belongs to the
pathology of automatic life. I here intend to relate only the dis-
orders of animal life.

The operations of animal life are the external senses, propen-
sities, sentiments, knowing and reflecting faculties. Let us see
what morbid appearances take place in those functions. The
muscular power bears the greatest changes : sometimes it loses all
activity, and sometimes it shows inconceivable strength, so that it is
difficult to find means of coercion. Pinel states that he has seen
some instances of muscular energy that impressed him with the
idea of a strength almost supernatural. The strongest bands yield-
ed to the efforts of the maniac, i know similar instances. Pinel
adds, ' But this muscular power is far from being common to every
form of insanity. In many instances there is a considerable de-
gree of muscular debility.' The skin is sometimes, as it were,
benumbed, the patients feel every thing like cotton ; or it is quite
insensible, so that the patients do not feel punctures, blisters, or se-
tons ; at other times it is extremely sensible. A sensation of gen-
eral or partial formication, burning heat, or shivering cold, over
the whole body, or at certain parts, are observed. Haslam says,*
' In some an appearance takes place which has not hitherto been
noticed by authors. This is a relaxation of the integuments of the
cranium, by which they may be wrinkled or rather gathered up
by the hand to a considerable degree. It is generally most remark-
able on the posterior part of the scalp.' This, however, is not
characteristic in insanity ; it may occur like other symptoms.

Taste and smell suffer various disorders. Sometimes they are
quite blunted, often much excited. It is a common observation
that insane people are fond of snuff. Vision is often molested
with transient clouds, floating insects, flashes of light, weakness ;
but often it is very acute. The look varies according to the in-

* Observations on Madness, 2d edit. p. 82.

60 INSANITY.

ternal feelings, is staring and wild, or calm and grieved, &z,c. ; the
iris is contracted or dilated ; the eyes are red and sparkling, or
yellowish, or of lead color and tarnished. Insane people often
hear various noises, extraordinary voices, the song of angels, blas-
phemies, obscenities. I think with Haslam,* that of the organs
of sense which become affected in those laboring under insanity,
the oar more particularly suffers.' There are also more deaf than
blind among insane people.

The derangements of the feelings are numerous. Hunger and
thirst may be diminished to inactivity, or increased to insatiable-
ness. Some are indeed voracious, and languish even to fainting
from want or deficiency of nourishment. The most modest
young females are sometimes seized with the feeling, countenance,
and language of a loose libertine. I have seen several who fancied
themselves to be pregnant. Pinel says, ' I have nowhere met,
except in romances, with fonder husbands, more affectionate
parents, more impassionate lovers, more pure and exalted patriots,
than in the lunatic asylum.'

Some are prone to controversy, show excessive irascibility,
blind and savage ferocity, ungovernable fury. Pinel speaks of a
young man, who was attached to his father, but who committed
acts of outrage, and even attempted to strike at his father, when
under the influence of the disease. Pinel mentions another
maniac, who was naturally of a mild and pacific disposition, but
appeared to be inspired by a demon of malice and mischief during
the whole period of attack. There are insane persons who feel an
aversion against any one thing they see ; they are fond of kicking,
biting, and throwing the head against others who come near ; who
never forget or forgive an offence ; who consume the whole of
the day, and the greatest part of the night, in pouring forth abuses
and blasphemies, and roaring out the most horrid imprecations.

Murderous impulse, however unaccountable it may appear to
others, is not always obedient to will. Pinel says, there are
some who feel a blind and ferocious * propensity to imbrue their

* Lib. cit. p. 67.

SYMPTOMS. 61

hands in human blood. Some are actuated by an instinct to com-
mit to the flames every thing of a combustible nature. Dr. Long-
worthy, of Bathj had a patient who with her naked hands carried
burning coals to straw, in order to put it in flame. Mr. Hill re-
lates the following example : — ' At the Norwich Assizes, in the
summer of 1805, Thomas Callaby was tried for the murder of
his grandchild. A witness found the prisoner sitting at the side
ofhisbedone morning in March, about four o'clock. He had
dreadfully wounded his wife in various parts of her body. The
prisoner's daughter brought down the child with its throat cut ;
the bloody knife lay in the room. He was charged with and con-
fessed these acts, but said he did not care any thing about it.
His wife had heard him say a short time before, that he should
certainly murder some one, and he had begged to be confined.
It further appeared that he knew when his fits of madness were
coming on him, and that at those times he has been known to tie
himself with ropes down to the floor.'* More examples of this
and of other propensities may be read in my work on phrenology,
where I have treated of the primitive faculties of the mind, and
their respective organs. I prefer to extract examples from other
writers, not because I have not seen such cases, and sometimes
repeatedly, in different mad-houses, but because such facts, being
ascertained by other observers, will perhaps be more easily admit-
ted by adversaries.

' 1 could mention,' says Pinel, * several instances of insane per-
sons, of known integrity and honesty during their intervals of calm-
ness, who had an irresistible propensity to cheat or to steal, upon
the accession of their maniacal paroxysms.' Gall possesses, in his
collection, two skulls of such individuals, who were confined in the
lunatic asylum at Vienna. I have one of a man who died at
Prague in Bohemia, which Professor Mican, Jun. was so kind as
to give me. Many insane play the hypocrite, are cunning in the
highest degree, and most dexterously conceal their disease.
Sometimes violent patients, being confined, become tranquil and

" P. 93.

62 INSANITY.

orderly, urge the correctness of their conduct as an argument for
their liberation, and manage themselves with admirable address.

When brought home, their derangement, or mischievous dispo-
sition, appears again.

The examples are not rare that insane people think themselves
emperors, kings, ministers, generals, high-priests, bishops, dukes,
lords, prophets, God Almighty, or God the Son, &c. Pinel re-
lates that, at the same time, four madmen of Bicetre believed them-
selves in possession of the supreme power in the state, and assum-
ed the title of Louis XVI. The hospital was not less richly en-
dowed witii divine personages, so that some of the maniacs were
called after the provinces, as the God of Brittany, the God of the
Low Countries, &ic. Many are ambitious, wish to be approved
of by others, and to appear as persons of fashion and distinction.
They seldom forget to decorate themselves with any thing which
they consider to be an ornament. They are conceited and osten-
tatious, singular in gait and phraseology.

Others are thoughtful, gloomy, taciturn, austere, morose, and
like to be alone. Some are anxious, fearful, and terrified by the
most alarming apprehensions. Some express their affliction by
tears, others sink without a tear into distressing anxiety. Some
fear external prosecutions, and the most ridiculous and imaginary
things ; others think themselves lost to all the comforts of this life,
and desire to be buried. Some also are alarmed for the salvation
of their souls, or even think themselves abandoned for ever by
God, and condemned to hell and eternal sufferings. Others are
remarkable for good humor and merriment ; they are cheerful,
sing from morning till evening, and sometimes express their joy by
fits of loud and immoderate laughter. There are others who feel
an extraordinary liberality, and unbounded generosity. Some are
very pious. Dr. Hallaran"* says, * 1 have often known maniacs
of the worst class, in v^hom the faculty of thinking correctly on all
other subjects had been entirely suspended, still retain the power
of addressing the Deity in a consistent and fervent manner, and to

* On Insanity, p, 21.

SYMPTOMS. 63

attend the call for devotion with the most regular demeanor.'
Some show the most invincible obstinacy, and nothing could shake
their intention, though sometimes they blame the keepers for not
securing them sufficiently.

The derangements of the intellectual faculties are not less nu-
merous or singular. Some fancy themselves dead, or to be
changed into animals of particular kinds ; to be made of glass or
wax ; to be infected by syphilis, the itch, or other diseases ; to be
a prey of spirits or devils, or under the influence of magic spells
and vows. Sometimes the intellectual faculties are much excited,
sometimes diminished or almost suppressed ; sometimes only one
intellectual power seems to be under the morbific influence, while
the others appear with natural strength. In greater activity
sleeplessness is a common symptom ; some see external objects
in erroneous forms and colors. A maniac took for a legion of
devils every assemblage of people whom he saw.

There are many examples of the surprising strength of intel-
lectual power during the fits of insanity. They sometimes show
the most briHiant and ingenious thoughts, the most proper and lu-
minous comparisons. The recollection of the past often unrolls
with great rapidity, and what had been unthought of or forgotten
is presented to the mind with animated colors. Insane people,
like ihose of sound minds, recollect the scenes of youth and
former times better than the transactions of later dates. Many
know, in the intervals, all circumstances during the fits, all their
extravagances and inconsistent actions, all the absurdities they
have maintained, and all the violence in which they have indul-
ged. Many even are penetrated with remorse. Persons who,
in their sound state of mind, labored under an invincible impedi-
ment of speech have, in insanity, expressed themselves without
the least hesitation. Some are quick in repartee, and exceed-
ingly acute in their remarks; others feel an extraordinary poetic
inspiration. Willis cured a madman, who expected with impa-
tience the accession of the paroxysms, since he enjoyed during
their presence a high degree of pleasure ; they lasted ten or

64 INSANITY

twelve hours. Then every thing appeared easy to him : no ob-
stacles presented themselves, either in theory or practice. His
memory acquired, all of a sudden, a singular degree of perfecuon :
long passages of Latin authors recurred to his mind. In general
he had great difficulty in finding rhythmical terminations, but, on
these occasions, he could write in verse with as much facility as
in prose.

Dr. Rush* says, ' Talents for elocution, poetry, music, and
painting, and uncommon ingenuity in several of the mechanical
arts, are often evolved in madness. A gentleman whom I
attended in our hospital, in the year 1810, often delighted and
astonished the patients and officers of our hospital, by his displays
of oratory, in preaching from a table in the hospital yard every
Sunday. A female patient of mine, who became insane after
parturition, in the year 1807, sang hymos and songs of her own
composition, during the latter stag^ of her illness, with a tone of
voice so soft and pleasant, that I hung upon it with delight every
time I visited her. She had never discovered a talent for poetry,
nor music, in any previous part of her life. Two instances of a
talent for drawing, evolved by madness, have occurred within my
knowledge ; and where is the hospital for mad people, in which
elegant and completely rigged, ships, and curious pieces of
machinery, have not been exhibited by persons who never dis-
covered the least turn for mechanical art previously to their de-
rangement ? Sometimes we observe in mad people an unex-
pected resuscitation of knowledge ; hence we hear them describe
past events, and speak in ancient or modern languages, or repeat
long and interesting passages from books, npnQ of which, we are
sure, they were capable of recollecting in the natural and healthy
state of their minds.'

In the greater number of insane people, the reflecting faculties
of the mind are much diminished, but in some they are surprisingly
improved. Some patients reply with an air of calmness and

* Medical Inquiries and Observations on the Diseases of the Mind. Phila-
delphia, 1812. p. 153.

SYMPTOMS. 65

reflection, and often with the greatest accuracy ; some indicate
with great exactness the happy time when it is no longer neces-
sary to restrain them, while others will solicit permission to go to
the airing grounds at unseasonable hours, and in improper states
of mindo

In the preceding narration of the symptoms of insanity, I have,
in a certain degree, followed the order in which I am accustomed
to treat of the faculties of the mind. The derangements of those
faculties, however, present an infinite number of modifications
and combinations. These will be understood in the same
way as the modifications and combinations of the functions of
the mind in its state of health. These symptoms as I have
already mentioned, are only the disturbed functions of the dif-
ferent faculties, and not at all the disease. The same disease may,
in different individuals, or in the same individual at different times
according to his natural condition, derange the functions of quite
different faculties, in the same way as the same object or event
will suggest very different reflections to different persons, or to
the same person at different times. For that reason we may con-
ceive why the life of a madman may be divided between furious
paroxysms and melancholic languor ; why sometimes the external
appearance is entirely changed, so that a fearful patient becomes
exalted and proud ; why the same patient, at different times, may
exhibit the appearance both of high and depressed passions; why
at one time he may be furious, at another placid ; talking for seve-
ral days, then dumb, as if he had lost his voice ; at one time lament-
ing in the most plaintive accents, and at another laughing from
morning till evening ; finally, why, in other patients, the same
state of mind may last several years without any change in the
object of derangement, just as is the case in other parts of the
body. The latter case happens if the morbific cause always act
on the same organic parts.

The mutual influence of the cerebral parts and of the faculties
of the mind on each other explains why one deranged idea may
lay the foundation of an innumerable number of erroneous com-
9

66 INSANITY.

binations, in the same way as the disorder of one eye often dis-
turbs the function of the other, and as an affection of the larynx is
easily propagated to the lungs. By the same reason it is under-
stood why, sometimes, a partial insanity degenerates into a gene-
ral one ; in the same way as a single liver complaint sometimes
affects the whole automatic life.

RECAPITULATION.

In this section I intended to enumerate various symptoms which
may be observed in insanity. I have quoted examples with re-
spect to almost every primitive faculty of the mind. I have,
however, mentioned that the number of di3turbed functions is in-
numerable : that they are modified in different individuals, and
often at different times in the same individual; tha.,t their combin-
ed appearances are infinite ; that one symptom may produce
another 5 and that all these phenomena are explained only by the
plurality of independent faculties and respective organs, and their
mutual influence-

SECTION III.

Division of Insanity.

I have enumerated a great number of symptoms, and many
more might be related : the question now arises, whether they be-
long to the same disease, or whether insanity is a generic term
and may be divided into several species.

The oldest division, which is known and n^entioned by Hip-
pocrates, is that into melancholia and mania. The characteris-
tics of the former were fear and permanent distress, while the
latter was insanity with violence. Galen followed his predeces-
sors, particularly Hippocrates. He was attentive to the difference
of insanity with or without fever, and called insanity with fever,
frenzy ; and insanity without fever, when accompanied with vio-

DIVISION. 67

lence, mania; and when with fear and distress, melancholia.
That distinction of Galen into derangement of the mind, with or
without fever, and of the latter into mania and melancholia, has
been adopted by many ancient and modern authors.

The distinction, however, of insanity into mania and melan-
cholia is very imperfect, and it has been observed by Aretaeus,
Alexander Trallianus, Boerhaave, and many modern writers, that
one is frequently changed into the other. Sometimes mania be-
gins and melancholia succeeds, or melancholia begins and mania
is its offspring ; and often, in the same patient, both forms alter-
nate with each other, or are several times interchanged.

Aretaeus maintained, that in melancholia the distress is confined
to one subject, Pinel, in our days also called every partial in-
sanity melancholia. The latter author divides insanity according
to the intellectual powers, such as perception, memory, judgment,
and imagination, and speaks of melancholia or partial hallucina-
tions and idiotism. Notwithstanding he says, * My experience
authorizes me to afhrm, that there is no necessary connexion be-
tween the specific character of insanity, and the nature of the ex-
citing cause.' He is right, if the derangement of attention, mem-
ory, judgment, or imagination, or melancholy or fury, are consid-
ered as specific characters. All these derangements may be pro-
duced by the same cause ; but these symptoms do not constitute
different species of insanity, and cannot be considered as the
basis of a practical division, as T shall elucidate in the section on
the Causes of Insanity.

Cullen, with many ancient writers, considers melancholia and
mania as degrees of the same disease. Also Haslam says,* ' As
the terms mania and melancholia are in general use, and serve to
distinguish the forms under which insanity is exhibited, there can
be no objection to retain them : but I would strongly oppose their
being considered as opposite diseases. Jn both, the associations
of ideas is equally incorrect, and they appear to differ only from

** Lib. cit. p. 3o.

68 INSANITY.

tlie difFerent passions which accompany them. On dissection, the
state of the brain does not show any appearances peculiar to mel-
ancholy, nor is the treatment, which I have observed most suc-
cessful, difFerent from that which is employed in mania. We
every day see the most furious maniacs suddenly sink into a pro-
found melancholy, and the most depressed and miserable objects
become violent and raving.' In another passage he adds,* ' Dis-
tinctions have been created rather from the peculiar turn of the
patient's propensities and discourse, than from any marked differ-
ence in the varieties and species of the disorder.'

Undoubtedly in the same disease, or in the same patient diseas-
ed by the same cause at difFerent periods, the symptoms may be
very difFerent, and in difFerent degrees. The same hysterical
person, for instance, may tremble at one moment, and become
blind, or deaf, or lose the use of a limb at another, and then blind-
ness and palsy may cease, and a sneezing and retching of th©
most excessive violence may supervene ; now she may be molest-
ed with painful acuteness of hearing, then with deafness ; after-
wards a fit of laughing or crying may follow, or other infinitely
diversified symptoms.

Arnold,! according to the philosophy of Locke, who admitted
two sources of consciousness, sensation and reflection, divides in-
sanity into the derangements of the functions of the five senses, and
terms them ideal insanities^ and into derangements of the internal
conceptions, which he calls notional insanities. He then divides
these genera of insanities into species, and each species into varieties.
The division of notional insanities, for instance, contains nine species,*
and one single species, that of pathetic insanity, is subdivided into
sixteen varieties, such as amorous, jealous, avaricious, misanthropic,
arrogant, irascible, abhorrent, suspicious, bashful, timid, sorrowful,
distressful, nostalgic, superstitious, enthusiastic, and desponding.

*Lib.cit. p. 39.

t Observations on the Nature, Kinds, Causes, and Prevention of Insanity.
Two vols.

DIVISION. 69

Beddoes* considers such divisions, as if a physiologist might di-
vide the human appetite into the appetite for animal and vegetable
food, and the former into the appetite for mutton, veal, pork,
venison, he ; and the latter into appetite for potatoes^ peas, beans,
carrots, turnips, cauliflower. &.c. Every practical physician must
think with Pinel, that such divisions are more calculated to retard
than to accelerate the progress of science. They are of no prac-
tical use, and I shall no longer intrude on the time of my readers
with their considerations.

It is known that, in the system of Brown, health was considered
as the result of equable, and disease as that of excessive or de-
fective stimulation. Mr. Hill, in his publication on Insanity, also
derives this complaint from stheny or astheny. He admits one
species of Insanity under the two mentioned forms. There can-
not be any doubt, and it is too much overlooked by common prac-
titioners, that the congenital bodily strength, the natural powers,
and individual conditions of the patients have the greatest influence
on re-establishing health. Great physicians of all times paid the
greatest attention to such considerations. Experience, however,
shows also, that asthenia and hyperasthenia are not sufficient to
explain all morbid phenomena, and are still less satisfactory in
curing every disease according to such conceptions.

Mr. Hill, for instance, admits sthenia, in observing torpor of the
skin and insensibility; if the patient is capable of bearing great
extremes of heat and cold, of hunger and thirst ; if he is less sel-
fish ; speaks in a quick and snappish manner ; has a train of
thoughts extremely vivid, versatile, and accompanied with rapid
utterance, forming new and endless associations ; if his attention is
arrested sooner, and more forcibly by pleasurable objects ; if he
now is angry, now pleased ; at one time generous, at another par-
simonious. According to Mr. Hill, in asthenia, on the contrary,
the patient is more selfish and cowardly, may shrink like a sensi-
tive plant on the approach of a blister, cannot bear hunger and

** Essay on Insanity.

70 INSANITY.

thirst, has a deep, grave voice^ a measured solemn order of oral
delivery ; his cogitations are more pertinaciously employed in
one train, or wholly confined to one subject ; has painful thoughts ;
the feelings are more connected with, and dependent on, associa-
tions of past than of present ideas ; and he likes silence and
solitude.

Practitioners may know that such symptoms do not enable
them to establish d curative plan. I have often seen rigid adhe-
rence to the same errors, painful thoughts, fondness of solitude, a
measured order of orcil delivery ; and Brownians ought to reckon
them in the class of sthenia. On the other hand, I have many
times found torpor and insensibility of the skin, great versatility of
thoughts, and endless associations, continual change of feehngs,
and the patients evidently belonged to the class of asthenia. Mr.
Hill himself felt the insufficiency of those symptoms, and observes,*
' Some apparently low asthenic cases will, upon close examination,
be discovered to belong to the mild sthenic class. Just discrimi-
nation usually follows the due consideration of the age, sex, pre-
vious health, and former diseases, natural temperament, together
with the situation of life of the sufferer. Males are commonly
found suffering under the high and impetuous degree ; and under
the mild sthenic insanity, females from the age of twenty to forty
or fifty, of muscular form, having dark hair and eyes, brunette
skiuj unmarried, irregular as to menstrual and alvine discharges, of
sedentary lives, appertaining to the middle and lower classes of
society.'

I have often observed that females of such a description suffer-
ed under the high degree of sthenia, according to the language of
Mr. Hill. What shall we then do, if the detailed symptoms of
sthenia and asthenia are mutually interchanged? Shall we adopt
today an asthenic plan of cure, tomorrow that of sthenia, and the
following day stimulate again ? With that view we should
sometimes be obliged to change our curative proceeding in the

* Lib. cit. p. 274.

DIVISION, 71

same day. In general^ any division founded on the deranged
manifestations of the mind is of no medical use. It disguises truth
and perplexes all just distinction.

Dr. Hallaranj of Cork, who, in his treatise on Insanity, shows
practical attention and talent for observation, admits two distinct
species of that disorder. He founds his division on causes, which
is undoubtedly the only reasonable way of proceeding. He ex-
pressly states that ' the due observance of the causes connected
with the origin of this malady is the first step towards establishing
a basis upon which a hope of recovery may be founded.' He
refers one species to mentals causes, and denominates it mental
insanity ; the other species owes its origin to organic injury, either
idiopathically affecting the brain itself, or arising from a specific
action of the liver, lungs, or mesentery. In consequence he adopts
a different treatment in each species.

That is certainly the proceeding of a philosophical mind. I can-
not, however, adopt this division, since I reject a mere mental
insanity, and consider the cause of every derangement of the
manifestations of the mind as belonging to organic parts. My
reasons will be stated in the section on the causes of insanity.

In order to become acquainted with the different symptoms, or
various derangements of the manifestadons of the mind, it is useful
to study the different divisions which have been made ; but the
only practical division of insanity, I repeat, is that which is founded
on the causes. The most useless, though the most common, is
that according to the symptoms, such as into mania and melan-
cholia.

Another division might be established according to the extent
and degree of insanity, viz. the faculties of the mind may be
enUrely prohibited from manifesting themselves ; or their activity
may be too great 5 or their natural manifestations may be altered
or alienated. The state of inactivity, where the faculties cannot
manifest themselves, is imbecility or idiotism. It is to be remark-
ed, that this expression is commonly applied to the intellectual
faculties, because understanding was considered as the basis of the

72 INSANlTf.

mind. According to our investigations, however, it may happen
with the feelings as well as the intellectual faculties. Such com-
plete inactivity may exist in every primitive faculty of the mind, or
in several, or in all together. It may be from birth, or from a
later event. Experience shows that it is so ; and only our ana-
tomical and physiological discoveries of the brain, and philosophical
inductions, can explain such facts. Different names, therefore,
ought to be pointed out. Idiotism, for instance, might be called the
diseased inactivity of any faculty of the mind from birth ; and fatu-
ity, if the patients have manifested the powers of the mind, but
have lost their activity by any eventual cause. There is then a
partial and a general idiotism, and a partial and general fatuity.

A second sort of derangements of the manifestations of the
mind, is when its faculties are too active, and beyond the in-
fluence of the will. This is, perhaps, never the case with all
faculties ; but it happens often, partially, with the propensities,
sentiments, and intellectual powers, as may be understood by the
symptoms which I have related in the preceding section. Such
hallucinations may be continual or intermittent, and the latter
regular or irregular. Moreover, in succeeding fits, the too pow-
erful activity may take place in the same faculty, or in different
mental powers ; so that, for instance, in one fit the patient de-
spairs, and in another commands the world. Volumes of facts
illustrate this truth.

Such partial and intermittent hallucinations are often pointed
out with difficulty. The patients carry on any conversation so
much in the usual manner, that it may be suspected whether they
be actually insane. But let the hallucination be touched upon,
then the truth will appear. A man whose lunacy v/as tried to be
proved at Chester before Lord Mansfield, had absolutely eluded
by his coolness and subtilty every question which tended to effect
this purpose, and appeared as perfectly rational and collected as
possible till Dr. Battle came into court, who asked him what had
become of the Princess he had corresponded with in cherry-
juice? He immediately forgot himself; replied, it was very

DIVISION. 73

true ; he had been confined in a castle with a very high tower,
and denied the use of ink, on which he wrote to the Princess in
cherry-juice, threw the letter into the river, and it went down the
stream.

The manifestations of the faculties of the mind may also be
altered or alienated in their specific appearance ; that is, they
may be morbid in quality. The eyes, for instance, sometimes
see every object red ; the taste is pleased with chalk ; a patient
fancies himself affected with the itch, or that his body is made of
butter, and avoids carefully coming near the fire. Dr. Cox*
speaks of a professor in music, whose talents for music seemed
even improved ; his ideas executed on the violin were wonder-
fully striking, singular, and original, but on other subjects he
reasoned absurdly. I doubt whether this sort of insanity be ever
quite general in the mind ; it is mostly partial, and then perma-
nent or intermittent. It may happen with every primitive faculty
of the mind, and the phenomena can be understood only by the
plurality and independence of the organs by which the single
powers of the mind are manifested. These modes of derange-
ments might be properly called alienation.

With respect to partial and intermittent insanity, I once more
take the liberty of saying, as it is certain that, in many instances,
persons with a large portion of intellect, and a highly cultivated
mind, would pass whole months without betraying any symptom
of insanity, the disease being confined to one particular subject,
and as the derangement will only be detected if that object be
touched upon ; as on all other occasions they are capable of
thinking, reflecting, reasoning, comparing, judging, and acting
like men in general ; ought they to have no moral and legal free-
dom in other points to which the insanity has no relation ? In
the same way, as there are insane persons who enjoy distinct in-
tervals, their reason, sobriety, and steadiness ; where the mind
manifests all its faculties ; where the intellect is perfectly clear ;

* Lib. cit. p. 94.

10

74 INSANITY.

the actions subject to the will ; where the mind is capable of esti-
mating the morality of actions ; should such persons, at their lucid
intervals, be incapable of giving evidence in a court of justice, of
making contracts, disposing of property, and performing all the
functions of a sound mind ? Dr. Rush says, ^ I have known a
clergyman whose sermons and prayers discovered every mark of
a sound mind, but who was constantly deranged when out of the
pulpit.' He speaks also of a judge in a neighboring state who
was deranged in a high degree in his family and in company, but
who astonished the court of which he was a member, by the cor-
rectness of his opinions and conduct when he took his seat upon
the bench.

With respect to duration, the derangements of the mind may
be divided into acute and chronic, and both again into continual
or intermittent. Several writers on insanity consider it as always
chronic. This, however, is not the case. I have seen it cured
in a short time ; and I hope the time will come when we shall
better understand the nature of insanity, and cure it as well as
other disturbances. The brain is an organic part, and must be
curable. Its organization is only more delicate, and requires
more attention from the beginning of its deranged functions, in
order to prevent its organic changes. Proper means, at the com-
mencement of the disease, are certainly more efficacious than at
a later period.

Another division of insanity, as to the event, is into curable and
incurable ; that is, the cause can or cannot be removed. Finally,
the most important division is that according to its causes. This
consideration is the object of the following section.

CAUSES. 75

SECTION IV.

Causes of Insanity.

This investigation is the most important, p.nd the basis of all
curative proceedings. In any disease a reasonable mode of treat-
ment must be adapted to the cause and its nature, and modified
according to the individual constitution, age, and peculiar circum-
stances of the patient ; if this be impossible, the whole curative
plan must be vague, and merely experimental. I shall bring
these individual considerations under three heads. First, I shall
examine whether there are diseases of the mind, or whether the
proximate cause of insanity is only corporeal : then I shall con-
sider the seat of this proximate cause : finally, I shall endeavor to
elucidate the nature of the causes of insanity.

I. The proximate cause of Insanity is corporeal.

Many physicians speak of diseases of the mind ; others admit
both mental and corporeal causes of insanity ; a few acknowledge
only corporeal diseases, and with the latter I decidedly agree.
The idea of mental derangements must not, however, be con-
founded with mental causes. Certainly the manifestations of the
mind may be deranged ; but I have no idea of any disease, or of
any derangement of an immaterial being itself, such as the mind or
soul is. The soul cannot fall sick, any more than it can die. As
this point is so important in practice, when it is necessary to act
and to cure, or when institutions for such unfortunate creatures as
are insane persons, are to be established, I shall enter into more
details. I consider the mind in this life confined to the body, of
which it makes use ; that is, the powers of the mind want instru-
ments for their manifestations ; or, these manifestations are de-
pendent on the instruments ; cannot appear without them ; and
are modified, diminished, increased, or deranged, according to

76 INSANITY.

the condition of the instruments or organs. That the proximate
cause of insanity is corporeal, I infer from the following observa-
tions.

I. Insanity is connate and hereditary.

This investigation is of the utmost importance, both in a legal
and moral point of view. Considerable diversity of opinion has
prevailed, whether insanity be hereditary or not ; and much is
said on both sides. With Darwin, Chrichton, Cox, Haslam, Hal-
laran, and many others, I consider insanity as hereditary. It is
indubitable, that children inherit from their parents the constitu-
tion of body, and the dispositions of mind. There are family
faces, and family likenesses. Children often possess the make
and fashion of the body peculiar to one or the other of their parents.
Haslam quotes an example where the son had the gait, voice, and
hand-writing of his father, though the father died before the son
had been taught the use of the pen, and who probably never saw
the hand-writing of his father. I know similar facts.

Personal deformities, and many bodily diseases, are transmitted
from generation to generation ; such as gout, stone, dropsy, scro-
fula, pthysis, deafness, blindness, struma, apoplexy. The inter-
nal viscera, such as lungs, stomach, intestines, kidney, bladder,
uterus, &c. with their various dispositions, participate of inherit-
ance, why should it not be the case with the brain } Numerous
facts, indeed, are unfortunately too well ascertained, that the off-
spring of insane parents are more liable to insanity than those
whose parents have never shown any deranged manifestations of
the mind. I have observed several examples. Haslam mentions
ten ;^ I shall copy only one. ' R. G. his grandfather was mad,
but there was no insanity in his grandmother's family. His father
was occasionally melancholic, and once had a raving paroxysm ;
his mother's family was sane. R. G. has a brother and five sis-

^ Lib. cit. p. 231.

CAUSES. 77

ters : his brother has been confined in St. Luke's ; all his sisters
have been insane ; with the three youngest the disease came on
after delivery.'

Those who deny hereditary diseases must at least admit heredi-
tary predisposition to diseases. As weakness of certain parts runs
through whole families, so at least a predisposition to insanity is
propagated from parents to children. Now, as the exciting causes
occur so easily, and the susceptibility of being affected is so
great, such individuals escape with the greatest difficulty. In
many cases we must admit even hereditary diseases, as in deaf-
ness, blindness, idiotism, from birth.

This object is involved in deep obscurity, and I do not intend
to hazard an explanation ; but the fact is indubitable. On the
other hand, it must be admitted that children born from insane
parents may escape, as is the case in other hereditary complaints ;
and that insanity may be produced in every person, born from the
strongest and most healthy parents. Many scrofulous children
are confined to their chamber half the time anterior to their puber-
ty, and their progenitors are strong and healthy. The probability
of hereditary insanity is the same as of other transmissions ; it may
begin in any one. The longer it has existed in a family, and the
greater the number of generations which have been affected, the
greater is the danger. Fodere * has observed that, among Cre-
tins, children of the first generation are less disposed to that dis-
ease ; that, if such children intermarry with other Cretins, the
propagation of the disease is more certain ; and that, if during
three generations consecutively they intermix, the disease is a
certain event. In the same proportion, the probability of heredi-
tary transmission lessens in intermarrying successively with heal-
thy persons. In general, the hereditary disposition to diseases is
proportionate to the change which has taken place in the organiza-
tion It is, however, to be remarked, that any defect produced
by nature is more easily propagated than if it be the result of art.

On Goitre and Crrtinism.

78 INSANITY.

It is, for instance, more probable that an animal born without a
tail will propagate young ones with the same defect, than another
which has been mutilated by art. Several natural philosophers
even doubt that art has such an influence on the change of beings.
At least a long series of experiments, repeated from generation to
generation, is necessary before the artificial change is transmitted.
With respect to this object I refer to Fodere on Cretinism, and to
Dr. Prichard^s work on the Natural History of Man.

The hereditary dispositions cannot be explained by the mind
itself, which we consider as a free agent. If it could it certainly
would escape such miserable situations. Nobody, I suppose, will
maintain that there are peculiar minds of Cretins, any more than
that there are specific minds of musical genius, or of any other tal-
ent, which is propagated from parents to children. I think it more
natural to explain hereditary insanity, like all other hereditary dis-
positions, by the corporeal conditions by which the powers of the
mind are manifested. Sight and hearing are endowments of the
mind ; but there is hereditary blindness and deafness, on account
of the material conditions on which the power of seeing and hear-
ing depend. In the same way I consider hereditary idiotism, and
every hereditary predisposition to insanity, as the result of the
bodily apparatus by which the faculties of the mind are manifest-
ed. The natural inference is, that parents and guardians, in the
disposal or direction of the choice of their children in marriage,
ought to be aware of the danger of forming an alliance with a
family in which insanity is prevailing. Indeed, the subject must
rouse dreadful apprehensions in the minds of those whose views
are directed to the future health of their progeny.*

* ' It is of little real importance,' says Burrows, ' whether it be a predisposi-
tion, or the malady itself, which descends and becomes hereditary ; but no fact
is more incontrovertibly established than that insanity is susceptible of being
propagated ; or, in other words, that a specific morbid condition sometimes ex-
ists in the human constitution, which by intermarriage, or according to the
vulgar but expressive language of cattle breeders, by breeding in and in, may
be perpetuated ad infinitum.'

CAUSES. 79

2. Jlge has an influence on Insanity.

It is not probable that the immortal mind changes with age,
and is different in the same person, when a child, adult, or de-
crepid. Insanity, however, is connected with certain periods of
life. It has been generally observed, that insanity, idiotism from
birth excepted, is the most frequent between 30 and 40 years of

Hereditary predisposition, therefore, is a prominent cause of mental derange-
ment.

Mania and melancholia do not propagate their respective types : a maniac
may beget a melancholic, and vice versa.'

Esquirol assigns one hundred and fifty out of two hundred and sixty-four
cases in his own practice, to hiriditi.

Dr. Burrows says he ' has clearly ascertained that an hereditary predisposi-
tion existed in six-sevenths of the whole of his patients.

Hereditary insanity is more prevalent among the higher ranks of society
than among the lower, and for the reason that the ' former most frequently
contract marriages with their own rank, or even with their own family,'

There are numerous instances in ancient Scottish families, proving this posi-
tion. It is a truth well worthy the consideration of those who isolate them-
selves from the middling classes of society, on account of the great respectability
df their own family connexions. Respectability is a word that is daily losing
its meaning ; e. g. a rogue is called respectable, if he has but wealth .''

The Jews, probably less than any other people, have intermarried with
strangers, and it is supposed that they are most liable to insanity.

* Insanity among the society of friends,' says Dr. Burrows, * who usually in-
termarry in their own fraternity, is very prevalent.'

As it may be interesting and useful to some to know more definitely the
nature of insanity, — so far as marriage is concerned, we add the opinions of Dr.
Burrows, which follow :

* My opinion upon two points relating to this interesting question, has been
sometimes professionally required by those contemplating marriage, and who
were conscious that insanity had existed in one or the other of their progen-
itors ; First, whether a person born of parents in whom insanity has never
been developed, but who, one or the other, were descended from a family so
afiiicted, was capable of propagating it in his own children? Secondly,
whether a child born before insanity had been developed in either parent was
as liable to become insane as one born after it had been developed .'*

To the first question I have answered in the affirmative ; because I have met
with many insane persons neither of whose parents had themselves been in

80 INSANITY.

age, less between 20 and 30 ; still less between 40 and 50 ; less
ao-ain between 50 and 60 ; in a smaller number between 10 and
20 ; and very rare after 60. Very young and very old people
are hardly known to become insane, properly speaking. Thus
the manifestations of the mind are the most liable to derange-
ments when they are the most energetic, and this is the case
when the cerebral organization is the most active.

In children idiotism from birth is often observed. There are
also numerous cases where children, by accidental causes, lose
the manifestations of the mind. But it may be asked, whether
children suffer mania and insanity. Mr. Haslam* describes sev-
eral cases of insane children. These cases, however, belong to
one of the two already noticed sorts of idiotism. I have seen
several examples of that kind in different countries. They are
mostly partial idiots from birth, and I shall detail their history
when I treat of the nature of the causes of insanity. The reason
that children do not appear as insane, strictly speaking, in my
opinion is, because their cerebral organization is too delicate, and
does not bear a strong morbid affection without entirely losing its
fitness for the mind and endangering life. The disturbances of
the organization appear merely as organic diseases, because the
functions are entirely suppressed. Later, in proportion as the
brain becomes firmer, it bears morbid changes longer without be-
coming entirely unfit for its functions or causing death. Its func-
tions then are only disturbed, and appear under the symptoms
called insanity.

sane, but the progenitor's brother, or sister, of one or the other of those parents,
were so.

' To the second I have replied, that a child born either before, or after the ac-
cession of insanity in a parent, provided that parents, progenitors or relations in
blood had been insane, was liable to hereditary insanity.

' But if the insanity of the parent were adventitious, and not hereditary, the
child born before the mental disorder had occurred, of course could not have it
by inheritance ; but how far a child born after the occurrence of the adventi-
tious insanity was liable, I could not decide/
'^ T,ib. cit. p. 185.

CAUSES. 81

In old age, the manifestations of the internal operations of the
mind diminish like those of the external senses, and the com-
plaints consist more in weakness and inaptitude, than in too great
or disordered activity. In the middle age the powers of the
mind show the greatest activity, and the cerebral organization is
the strongest ; hence, disorders in the functions are more distinct,
and less apt to destroy hfe. If love does not yet exist, or if it
becomes inactive by age, the other faculties will not be disturbed
by it, as is so often the case during the period of life, when it is
one of the prevailing passions. Thus, the deranged functions of
the mind bear a close relation to their degrees of activity, and to
the perfection of the organization of the brain, just as happens
with the bodily functions ; and as the mind cannot suffer by age,
I infer that insanity, which depends on age, is the result of corpo-
real causes.

3. Causes, which evidently injure the body alone, produce Insanity.

All that disturbs, excites, or weakens the organization, chiefly
the nervous system, has an influence on the manifestations of the
mind. It is a common observation, that the powers of the mind
are less energetic, when the body increases too rapidly, and that a
too great acUvity is often too soon exhausted ; so that early gen-
ius frequently sinks under the level of mediocrity. Moreover,
who can deny the influence of digestion, excretions, of continued
fasting, or of all that exhausts the bodily powers, on the manifes-
tations of the mind ? Early dissipation, habitual luxury, sickly
sensibility, are frequent causes of insanity. Pregnancy, and the
bodily changes at the time of delivery, often derange the functions
of the mind. Aliments, particularly drinks, in quantity and qual-
ity have an influence on the morals. The frequent fasts of the
Jews were instituted to keep down the passions. Fermented
liquors in excess rouse, if I may be allowed the expression, every
latent spark of vice and virtue. Dr. Parry of Bath,* in the ex-

^ Elements oi' Vsiilujlogy and Tlieriipoutics,

u

82 INSANITY.

position of his practical observations, has sufficiently detailed the
influence of circulation, and of the excessive determination of
blood to the brain, on the diseases commonly called nervous, and
on insanity. Now all these circumstances act on the organiza-
tion alone ; hence the deranged functions of the mind, which re-
sult from them, depend on organization.

4. Insanity depends on season and weather.

It is an old opinion, which still continues to prevail, that the in-
fluence of the celestial bodies, such as stars, comets, and planets
is connected with the mind, and especially that the periodical re-
turns of insanity are regulated by the moon. For that reason
this complaint was designated by the name lunacy. I am not in-
clined to deny all influence df the celestial bodies on the animal
economy, if it be true that the moon produces the stupendous
phenomenon of the tide. It is, however, certain, that the period-
ical fits of insanity are not regulated by the moon, and that the
name lunacy ought to be abolished. I here copy, from Mr. Has-
lam's work, a passage which confirms how prevalent this errone-
ous opinion still is. He says,^ ' Such has been the prevalence of
this opinion that, when patients have been brought to Bethlem
Hospital, especially those from the country, their friends have
generally stated them to be worse at some particular change of
the moon, and of the necessity they were under, at those times,
to have recourse to a severe coercion. Indeed I have understood
from such of these lunatics who have recovered, that the over-
seer or master of the workhouse himself has frequently been so
much under the dominion of this planet, and keeping steadily in
mind the old maxim, Venienti occurrite morbo, that without wait-
ing for any display of increased turbulence on the part of the pa-
tient, he has bound, chained, flogged, and deprived these miser-
able people of food, according as he discovered the moon's age

* Lib. cit. p. 215.

CAUSES. 83

by the almanack. To ascertain how far this opinion was founded
in fact, I kept during more than two years an exact register ; but
without finding, in any instance, that the aberrations of the human
intellect corresponded with, or were influenced by, the vicissitudes
of this luminary.'

On the other hand it is certain, that season and weather have
an influence on the manifestations of the mind, as well as on the
functions of the body. In certain years more boys, in others,
more girls are born ; and there are years when abortions are more
frequent, as it has been long ago observed by Plutarch. In one
season the alimentary canal, in another the organs of respiration,
now the eyes, then the larynx, are more affected. The diseases
are not only more common according to the season, but also more
intense, and of longer duration ; it is the same with the manifesta-
tions of the mind and insanity. The vernal sun gives more activ-
ity to plants and animals, and exhilarates the human mind. The
different instincts of animals appear and disappear at certain sea-
sons : also in man the mental faculties do not always act with the
same energy. Constant fogs and rains render the mind gloomy.
Melancholy, with the propensity to suicide, is at certain periods
more powerful than at others. Every one of a sensitive temper-
ament, and endowed with a serious, gloomy train of thoughts, will
recollect that at certain periods his gloomy feelings are increased ;
that he is displeased with almost every impression from without,
and unfit for society. Suicide is more common, in one climate,
in one year, and in one season, than in others. In Vienna suicide
is rare ; but in one year there were in one week seven suicides,
so that the government became attentive, and ordered that the
causes should be investigated. No moral event, which might ex-
plain it, could be pointed out. Pinei observed maniacal parox-
ysms which were dependent on the season and weather, and re-
marked that they were more easily excited by high temperature
of the atmosphere. He mentions cases where the remission and
exacerbation of paroxysms corresponded with the changes of the
temperature of the atmosphere from miklness to severe cold.

84 INSANITY.

Thus, as climale, season, and weather, influence insanity, it must
depend on corporeal causes.

5. Insanity is periodical, and has exacerbations.

It is superfluous to mention the periodical appearances and ex-
acerbations of bodily diseases ; they are generally known. Daily
experience also shows that insanity is periodical, and has exacer-
bations and remissions. Women frequently become suicides at
the period of menstruation. We find insane people on certain
days worse, as is the case with other diseases. Now there is no
reason to think that the mind suffers such repeated changes ; but
it seems natural to infer, that the changes of insanity, like those
of other diseases, depend on similar causes.

6. Insanity is often accompanied, or alternates, with corporeal

diseases.

In many well-ascertained cases, insanity has been known to
originate from bodily causes ; such as worms in the intestines,
other complaints of the viscera, suppression of hsemorrhoides, lo-
chia, old sores or drains dried up, concussion and injuries done
to the head, great determination of blood to the brain. More-
over, in insanity there are often other morbid appearances, such
as noise in the ears, dilatation or contraction of the pupil, habit-
ual headache, pain over the eyes, dizziness, a sense of weight,
stricture and numbness across the forehead, palsy ; many nervous
complaints, such as dyspepsia, hysteria, hypochondria. It even
happens that the same cause produces in one individual hysteria
or hypochondria, in another epilepsy, in a third melancholy, in a
fourth mania. Sometimes all these symptoms exist in the same
patient, and are occasionally converted into each other. Hypo-
chondria and irregular conduct sometimes advance in proportion
as some organic lesion increases. Insanity sometimes alternates
with intermittent fever, with epilepsy, and other bodily complaints y

CAUSES. 85

now as so many bodily diseases in their progress and effects, bear
the closest resemblance to insanity, it seems to me that to consider
insanity as independent of organic disease or vital lesion, is a doc-
trine as unfounded in nature as it is highly prejudicial to the inter-
ests of mankind.

7. Sleep is often disturbed in Insanity.

It is well known that the functions of the mind cannot continue
with equal energy, but want rest. Onljr corporeal organs, how-
ever, can be fatigued and exhausted, and this inactive state is
sleep : hence sleep is dependent on corporeal causes. Now,
uneasy and disturbed sleep, or entire sleeplessness, is, as well as
of some other diseases, a precursory symptom of insanity ; and
many insane persons are destitute of this means of recovering
strength. Moreover, there is the greatest analogy between dreams
and various symptoms of insanity. Dreams are conformable to the
age and organic constitution of the body. Individuals endowed
with a very irritable nervous system find in their dreams impedi-
ments without end, and suffer pain and anxiety ; bad digestion
gives uneasy dreams ; finally, in dreams we think that we re-
ceive external impressions by the senses ; we fancy we see or
hear, and keep up different trains of singular thoughts. All these
appearances take place in insanity. Now as disturbed sleep,
sleeplessness, and dreams, in common life and in other diseases,
are considered as the effect of corporeal causes, why should we,
in insanity, admit another cause for the same symptoms ?

Thus, from observation and reasoning, it results that the prox-
imate causes of the deranged manifestations of the mind must be
considered as corporeal. The soul, in its deranged manifestations
of feelings and intellectual powers, is no more diseased than in
the disturbances of the five senses, and voluntary motion. In
palsy, the cause is not looked for in the mind, but in the instru-
ments by which will is propagated, or voluntary motion perform-
ed. In the derangements of hunger and thirst, of hearing and
seeing, smelling, tasting and feeling, the seat of the proximate

86 INSANITY.

cause is admitted in the respective organs by which these powers
are manifested. It ought to be the same with the internal opera-
lions of the mind. Indeed, a too assiduous attention has hitherto
been paid to the development of moral or metaphysical causes,
while the corporeal, indisputably more within the sphere of hu-
man understanding, have been greatly neglected. If the mind
were diseased, it ought to be cured by reasoning. I think how-
ever with Haslam,* ' the good effects which have resulted from
exhibiting logic as a remedy for madness must be sufficiently known
to every one who has conversed with insane persons, and must
be considered as time lost.' I say also with Drs. Hallaran and
Cox, *that to talk at rather than talk to insane persons with a
view to convince, is the surest mode of exciting the train of nat-
ural ideas, to which the most labored and methodical contrivance,
when directly applied, will be found altogether incompetent.' I
cannot conceive for what reason the mind, a being endowed with
reflection and will, should be pleased to appear sometimes below
the nature of a brute. And if it be not its will, what has over-
powered the will ? Is it a supernatural being ? a good or bad
spirit? Then let us expect every salutary event from prayers
alone, and let us again have recourse to exorcism ! !

II. The proximate cause of Insanity is in the brain.

I have endeavored to show that the cause of insanity must be
considered as corporeal. I shall now examine where its seat is,
and I wish to prove that it resides in the brain. For that pur-
pose it is necessary to consider the functions of the brain, and its
morbid appearances in insanity.

1. The brain is the organ of the mind, and the cerebral parts
the organs of its primitive faculties.

With respect to these points, I refer the reader to the details

* Lib. cit. p. 241.

CAUSES. 87

mentioned in my work on Phrenology for and against them. If
it be proved that the brain is the organ of the mind, and that the
manifestations of erery primitive faculty of the mind depend on a
peculiar part of the brain ; and if all primitive powers of the mind
and their respective organs be once ascertained, it is evident that
the cause of insanity will be looked for in the brain, and the
cause of the deranged manifestations of every special faculty in a
peculiar part of the brain. I do not say that I am advanced in
this knowledge as far as I wish ; much more than what is already
known must be found out ; but from daily observations, and the
most positive facts, I am convinced that the basis of the above-
mentioned doctrine is founded on nature. Thus, instead of as-
cribing insanity^ or the disturbed reflecting powers and feelings,
to what is called moral causes, the deranged manifestations of
these faculties will always be considered as morbid affections of
the cerebral organization.

2. Morbid phenomena of the brain in Insanity,

Also with respect to this point I have given many details in my
other works. I have spoken of idiots from birth, and have an-
swered the objection, that there is not always a perceptible change
of organization. I add, the brain is an organic part, and we must
not expect to find more in it than in any other part of the body.
Nay, as its organization is the most delicate of the whole frame,
organic changes may occur which are imperceptible on dissection ;
since this is also the case in other parts, which may be affected
by various diseases, without offering the least morbid appearance
after death. The stomach, for instance, and intestines, have
often suffered for a long time, and the most skilful anatomists
cannot detect any thing different in their structure after death.
On the other hand, neither vomiting nor want of appetite have
taken place in persons in whose stomach mortification was found
after death. Abscesses have been observed in the livers of per-

88 INSANITY.

sons who have died without any one of the common symptoms of
hepatitis.

I know that anatomists and surgeons of celebrity relate that
they could not find any morbid appearance in the examination of
insane persons after death. I reply, that various obvious differen-
ces, as to size and form, of the brains of different sexes or indi-
viduals, have also been overlooked, while they may be easily ob-
served. I really think that all morbid effects which are observed
in other parts may also be distinguished in the brain, such as a too
defective or too large development of its substance, distension of
blood-vessels, inflammation, suppuration, serous effusion, dropsy,
rupture, or ossification of blood-vessels. I even maintain that
morbid changes of the physical appearances of color and texture
might be pointed out in the brains of many who have died insane,
if those who examine them were better acquainted with the ap-
pearances of the brains of individuals who had no particular de-
termination of blood to the head, and preserved their manifesta-
tions of the mind to the last moment of life. In fever with deliri-
um, in phrenitis, in insanity with too poweiful manifestations of
the faculties, in children who from birth were able to manifest
their powers of the mind, but lost them by accidental disease, and
in those who after violent mania became fatuous, or who died ap-
oplectic, I was always able to detect some morbid appearances or
organic alterations, either in the substance of the brain, or in the
blood-vessels, or membranes, or even in the skull, which some-
times is uncommonly thick, or dense like ivory.

III. Nature of the Causes of Insanity,

From the preceding considerations it results, that 1 always look
for the proximate cause of insanity in the organization of the brain.
In this organ then, as in any other part of the body, the deranged
functions and the morbid changes of the organization may be
spoken of; but they ought never to be separated with respect to
pathology, no more than disturbed respiration and diseased lungs.

CAUSES. 89

I have sometimes repeated, that the appearances of insanity are
merely symptoms of the deranged functions of the organs of the mind.
The organ of the feeling of self-esteem being deranged must naturally
produce symptoms different from the disorders of the organ of
the propensity to destroy or to conceal, or of cautiousness or be-
nevolence, &tc. ; hence there are as many sorts of symptoms as
primitive faculties of the mind, and their combinations. In this
manner alone we can understand why melancholia and mania are
often the same disease, may interchange with each other, and why
the same treatment may be successful in both, and why in other
cases they are different. In our physiological language I would
say, in melanchoHa the organ of cautiousness suffers more, and in
mania that of combativeness or destructiveness, or both ; now in
these cases the morbific cause may be the same or different.
Moreover, as the same disease, gout for instance, or rheumatism,
may affect different parts of the body, so the same morbific cause
may attack successively different parts of the brain, and in this
way alone we can explain why the same insane person in one fit
may be pious and say prayers, in another may curse and endeavor
to kick, bite, and destroy every thing which falls within his reach ;
may in one fit weep, in another laugh. Do we not see that the
cause of hysteria now affects the lungs, then the stomach, the
head, the teeth, the ears, eyes, and the different cerebral parts ?
The cause of the ague may produce the common symptoms of
cold, heat, and perspiration, or an intermission of headache, of
toothache, coma, or intermittent symptoms of inflamed lungs, &ic.

I have also spoken of the modified symptoms of the same dis-
turbed function in different persons, because the organs are modi-
fied in every one, and form different combinations with other
organs. For more details I refer the reader to my work on Phren-
ology. The same remarks may be made in the healthy and dis-
eased state.

There are writers, Johnston* for instance, who consider the

** Medical Jurisprudence, art. Madness : Birmingham, 1800.

12

90 INSANITY.

proximate cause of insanity as corporeal, but the nature of the
disease always the same, whatever the hallucination may be.
They consider the disease only different as to its degrees. It is
true the hallucinations do not indicate the different nature of the
disease, but the same symptom may be the result of different
causes ; diarrhoea, for instance, may be produced by fright, by cold
and wet feet, by crudities in the stomach, by dentition in a child ;
hence diarrhoea is merely a symptom, but its cause constitutes the
disease. On the other hand, as I have also repeated, the same
disease or cause, such as suppressed perspiration and refrigeration,
produces in one person symptoms or effects of ophthalmia, in
another of toothache, or sore throat, and cough, or diarrhoea, &c.
All these considerations must be applied to insanity.

The causes of insanity may be idiopathic, that is, confined to the
head ; or syrapathic, viz. residing in other parts and influencing
the brain.

Idiopathic causes of insanity.

The idiopathic causes of insanity, in its most extensive significa-
tion, either exist from birth, or originate from later events. These
latter are mechanical, that is, the effect of a violent cause ; or
dynamical, the result of the deranged functions of vitality, viz. of
the vital powers.

Idiopathic connate idiotism.

Insanity from birth is always idiotism, complete or partial.
There can be no doubt that, from birth, the cerebral organization
may be too defective, and unfit to perform its functions. A brain
too small is always accompanied with imbecility. Willis describes
the brain of an idiot from birth, which was not larger than half the
ordinary size. Professor Bonn, of Amsterdam, possesses two
such skulls, and the brain of one ; Pinel has one ; Gall two such
skulls. See PI. I., where there are six figures of different modifi-
cations, all taken from nature, and three of them (fig. 4, 5, and

CAUSES. 91

6,) from living persons, in the Lunatic Asylum at Cork in Ireland.
I have seen thousands of such unfortunate beings, idiotic in differ-
ent degrees ; and it is a certain fact that, in the greatest number of
idiots from birth, the heads, particularly the foreheads, are too
small; in a small number the heads are too large, that is, dis-
tended by an accumulation of water in the cavity of the brain.
(PI. II., fig. 3, 4, 5, and 6.) In others the size and form of the
heads do not offer any thing particular.

The Cretins, v^^hom we meet among the high mountains of
Tyrol and Switzerland, are of the same nature. It is, however,
an error to think that such stunted beings, and Albinos, are only
found in the valleys of the Alps^ or in other mountainous parts of
Europe. We have seen them in low and flat countries. In
Dublin there is a family of Albinos. I have found one of them in
the institution for blind boys in the same city. His irides were
reddish, and his hair, eyebrows, and eyelashes, were white. We
have made the same observation which Henry Reeve speaks of,*
viz. that the enlargement of the thyroid gland is a striking feature,
but not a constant attendant of Cretinism. Cretijiism is often ob-
served without any affection of the thyroid gland, and that gland is
often much enlarged without any affection of the intellectual fac-
ulties. The head of Cretiiis is deformed, the stature diminutive,
. the complexion sickly, the countenance vacant and destitute of
meaning, the lips and eyelids coarse, the skin and muscles flabby.
The qualities of the mind correspond to the deranged state of the
body, and there are various degrees of stupidity.

Cretinism, then, does not form a peculiar kind of disease. If
this were otherwise, we could believe, with as much reason, that
idiots in towns form a peculiar species different from those in the
country. Their cerebral organization is defective, and therefore
the manifestations of the mind are more or less impeded, sup-
pressed, or partially active, just as is the case with other idiots.

* Some Account of Cretinism. Edinb. Medical and Surgical Journal, 1809,
vol. V. p. 31.

92 INSANITY.

This opinion is supported by the observation, that Cretinism ori-
ginates from the same causes as idiotism, such as neglect of body
and mind, bad quality of air and food, various nuisances from
without, and from hereditary predisposition. The skulls of dif-
ferent Cretins is different, as well as of different idiots : hence the de-
scriptions of such skulls given by various writers, as Prochaska, Mal-
lacarne, Ackermann, are and must be different 5 for every author
described the skull he observed. All are right, and if others will
describe other skulls which they may observe, we shall read still
different descriptions. There is no peculiar form of Cretinism,
any more than of idiotism in general. .

Sometimes in children the brain is sufficiently larger, sometimes
even larger than the usual size, and without water in the cavities,
but there is no internal organic activity ; the mind is quite indo-
lent, and parents often despair of their rationality. Such children
learn to speak but late, are weak of body, and show evident
marks of a rickety constitution.

In Cretins, and in idiots in general, the manifestations of the
mind are more distinct, the inclinations more subordinate to the
will, the ideas clearer, and the natural language more significant,
in the same proportion as the organization of the brain is more
perfect. Moreover, idiotism is not always complete, but very
often only partial ; so that the parents, and sometimes even phy-
sicians, cannot conceive why a child should be deemed an idiot,
though he shows the manifestations of certain powers of the mind.
We saw at Hamburgh a young man, sixteen years of age, the
inferior parts of whose brain were favorably developed, but
whose forehead was scarcely one inch in height, and in whom
consequently the improvement of the superior parts of the brain
was impeded : he had only the functions of the inferior parts : he
recollected names, numbers and historical facts, and repeated
them in a mechanical manner ; but the functions of the superior
parts of the brain, such as comparison, reflection, sagacity, pene-
tration, and induction, were utterly wanting in him. I saw in the
poorhouse at Cork, in Ireland, a boy who excels in verbal memo-

CAUSES. 93

ry, but as to judgment he is an idiot. At Inverness, in Scotland,
Drs. Robertson and Nichol showed me a blind idiot who re-
peats passages of the Bible, merely from hearing them repeated.

Such partial idiots sometimes cannot speak, though they do
many things like reasonable persons, and sometimes they show a
great deal of cunning. Rush* has remarked, that great feebleness
of mind may be accompanied with cunning, and sometimes with
mimicry. Many of the idiots who cannot speak are not deaf 5
they can pronounce various words, yet they cannot speak ; and
physicians often look for the cause of this want in the organs of
voice, or in the tongue, amygdaloid glands, palate. See. but these
parts are never the cause of the want of language. Nay, certain
persons deprived of the tongue have yet continued to speak ; their
pronunciation of course could not be so distinct as that of other
persons ; they could not pronounce certain letters, but they felt
the necessity of speaking, or of communicating their sensations,
ideas and feelings, and they actually did contrive to speak. On
the contrary, these partial idiots pronounce single words very
well ; but they cannot maintain any discourse, they cannot keep
up their attention, nor combine their expressions.

In such partial idiots the five senses are often perfect, several
are deaf; in general they manifest the intellectual powers in va-
rious degrees, though imperfectly; but they are destitute of con-
sistent consciousness and perfect will, hence they belong to the
state of insanity. Some of them show mechanical talent. The
pretended savage of Aveyron, whom I saw at Paris in the Institu-
tion for Deaf and Dumb, knows several written signs and words,
and points out the objects denoted by them ; and he has the love
of order in a remarkable degree. A young person of this descrip-
tion was shown to me in Edinburgh. I saw an idiotic child who
sang several airs ; and if others began to sing, she accompanied
them with harmony and cadence. Some even learn to play a
few airs on the piano-forte. They recollect persons they have
seen before, &z;c.

* Medical Inquiries and Observations on the Diseases of the Mind, p. 298.

94 INSANITY.

Various propensities and sentiments are also active in different
degrees ; but it is not true that all Cretins are particularly in-
clined to physical love. In idiotic persons, however, such an in-
stinct, though it exist in a smaller degree, will be manifested in an
inordinate manner, since reflection and will are suppressed. I
have seen several idiots in whom this propensity was very power-
ful, but I have seen others who were quite indifferent in this re-
spect. Some idiots like to imitate other persons ; some are very
benevolent and cheerful ; others like to be caressed, or are very
obstinate ; some are. fearful ; others are irascible, and like to
quarrel and to fight. Several are incorrigible thieves ; others
have the most decisive instinct to bite, pinch, scratch, and even
to kill. Where I have treated of covetiveness and destructive-
ness in my work on Phrenology, I have quoted several examples
of such idiots. At Paris I have met with two partial idiots, who
were very mischievous, inclined to break every thing, and to take
revenge for the least offence. The parents themselves were ob-
liged to guard against their unfortunate propensity.

I shall copy two cases mentioned by Mr. Haslam.* They be-
long to this kind of insanity, and were incomplete idiots with
some energetic propensities. ' W. H. a boy nearly seven years
of age, was admitted into the hospital, June 8, 1799. His
mother, who frequently visited him, related the following particu-
lars respecting his case. She said, that, within a month of being
delivered of this child, she was frightened by a man in the street.
When the child was born, it was subject to startings, and became
convulsed on any slight indisposition. When a year old, he suf-
fered much with the measles : and afterwards had a mild kind of
inoculated small-pox. At this age she thought the child more
lively than usual, and that he slept less than her other children
had done. At two years the mother perceived he could not be
controled, and therefore frequently corrected him.

'There was a tardiness in the development of his physical

*Lib. cit. p. 188— 206.

CAUSES. 95

powers. He was fifteen months old before he had a tooth, and
unable to go alone at two years and a half ; his mind was equally-
slow ; he had arrived at his fourth year before he began to speak ;
and when in his fifth, he had not made a greater proficiency in
language than generally may be observed in children between two
and three years. When admitted into the hospital, he wept at
being separated from his mother, but his grief was of very short
continuance. He was placed on the female side, and seemed
highly delighted with the novelty of the scene : every object ex-
cited his curiosity, but he did not pause or dwell on any. He
was constantly in action, and rapidly examined the different apart-
ments of the buildina;. To the patients in general he behaved
with great insolence, he kicked and spit at them, and distorted
his face in derision ; but on the appearance of the nurse he im-
mediately desisted, and assured her he was a very good boy.
Great, but ineffectual pains were taken to make him understand
the nature of truth ; he could never be brought to confess any
mischief he had committed, and always took refuge in the con-
venient shelter of a lie. In a short time he acquired a striking
talent for mimicry, and imitated many of the patients in their in-
sane manners ; he generally selected for his m.odels those who
were confined, as he could practice from those with impunity.

' In about three months he had added considerably to his stock
of knowledge, but unluckily he had selected his expressions from
those patients who were addicted to swearing and obscene con-
versation. To teach him the letters of the alphabet had many
times been endeavored, but always without success. The attempt
uniformly disgusted him ; he was not to be stimulated by coaxing
or coercion ; he did not possess a sufficient power of attention to
become acquainted with arbitrary characters.

' He was in good health, his pulse and bowels were regular,
and his appetite was keen, but not voracious. In October he be-
came unwell, and at the mother's request was discharged from the
hospital. In September, 1805, I again saw the boy ; he was
then thirteen years of age, had grown very tall, and appeared to

96 INSANITY.

be in good health. He recollected me immediately, and men-
tioned the words, school, Moorfields, nasty physic. By this time
he had made, comparatively, a great progress in language ; he
knew the names of ordinary things, and was able to tell correctly
the street in which he resided, and the number of the house.
Having been taught when in the hospital, to use a bowl for his
necessary occasions, he obstinately continued the same practice
when he returned home, and could never be persuaded to retire
to the closet of convenience ; but the business did not terminate
here : when he had evacuated his intestines into the bowl, he
never failed to paint the room with its contents. To watch other
boys when they were playing, or to observe the progress of mis-
chief, gave him great satisfaction ; but he never joined them, nor
did he ever become attached to any one of them. Of his mother
he appeared excessively fond, and he was constantly caressing
her ; but in his paroxysms of fury he felt neither awe nor tender-
ness, and on two occasions he threw a knife at her. Every thing
splendid attracted his attention, but more especially soldiers and
martial music. He retained several tunes, and was able to whis-
tle them very correctly.

'The defect of this lad's mind appeared to be want of contin-
ued attention to things, in order to become acquainted with their
nature ; and he possessed less curiosity than other children, which
seems to excite such attention ; and this will in some degree ex-
plain why he had never acquired any knowledge of things in a
connected manner. His sentences were short, and he employed
no particles to join them together : he always spoke of himself in
the third person, and never made use of the pronoun. His atten-
tion was only roused by striking appearances or loud intonations ;
ordinary occurrences passed by unobserved.'

' In the month of July, 1803, my opinion was requested res-
pecting a young gentleman, ten years of age, who was sent here,
accompanied by a kind and decent young man to take care of him.
The parents are persons of sound mind, and they do not remem-
ber any branches of their respective families to have been, in any

CAUSES. 97

manner, disordered in their intellects. Their eldest son, at the
age of two years, became so mischievous and uncontrollable, that
he was sent from home to be nursed by his aunt. He was in-
dulged in every wish ; and thus he continued until he was nearly
nine years old, the creature of volition, and the terror of the fam-
ily. At the suggestion of a physician, a person was appointed to
watch over him. A different system of management was adopt-
ed. The superintendent was ordered to correct him for each in-
dividual impropriety. At this time the boy would neither dress
nor undress himself, though capable of doing both; when his
hands were at liberty he tore his clothes ; he broke every thing
that was presented to him, or which came within his reach, and
frequently refused to take food. He gave answers only to such
questions as pleased him, and acted in opposition to every direc-
tion. The superintendent exercised this plan for several months,
but perhaps not to the extent laid down ; for it may be presumed
that, after a few flagellations, his humanity prevailed over the
medical hypothesis. When he became the object of my own ob-
servation, he was of a very healthy appearance, and his head was
well formed ; this was also the opinion of several gentlemen, dis-
tinguished for their anatomical knowledge, to whom the boy was
presented.* His tongue was unusually thick, though his articu-
lation was perfectly distinct. His countenance was decidedly
maniacal. His stature, for his age, was short ; but he was well
compacted, and possessed great bodily strength. Although his
skin was smooth and clear, it was deficient in usual sensibility ;
he bore the whip and the cane with less evidence of pain than
other boys. His pulse was natural, and his bowels were regular.
His appetite was good, but not inordinate ; and he bore the pri-

* I doubt of his head having been well formed. This expression is vague
It is certain that the configuration of the head has hitherto not been sufficiently
attended to. I dare say that the upper part of the forehead of this subject, and
the whole coronal part of his head, were small in proportion to the basilar in-
termedial and inial regions.

13

98 INSANITY.

vation of food ior a considerable time without uneasiness. He
seemed to require a considerable duration of sleep.

* Few circumstances seemed to give him pleasure, but he
would describe very correctly any thing which had delighted
him. As he wanted the power of continued attention, and was
only attracted by fits and starts, it may be naturally supposed he
was not taught letters, and still less that he would copy them.
He had been several times to school, and was the hopeless pupil
of many masters, distinguished for their patience and rigid disci-
pline ; it may therefore be concluded, that from these gentlemen
he had derived all the benefits which could result from privations
to his stomach, and from the application of the rod to the more
delicate parts of his skin.

* On the fii'st interview I had with him, he contrived, after two
or three minutes' acquaintance, to break a window and tear the
frill of my shirt. He was an unrelenting foe to all- china, glass,
and crockery-ware ; whenever they came within his reach, he
shivered them instantly. In walking the street the keeper was
compelled to take the wall, as be uniformly broke the windows if
he could get near them, and this operation he performed so dex-
terously, and with such safety to himself, that he never cut his
fingers. To tear lace, and destroy the finer textures of female
ornament, seemed to gratify him exceedingly, and he seldom
walked out without finding an occasion of indulging this propen-
sity. He never became attached to any inferior animal, a benev-
olence so common to the generality of children : to these crea-
tures his conduct was that of a brute ; he oppressed the feeble,
and avoided the society of those more powerful than himself.
Considerable practice had taught him that he was the cat^s mas-
ter, and whenever this luckless animal approached him, he plucked
out its whiskers with wonderful rapidity ; to use his own lan-
guage, " 1 must have her heard o^." After this operation, he
commonly threw the creature on the fire or through the window.
If a little dog came near him, he kicked it ; if a large one, he
would not notice it. The usual games of children afforded him

CAUSES. 99

no amusement ; whenever boys were at play, he never joined
them; and he appeared incapable of forming a friendship with
any one : he felt no consideration for sex, and would as readily
kick or bite a girl as a boy. Of any kindness shown to him, he
was equally insensible ; he would receive an orange as a present,
and afterwards throw it in the face of the donor.

' To the man who looked after him, he appeared to entertain
something like an attachment : when this person went out of the
room, and pretended that he would go away, he raised a loud
outcry, and said, " JVhat ivill become of me if he goes away. I
like him, for he carries the cane which maizes me a good boy.^^
But the keeper doubted whether he really bore an affection for
him, and said, when he grew older, he should be afraid to con-
tinue with him, as he was persuaded the boy would destroy him
whenever he found the means and opportunity.

'Of his own disorder he was sometimes sensible. He would
often express a wish to die ; for he said, *' God had not made him
like other children ;" and, when provoked, he would threaten to
destroy himself. When conducted through Bethlem hospital, and
shown a mischievous maniac who was more strictly confined than
the rest, he said with great exultation, " This would be the right
place for me.^^ Several details are omitted, and to be looked for
in Mr. Haslam's work.

These, indeed, are curious facts, which cannot be explained by
the common principles of philosophy, but they are easily under-
stood according to our physiology of the brain. Some idiots are
good-natured, others mischievous, as is the case with other per-
sons ; in them some powers may show considerable activity, while
others cannot act at all ; and as attention is the result of the ac-
tivity of the powers, they may be attentive in some respects, and
not in others. The second boy, mentioned by Mr. Haslam. was
very attentive to every object which he could destroy, but insensi-
ble to the sufferings of other beings, or to friendship.

Mischievous idiots are not extremely rare. Dr. Hallaran also
speaks of several idiotic children who have been reported to him

100 INSANITY.

as mischievous from their infancy, and who, since Dr. Hallaran
observed them, have continued to evince strong evidences of in-
sanity.

In complete and incomplete idiots from birth, the automatic
functions are often w^eak, more or less suffering ; it is especially
the case with the functions of the intestines. Often, however, all
the functions of automatic life are quite healthy, and sometimes
very strong.

The complete idiots are rare in proportion to the incomplete ;
and in the latter there are numerous degrees. The natural lan-
guage always corresponds to the degree of idiotism. The low-
est class has the most stupid countenance, a gaping mouth from
which the saliva flows continually, a sneering face, a perpetual
rolling and tossing' of the head. A common appearance in
incomplete idiots is a vague, unsteady, wandering eye, which is
seldom fixed for any length of time on any one object ; they are
constantly moving about, and cannot keep up their attention or
reflection, nor combine different impressions : but in proportion
as their mental operations are more settled, their natural language
becomes more significative.

Idiopathic occasional idiotism.

Sometimes children are born in perfect health ; they improve
in body and mind, acquire notions of the external objects, reason
on them, and manifest feelings in a regular manner ; but ac-
cidentally lose the manifestations of the mind, and become com-
plete or incomplete idiots. Children naturally disposed to such a
disease are of a great nervous sensibility, and rickety subjects, of
an irritable temperament. Their cerebral parts often increase too
rapidly, and there is not sufficient time for the organs to grow
solid. The activity of the mind is sometimes stronger than the
brain can bear ; and it is a common observation, that too early
genius is often too soon exhausted. Moreover, the brain of such

CAUSES. 101

children easily suffers by different accidents, such as blows on
the head, spirituous aliments, insolation, especially during the time
of dentition. The blood is carried in greater quantity to the
head, and inflammation of the brain and its membranes is easily
produced. The children often die of the disease, or its effects, of
which 1 have spoken under the name Hydrocephalus acutus.
Sometimes the children overcome the disease, and escape with
life ; but the energy of their talents is lost, and the hopes of their
parents imbittered.

I have seen many such cases. Mr. Haslam* mentions one of
a female child three years and a quarter old. ^ When she was
brought to the hospital for medical advice, her mother related
that her child, until the age of two years and a half, was perfectly
well, of ordinary vivacity, and of promising talents ; when she
was inoculated for the small-pox. Severe convulsions ushered in
the disease, and a delirium continued during its course. The
eruption was of the mild kind, and the child was not marked with
pustules. From the termination of the small-pox to the above
date, nine months, the child continued in an iusane state. Pre-
viously to the small-pox, she could articulate many words, and
use them correctly for the things they signified ; but since that
time she completely forgot her former acquisitions, nor ever at-
tempted to imitate a significant sound. Whatever she wished to
perform, she effected with promptitude and facility. She ap-
peared anxious to possess every thing she saw, and cried if she
experienced any disappointment ; and on these occasions slie
would bite, or express her anger by kicking or striking. Her
appetite was voracious, and she would devour any thing that was
given to her without discrimination, as fat, raw animal food, or
tainted meat. To rake out the fire with the fingers was a favor-
ite amusement, nor was she deterred by having frequently burned
them. She passed her urine and faeces in any place, without re-
straint. Some cathartic remedies were ordered for her, with an

* Lib. cit. p. 185.

102 INSANITY.

emetic occasionally ; and she was brought to the hospital every
fortnight, but she did not appear in any degree amended. On
June 22 she was admitted a patient, and continued in the hos-
pital until the middle of October, when she was attacked with an
eruptive fever, and consequently discharged. During this time
little progress was made, although considerable pains were be-
stowed. She became more cunning, and her taste appeared im-
proved. The cathartic medicine which she drank at first without
reluctance, became afterwards highly disgusting ; and when she
saw the basket which contained it, she endeavored to escape and
hide herself. To peculiar persons she was friendly, and felt an
aversion to others. She was sensible to the authority of the
nurse who attended her, and understood by the tone of her voice
whether she were pleased or offended. The names of some
things she appeared to comprehend, although they were extremely
few ; when the words dinner, cakes, orange, and some more,
were mentioned, she smiled, and appeared in expectation of re-
ceiving them. After the lapse of three years the child had made
no intellectual progress.'

All that I have said of delicate and stout children, with prema-
ture faculties of the mind, as liable to hydrocephalus acutus, is to
be brought in connexion with this sort of idiotism. The soft cere-
bral organization of children is affected by various morbific causes;
neither disease nor effusion kills them always, but sometimes the
organization of the brain is deranged, its developments impeded,
and the head remains too small in proportion to what it ought to
be in later age. The automatic functions of such children are
often in good condition ; they are well nourished, and live long.
Often their bowels are very inactive, or convulsive motions are
observed. Sometimes, after several years, a long series of dis-
tressing events is terminated by death.

As insanity consists in the suppression of clear consciousness
and will, there cannot be any doubt that children can become in-
sane. But the deranged functions of their minds must exhibit
some modification, because the manifestations of many faculties

CAUSES. 103

have not yet acquired the same degree of energy which we com-
monly observe in adults, and several powers are not yet active.
Mostly, however, on account of the delicacy of their brains, they
die or become idiotic from severe affections of the head.

Fatuity.

There is another sort of occasional idiotism which is commonly
observed in adults, sometimes in young persons, often in those
who have suffered of chronic melancholia, and still more fre-
quently after chronic and continual mania. I have also seen in-
dividuals who, from a violent concussion by a fall or a blow on
the head, or from fear, suddenly sunk into a state of general ap-
athy. In other diseases, as in epilepsy, catalepsy, delirium with
fever, Stc. fatuity often succeeds, particularly in persons who, from
infancy, were endowed with a small share of intellect. Febrile
diseases, in general, often weaken memory and the other intel-
lectual operations. Thucydides relates, that, during the plague at
Athens, many who recovered lost their memory so completely,
that they not only forgot the names of their friends, but also their
own names. Such patients commonly recover the manifestations,
in proportion as their health returns. Sometimes the impedi-
ment of the manifestations of their mental powers lasts for life.
In such cases, organic changes take place in the brain, such as
thickening of the membranes, serous effusion, turgescence of the
blood-vessels, adhesions by pseudo-membranes ; in short, all ef-
fects of inflammatory diathesis ; often thickening of the skull, or
its bone growing dense like ivory. In such a state, the brain is
no longer fit for the manifestations of the mind. Fatuous persons,
indeed^ make a great proportion of the patients in asylums for in-
sane.

Idiopathic mechanical causes of insanity.

The manifestations of the mind may be deranged by various
mechanical causes, not only from without, such as violent blows.

104 INSANITY.

a fall, fracture or depression of the skull, but also from within, by
exostoses, for instance, or hydatis, ossified blood-vess(;ls, various
tumors, a collection of pus, of water, or a congestion of blood.
As by similar causes the manifestations of the mind are often sup-
pressed, so they may be excited, or alienated. I have mentioned
cases where violent blows have produced idiotism : on the other
hand, there are also examples where, by the same causes, in
stupid persons, the manifestations of the mind acquired more en-
ergy. I know the history of a boy, who, from the fall of a stone
on his head, became more stupid, but at the same time infinitely
more quarrelsome than he was before the accident. The history
of Pere Mabillon is generally known : he was a boy of inferior
abilities, till a tile fell on his head ; then he began to display great
talents. Acrell, in his Surgical Observations, relates the case of
a boy, who received a blow on the temporal bone, and whose
bone was depressed : the trepan was applied, and he recovered ;
but in his mind a singular change took place, for from that time
he felt an irresistible propensity to steal. Acrell, who declared
his mind deranged, delivered him from prison. Dr. Jenner told
me a similar fact from his own observation, where a mechanical
lesion of the head excited the same propensity. In my work on
Phrenology, 1 have mentioned more facts of this kind, in order to
show that the manifestations of the mind depend on the brain.

It is to be remarked, that the mechanical injuries of the head,
with respect to surgical considerations, are not within the limits of
this treatise. My intention here is merely to show that mechan-
ical lesions of the head may disturb the functions of the mind.
Moreover, it seems to me worth notice that, in numerous cases of
insane persons, various morbid appearances, observed after death,
have been considered as mechanical causes of insanity, while these
organic alterations ought to be considered rather as the effect of
the diseased state of the brain, which produced insanity and the
organic changes. Such are all morbid effusions, thickened mem-
branes, even increased thickness of the skull. It is, however, to
be added that some of these morbid changes, though produced by

CAUSES 105

the same disease as insanity, effusions for instance, may contribute
to a greater derangement of the manifestations of the mind, or
even entirely suppress them, and in so far act like mechanical
causes. I wish particularly to call the attention of practitioners
to that error according to which thick skulls are considered as a
cause of insanity, while it is only the effect ; that is, in chronic
diseases of the brain, and in consequence in chronic insanity, that
organ often diminishes in size ; the internal table of the skull fol-
lows the external surface of the brain, while the external table of
the skull remains in its natural position. Sometimes this thicken-
ing of the skull happens at certain places more than at othersi
Our opinion is particularly illustrated by the state of the two
plates, forming the upper part of the orbit, in many of such cases.
Commonly the two tables are so near and close to each other,
that they appear transparent : but in some diseased cases the ex-
ternal table remains in its natural situation ; and the internal, in
following the surface of the brain, is distant from the external
table half an inch, or even a whole one. With respect to the ob-
jection that injuries of the brain have not at all disturbed the func-
tions of the mind, I refer to my work on Phrenology.

Is the shape of the head a cause of insanity ?

Haller, Bichat, and others, consider the inequality of the two
hemispheres of the brain as a cause of insanity. This inequality
is often found in insane people, but it is not the cause of insanity ;
since in a great number of very intelligent individuals, and I can
say, in the majority of mankind, the two sides of the head are not
exactly alike. A friend of Gall has the right side of his forehead
half an inch higher than the left, and he feels and complains bit-
terly that he cannot think with the left side. At Dubhn, a gen-
tleman, whose forehead on the left side is about four lines less
developed than on the right, often feels headache on the defec-
tive side, and assured me that he is conscious of not thinking with

that side. He, however, never had any attack of insanity. At
14

106 INSANITY.

Vienna there is a family in which the children resemble the father
with respect to a great irregularity and deformity of the head,
but no one among them has mani/ested any derangement of the
mind. Laland's head was much higher on the right side than on
the left. The sides of Bichat's own forehead were very une-
qual; no one, however, will doubt of his extraordinary talents.

There are persons who suppose that we maintain the possibility
of knowing by the external shape of the head whether any one is
predisposed to insanity or not. Pinel was of that opinion ; and, in
order to show the erroneousness of the assertion attributed to us,
he caused two skulls to be drawn of nearly the same size and shape.
One of these skulls belonged to a madman, and the other to a
person of sound senses.

That this is our opinion is merely imaginary, and no one will
find it in any part of our writings. The contrary is easily under-
stood from our general considerations with respect to the brain.
We continually repeat that the brain is an organic part, and, as to
anatomy, physiology, and pathology, subject to the same consider-
ations as any other organ. Now, every part of the body, what-
ever its configuration may be, can become diseased. The eyes,
for instance, of every size, form, and color, may be inflamed ; the
respiration of small and large lungs may be disturbed ; and the
same may happen with any other part of the body, and with the
brain and its parts ; I say, that brains of all sizes and forms can be
disordered. As, however, certain eyes are more disposed to in-
flammation than others, and certain lungs more to consumption ;
and in the same way as medical men speak of an apoplectic con-
figuration of the neck, a consumptive habit of the thorax ; so we
find that certain brains are more disposed to disease, and certain
configurations more liable to insanity. This is particularly the
case with idiotism from birth, and partial insanities, called halluci-
nations. Pinel, however, though he refuted the above-mentioned
opinion, thought it worth his attention and labor to measure the
skulls of insane people in all their dimensions, to compare both
sides with each other, and the whole with the proportions of the

CAUSES. 107

head of Apollo de Belvedere, which he considered as the model
of perfection. But Pinel does not dare to draw any Inference,
not even from the small heads of idiots. ' I must be,' says he,
* on my guard against too hasty conclusions. I confine myself to
historical facts, without pronouncing that there is a connexion be-
tween idiotism and the defect of organization.'

We are very well aware that a great number of facts, repeated
under various circumstances, are necessary before we can draw a
general conclusion ; but, with respect to idiotism from birth, we
have made such a number of observations in various countries,
that we have no hesitation in affirming that a too small brain is
unfit for the manifestation of the mind. I beg to remark, that 1
do not say that idiotism is the attribute of a too small brain only ;
idiotism may be the result of different causes, one of which is a
too small brain. We are convinced from observation, that the
laws of nature are constant ; and, if we continually observe that
the same phenomenon takes place under the same circumstances,
we consider our conclusion as certain, till experience shows the
contrary. If such a proceeding be not allowed, there is no phys-
ical truth. No one then has the right to maintain that an infer-
ence is too hastily drawn because he has not made a sufficient
number of observations, it is his duty to show facts which [)rove
the contrary, if he intend to deny the inference.

With respect to the configuration of partial Insanities or hallu-
cinations, we cannot so positively decide as with respect to a too
small brain. As every person with a narrow and compressed tho-
rax, and hectic appearance, does not become consumptive, nor
another with a large elevated breast remain always exempt, so
certain configurations of the brain, which predispose to certain
hallucinations if the individual become Insane, are not necessarily
affected ; nor are those who have not that peculiar configuration
absolutely free from such a disorder. In the same way it is often
remarked, that individuals with a certain character predominant
from infancy are disposed to that sor^ of Insanity, as is the case
with great genius in respect to the intellectual facuhies. Dr.

108 INSANITY.

Rush*'^ details that the natural conduct of insane people frequently
accords with their natural temper and disposition. Proud and
ambitious persons imagine themselves to be kings, and demand
homage : are they ferocious, they assume the nature of wild
beasts ; are they pious and benevolent, they are inoffensive in
their deportment. He, however, also speaks of exceptions ; per-
sons, for instance, of exemplary piety and purity of character utter
profane, or impious, or indelicate language, and behave in other
respects contrary to their moral habits.

It is a fact, that by far the greatest number of those who are
insane by pride have the organ of self-esteem large in proportion
to the other organs of the mind. It does not follow, however,
that every one who has this organ large must become insane by
pride, nor that every one who has this organ small will be abso-
lutely exempt from such an hallucination ; for every small organ
may be excited by diseased affection, and show too great activity
and deranged manifestations. The influence of the size seems to
be obvious, since the greatest number of persons, insane with pe-
culiar hallucinations, have the respective organs larger. Gall
possesses the skull of a madman, from amativeness, who fancied
himself husband to six wives, and manifested various ideas of that
kind. His cerebellum was extremely large. Gall has also the
skull of a woman who imagined herself pregnant with five chil-
dren ; the organ of the love of offspring is of extraordinary devel-
opment. I have seen several insane women who fancied them-
selves with child, and they had the respective organ elevated. I
can, however, conceive that an insane woman, with a general
indolence and apathy, might have the organ large, and take no
care of her children. In the healthy and diseased state of the
body, when there is no activity of the mind, the size of the organs
is no indication at all.

Insane people, who show a peculiar degree of vanity, who like
decorations and all sorts of distinction and ornament, commonly

* On the Diseases of the Mind, p. 155.

CAUSES. 109

have the organ of approbation large. Persons insane from re-
hgion have generally elevated heads. Visionaries, or those who
think they have communications with spirits usually have the head
elevated at the middle lateral parts of the coronal suture, between
ideality and imitation. Those who are of an anxious melancholic
character, who are afraid of persecutions, or fear where there is
not the least reason, mostly have the midst of the parietal bones
prominent. Those who suffer the violent impulse to destroy, or
to do mischief, though their reflection and will resist, who beg to
be loaded with chains to be prevented from their extraordinary
propensity, are commonly broad above the ears. This considera-
tion may be applied to all primitive powers. But I repeat, that
only in the greater number of cases, not always, the respective
organs will be found larger, in the same way as the predominant
character is mostly, but not always, preserved. Particularly in
those who, when young, adult, and insane, manifest great energy
of the same dispositions, the respective organs will be found large.
In such cases I am not aware of any exception. The influence
of larger organs on peculiar hallucinations is partly understood
from our physiological investigations, and will be partly explained
in the next section on dynamic causes of insanity.

The greatest difficulty to understand the diseases of the brain,
as well as of other parts of the body, results from the infinite
modifications to which organization is liable. It is impossible to
explain the idiosyncrasies of the stomach and the five senses.
No one can show why mutton produces in one stomach all the
symptoms of poison, while it is digested by another. No one can
point out the organic cause why one taste likes coal or chalk,
another herbs, a third meat, one sweet, another bitter, &c.
These modifications, however inexplicable they are, exist in the
healthy and diseased state of automatic and animal life.

Thus, in insanity, the configuration of heads is neither to be
overlooked, nor to be over-rated.

110 INSANITY.

Idiopathic dynamic causes of insanity.

To this class of causes belong all those which immediately in-
fluence the functions of the brain. From the preceding consid-
eration it results that a peculiar development of the individual
parts of the brain predisposes to insanity. This may be explained
in the following manner : The larger size has an influence on the
greater activity of the organs, and a too great activity may derange
the functions ; or, the organs being continually put into action
may become so active, that the will has no longer the control
over them. The functions of the brain are disturbed in the same
way as the functions of other parts ; that is, by the deranged or-
ganization, or by an irregular use of the functions. The stomach
may be affected, and its functions deranged, by causes which im-
mediately exist in the organization, as inflammation, gout, &c. or
aliments may be introduced which are not adapted to the diges-
tive power. Vision may suffer by causes which first affect the
visual apparatus and disturb sight, or vision may be disordered by
light itself. The proper use of the functions of any part contri-
butes, and is even necessary to its healthy state. The proper use
will strengthen, the misuse disturb the function. Continual dark-
ness weakens the eyes, too strong light offends or blunts sight.
The regulation of the functions of the brain is as necessary as that
of aliments to the stomach, and of air to the lungs. Inactivity
weakens the functions of the brain, proper exercise strengthens
them, too strong application brings disorder. These disorderly
applications, or manner of using the functions of the brain, are
commonly called moral causes of insanity.

I shall first treat of the dynamic causes of insanity, which im-
mediately depend on the organization. I have shown that the
brain and its parts are sometimes too small, or unfit by other
causes to act. In the same manner their activity may be too great
on account of their size, or internal activity. I have mentioned
that the brains of children with premature development, and too

CAUSES. Ill

great energy .of the mind, are the most Hable to diseases. In
adults also a too great energy of one power will easily disturb the
balance of the healthy functions. For that reason a genius is so
often near insanity ; that is, his power is so energetic that it acts
independently of the will. Now, this may be the case of every
faculty ; but it is curious to consider the influence of the organiza-
tion. It is a fact, that there are more insane from feelings than
from intellectual powers ; and from certain feelings, and from cer-
tain intellectual faculties, more than from others. Moreover, it is
also a fact, that the most energetic powers produce the greatest
number of insane cases, and that the manifestations of the most
active faculties depend on the largest organs. Such are amative-
ness, combativeness and destructiveness, cautiousness, self-esteem,
approbation, religious feelings, ideality, attachment. Among the
intellectual faculties there are more musicians and painters insane
than mathematicians. Pinel did not observe any mathematician
at Vicetre. 1 know, however, positively, that mathematicians
are not exempt from insanity. I possess the skull of an individ-
ual who excelled in mathematics, and was insane by pride and
vanity. It generally happens that, even in those classes of society
who cultivate the intellectual faculties, by far the majority are in-
sane by feehngs. I think there are several reasons why the study
of mathematics seldom will produce insanity. First, there are
extremely few who make an intense study of mathematics, in
proportion to the immense number of those who are tormented by
amativeness, pride, and ambition. Then the organ of number is
very small, and its great activity will not so easily derange larger
organs, while the disorder of larger organs has a greater influence
on the rest of the organization. More individuals, by love, will
forget to think of mathematics, than by number forget to feel love.
Moreover, the study of reality, which prevents eccentric and
chimeric conceptions, will be less liable to insanity. Finally, he
who likes mathematics commonly finds opportunity of gratifying
his inclination, while the satisfaction of other strong propensities
depends on various circumstances, which often are the most un-

112 INSANITY.

favorable. Thus, the first idiopathic dynamic cause of insanity is
the too great energy of the organs dependent on their size, inter-
nal organic constitution, and continual exercise.

Other dynamic causes, which sometimes affect the organiza-
tion of the brain, and derange its functions, are an inflammatory
state of the brain, increased arterial activity, or diminished circu-
lation in the veins. There is no doubt that the deranged circula-
tion of the brain in general, or in single parts, is a great cause of its
derangements. In this respect Dr. Parry's work deserves the
peculiar attention of the practitioners. It is, however, to be con-
sidered that the determination of blood is only an occasional
cause ; the influence of the different degrees of irritability of the
cerebral fibres is obvious, since in many individuals the pulse is
often very quick, and no delirium or other symptom of insanity is
observed. The same quickness of circulation may suppress the
activity of one brain, give to another pain, to others various de-
grees of activity, to one epilepsy, to the other catalepsy, or insan-
ity with very different symptoms. Moreover, not only the quan-
tity of blood, but also its quality to nourish the brain, and the mor-
bid change which may result in the brain, must be considered.
The internal organic constitution of any living being and its parts
is modified according to the state of nutrition. I have already
mentioned that, sometimes, weak and sickly children, with very
large heads, suffer from general apathy, because the organization
has no internal strength. Messrs. Young and Hodgson, of Lon-
don, were so kind as to invite me to the dissection of an idiotic
child, two years of age. Both substances of the brain, grey and
white, had more the aspect of the cerebral organization of very
young children, that of a more grey-bluish color and gelatinous
nature, than we find the substance in children two years old. It
seems that the cerebral organization was retarded in its develop-
ment, and unfit to manifest the powers of the mind.

Various morbific causes may affect the brain alone as well as
other single parts, as rheumatismus vagus, repelled cutaneous af-
fections, &c. I cannot doubt that, in many morbid affections of

CAUSES. lis

the body, there exists what has been called morbific cause, what-
ever its nature may be : this exciting cause may affect the brain
and its parts as well as other parts. Children who have opthal-
mia are often delivered from it by a few pustules on the lips.
Sudden metastases cannot be explained in any other satisfactory
manner. The morbific cause often changes one place with anoth-
er ; alternates, for instance, in the lungs, stomach, kidney, &;c.
A great many examples are mentioned in various works. I shall
only observe, that, sometimes, if the perspiration of feet, on ac-
count of its offensive smell, is suppressed, and the patients com-
plain of headache, bad digestion, difficult respiration, and can-
not be relieved till the disagreeable perspiration at the feet is re-
estabhshed, the existence of a morbific cause cannot be denied.
The use of setons and blisters as derivatives is admitted by all
those who have more confidence in facts than in explanations. 1
think we may suspect such a cause if insanity alternates, or is in-
terchanged with morbid affections of other parts.

I come now to the second sort of dynamic causes of insanity,
viz. to those which concern the use of the cerebral functions, or
the exercise of the manifestations of the mind. Every one ad-
mits affections and passions, and intense study, as causes of in-
sanity. J think our anatomical and physiological investigations
alone give an explanation, if we are not satisfied with unmeaning
words. The mind, being endowed with reflection and will, why
does it become passionate? Why, in so many cases, can it not
abandon the disagreeable affections which disturb its happiness, if
the manifestations of the mental powers, and of the affections them-
selves, are independent of organization.

In my work on Phrenology I have detailed what we understand
by passions and affections. I here only repeat, that passion is
the highest degree of activity of every faculty, and that there are
as many passions as individual primitive faculties of the mind ;
while affections are the different modes in which the faculties
may be affected. I have already mentioned that the regulation
of the activity of the faculties is of the highest importance ; that
15

114 INSANITY.

inactivity weakens, moderate and convenient exercise strengthens
and too great exercise exhausts or disturbs the functions. As the
functions depend on the organization, disturbed functions will de-
range the organization, and one deranged cerebral part will have
an influence on others, and so arises insanity. This may happen
suddenly, or by degrees.

Whatever occupies the mind too intensely or exclusively is
hurtful to the brain, and induces a state favorable to insanity, in
diminishing the influence of will. If the external senses are im-
pressed for a considerable lime, the impression, though it is gone,
seems still to be present. Card-players sometimes cannot lose
the sight of the figures, though they have ceased from playing-
Those who are fond of music hear the tones after the music
ceases. After a voyage the gyration continues when we are on
shore. In the same way the strong activity of every faculty may
become involuntary, and even derange other functions. Now it
is a fact, that the most active powers of the mind produce insanity
most easily. One of the most powerful feelings is amativeness.
Though it is given for the preservation of the species, and in mil-
lions of beings fills all nerves with pleasure and rapture, many
individuals become its victims. In many persons it constantly
occupies the mind, excites the other faculties in an extraordinary
way, causes sleepless nights, the most extravagant reveries, and is
a fruitful source of insanity. It may act alone, or combined with
other feelings, and appears, therefore, under various modifications,
as unsatisfied, disappointed, seduced, or jealous. I cannot help
copying a passage from Dr. Cox's work.* ' The detestable
crime of seduction is a very fertile source of insanity. Its cruelty
and criminality must strongly impress every heart in which hu-
manity is not wholly obliterated. The common consequences of
seduction are the fear of discovery, consciousness of guilt, and
the reproaches of the world. The female sufferer sinks to de-
spondency, while experiencing the neglect of the inhuman being

* On Insanity, 3d. Edit. p. 32.

CAUSES. 115

in whom she confided; her tenderness is thrown back on her
own heart ; with no eye to pity, nor ear to listen to her tale of
woe. Can we wonder if women suffer the loss of reason in such
distressing circumstances? Perhaps the most disinterested affec-
tion has been the original cause of their deviation from the path
of virtue, and thus tenderness became the instrument of their
ruin ; for in proportion to the sensibility, consciousness of shame,
and remaining virtue of the victim, may we apprehend the degree
of morbid effect on the intellect. Sometimes the unprincipled
seducer himself falls a sacrifice to his infamy, if he be not a prac-
tised villain ; but, unfortunately for the present age, the crime is
too common, and we more frequently meet with men glorying in
their cruel success than suffering from remorse.'

Religion is another fertile cause of insanity. Mr. Haslam,
though he declares it sinful to consider religion as a cause of in-
sanity, adds, however, that he would be ungrateful, did he not
avow his obligation to Methodism for its supply of numerous cases.
Hence the primitive feelings of religion may be misled and pro-
duce insanity ; that is what I contend for, and in that sense re-
ligion often leads to insanity. The Domestic Guide for Insanity
says, ' How often has the preacher of Christianity been stigma-
tised as the cause of insanity in some dark-minded hearer? When
at the same time out of a hundred people, all living in the same
neighborhood, possessing nearly the same means of information,
all reading the same religious books, and receiving the same reli-
gious instruction from the same preacher, ninety-nine have felt the
cheering influences of religion. Surely, if the cause had been in
the preacher or religious instruction, the bad effects would have
been more general ; but the poor creature had a predisposition to
insanity, and religion happened to be the thing by which it was
first discovered to the world.'

The same observations might be made with respect to all maa-
raen and their exciting causes ; and it shows the error of consid-
ering the external impressions alone as sufficient causes. The
internal predispositions of the mind, in its state of health and dis-

116 INSANITY.

ease are too often overlooked. In my work on Phrenology I have
sufficiently detailed the innate dispositions of the mind, which
may be diminished, excited, cultivated, and directed in their ac-
tions by external circumstances ; but their activity is the result of
internal innate power and external exciting causes together. It
is the same in the state of disease or deranged functions. The
internal predispositions are often of more consequence than the
external impressions. The great philosopher Kant was right in
saying. When a common man falls in love with a Queen and be-
comes insane, he was insane before, because he fell in love with
a Queen. However, as many faculties could not act if they were
not excited by external circumstances, in the same manner, they
would not be deranged without the external impressions. Real
religion certainly is a blessing to mankind, and no one will reject
it by the consideration that such a feeling may be ill regulated, and
contribute to diminish reflection and will. Charity, veneration,
hope, satisfaction, cheerfulness, consolation, mutual assistance and
forbearance, peace, righteousness, and wisdom, are the aim of
Christianity ; not grief, gloominess, moroseness, despair, persecu-
tion and stupidity. Certain individuals are naturally very anxious,
and sometimes despair of their temporal and external happiness,
without being influenced by any sermons. It cannot fail, howev-
er, that a minute description of the consequences of sin, of the
horrors of hell, and the dreadful sufferings of the damned, in the
most glowing colors, should make a deep impression on weak
minds, and that those, who naturally are disposed to insanity,
should lose the free actions of their will. It is, therefore, a great
error to preach to every one in the same manner. A good shep-
herd ought to know his sheep. A hardened and impenitent flock
requires strong impressions to be moved, while a fearful, pious,
and righteous mind wants encouragement and confidence.

Insanity often originates from ungovernable or disappointed am-
bition, love of glory and fame ; from reverse of fortune, and from
various affections of other feelings, such as from sorrow, grief, anx-
iety, apprehension, melancholy, fear, and despair, in cautious-

CAUSES. 117

ness ; from anger, fury, wrath, and hatred, in combativeness and
destructiveness ; from pride, haughtiness, contempt, and disdain,
in self-esteem, &;c. Several compound affections also, such as
jealousy, envy, shame, often disturb the functions of the mind.

The disagreeable affections have a great influence on automatic
life. They often produce torpor in every irritable part, espe-
cially in the circulating and absorbent system ; contraction and
slowness of the pulse, a laborious slow respiration, sighing, a gen-
eral languor and lassitude, and a sense of oppression ; the lungs
are loaded with blood ; the heart is full, and like to burst ; con-
traction, shrinking, and paleness of the skin, and coldness in the
extremities. The effects, however, differ in various individuals.
Sometimes in anger the face glows with heat, and flushes with
blood ; at another time it is deadly pale, and the features shrink :
in general, anger has a great influence on the skin, and raises the
hair of animals ; excites spasmodic contractions in the liver, and
alters the secretion of the bile, not only in quantity but also in
quality, whence diarrhoea, vomiting, colic, or jaundice arise. It
excites the heart and arteries to a preternatural degree of action,
and accelerates the circulation of blood through the heart and ar-
teries, but retards its return through the veins.

Too sudden affections, agreeable or disagreeable, often produce
various disturbances of automatic and animal life. There are in-
stances on record that sudden joy was the cause of death. I have
seen several examples of persons, who from fear became insane,
some quite idiotic. The affections of the mind, which take place
in the brain, act immediately on its substance and blood-vessels ;
then on circulation in general, on the digestive organs and on nu-
trition, and, by the disorders of those functions, again mediately
on the brain. In this manner it is conceivable, why afle- cions
produce insanity. Thus, every thing which excites the feelings
and their affections too much, will contribute to insanity. This
may be proved by the effect of revolutions, since in all great po-
litical changes and disturbances, all feelings and selfish passions,
such as ambition, pride, courage, fear, anxiety, are more active ;

118 INSANITY.

and many feelings are disappointed whence insanity is often the
natural consequence. In later years, France and Ireland have
."urnished many examples in support of this truth.

It is believed that insanity is more or less frequent according to
the state of civilization. Dr. Rush* says, * After much inquiry, I
have not been able to find a single instance of fatuity among the
Indians, and but few instances of melancholy and madness :' and
in another workf he states, what he was told by Baron de Hum-
boldt, that he did not hear of a single instance of madness among
the uncivilized Indians in South America. In proportion as lux-
ury and refinement extend their influence, diseases increase in
number and varieties, nervous sensibility and imagination are ex-
alted, and more examples of insanity afflict mankind. Misunder-
stood education, romantic or ideal notions of the world, hence dis-
appointment in finding the world as it is, and not as it ought to be
according to fanciful dreams, have often reduced the mind to a
state of insanity.

A too intense application of the intellectual faculties, deep
thought, incessant study during day and night, may equally lead
to the derangement of the mental operations, either to exhaustion
or alienation. The greatest harm is done, if the inclination to
study is greater than the power ; if the individual excite himself
by spirits or stimulating liquors of any sort : the vascular action
increases, various feelings are excited, and different disordeis of
the brain produced. Among scientific professions, however, with
respect to insanity, it may be observed that those whose occupa-
tions naturally excite the feelings at the same time, such as priests,
poets, advocates, actors, musicians, painters, sculptors, are more
disposed to insanity than those who study geometry, mathematics,
and natural philosophy in general. I have already mentioned the
reasons which seem to account for this observation.

* Medical Inquiries, vol. i. p. 19. t Diseases of the Mind, p. 65.

CAUSES 119

Sympathic causes of Insanity,

Every cause which mediately affects the brain, and deranges
the manifestations of the mind, is sympathic. Of such a nature
are those morbid causes which change their place, as erysipelas,
gout, rheumatismus vagus, repelled cutaneous affections. More-
over, insanity from sympathy is that from suppressed lochia, men-
ses, milk in nurses, haemorrhoides, old drains dried up, as setons,
issues, or habitual sweat. Sometimes general diseases, such as
small-pox, measles, scarlatine, fevers of various sorts, affect the
whole body, but sometimes produce morbid changes in the organ-
ization of the brain, and hence insanity. A precipitate retire-
ment from active life is a cause of various disorders in automatic
and animal life. From every circumstance that weakens much
the body, and causes inanition, such as continual evacuations of
blood, semen, or want of nourishment, various nervous complaints,
and different symptoms of insanity, may originate.

In pathology nothing is more generally admitted than the recip-
rocal influence of the disorders of the head and the digestive or-
gans on each other. The diseased state of the abdominal viscera,
as of the stomach, intestines, mesenteric glands, pancreas, liver,
spleen, ovaria, uterus; or indigestible aliments, narcotics, poisons,
and worms, often affect the brain by sympathy. I shall never
agree however with Dr. Prost at Paris, that madness is always
the effect of a disease in the abdomen. Intemperance, and the
abuse of intoxicating liquors, is a frequent cause of insanity. In-
deed, the consequences of intemperance are dreadful. Not only
the functions of the body are greatly disturbed, but also those of the
brain are formidably deranged. It affects the stomach, liver, in-
testines, the circulation, and the brain; it is the cause of numer-
ous complaints, of indigestion, obstructions, cardialgia, cephalgia,
vertigo, numbness of the senses, melancholia, mania, epilepsy, and
apoplexy. It is particularly dangerous to persons who have a
natural disposition to insanity. Who then might not wish to see
this perverted appetite restrained within moderate boundaries.

120 msANiTv.

The exceptions, however, of the mutual influence between the
head and abdomen are not to be overlooked. Some persons have
great disorder of the digestive organs without any apparent affection
of the brain ; and even disorders of a fatal nature may take place
in each of these parts without affecting the other. Similar ex-
ceptions are observed in all parts, which generally sympathize to-
gether ; for instance, stomach and uterus. Idiots from birth are
sometimes well nourished, and the defective brain has no influence
on the functions of the viscera.

The sympathies of automatic and animal life, and those of the
different parts of each, are subject to the lav/, that the weakest
part suffers the most from the affection of another ; and if the
parts are very strong, there is no sympathy at all. Hence grief
or fear disturbs, in one, respiration ; in another, digestion ; in a
third, the secretion of bile, or the phenomena of the uterus ; and
in one it perhaps scarcely alters the functions of any viscus. It
may be in general observed that one deranged function of auto-
matic life may derange one or the other, or all, the functions of
animal life ; and, vice versa, one disordered animal function may
derange one or the other, or all, the functions of automatic life.
Moreover, each diseased part of automatic life may affect any
other automatic function ; and in the same manner, in animal life,
one deranged function of the brain may disturb any other. The
individual conditions of the parts, however, and their modifications
of irritability, are infinite, and can only be observed in given cases
without any other knowledge, but that such is the case.

After the preceding considerations we may easily understand,
why insanity is most frequent between twenty and forty years of
age. At that period all the dynamic idiopathic, and sympathic
causes of insanity exercise the greatest influence. Then the feel-
ings and intellectual powers are the most active ; then there is
more anxiety to succeed, more regret and disappointment ; the
habit of intoxication is formed, and an infinite number of causes
produce more disorders of body and brain during this, than in
later periods. I have already stated, that then the brain is strong

CAUSES. 121

enough to suffer morbid disorders, while in children its affections
soon terminate in death.

I have mentioned that, in insanity, the ears suffer more than
the eyes. This may be explained, because the feelings are far
the most frequent causes of insanity, and the auditory nerve is in
a more intimate connexion with the organs of the feelings than
the optic nerve. For the same reason, in my work on Phrenol-
ogy, I have stated that, in the natural language, the sense of hear-
ing and the organs of voice are more active in the manifestations
of the feelings than the eyes. More attention ought to be paid to
the derangement of the senses, combined with those of the mani-
festations of internal powers, than hitherto has been done. In
what cases, for instance, is the smell more excited, and the pa-
tients so fond of snuff? Previous habit certainly ought to be con-
sidered.

I shall add a few observations on insanity with respect to sexes
and temperaments, and finish this section with the examination of
the question, Why is insanity so frequent in England ?

Sexes.

It seems that the female sex is the weakest. Among mon-
strous foetuses there are more females than males. More girls
than boys are affected with real dropsy of the brain ; and, gener-
ally speaking, there are more women than men liable to insanity.*
At the period of puberty, young females suffer from various com-
plaints more than males. Many delicate, premature females, of
lively dispositions, at the period of menstruation, or soon after, by
imperceptible degrees, lose the manifestations of the mind ; they

* This is more particularly the case when religious fanaticism is the exciting
cause. The proportion is as five to one. This is not an estimate predicated
upon a few examples, but upon the experience and observation of years. It is
a fact that women should know and understand, as it will lead them to mistrust
those appeals of men, which originate in the passions, and are addressed to the
passions. In such cases reason has but little participation.

J.6

122 INSANITY.

become inactive, and neglect those objects and pursuits which
formerly were to them sources of instruction and delight. They
do not show the same attachment to their parents and friends ;
they are careless of reproof, and unfeeling to kindness ; they are
negligent in their dress, inattentive to personal cleanliness, and
finish with a general apathy and idiotism.

vVomen are exposed to all connate and occasional causes of
insanity to which men are liable. Besides, they undergo the nat-
ural processes of menstruation, pregnancy, parturition, and of pre-
paring nutriment for the infant, which are frequent causes of in-
sanity. Moreover, women in general have the feelings stronger
than men in proportion to the intellectual faculties. On account
of the manners of society, they are exposed to more disappoint-
ments, and have fewer resources ; they become oftener the vic-
tims of circumstances, while a man is more favored by nature
and society to choose his situation. Thus there are physical and
moral causes which account for the greater number of insane
women.

Temperaments,

It might be asked whether the various temperaments are more
or less disposed to insanity? Such a question, however, indicates
ignorance with respect to the nature of insanity. From the pre-
ceding considerations it results, that the brains of all temperaments
are liable to insanity, in the same way as bodies of all tempera-
ments may be affected by diseases. The only difference which
must occur is, that certain brains are more easily affected than
others, and] more by such a cause than by another. It is also
natural that persons of greater nervous sensibility, in whom one
sort of manifestations of the mind is extremely active, are more
subject to insanity than dull, insensible, and unthinking people.
But such individuals of both descriptions will be found among
persons of all temperaments. There are idiots from birth, and,
among adults, insane persons of all temperaments. It is less the

CAUSES. 123

temperament than the other circumstances already mentioned,
which predispose to insanity.

Insanity is frequent in England.

It is certain that in the united kingdoms of Great Britain and
Ireland the number of insane people is, in proportion to the pop-
ulation, more considerable than in other countries of Europe ;
and in England it is the most frequent. Several writers even
state that it is rapidly increasing. I was therefore particularly
attentive to the reasons of that alarming disease, and to the nature
of the insanity which I met with in private and public institutions.
I shall communicate several ideas, which I consider as founded on
observations. A mutual communication and an exact statement
of the nature and causes of insanity, in all establishments through-
out the kingdoms, might enable a philosophical observer to draw
more satisfactory inferences. Though our knowledge and every
thing we do is naturally imperfect, there is, however, no branch
of human institutions which requires and is capable of more im-
provement than that of insanity. I shall first examine what sort
of insanity is most frequent*

I have divided insanity into idiotism, fatuity, and alienation.
Idiotism from birth does not seem to be more frequent in England
than in other countries. But I met, in the English institutions
for insane, a greater number of fatuous ; viz. those who by chro-
nic alienations sunk into that state, or those who prove our igno-
rance with respect to the cure, that is, the chronic affections of
the brain have produced in the organization alterations which can-
not be cured while it is the object of the healing art to prevent
such organic changes. In saying so, I do not maintain that, in
other countries, a better treatment is understood. Medical skill,
as to insanity, seems to be every where equally advanced ; I
mean, the patient who could be cured by nature was cured, and
medicine had very little or no merit in it. But as there were
more insane persons in England, and as neither nature nor art

124 INSANITY.

were more successful in curing them, a greater number of incu-
rable was the result.

In order to give a clear idea, I shall recapitulate the causes of
insanity, and show that, in England, they exist in greater number.
It must be understood that one cause cannot explain the facts, and
that insanity is the effect of the natural dispositions, and the oc-
casional causes. The first cause of insanity is a hereditary dis-
position ; and as actually that disposition exists in many families,
their frequent intermarriages must increase the number of mental
disorders, particularly as the other reasons which have produced
that predisposition continue to exercise their influence.

Among the idiopathic causes of insanity, the activity of the ce-
rebral functions is one of the most important. In Englan d, in-
deed, this cause is very powerful. Here all faculties of the mind
act with great energy. No nation in Europe, for instance, in po-
litical and private views, has the right to indulge so much in the
sentiment of self-esteem and independency ; and the English do it
to a great degree. Here every thing finds opposition, and oppo-
sition naturally excites the feelings. In England no plan will be
conceived by the government, however salutary it may be to the
country, without opposition. No church will be erected to ex-
plain the meaning of the Bible, but another preaching house will
soon be in the neighborhood to give another explanation. Every
one may form a party, but he will find opposition. This spirit of
party and opposition is continually nourished, and all selfish pas-
sions must be exasperated. The fanciful gratification of the pro-
pensities is seen in many respects. Here only, two persons, in
good humor and smiling, will shake hands, and then try to give
to each other death-blows, while thousands of spectators are at-
tracted."^

Religious feelings are extremely active in this country, and may
act without any restraint. Every one who thinks himself enlight-
ened enough, or perhaps inspired by supernatural influence, may

* These truths are applicable to the United States.

CAUSES. 125

preach to all who will listen to him. Whether he understands
human nature, or is an artisan ; whether he has studied the feelings
of man, or has been employed in manual labor, that is no matter.
He may consider the individuals of his congregation all alike, and
speak to the mild, gloomy, and timid, as to the disobedient, hard-
hearted, and stiff-necked. He may damn to hell and eternal
pains all those who do not believe with him. I am convinced
that a gloomy preacher who does not know the God of Christians,
and the method of instruction of the great Apostle, who modified
his speech according to those to whom he spoke, in order to save
them all, easily deranges a tender mind by his picture of a jeal-
ous God, of a God of wrath and of vengeance, by a language
which is perhaps necessary to guide his own feelings. Indeed,
how often must an anxious mind be overpowered ! Moreover, it
is easily conceived that individuals, who are anxious for their
eternal beatitude, and listen to so many different explanations,
torment their brains in order to find truth. Now, if at the same
time other feelings are excited, it must occur that reflection and
will are lost.

Ambition, a frequent cause of insanity, is not quiescent in Eng-
land. Even in charitable works, ostentation is never forgotten.
Moreover, England is a mercantile nation 5 the mind is continual-
ly occupied with speculations, wavers between fear and hope,
since the success depends on so many chances. Selfishness, the
soul of commerce, easily becomes jealous, envious, and often calls
on many other powers for assistance. In short, it seems to me
that in England all feelings, selfish and liberal, religious and moral,
low and high, are extremely active.

Not only the feehngs, but also the intellectual faculties, have no
restraint but that of their own power. If genius be not always en-
couraged, its activity at least is not suppressed, and every one
may hope to profit by his labors and speculations in one way or
other. Thus, the powerful activity of the mind seems to me a
great cause why insanity is so frequent in England ; and, indeed,
it is a singular fact, that the greatest desire of man, his personal

126 INSANITY.

libertv, also has its bad efFects. * In despotic countries,* says Dr*
Rush,^ * where the public passions are torpid, and where life and
property are secured only by the extinction of domestic affections,
raadness is a rare disease. Of the truth of this remark,' continues
Dr. Rush, ' I have been satisfied by Mr. Stewart, the pedestrian
traveller, who spent some time in Turkey ; also by Dr. Scott,
who accompanied Lord Macartney in his embassy to China, and
by Mr. Jos. Roxes, a native of Mexico, who passed nearly forty
years of his life among the civilized but depressed nations of that
country. Dr. Scott informed me that he beard but of one single
instance of madness in China.'

The other causes of insanity also act with great power in Eng-
land. I have mentioned that luxury and cockering produce ner-
vous complaints and insanity. Now, there is no country where
comfort is enjoyed to such an extent, and where the richer classes
are so numerous. In no country have so many individuals in-
dependent fortune, and can so much indulge in their fancies.
Many cultivate their feelings at the expense of their body* In
fact, proportionally, the rich are more vexed by nervous com*
plaints and insanity than the poor.

Moreover, it is also certain that single persons are more dis-
posed to madness than married people. But luxury and expen-
sive fashions require in England a large fortune to enable a man
to marry ; hence only rich females have a claim to marriage, the
others mourn in silence, and look for other sorts of satisfaction.
Sometimes they have recourse to means which weaken the body,
and contribute to derange the mind. Now, there is no doubt that
in all countries, even where love is less restrained by fashion and
law, the greatest number of insane females are the victims of am-
ativeness.

Great and sudden changes in our manner of living have a great
influence on the body. Many English became lately extremely

* Medical Inquiries and Observations on the Diseases of the Mind, p. 69,

CAUSES. 127

rich, and naturally changed their manner of living. Many for
some time worked hard day and night ; then they retired, and
being often without occupation, found their life tiresome, indulged
their fancies, and suffered from various complaints.

I have spoken of the influence of circulation, and of the abdom-
inal viscera, on the brain. The manner of living in England must
affect the nervous system and the digestive organs. Climate and
weather require food and drink somewhat different from those in
warmer countries, but the English evidently indulge too much in
spirituous hquors. The abuse of spirits, and the habits of intox-
ication, is admitted as a frequent cause of insanity by all those
who have treated on that disorder. The brain suffers immediately
and mediately. The circulation in general, and the deter-
mination of blood to the head, are increased ; several faculties are
excited ; others are suppressed ; and various morbid changes
successively result in the brain and abdominal viscera. Gene-
rally speaking, I have remarked that the brains of individuals who
die in the hospitals in London are firmer than those on the Con-
tinent and in Dublin. Nourishment is the probable cause.

I have mentioned that all causes must be considered, to ex-
plain the frequency of insanity in England. Hard drinking, for
instance, cannot be the only cause ; since the females, who in
better classes cannot be accused of that fault, are in great num-
bers subject to insanity. It is possible, however, that a daughter
may suffer for the faults of her father, whose dissipation might be
the cause of her weakly and nervous constitution.

The manner of living in England is not conformable to dietetic
principles. It is known that the same quantity of food taken at
different times is better digested than taken at once, and that
medicine administered in smaller and repeated doses, produces
more effect than the whole quantity taken at once. The English
commonly take one plentiful meal and at a time when the circu-
lation is naturally quicker, that is, towards the evening. Besides,
they excite the circulation by strong wines and tea ; and instead of

128 INSANITY,

being quiet during the time of digestion, like other living beings,
they directly after dinner frequent crowded assemblies, are
squeezed and tired, and have no place to repose. Is it then a
wonder that dyspepsia, Hver complaints, disorders of the abdom-
inal viscera in general, and so many affections of the brain, are
observed ?

The manifestations of the mind depend on the body, and the
body on climate and weather. The agreeable Sensations of a mild
climate, dry air, and a beautiful sky, give hilarity to the mind ;
while cold and moist weather make it gloomy. Insanity, indeed,
is more common in climates where cold and warm frequently al-
ternate ; but it is most frequent where the air is moist and cold,
and accompanied at the same time with a cloudy sky. Gloomi-
ness, indeed, is not rare in England.

All other causes are common to the inhabitants of England,
and of other countries : in females, for instance, pregnancy, diffi-
cult parturition, the preparing of nutriment for the infant ; in both
sexes transpositions of various morbific causes to the brain, &c.
Before I finish, I beg the preceding remarks to be considered as
hints to both the attention and examination of medical men. It
is not sufficient to mention the rapid progress of this alarming dis-
ease, we must also try to contribute to the elucidation of the
causes. In preventing them, we are of greater use to society
than in taking care of the moral treatment of the patients.

RECAPITULATION.

In this section I have entered into more details, because I con-
sider a clear knovdedge of the causes of any disease as the basis
of treatment, and without that previous knowledge no rational
plan of cure can be established. I have divided the causes of in-
sanity, like those of other diseases, into proximate and remote. I
have mentioned the reasons why I consider the proximate cause
of insanity as corporeal, and residing in the brain. In examining
the nature of the causes, I have divided them into idiopathic and

FORMS. 129

sympathic, and detailed each sort. At the end 1 have added a
few remarks, whether the sexes and temperaments predispose to
insanity, and why insanity is so frequent in England.

SECTION V.

Forms of Insanity.

Three forms of insanity are commonly spoken of; idiotism,
mania, and melancholia. Modern pathologists, however, have
observed that mania and melancholia cannot be considered as two
species of insanity, because they are often interchanged into, and
often alternate with, each other ; and the treatment which in bot'i
forms has been found the most profitable is the same. Idiotism,
anger and fury, or melancholy and despondency, are the most
striking appearances; and for that reason insanity, probably, has
been divided accordingly. But those who keep up that symp-
tomatica! division, may adopt with the same reason the multifari-
ous forms established by Dr. Arnold ; for there are many insane
people who are not furious nor despondent, but quite cheerful and
continually laughing. They may also, with Sauvage,* subdivide
melancholia into fourteen species ; as, vulgaris, amatoria, rellgiosa,
saltans, he.

The more we examine insanity, the less can we be satisfied
with the common knowledge of the mind. Every treatise on in-
sanity shows that we must be in darkness, and cannpt understand
the deranged functions, as long as Vv'e are ignorant with respect to
the conditions of their healthy functions. Crichton* says, ' It is
very intricate to deveiope why melancholy in one case terminates
in furious delirium, and in another is succeeded by a very mild
aberration of reason.' Pinel, who gives quite an arbitrary mean-
ing to the name melancholia, in calling so every partial insanity.

'"^ Nosol. Method, torn. ii. * On Insanity, vol. ii. p. 2'J().

17

130 INSANITY.

must naturally complain that ' nothing appears more inexplicable,
at the same time nothing can be more certain, than the various
and opposite forms of melanclioly. Sometimes it is distinguished
by an exalted sentiment of self-importance, associated with chi-
merical pretensions to unbounded power, or inexhaustible riches.
At other times it is characterised by great depression of spirits,
pusillanimous apprehensions, and even absolute despair.' Those
who consider the manifestations of the mind as independent of the
body, or even our common knowledge of the influence of the
body on the mind, will not explain an infinite number of insane
appearances. How will the former account for the cases of idiots
from birth ? Have those individuals no mind ? How can they
understand why in others the independent mind, endowed with
reflection and will, is mischievous beyond measure ; or that others
think themselves the vilest of the vile, without any previous fault ?
Where is the mind in those who sit whole days with their eyes
immovably fixed on one object, and seem wholly absorbed in
their own contemplation, and refuse all kind of nourishment?
How will they account by the mind, that some are given up to the
most brutal instincts, and others disposed to devotional melan-
choly, and continually engaged in penetrating the hidden myste-
ries, combating the various opinions of different sects, and in pro-
pagating their own ? The doctrine of temperaments is not more
fit to explain such disorders of the mind. There is no tempera-
ment of idiotism, of mania, or melancholia. Many melancholic
patients have the external characters of a sanguine temperament,
such as a fair complexion, a fine skin, clear colored hair, and blue
eyes ; or the signs of a bilious temperament, as a lean dry frame,
sallow skin, a complexion of a brownish yellow color, dark black
stiff hair, and dark sunk eyes. Finally, the diseases of the ab-
dominal viscera are not sufficient to explain insanity. In many
idiots the viscera are in perfect health, and in many cases the vis-
cera are greatly diseased, but there Is not the slightest derange-
ment of the mind. The physiology and pathology of the brain
alone can explain the manifestations of the mind in the state of
health or disease.

FORMS. 131

I admit four general forms of insanity; viz. idiotism^ which is
partial or general ; fatuity^ also partial or general ; irresistihility,
if any power be so active that the will has no influence on its ac-
tions ; and alienation, if the manifestations of the faculties are
deranged in their quality, and the intellect is incapable of distin-
guishing the derangement. These four forms designate different
states of insanity, while mania and melancholia are merely sorts
of alienations.

I have often repeated, that in insanity, as in other diseases, not
the symptoms, but the nature of the causes, is the essential point
to be discovered. On account of the importance of that proposi-
tion I shall elucidate my manner of considering melancholia.

Melancholia,

This name originates from the supposed cause alra hills, hence
morbus niger, of which the most striking symptom is desponden-
cy. Pinel, with Aretaeus, gave this name to all partial insanities
or hallucinations. According to our views, there is a peculiar
sentiment in the mind, termed cautiousness, and the manifesta-
tions of this sentiment depend on a peculiar part of the brain.
Now, the influence of this sentiment may be extremely powerful
by means of the internal activity of the organ. Individuals under
such active influence are consequently naturally timid, fearful,
anxious, hesitating, and subject to sorrow and low spirits. Cau-
tiousness then may be excited by various causes, which affect the
respective organ. This organ, however, is seldom attacked alone,
but in most cases other parts of the brain and body suffer at the same
time. Sometimes the disease first results from the organ of cau-
tiousness, and its too great activity deranges the other functions of
the brain and body, especially those of the digestive organs. At
other times, disorders begin in the digestive organs, and influence
the organ of cautiousness, or various other parts of the brain. It
is generally known that sorrow and grief easily disturb the digestion,
and bad digestion gives uneasiness to the mind, certainly through the

132 INSANITY.

medium of the organization. No one, however, will maintain that
the mind resides in the digestive organs. It seems to me, that the
variety of deranged functions of automatic life, and the diversity
of deranged manifestations of the mind, can be explained only by
the various parts of the body, and the different organs of the mind.

In this way it may be understood why different morbid appear-
ances are often closely connected with melancholia, such as dys-
pepsia, hystery, and hypochondry, with all their innumerable ap-
pearances. In this way only, it is clear why the same causes
may produce melancholy with its modified symptoms, from se-
riousness to suicide — and all sorts of nerv^ous complaints, such as
convulsions, epilepsy, catalepsy, palsy, all symptoms of insanity,
and even death. In this way alone we can explain why some-
times there are various precursory symptoms, which evince a de-
ranged state of health, before melancholia or mania, or any other
symptom of insanity, take place.

Thus, when melancholy appears, it is necessary to consider, at
the same time, all other morbid symptoms of automatic and ani-
mal life, in order to form a just idea of the state of disease which
produces all the symptoms. In automatic life, the viscera of the
abdomen and thorax, and their functions, such as stomach, liver,
intestines, mesenteric glands, uterus, lungs, heart, deserve our pe-
culiar attention. There is often want of appetite, flatulency,
acidity, rancid eructations, borborigmi, irregularity in the alvine
discharge, constant costiveness, sudden diarrhoea, distension of the
stomach, colic pains, tightness in the region of the stomach, a
sensation of heat in the bowels; the urine is sometimes milky,
white-colored, or copious and pale ; the complexion is often pale
and yellowish, and the white of the eye of a lead color.

In animal life there are also various symptoms which indicate
the morbid state of the brain and nerves. Such patients often
complain of external pains, seated immediately under the skin, at
various parts, as at the leg, thigh, arm, back, or in the head.
These pains commonly shift from one part to another. Other
symptoms in the head are headache, giddiness, tingling of the

FORMS. 133

ears, a kind of undescribable uneasiness, little disposition or abso-
lute incapacity to sleep, incoherence, or confusion of ideas, unu-
sual gestures, and an altered countenance ; thoughtfulness, fond-
ness for solitude, taciturnity, the patients often lament, weep and
sigh heavily without any apparent cause, are low-spirited, have
sometimes indescribable anxiety, and abandon themselves to tears
and affections of grief. They are subject to impressions of fear,
distress, and many imaginary objects of terror. Sometimes the
most extravagant ideas enter into their mind ; some think that
they are persecuted, or that they must die of hunger, that they are
damned, or have no soul, &lc. Sometimes, at the beginning of
the affection of the brain, they preserve understanding enough to
acknowledge their unhappy and deranged state ; there is a strug-
gle between reason and madness, but they finish too often by be-
lieving in their absurdities.

In hystery and hypochondry, many of the related symptoms of
automatic and animal life are observed ; hysteric patients are lia-
ble to frequent mental delusions, groundless apprehensions, and
disorders of the reflecting powers. Hypochondriacs also suffer
from various nervous complaints, exhibit gloom with groundless
fear, and are inclined to see all objects on the darkest side ; so
that their anxiety and great attention to their senations, and the
minuteness of their descriptions, frequently exhaust the patience
of their physicians.

I have already mentioned that deranged functions of the vis-
cera may exist and continue for years without deranging the func-
tions of the brain, and vice versa : but sometimes the mutual in-
fluence is observed from the beginning ; sometimes the functions
of the different parts of the body are disordered slowly, and by
degrees; but sometimes insanity bursts out suddenly, just as
sometimes the affections of other parts : often all morbid symp-
toms of automatic and animal life subside, and return again.

In the same way as, in melancholic patients, cautiousness and
religious feelings are too much excited, so the lower feelings may
become too active, and constitute the prevailing features. The

134 IN S AN II V.

patients then become restless, walk with a quick and precipitated
step, are more loquacious or suspicious, captious, haughty, or ma-
licious and mischievous ; they halloo, swear, talk lasciviously, lose
all bash fulness ; their hearing is quick, the eyes red, the look fixed,
and the whole aspect furious. These symptoms often interchange
or alternate. It is, however, more common that melancholia, par-
ticularly chronic melancholia, is changed into mania, than the lat-
ter into the former ; chronic mania, mostly terminates in incurable
fatuity. If, in individuals who from infancy had a serious, quiet,
gloomy, timorous character, insanity take place, at the beginning
the symptoms are in most cases of a melancholic nature, and far
the greatest number of such individuals have the organ of cau-
tiousness proportionately large.

i.
Suicide .

The morbid inclination to suicide is the same disease which is
commonly called melancholy, only producing that singular effect.
That many people feel a strong propensity to terminate their own
existence, is a fact too notorious to be denied. It is also intelligi-
ble, that a man who is miserable in all respects, who has to con-
tend with poverty, all sorts of disappointment, continual misfor-
tunes, should desire to put an end to his mortal existence ; but it
seems curious to observe, that persons who are fortunately placed
in society, excel by talents and rank, and have money at com-
mand, despair and feel the greatest inclination to destroy them-
selves. Moreover, disappointed love, jealousy, the loss of a be-
loved friend, bodily infirmities, incurable maladies, all miseries of
corporeal existence, are plausible reasons for suicide. They,
however, rarely produce that effect. Suicide may be the effect
of momentary decision and of violent affections, but very often it
is produced by disease.

This propensity to suicide appears under three modifications.
The patients destroy themselves ; or they kill first their relations,
and then themselves ; or they kill others in order to be put to

FORMS. 135

death. I shall first mention several examples of suicide, and then
show that, in many cases, suicide must be considered as the effect
of corporeal disease. Simple suicides are so common, that it is
quite unnecessary to quote any case. Examples of the two other
modifications are not so numerous, and not always sufficiently un-
derstood. A shoemaker at Strasburg killed his wife and three of
his children, then he wounded his stomach, and, as the wound
was not mortal, he pierced his heart with a knife. This man had
a good reputation, was mild, just, a good husband and good
father. At Lemberg, in Gallicia, one K*** killed his wife,
whom he loved tenderly ; then he tried to blow out his brains
with a pistol ; the first shot failed, but a second killed him. His
behavior was always blameless ; it was found that he was merely
dissatisfied with his place, and thought he deserved a better.
In the year 1804, at Hamburg, a respectable schoolmaster, R'^**
killed his wife and his five children in a single night, and spared
the lives of two other children who were entrusted to his care.
He bore a good character, lived happily with his family ; he had
been unsuccessful in a trifling lawsuit, which he feared would in-
volve his family in distress. He expiated his disease upon the
rack. We saw at Manheim a baker, who, from his infancy, had
manifested a timorous character, and who had been melancholy
for ten years. He complained of a general weakness, and fan-
cied he was ruined for having bought a house. He considered
his situation as the most unfortunate, and incessantly wished to be
dead, and would have destroyed himself, if, according to his ex-
pressions, it were not a sin. He often spoke to his wife of a French
smith, who had killed his wife and himself. He loved his wife,
and often repeated to her, ^ You are unhappy, I shall be obliged
to do what the French emigrant has done.' At Paris we met
with a woman, twenty-six years of age, who, principally at the pe-
riod of her menses, felt extreme anxiety, and the horrible propen-
sity to kill herself, her husband, and her children, whom she loved
tenderly. She trembled in describing the struggle of her mind
between moral and religious principles, and the internal impulse

136 INSANITY.

to commit such an odious action. She was accustomed to bathe
her child in a small river 5 but for a long time she did not dare to
do so, because an internal voice told her incessantly, ' Let hitn
sink, let him sink.' Sometimes she had scarcely time to throw
away a knife she was inclined to plunge into the bosom of her
children, or her husband. When she went into the room where
her husband and children slept, she felt immediately the propen-
sity to kill them. Sometimes she was obliged to run out; she
hastily shut the door, and threw away the key, in order not to be
able to return during the night, if she was troubled by this horrible
feeling.

Sometimes this disease is hidden under a peculiar mask.
Such patients are sometimes disgusted with life, but they have
not courage enough to kill themselves ; hence they contrive
means of being destroyed by otherl. To this end they commonly
commit a murder on another innocent person, mostly on a child.
Then they accuse themselves, and require to be punished with
death. Sometimes they consider it less criminal to destroy
another than to commit suicide. Crichton relates several facts
mentioned in the Psychologisches Magazin.

* Daniel Voelkner, born in Friedland, lost his father when
fourteen years of age, about which time he was put an apprentice
to a shoemaker. Afterwards he enlisted himself for sixteen years
in the service of his Danish Majesty. After this time he returned
to his native country, and enlisted himself once more a soldier in
the cavalry.

' From this period his ideas of the happiness of a future life
were of the most vivid kind, since they terminated in weariness
of life, and in the desire of throwing off his mortal burthen. The
only way which presented itself to his mind, to obtain this desira-
ble end, was to forfeit his life by murder. After the accomplish-
ment of this act he imagined he should have time enough to
make his peace with God.

* According to the testimony of his comrade and bedfellow,
this man hved a pious life, singing reliyious hymns and reading

FORMS, 137

godly books, one of which he offered to his companion for his
edification. He often admonished him to become devout, add-
ing, that he himself had been very v^ild in his youth, but that he
was now in the right way.

' One night, when in bed, the idea of teasing Voelkner a little,
on account of his extravagant piety, occurred to his bedfellow.
He said, he looked upon it to be a thing unreasonable in some
people to act so uncommonly devout a part, as if with a view of
making it appear that they alone merited happiness hereafter
Upon which Voelkner answered, it was extremely unjust in him
to think so, and immediately began to cry out, " I must, I will be
happy hereafter." These words he repeatedly uttered with a
loud and harsh voice, tossing his legs and arms about in a violent
manner, and starting from one part of the bed to another. After
this he broke forth in sorrowful complaints about his past life, and
began to exclaim, "lam come to this at last, I am come to this
at last," which words he repeated three or four times. Upon his
companion asking him to what he was come, he answered the
same thing,

' According to Voelkner's own testimony, he had long enter-
tained the idea of murdering a child, because he thought that,
after having confessed and made his peace with God, he would
soon reach that place, and that happy life, for which he sighed.
Three weeks previous to the act he suffered indescribable anxiety
and uneasiness. It appeared to him as if he was obliged to kill
some one. On some nights he slept well, on others not at all ;
but the idea of murdering some one always returned with the
light of the day.

* Three days before he committed the crime, he went to the
churchyard, and played with the children who were there, in-
tending, if he had an opportunity, to kill one of them. At last, in
one evening, he accomplished his horrid purpose. A little girl,
who had a companion in the house where Voelkner was quar-
tered, came that evening to pay her a visit. The landlord of the
house and his comrade were both gone out about an hour before.
18

138 iNSANixy.

Voelkner invited the two little girls into his room, and divided be
Iween them his supper. Immediately after which, placing his
hand on the forehead of one of them, he bent her head back, and
with a knife, which he had sharpened on purpose a day or two
before, he cut her throat. He then went to the guardhouse, sur-
rendered himself, told what he had done, and acknowledged that
it now caused him much regret. He was immediately taken to
prison, where he slept calmly the whole night ; for he acknowl-
edged, that the uncommon uneasiness he had experienced for
three weeks before, ceased upon his committing the act.

' During his examination he answered like a reasonable man,
and expressed himself with precision, behaving himself decently,
both in word and deed. He narrated the principal circumstances
of his life, and said, he knew perfectly well what consequences
were to be expected from such an action, and that he would be
obliged to answer with his blood. But this thought was at that
time by no means disagreeable to him.'

' Seybell, a shoemaker at Potsdam, from infancy quiet and
pious, simple and timorous, and more inclined to grief than to joy.
Even in his early years he fell into a state of melancholy. He
was exceedingly platonic, unfortunate, and his mind was filled with
displeasure on account of his own inferiority and want of talents..
From 1772 to 1781, he lived in a state of great poverty, support-
ing himself by sewing, the profits of which were hardly sufficient
to supply his most urgent wants. He had a few debts ; tortured
by constant anxiety and distress, and fearful to be arrested on ac-
count of his debts, he thought that his afflictions would not ter-
minate but by his death. The unlucky thought sprung up in his
mind, of accelerating that wished-for event by murdering a child.
The child whom he selected as the instrument by which he was
to attain heaven, he loved to excess, as he himself avowed, and
as the parents testified, who said that he had taught the child
many prayers and several passages of the Bible. This love pre-
vented him once from killing this little object, but one day, being
suddenly seized with delirium, he quickly murdered the child.

FORMS. 139

He tried to conceal the body, and yet, a moment after, he went
out of the house and told what he had done.

Haslam* relates the history of a woman, aged 36, who, under
the impression that she ought to be hanged, destroyed her infant,
with the view of meeting with that punishment. When she came
into the house, she was very sensible of the crime she had commit-
ted, and felt the most poignant affliction for the act. For about a
month she continued to amend, after which time she became more
thoughtful, and frequently spoke about the child : great anxiety
and restlessness succeeded. In this state she remained from
February until April, when her tongue became thickly furred, the
skin parched, her eyes inflamed and glassy, and her pulse quick.
She now talked incoherently, and toward the evening merely
muttered to herself. She died on the following day comatose.

Circumstances which accompany suicide evidendy show that
it is a corporeal disease. There are countries and districts where
suicide is endemical. In Germany, about Hamburg, Potsdam,
Halle, Jena, it is much more common than in Austria ; and at
certain periods it is more frequent than at others ; sometimes ep-
idemic, so that in a short time there are a great number of in-
stances, and then much fewer during a long interval. Like other
forms of insanity, the inclination of self-destruction is hereditary.
Gall was physician to a family at Vienna, in which two brothers
killed themselves ; and the sisters have the same propensity,
especially at the period of their menses.

The morbid symptoms, which are commonly observed in such
unfortunate beings, resemble those of melancholy in general.
There is a great disorder in the viscera of the abdomen ; inordi-
nate appetite, eructations, flatulencies, irregular evacuations, de-
rangement of the menses ;' a yellowish sallow complexion, of an
earthy color, especially about the nose and mouth; the eyes are
dim and weak ; the white of the eyes is of bluish lead-color.
Some grow lean, others preserve their plumpness, have the face

* Lib. cit. p. 102.

140 INSANITY.

high-colored and animated. The patients often complain that
their hands and feet are stiff and benumbed ; more frequently the
sensibility of the skin is increased ; they feel either in the whole
body, or in certain parts, principally in the intestines, or in the
thighs and feet, an ardent heat, as if it were produced by burning
coals. The greatest number of these patients are timorous and
pusillanimous, so that sometimes very tall men tremble like
children, feel a strong and permanent pain above the root of the
nose, and in the midst of the inferior part of the forehead, some-
times at the top of the head. Others complain of an insup-
portable tension in the forehead, and of tightness in the region of
the stomach. Some vex themselves, and others around them,
about trifles, feel suffocating anxieties, a sentiment of despair, and
see nothing but misfortune and wickedness, though sometimes their
situation is extremely fortunate. All external circumstances often
indicate prosperity, when they despair and fancy that they and
their family will die of hunger and misery. Certain individuals
imagine they are despised or persecuted by every body. Some
have inspirations and visions. They see and hear angels, who
excite them to put an end to their days.

Sometimes the various symptoms disappear, but return. The
visionaries, at the beginning, often judge exactly their situation ;
they consider their sensations and ideas as illusions, but when the
disease increases they think they are real. They sometimes feel
the impulse to self-destruction for years. They sometimes keep
a note-book, and manifest evidently, by the sentences they write
down, that their mind is deranged. They often note, / am mad ;
I am distracted ; and in thinking of self-destruction, J, however,
shall do it. Such persons sometimes bear about them a knife,
or other destructive weapon, for several years, uncertain and un-
resolved as to manner, place, and time, when they will destroy
themselves or others. Several who attempted to break the ties
which keep them from a better life, have not succeeded. After
a few days they often seem to repent of their action, but commonly
new fits take place, and they repeat their attempts till they succeed.

FORMS. 141

Those who begin with destroying their relations or others, do not
always give the mortal blow to themselves, but they surrender
themselves to justice, and request to be punished with death.

Another proof, that the chronic impulse to suicide is disease,
results from the appearance of the skulls of such patients. They
are very often dense like ivory, and often thick. It is, however,
necessary to distinguish those who destroy themselves in a fit of
momentary despair, or from a chronic melancholy. It is impossible
that the state of the ossification should be changed in a very short
time.

A great number of persons consider suicide, especially the
actions of those who kill others, and sometimes their beloved re-
lations, as the most horrible crimes, because such individuals de-
stroy the lives of others, on account of being tired with their own;
but the judgment of a philosophic physician is quite different. He
perceives in these deplorable actions only the signs of a terrible
disease, most deserving our pity. The contrast of such actions
with nature ought to have excited the attention and reflection of
every one who studies mankind. It is inconceivable that a wife,
who loves her husband, and vice versd, and that parents who
love their children, will assassinate them, as long as their mind is
not at all deranged. The judgment of the wise Solomon ought
to have been thought of. Add to this, that murderers of this kind
have neither terrestrial advantage nor revenge in view ; that after
such actions they either kill themselves, or surrender to the mag-
istrate, and ask for death. How is it possible not to observe a
derangement of the mind, especially if a true picture of all pre-
ceding symptoms be taken into consideration ?

Similar patients are commonly considered as turbulent and
fractious men ; they are often ill-treated, reproached, or derided ;
they are even accused as impious, instead of being treated with
cheerfulness and patience, and trusted to the care of a philosophic
physician. Such persons are censured as if their excitement and
depraved imagination were the result of their own will ; and, when
the catastrophe happens, different external and accidental circum-

142 INSANITY.

Stances are considered as a sufficient cause of such an event.
The unfortunate person was overburthened with debts ; her hope
had been disappointed ; or her partner was faithless, &tc. We
must, however, be aware, that similar incidents happen daily,
without producing such effects ; hence the predisposition of such
patients is not to be overlooked.

Fits of Insanity.

It is generally known, and I have sufficiently detailed, that,
idiotism and fatuity excepted, insanity is often intermittent, like
many nervous complaints, and has exacerbations and remissions.
In all these affections, the cause of disease may be permanent,
but does not continually produce morbid appearances, nor in
every fit the same symptoms. I have mentioned, that the melan-
choly attacks subside, and return again. It is the same with the in-
clination to suicide, with mania, epilepsy, catalepsy, convulsions, &c.
Much has been said with respect to the cause of the fits. The
ancient opinion, that the moon regulates the nervous complaints,
and other phenomena, is entirely destitute of foundation. If a
greater determination of blood to the brain be considered as the
effectual cause of various nervous symptoms, and the lesions of
the brain from exostoses or violent depression of the skull, &z;c. as
the predisposing cause, this question remains unanswered : how
comes it, that the same predisposing cause may exist continually,
and only at certain periods, the blood is carried in larger quantity
to the brain, and various morbid symptoms take place ?

The functions of the nervous system are exhausted, and its
powers require rest, to be repaired. They are excited, and even
deranged, by various stimuli, as light, caloric, galvanic fluid and
especially by blood. But the greater irritability of the nervous
system at certain periods is unexplained. The fact, that ?A
certain times the irritability of the nervous system (nerves and
brain) is greater than at others, is indubitable, and, as it seems,
dependent on determinate laws, and on other phenomena of nature,

FORMS. 143

which are not yet ascertained. These periods of irritability are
of the highest importance in the state of health and disease, with
respect both to automatic and animal life.

It seems to be a great law of nature, that all phenomena happen
with a certain periodicity. Plants at two periods, in the spring,
and at about the end of July and the beginning of August, grow
particularly in extent; at the other time of the summer and
autumn the young shoots become solid, and the plants perform
other functions, especially those of fructification. Animals are
born and increase according to periods. The climacteric years
are known, and then the body increases more than at other times.
Moreover it is a fact, that the different parts of the body, such as
teeth, cerebral parts, sexual parts, are developed at different
periods. During the whole life the change of matter of our body
is greater at certain times than at others, the alvine evacuations
are more abundant, the urine turbid, the exhalation of the skin
and lungs more considerable ; in short, the function of every part
more or less active at different periods. In animal life it is the
same ; sleep is necessary ; and the instinct of animals, all feelings
of man, even the intellectual faculties, are more energetic at one
time than at another.

Many diseases require a certain lapse of thne before the natural
state can be re-established, and they are subject to certain perio-
dicity. A philosophical treatise on the periodicity of the phe-
nomena of nature in general, and of man in particular, in his state
of health and disease, would be at the same time very interesting
for anthropology, and very useful for practical medicine. There
is one sort of periods which I call the periods of irritability, w^hich
have an influence on man in general, but particularly on the mani-
festations of the mind.

Dr. Gall first made the observation, that at certain periods more
women menstruate than at others, and that in a lunar month there
are two such periods. This periodicity with respect to menstru-
ation must be understood as follows. There are many females,
who have their menses within eight days ; they, independently of

144 INSANITY.

bodily size and temperament, form a class, and without a violent
cause, such as strong affections, they belong always together, with
this difference only, that several overcome that inconveniency in
a greater or smaller number of days ; but within eight days all
individuals of that class menstruate. There is another class of
females, who also, independently of bodily size or temperament,
have their menses at another period with the same modifications
as those of the former. Both periods happen within a lunary
month. It must, however, be observed, that the season and
weather have an influence on the periods ; in the spring and in
hot weather they commonly anticipate, and their effect is greater.
At other times they postpone, but always the whole class antici-
pate or postpone, which indicates, that the cause is general. In
a small number of females, menstruation is sporadic. Extremely
weak and delicate women fee the influence of both periods ; for
that reason some females are unwell every fortnight. Many
women think that it is always the case at the same date of the
month, but they are mistaken, and were not attentive enough.

This observation is very curious, and may become useful in
many practical cases. It is, for instance, a fact, that pregnant
women are delivered at the tenth period of menstruation. Ac-
coucheurs may now explain why, during a few days sometimes
they cannot do and run enough, and then for eight days they are
not called for. If an accoucheur be acquainted with females who
menstruate together, and any one is with child, he can know
before when she will be delivered. He knows it by the other
women of her class who are not pregnant. It is known, that
women are often mistaken in their calculation, the reason is be-
cause the conception can take place immediately before or after
the time of menstruation, and the delivery always happen at the
tenth period. If, for instance, an accoucheur be called at the
term of five or eight days after the others of her class were regu-
lated, he can be sure that there will be no delivery, till the next
period of the class.

If he be attentive, he will find, that he can often be free of un-

FORMS. 145

necessary anxiety. On the other hand, if during pregnancy some
conamina of parturition happen, and he knows that in the period
of menstruation, which he may learn from the others, abortus
easily occurs, he takes greater care. If a pregnant woman be
subject to haemoptosis, at such a period it is less dangerous, as to
its consequences.

These periods, when women menstruate, have an influence on
the whole of mankind, on the state of health and disease ; they
affect men and women at the same time over Europe. Almost
every one feels from time to time, during a few days, a greater
irritability; he is easily displeased with any impressions of the
senses ; his mind is not disposed to any application, and is easily
fatigued ; his thoughts are not consecutive ; he may be offended
by things which, at other times, would be indifferent ; he is morose,
and more inclined to quarrel or to dispute ; his appetite is les-
sened, and all his excretions are more copious. This state comes
and goes away without our being able to account for it.

These periods are extremely important in medicine : all chron-
ical diseases have at these times exacerbations ; these who suffer
by piles are m,ore tormented : many morbific causes, which are
permanent, produce greater derangement. They have also their
influence on nervous complaints, and all sorts of periodical fits, on
visionaries, and on all madmen. They explain why suicide is
more frequent at one time than at another ; why sometimes their
melancholy seems to be cured, but returns ; why such individuals,
being saved or prevented from destroying themselves, after a few
days are glad to be alive : why, yet a short time after, they make
new attempts to finish their existence ? and why they repeat them
three, four, five, and more times, till at last they succeed. The
cause of this general influence is unknown.

Beside this period of irritability, there are still other causes
which have an influence on nervous complaints and on the forms
of insanity ; but they are only known, and no more understood
than the periods of irritability. There is no doubt that light and
caloric have a great influence on the functions of our body, and
19

146 INSANITY.

of every system. We see, therefore, the changes of various gen-
eral diseases, of nervous complaints, and of insanity, according to
season, weather, day and night. The question is, whether in-
sanity has its exacerbations in the evening or in the morning ?
Both sorts of cases have been observed, but they are not detailed.
As insanity is not the disease, but merely the morbid appearance
of the same causes, which may also affect other parts and derange
their functions, it seems to me, that insanity is subject to the pe-
riods of the real diseases. It is known, that inflammatory diseases
have their exacerbations in the evening ; hence such a state of the
brain may undergo the same modifications. Hysteric and hypo-
chondriac persons are litde refreshed by sleep, and they complain
more in the morning than in the evening ; hence melancholy, and
even mania, which sometimes is a symptom of the same diseased
state, hysteria and hypochondria, may be worse at the same pe-
riods. The object is highly interesting, and deserves the atten-
tion of philosophical observers. Our ignoiance of insanity is too
lamentable not to excite our mental faculties to farther investiga-
tions. In fact, as long as we have no clear idea of the diseased
state of the body, and the nature of morbid appearances, our pro-
ceeding must be that of mere empiricism^

RECAPITULATIOJSr.

In this Section I have spoken of the forms under which insanity
may appear. I have explained that the disease does not consist
in the forms, but in the peculiar states of the organization on
which the manifestations of the mind depend. I have treated of
the different modifications of melancholy, especially of that accom-
panied with the inclination to suicide ; and I have finished with a
few remarks on the periodical fits and exacerbations of insanity.

I shall not write a peculiar Section on the means of preventing
insanity ; though I think with Bacon that the wisdom of foresight

PROGNOSIS. 147

is far above the wisdom of remedy. They may be reduced to
the general advice — to prevent the causes ; hence all the consid-
erations concerning the causes must be attended to. If a dispo-
sition to insanity exist in families, it is obvious that intermarriage
ought to be avoided, Sic.

SECTION VI.

Prognosis of Insanity,

With respect to prognosis, the same terms, which are used in
other diseases, may be applied to insanity. Any disease is incu-
rable or curable ; the latter is acute or chronic, it is cured with fa-
cility or difficulty. Such expressions, however, are quite rela-
tive ; they depend a great deal on our knowledge or ignorance of
the diseases. There was a time, when the ague was considered
as a very dangerous complaint, and syphilis was incurable. In
our days, however, we are enabled to make a different prognosis
of those diseases. The term incurable ought to be applied only
to an organic alteration, which cannot be reduced to its former
condition ; a suppurated internal organ, for instance ; ossification
of blood-vessels ; an effusion of blood or of serous matter in the
cavities of the brain, a tumor, he. On the other hand, all dis-
eases from dynamic causes ought to be considered as curable.

We must confess that hitherto medical art has acquired very lit-
tle merit in the cure of insanity ; nature alone does almost every
thing. It is, however, interesting, and even necessary, to know
what nature can do, in order to understand and appreciate the
merits of the art.

The prognosis of insanity, like that of any other disease, de-
pends on the predisposition of the patient, his bodily strength, the
particulars of his constitution, sex, age, the nature of the disease
and its cause ; its duration, the organic change it has produced in
the brain, and the degree of our knowledge. A few remarks
will elucidate my ideas.

148 INSANITY.

Natural predisposition to insanity makes a perfect cure more
difficult, and the relapses more likely. Strong constitutions longer
resist the morbific causes, and when affected they are more
easily restored. I have mentioned that in all sympathic disturb-
ances the weakest parts are the most easily affected. In young
and middle age, and in vigorous persons, insanity is the most
easily cured ; and the probability of recovery lessens, the nearer
life approaches its termination- In females the prognosis of in-
sanity connected with pregnancy, parturition, and uterine affec-
tions is mostly favorable. Singularities in the brain exist as well
as idiosyncrasies in the stomach and five senses ; their prognosis
cannot be submitted to any postive decision. Often, however,
they are dependent on the general constitution.

Moreover the prognosis depends particularly on the cause and
nature of the disease. Either it is impossible to remove the
cause, and insanity is incurable, or it is removed with less or more
difficulty. Idiotism from too small a brain is incurable. If strong
and predominant feelings be the cause, the cure is difficult. Pinel
says, religious melancholy is seldom known to terminate in any
other way than by death. Hallaran, Haslam, Cox, and others
speak of the same difficulty. A professed drunkard is not easily
restored to a permanent abstinence from such a habit. The prog-
nosis of insanity, from idiopathic causes is more unfavorable than
from sympathic. When insanity supervenes epilepsy or palsy,
or when these appearances join insanity, a cure is very seldom
effected. On that account such patients are excluded from cer-
tain establishments for the insane.

It is a general observation that maniac patients recover in a
larger proportion than those who are melancholy. The reasons
seem to be various. First, in mania, the symptoms are alarming,
make stronger impressions on the beholders ; hence rehef is
sooner looked for, and more attention is paid to the diseased state.
In melancholy the patients, sometimes for years, are given up to
their fate ; they are considered as fanciful and imaginary. It is,
however, a great fault on the part of the friends, and even of

PROGNOSIS. 149

physicians, not to consider the deranged imagination as the effect
of a bodily cause. The advances of the disease, which produce
melancholy, are insidious and imperceptible, and after a long du-
ration the removal of the cause must be more difficult. Moreover
the nature of the disease in mania and melancholia may be the
same as well as different. An inflammatory state of certain cere-
bral parts may produce mania, and is cured by blood-letting.
This will be often the case in acute mania. Chronic melancholy,
on the contrary, in weak, delicate, and nervous individuals, is
mostly the result of debilitating causes, but if irritability increases,
and a great determination of blood to the head excites maniac
symptoms, it is conceivable that the same treatment, which has
cured the acute inflammatory state, will fail in the second case.
Now for the relief of the symptoms of melancholy nothing is
done ; and if they are combined with maniacal symptoms, and
the treatment which had good effect in another disease with mani-
acal appearances does not succeed, melancholy is declared incur-
able. It is, however, not sufficient to observe only symptoms of
mania or melancholy, to form the prognosis ; it is of greater im-
portance to know the nature of the disease.

Insanity from an inflammatory state of the brain, is liable to the
same events as inflammation in any other part ; it may be acute
or chronic, the chronic continual or intermittent. Ophthalmia is
often interrupted, and returns from time to time. In acute in-
flammations, we make a good prognosis, if the disease has not
lasted long, was not too violent, or even in that case, if evacuations
take place, first by the skin, then by the urine, and at the end by
the intestines ; and if the symptoms of inflammation gradually di-
minish. The most violent patients very often recover in the same
manner. The paroxysms diminish gradually in their intensity,
till at length no vestiges are to be traced, and such a gradual
return to sanity is the most favorable to its durability.

The inflammatory state of the brain often terminates in secre-
tions of serum, in the formation of pseudo-membranes, thickening
of the membranes, hardening the bone, or in suppuration. If in-

150 IN8ANITY*

sanity degenerate into fatuity or dementia, or if emaciation be in-
creasing, though the patient eat with a voracious appetite, the case
is hopeless. Then incurable changes have taken place in the
substance of the brain, in its membranes or blood-vessels.

Remissions and intermissions are favorable : they show that
the cause is not so active, and that organic changes do not so
easily take place. In such cases the prognosis is particularly fa-
vorable, if the successive paroxysms are weaker. For there are
diseases which, so to say, exhaust themselves.

Insanity without alteration of the pulse in the body is more
difficult to be cured, because the disease is idiopathic. The
prognosis is also unfavorable in insanity connected with violent
chronic headache, especially in the neck, or in cases where
drastic remedies fail to produce any effect; or if blisters neither
vesicate the cuticle, nor increase the heat about the parts to which
they are applied.

If weakness of memory or deranged judgment proceed from
debilitating causes or follow a too debilitating treatment of acute
mania, the patient is frequently restored by good diet, humane
treatment, and tonics. But if naturally weak intellectual powers
still gradually diminish and terminate in imbecihty, there is little
hope.

In proportion to the duration of insanity, the prognosis is more
or less favorable, so that the probability of recovery diminishes as
the length of its duration increases. The question is, how long
insanity can last before it is incurable ? The question shows, that
we have no idea of what is to be called insanity. According to
the report from the select committee for the better regulation of
madhouses, 'In Bethlem at London, after a residence of twelve
months, if such persons have exhibited symptoms of malevolence
or are mischievous, and it is considered necessary that society
should be delivered from them, they are declared incurable,
which declaration is subsequently confirmed by the governors, and
then they are no more treated with a view to cure their disease.'
According to the same report, ' Dr. Sutherland is of opinion that

PROGNOSIS.

151

one year is decidedly too short a period at which to give up any
expectation of cure and consequently any medical treatment.
There are frequently patients who recover after that period.
Therefore dismissing a patient after having been twelve months
in St. Luke's hospital, they never make use of the term incurable ;
they merely dismiss them uncured.' *

* The difference in the proportion of cures to the admissions, in different in-
stitutions, is very great. This variation can hardly be attributed to accidental
circumstances, as they would not give tiniform results, but rather to different
degrees of skill, or knowledge, possessed upon the subject.

We subjoin a table of comparison, being extracts from statistical notices of
some of the LunaticAsylums in theUnited States,

PROPORTION OP CURED.

Centesimal proper*
Admitted. Cured, tion, or No. cured
in every 100.

New York Lunatic Asylum, from 1795 to 1821, 1584 700 44.19

Bloomingdale Asylum 7^ years, 1043 436 41,80

Pennsylvania Hospital, from 1752 to 1828, 3487 1254 35.96

Friends' Asylum, near Philadelphia, 8 years, 158 53 33.54

Connecticut Retreat, 5 years, 196 100 51 ,01

Mean, .... . 41,31

FOREIGN INSTITUTIONS.

Admissions. Cured. Percent.

Cork Lunatic Asylum, from 1798 to 1818, 1431 751 52.49

Salpetriere and Bicetre, Paris, from 1801 to 1821, 1259 4968 30

Aversa, near Naples, 1814 to 1823, 29.70

Charenton, Paris, 1826-7-8, 33

Bethlem,^;^London, 1817 to 1820, - 54

St. Lukes, London, 1800 to 1819, ...... 46

PROPORTION OF CURED, IN RECENT AND OLD CASES.

Bloomins[dale Asylum,

Admitted Cured Per Cent

Recent Cases, ... - - 581 341 58.69

Old Cases, 422 76 18,00

Connecticut Retreat,

Recent Cases, 97 86 88.66

Old Cases, 99 14 14.14

These may be compared with the result at the

Retreat near York, from 1796 to 1819,

Recent Cases, 92 65 70,65

Old cases, ...... 161 47 29.19

152 INSANITY.

Mr. Haslam has observed, that many patients are dismissed from
Bethlem as cured who come back with relapse, and that others
are sent away as incurable and recover. Dr. Hallaran finds it
improper to give up as hopeless any case of insanity, so long as
the vigor of youth or disposition to a diversified form of the dis-
ease has continued. He tells us more than we learn from the
preceding statements, but it seems to me that the proposition is
not sufficiently determinate. In many cases of young individuals
insanity is incurable, though the body is vigorous ; and in many
more weak persons insanity will be cured as soon as we shall
better understand its nature. At St. Luke's hospital they are
prudent in dismissing the patients only as uncured ; but this ex-
pression is employed indiscriminately, and must be so as long as
we do not know the nature and cause of insanity, according to
which alone it is to be declared incurable or curable.

There are cases where insanity can be declared incurable,
idiotism for instance, from a defective organization of the brain, or
fatuity from organic changes after a violent, continual, and chronic
mania. But in many cases twelve months are not sufficient to
give a decided opinion. Dr. Rush* relates, that manalgia has
been cured in a woman who had been insane nine years. In
another woman manalgia had continued two years, and was cured
by an acute dysentery. Four patients have been cured of man-
algia by abscesses at different parts of the body ; one of them
had passed a third of his life in the hospital at Philadelphia. In
another passagef he mentions spontaneous recoveries after the
disease had continued eighteen and twenty years.

These facts prove that in the brain the same phenomena take

Dr Burrow's Private Asylum,

Recent Cases, - - 242 221 91.32

Old Cases, --....-. 54 19 35.18

Glasgow Lunatic Asylum,

Recent Cases, - - 50.00

Old Cases, -......--- 13.00

* Medical Inquiries and Observations on the Diseases of the Mind, p. 223.
t Lib. cit. p. 256.

PROGNOSIS. 153

place which are observed in other organic parts. I doubt whether
physicians would agree in declaring all diseases of other parts
incurable after they have lasted twelve months. Chronic inflam-
mation sometimes disturbs vision for years, before the patient finds
relief for the rest of his days. And if chronic affections of the
skin, lungs, liver, stomach, or uterus, are cured after several years
duration, why should it not be possible with diseases of the brain ?

Finally, the prognosis of any disease depends on our knowledge
and ability. In the aphorisms of Hippocrates we find many symp-
toms declared mortal ; in our days, however, a physician would
be very blameable, did he lose his patient under such appear-
ances ; and a physician would be considered as ignorant, if his
patients should sufer as many relapses as the patients of Hip-
pocrates did. Melancholy and insanity, with the propensity to
suicide, are seldom cured, according to the assertion of all writers
on insanity. I am, however, convinced from repeated observa-
tions, that it is curable, and as often as mania. In general, I am
decidedly of opinion, that in insanity, if we immediately employ
the proper means, and continue the true treatment for a sufficient
length of time, the number of curable cases will greatly enlarge.
In many cases the power of nature, without support, is insuffi-
cient ; and in many others it is more difficult to repair the mis-
chief induced by improper treatment of insanity, than it would
have been to cure the original complaint ; just as it often happens
in other diseases.

If re-convalescents return to their primitive tastes, pursuits, and
habits, it is a good indication of their final and complete re-
establishment. Dr. Rush* relates, that ' in a young man of the
name of Wilkison, the habit of stammering was suspended during
his derangement, but returned as soon as he began to mend.' Dr.

Rushf also mentions, that * a Mrs. D said to him one day,

in passing by her in the hospital, and asking how she was, that
she was perfectly well, and that she was sure this was the case,

** Lib. cit. p. 254. t Lib. cit. p. 255.

20

154 INSANITY.

because she had at last ceased to hate him.' A similar instancd
of a perfect recovery, Succeeding the revival of domestic respect
and affection, occurred in a Miss H- — ~- who was confined in the
year 1800. For several weeks she discovered every mark of a
sound mind, except one : she hated her father. On a certain day
she acknowledged with pleasure a return of her filial attachment
and affection for him. Soon after she was discharged cured.
Similar observations are made in other diseases. Sometimes in-
sanity, as well as other complaints of internal parts, cease at the
return of piles, cutaneous eruptions, erysipelas. Sometimes af-
fections of the brain change with asthma, dyspepsia, and other
morbid appearances of internal parts.

The natural language of insane persons, as Voice, gesture, man-
ner of talking, looking, walking, &c. is different from that of a
sound one ; it is, therefore, a good sign in insanity, if we observe
a progressive amendment in the more obvious and striking symp-
toms, if in the intervals the countenance and behavior are more
regular, and the whole appearance more natural.

Like other persons, insane patients recollect better the very
early impressions than recent ones ; and they often show knowl-
edge of things which they had forgotten in the healthy state, just
as is the case in other diseases. The instance of the Countess of
Laval is known, who was nursed among the Welsh, and appeared
to have entirely forgotten the Welsh language. But long after
she had grown up, in the delirium of a fever she spoke many
Words in a language unknown to her attendants, which was at
length discovered by an old Welsh woman.

Like old persons, who sometimes a short time before their
death show increased activity of their powers, many insane, be-
fore the end of their days, show often a sudden restoration of rea-
son. The mind of Dean Swift awoke from its long repose in
fatuity in consequence of an abscess in one of his eyes. Dr.
Percival relates an instance of a woman, who lived from her in-
fancy to the 35th year of her age in a state of fatuity, and died of
a pulmonary consumption, in which he discovered a degree of
intellectual vigor that astonished her family and friends.

PROGNOSIS. 155

Insanity^ as well as other diseases, is liable to relapses. Any
part of the body, and so also the brain, being once affected, pre-
serves a predisposition to the same disease. I know a gentleman
who was accustomed to drink, and, without being intoxicated, he
could drink more wine than any of his acquaintances, till once he
became intoxicated by rum. Since that time he felt the effects
of wine as soon as any other. It is a general observation that, if
an attack of insanity cease suddenly, the relapse is to be expected.
Dr. Hallaran says : * When I have found mania to subside
speedily and suddenly on the first attack, I have ever laid my ac-
count on its hasty return with redoubled violence. In this I have
never been deceived, though the interval has been in the strictest
sense a lucid one.' He adds, that he has ^ never witnessed a
perfect recovery in recent cases of insanity, where the symptoms
had suddenly given way.' This is the case in many periodical
affections, and proves that mania can be the result of different oc-
casional causes. In insanity, however, as in any other disease, a
relapse is no proof that it was not cured before. Ophthalmia often
returns, and each time it is said to be cured ; in the same way
the ague, a catharral affection, an erysipelas, he. are said to be
cured, notwithstanding the relapses to which they are liable.

There are writers who think that insane people cannot live
long ; and atrophy, pulmonary consumption, dropsy, particularly
hydrothorax and anasarca, are considered as the most frequent
occasion of death among them. Samuel Tuke, however, states,
that it is perhaps a matter of doubt, whether the frequency of
these diseases is more connected with the mode of treatment than
with the mental disorder. In the retreat insanity is not essentially
prejudicial to automatic life. Samuel Tuke speaks of one eighty-
seven years old, of eleven between sixty and seventy, and of
four between seventy and eighty years. In the section on moral
treatment I shall mention reasons enough why insane people com-
monly do not live long. In the first report from the select com-
mittee for a better regulation of madhouses, there is an example
quoted, that a patient was so much neglected that he was spoken

156 mSANITF.

of as a dying man ; but the poor creature being removed and
better attended to, in a few months was so much recovered as to
be able to be removed to his parish in an inoifensive, though im-
becile state of mind.

RECAPITULATION.

In this section I had the intention to show that the prognosis of
insanity must be instituted in conformity to the same considerations
as those of any other disease, viz., according to the predispositions
of the patients, the constitution of the whole body, or of single
parts ; according to age and sex ; especially according to the
cause and nature of the disease, its duration, organic changes in
the cerebral organization; finally, according to its disposition to
relapses, and our knowledge and ability of curing the disease.

SECTION VII.

Treatment of Insanity,

I come now to those considerations in which the patients are
most interested, and where experience and our own conscience
attest our ignorance. We must, indeed, all agree, that the
method of curing insanity is not at all satisfactory. I will not
censure, I only relate simple facts. The Greeks and Romans
endeavored to cure every insanity by hellebore ; in the middle
age superstition had recourse to exorcisms ; according to the report
of the select committee for a better regulation of madhouses, at
Bethlem, in London, in our days, the patients were bled, vomited,
purged and blistered, according to the season ; and at Charenton,
near Paris, the patients are said to be cured by playing comedies.

Two sorts of treatment are commonly spoken of; one is termed
moral, the other medical. At all times the opinions have been

MORAL TREATMENT.

157

different, which is the most important. Araeteus, who treated pro-
fessedly on the diseases of the mind, overlooked the moral treatment ;
Celsus, on the other hand, had the greatest confidence in it. In our
days, far the greatest number even of medical men expect better
effect from the former than from the latter. I shall therefore begin
with its elucidation.

Moral Treatment of Insanity.

Pharmaceutic preparations and medicines excepted, all the rest
belongs to the moral treatment ; habitation, for instance, nourish-
ment, coercion, occupation and personal treatment. I shall first
mention die things as they are, and then propose some im-
provements.

I shall begin with the habitation. As to their situation, I have
seen madhouses near rivers, in marshy districts, where the atmos-
phere was constantly damp ; sometimes near issues of sewers ;
or in the neighborhood of large hospitals, where thousands of
patients were crowded together to infect the air ; or where the
galleries looked over large burial grounds, where interments daily
happened under the eyes of the most gloomy and melancholy pa-
tients. With respect to their construction, T have found round
towers, or square buildings, two or three stories high, and the airing
grounds in the centre. In this way the free communication of
air was prevented, and the cells at the ground-floor were dark and
moist. I read even that buildings of four stories are proposed,
because they are preferable for economy, as only requiring the
same quantity of roofing that is requisite for a building of one or
two stories. I find also that such a height is excused, because the
place is so small, and airing ground wanted. In that case I would
object against the situation in general : for not the place, but the
patients, deserve the first attention. I have seen the staircases
of all stories, or the oudet of all cells, common ; sometimes there
were no means of ventilating the cells when they were inhabited,
or the cells were not glazed j hence it was necessary to exclude

158 INSANITY.

light with the cold air. Commonly there were no means of
warming the apartments ; the cells sometimes resembled stables
or dungeons; the water-closets often too near, and the smell of-
fensive ; no airing grounds at all, or small damp ones within the
square buildings, and these still encumbered with rubbish ; some-
times I have observed them exposed to the sun without any shel-
ter ; at other times surrounded with high walls, that no sunbeam
could reach them. A want of sufficient room to classify the
patients is almost general.

In considering the treatment of the patients, it is impossible to
remain indifferent. Even the most obvious idea, which is indis-
pensably necessary, viz., the separation of the patients, is neglect-
ed. The most furious and the most melancholy; the most impe*
rious and the most fearful; the most vociferous and the most
cheerful ; the most villanous and most religious ; clean and
unclean ; curable, convalescent, and incurable, are put together ;
all is chaos and confusion. In the same day-room the furious
are chained, and the gloomy walk round them. Sometimes men
and women are put together, and it is reported that the insane
were pleased to propagate their race. If any separation of patients
exist, it is made according to what can be paid for them. I have met
insane persons, who were reasonable in many respects, of accom-
plished manners, and who were fully sensible of their situation, in
the same floor with wretched beings without clothing, who were
unaware of the necessity of nature ; in short, with beings of the
most degrading and brutalizing condition.

I have seen patients fastened by chains, sitting at the grating of
their doors or windows like savage animals in cages. Often I
have found them in workhouses, under the care of persons totally
ignorant of the proper treatment which such patients require, and
in rooms not at all adapted to them. Such unfortunate creatures
naturally are a great annoyance to the other inhabitants of the
house ; they are then either confined in a strait waistcoat, or tied
to their bed day and night. If they walk about the house, they
are made the sport of children ; hence they are often huddled
together in rooms, and several in one bed.

MORAL TREATMENT. 159

1 have also found them confined in houses of correction , or in
prisons, in dark, cold, and dirty cells, separated from every living
creature ; while the felons were comfortable round the fire.
Several keepers seemed to possess all the qualifications necessary
for superintending a jail, but they seemed to me quite unfit for
taking care of the insane. They also attended rather to the
complaints of the criminals, than of the unhappy lunatics. They
had more compassion for the felons, or perhaps more fear of the
justice which defends their cause, while the insane are abandoned,
and given up in loathsome cells to the most arbitrary system of
cruelty. Sometimes I have seen such deplorable beings in stables,
naked, and exposed to the temperature of the atmosphere, during
winter and summer. I confess to have left many such places
with the utmost indignation at our ignorance, and at the inhu-
manity of treating insanity worse than crime ; of excluding the
insane alone from the humane feelings of society, and of abhorring
them more than evil spirits. No one, who has witnessed the
deplorable situation of such unhappy creatures, or who has read
the report of Dr. Latham, the President of the College of Physi-
cians of London, or of the secretary, Dr. Powell, and who is a friend
of humanity, can remain indifferent. The former tells us,* 'All
the madhouses under the present regime are more calcu-
lated for places of confinement, than as places of cure ; the
relations of the unfortunate people shut them up there, in order to
put them out of the way, and in nine cases out of ten this is the
fact.' The latter says, ' Insane houses are places which seem
rather intended for the confinement and imprisonment of lunatics,
but not one of them seems fully calculated for the cure of them.'
I think we can add, the greatest number of madhouses are calcu-
lated to produce insanity, or at least to prevent the cure, rather
than to promote it.

It seems to me a horrible idea to confine the insane in prisons.
How excruciating the feeling must be of an individual, who can

" First Report, p. 111.

160 INSANITY.

Still reflect on his situation, and sees himself in a prison, and lock-
ed up by a keeper. I have heard melancholic persons bitterly
complaining of such an abode ; indeed if an insane person should
think himself persecuted by the justice, he would be confirmed in
his insanity. Those who infect society with the itch, or syphilis,
are never confounded with felons ; they have separate hospitals.
The insane alone, who often are the victims of the most noble feel-
ings, experience less attention.

The thing which strikes me as the most shocking and abomi-
nable is, that the villains who have disturbed the peace of society
live in palaces, have an airing, sometimes a play-ground, have
often the whole building, even their place of worship, warmed, fresh
water in the yards, often cold and warm baths, and every thing
comfortable and clean ; while the poor insane, who want and de-
serve our pity, lie on straw and dirt, exposed to all vicissitudes of
season and weather, reduced to the mercy of the turnkey, and
less attended to than a horse or a wild beast. No one who can
contribute to the abolition of such abominations ought to be in-
active. It is not less the duty of a Christian to relieve the suf-
ferings of his countrymen and fellow-citizens, who according to Dr.
Latham^s testimony are rejected as burthens, than those of ne-
groes, who, on account of their usefulness, at least are taken care
of like animals. If any one find this passage a digression on my
side, I beg him, instead of examining the reports, to visit the in-
sane of Europe, in public and private establishments, wherever he
can meet them, and I am convinced he will not treat professedly
on insanity without an emotion of horror.*

* Europe is not alone in this guilt, as may be seen from the subjoined ex-
tract from the Second Report of the ' Prison Discipline Society.'

* In Massachusetts, by an examination made with care, about thirty lunatics
have been found in prison. In one prison were found three ; in another five ;
in another six, and in another ten. It is a source of great complaint with the
sheriffs and jailors, that they must receive such persons, because they have no
suitable accommodations for them. Of those, last mentioned, one was found
in an apartment in which he has been nine years. He had a wreath of rags
round his body, and another round his neck. This was all his clothing. He

MORAL TREATMENT. 161

Principal requisites of a madhouse.

The want of better establishments for the insane is felt by all
those who take interest in the condition of these helpless beings.
But who shall make the plan ? Who shall decide on its adop-
tion ? The architect, who is fond of his art, and likes to display
architectural beauties, fine columns, and external decorations?

had no bed, chair or bench. Two or three rough plank were strewed around
the room ; . a heap of filthy straw, like the nest of swine, was in the corner. He
had built a bird's nest of mud in the iron grate of his den. Connected with hi3
wretched apartment was a dark dungeon, having no orifice for the admission
of light, heat, or air, except the iron door, about 2 1-2 feet square, opening into
it from the prison,'

' The other lunatics in the same prison were scattered about in dififerent
apartments with thieves and murderers, and persons under arrest, but not yet
convicted of guilt.'

' In the prison of five lunatics, they were confined in separate cells, which
were almost dark dungeons. It was difficult, after the door was open to see
them distinctly. The ventilation was so incomplete that more than one person
on entering them has found the air so fetid as to produce nauseousness and
almost vomiting. The old straw on which they were laid, and their filthy gar-
ments were such as to make their insanity more hopeless, and at one time it
was not considered within the province of the physician's department to ex-
amine particularly the condition of the lunatics, in these circumstances any
improvement of their minds could hardly be expected. Instead of having three
out of four restored to reason, as is the fact in some of the favored Lunatic
Asylums, it is to be feared that, in these circumstances, some, who might
otherwise be restored, would become incurable, and that others might lose their
lives, to say nothing of present suffering.'

' In the prison in which were six lunatics, their condition Avas less wretched.
But tliey were sometimes an annoyance, and sometimes a sport to the con-
victs ; and even the apartment, in which the females were confined, opened
into the yard of the men ; and there was an injurious interchange of obscenity
and profanencss between them, which was not restrained by the presence of
the keeper.'

' In the prison, or House of Correction, so called, in which were ten luna-
tics, two were found about seventy years of age, a male and female, in the same
apartment of an upper story. The female was lying on a heap of straw under
a broken window. The snow in a severe storm, was beating through the win-
dow, and lay upon the straw around her withered body which was partially
covered with a few filthy and tattered garments. The man was lying in the

21

162 INSANITY.

or he who is ignorant of the human mind in its state of health and
disease ? or medical men, who have paid peculiar attention to
insanity ?

Any hospital whatever ought to be adapted to its purpose, and
placed in a healthy situation. With that view I dare propose
some ideas, as I have conceived them from numerous observa-
tions. I declare not beautiful architecture, not fine columns, su-
perb staircases, lofty domes, external decorations, magnificent
committee rooms, to which my attention has often been called
when I visited public establishments, but quite other requisites of
a madhouse, seem to me the most essential. I shall divide them
into two parts : in the first I shall consider the requisites in rela-
tion to architecture ; and in the second, those of internal manage-
ment, or moral treatment.*

corner of the room in a similar situation, except that he was less exposed to
the storm. The former had been in this apartment six, and the latter twenty-
one years.'

* Another lunatic, in the same prison was found in a plank apartment of the
first story, where he had been eight years. During this time he had never left
the room but twice. The door of this apartment had not been opened in eigh-
teen months. The food was furnished through a small orifice in the door. The
room was warmed by no fire ; and still the woman of the house said ' he had
never froze.^ As he was seen through the orifice in the door, the first question
was, ' is that a human being ?' The hair was gone from one side of his head,
and his eyes were like balls of fire.'

' In the cellar of the same prison were five lunatics. The windows of this
cellar were no defence against the storm, and, as might be supposed, the wo-
man of the house said, ' we have a sight to do to keep them from freezing.^ There
was no fire in this cellar which could be felt by four of the lunatics. One of
the five had a little fire of turf in an apartment of the cellar by himself. She
was, however, infuriate, if any one came near her. This woman was com-
mitted to this cellar seventeen years ago. The apartments are about 6 feet by
8. They are made of coarse plank and have an orifice in the door for the ad-
mission of light and air, about 6 inches by 4. The darkness was such in two of
these apartments, that nothing could be seen by looking through the orifice in
the door. At the same time there was a poor lunatic in each. A man who
has grown old was committed to one of them in 1810, and had lived in it seven-
teen years.'

' An emaciated female was found in a similar apartment, in the dark, with-
out fire, almost without covering, where she had been nearly two years.'

* The Practical Hints of Samuel Tuke, on the Construction and Economy

MORAL TREATMENT. _ 163

As every hospital ought to be appropriated to its purpose, I can-
not agree that only one sort of building is to be erected. In-
sanity is incurable and curable ; both sorts of patients require in
many respects a different treatment. Their hospitals then ought
to be different also. Many arrangements necessary for curable
patients are quite superfluous for incurable idiots and fatuous, who
make up the greater number of insane in many houses, because
they remain for life. A building which shelters them against
the inconveniences of season and weather is sufficient ; to treat
them with humanity, to provide for theii; natural wants, and secure
them against any injury, is all that we can do ; and if they are
considered as a department of the poorhouses, they should not
become an annoyance of the other poor. It is, however, not my
intention to detail their estabhshments : I remark only that in such
departments some divisions must be made, because some are clean,
others dirty ; some cheerful and innoxious, others mischievous ;
some incapable of doing any thing, others only partial idiots, and
fit for manual labor, so that they could plant and cultivate the
vegetables which they and others eat. Thus, the incurable and
curable ought to be separated, and confined to different institu-
tions. The curable again require two sorts of establishments, one
for the patients under treatment, and the other for convalescents.
I shall first speak of an hospital, for curable insane, and then of
that for convalescents.

Architectural requisites of an hospital for curable insane.

I shall treat of these requisites in the order as I think them
most important.

] . Healthy situation.

I have already mentioned the faults which I have observed with
respect to the situation of some public institutions. It is obvious

of Pauper Lunatic Asylums deserve the attention and consideratioH of those
who can contribute to the amelioration of the unfortunate insane.

164 INSANITY.

that they ought to be avoided ; and the idea is so striking to the
senses, that it is sufficient to call the attention to the subject. I
should propose to erect such hospitals in the neighborhood of
places where the medical schools exist, in order to give oppor-
tunity to medical pupils to become acquainted with this important
branch of medicine. 9

2. An ample space, and proper distributions.

This is an indispensable condition of such an establishment.
It seems to me there is no occasion for palaces, to waste the
funds, and to prevent the patients from being taken in. I am
sorry to read, that a building, calculated for thirty patients, costs
eight thousand pounds, and that on that account the governors are
obliged to confess their want of money, and to announce to the
public, that they cannot admit patients from the lower classes of
society on moderate terms. A building which costs a hundred
thousand pounds is of less use than another might be which would
cost half the sum, if the other half was expended in the purchase
of fields surrounding it. To what purpose does ostentation with
respect to walls, columns, and other architectural beauties, lead I
The means of curing the patients ought to be first attended to : hence
a convenient and sufficiently large place is to be surrounded with a
wall ; proper divisions and subdivisions of the patients are to be
made, and proper buildings to be erected ; large airing grounds,
large fields, and places for various occupations, to be looked for.

I have mentioned the reasons why buildings surrounding an
interior space are to be avoided. I am also hostile to high
buildings because it is troublesome to bring the patients from the
third or fourth floor down to the airing grounds. Keepers will
easily excuse their negligence, and the patients themselves will
often dislike to go down ; while being on a level with the airing
ground, they will enjoy the free air at every fine moment. Our
buildings are commonly erected according to one general plan.
At the airing ground one patient perhaps might escape over a

MORAL TREATMENT. 165

wall of middling height ; hence we make enclosures which look
like fortresses, and prevent the free communication of air.
There are some furious patients ; hence the most timid are also
confined between thick walls and behind iron doors. Why do
we not construct different sorts of cells, and make a proper division
of the patients ?

As the separation of the patients is indispensably necessary, the
buildings must be constructed accordingly. All other hospitals
have divisions ; there are medical and surgical wards : those with
itch and syphilis are separated from the others, in order to prevent
infection, and mutual harm. It is, however, certain that clean,
dirty, noisy, furious, and melancholy patients, together, prevent
the cure of each other. It seems to me that the division of the
insane is more necessary than of all other patients. There are
some furious, who require stronger cells than tigers, but simple
cells will be sufficient for the majority of patients. It is an
obvious rule to remove the furious, noisy, and dirty patients from
the others. Their airing grounds ought to be outward, and in a
direction opposite to the other divisions. Airing grounds, however,
are to be provided for them, because it is extremely rare that
an individual must be constantly confined to his cell. The
greatest number of those who are troublesome, noisy, and dirty,
are able to walk with some precaution and proper means of
coercion, and walking in free air will undoubtedly contribute to
their recovery.

The department of harmless, quiet, and melancholic patients,
requires a different arrangement ; the common airing grounds are
not sufficient. Open fields, agreeable sceneries, adjoining
gardens, large places to engage them in horticulture and agricul-
ture, are preferable. The temples in Egypt, dedicated to
Saturn, have shown what may be effected on melancholy by
moral treatment. Without favoring superstition, we ought not
to neglect the beneficial use of natural means. Almost all are
fit for one or the other occupation. Distributions of that kind
ought to be attended to. Large day-rooms, where many patients

166 INSANITY.

are crowded together, are often cause of great disorders, and
mutual vexations. The proper classification and separation of the
insane patients will obviate inconveniences of that kind. In
small associations the patients become more attached to each
other. The communication of the departments, and the easy
transmission from one room to another must not be overlooked.
I have given such a plan of an hospital as I consider the best for
curable insane. (PI. III.) The details may be seen in the
explanation of the figures.

3. Regulation of air and light.

The influence of air and light on inorganic and organic beings
is too well known to require any elucidation. From ancient
times air has been called pahulmn mice ; but from modern dis-
coveries we have learnt to understand its nature and varieties.
Every morning we experience that light awakens the activity of
the mind. The architect then must take into consideration these
conditions of health, and procure means for regulating them. In
any large hospital, where many patients live together, the air
becomes noxious, and ventilation necessary. In every cell there
ought to be two openings, one communicating with the external
free air, and one with the gallery. Both must be fitted to be
opened or shut as it is required. The ventilation from without
may take place at the upper end of the wall by means of
windows and shutters. These then must be fitted so that each
can be shut up, or let down, or placed in any position. The
opening into the gallery must be arranged so that it can be shut or
opened from without, and withdrawn from the reach of the
patient. In short, the construction of the building and the cells
must be such, that the admission of air and light can be regulated.

MORAL TREATMENT. 167

4. Regulation of tem'perature.

When shall we abandon the unpardonable error, which prevails
in all institutions of mankind, viz. to take one individual as a pro-
totype for all ? There are insane people, who can bear cold
with great impunity ; others are insensible to cold, though their
health suffers from it ; and again others complain of heat, and
cold is beneficial to them. Ignorance and idleness immediately
say, madmen do not want the enlivening power of heat. We
see, however, the majority anxious to come as near the fire as
possible ; and medical men of such institutions know that many
suffer in consequence of cold ; that even mortifications, or gan-
grenous sores of the lower extremities, and lameness for life, are
frequent complaints. I have often witnessed criminal neglect in
such establishments with respect to temperature. More than
once 1 have found the poor creatures, in the depth of winter, on
the ground floor without fire, contracted and shivering. I know
and acknowledge the influence of habit, but it has its limits. A
delicate plant can never be treated as a robust tree. Thus as
the majority of insane require warmth, the architect must think
of means to regulate the temperature. I dislike the idea of
making a fire only in the sitting rooms at the extremity of the
gallery. Where warmth is useful, the interior of the house, gal-
lery and cells, ought to be warmed by means of flues and heated
air. A few cells might be left without being warm. Only in
these, and in the cells of dirty patients, the floor ought to be
paved with flagstones.

5. Cleanliness.

Cleanliness is a great comfort, and is absolutely necessary to
health, and to the cure of patients ; but in an hospital for insane
many circumstances are opposed to it. Hence the architect
must pay a peculiar attention to furnish the means which depend
on the building. It is obvious that the dirty patients must be

168 INSANITY.

kept in a separate division. Cells and beds must be arranged, so
that they may be easily cleaned ; the bottoms of the beds ought
to have holes to let the urine pass, which may be received by
some contrivance under it, which could be taken away, emptied,
cleaned, and replaced. The floor of the cells might be inclined
towards the door. A sufficient quantity of water ought to be
provided over the whole house. The privies for those who can
make use of them must be constructed and situated so that they
do not incommode by the smell, or infect the air of the gallery
and cells. For patients who cannot leave their cells, an appa-
ratus must be provided within.

6. Means of occupying the patients.

The necessity of occupying the patients is generally felt ; and
it is inconceivable why so little attention is paid to it in the
erection of hospitals for insane. I shall detail the advantages of
occupation, in treating of the internal management. Here I call
the attention of architects to such a distribution of buildings, that
proper places are assigned to that purpose. I have already men-
tioned that the common airing grounds are not sufficiently exten-
sive for harmless patients, but that large fields, gardens, places
for manual labors, playing grounds, long walks, ought to be pre-
pared.

7. Economical concerns.

Dietetic and medical care require places for cold and warm
baths, a shower-bath, a swing, a place for the dead and their
examination, an apothecary and laboratory. The household affairs
need the attention of the architect with respect to kitchen,
wash-house, drying-room, store-house, pantry, straw-room, coal-
room, lodging of the steward and matron, bed-rooms of the other
attendants, all necessary accommodations, and also a committee-
room.

These general ideas may be sufficient to call the attention of

MORAL TREATMENT. 169

those who direct madhouses, to the architectural requisites of an
hospital for curable insane. There remains still to speak of the
department for convalescents.

Department for convalescents »

Convalescents ought to be separated from tiie patients under
curative treatment. Their habitation requires less care as to di-
vision ; the internal management may be more general. Beside
the general requisites of any hospital, such as healthy situation,
regulation of temperature, air and light, and cleanliness, the most
important part is to provide for the occupation of the patients.
They ought to form a large family, and not one ought to be idle.
Those whose natural dispositions and situation in the world per-
mit mental occupations, may attend to the most suitable objects.
Others, who are only fit for manual labors, may be employed in
those sorts of occupations, to which they have been accustomed.
More details will be mentioned where I treat of the internal man-
agement. The house for convalescents may be in the neighbor-
hood of the division for harmless patients, so that from their en-
closure they might be immediately removed to the department
for convalescents.

In this manner the expenses of the establishment must increase ;
but I am convinced with Dr. Hallaran* that the expenditure of
suitable buildings, and the purchase of such implements of hus-
bandry as may be required to carry on the work, is the only ex-
pense. As to the rest, a moderate and well regulated labor of all
barmless patients and convalescents, ' fed and clothed as they still
must be, will clear the current expenses and all incidental charges
of a large farm.' Moreover the curative means, the comfort and
improved situation of the patients, which necessarily will be the
result of such a treatment, cannot be looked upon with indiffer-
ence. Few are actually cured ; and many, being incurable, like
other poor, live at the expenses of their parishes. A small sum

* On Insanity, p. 109.

22

170 ^ INSANITY.

furnished for the purchase of such fields will save a much larger^
which is annually consumed by the incurable. I have joined a
plan of a house lor convalescents. (PL IV.) The explanation
of the figures gives the details.

From the preceding considerations it results that, in my opinion^
an architect has only to execute the peculiar requisites, while the
plan of an hospital for insane must be dictated by those who un-
derstand the wants of the patients.

Internal management of an hospital for the curable insane.

Far the greatest number of medical men, and those who take
care of insane persons, place the greatest confidence in what is
called moral treatment. This treatment being employed exclu-
sively, it seems the more singular, as it constantly proves itself
erroneous. Even the common behavior towards such unhappy
beings cannot be termed rational. .1 beg to think only of the
neglect of separating the diiFerent patients, or of their classification
according to the payments made by their friends. The objects^
of the internal management are the reception and distribution of
the patients, cleanliness, temperature, diet, coercion, and occu-
pation. I shall mention what I think the best ; but I am well aware
that the most essential point is to put good rules into effect. I
have often found that ' what is the best administered is the best.'
I have seen abundant means, and very little use made of them ;.
and sometimes much was done by small means. An inferior plan
well executed is more beneficial than a better system under neg-
ligent management. 1 shall speak of several points worth the at-
tention of managers and inspectors of such establishments.

1 . Reception of patients^

As t speak of an hospital for curable insane, it is understood
that idiots, fatuous, epileptics, and paralytics, are excluded from
such an establishment. Then the first question is, under what

MORAL TREATMENT. 171

circumstances curable patients can be received ? If payment be
the principal condition, the interest of the establishment must be
secured before the patient can be taken in. Moreover, as abuses
may easily take place, and innocent persons be confined as insane,
the government takes care of the individuals, and orders that the
insane state of the patient be ascertained by the certificate of a
medical man and witnesses. The question arises, whether the
law shall prevent the reception of a patient till all formalities be
fulfilled ? In my plan for curable patients I place the cure above
every other consideration ; and in that view I wish it to be
judged of.

No human arrangement will ever be without imperfections ;
that which presents the least is the best. The following error,
however, seems to be obvious. In a great asylum for insane at
London, where those who can afford to pay must do it, or the
parishes for them, but where also poor are admitted, the patient
must first send in a certificate signed by any medical man and two
witnesses with the petition. Certificate and pethion are then laid
before the committee, who sit once a week, and order that as
soon as there is a vacancy the patient should be brought in, view-
ed, and examined by them and the physician, and then to be ad-
mitted, if a proper object. For my profession's sake, I was
ashamed to read the report that the patient could not be admitted
' if he be not strong enough to undergo a course of physic ; ' that
is, could not bear to be bled, vomited, and purged, according to
the season and weather. vSuch a regulation, and its interpretation,
I hope will be abolished for ever.

Anxious respecting the gradual improvement of our knowledge
of the deranged manifestations of the mind, and respecting ihe
fate of insane people, I take the liberty of submitting a few remarks
to the consideration of those who can contribute to a better regu-
lation of madhouses. The bill, as it stands, will certainly ameli-
orate the condition of these helpless creatures. Its tendency,
however, seems rather to prevent the most degrading abuses, than
tluly to regulate the treatment of insane persons.

172 INSANITY.

The bill states that, in London, and within seven miles, without
a certificate in writing under the hands of two fellows or hcentiates
of the College of Physicians, or members of the College of Sur-
geons, or members of the Company of Apothecaries in London ;
and, in other parts of Great Britain, without a certificate in writing
under the hand of some physician, surgeon, or apothecary prac-
tising as such, no keeper or keepers of a. madhouse can confine a
person longer than forty-eight hours.

In this respect I repeat what I have mentioned in the section on
the definition of insanity, that the complicated nature of the human
mind, the various conditions of its manifestations, and our imper-
fect knowledge as to its operations, make the examination of its
derangements extremely difficult, and the decision upon certain
cases almost impossible ; that few medical men make insanity an
object of their study ; that the attention of medical students is
never called to this branch of their art, not to say that in any pro-
fession there are individuals without a sufficient degree of skillj
nay, without probity and moral principles. Hence not every one
who knows how to compose some prescriptions ought to be en-
trusted with the privilege of disposing of the liberty of his fellow-
citizens.

The regulation as proposed overlooks another difficulty ; viz.
that insanity is acute or chronic, and often intermittent. Some
fits of insanity, like other diseases, require prompt assistance.
A patient, for instance, may have fits of the propensity to suicide,
or to kill others, which make speedy confinement necessary ; but
before the medical man has time to examine the patient, the fit
may be over, and the person may appear sane and conceal his
state with great cunning. Shall he then under such circumstances
be left at liberty, while in a new fit he may produce great mis-
chief?

The bill orders, that the physician, surgeon, or apothecary,
shall not give a certificate without having carefully visited and
examined the person in relation to whom the certificate is given,
and without having ascertained, by such examination, that sucli

MORAL TREATMENT. 173

person is, to the best of his judgment, a lunatic, and proper to be
confined in the house for the reception of lunatics. But it re-
quires often long time and daily observations, before the insane
state of a person can be ascertained. The physician very often
cannot have the least confidence in the account which the patient
gives of himself, or even in the aspect which he artfully assumes.
How then, in the mean while, shall the patient be disposed of?

To obviate these difficulties, it would seem proper, 1st, that the
oath of two relatives or respectable witnesses should alone be
necessary to obtain the reception of an insane person into a mad-
house ; 2dly, that within twenty-four hours every person confined
in any house for insane persons should be reported to the magistrate
of his county, or to the authorized commissioners, by the medical
man attending the house ; and 3dly, that where the case in his
opinion is doubtful, there should, within forty-eight hours, take
place, before the magistrate or the commissioners, a personal ex-
amination of those upon whose call the patient was committed.

It must be admitted, that unfrequent visits are seldom sufficient
to decide on insanity ; hence it seems to me that every estab-
lishment for insane ought to be attended regularly by a medical
man of acknowledged skill in sanity, and of moral probity. Be-
ing answerable for his opinion, he will try to ascertain the state of
the confined person, and being obliged to make daily visits, he
may be able to do so. In case of doubt, information being given
to the magistrate, juridical investigation may be made, and farther
medical advice may be taken. In public hospitals, such a pro-
ceeding will prove of great value to the patient, and less improper
conduct can be suspected, than if every medical man have a right
to declare a person insane. Greater precaution is necessary, if
a medical man keep a madhouse, and derive emolument from his
patients. Even then, however, he will be controlled, by being
obliged, like other keepers, to intimate within twenty-four hours
the admission of any individual into the establishment.

Various considerations, respecting this branch of legislation,
may be made. I will mention some which immediately concern

174 INSANITY.

the healing art. To improve our knowledge of insanity, the law
might assist the medical profession in procuring means of judging
of insane persons. As the physician often cannot have the least
confidence in the account which the patient gives of himself, the
clergyman of the parish, or of the congregation^ who is supposed
to know his flock, has the best opportunity to furnish the evidence*
He should be obliged to particularise certain points concerning
the cause of the disease ; whether, for instance, other individuals
in the family were affected with nervous disorders or insanity 5
whether the patient was subject to any, and to what disease;
what his manner of living was ; what his occupations, &ic. were.
The physicians, appointed to such establishments, ought to make
the best use of every opportunity. They ought to publish an
annual report of the number, age, and sex of the patients, their
diseases, outlines of the treatment, the event, and, in case of
death, the appearances in the brain and abdomen. Exact casts
in plaster ought to be taken from the heads of all those with par-
tial hallucinations, of those, for instance, who are insane by pride,
or vanity, or religion, fear, &c. The money laid out for such a
purpose will be a great means of improving our knowledge, and to
the patient of greater use than external decorations of the house.

There are still other reasons which prevent me from approving
of the regulation, that houses which contain a hundred patients
and upwards shall alone be visited daily, or at least twice a week,
by a medical man. Does not every insane person deserve
assistance and protection. I can even easily conceive that in a
house containing a small number, there may be individuals more
important to their families or to society at large, than the hundreds
contained in others. Assuredly every curable patient ought to
be visited every day, especially if the disease be of an acute
nature. Such patients may be sent in every day, their restoration
to health may depend on speedy assistance ; and the disease,
when protracted, may produce incurable alteration in the organi-
zation.

As the greatest confidence is placed in the moral treatment of

MORAL TREATMEINT. 175

insanity, it is obvious that the rules with respect to the distribution
of the patients, to cleanliness, temperature, diet, coercion, and
occupation, are to be modified by those who ought to understand
most the influence of the body on the manifestations of the mind.
The medical profession establishes dietetic rules ; it ought to
direct also the modified applications. On account of their im-
portance, I shall consider these various points of moral treatment.

Classification of patients.

This point ought to be remitted to the physician, as he finds it
conducive to the cure. He will separate the noisy and dirty, will
bring cheerful and gloomy together, exhilarate or temperate one
by the other ; in short, will modify their situation according to
their individual characters. Some are more noisy when alone,
others in society. It follows, the physician of the insane ought
to know more than to bleed and purge ; and that daily visits are
required.

Cleanliness, air, and light.

The regulation of these points belongs to the treatment ; and
the physician, visiting the patients every day, will take care of
them. If sufficient means and accommodations are furnished,
the trouble will be less, and the neglect the more unpardonable.
The disagreeable smell will be only in the cells of the most dirty
patients ; the suffocating stench, which sometimes pervades the
whole asylum so as to excite nausea and vomiting, will no longer
exist under daily inspection. The patients will no more be confined
for weeks in dark cells ; they will breathe fresh air, and will be no
longer suffocated in the effluvia of their own bodies. Dyspnoea,
cachexy, and scurvy, will become rarer in such institutions. To
the impressions of light, which must be modified according to the
irritability and bodily constitution of the patient, as is the case in
other diseases, better attention will be paid ; the physician will

176 INSANITY.

remember that in fearful patients, with irritable senses, all symp-
toms are aggravated by darkness ; while it may be useful to rest-
less and sleepless individuals. He will not overlook either the
passage from long darkness to light ; or cleanliness with respect
to beds, cells, and galleries; or the influence of washing and
cleaning the patients every morning, &:c.

Temperature.

There are many examples upon record of insane who like
cold, and resist the strongest frost. Pinel m^entions the history of
a maniac, who during the winter sat up whole nights in his
chamber, with no other covering than his shirt; and no sooner
was the door opened in the morning, than he ran in that condition
to the interior court of the hospital, where he seized a handful of
snow and applied it to, and left it to melt on, his naked bosom.
This seemed to give him great delight and satisfaction. But
such a propensity for applying, and the capacity of resisting the
effects of, cold, are by no means general. There are many who
are severely affected by cold. In the winter it is common to see
the patients crowded about the fire.

Indeed, various fatal accidents from cold at the extremities
may be observed. Pinel states that, in cold weather, there is the
greatest danger for those who lie motionless in the bed with weak
and depressed pulse. He mentions that such patients, at the
commencement of the winter, have been found dead in the bed.
Dr. Hallaran* observes, that ' insane people, during a tedious
confinement, if not kept carefully and warmly covered, and made
to extend their limbs in the bed, will acquire the habit of con-
tracting their limbs together for the sake of warmth.' He
mentions that there is sometimes an extreme degree of muscular
debility, which very often degenerates into a rigidity of fibres,
sometimes in a curvature of the spine and a total inability to extend

* Lib. cit. p. 99.

MORAL TREATMENT. 177

the lower extremities. I have met several individuals of that
kind at different places.

The condition of the skin is of importance in any disease, and
not a matter of indifference in the treatment of insanity. The
physician then will take care that the patients are comfortable
as to temperature in their abodes. To that purpose the architect
has provided means of artificial heat. Clothing and covering are
not to be overlooked.

DieU

It seems to me that the diet of the insane is not sufficiently un-
derstood, nor the articles of food sufficiently attended to ; yet their
importance in all acute and chronic diseases is obvious. Com-
monly all are nourished out of the same kettle. Sometimes I
have found the improper practice of deluging the stomach with
warm, thin fluids, in the form of tea or ptisan, which impair the
stomach, and produce flatulency. To give the same sort of food
to all insane persons is to allow that we do not believe in their
corporeal disease, nor in the constitutional varieties of the stomach.
It is the more surprising that, in institutions where the medical
men consider insanity as the result of corporeal causes, the same
character of diet is indiscriminately applied to all forms and varie-
ties of this afflicting disease. On Mondays for breakfast, a large
bason of water-gruel with two ounces of bread in it 5 for dinner
they have a quart of milk porridge, seven ounces of bread, two
ounces of cheese, and a quart of beer ; for supper they have
seven ounces of bread, and the same quantity of cheese. This
is the diet on a meagre day, of which there are four in the week.
The other three are meat days. Then they have for breakfast
water-gruel and bread ; for dinner eight ounces of meat after being
dressed, seven ounces of bread, about a pound of potatoes, and a
quart of table beer, &ic. At the same time it is said, that for the
sick the apothecary orders what he thinks fit.

The only excuse for such a mode of proceeding is, that incu-
23

178 INSANITY,

rable and curable patients are together in the establishnaents, and
that the former make out the greater number. In an hospital for
curable only, such a degree of ignorance should be unpardonable.
In such an institution as that which I propose, it cannot be tolerat-
ed any more than in an hospital for other patients. In every
point, insane persons are the worst treated. For other patients
the diet is adapted to the disease ; but the poor insane are not
considered as sick, and even those who are treated as sick, must
submit to the general prescription. Because there are patients
who require the lowering diet, and often support the extremes of
hunger, the diet in general must, it is said, be lowering. We
have seen that, in many cases, melancholy is the same disease as
hystery and hypochondria. Such individuals are known to have
commonly weak digestive organs ; and if no medical man pre-
scribe milk, cheese, light beer in hysteria and hypochondria, why
is it done in melancholy ? In certain cases, animal diet is too
stimulating and nutritious; and it would rather increase than di-
minish insanity : but are now all patients to be reduced indis-
criminately to vegetable diet ? And as in apathy of the digestive
organs, animal food is more salutary than vegetables, shall there-
fore the general diet consist of meat ? It evidently results, that
the diet must be modified, and that bleeding and purging are not
the only indications to be observed. I say this, because I have
seen that a patient, who was bled the day before, got his cheese
in the evening, which he vomited during the night indigested, and
then he was purged. Such a treatment would, indeed, deserve
retaliation.

There are very few to whom an indiscriminate diet will do no
harm ; and not only the quantity, but also the quality of the ali-
ments require our attention. Moreover, even the time when food
is to be taken is of importance, and many modifications are to be
admitted. The diet ought to be ordered every day by the physi-
cian as in other diseases, and adapted to the state of the patient
and of his digestive organs, which vary according to tempera-
ment, age, previous manner of living, and particular idiosyncrasies-

MORAL TREATMENT. 179

The quantity must be sufEcienl, but there can be no general
measurement. Some need a great quantity of food, and languish
even to fainting from want or deficiency of nourishment. Low
diet ought not to be confounded with a diet nearly approaching to
starvation. Pinel describes the greater mortality in the asylum of
Eicetre, before and at the beginning of the French revolution, to
the insufficiency of food, which, says he, when it does not alto-
gether extinguish the vital principle, is not a litde calculated to
exasperate and to prolong the disease. If in protracted paroxysm
and general weakness, the lowering diet be continued, fatuity is
often the consequence. Hence at the more advanced period of
convalescence, and under the common appearance of debility,
arising either from age, or the protraction of the disease, the ne-
cessity of allowing a gradual indulgence of animal food must be
obvious ; and where this has been found admissible in a progres-
sive degree, it has afforded one of th^e best securities ; for when-
ever convalescents acquire corpulency from good nourishment,
there is great hope of recovery.

Every kind of food ought to be easy of digestion. Here again
the peculiar constitution of the patients deserves a particular atten-
tion. Some persons digest fruit very well, in others it produces
jSatulency, a sign of indigestibleness. With some patients animal
diet will agree better, with others vegetables ; and the same thing
may be agreeable or disagreeable to the same patient at different
periods. Insane persons, liable to fits, sometimes, a few days be-
fore the paroxysm, refuse animal food. A great deal depends on
the previous habits and manner of living. Drunkards often dislike
vegetable diet ; very sober individuals, however, may also prefer
animal food. All kinds of aliments, which occasion flatulencies,
ought to be avoided or withdrawn from individuals with whom
they disagree.

With respect to the time when the aliments are to be given, it
seems to me that it is better to give food oftener and less at a time,
than much and seldom ; particularly if the digestive organs be

180 INSANITY.

weak. In many cases of the aged and more infirm patients, in
the state of convalescence, particular allowances are to be made.

Dr. Hallaran, of Cork, mentions a singular abuse as to diet,
and he is right in blaming it : that at certain seasons of the year,
the insane participate in the general festivity of the city ; he has
observed, that such an unusual stimulus in food or drink never
fails to aggravate the symptoms. Such a rule shows general be-
nevolence in the managers, but this exalted feeling is here misap-
plied, and ought to be corrected.

Thus, the diet must be conformable to the general curative plan
of insane persons. If the whole treatment is antiphlogistic or
lowering, the diet must be similar ; if the curative plan be tonicy
the diet must correspond; and if at the same time tonics combined
with aperients are indicated, the diet ought not to be in opposition.

Coercion c

Coercion forms a material part of, and is intimately connected
with, the general treatment of insanity. In this point the abuses
are enormous. Pinel calls the asylums for insane medical prisons ;
and says that he cannot speak without horror of the barbarous
methods which are employed for the repression of maniacs. I
think, in certain countries, these institutions are infinitely worse
than prisons ; and the treatment of the insane more inhuman than
that of wild beasts. Such unhappy creatures have been, and
sometimes still are, flogged and exposed to personal indignity. I
have seen them chained to the stone floor, to sleep on straw, cov-
ered with vermin and filth.

It is evident that there is no occasion for confinement or per-
sonal coercion, if the feelings of insane persons are innoxious.
Personal coercion is only necessary, and only justifiable, in pre-'
venting the patients from doing mischief to themselves and others.
Coercion must be considered only as protecting and salutary re-
straint. When it is become absolutely necessary, it must be ap-
plied without silly coaxing or vague insinuations, but with human-

MORAL TREATMENT. , 181

ity and firmness, and as little noise as possible. Strong coercive
measures are seldom necessary ; but there are patients perfectly
unmanageable without bodily restraint, and different means of
security must be allowed.

The essential point is to understand the different means of
coercion which different patients require. It is a very convenient
mode for the keeper to iron every one who is a little troublesome ;
but there can be no doubt that, in many cases of irritable patients,
such a coercion injures the health of body and mind. Pinelsays,
' a method of treatment, simple enough in its application, but
highly calculated to render the disease incurable, has been adopt-
ed from time immemorial, that of abandoning the patient to his
melancholy fate as an untameable being, to be immured in solitary
durance, loaded with chains, or otherwise treated with extreme
severity, until the natural close of a life so wretched shall rescue
him from his misery, and convey him from the cells of the mad-
house to the chamber of the grave. But this treatment, conve-
nient indeed to a governor, more remarkable for his indolence and
ignorance than for his prudence and humanity, deserves at the
present day to be held up to public execration, and classed with
the other prejudices which have degraded the character and pre-
tensions of the human species.'

There was a time when it was a general opinion, and there
are still persons and practitioners so ignorant as to fancy, that the
insane ought to fear, and that stripes and blows are the best means
of effectuating a permanent impression. Corporeal punishment
was, and sometimes still is, recommended even by medical au-
thority, with a view of rendering insane people rational by impress-
ing terror. This is, however, not only cruel and against Christian
charity, in cases where the patients are partially deprived of under-
standing, but it is even absurd. Indeed, experience has shown
the greater efficacy of milder methods of treatment. The most
tender method generally produces the best effect ; and in coercion
the mildest possible means ought to be adopted. No corporeal
punishment, as stripes and blows, no resentment, no return of

182 INSANITY.

injury, is to be allowed ; and unnecessary severity ought to be
punished as criminal. No deception ought to be permitted ; but
a confidential behavior and firm authority are to be observed.

Sometimes it will be sufficient to confine a patient to a solitary
cell, and to show him that he has some superior who can control
him. In many cases it will create a tacit acquiescence ; but,
unfortunately, there are insane to be met with where the possi-
bility of gaining such an ascendency is out of the question, and
more restraint is necessary. Dr. Hallaran has invented a kind of
belt of leather round the body, with straps to confine the arms.
It is a milder means in hot weather ; the fore arms are free. In
cold weather the strait waistcoat is an admirable contrivance ; in
the hot season manacles may be preferred. Chaining to the
walls, or bolting fast into a chair, from which they cannot move,
seems to me in most cases improper. Confinement by means of
a chair may be useful, if there be a strong impetus of blood to the
brain. This position also favors the application of cold water and
ice to the head, warm water to the feet and enables the surgeon
to bleed without any trouble. Dr. Hallaran praises the swing as
a means of coercion. Sometimes, in the most violent fits of
young and powerful maniacs, chains may be necessary ; but it
ought to be a fixed rule to employ coercion no more, and no
longer, than personal safety requires. Every cause of irritation
ought to be avoided.

There is never, perhaps, occasion to keep a man under close
confinement for months ; but an individual, being furious for a
few days, is fettered for years. I have seen several cases of that
kind. Unnecessary confinement, however, interferes with the
cure ; and a continued coercion is calculated to make a man lose
his reason rather than to restore a madman to his senses. Pinel
says, ' When the furious and extravagant madmen are continually
chained down in their cells, as they were when I entered on the
duties at Bicetre, they were incessantly and ravingly agitated ;
cries, howlings, and tumults echoed, at all hours, throughout the
melancholy mansion. But since the strait waistcoat has been

MORAL TREATMENT. 183

substituted for chains, and limited liberty for absolute confine-
mentj there is more calmness and tranquillity.' If in a moment
of indulgence mischief be committed, no other means should be
used than those which are necessary to prevent the patient from
repeating it.

In cases where patients are bent on starving themselves, or
where thev resist the introduction of remedies, Mr. Haslam has
invented a simple instrument, of which a drawing is given in his
work on Insanity. The patient is kept secured, the nostrils shut,
the instrument introduced into the mouth, and the medicine or
liquid aliments poured into it in small quantities.

Thus, to allow every patient the latitude of personal liberty
consistent with safety, to proportion the degree of coercion to the
character of the patient, to be kind with unyielding authority, and
to proscribe absolutely all violence, ill-treatment, or partiality on
the part of the keepers, are rules of fundamental importance, and
essential to the successful treatment of the patients.

Treatment of the feelings.

Insanity particularly concerns the deranged feelings ; and, as
their functions appear often disordered in the state of heahh, it
has been said that the whole world is a madhouse. It is real
madness as soon as the will has lost its influence on the actions
of the feelings ; besides, we find in insane people the activity of
all the primitive powers of the mind, and their manifestations
modified in every individual, as is the case in the rest of mankind.
There are good and ill-tempered insane ; some are bashful ; others
do not know what is due to decency : some are morose and quarrel-
some ; others, gay and cheerful : some, being with other patients,
continually create insurrections, and persuade the patients to
commit acts of mischief; others are peaceable and obedient ; we
meet among them with noisy and quiet, cunning, stubborn, though
tender in their appearance ; distrustful, jealous, envious, vindic-
tive, irascible, or forbearing ; open, candid, and mild ; proud or

184 INSANITY.

modest ; and, in short, every variety of character. Many have
the propensity to escape; they feel uneasy, and expect to be
better somewhere else, he.

These different characters of the insane ought to be understood
by those who take care of them. They are explained in the
same manner as in the state of health. It is impossible to lay
down general rules, which are sufficiently comprehensive to meet
each circumstance which may enter and materially affect the
particular case. One must be soothed, the other threatened.
Pinel says, * The doctrine of balancing the passions of man, by
others of equal or superior force, is not less applicable to the
treatment of insane than to the science of politics. Unfortunate
then is the fate of those maniacs who are placed in hospitals for
insane where the basis of practice is routine, and where perhaps
the patients are abandoned to the savage cruelty of underlings.'

Insane people require a modified treatment, as well as children
and adults, in the state of health. It ought never to be forgotten
that, with respect to other persons, man always acts by feelings
and not by reasoning. Mr. Haslam* says, * We have a number
of patients in Bethlem Hospital whose ideas are in the most dis-
ordered state, who yet act v/ith great steadiness and propriety,
and are capable of being trusted to a considerable extent.'
Moreover, it is to be remembered that sane and insane, acting by
feelings, are guided by different motives ; that is, what is motive
for one is none for another ; and though the intellectual faculties
are deranged, he who understands the feelings will regulate the
actions. One insane will behave well by veneration; another,
by- fear ; a third will be guided by the love of approbation, often
by attention paid to his self-esteem ; many, by gentle manners
and kindness ; melancholic, anxious, and fearful patients, by the
greatest mildness. The conversation must be fitted to the various
States of mind wherein we find the patients ; for they are not
always disposed in the same manner. Derision does great harmj

^ Lib. cit. p. 299.

MORAL TREATMENT. 185

particularly in those who have much self-esteem. Such a feeling
being disdained, will be excited and excite others : on the other
hand, their haughtiness must not be coaxed ; they must be
respected, but made obedient to kind and firm authority. For
that reason persons insane by pride are seldom cured in the
bosom of their family, where they are accustomed to command.

All who have had experience in this department agree that
deception is extremely hurtful to madmen : if they detect it, they
naturally lose the confidence and respect which they ought to
entertain for the persons who treat and govern them. Dr. Halla-
ran says well, 'Maniacs, when in a state to be influenced by
moral agents,, are not to be subdued by measures of mere force ;
and he who will attempt to impose upon their credulity by aiming
at a too great refinement in address or intellect, will often find
himself detected, and treated by them with marked contempt.'

A sore or inflamed part of the body is not to be rubbed, an
inflamed muscle is not to be moved, and an inflamed eye is not
to be exposed to strong light : in the same way any feeling, being
too active or deranged, ought not to be put into action. Irritating
an angry dog or man is irritating the respective feeling. Every
object which may excite the deranged feelings must be removed.
This is the case with religious insanity, in pride, in melancholy,
and in an}^ other feeling. How injudicious is it therefore to give
books to persons insane from religion, or to let them hear
sermons, which nourish their disorders ; or to keep with melan-
cholies a conversation on the subject of their despondency !*
Persons who are susceptible of the liveliest emotions of joy or grief,
or very irritable in general, require a particular care.

Thus, the mutual influence of the faculties may be employed

* This is a most fatal error, and yet it pervades all society. If a person becomes
melancholy in the study of religion the pJajsician is not even thought of, much
less called ; the clergyman is sent for, religious matters being considered as
entirely within his province. His prescriptions are prayers and exhortations ; of
all things, in such cases, the most to be avoided. It is like the application of
friction to a wound, to allay an inflammation.

24

186 INSANITY.

as a means of curing the disordered feelings. Every irritaWe
power then is to be spared and kept quiet, while the other feelings
are to be excited. In this manner hysteria and hypochondria are
often cured by love or attachment. Hence I may say again, he
who takes care of the insane ought to understand the primitive
powers of the rnind, and the individual dispositions of the patients ;
and it is not sufficient for a physician to make his first approach
with the assumed aspect of unbridled authority. Indeed the
suitable regulation of the feelings of insane people requires
something more important than muscular strength ; a martial look,
a haughty countenance, and the assistance of keepers, manacles,
and fetters.

Treatment of the Intellectual Faculties,

In the section on the causes of insanity, I have shown that the
disorders of the manifestations of the mind are not so often the
result of the intellectual faculties as of the feelings ; and that the
activity of the intellectual faculties, combined with the feelings, is
a more fertile source of insanity than understanding alone. To
elucidate this I have mentioned the greater number of insane
among painters, poets, actors, musicians, advocates, than among
mathematicians and natural philosophers. There are, however,
cases where too great or disordered activity of the intellectual
powers produces insanity.

The question, what is the influence of understanding on insanity,
has two meanings, either whether we can become insane by
understanding, or whether we can cure insanity by reasoning.
The first question has been sufficiently detailed, where I have
treated of the idiopathic dynamic causes of insanity^ Here I
shall examine, whether reasoning may cure the deranged functions
of the mind.

Those who derive all activity of the mind, its perceptions and
feelings, from without, ought in insanity to expect the best effect
from external impressions on the senses. Our understanding

MORAL TREATMENT. 1B7

'Ought to have the greatest influence on insane persons. This
ought particularly to be the case if insanity were not the result
of a corporeal cause. All practitioners, however, who have con-
versed with insane persons, and tried to exhibit logic as a remedy
for insanity, agree that such a treatment is attended with little
success. ' An endeavor,' says Mr. Haslam, ' to convince madmen
of their errors by reasoning, is folly in those who attempt it, since
there is always in madness the firmest conviction of the truth
of what is false, and which the clearest and most circumstantial
evidence cannot remove.' At the Retreat, near York, no advan*
lage has been found to arise from reasoning with them on their
peculiar hallucinations. The attempt to refute their notions
generally irritates them, and rivets the false perception more
strongly on the mind. Dr. Hallaran states, that * it has been very
generally allowed, that the attempt to argue an insane person out
of the opinion to which he may at the moment seem to be most
attached is even worse than labor in vain. In those cases where
the difficulty is greatest, the effort on the part of the attendant is
sure to be productive of additional mischief; and it most com-
monly happens that, at such a time, the prevailing hallucination
is so intimately connected with the root of the complaint, that, in
order to modify the one, the other must be fairly eradicated : all
argument, therefore, should be carefully avoided. On the whole^
the less notice there can be taken even of the most obstinate
fancies of the insane, the less disposed will they be to retain them.
So fully satisfied am I of this, that I never think of diverting them
from their opinions, until they begin of themselves to show surprise
at their credulity. On the contrary, I make it a rule rather to
coincide with their greatest extravagancies, unless where the
delirium of fever would enjoin the strictest silence, or the dispo-
sition to commit an injury, a positive interdiction.'

There are, however, examples where reasoning has if not cured
the patient, at least changed one train of disordered manifestations.
Pinel relates the example of a very intelligent watchmaker who
became deranged, and believed that he had been guillotined,

188 INSANITY.

his head mixed with those of other victims, and that another
head had been replaced on his body ; hence that his former head
was exchanged for his actual one. He was corrected by the
representation of the miracle of St. Denis, who carried his head
under his arm, and kissed it as he went along. When the watch-
maker maintained the possibility of the fact, and endeavored to
confirm it by the appeal to his own case, a companion burst out
into a loud laugh, and said to him, 'What a fool you are ; how
could St. Denis kiss his own head ? was it with his heel ?' This
repartee struck the insane ; he returned, and never after spoke
of the misplacement of his head. Dr. Cox mentions, that one
patient asserted that he was the Holy Ghost. Another asked
him, 'Are there two Holy Ghosts? how can you be the Holy
Ghost, and I be so too ?' He appeared surprised, and after a
short pause said, 'But are you the Holy Ghost?' and when the
other replied, ' Did you not know that I was ?' he answered, ' I
did not know it before ; then I cannot be the Holy Ghost.^
Several other facts of that kind are related ; but few will give up
their opinion so easily as the patient of Dr. Cox.

I expect the least effect from reasoning, wherever strong feel-
ings are deranged. Reasoning will rather excite than diminish
them. Neither in the healthy, nor in the diseased state, has rea-
soning an influence on the existence of the feelings : these exist
independently, and reasoning cannot destroy them, any more than
it can annihilate hunger and thirst. Even in the healthy state
reasoning has an influence only on the instruments by which the
feelings act, that is, voluntary motion. Reasoning can only pre-
vent eating, while the inclination to eat continues. Moreover,
reasoning cannot take away any deranged sensation, such as,
hearing the angels sing, or the devil roar, feeling burning heat on
the skin, &;c. This observation is the more founded on nature,
that insane with deranged sensations and feelings reason often with
consistency, if we grant their sensations and feelings. If a cure
by reasoning be performed, it will be the most in conceptions or
ideas of the mind. It seems to me, however, very obvious, that

MORAL TREATMENT. 189

the cases must be extremely rare. Sane persons have often vari-
ous transitory ideas, and insane people often declare that certain
ideas are forced into their mind, and that they cannot prevent
their intrusions. Now as such ideas involuntarily present them-
selves to the mind of healthy persons ; in insane, who. believe in
the illusions, reasoning must have less effect. Moreover, few per-
sons are capable of, and still a smaller number are accustomed to,
close reasoning in the state of health ; from infancy they have ac-
quired certain habits of thinking, and never account for their opin-
ions : now what influence can we expect from their reasoning in
insanity ? In general, however, we have more power of control
over the intellectual faculties than over the feelings, because their
activity depends on the external impressions. Hence if an intel-
lectual power is too active, the respective impressions from with-
out must be avoided.

In the treatment of insane, the regulation of the five senses
and voluntary motion is not to be neglected ; since by means of
the senses we act on the manifestations of the mind. Even the
smell ought to be attended to. In fainting, and various nervous
complaints, we act on the brain by means of the smell. Insane
people are commonly fond of taking snuff. In debility or inac-
tivity of the intellectual faculties excitement of the smell may be
useful ; and anatomy and physiology prove that the olfactory
nerve is in the most intimate connexion with the organs of the
intellectual faculties. In short, I think with Dr. Cox,^ that ' no
means are to be despised which are capable of changing the train
of thoughts, interesting the affections, removing or diminishing
painful sensations.' Hence we ought to have recourse also to
seeing and hearing. Various colors, harmoniously or inharmo-
niously arranged, are to many individuals a source of pleasure or
pain. It is, indeed, astonishing that no more contrivances have
been invented to amuse the eyes, as is done with the ears ; in
our language I should say, to amuse the power of coloring as well
as that of tune.

* Lib. cit. p. 97.

190 INSANITY.

In this respect I observe the same error committed by writers
on insanity, which we find throughout all mankind ; that is, every
one judges of others according to himself. There are physicians
who have very little taste for music, and they will maintain that
music has no influence on the feelings of the insane ; they will
even ridicule such a proposition. Those, on the contrary, who
possess that talent, and feel the influence of music on themselves,
will praise and recommend it for insanity. Dr. Cox says, ' I
Would ask the musical amateur, or the experienced professor, if
he has not frequently felt sensations the most exquisite and inde-
scribable ; if he lias not experienced the whole frame thrilling
with inexpressible delight, when the tide of full harmony has flown
on his ear ; and the most wretched miserable feeling, universal
horripilatio, and cutis anserina, from the grating crash of discord ?
All the varied sensations, from transport to disgust, have been oc-
casioned by the different movements in one piece of music'

There can be no doubt that music has a great effect on many
individuals, and on more in one nation than in another. Accord-
ing to the different dispositions of the individuals, and to the na-
ture of the music, different feelings will be more or less excited.
Warlike persons will feel a great impression from warlike music ;
melancholic feelings will be nourished by gloomy songs. Hence,
if music should be employed to distract the mind of insane per-
sons, it must be regulated according to the feelings of the patients,
and it ought never to be analogous to the deranged manifestations
of the mind. This would be as noxious as a conversation on the
respective feeling. The director then ought to have knowledge
enough to select the compositions. It is even necessary to choose
the pieces which are performed, allegro, andante, or presto, forte
or piano, according to the feelings of the patients. There are
who could not bear a high tone, or the tone of such or such an
instrument.

The rule to adapt the external impressions to the individual
feelings of the patients is quite general, and must be observed, if
music and painting are employed as occupations. A person, for

MORAL TREATMENT. 191

instance, insane by religious feelings, and who naight amuse him-
self with painting, ought not to be permitted to represent scenes
which could keep up, or increase, the derangement of the mind
no more than he should be allowed to read books on religious
subjects. It is an essential point, that all faculties which are de-
ranged should be kept inactive, and others exercised.

Occupations of the insane.

All practitioners who have taken care of insane people agree
with respect to the usefulness of employment. It is, indeed, a
fact, that in those asylums for insane, where labor makes a part
of the regimen, a greater number of patients recover. Is it then
not surprising that this important point is so little attended to in
the erection and management of madhouses? Sufficient occu-
pation of the mind is beneficial in two respects, in point of cure,
and economical advantage. In many cases, from want of suitable
occupation the disease is nourished : the patients indulge in their
fancies, and injure their health by want of bodily exercise. In
the asylums for insane, however, we meet many persons of both
sexes, vigorous, strong, and, in many instances, fully capable for
manual labors. They loiter away their time in apathy, and live
often at the expense of the institution, wHile many economical
concerns, and the necessary affairs of the house, might be done
by such patients. Many, from previous habits, could be enployed
in the handicraft line, as white-washers, carpenters, and tilers;
others ought to be employed in the ordinary concerns of horti-
culture and husbandry, in digging, planting, weeding, v^^heeling ;
some might be employed in sowing, stone-cutting, twining ropes ;
female patients in washing, mending, getting up the linen, &:c.
It has been observed that, in all institutions for insane, the male
patients who assist in cutting wood, making fire, and digging in
the garden, and the females who are employed in washing, iron-
ing, and scrubbing floors, often recover -, while persons, whose
rank exempts them from performing such services, languish away
their life within the walls.

192 INSANITY.

It is understood that the labor ought to be relieved by suffi-
cient rest, by recreation, and amusement. The fatigue of the
day would prepare the laborers for sleep and repose during night.
Many individuals are very solicitous for some kind of occupation,
and during their employment in moderate labor they never fail to
enjoy a more happy state. The rich ought to exercise the fine
arts, ought to be amused with various games, such as bowling,
cricket, billiards, and in general with such occupations as keep
body and mind in activity. We meet, in many institutions, draw-
ings of various kinds made by patients. Dr. Hallaran, therefore,
wishes ' to pay the earliest attention to the capacity of every in-
dividual, in order to ascertain, at the period of convalescence, the
practicability of employing the mind by any species of bodily
exertion.'

Occupation is particularly necessary for convalescents. To
that end, I propose for them a separate building, with workshops
for handicraftsmen, with grounds for tilling, and every other sort
of occupation and amusement. The rich may cultivate music
and painting, may read aloud entertaining books of history and
travels, may walk and play. In what a dreadful situation must a
man find himself, when, returning to reason, he sees himself sur-
rounded by persons under all the different gradations of mental
misery.

I could quote many facts in support of the truth that the insane
more easily recover if body and mind are occupied. I shall copy
only one fact from the work of Dr. Hallaran. • A young man,
who had been an entire stranger at Cork, and who was remitted,
from a distant part of the county, to the asylum in the usual form,
came under my care in the state of acute mania, and continued so
full three months without any intermission. The symptoms hav-
ing at length given way, he was treated as a convalescent patient,
and every means tried to encourage him to some light work,
merely as a pastime, but all to no purpose. Though the ma-
niacal appearance had totally subsided, he still betrayed an im-
becility of mind that bordered closely on dementia, and it was

MORAL TREATMENT. 193

found impossible to excite in him the smallest interest either for
himself, or, in any measure, for that which had been proposed for
his amendment. This man had nearly been ranked amongst the
incurable idiots of the house; when, by accident, he was discov-
ered in the act of amusing himself with some rude coloring on the
walls of his apartment. From the specimen he had then given,
he was questioned as to his knowledge of drawing ; and he, having
signified some acquaintance with that art, was immediately prom-
ised colors of a better description, if he would undertake to use
them. This evidently gave immediate cheerfulness to his coun-
tenance, and he shortly evinced an impatience for the indulgence
proffered to him. On his being furnished with the necessary
apparatus for painting, he immediately commenced a systematic
combination of colors, and having completed his arrangement, he
requested one of the attendants to sit to him. This essay was
sufficient to satisfy me, that his recovery was not so remote as I
had reason to suppose. The portrait was an exact representation
of the person who sat before him ; and in a few days there were
several other proofs of his skill in this line, which bore ample tes-
timony of his ability. He soon became elated with the appro-
bation he had met with, and continued to employ himself in this
manner for nearly two months ; after which, progressive improve-
ment as to his mental faculties took place, when he was dismissed,
curedj under the protection of some gentlemen amateurs, who
took a kind interest in his preferment. He pursued his profes-
sion of miniature painting in this city for some time after, and has
since, as I understand, removed to London, where he practises it
with singular success.' As no public establishment is properly
adapted to occupy the insane, it confers the more honor on the
superintendents and managers, who pay particular attention to this
point, and make the best use of the situation to which they are
reduced by the plan of the architect. 1 do not like to criticise
any public institution, and to name it ; but I cannot help men-
tioning how much I was pleased with the zeal with which the
establishment at Glasgow is conducted, and with the anxiety man-
25

194 INSANITY.

ifested to improve the fate of their unfortunate fellow creatures.*
The treatment of the insane at the Retreat, near York, notoriously
exists in mildness, but occupation for the male patients is wanting.
Thus, in my opinion, a well-constructed and well-conducted
madhouse requires more than the architectural beauties of a palace,
a fine committee-room, and comfortable accommodations for the
attendants, a fine kitchen, or good provisions, clean staircases,
and mild treatment.

Inspection and visitation.

The question is, whether things are better done by committees,
or by single individuals. I am convinced that, on the Continent,
quod commissionaliter Jitj miser ahiliter Jit, particularly if some
like to show their decisive influence. An individual who takes
interest in a thing, who works with pleasure, and lives for an ob-
ject, will do much more without restraint of the opinions of those
who are fond of showing their personal authority. On the other
hand, I am also convinced that, if several together have nothing in
view but the success of an object, their united labors will produce
more effect than that of one individual alone ; but if the directors
be hired, and do their business merely because they are paid,
measures must be taken to prevent abuses. I think that every
mere hireling, in any branch whatever of society, ought to be
under inspection.

Now, it may be asked, who ought to be the manager of an hos-
pital for insane ? It is reported that medical men are the most
unfit for inspecting and controlling madhouses, because medicine
has little or no effect on insanity, and because the medical atten-
dants of such public institutions often have private houses, and
are therefore all interested in the object. The objection is not
quite clear : the meaning seems to be, that, in the management

* Second Annual Report of the Directors of the Glasgow Asylum for Luna-
tics, p. 16 and 19.

MORAL TREATMENT. 195

of hospitals for insane, the opinion of medical men ought to be of
the least influence. I agree that interest is a great enemy to
duty, but I cannot conceive that such an objection can be espe-
cially applied to medical attendants of public institutions for insane,
because some keep private establishments. In that case, a med-
ical man who takes care of any public hospital ought to have no
private practice. It seems to me, that the only thing to be attend-
ed to is, that the private practice, or the private institution, does
not prevent the physicians from seeing the patients at the public
establishments. For that reason it should be necessary that every
medical attendant writes down, in a book kept on purpose, the
time when he comes into the institution, and when he goes out,
signed with his name, and that every day.

As to the skill of directing madhouses, if the mind acted inde-
pendently of the body, a speculative philosopher, who studies
man in his closet, would be the best inspector of a madhouse ;
but as the operations of the mind are influenced by the body,
and the medical profession particularly studies the body in its
state of health and disease, this profession will be the best in-
formed with respect to dietetic influence, and must have an im-
portant vote in the management of insane. Moreover, as insanity
is a corporeal disease, I can never admit that medicine, strictly
speaking, has no influence on it. Syphilis was once incurable ;
has medicine in our days no power over It? When the Influence
of the nervous system, and of the cerebral parts, on the manifes-
tations of the mind shall be known and better understood, such a
discussion as this will be at an end. It Is, however, obvious that
I speak in favor of the profession, and not of all those who
follow. It.

Thus, in establishing the rules according to which an hospital
for insane is to be managed, the medical profession Is the most
fit. But still inspection Is necessary, that the rules may be en-
forced ; now who ought to be the Inspector ? I think, any ac-
tive, charitable, conscientious man, who knows the nature of In-
sanity, and the wants of the patients. Could medical men be

196 INSANITY.

found, who have nothing else to do but to visit madhouses, their
profession would entitle them to that place.

Such inspectors ought to be appointed by the government :
they ought to have free access at all hours to any madhouse ; and
in every madhouse which they inspect, they ought to write in a
peculiar book, when they come in and go out, with their remarks
of satisfaction or discontent ; these books ought to be presented
every year to a committee appointed by the government. They
ought not to receive fees for their visits, but to be paid m general
by the government. The common inspection, made once, twice,
even four times a year, is good for nothing ; the institutions must
be visited as many times as possible, and at moments when they
are not prepared. The inspector must have time to visit all cellsj
and not haste to return to his private practice. This, however,
is impossible, considering the manner in which inspection is usu-
ally made. I have seen enough with my own eyes to disapprove
of the actual manner of visiting the madhouses in Great Britain :
but I appeal to higher authority, to gentlemen who have under-
standing to judge, and probity to place duty above interest ; I
mean, the president and the secretary of the visitors. The for-
mer, Dr. Latham, in his evidence to the select committee for a
better regulation of madhouses stated :* * The first time I was a
commissioner, we examined a house at Plaistow ; there were two
women confined, which I thought were not insane. The keeper
said they were, and that we were mistaken : we desired them to
write to their friends to give them a trial. We were all of opin-
ion these women were improperly confined, and desired their
friends would take them out. Upon our next visitation, the fol-
lowing year, I had, of course, considerable curiosity to know what
had become of these two people. One had drowned herself, and
the other had hanged herself; so that if we suppose the patient is
really sane, we feel a great deal of difficulty, and we must very
often trust to what the keepers say. We are obliged now and
then to take their opinion upon the subject, as to whether they

* First Report, p. 113.

MORAL TREATMENT. 197

have for the last month been orderly, and whether their friends
talk of removing them.' In support of my opinion, I shall add
the candid evidence of Dr. Powell to the same committee.* ' It
is obvious,' says this intelligent observer, ' that the commissioners
cannot, on their visitations, have time enough to examine into in-
dividual cases of lunacy ; for doubtful ones may require many
hours, and repeated visits ; and if the commissioners were to act
from the impulse of the moment, or barely to judge from tem-
porary propriety of conversation, they might let half the lunatics
they see loose, though they were unfit to be so.' It is not to be
overlooked that, when Dr. Powell gave his evidence, there were
thirty-four licensed madhouses which contained about two thousand
patients, to be visited by the commissioners of the College of
Physicians at London. I repeat, however, that I do not main-
tain that the medical profession is unfit for that office ; that on
the contrary, in my opinion, it is the most entitled to it ; and
that I am hostile only to the mode in which madhouses are
inspected.

It will be more easy to inspect the public than the private mad-
houses ; the latter present unavoidable difficulties. I fear the
government is in the situation of a physician who treats an incu-
rable disease. Something must be done, though the remedy is
uncertain and insufficient. Indeed the abuses are enormous ;
better arrangements must be made, but a radical cure seems at
present impossible.

Inspection alone is not sufficient; we must come nearer the
root of the evil. To this end, I shall consider two points : viz.
to whom are licenses to be granted, and on what conditions .''
Shall sufficient money entitle every one to keep a madhouse ? It
seems to me the government ought to consider above all the qual-
ities which contribute to the comfort and cure of the patients ;
and that these alone ought to entitle an individual to the permis-
sion to keep them.

The best thing would be, if the government at different districts

* First Report, p. 75.

198 INSANITY.

erected suitable institutions for poor and rich 5 these then could
be at once managed and inspected according to a reasonable plan.
The incurable, who are to be excluded from such establishments,
might be taken care of, as I have mentioned above, in a depart-
ment of the poorhouses in every county. The purchase of the
land, and the erection of the buildings for curable, would be the
principal expenses of the government. The rich boarders would
contribute to defray the expenses of the poor. If this were not
the case, how should it be possible that so many families pay the
licenses, and make money by keeping the patients ? Moreover,
buildings constructed only for the purpose of proper treatment,
and not for ostentation, and the whole managed as 1 have detailed,
would greatly diminish the expenses.

As, however, private families cannot be obliged to send their
diseased relations or friends to public hospitals, private establish-
ments must be permitted; but general regulations as to the
situation and construction of the houses, the internal management,
and medical attendance, might be prescribed, and I think the
same as in public institutions.

The license being granted, the inspection ought to begin with
the daily visit of a well-informed physician, appointed by the
consent of the government. If the same medical man take care
of several estabhshments, the daily visit ought to be the conditio
sine qua non. He is to be paid by the keeper of the house
according to the number of licensed patients, and his salary might
be regulated by the government. Th*e friends of the patient,
however, are to be permitted to send any other medical man in
whom they place particular confidence, to deliberate with the
regular physician of the institution on the treatment. The
medical man sent by the friends or relations of the patients,
should be paid by them. In the same way, they should be
obliged to pay for those medicines which the consulting physician
prescribes by his particular advice, while those, which are given
by common consent, like the rest of the remedies, ought to be
furnished by the estabhshment.

MORAL TREATMENT. 199

Thus the regular physician, who makes daily visits, has not
only opportunity of directing better the distribution of the patients,
of watching every change, of modifying diet and the whole treat-
ment, according to sound principles of the healing art, but, being
obliged to inform the magistrate whenever a patient is received,
or dismissed, or dies, he also controls illegal confinements. Such
a medical attendance, in many respects, under the control of
general inspectors who are obliged to visit public and private
establishments, their responsibility to a committee, and all being
answerable to the government, will be more effectual than the
present and newly-proposed mode of visiting madhouses.

There is still an important consideration to be made concerning
strangers and friends who request permission to see the establish-
ments or the patients. The communications between the insane
and persons from without are to be prudently restricted. The
visits of their friends are productive of great inconveniencies.
The patients are always more unquiet and ungovernable for some
time afterwards. Many relapses have taken place, when, in con-
valescents, their meeting with friends was not conducted with
sufficient precaution. The most intimate friend is often the last
to be suffered to approach. No general rule can be given. All
the natural dispositions of the patients, the causes of their diseases,
are to be considered ; and accordingly, the communication with
strangers and friends admissible. I think also that this branch
ought to be regulated by the physician of the house. No one,
without his special permission, ought to have the liberty of seeing
any patient, or the cells where the patients are. It is obvious
that patients never ought to be exhibited to gratify the curiosity
of strangers. Yet professional men, or those who take particular
interest in the treatment of insanity, never ought to be prevented
from visiting at seasonable hours every part of the establishment,
but the patients only in presence of the physician. It is under-
stood, that the discretion of strangers must rely on the judgment
of the physician. If certain individuals cannot be shown to them.
Thus I am decidedly of opinion, that the institutions for insane

200 INSANITY.

must be better provided with medical attendance ; but then the
important situation of physicians appointed to such establishments
also requires that this branch of medicine be better cultivated,
and taken up as a study. It evidently follows that theoretical and
practical instruction on the deranged manifestations of the mind
are desirable, and ought to be particularly attended to by those
who wish to be trusted with the care of insane patients.

Are private or public madhouses preferable ? I take for granted
that, in this question, the actual state of both sorts of madhouses
cannot be taken into consideration, because, according to the
evidences given to the select committee for the better regulation
of madhouses, all are bad, and not calculated for curing, but for mere
confinement. I consider this jquestion in the supposition that
both sorts of institutions are well regulated. In the actual state,
the keepers of private houses object with right against the general
routine of public practice, while insane people require modifications
in their treatment.

I think the question cannot be answered in a general way. In
several cases, the patients would much rather stay in their families,
than go into any madhouse ; but in other cases they could never
be cured at home. If, for instance, a patient be rich, quiet, and
manageable without coercion, the attendance of an affectionate
wife or husband, brother, sister, or friend, may, with proper
instruction, be able to do much more than can be expected where
a great number are to be attended to. But patients in a furious
state are seldom cured at home. The idea of being under
restraint in their own house will be a constant source of irritation
to their mind. Even in institutions, the visits of friends make
such patients more ungovernable. They are more easily restrained
by strangers. It is often the case that patients violent in their
families become quiet as soon as they are confined in an asylum.
Insane by pride are never cured in their families, where every
one formerly was obliged and accustomed to obey. Hence there
must be institutions for the rich as well as poor.

As long as public establishments are not adapted to the comforts

MORAL TREATMENT. 201

of the rich insane, private madhouses are preferable for them,
because every thing can be better attended to. The government
has only to prevent illegal confinements, and ought to take care
that those who attend such patients understand insanity. The
rich families themselves will consider the domestic comforts of
their unhappy friends. But the poorer classes need the assistance
of the society at large, and of the government in particular.
There ought to be public establishments for them. The parishes
actually pay ; but those who keep them wish to gain, and not to
lose. It is, however, impossible to give a single cell and a bed,
to warm the room, pay necessary attendance, medical assistance,
medicine, food, bath, and every thing that may be necessary, for
ten shilhngs a week. For the sake of emolument, the keepers of
such houses crowd the patients together, provide double bedsteads,
and chain them, if they be the least troublesome. The only way
to improve the fate of these unfortunate beings is to erect public
hospitals, conformable to the wants of the patients. This kind of
distressed has the best right, and the most urgent claim, to the
assistance of the government, because they have lost all, even their
personal liberty, by disease, and not by criminal conduct, like
felons, whom every county is obliged to treat with great humanity.

RECAPITULATION.

From the preceding consideration it results, that the moral
treatment of insanity must undergo great improvements ; that the
buildings must be adapted to the particular condition of the
patients, and the internal management founded on sounder prin-
ciples. To the elucidation of those points, I have spoken of the
architectural requisites of an hospital for the insane, and of the
internal management, such as reception and classification of the
patients, regulation of temperature, cleanliness, diet, coercion,
treatment of the feelings, treatment of the intellectual faculties, occu-
pations of the patients, inspection, and the difference between private
and public establishments. The regulations for the master, matron,
porter, male and female keepers, and economical concerns, are cer-
26

202 INSANITY.

tainly of importance, and must be properly arranged and conducted;
but such details are not within the reach of my present consider-
ations. I wish to call particular attention to the most essential
points which concern the medical profession, and the immediate
treatment of the patients.

•Medical treatment of insanity.

In the greatest number of houses for insane medical treatment Is
scarcely thought of, because insanity is not considered as a corpo-
real disease. ^ The successful apphcation,' says Pinel, * of moral
treatment exclusively gives great weight to the supposition that, in
a majority of instances, there is no organic lesion of the brain or
the cranium. . . . Attaching little importance to pharmaceutic
preparations, and all sufficiency in curable cases to physical and
moral regimen, T intend not to devote many of my pages to the
exclusive consideration of drugs and medicaments.' Many think,
with Pinel, that medical treatment is of no use in insanity.
There are only two ways of excusing such an assertion ; either
they must confess our ignorance as to the application of medical
treatment, or contend that insanity is not a corporeal complaint.
Now self-esteem does not like to confess ignorance ; hence the
second proposition is the natural consequence. In many complaints
of the body we can say with Pinel, that medicine is of no use, and
does rather harm, and nature alone will cure sooner if it be not
disturbed by our prescriptions ; indeed, we rather would confine
ourselves to mere medicine expectante; but does it therefore
result that medical treatment could not assist nature ?

Dr. Rush says,* ' It is perhaps only because the diseases of the
moral faculty have not been traced to a connexion with physical
causes, that medical writers have neglected to give them a place
in their systems of nosology, and that so few attempts have been
hitherto made to lessen or remove them by physical as well as

* Medical Inquiries and Observations, vol. ii. p. 22.

MEDICAL TREATMENT. 203

rational and moral remedies.' Moreover, those who have treated
insanity as a corporeal disease have made too little discrimination.
All the means are applied chiefly to the alleviation and suppression
of symptoms, and not according to the disease ; that is, all treat-
ment is symptomatical, as if there were a remedy against every
symptom. The nerves, for instance, suffer, and there are con-
vulsions, hence opium, Valeriana, ether, camphor, &:c- ; the circu-
lation of blood is accelerated, hence digitalis; there is delirium,
hence bleeding ; there is nausea, hence a vomiting, he. Indeed,
nothing is more easy than such a medical knowledge ; but such a
physician is like a judge who knows only the letter of the law, and
neglects all modifications. Insanity is commonJy treated in the
same routine. Insanity, however, and its symptoms present as
much variety with respect to causes and circumstances as any
other disease ; and it cannot be treated by any general method,
as by bleeding, vomiting, purging, blistering, bathing, the use of
opium, caustics, digitalis, mercury, &z;c. There is not, and there
cannot be, a specific remedy against insanity. There are specifics
against determinate diseases, under whatever form they appear,
or whatever part they affect ; but the morbid symptoms of the
lungs have no specific remedy, because the functions of the lungs
may be deranged by various causes, as by an inflammation of the
lungs, bad digestion, hysteric affection, and according to these
causes the treatment must be modified. The same must be done
in the brain.

There is no doubt that nature often cures insanity. But, as in
other diseases the patient is often relieved by art, and would die
without it, so it is in insanity. Medicine expectants, though prac-
tised by Hippocrates, can no longer satisfy any rational pathologist.
Nature has been observed long enough in insanity, and we know
what she alone can do, viz., cause a great number of insane
persons to become fatuous ; indeed, further indolence deserves to
be reprobated.

My manner of considering the medical treatment in insanity is
conformable to the general principle of pathology. The proximate

204 INSANITY.

cause of Insanity is corporeal, and resides in the brain. Now
either we can cure the diseases of any bodily part, or we cannot.
In the former case it must be possible with the brain as well as
with the lungs, the bladder, the blood-vessels, the muscles. But
then we may say, with Mead and other great physicians, ' in all
things which our art contains, there is nothing that does good but
what may also do harm ; and when a remedy is used indiscrimi-
fiately it must of necessity be used improperly.' I shall first state
tvhat is commonly done, and with what effect, and then propose
my ideas.

The usual treatment of insanity is merely symptomatical. In
mania they bleed ; in melancholia they purge. At the Bethlem
in London the same method was used in mania and melanchoha;
and Haslam mentions, that patients who were in a furious
state recovered in a larger proportion than those who were
melancholic. Out of a hundred violent, sixty-two were cured ;
and from the same number of melancholic, only twenty-seven.
The author of the Domestic Guide in Insanity thinks* that,
' in nine cases out of ten, too much stimulus of one kind or
other is the cause of insanity. A general system of relaxation
may therefore be laid down as the best general rule.' He con-
tinues : ' Even in cases that had the hypochondriacal appearance,
and which might ultimately require the tonic treatment, I should
use the relaxing system for a fortnight or three weeks, but not
less than a fortnight ; then to administer two or three smart vomits
in as many days, yet not to give vomits at a time of amendment,
nor till smart purges have been given ; nor, if there is any fulness
of blood, to continue the same treatment during six months.'
After that time he recommends sudden shocks by plunging the
patient into water, and violent motion by the swing. If these
measures produce no alteration, he tries repletion, and fills the
vessels as full as possible by good living, and proposes to make
the patients drunk; and, when this is accomplished, to recom-

* Page 63.

MEDICAL TREATMENT. 205

mence the first plan.' He candidly confesses that he has very
litde variety of treatment to recommend.

I hope he has no curable patient under his care, and I confess
such a medical man should not be the guide of my friends in
cases of insanity. His candid confession of ignorance would have
induced me not to trouble the reader with his opinion, were it not
publicly known that a similar routine of hospital practice degrades
our profession. Idiots, furious, melancholic, in short, insane
people of all descriptions, were bled, purged, and vomited, accord-
ing to season and weather ; and all was done on a particular day.
During the rest of the year, the keeper was furnished with
powders, which he distributed as he found it necessary ; and if
any male or female patient complained, the keeper said, he or
she wants a powder. If the patients became sick and weak, or
were not able to undergo the discipline of the house, they were
immediately discharged. If it was not the season, it was not
minded whether the patient wanted alvine excretions ; he might
die of constipation, and the bowels burst in consequence of the
accumulation of the contents. Moreover, we are told that other
persons have been insane for fourteen years, without taking a
single grain of medicine ; that a warm bath never was heard of ;
that the surgeon was mostly drunk and insane himself for ten
years. Finally, the physician has been represented as a physiol-
ogist, who understands the influence of external circumstances on
our body so well, that he thinks ' a person could have had about
him a weight of iron six or eight and twenty pounds, that he could
have been confined to his bed without being allowed to turn round for
nine years, or without being able to get out and sit on the side of
his bed, being chained by the head by a chain only twelve inches
from the iron stanchion, and that that would have no effect upon
the general health.' Every one, however, will believe that such
a treatment, only for nine days, should have convinced him of its
influence on the body. I know that, in another establishment, it
was the custom to put all sorts of insane persons head foremost

206 INSANITY.

into a cask, nearly filled with water, to work their way up the
best they could.

If insane patients are only consigned to such a routine of prac-
tice, to painful coercion, to starving, indiscriminate abstraction of
light, to bleeding and purging, ad libitum, there is no doubt that
neither physicians nor the public can gain confidence in medicine
with respect to insanity. I fully agree that, if we continue such
a proceeding in insanity, our profession ought to be interdicted by
those who have the will and the power to improve the public
good. If such be our skill in treating insanity, or also if medicine
have no influence on insanity, the commissioners for establish-
ments of insane must be excused for making no particular inquiry
into the disease of the patient, nor into the medical treatment ; for
thinking it their only duty to direct their inquiry chiefly to lodg-
ing, victualling, and general accommodations of the patients ; for
observing that none, but such as are afflicted with insanity, have
been received into the institution ; and that none are retained in
it after being sufficiently recovered to be discharged. It is, how-
ever, allowed that the latter points cannot be decided upon in one .
short visit, during three months.

If, according to Pinel, opium, camphor in large doses, the
moxa, sudden immersion in cold water, copious bleeding, are the
remedies to be resorted to in ungovernable fury, excessive irasci-
bility, and blind and savage ferocity, there is no wonder that,
under that treatment, this disorder must commonly be considered
as incurable. Nature is not strong enough to correct all our errors ;
and, in my opinion, Pinel would have done much better, had he
adhered to his favorite plan of medicine expectante than to give
such advice.

The incongruity of remedies administered to the same patient
must excite indignation. I am pleased with the remark of Mr.
Hill* when he says: 'The young and the aged, the infirm and
the athletic, the debilitated and the plethoric, all are included in

* Lib. cit. p. 283 and 328.

MEDICAL TREATMENT. 207

one indiscriminate mass, and a copious bleeding is instantaneously
directed. This procedure, though erroneous, has the sanction
of ages and of names illustrious in the public opinion ; and no
sooner is the disease determined to belong to the class of insanity,
but bleeding, hellebore, chains, painful degrading coercion, starv-
ing, and dark dungeons, crowd on the mind by the common as-
sociation of ideas, forming an endless circle applicable to all cases.
In the same disease of the same patient they have recourse to
every thing that suggests itself; so that when a cure has occasion-
ally taken place, it appears to have been effected upon empirical
principles, more from chance than the result of any consistent
rules of practice ; while, on the other hand, if such a happy ter-
mination does not follow, the cure is declared to have been, from
the first attack, impracticable.'

I find his feelings laudable, when he ranks *with the puffing
advertisements of charlatans, the conce-alment of a preventative of
insanity, or of the proper treatment which, under strong family
obligation, cannot be disclosed.' Indeed he who is fond of truth
likes candor and openness. Experience has always shown, that
ignorance wishes to be covered with the veil of haughty deport-
ment. Without considering that Christian principles exclude sel-
fishness as the supreme motive, it must be admitted, that where
arcana are tolerated, quackery is patronised, and the health of the
public delivered to discretion.

1 am of opinion that the medical treatment of insanity must be
entirely reformed ; it is to be reduced to sound principles of pa-
thology in general.

Every one, who examines nature with reflection, will find that
all considerations, which may be made with respect to anatomy,
physiology, and pathology of any other organic part, must be also
applied to the brain. Now the pathology of every part must be
founded on the knowledge of its healthy state ; and he who will
study insanity must understand the functions of the mind in their
state of health. Moreover, in pathology, the most essential object
is to point out the cause of the disorder. This then can be re-

208 INSANITY.

moved or not. Every other proceeding is merely experimental.
After this, the modifications of the disease, dependent on sex,
temperament, and individual idiosyncrasies of the patients, on cli-
mate, season, weather, and external circumstances, are to be ex-
amined, and the treatment to be modified accordingly.

In any disease, however, our art has its limits, and so it is in
insanity. This complaint is incurable or curable. Idiots from
birth, by a defect of the cerebral organization, and fatuous from
violent mania for many years, belong to the former sort. If a
child from early youth be a complete or incomplete idiot from a
defective organization, or by water in the brain, medical attend-
ance, strictly speaking, is of no use. Nothing specific can be done
with advantage. The bodily constitution in general must be taken
care of by dietetic means, such as regulation of food, air, tempera-
ture, light. In short, to a good, commonly called physical, edu-
cation, the parents or friends ought to have recourse. The digest-
ive organs deserve a particular attention, because their functions
are often deranged.

Sometimes it happens in idiotic children, that, at the periods of
climacteric years, when the organization acquires more develop-
ment, and afterwards more solidity, the manifestations of the mind
appear. We ought to know that, in such children, the intellect-
ual operations cannot be acquired by force. I have seen children
of that sort treated in the most unreasonable manner ; but all blows
and vexations could not produce talents. Force may excite pow-
ers which exist ; but where they are wanting, all labor is lost.
Such a treatment rather increases their state of idiotism. More-
over, it ought not to be overlooked that, in delicate and sickly
children, from a too early and too continued application of their
intellectual powers, exhaustion originates, and the foundation of
weakness of the mind or of insanity is laid.

Those who, during madness, become fatuous are partly cura-
ble, or partly incurable. Among the curable may often be found
those who, in mania, have undergone too much lowering treat-
ment. It is known, that after fever with delirium, a debility of

MEDICAL TREATMENT. 209

the whole body, weakness of the external senses, and inaptitude
of the intellectual facuhies, are observed ; every funciion then im-
proves in proportion as bodily strength is re-established. If fatuity
be the result of mere debility, for instance, after great evacuations
of any kind, after dysentery, continual loss of semen, after haemorr-
hages, too much bleeding and purging in inflammations, tonic
treatment, adapted to the individuals, will be of the best effect.
Dr. Rush mentioned in his lectures, attended by Dr. Jardine of
Liverpool, who was so kind as to communicate the fact to me,
that * the Rev. Mr. Tennent, of New Jersey, lost his memory
entirely at the age of nineteen from a fever, during which he lay
in a lethargy so deep, that he was suspected to be dead for some
days. He had previously made considerable progress, but was
obliged to begin his grammar again. Some weeks after his recov-
ery, while he was repeating one of the early grammar rules, he
suddenly stopped, and told his master that his knowledge was re-
turned and he was afterwards as well as usual. Similar facts are
known to medical practitioners. I have quoted several in my book
on Phrenology. I shall add a few examples where fatuous per-
sons after insanity were cured. Dr. Rush* says, ' In the year
3795 a young man of the name of Donaldson, from York county
in Pennsylvania, was admitted into our hospital, in the lowest state
of monalgia. Reappeared to have no mind, and scarcely any
locomotive powers. When placed at the head of a pair of stairs,
he rolled to the bottom of it. By means of most of the remedies
I have recommended, he was nearly cured. He acquired the use
of his speech, knew his attendants, and called me by my name
when 1 visited him. Unhappily, in his progress to a perfect cure,
he was attacked with a malignant fever, and died in the hospital on
the fifth day of his disease.' Dr. Rush relates another fact which
happened at the Lunatic Asylum at York in Great Britain. * On
the 25th of October, 1778, a seafaring person, about forty years
of age, was recommended to the Lunatic Asylum for cure. About

* Inquiries and Observations on the Disease of the Mind, p. 233.

27

210 ' INSANITY.

two years before that time, he had sustained a considerable loss
by sea, which operated so violently upon his mind, as to deprive
him, almost instantly, of all his reasoning faculties. In that state
of insensibility he was received into the asylum. During his abode
there, he was never observed to express any desire for nourish-
ment, and so great was his inattention to this particular, that for
the first six weeks it was necessary to feed him in the manner of
an infant. Food and medicines were equally indifferent to him.
A servant undressed him at night, and dressed him in the morn-
ing ; after which he was conducted to his seat in the common
parlor, where he remained all day, with his body bent and his
eyes fixed upon the ground. From all the circumstances of his
behavior, he did not appear capable of reflection. Every thing
was indifferent to him ; and from the fairest judgment that could
be formed, he was considered by all about him as an animal con-
verted nearly into a vegetable. In this state of insensibility he
remained till the morning of Tuesday, the 14th of May, 1783,
when upon entering the parlor he saluted the recovering patients
with a " Good morning to you all." He then thanked the servants
of the house, in the most affectionate manner, for their tenderness
to him, of which, he said, he began to be sensible some weeks
before, but had not, till then, the resolution to express his grati-
tude. A few days after this unexpected return to reason, he was
permitted to write a letter to his wife, in which he expressed him-
self with decency and propriety. At this time he seemed to have
peculiar pleasure in the enjoyment of the open air, and in his
walks conversed with freedom and serenity. Talking with him
what he felt during the suspension of reason, he said that his mind
was totally lost ; but that about two months before his return to
himself, he began to have thoughts and sensations ; these, how-
ever, only served to convey to him fears and apprehensions, espe-
cially in the night-time. With regard to his medical treatment,
the medicines usually prescribed for melancholic persons were in
his case studiously avoided ; and, instead of evacuants, cordials
and a generous diet were constantly recommended. Finding his

MEDICAL TREATMENT. 211

mind sufficiently strong, he was dismissed, and afterwards appoint-
ed to the command of a ship employed in the Baltic trade.'

A too great loss of semen undoubtedly weakens the intellectual
powers ; but we have often met idiotic individuals in hospitals for
insane, whose imbecility was considered as the effect of their las^
civiousness, while this rather originated from the want of moral
feelings and reflection ; that is, amativeness was active, without
restraint, as in animals.

Acute mania is oftener cured than melancholia ; but there are
more fatuous restored after simple melancholia than after chronic
violent mania. If in the latter cases the manifestations of the
mind are lost by degrees, and the patients become quite fatuous
without having suffered by debilitating causes, their state is per-
haps always hopeless. In such cases organic changes have taken
place in the brain, and the effects of the primary disease catinot
be removed. Such patients then are no longer the object of an
hospital for curable patients. It is easily conceived, what Haslam
has stated, that ' In bodily weakness, if the raving paroxysms
have continued for a considerable time, and the scalp has become
unusually flaccid, or where a stupid state has succeeded to vio-
lence, no benefit has been derived from bleeding.' If there be
mere bodily weakness, bleeding will increase it, and if organic
changes have taken place in the brain, no treatment will cure
the derangement.

The best treatment of the curable fatuous consists in evacuants,
to keep the bowels open without purging, combined with tonics,
generous diet, dry and warm abode, pure air, aromatic baths,
shower bath, rubefacientia along the spine, issues, and a prurient
eruption on the shaved scalp, produced by the lotion, with a strong
solution of antimonium tartarisatum. This treatment must be
continued for a long time, and its effect will depend on the state
of the cerebral organization.

I shall now examine the medical treatment of alienation, or in-
sanity strictly speaking. In considering the opinions of various
authors, we find that the same means are blamed and praised.

212 INSANITY.

These contradictions can be reconciled only by supposing that
the reniedy was employed in different diseases, or in modified
individuals. It is to be remembered, that the symptoms of insane
patients are innumerable and that it is necessary to point out the
cause of the deranged functions of the brain. Moreover, it must
be understood, what all intelligent practitioners admit, that the art
of medicine does not consist in multiplying medical formulas, but
in judiciously prescribing a few select and active remedies. As
it is so important to understand the nature of every disease, be-
fore we can form a sound treatment, the physician of institutions
for insane should be made perfectly acquainted with the history
of every case from its commencement.* The treatment of in-
sanity, as it is detailed by Dr. Rush, seems to me more satisfac*
tory than tliat of any other writer. I think with him,f that ' the
successive and alternate changes of the different forms of madness
into each other, shows the necessity of renouncing all prescrip-
tions for its names, and of constantly and closely watching the
disease.' 1 shall speak of the medical treatment in the same
order as I have mentioned the causes.

Treatment of mechanic causes of insanity.

Mechanic injuries of the brain, such as concussion or com-
pression by blows, a fall, wounds, fracture, or depression of the
skull, exostoses, fungus of the dura mater, collection of blood or
pus, produce various derangements of the cerebral functions. The
nice distinctions made by some theoretical authors, as to concus-
sion or compression of the brain, cannot be ascertained in practice.
The same symptoms may occur in both cases. Sometimes there
is concussion and compression, without the symptoms which are
ascribed to them ; and at other times such symptoms exist with-
-it is truly lamentable that some, either from a false delicacy or pride, so far
forget their duty as to deny altogether this important information to the phy-
sician. There are many cases of this kind in Massachusetts.

t Medical Inquiries and Observations on the Diseases of the Mind, p. 237.

MEDICAL TREATMENT. 213

out previous concussion or visible compression. From violent
causes may originate vertigo, giddiness, numbness, stupor, de-
lirium, inflammation, suppuration, extravasation, epilepsy, idiotism,
palsy, trismus, insanity, or apoplexy.

In violent injuries from without, the teguments and the skull
are to be examined. If the skull be fractured, and a portion de-
pressed, this must be elevated by surgical operations. Some-
times there are great disorders in the brain, and the skull has not
suffered at all. At Liverpool I have seen, with Mr. Brandreth
and Dr. Renwick, a man who received a blow on the head with
the fist, and sank dead to the ground. There was no injury of
the teguments or skull, but a great turgescence of the blood-ves-
sels of the scalp, a great congestion over the whole brain, and a
great extravasation at the basis of the brain, particularly at about
the great commissure of the cerebellum (pons Varoli). If ex-
travasation be suspected, they advise to apply the trephina ; but
sometimes it is difficult to determine the place of the extravasa-
tion ; sometimes it is at the side of the head opposite to the blow
or the wound. There are also cases on record, where extrava-
sation was suspected, and nothing found after the operation; and
at other times the operation was neglected, and extravasation or
consecutive suppuration detected after death. These cases are
sometimes extremely intricate ; and if the extravasation be not at
the surface of the brain, nothing can be done. Sometimes we
open individuals who die suddenly from violent blows, and noth-
ing but congestion of blood is found, or paleness and a collapsion
of the brain. I have seen patients, after violent injuries on the
head, lingering for a long time, and declining to dissolution.
After death, suppuration was observed.

Surgical operations do not belong to my considerations. If
they are necessary, the disease requires an antiphlogistic medical
treatment ; such as bleeding, cold applications to the head, keep-
ing the bowels open, low diet, &,c. In the greatest number of
cases, no surgical operation is indicated ; but very often blows
derange the functions of the brain in disturbing the circulation of

214 INSANITY.

blood, or the delicate structure of the cerebral fibres. I have
seen individuals, the operations of whose mind were entirely sup-
pressed, by their head being violently shaken, while organic life
continued its functions. Many persons feel headache, vertigo, gid-
diness, or become insane ; and if such individuals die sooner or
later after the injury, congestion of blood is detected. Hence it
happens in the head, what we perceive in external bruises ; and
the curative plan is obvious : bleeding, application of ice, snow,
or cold water on the head, aspersion with ether ; the bowels are
to be kept open, and every thing which carries the blood to the
head avoided, as spirituous liquors, indigestible aliments, costive-
ness, violent affections. Moreover, v/hatever removes the blood
from the head must be employed. To this end a more upright
]josition is preferable, mild evacuants to open the bowels, low
diet, &c. Sometimes a great weakness of the blood vessels re-
mains for a long time, and the general treatment is to be contin-
ued, as washing the head with ether, cold water, cataplasmata of
aromatic herbs boiled in wine, and every thing that can give tone
to the blood vessels. After the first period, bleeding will be of
less use ; but whatever can determinate the blood to the head
must be avoided, as walking in hot weather, dancing, going on
horseback, swimming, stooping, &c.

Blisters and vomiting are highly improper. Nothing is more
common than vomiting the patients, who have suffered some
violent injury of the head, especially, if they have nausea.
Nothing but routine, however, can excuse such a proceeding.
The most common observer, who has looked at persons during
that act, must have seen, and he who has once taken a vomit
must have felt, that the blood is determined to the head.

Sometimes external injuries may be succeeded by an inflamma-
tory state of the brain, and various symptoms of insanity. Their
treatment then follows the general principles of pathology ; hence no
vomiting, no blisters, no opium, no ether, no camphor, and such
things, but the antiphlogistic treatment must be adapted to the
individual, just as in headache, vertigo, or stupor, &:c. Whatever

MEDICAL TREATMENT. 215

may be said with respect to the general use of vomits in such
cases, we must agree, that even universal practice cannot alter
the nature of things, nor universal error change the nature of
truth.

Treatment of the idiopathic dynamic causes of insanity.

Here also pathological facts prove that our common knowledge
of insanity is not satisfactory, and that Dr. Powell was right in
saying ' the whole should be new modelled.' It seems to me
that, with respect to idiopathic dynamic causes of insanity, there
are three different states of the cerebral organization, every one of
which requires a different treatment.

There can be no doubt that the functions of the brain may be
deranged by too ^reat a stimulus. I shall call that state of the
brain hypersthenic ; if, however, any nosologist prefer the term
inflammatory, I shall never dispute about names. The essential
point is to understand the state of the brain designated by that
name. This state of too great excitement may affect the brain,
but one part more than the others ; and hence it may
produce various symptoms. In symptoms of erotomania, or
nymphomania, for instance, the cerebellum suffers particularly ;
in fury and mania the middle lobes ; in too great self-esteem
or pride, the cerebral parts at the vertex of the head, he.

This hypersthenic state of the brain may be only local, that is,
confined to the brain; or it may be combined with various symp-
toms of automatic life ; in the same way as tlie affections of other
parts sometimes are local, such as opthalmia, diarrhoea, &ic. or are
accompanied with various other symptoms. Dr. Parry says,* ' I
have many times known the pulse in the temporal artery so weak,
that blood would not flow from it, however well it was punctured, and
in other instances it was loo weak to be felt ; and yet in all, the
pulse in the carotid has been extremely strong, and there has
been the most decisive evidence of preternatural impulse of blood

" Lib. cit p.34G.

216 INSANITV.

to the brain. In erotomania, or the hypersthenic state of the
cerebellum, there is often involuntary priapismus, as a secondary
symptom. The treatment of all those secondary symptoms
depend on the general disease. In this case, it would be bleeding
behind the ears, cold applications on the neck, low diet ; while
poultices alone, against priapismus, are of no use. Also the
castration, which has been made in animals and in man against
that disease, may be prevented. In hypersthenic erotomania, the
debilitating method will succeed in the safest manner, as in this
state of the brain in general. Such patients must be kept in
solitude and darkness, and exposed to cold. There are examples
known, where nature cured them by spontaneous bleeding or
cold. Dr. Rush* mentions two facts, where the patients escaped
from the keepers in the evening, and passed the night in the open
air, in the midst of the winter, to their advantage.

The question arises, how we can distinguish this state of the
brain, or its parts ? If it be local, it is more difficult to be under-
stood ; but it is much more easily pointed out, if it be con-
nected with morbid appearances of automatic life. It may be
suspected, in young, phlethoric, well-nourished and strong indi-
viduals, where no cause of weakness, but rather stimulating causes,
have preceded ; where the disease began suddenly, and is still of
short duration ; hence where the whole condition of the patient, his
age, temperame:U, previous health, manner of living, all external
influences of season and weather, indicate inflammation. The
diagnosis becomes more easy, if other parts are affected at the
same time ; if, for instance, there is a certain glittering appearance
of the eyes as in other inflammations, a flushing of the face. The
pulse is often deceitful : sometimes it is suppressed and small, as
in spasm, and rises after venesection ; sometimes it is full and
strong. If such patients die in a short time, we find the texture of
the blood-vessels firm ; and of greater resistance than the fibres
of the brain ; so that I do not like the brains of such individuals
for the demonstration of the cerebral organization.

* On the Diseases of the Mind, p. 197.

MEDICAL TREATMENT. 2\1

The inflammatory state of the brain is often without pain, and
practitioners are then led into error, if they forget that the brain
is not sensible, and differs in this respect from the nerves of the
body. They ought to know that fear, fury, disdain, and other
disagreeable affections or modes of the feelings, are, with respect
to certain cerebral parts, what pain, in the common acceptation,
is with respect to the nerves of the body. In order to understand
this idea, I refer the reader to the chapter on the modes of the
faculties in my book on Phrenology.

Another common error, which I have already mentioned, is to
think that violent delirium and fury are the only signs of the
inflammatory state of the brain. Inflammation, however, may
exist without such symptoms, and both symptoms may exist
without inflammatory state of the brain. On account of its impor-
tance I repeat that numerous dissections have convinced me that
^ inflammation of the brain is by no means infrequent, while we
rarely find it unaccompanied by the symptoms which ' (according
to the theoretical opinions of the schools,) ^ should designate
phrenitis. The symptoms are referable rather to oppression of
the nervous power, than to increased activity of the blood vessels.'*
Fury depends only on the excitement of the organs of combative-
ness and destructiveness, while a too great activity of cautiousness
produces melancholy or despondency. This explains why, some-
times, fury and despondency may exist in the same person.
There are, indeed, positive facts on record, that individuals felt
the greatest inclination to destroy every being around them, and
at the same time the greatest anxiety and fear of committing
such atrocities ; they became quite disgusted of life, and disposed
to suicide. Such an opposite state in the feehngs cannot be
explained by a single mind, nor by a single state of disease of the
brain ; the only way of understanding it is by the plurality of the
functions of the cerebral parts, which may be affected singly or
together by the same disease, and produce various symptoms.

* Some cases illustrative of the pathology of the brain, read in the College
by Dr. Powel. Medical Transactions, vol. v.
28

218 INSANITY*

This explains also why mania and melancholia are often cuned
by the lowering proceeding, and at other times increase under the
same treatment. Hence not one single symptom can guide our
indication ; not the pulse alone, because in phrenitis with mania
it may be contracted, and in irritable and nervous subjects it may
be full and hard, while the disease is not at all hypersthenic, and
will increase under bleeding and the lowering method.

Thus the treatment of the hypersthenic state of the brain,
whatever the symptoms of insanity may be, such as erotomania,
fury, despondency, religious fanaticism, pride, liberality, &ic. is the
same, and may be termed loweriug. Bleeding is the genuine
remedy, opening of the temporal artery, cupping at the temples
or behind the ears, at the neck, leeches to those parts, venesection
at the arm, shaving the head, application of ice, cold water,
aspersion with water, or vinegar and water ; evacuants to keep
the bowels open, frequent use of serum lactis, decoctum hordei,
althese, lemonade 5 in short, the whole antiphlogistic treatment, as
in that state of the lungs or any part. If it be the result of refrig-
eratiouj called by some authors injiammatio 7'heumatica, blisters
will be of use ; but if it originate from spirituous liquors, inso-
lation, hard working without refrigeration, great application of the
mental powers, or any internal excitement, blistering will do harm,
in accelerating the circulation, and determining the blood to the
head. Any thing that irritates must be avoided, such as light,
caloric, camphor, vomiting. It even seems to me that we ought
to be very careful in administering opium and digitalis. I have
seen that, under their use in irritable persons, the symptoms
rather increased than decreased.

In this state of the brain is applicable what Dr. Hallaran says :
' Opening the temporal artery in recent cases of insanity affords
the most direct means of diminishing the excessive impetus of
the heart, and gives the most immediate relief. . . . Unless in young
persons, where the pulse stands from ninety-six to a hundred,
with a white tongue, hot skin, and suffused eyes, it should not be
resorted to. When these appearances are present it will un-

M£DICAL treatmejst. 219

^oubtedly be found expedient, if not essential, to the safety of
the patient.' In such cases bleeding is of urgent necessity ; I
Would not, however, consider it admissible merely under such
circumstances, but in la smaller extent it will be useful in cases
where the inflammatory symptoms are not quite so strong. For
it must be observed that inflammation is acute or chronic, violent
or slight, in various degrees ; and the antiphlogistic proceeding
must be always proportionate.

This is the real point where the talent of the physician appears*
It cannot be taught by any rule ; it requires what is called the
natural tact, but it can be exercised by practice. The patient is
treated according to the precepts of the school; and, if he die, it
is not the fault of the rule but of the physician, who does not un*
derstand how to modify its application. We may often see that
the general indication is well distinguished, but no distinction
made as to the individual modifications. I have seen inflammations
treated by physicians of celebrity without any consideration of the
individual forces of the patients. Commonly the quantity of any
remedy is mentioned, while it is often forgotten to add, that it is
necessary to consider the effect rather than the quantity, because,
supposing the indication is well established, the dose required to
produce the desired effect varies extremely in different individ-
uals. Such misapplications of the general rules take place in the
affections of the brain, as of the lungs, kidneys, bladder, he. ; and
the result will be the same ; that is, our ignorance as to the modi-
fications kills the patient, or makes the disease degenerate into
incurable disorders.

Another state of the brain, accompanied with its deranged func-
tions, is the result of debility ; I call it asthenic. Haslam ob-
serves : ' In bodily weakness, if the raving paroxysms have con-
tinued for a considerable time, and the scalp has become unusu-
ally flaccid, no benefit has been derived from bleeding.' To
this state particularly is applicable the opinion of Pine], * that
bleeding without rule and bounds often exasperates insanity, and
causes curable mania to degenerate into dementia and idiotism ;'

220 INSANITY.

and the other passage, where Pinel says, * The blood of maniacs
is so lavishly spilled, and with so little discernment, as to render
it doubtful whether the patient or his physician has the best claim
to the appellation of a madman.' Indeed, the lancet has been
very frequently applied to insane people merely for the purpose
of rendering them less noisy. I, however, do not wish to be un-
derstood as proscribing altogether the use of the lancet, even in
this state of the brain ; but it will be seldom necessary, and the
bodily strength is always to be considered, and bleeding modified.

This disease does not consist in melancholy or despondency ;
it may, like the former, produce all the symptoms of insanity,
such as melancholia, mania, pride, liberality, or a weakness of the
manifestations of the mind ; nay, entire apathy. On dissection in
these cases there is great congestion of the blood vessels; they
are weak, and the substance of the brain soft. The general con-
stitution of the patient is weak. Thus the bodily strength of the
patient before insanity, the beginning and progress of the disease,
previous debilitating causes, and all circumstances together, will
guide our decision. Such patients are weak and delicate, of a
nervous irritable temperament, a florid complexion, flushing face,
subject to haemorrhages, exhausted by evacuations, or of an inert
phlegmatic constitution. The quantity of blood, or the great ac-
tivity of the blood-vessels, is not the cause of insanity ; it is not
plethora vera, but congestion from weakness. Hence blood-let-
ting will not remove the cause of the complaint. Every thing,
however, which determines the blood to the head increases the
disease; such as spirituous liquors, artificial heat, hot weather,
affections of the mind, &:c. Such things then must be avoided.
The treatment must be tonic and nourishing without stimulating.

In great exacerbations of the symptoms blood may be drawn,
with precaution to empty the blood-vessels ; but without giving
strength to the blood-vessels, and tone to the cerebral organiza-
tion, they will soon be over-filled again. It is, indeed, a great
error to confound congestion with inflammation. In the latter
bleeding is the genuine remedy, and the whole treatment must be

MEDICAL TREATMENT. 221

lowering ; while in the former, at the beginning, a part of the
blood must be removed in order to procure a free circulation to
the rest ; but the cause of the congestion, viz. weakness, must be
removed by other means. The head is to be kept cold by-
shaving the hair, making aspersion with water, or washing the
head with cold water, or application of ice, mild evacuation of the
bowels. The internal remedies must be tonic without stimulating,
such as amara, decoctum cinchorus, cinnamomum, acidum sul-
phuricum, and, with the greatest caution, opium and digitalis.
The diet must be light, digestive, not lowering nor stimulating,
but nourishing. Good and well hopped beer ; milk, if digested ;
soft eggs, good broth, more animal than vegetable diet. Every
aliment that gives flatulencies and acid eructations must be
avoided.

A third state of the brain in insanity, from idiopathic causes,
may be called nervous. It has many symptoms common with
the second, but it is more dangerous. It exists in very irritable,
delicate, and so called nervous temperaments, where violent or
long-continued disagreeable affections, as anger, jealousy, envy,
offended self-love, sorrow, grief, disappointed love, &;c. have ex-
hausted the bodily strength. In such individuals, all diseases
offer a more severe and dangerous character, because the vis
medicatrix naturcB is enfeebled, and the symptoms are deceitful.
Appearances of inflammation, and crudities in the digestive organs,
are too often considered as causes of insanity, while they are, like
insanity, the effect of the same morbific cause.

The treatment of this state is not bleeding, purging, or vomiting,
but antispasmodics and tonics. The remainder of bodily strength
must be spared, the loss repaired, and the irritability calmed.
All that debilitates increases the disease. At the beginning of
insanity by violent affections, as fear, grief, anger, fury, he. opium
and other anodyne medicines are indicated. In anger a draught of
cold water is often useful, or cold water thrown over the whole
body and silence. Opium has a high rank in other irregularities,
and nervous affections of the body, and it is of great importance

222 INSANITY.

also in the derangements of the brain from moral causes ; but itsJ
tendency to diminish at the same time the action of the bowels is
not to be overlooked, if it be necessary to keep them open.
Then hyosciamus, moschus, castoreum, may deserve the prefer-
ence. Camphor in small doses is here often useful. The antispas-
modics have the first rank, then come the tonics, such as floras,
chamom, calumba, uqassia, gentiana, cortex peruvianus, martialia.
The external and dietetic treatment is the same as in the asthenic
state of the brain. In the same way, every thing which carries
the blood to the head must be avoided. ^

The preceding considerations easily explain why medical prac-
titioners often bestow much praise on the virtues of a remedy in
the cure of insanity, while others equally respectable decry it as
useless, and a third party declare it to be pernicious. Such
contradictions and opposite opinions may be all true and false,
because insanity is a mere symptom, and may be the result of
quite different states of the brain. Sometimes also the failure of
success arises more from the manner of using the remedies than
from any radical defect in their properties. I have already men-
tioned that sufficient attention is not always paid to all the indi-
vidual circumstances of the patient. The following remarks will
prove still more, that there cannot be a general antimaniacal
remedy, and that it is not sufficient to follow the common routine,
and prescribe copious and repeated blood-letting, water and
shower bath, blistering, vomiting, opium, purging, low diet, and a
rigorous system of coercion. Indeed such a medical treatment
must prove unsuccessful, and inspire indignation, and the complete
interdicuon of our profession.

Treatment of insanity from sympathic causes.

The greatest number of these cases may be reduced to four
sorts: viz. insanity is the result either of atony, or inanition of the
whole ; or of repelled cutaneous affections ; or of disturbed
functions of parturition, or of the deranged digestive organs. The

MEDICAL TREATMENT. 223

cases occur, as to number, ia an ascending proportion as the
divisions are mentioned, so that the first (from mere inanition) are
the rarest, and the last the most common.

In the first sort of cases, there are symptoms of general
exhaustion, and of inactivity of the mind. This state of insanity
may be cured, if there be no organic changes in the brain, as I
have already mentioned in speaking of fatuous patients. There
1 have detailed the Imedical treatment : viz. every thing that
awakens the vital power is indicated, and all debilitating causes
are to be avoided. The details may be looked for in the treat-
ment of the fatuous.

It often happens, that repelled cutaneous eruptions, suppressed
hsemorrhoides, drained up sores, rheumatismus vagus, produce
various internal complaints, in affecting such or such internal part
of the abdomen or thorax. The same causes may attack the
brain, and produce insanity. Now the deranged functions of the
brain must be cured in the same way as the other internal disor-
ders, such as bad digestion, difficult breathing, he. from the same
causes. The piles must be recalled by leeches adanum,
and by the application of the vapor-bath on that part. The
cutaneous discharge is to be re-established by blisters, issues, or
setons. These means, like others, having been employed indis-
criminately, in every sort and in almost every stage of insanity,
have had the fate of all other remedies ; they are praised or
blamed according to the efiect, while the nature of the disease is
overlooked. These means will be useful, where an excitement,
or a deviation of a morbific matter, or, as others like to say, of an
exciting cause, is wished for ; but in all cases, where excitement
is hurtful, their use is to be rejected. I think with Dr. Hallaran,*
' The early application of blisters, so long as the symptoms of a
powerful determination to the head can be discernible, cannot
well be persisted in by those who, taking into account the extreme
degree of excitement already produced, must be attentive in
avoiding every unnecessary source of irritation. An acquiescence

* Lib. cit. p. 89.

224 INSANITY.

with common custom, more than a feeling of conviction, has, 1 am
satisfied, induced many to commence the use of bhsters in the
cure of insanity at a time when, at best, their effect must have
been nugatory, and in most instances altogether improper. Their
direct application to the head under the above circumstances
cannot be too strictly condemned, nor do I consider them as ad-
missible in any direction, when the absorption of cantharides into
the circulation may act as an additional stimulus. Where a want
of energy and inaptitude to participate in the usual objects of vo-
lition, succeed to the previous temper of activity, the occasional
application of a blister round the lower part of the neck, will often
be found highly beneficial by its local irritation. The fever
excited by it rather tends to animate than to disturb.'

Dr. Hallaran mentions another inconveniency which happens
when, in maniacs, blisters are placed on the calves and other parts
of the body. The patients sometimes attempt to swallow them.
Moreover, it is a difficult matter to prevail on maniacs to allow
blisters to remain at the place. If the hands be secured, they
rub with the feet and dislodge the blisters. Thus, in far the
greatest number of cases of insanity, blisters, setons, or issues are
hurtful; in other cases they are of great use.

In women, a frequent cause of insanity is pregnancy, and the
deranged functions of parturition and lactation. The uterus is in
great sympathy with the stomach, the brain, and the five senses.
It is known that pregnancy produces various affections of the
digestive organs, excites various idiosyncrasies in appetite and
taste. In the same manner, often the manifestations of the feelings
are much excited or deranged ; sometimes amativeness, com-
bativeness, destructiveness, covetiveness, cautiousness, or any
other propensity or sentiment. There are examples on record,
that pregnant women liked coals, chalk, dirt, became extremely
lascivious, felt the greatest inclination to kill, to steal, or to build.
It is not necessary to mention examples that a difficult parturition
and the suppression of the usual evacuations which follow partu-
rition, may produce insanity ; they are generally known.

MEDICAL TREATMENT. 225

if pregnancy be the cause of insanity, the time of delivery must
he expected with patience, and we must confine our assistance to
mere palliative means against the most striking symptoms. If the
manifestations of the mind are deranged by suppression of the
usual evacuations, it has been cured by spontaneous diarrhoea.
In general, the best treatment of this sort of insanity consists in
purgatives, modified according to the individual patients. In such
delicate women the bowels are sometimes very irritable, and
strong purgatives will be very prejudicial. Here, as in every
disease, the vital power is not to be overlooked. Moreover, in
this sort of insanity, there are commonly derangements of other
functions, which are to be taken into consideration, and according
to which the treatment must be modified, always, however, with
the view of necessary evacuations.

The greatest number of cases of insanity, produced by sym-
pathic causes, originate from deranged functions of the digestive
organs. To this sort belong very often the cases of hysteria,
hypochondria, melancholy, and suicide from disease ; that sort of
insanity which is very seldom cured by nature alone, and which
is not sufficiently understood by medical practitioners. It often
begins as melancholy, and terminates in mania ; or both alternate.

The incongruity of remedies administered in this form of
insanity is inconceivable. As the disease is chronic, and its
nature not understood, one remedy after another has been tried,
and sometimes the most opposite things employed at the same
time. The patient is bled, purged, vomited, blistered ; he must
suffer issues, or setons ; swallow camphor, opium, digitalis, and
mercury ; he is plunge'd into cold water, takes warm baths ', and
whatever has been used in medicine is prescribed ; and — what is
to be expected — the patient is not cured.

It is known that the ancients considered hellebore as a capital
remedy against melancholy. Their explanation is erroneous, but
their method of curing is founded on observation. In speaking
of the forms of insanity, I have sufficiently detailed the symptoms
which occur in melancholy and suicide ; here I speak only of its
29

226 ■ INSANITY.

treatment. Because all things have been used without success,
almost everywhere these patients are given up to nature, or the
disease is considered as incurable.

In this form of insanity the lowering treatment is to be avoid-
ed ; the whole proceeding must be enlivening, animating, and
tonic. The lancet is destructive, and reasoning good for nothing.
The behavior towards such patients ought to be easy, kind, and
accompanied with looks of complacency, and not impatient, rough
and pitiless. Ridicule ought to be entirely prohibited. Change
of situation, and occupation of the mind, are of the highest im-
portance. The disease is cured according to the possibility of
removing the cause. If, for instance, a delicate female with
great sensibility be married with a drunkard or brutal husband,
and for that reason insane, it will be difficult to cure the disease
without removing the cause. The direction of the feelings, and
the whole moral treatment, are of great importance, but not
always sufficient ; and the effect of a proper medical treatment is
much greater than is commonly understood.

During a long period, aperient medicines are to be administered
in such a dose, that the bowels are at liberty ; that the evacua-
tions are not hard, nor liquid like water, but soft. Whatever
laxative is adopted, it must simply act as such, day by day, being
augmented, diminished, or interrupted, according to the strength
of the patient. Mercury is often administered on the purgative
principle. There are, however, patients with whom calomel does
not agree, and who from a small dose suffer all the symptoms of
salivation. Aperient mineral waters, or vegetable eccoprotics,
will be of more proper use. Sometimes there is spontaneous
diarrhoea in insanity ; the effect must decide whether it is salutary
or not. If debility increase, the violence of diarrhoea ought to be
diminished, if not entirely suppressed. The vital powers are of
the first condition ; and the greater their want, the longer time is
required to change the organization ; it must therefore be sup-
ported by amara and antispasmodica.

Mr. Haslam thinks that insane people have naturally irritable

MEDICAL TREATMENT. 227

bowels, and are easily purged. He has observed, that diarrhoea and
dysentery are common among them. Others think that they are
difficult to be purged. Dr. Hallaran, for instance, positively con-
tradicts the opinion of Mr. Haslam. The greater number of
melancholic patients, I know of, were rather costive than free in
the bowels. Sometimes diarrhcea and constipation have alter-
nated. The dysentery, of which Mr. Haslam speaks, seems to
be rather the effect of the moral treatment and of the diet of the
patients, than of the natural disease. Mr. Haslam himself has
observed, that sometimes the stomach and intestines are very
inert and quite insensible, in the same way as the skin. Such
patients feel no appetite, have a foul tongue, the bowels consti-
pated, the urine retained in the bladder, and the patients do not
feel the want to evacuate urine or faeces ; they sometimes require
the strongest purgatives to have one opening. Such patients
sometimes scarcely feel setons, blisters, and punctures.

The whole constitution must be changed, but no trespass is to
be committed on the prevailing debility. There must be moder-
ation according to the general state of the patient. The first evo-
lution is to be made by aperient medicines ; then mostly tonics,
such as amara, bark, martialia, and antispasmodics, become ne-
cessary. But every thing that irritates, such as spirituous liquors,
strong wines, spicy dishes, is to be avoided. The diet must be
simple and nourishing, not stimulating ; flatulent vegetables are to
be prohibited ; animal food is preferable, especially roasted meat :
good and well hopped beer; water and wine mixed. Many pa-
tients cannot digest milk, cheese, and such things as are given in
common hospitals for insane.

The perspiration of the skin is important in this disease.
The skin may be rubbed over with rough linen or proper brushes.
Tepid baths will be found beneficial. It is to be remarked
in general that practitioners do not agree with respect to the
usefulness of bathing in insanity. Pinel expressly declares,
' the utility of bathing in maniacal disorders remains yet to be
ascertained.' Haslam says that it is difficult to ascertain how

228 INSANITY.

far it is useful, since it has never been exclusively employed*
At the Retreat, near York, it has been thought rather to aggra-
vate the symptoms of mania ; but in melancholia it has been of
greater efficacy than all other medical means which have been
employed there. I think, in the plethoric inflammatory state of
the brain, and when the determination of blood to the head is
great, the shower bath or w^arm bathing is hurtful, and will in-
crease delirium or headache ; but in inactivity of the brain, in
dryness of the skin, rigidity or spasmodic contraction of the
muscular system, tepid bathing is useful. Tepid bath, in fine
weather, may also be employed for the sake of cleanliness^
Partial cold bath, or application of ice or cold water on the
head, is admissible only in a too great excitement of the brain,
both in the inflammatory state and in congestion of blood.

In former times, practitioners have been warm advocates for
a hberal use of emetics. Dr. WiUis mentions the deeper sem-
inaries of disease are seldom rooted out without the administering;
of vomits, but especially in the disorders of the brain and nerves,
where their use is found very advantageous. Dr. Cox still
thinks that ' vomiting takes the precedence of every other cu-
rative means. The action of emetics is not only confined to
the stomach, it extends through the whole system, affecting all
the vital and animal functions, agitating every part of the animal
economy.' It seems to me that, just on account of its great
influence on the whole frame, it cannot be indiscriminately
recom,mended. In a general apathy, if there be no great re-
laxation of the blood-vessels especially of the brain, or if the
faculties are suppressed by saburra in the stomach, vomiting is
indicated, biU wherever the vessels of the brain may be suspected
to be much clogged, it is to be avoided. I say with Dr. Hal-
laran,* ' The propriety of relieving the stomach from indigesti-
ble impurities, or of altering its action by the efibrt of vomiting,
I am very willing to subscribe to, though I cannot too forcibly
resist the practice of administering emetics to insane patients m

* Lib. cit. p. 52.

MEDICAL TREATMENT. 229

such doses as may suddenly promote the violent action of the
stomach, at a time when the vessels of the head may be sur-
charged with blood, and when the danger of over distension is
to be apprehended.'

From the preceding observations it results, that melancholia,
accompanied with the symptoms of hystery or hypochondry, or
the propensity to suicide, is the same disease, and must be
treated in the same manner. It is mostly considered as incu-
rable ; but I am convinced from experience that ignorance
alone is the cause of such a prognosis, and as soon as it will be
properly treated, its curableness will no longer be contested.

Before I finish, I shall make a few remarks on the use of digi-
talis and of the swing in insanity. Digitalis, from its known
influence on the circulation, is particularly used in insanity. It,
however, ought not to be administered indiscriminately. Young,
sanguineous, and very irritable patients cannot generally bear it.
In relaxation it is useful. Dr. Hallaran employs digitahs, where
evacuants have been given before. He prepares the patients
by purgatives to bear its employment. In such cases he prefers
it to opium as anodyne and soporific, since it procures a sound
and refreshing sleep, and is free from the objections which may
be made to opium. If its effect is too strong in producing
vertigo, nausea, vomiting, and a too slow pulse, he temporizes
and gives purgative medicines during the suspension. In this
manner he is induced to act with as much confidence as to the
expectation of recovery as he would in cases of lues from the
operation of the mercurial action. He recommends table beer
as a vehicle, if it be necessary to conceal digitalis. The de-
tails which he gives are worth the attention of practitioners;
hence I refer the reader to Dr. Hallaran 's own work. Among
all authors on insanity he certainly has given the best account
of this remedy. Our observations agree with his and with those
of Dr. Sanders,* viz. that it acts as a great stimulus ; hence its
influence must be carefully attended to.

' On Foxirlove.

230 JNSANITY.

The Swing, which has been made known to the public by
Dr. Cox as a moral and medical means, is a peculiar remedy in
insanity. Dr. Hallaran gives his full approbation. It is em-
ployed under two circumstances as a means of establishing a
supreme authority over the most unruly, and as a means of pro-
curing sleep. The swing, however, cannot be considered as a
general antimaniacal remedy, because there is no general remedy
against insanity. The immediate influence of the swing is low-
ering the circulation and general temperature of the body.
As its use determines the blood to the head, its employment
is contra-indicated in young plethoric patients in the inflamma-
tory state, or in congestion of the blood-vessels. More details
may be looked for in the works of Dr. Cox and Dr. Hallaran.

The preceding details may be sufficient to show that the med-
ical treatment of insanity must undergo an entire change, and be
reduced to the general principles of pathology. I finish with
repeating that the brain is an organic part, and is liable, as to
anatomy, physiology, and pathology, to every consideration of
any other organ. It is generated and nourished, it increases
and decreases, falls sick and is cured, like the rest of the body.
The material changes of the instruments alone are the cause
that the manifestations of the mind are deranged ; and in the
cure of insanity the instruments alone are restored to their natu-
ral state. The mind, as immaterial, cannot undergo any physi-
cal change.

CONCLUSION.

My intention was to contribute to the elucidation of the most
complex, most difficult, and entirely neglected branch of medi-
cine. This study, indeed, is in its infancy, and in our days we
cannot expect to see it in its maturity. I know the defects of
the preceding considerations ; but I know also the defects of
other works on this complaint. The new ideas I have com-
municated are founded on observations ; and if I have succeed-

MEDICAL TREATMENT. 231

ed to bring more order and a better arrangement into this
obscure matter, I am greatly rewarded. The manifestations of
the mind in their state of heahh and disease, during many years,
have been the favorite occupation of my intellectual powers,
and will continue to be so. Meanwhile I rejoice in the idea
that insane people will no longer be treated as outcasts, and that,
by degrees, we shall learn to alleviate their sufferings, to ame-
liorate their condition, and to restore their health.

ERRATA.

Page 237, line 1, for EsguiiiolfTea.d Esquirol. — Line 8, for where, read were.

Page 238, line 11, for or, read of.

Page 247, line 4 from bottom, for improvements, read improvement.

Page 250, line 5 from bottom, for 1252, read 1254. — Last line, for 2541, read
2543.

Page 254, line 10, for hemoral, read humoral.

Page 255, line 6, for a sudden course, while by adopting this cure, read a sudden
cure, while by adopting this course.

APPENDIX.

Insanity.

Of the various diseases which afflict mankind, none is viewed
with more painful feehngs or looked forward to with more dread
than that of insanity. This disease prevails however throughout
the civilized world, though to a far greater extent in some coun-
tries than in others. Dr. Spurzheim remarks, that it may he
considered almost endemical in England, and that the number of
the insane there, is, in proportion to the population, more consid-
erable than in other countries of Europe. Had he lived to have
travelled through the United States and made inquiries respecting
insanity, I have no doubt he would have found it to prevail to a
still greater degree here, than even in England.

To no people in the world, therefore, is a knowledge of the
causes of this disease ; methods of prevention and cure ; and the
general certainty of curing it In the early stage, more important
than to those of this country; and I am very desirous of awaken-
ing public attention to these particulars.

And, first, that it prevails more extensively in thus country at
present, especially in the Atlantic States, than in any country in
Europe, is, I believe, the opinion of all those who have made much
inquiry upon this subject.

We have no means of determining correctly the number of
insane persons in the United States ; but if there are as many in
the other States of the Union as in Connecticut, the number can-
not be less th^n fifty thousand, or one to two hundred and sixty
two of the population ; as is evident from the following facts. In
1812, a committee was appointed to ascertain the number of
30

234 APPENDIX.

insane persons then in the State of Connecticut. The members of
this committee addressed letters to the physicians and other per-
sons in every town in the State, requesting correct information
upon this subject. They received answers so as to enable them
to determine the number of insane in seventy towns, and after
much deliberation and further inquiry, reported they were ' satis-
fied there were one thousand individuals within the bounds of the
State mentally deranged, and that the condition of many of
them was truly deplorable.' On mentioning this statement,
recently, to the Physician of the Retreat for the Insane at Hart-
ford, and my surprise at the great number reported by the com-
mittee, he assured me, it was less, he believed, than the actual
number of insane persons in Connecticut. Other members of
the committee who made the investigation and the above report,
have also stated to me that they are convinced from subsequent
inquiry that 07ie thousand is considerably less than the actual
number of idiots and insane persons in the state. But if we
admit there were 1000 individuals mentally deranged in 1812, or
1 to 262 of the inhabitants, then there were more than twice as
many in this deplorable condition, as in any country in Europe,
in proportion to the population. The number of the insane in
England has increased within the last twenty years, but still
there are but about 14,000 in that country, one half of whom are
idiots.

In Scotland the proportion of insane to the population, is 1 to
574, and in the agricuhural districts of England, 1 to 820.

I am not aware that any State in the Union has correct returns
of the number of its insane. Dr. Beck mentions, that accord-
ing to the census of 1825, the State of New York contained
1,616,458 inhabitants, and 819 lunatics, and 1421 idiots.
Whether the inquiry as to the number of the insane in that State
was made in such a manner as to ascertain correctly the number,
I cannot say ; if it was, then there is far less insanity in that State
than in several others in the Union.

Dr. Parkman of Boston stated in 1818, that 289 male, and

INSANITY.

235

252 female insane persons had come to his knowledge in the
State of Massachusetts. He supposes, however, that he has
heard but of part.

According to a report of a committee of the legislature of that
State, made in January, 1833, it appears that they had ascertained,
that in 68 towns, containing a population of 264,327', there were
168 insane persons, and 111 idiots in confinement in jails, alms-
houses, and houses of correction.

This would make above 600 of insane and idiots in confine-
ment in the State, which contains but 610,014 inhabitants. But
it is probable that only a small part of the insane and idiots are
thus confined, and no doubt an accurate inquiry would exhibit
more than double, if not triple that number in the State.

But these facts are sufficient, when properly appreciated, to
call public attention to the great prevalence of insanity, and
awaken the philanthropists and statesmen to devise measures for
its relief and prevention.

The Causes of Insanity in this country are various. But
among those that are most operative in this country are in my
opinion,

First, Too constant and too powerful excitement of the mind
and feelings, which the strife for wealth, office, political distinc-
tion, and party success produces in this free country, and the
great anxiety, and excitement of the mind upon religious subjects,
caused by injudicious appeals to the feelings and imagination, and
by sectarian controversy.

Second, The predominance given to the nervous system, by
too early cultivating the mind and exciting the feelings of children,
to the neglect of physical education, or the equal and proper
development of all the organs of the body.

Third, The general and powerful excitement of the female
mind. Females, being endowed with quicker and finer sensi-
bilities than men, are more likely to be injured by strong emotion ;
but as we shall see, such emotions may have deplorable effects
upon their offspring.

236 APPENDIX.

Fourth, Intemperance, and to this cause, no doubt, a very-
considerable part of the insanity and idiocy that prevails in this
country is to be attributed.

That these are the most frequent causes of this affliction in this
country, is evident from the following facts and observations.

In all countries the disease prevails most among those, whose
minds are most excited. Aristotle noticed in his day, the great
prevalence of insanity among statesmen and politicians. Thus
we find that insanity prevails most in those countries where peo-
ple enjoy civil and religious freedom, where every person has
liberty to engage in the strife for the highest honors and stations
in society, and where the road to wealth and distinction of every
kind is equally open to all. There is but little insanity in those
countries where the government is despotic. The inhabitants of
such countries possess but little mental activity, compared with
those who live in a republic, or under a representative govern-
ment. There is but little insanity in China, and travellers state
that there is but little in Turkey. The disease is uncommon in
Spain and Portugal, though idiots are numerous in those countries.

In France there is much less insanity in the country than in
the cities; and the same is true of Russia and Ireland. Hum-
boldt states that he saw very few cases of mental derangement
among the American savages. In such countries, the spirit of
inquiry and improvement is seldom awakened, or is soon stifled
when it is ; and the inhabitants exhibit but little more mental
excitement than the brute creation.

In all ages and countries, insanity has prevailed most in times
of great moral and mental commotion. The crusades, and the
spirit of chivalry that followed them ; the reformation of Luther ;
the civil and religious discords of Europe 5 the French revolu-
tion, and the American revolution, and the rebellion in Ireland
greatly multiplied cases of insanity.

But not only do the commotions which powerfully affect the
minds of people, occasion immediate insanity in adults, but they
predispose the next generation to this terrible disease : and this

INSANITY. 237

is a fact that deserves great consideration. Esquinol says, that
many women, strongly affected by the events of the revolution,
bore children that the slightest cause rendered insane. He is
supported by others in this opinion, that strong mental emotion of
the mother predisposes the offspring to insanity.

Another cause which J believe is very operative in this country
In producing insanity, is thus alluded to by Dr. Burrows.

* Where I to allege one cause, which 1 thought was operating
with more force than another, to increase the victims of insanity,
1 should pronounce, that it was the overweaning zeal with which
it is attempted to impress on youth the subtle distinctions of the-
ology, and an unrelenting devotion to a dubious doctrine. I
have seen so many melancholy cases of young and excellently
disposed persons, of respectable families, deranged from either
ill-suited or ill-timed religious communication, that I cannot avoid
impugning such conduct as an infatuation, which, as long as per-
severed in, will be a fruitful source of moral evil.'

Lastly, That the abuse of intoxicating liquors produces insan-
ity, is a fact, which the records of all lunatic hospitals exhibit.
It has been observed in other countries, and in our own. Dr.
Combe remarks, that ' the remarkable increase of insanity among
the lower orders in Great Britain, particularly in the manufac-
turing districts, has been pretty accurately traced, partly to the
miseries, want, and anxiety inseparable from the fiucmations to
which they are exposed ; and partly to the prevalence of dram-
drinking, as the only means of relief within their reach. That it
is not the mental distress alone which is the cause, is proved by
finding the large majority of the patients to be among those who
have been most intemperate.'

The general certainty of curing this disease in its early stage,
is a fact that ought to be universally known, and then it would be
properly appreciated and acted upon by the public. That the
greater proportion of the insane, who receive proper remedial
attention, in the early period of the disease, are cured, is evident
from the followins; facts, selected from a sreat number of similar

238 APPENDIX.

ones. Dr. Willis, in his evidence before the committee of
Parliament, in 1789, averred that nine out o^ ten cases of insan-
ity recovered, if placed under his care within three months from
the attack. Dr. Burrows stated in 1820, that of recent cases
under his care, 91 in 100 recovered, and in 1828 he adds, that
the subsequent annual reports of various lunatic institutions, and
his own wider field of observation confirm the above statement.
In La Salpetriere at Paris, the proportion of cures of recent
cases was in 1806-7, according to Dr. Carter, almost as high as
that of Dr. Willis, and according to Dr. Veitch's official statement
to Parliament, nearly two or three of the recent cases were
discharged cured, while only five out of 152 old cases recov-
ered.

Dr. Ellis, director of the York West-Riding Lunatic Asylum,
England, stated in 1827, that of 312 patients admitted within
three months, after their first attack, 216 recovered ; while in con-
trast with this he adds, that of 318 patients admitted, who had
been insane from upwards of one year to 30, only 26 recovered.

The same happy result has attended upon remedial measures
adopted in the early stage of insanity, in this country. At the
Bloomingdale Asylum, New York, of 581 recent cases, 341 were
discharged cured ; and at the Connecticut Retreat, during the
first five years, of 97 recent cases, 86 were cured.

From these facts, every one will be able to arrive at a correct
conclusion, as respects some of the most frequent causes of insan-
ity in this country, and all will see the vast importance of early
attention to remedial measures.

EpiLEPsy.

According to the researches of M. M. Bouchet and Cas-
auvielh, a great analogy exists between epilepsy and mental
alienation. Epilepsy, they say, results from chronic inflam-
mation of the white substance of the brain, while chronic
mental alienation is the result of slow inflammation of the grey

EPILEPSY. 239

substance of the circumvolutions of the same organ. This con-
clusion as to the cause of epilepsy is hardly reconcilable with the
sudden invasion and short duration of the attacks of this disease ;
but certain it is, that a great analogy exists between these two
diseases. Most epileptics ultimately become insane ; some, how-
ever, never do.

On examining the bodies of those who have had attacks of epi-
lepsy, but who have died from other diseases, and who had
exhibited no symptoms of intellectual disorder ; no alteration is
found in the brain, and often their bodies present no viiible signs
of disease ; but if they have died during an attack of epilepsy, the
brain is found engorged with blood. If they have died after fre-
quent epileptic attacks complicated with intellectual disorder, the
white substance of the brain is generally found hardened and
rough, and injected with blood ; sometimes, however, this sub-
stance is softer than natural, and its blood vessels enlarged.

In such cases, the grey substance of the brain has undergone
an alteration, its consistence has increased or diminished, and
often we find adhesions between the surface of the circumvolu-
tions and the membranes, and traces of chronic inflammation in
other parts of the brain.

The treatment of epilepsy, as Dr. Spurzheim observes, should
vary with the cause that produced it. I have known many epilep-
tics very much benefited even when the cause appeared to be
some organic affection of the head, by a seton in the neck, a light
regimen, moderate but daily exercise in the open air, and the
avoidance of all moral and mental excitement. Attention to these
last particulars, is very important with children who exhibit a ten-
dency to this disease. I have frequently noticed attacks of epi-
lepsy and convulsion in children with large heads, and premature
manifestation of the mental powers, and have known these attacks
lessened and prevented by withdrawing such children from study,
and all mental labor and excitement, and allowing them daily, but
e;entle exercise out of doors.

240 APPENDIX.

Palsy.

Numerous cases are recorded of persons losing the power of
moving their limbs while sensibility remained undiminished in the
same parts. I have recently seen a young man who having slept
on the ground for several successive nights, suddenly lost all
power of moving any part of his body except his head, while sen-
sation remained unimpaired. Other cases have occurred in
which sensibility has been destroyed, while the power of voluntary
motion remained.

Such cases long perplexed physiologists. Galen and others
advanced the opinion that there were two sets of nerves distributed
to every part of the body, one to give sensibility, and the other to
confer the power of moving the muscles.

These theoretical views have recently been shown to be true
by the experiments of Sir Charles Bell and M. Magendie. These
celebrated physiologists have ascertained by examination and
experiments, that the spinal marrow gives off two sets of nerves,
and that the nerves from the anterior column of the spinal mar-
row are for motion, while those from the posterior part are for
sensation. At the place where these nerves come off from the
spinal marrow, their separation is very distinct, and if the anterior
nerves are compressed or cut, all power of voluntary motion is
destroyed, while sensibility remains ; but if these anterior nerves
are not injured and the posterior cut or compressed, then sensation
is diminished in the parts to which these nerves are distributed.
These important facts have been verified by examination of the
spinal column and nerves of those who have died paralytic, and
fully explain the phenomena above mentioned.

Apoplexy.

Half of the sudden deaths at Paris, according to Falret, are
from Apoplexy; and it is a curious fact that this disease as well
as Palsy and other diseases of the head and nervous system, have
greatly increased of late years, as the following statements exhibit.

APOPLEXY. 241

There died of Apoplexy at Paris, during the ten years preced-
ing 1803, or from 1793 to 1803, 339. In the next ten years,
1803 to 1813, 979. From I8i3 to 1823, 919.

In London the same increase of Apoplexy and Palsy has been
noticed. During the last four years of the seventeenth century,
from 1696 to 1700, there were 80,586 deaths in London; and
during the four last years of the eighteenth century, 72,591. But
though the deaths during the four first years were most numerous, on-
ly 442 were by apoplexy, and 89 by palsy ; while during the last
four years 912 were by apoplexy, and 363 by palsy. What is
this difference to be ascribed to ? In my opinion to those causes
which have called forth the intellectual energies, and excited the
feelings of men more at one period than another.

Treatment of Apoplexy, In addition to the methods of treat-
ment mentioned by Dr. S., it is of great importance to keep both
the body and the mind of the patient quiet. The body should be
kept erect or nearly so, and no excitement of the senses should
be allowed. Light ought to be excluded, and no noise or con-
versation allowed in the apartment of the sick person.

The patient should not be moved, for his brain is wounded, and
no motion should be allowed it, any more than to a fractured limb
that we wish to have heal.

Bleeding from the nose by the lancet or by leeches is import-
ant ; a small quantity of blood obtained from the nose often does
more good than a very large quantity taken from the arm. If the
patient recovers from one attack he should forever after refrain
from intellectual labor, and avoid as much as possible the excite-
ment of the feelings. His diet should be light, and he should
sleep with his head elevated and have recourse to daily but moder-
ate exercise, and by these means, and by preserving a quiet state

of mind, he may perhaps avoid a second attack.
31

242 APPENDIX.

Phrenitis. Inflammation of the Brain.

M. Foville, in the * Dictionnaire de Medicine et de Chirurgie
Pratiques,' has advanced a new method of procedure in the treat-
ment of this fatal disease. He recommends recourse to the
trepan in violent cases. He says that the brain, occupying the
whole of the interior of the skull, and being enveloped in a solid
case, does not as other parts of the body receive pressure fronn
the atmosphere. Consequently when more blood than usual goes
to the brain, pressure of its substance must occur, and it often
does to such a degree as to destroy life.

He states the well-known fact, that bleeding does not so fully
relieve this pressure on the brain as it does other organs, unless
aided by the pressure of the atmosphere. And we know that in
animals bled to death, though die lungs and other organs are pale
and free from blood, yet the brain still contains a large quantity.
M. Foville refers to numerous cases in which the removal of
large portions of the skull by wounds and blows and even by fire
was unaccompanied by severe inflammation or other bad symp-
toms.

I am disposed to think this method deserves consideration and
trial, considering the fatal tendency of the disease. I have often
been surprised to notice that severe blows on the head which
fractured the skull to such a degree as to make it necessary to
remove considerable portions of it, have been followed by no bad
consequences; while on the other hand, I have frequently known
slight blows upon the head, which in some instances have not
fractured the skull at all, and in others only the outer table, to be
followed by inflammation and other alarming symptoms and death.
I am therefore of opinion thai an opening in the skull might be
beneficial in such cases.

Hydrocephalus Acutus.

This exceeding dangerous disease of children appears to have
greatly increased of late years. Fifty years ago, 1783, but 19

IDIOTS. 243

deaths occurred from this disease in London, but during the last
year, 1832, there died at London of Hydroceplialus 858.

Dr. S. has well remarked, that 'those whose brain is developed
early and rapidly, and whose mental powers show a great and
premature energy are most liable to this disease ; ' and a late wti-
ter in the Medico-Chirurgical Review observes, ' The present
plan of education, in which the intellectual powers are prematurely
exercised, may be considered as one of the causes of the more
frequent occurrence of Hydrocephalus.'

I have witnessed several fatal cases of this disease, in children
remarkable for superior mental powers, and so closely was the
disease connected with great mental application at the infant school,
that I could not but believe that this severe mental application pro-
duced the disease. I therefore concur in the above opinion that
the present plan of prematurely developing the minds of children
is one cause of the increase of this almost uniformly fatal disease.

Idiots.

The brain of an idiot never resembles that of a sane person.
Its form or texture is different. Often it is found to be very small,
even when the external appearance of the head is not bad. I
have known the skull of an idiot boy to be three fourths of an
inch in thickness. Sometimes the anterior and upper parts of the
brain are not formed. M. Payan of the Hospital des Enfans in
Paris, in 1825, found in the head of an idiot, only the lower con-
volutions of the brain.

Sometimes the brain appears to have wasted away, or to have
been absorbed. This state of the brain is usually accompanied
by atrophy of the members. A very remarkable case of this kind
and one very deserving of the attention of the physiologist, occur-
red at Paris in 1823. It was that of an idiot whose head was ex-
amined by Esquirol in the presence of a great number of pupils.
Previous to his death, this idiot exhibited a very singular appear-
ance. One side of his body was in a state of atrophy. The
limbs of this side, the right, were wasted away so that nothing

2i4 APPENDIX.

apparently remained but the skin and bones, and were consider-
ably shorter than those of the left side ; and incapable of move-
ment. The limbs of the opposite side had their natural develop-
ment, and were capable of voluntary motion. The head was
small, but the bones of the skull presented nothing remarkable.
On opening the head nearly all the grey cortical substance of both
hemispheres of the brain was found wanting. In place of the
usual convolutions, were small irregular granulations. As regard-
ed the white substance of the brain, that of the right hemisphere
was not affected, but scarcely any at all was to be found in the left
hemisphere, and its place was filled by a sac or cyst of transparent
fluid. All the other parts of the brain were natural.

This case throws much light upon some disputed points in
physiology, and demonstrates that the grey substance is not
essential to voluntary motion, for if it is, the limbs of the left
side of the body should have been affected as well as those of the
right.

This case gives support to the opinion of Sir Charles Bell and
others, that the grey cortical substance of the brain is the seat of
the intellect, and the white medullary portion merely transmits
sensation and volition. Sir Charles states, that he has found at
different times all the internal parts of the brain diseased, without
loss of sense, but that he has never seen disease general on the
surface of the hemispheres without disorder of the mind.

This view is probably correct. Prof. Jackson of Philadelphia,
says that if the superior parts of the brain are removed in animals,
the intellectual faculties as far as they are possessed by them, are
annihilated ; and he adds, that pathological observations justify
the above conclusion of Sir Charles Bell. Dr. Warren of Boston
remarks, « that the cortical part of the brain is the seat of memory,
is an opinion I have long entertained, from finding that any con-
tinued undue pressure upon the upper and anterior part of the
brain entirely destroys memory, and a less degree materially
diminishes it.

HALLUCINATIONS. SUICIDE. 245

Hallucinations.

Hallucinations of sight and hearing may depend upon some alter-
ation of the nerves of sight and hearing. The alteration of the
nerves in insanity has been as yet but little attended to. M. Foville
says he found the optic nerves hard, half transparent and changed
from their natural structure in their whole extent, in an insane
patient who had been tormented until his death with horrible
hallucinations of sight. The eye itself presented no change
during life, with the exception of a contracted state of the pupil.
I have observed in patients troubled with hallucinations of sight,
that they complained of pain on pressure of the eye, and that their
eyes were frequently red and inflamed, and the pupils contracted.

Suicide.

This appears to be an increasing propensity. We almost
daily hear of suicide from different parts of our own country, and we
have long known that it was common in England and France.
In 1817 and 1818 there were 681 suicides in Paris and vicinity.

The causes of this propensity to self-destruction are no doubt
numerous. Though it appears to be a form or species of mental
alienation which is often hereditary, as is stated by those who have
written upon this subject, yet vicious modes of education, the
violence of the passions, and intemperance, appear often to pro-
duce this tendency. Under the influence of intoxicating drink or
the violence of passion, the whole physical, intellectual and moral
system is deranged, and men then act totally different from what
they intended to, when sober and sane. I have several times
noticed this propensity during intoxication of individuals, who at
other times were not in the least inclined to it.

It is also true that the abuse of religion, the excitement of the
feelings upon religious subjects, awakened often by powerful, but
improper appeals, to the feelings and imagination, have often given
rise to this propensity, and should lead religious teachers to be
extremely careful and timely in these respects.

246 . APPEJSDIX.

Of all the sentiments of the human heart, none is so powerful as
religion. An accurate observer remarked, that religion has more
influence on mankind than all their passions combined. And as
each passion may be excited to excess, so as to cause mental
derangement and suicide, so may the religious feelings be so
strongly excited as to produce like consequences. But it is the
abuse of religion that leads to insanity and suicide ; for pure
religion, Christianity, tends to subdue the passions of men.

But if the abuse of religion sometimes leads to suicide, the
entire neglect of it does more frequently 5 as is evident from the
writings of Esquirol, Falret and others.

' Irreligion, ' says Falret, 'is certainly a very frequent cause of
suicide. Those who think all there is of man perishes at once,
who do not believe in another life, are necessarily disposed to
abandon this, when it appears to be but a source of calamities.'

The details of suicide in newspapers is probably injudicious,
and by many writers supposed to lead others to commit the same
act.

However strange it may appear, yet suicide is sometimes recip-
rocal, and two individuals destroy themselves at once by agreement.
An instance of this kind occurred recently in Boston, and several
others are related by writers on suicide. One instance occurred
in London in 1726, and another at Lyons in 1770.

Monomania.

It is 'seldom that all the mental facukies are deranged at once.
Most usually but one faculty is affected, though sometimes sev-
eral appear to be and probably are. Such cases of partial insan-
ity are better explained by the system of Phrenology than any
other. Every Lunatic Hospital presents instances of individuals
in whom the primitive faculties as established by Gall and Spurzheim
are disordered. Numerous cases are related by writers on insan-
ity in which the organ of Tune is diseased ; and others in which
the organs of Locality, Form, Size, Color and Number are
affected.

MONOMANIA. 247

I have a patient at the present time, a respectable and intelligent
gentleman of this town, sixty years of age, who exhibits no other
symptom of mental derangement than a total loss of the memory
of places. He has perfect recollection of persons and events,
enjoys good health, and his sight and hearing are remarkably good
for a person of his age, yet he does not recognise the place where
he has lived for the last twenty years, not even his own house.
If he rides from home but a few miles, though he recognises his
former acquaintances whom he meets, and converses rationally
on all subjects, yet on returning to his house he has no recollection
of ever having seen it before, inquires who lives in it, and is
surprised to find that his family had arrived before him.

Age has an influence on Insanity.

As Dr. Spurzheim observes, insanity is not a disease very often
noticed in the very young or the very old. and he thinks that gen-
erally those cases which are reported as cases of insanity in very
early life are cases of partial idiocy from imperfect developement
of the brain. But there are some unquestionable cases reported.
Esquirol relates three cases, and says he has known children ren-
dered insane by jealousy, by fear and the severity of their parents ;
and Pinel has made the same observation. The former relates
the case of a child, ' endowed with precocious intelligence, with a
head uncommonly large,' and who became menially deranged at
the age of eleven. He states also, that he has known many stu-
dents, animated by a desire to surpass their comrades, to be-
come insane after pursuing severe studies. Such cases are not
uncommon in this country. I have seen several, and they ap-
peared to me to have arisen from too severe and too incessant
labor put upon a brain deficient in size. Scholars of strong
ambition and but little talent, who, actuated by a great desire
to equal or surpass their companions in study, labor incessantly,
and strive to make rapid improvements, and thus, as Dr. Combe
observes, 'goad on and lax their limited powers to the uttermost,
pi ace their cerebral organization on the brink of disease, and
require only a trifling cause to produce mental alienation.'

248 APPENDIX.

M. Foville says, he has seen a child of ten years of age, whom
the assiduous reading of romances rendered insane. This child at
last believed himself one of the heroes of the works he had read,
and passed most of his time in striking the walls, trees, &ic. which
he took to be enemies.

Hereditary Insanity.

No doubt insanity is hereditary, but it does not follow, however,
that every child of an insane parent will become insane. But it
should lead all those in whom this predisposition exists to adopt such
measures as will be likely to prevent its explosion. Children of
insane parents should be very carefully educated, they should
be kept from all mental excitement when young, and great
attention should be paid to the developement of the physical
powers, and they should be strengthened by exercise and
labor. Such children should not be sent to school at an
early age ; as the early exercise of the mind increases the action
of the brain and thus increases the tendency to this disease.

Pathological Appearances.

That insanity is a corporeal disease, and that the manifestations
of the mind are disordered because the brain, the organ of the
mind, is disordered, none will now dispute ; and generally though
not always mental derangement is connected with alteration of the
structure of the brain. Sometimes, no doubt, especially in the early
stage of insanity, the disease is cnly functional, and patients who
die in this stage may exhibit no trace of organic disease in the
brain, but they usually do. Dr. Haslam says, that insanity is al-
ways connected with organic alterations of the brain. Greding
noticed, (besides other organic disease) thickening of the skull in
one hundred and sixty-seven, out of two hundred and sixteen
cases. Georget, Bayle, Wright and nume rous other observers, have
usually noticed some organic affection in those who died from
insanity. Mr. Davidson, house surgeon to the Lancaster County
Lunatic Asylum, examined with great care the heads of two
hundred patients who died in the Asylum, and he says, he 'scarcely

INSANITY. 249

met with a single instance in which traces of disease in the brain
or its membranes were not evident, even when the lunacy was
recent, and the patient died of a different disease.'

Sanability and mortality of insanity.

The degree of sanability and mortality in Insanity will be
sufficiently exhibited by the following tables, drawn up from official
reports.

33

250

TABLE.

FRANCE.

Period.

S a
S a;

^^

1002
333

289
891

102

97
499
355
214
335
300

4417

o

473
160
136
413

33

33
161
134

91
173
177

1984

03
o

Q

250
33

70

36

•s

B

<u

Pi

270
140

83

142

!3 .

.w be
Q

5

Decimal
propor-
tion of
cured.

Hospital Salpetriere

Pinel,

Esquirol . .

The same . .

Pinel . . .
Hospital Bicetre . .

Chamseru . .
Hospital Charenton . .

Pinel . . .

Foder6 . . .
Royer — Collard . . •

Chamseru . .
Esquirol's private Institut.
Dubuisson's . ...

1801—1805
1806
1807

1812—1814

1807

1789—1800

1803

1806

1-2 of 1807

1801—1813

0.47 1-5
.48

.47 1-18
.46 1-5

.32 1-3

.34

.32 1-4
.36 2-3
.42 1-2
.51 7-11
.59

Sum for France . . .

0.44 9-11

ENGLAND.

Bethlem, ace. to Haslam
Haslam, (different account)
St. Luke's— Tuke . .
Hospital at York — Fodere
Retreat at York — Tuke
Hos. at Manchester — Fod.
Hosp. Montrose — Act Pari.
Hos. Nottingham—Burrows
Hosp. at Exeter — Burrows
Hosp. Glasgow — Burrows
Hos. Manchester — Burro.
Bethlem — Act of Parliara.

1748—1794
1784 1794
1751—1819
1777—1807
1796—1811
1766—1805
1805—1815
1812—1819
1801—1819
1819
]820
1800—1815

8874
1664

12173

1739
149

1686
154
336
626
183
350

4810

32744

2557

574

5091

746
49

667
34

179

355

39

74

1839

12204

1013
192
26
190
36
39
53
10
31

166

141

47

85
54
48
45
106
190

410

18

220

25

2

5903

250

9

324

5

70

173

28

71

.28 7-9
.341-2
.41 5-6
.42 7-8
.32 4-5
.39 1-2
.22 1-13
.53 1-4
.56 5-7
.21 1-3
.21 1-7
.39 1-4

Sum for England . .

0.37 2-5

UNITED STATES.

NewYork Lunatic Asylum
Pennsylvania Hospital
Bloomingdale Asylum
Friends' Asylum, Penn.
Connecticut Retreat

Sum for United States

1795—1821

1752—1828

7 1-2 years

8 years
5 years

1584

700

153

3487

1252

526

1043

436

59

158

53

21

196
6468

100
2541

8

44.19
35.96
41.80
33.54
51.01

41.30

H

p

t^

52

•> CQ

w 2

« '^

o

<ii S t; — c3 ^ ca

s2 4) 4J ■ ~ tn

1 O bJD C CI — _ij -

;io ts o MO) cs~js

*-^ cj (y s ;; ^^ /-^

CO

• If*

o

1i

OS

CO

^

d

o

"I^PI,

•uaxuo^

O CO 0> Ci 1— 1 ■>* O

•U8I^

<
O

o ^ .

•p^oj^

•uarao^

•naH

1-M Tj* lO CO O? O^ r-t

1> Tj<

o o

O CO

1-1 oi

rl GO

CI w

XlG0C30rH(MOOJ>O

i> c: -^ CO CO '^ i>

T-( C^ CQ 1— 1 rH

a .TO

O CO

.2^

1-1 c4

X O? lO QO O UO 1> 1-1 O
lO uO UO '«*' uO CO t>. T-i
CO<M T-t

O ^

Ci 1> CO iC 00 O ^
O? CO CO Oi — I -^ o

C^ rH r-1

G CO

Ciiocico(rjcicoi>co

C>? 1-1 tH C< CO 1-1 J>

I CD CO

G CO

.-I T— 1

C>?
CD

•uarao^

•nan

Tj< O CO iTi lO ^H Tf
rH 1—1 (>? 1—1 J> lO CO

CO CO
(71

•-1(7?

CO (7i rti 00 Ci CO rf
tP CO (»

(?J(M

LO

CO
CD

•uarao^

•U8I\[

oocoi>cocriOco(7?

tH l>. '^ (7?

— I CO

(3 CO

X) uO O i-< t* J> Tt o
1-t 1— I rH CO CO (>i

CO ^.
•^ CO

c?

00

•nauiOjW

•naj^

i>COC01>'^lCr-'(7l
CO LO Tt*

IC (3^

.3 CO

1—1 CO

O O t>. 00 J> CO Ci
T-i 1— 1 "^ -^ C<!

lO 1>

i-0(7i

1— i Ift

o ^

S to

—I gj

(15 ^

•p?oX

CQ CO 1> CO

QO rt rH t^

•<* UO '^

lO Ci
00 00

^ CO

GO

.-H ,—1

1-1 (7?

uarao^

CO O 00 lO

CO CO QO CO

(7? (MOi

CO o

^H CI

00 CO

-H(7i

•n8i\[

wi CO Ci GO

Tji 00 C7J O

rH(7i (M

Ci Ci
CO(>J

QO

•uamo^

1-1 00 1> 00
^ i> 00 1>

"* lO
(M— I

G "^

•U8I\[

IlO CO CO O
1-1 CO 00 to

CO Ci

G lO

(7?

00

•U9UI0^

i-H 1— GO 00
rH 00 Ci 00

X) tH
CQ T-l

•U9K

CO

U9tUO^

•uaW

s

a;
bo

CT: in ■^ Ci
r- CO l> CO

(MCi

1— ! -H CO Cs
r^ l> o (T:)

TO CJ

(7J 1-1

lO (7J (7J O
1— < to 1> 00

c:i CO
— o

(7J T-^

r-<(7?CO'^tOCOt^00 O

ooOoooooS

G

fi .2

r/i >::,

Oi 1

o ^

G CO

1-1 (>i

G "^

•is CO

r-l(?j

G C^
1-1 G<!

1-1 (??

OOOOOOOO
i-i(7JC0'<S<tOCOi>CD

o :: :; :;

•^ " bo

15

S2

o

^'o

•^ *J

erf
01

G

-P o

F! o

w

-6^

P^ S

G
O

H

O

09

252 APPENDIX.

Lunatic Asylums.

These are numerous and increasing, and are well conducted in
England, Ireland and Scotland. But this is only recently the
case. Until a short period the insane belonging to the poorer class
have been crowded into public workhouses, or shut up in houses of
correction or in prisons ; and associated with thieves and murder-
ers. This practice still prevails in many countries, and I fear it
does to a great degree in our own. Instead of being classed as
they should be with the sick and infirm they are treated often
as criminals.

In France, lunatics have long been well treated, and consid-
ered as sick persons and attended upon in hospitals by the bro-
thers and sisters of the religious order of La Charite.

In the Netherlands the insane are exceedingly well provided for,
but in several other of the northern continental States they are
not. In Hanover, according to Halliday, the whole of the luna-
tics of the kingdom are shut up in the national prison at Celle.

In Prussia, the lunatic hospitals are well conducted, as well
as a]l the charitable establishments of that country.

In Spain and Portugal are lunatic asylums, where the inmates
are kindly attended by friars and nuns, but little is done in
way of cure. Insanity is not however very prevalent in those
countries.

In Italy are several excellent establishments for lunatics, es-
pecially at Milan and Naples. Austria has not made the im-
provement in the treatment of the insane, which the neighboring
countries have. Dr. Burrows says, the present lunatic establish-
ment at Vienna is a disgrace to the capital and the era of the nine-
teenth century.

It may be truly said however of all countries, that asylums for
the insane are too few. Though by an act of Parliament in 1806,
the magistrates of the several counties in England and Wales,
were authorised to erect asylums for the insane poor, yet many
counties still remain destitute, and the insane still suffer for want
of care. In the United States are a few asylums, and well con-

LUNATIC ASYLUMS. 253

ducted ones, but they are only enough to relieve a small por-
tion of the suffering that abounds from insanity, and which might
be relieved by more numerous and larger asylums. But we trust
the time is not far distant when every State in the Union will have
one or more for the insane poor.

There are several private establishments in this country, where
the insane who have property, can be well provided for and at-
tended to, but as yet there are but ^ew public establishments.

In the State of New York there is one at Bloomingdale, a few
miles from the city of New York, and which usually contains
about 150 inmates. There are two in Pennsylvania, and some of
the other slates have recently erected asylums for the insane.

There is one in Connecticut at Hartford, erected in part by
the funds of the State, and partly by individual liberality. This
contains about fifty inmates and is well conducted, but it is al-
together inadequate to meet the wants of the insane even of this
small State.

The State of Massachusetts has during the past year completed
a magnificent establishment for lunatics at Worcester, near the
middle of the State. It is called, 'The Massachusetts State Hos-
pital for the Insane,' and as its name implies, was erected exclu-
sively by the funds of the State. The first appropriation for the
building was $30,000. The second for furnishing the hospital
and preparing the grounds and outbuildings, was $20,000. This
may be considered as the actual cost to the State, as the land,
consisting of about twelve acres, was given by the town of Worces-
ter, and the sum of $500 was left by Nathaniel Mc Carty in his
will, for ornamenting the grounds.

Accommodations are provided in the building for J 20 inmates,
and it now (in April, 1833,) three months after its completion has
79 inmates. All patients are supported by themselves if they have
property, if not by their relatives in the direct line. On failure
of these sources, they are supported by the towns where they have
a selilement.

This hospital is intended for lunatics furiously mad, and dan-

254 APPENDIX.

geroiis to the peace and safety of the community. This class have
the preference of all others. Town pauper lunatics have the next
preference. Dr. Samuel B. Woodward is the physician of the
institution.

Treatment of Insanity.

This subject has usually been treated of under the division of
medical and moral treatment.

The medical treatment has been as various as the theories of
medicine. At one time copious bleeding has been resorted to,
and during the prevalence of the belief in the hemoral pathology,
attempts to evacuate and purify the bile were supposed to be the
only rational method of treating the disease. Some have advised
shower-baths, and cold and warm-baths ; others purgatives, others
opium, digitalis and other narcotics, and bark, as the best reme-
dies for insanity.

[ think with Dr. Spurzheim that the medical treatment of In-
sanity is to be reduced to sound principles of pathology in general,
and hence no one method of treatment is applicable to all cases.

The treatment proper for recent cases may be injurious to those
of longer standing. The previous health of the patient, age,
and duration of the disorder, necessarily demands a different course
of treatment.

According to M. Foville, Bayle and others, who had opportuni-
ties of opening the heads of hundreds of insane persons, no adhe-
sions were found in recent cases, while they are very common in
chronic cases. To prevent therefore those adhesions so generally
found in chronic cases, is one of the most important objects to be
kept in view, and as they indicate a previous inflammatory state,
it is therefore evident that depletion, bleeding, and the withdrawal
of stimulants are necessary in the first attacks. But, adds M.
Foville, these reasons would have no influence with me, if there-
suits of my practice had not shown that they were correct. In
this opinion he is supported by Rush, Burrows, Halloran, Brous-
sais, Georget and the latest and best writers on Insanity. Bur-

MORAL TREATMENT. 255

rows says, he is sure that leeching can seldom be dispensed with
in recent cases.

Broussais observes, that since the time of Pinel bleeding has
been too much neglected in the early stage of the disease, and it
is owing to this, he says, that those who do not practise it, seldom
effect a sudden course, while by adopting this cure he states that
often the irritation of the brain is at once subdued and the patient
very soon restored to reason. The brain is relieved in the same
manner as the lungs in a commencing peripenumony — by abstrac-
tion of the blood. This writer however and all others of deserved
celebrity caution against copious bleedings, and say that for the
most part topical bleeding is the best, and should be practised in
the early stage.

But the acute stage which it is so important rightly to appre-
ciate and treat, soon passes into the chronic, and then bleeding is
not very often admissible. Then, plain but nutritious diet, decoc-
tion of bark, and often good wines are necessary. Narcotics have
been used by different practitioners with various success. Ac-
cording to the celebrated Wepfer, opium is one of the most pow-
erful means of cure, but according to Esquirol narcotics are more
injurious than useful. No doubt there are cases in which they are
highly necessary and servicable, while in others they are injurious.

Moral Treatment.

This subject is very ably treated by Dr. Spurzheim, and deserves
the profound consideration of all who are interested in treating the
insane.

On one point there is great uniformity of opinion among medi-
cal men with regard to the insane, and that is the importance of
separating the patient from his family and customary associations.
This, though revolting to the feelings of friends and of the public,
is a point urged by all writers upon this disease, and it is unfortu-
nate for this afflicted portion of our fellow creatures that such a
state of feeling should exist, as it lessens the chance of recovery,
by the delay it produces.

256 APPENDIX.

It is also to be lamented that many look upon insanity as a dis-
grace, or as a disease that results from some criminal offence.
This inclines many to conceal the fact that disease exists in their
families, and thus the precious time for curing the disease passes
away. More just views are however beginning to prevail, and we
hope the time is not far distant, when those who are deprived of
their reason will be immediately placed in institutions where they
will have all the advantages which the best moral and medical treat-
ment united can afford. Where they will be treated at all times
with kindness and perfect candor, and as reasonable beings, and
where they will have all the enjoyments of society and comforts of
domestic life, not incompatible with their safety and the means
used for their recovery. When this course is adopted, we shall
expect to find not only a diminution of the number of the insane,
but those who unfortunately become so, very generally and speedily
restored to usefulness, to their families and to society.

A. B.

Hartford, April 2bth, 1833.

BIBLIOGRAPHY.

The foUoioing list comprises most of the valuable works on Insanity j
which have appeared within the last fifty years.

Chrichton (Alexander,) An Inquiry into the Nature and Origin of
Mental Derangement, etc. London, 1798.

Pinel, Memoire sur la Manie Periodique ou Intermittente. Tom.
1. des Memoires de la Societe Medicale d'Emulation. Paris, 1797.

Do. Recherches et Observations sur le Traitement Moral des
Alienes. Tom. 2, des Memoires de la Societe d'Emulation.

Do. Observations sur les Alienes et leurs Divisions en Especes
Distinctes. Tom. 3, des Memoires de la Societe d'Emulation.

Di. Traite Medico-philosophique sur 1' Alienation Mentale ou la
Mama. Paris, 1809.

Cogan, An Ethiological Treatise on the Passions, 1803.

Reil, Rapsodien uber die anwendung der Phychischen cur-meth-
ode auf'eistes Zerruettungen, 1803.

Arnold, Observations on Insanity, etc. London, 1806.

Amard, Traite Analytique de la Folie, 1807.

Haslam, Observations on Madness, etc. London, 1809.

Hallaran, Observations on Insanity, London, 1810.
. Rush, On Diseases of the Mind.

Cox, Practical Observations on Insanity, etc.

Hill, On the Prevention and Cure of Insanity, London, 1814.

Jacquelin-Duhuisson , Des Vesaines ou Malades Mentales, Paris,
1816.

Esquirol, Memoire sur les Crises de I'Alienation Mentale. Journal
de Medicine de Sedillot, 1804.

Ditto, Articles, Folie, Manie, Monomanie, Demence, Idiotisme, du
Dictionnaire des Sciences Medicales.
33

258 BIBLIOGRAPHY.

Esquirol des Passions considerees comme Causes, Symptom eset
moyens de Traitement de 1' Alienation, Paris, 1805.

Georget, Traite de la Folie, Paris, 1827.

Do. Articles, Folie, Idiotic, dii Nouveau Dictionnaire de Medicine.

Do. Examen Medical de plusieurs proces Criminels.

Falret, du Suicide, de I'Hypochondrie, Paris, 1822.

Hoffbauer, Medicine legale, relative aux alienes, etc. trac,de I'alle-
mand pas Chambeyron, avec notes de MM, Esquirol et Hard, 'Paris,

1826.

Voison, des Causes Morales et Physiques des Maladies Mentales,

Paris, 1826.

Bouchet, et Cazauvielh, de I'Epilepsie consideree dans ses Rapports
avec 1' Alienation Mentale, Paris, 1826.

Calmeil, (L. F.) de la Paralysie consideree chez les Alienes, Paris,
1826.

Delaye (J. B.) Dissertation inaugerale sur la paralysie des Alienes,
Paris, 1825.

Bayle, Traite des Maladies du Cerveau et de ses Membranes, Par-
is, 1826.

Knight, (P. S.) Observations on Derangement of Mind, 1826.

Hallidai/ , Sir A. On Lunatic Asylums, London, 1828.

Burroivs, On Insanity, London, 1828.

Broussais, De I'lrritation et de la Folie, Paris, 1828.

Conolly, Indications of Insanity, etc. London, 1830.

Foville, Art. Alienation Mentale, Dictionnaire de Medicine, et de
Chirurgie Pratiques, 1830.

Combe, (Andrew,) Observations on Mental Derangement, 1831.

EXPLANATION OF THE PLATES.

PLATE I.

Six figures of idiots, whose brains,
with respect to size, were defec-
tive in different degrees.

PLATE IL

Fig. 1. The skull of an idiotic
child of eight years.

Fig. 2. The skull of an old per-
son idiotic from birth.

Fig. 3. A skull, and fig. 4, 5, and
6, three heads, distended by wa-
ter in the interior of the brain.

PLATE III.

The plan of an hospital for cur-
able insane. A large place is
surrounded with a wall, and
divided into two parts, A and
B, one for men, the other for
women.

1. Entrance.

2. Hall.

3. Porter's lodge.

4. Committee room.

5. Reception room.

6. Apothecary's shop.

7. Physician's and visitors' room.

8. Laboratory.

9. Linen stores.

Under ground are the kitchen
and provision stores.

10. Yard.

Both wings of the front build-
ing are only on the ground
floor, and destined for the dir-
ty, noisy, and dangerous pa-
tients. There are two subdi-
visions.
11 and 16. Galleries.

12. Keeper's lodge.

13. Yard for the dirty and noisy.

14. Shelter.

15. Cells for dirty and noisy pa-
tients. As they are near the
attendants, cleanliness will be
attended to.

17. Yard for dangerous patients.

18. Shelter.

19. Strong cells.

20. A very strong cell.

21. Swing, and shower bath.

22. Cold and warm bath.

23. Straw stores.

24 and 25. For keeping and ex-
amining the dead.

26. Wash-house.

27. Drying room for the winter.

28. Drying place for the summer.

29. Gravel walk, j^which admits
free communication of air.

30. A great door.

The middle part of the front
building consists of the ground
floor, first floor, and garrets.
The first floor is inhabited (if

260

EXPLANATION OF THE PLATES.

the side A contain the men),
over 3 and 4, by the master, so
that from his abode he can over-
look the yards of the dirty, noi-
sy, and dangerous patients. For
the same reason, the matron
lives over 5 and 6. The rest of
the first floor may belong to the
medical attendants living in the
house. In the upper story are
the abodes of other attendants
and servants.

The longitudinal wings may be
one or two stories high ; they
are isolated from all sides for
the sake of free circulation of
air ; they contain the quiet and
innoxious patients.

31. Place whence the whole wing
is to be warmed by means of flues.

32. Gallery.

33. Keeper's lodge.

34. Eating room.

35. Single cells.

36. Cells for two beds, to prepare
the patients for the house of con-
valescents. If necessary, some
of these may serve as day rooms.

37. Water-closets.

38. Place for rabbits, pigeons, &c.

39. Gravel walks round the house
and within the walls.

40. Fields and gardens.

PLATE IV.

The plan of the house for conva-
lescents. It is divided into two
sides ; A for men, B for women.

1. Entrance.

2. Porter's lodge.

3. Visitor's room.

4. Eating room.

5. Long table.

6. Work rooms.

7. Water-closets.

8. Staircase, leading the patients
to the first floor.

9. Yard.

10. Bath.

11 and 12. Work places for saw-
ing stones, or twining ropes.

13. Wash-house.

14. Door.

The figure at the upper end of
the plate is the plan for the sec-
ond floor.

15. 16, and 17 are inhabited by the
master and matron of the house ;
15 may serve, at the same time,
as a committee room.

18. Large sleeping rooms with two
rows of beds.

19. Iron grate, which separates
men and women, but allows
them to see each other.

20. Fields and gardens.

Fzcf.l

^^

^

/ .':

PlI

s

\

K

^\

4

S

K

r-\

■ i

^//^

/

J^U Ty. by M'cc -rs'h., Caf> eri., JK Ltfo n..

Anrnrn, Sm ith JiCco 's Xith. ^

Fzc^I

L..--

^

w-^'-,.

Pin

-J?ts .& '"i ' f, X> .''»>

^A

3

^.i^'

D

j^S^^^^^ij

^^^iiSfeaiS^''-^

'•'~s>-'*~'S! T ; )•

<0

^'uh. 'hij Afar^'h, Cupe-'n.^CT.i/cn.

A'nyLin.,S'>n'ith&l Co's Zith^

\S\«!

\A\H

.'vilf/V'

WW

..lAii. •.;;wi/:rv;iii/;.

'■V'-'tvi'" 'nvu- ■■•nil, .mu/.,, ..,\\|^/ -,>vM// .:.,■,., ..,';,7;i

3S

'•\ur. .A\w..ii/i

•" ;\UI .If/.
,A\(/ 'III/ .AU/I

I'l' Ml/, ,»\(/,.i

^J

34

S6

33
3

'■"■■'11/ oil//... I

u!m\i/!. '.MUf.'

^'\^\i/.\* '.!v\wl.\'l,'

ii"V<(i;.V'.:\Vii^.j
.•.'aViv;'1A\V/V.;i(!

'■■..i\\i...\vr ..'.'■

2.5

?^

Li

J"*?

24

^5

.llMli_lf£lfi-

^6'

J7

gJI 7.f

^:^

Jl

13

^

pim.

•:;:l:;'>.. -m. ...it. '.:„-.,u
.■i(...h...n„. ...|(. .:'.i.

..^>A{...\ ..« il... -

'f.A,.i.A ..ill,/ 'Vi£.,

,»■..«,. .'..I ..111,/ >""»"i"'- •«■ ■■— -..)...• ^.......,„i„ ^,,„ ,^,1, Tj.| .,U,^

,.■(..;«/,. .ii"i„7'.vi(;.'".l.t.';'.v,/ x'i!/.:'.-".';.';,!,. '.' '-!, .." ';.,iu' ' Jii j vj'!^-:','.!
tUk'Ji:::AC''^-^-'<ii:'-^^i'"-M''-.'.>\::" .' ■;■. -'",".i^-:.V''.'i"ii'>

;r;ij ",w.

39

\\u.mi. '"w/.
i.viW",'va"A'.<;i,vi

•.'Mi- .^\\\l^ ,

'.i\W/..u,, ..nil/'

37

1.1/ ■\\\\\

,\\l//,

'•'.\\u(/,'V"ixCil/,'

'>.( .\\V(I/ ..Ul/,'

S6

3S

iJL

38

So

84

.■'/".'i'\i/".);i\V;'.|

1h/..v\ii ..•i\i/ ,
k\\u ,iui .ii'.y

|.*\U/..\\NV.,Al/
J,AV/:-.\M(..il'..|

'.MrAw'iV/'l.'.Wi/]

u6f.'A\i,':.".;v{i.y
>".7.'.\\\vv;;ii/.'

SS>

lo

■.T.fMiiMlL

-^

^5

^—^

2S

i^

Ji

^^5

^tj?

1

24

A

Pictf. by IkCursh, CtxpariSC Lyon.

1(^

17

IS p6

B

A'tJ'iin, 3rmtU if Go's I.ii'i'c^^J

P1.I\"

IS

17

25 IS

18

4W/..IM/ ..11/ , <.l\W" -ilXf- -WWl -'Uu. ..VVVI/.. .'.SKI .. I

;..v\w/\AU(/:;.^Ah;:";Au/;!"/,,;;u/:'*\lvu/r'''.;v\\;',v"^,r''''

; ..aA\I/..v«1( ■• .«!/■ .AU(r A\UI|(/ .Mil, ,,\ui/ .. svwl'/ '(\U," l/i

r.4\i/-.iu// -.uw, ..uu<...,»Ui, ..,»w- ..AUi./~..,M/:;,.i;.i

; ..v\\U,.A\H(/,. ,A\\ll.. A^vl/..^^\\/,, .,v,^;l/,, .v\Ul/,.A\\//. '
, •l\l(' -.WI/'-WU/ ;A\\U' ..\\\(/ ..iVI/, „U(,, .«,1/,. .w!

..A\M//. -WWll/ AM/- .\\//. .AW/., .,^^1/^ .^^,|, .,

^.t^..«l(. ...\M// ..AMI/ ..Nv\i/,. .,uw.. AVU. AW.

l,'>ll( MM// -n /,, ,H//,, ,i\i/, , ..,, .AVIfl/ .A\\l//,

u„, i«i(/., .v^\i/.. ..ftvii/, ..aw/'... ,\\i//..'\,\vw/

■\\U.. ~\\\i

r>' :,,;:.(';" /vV""'';; ''".•■■,■","';;■ ■>'"'".. iw/., ,\\\i/, • i .iu.avi/.- ■ui--. ^viw^,, .,\m//., .a\i/;",x;\(/'"";
^'l^•A«/, ,.^^,/,/ ..«,, . ...„/<^y-,u,/ ,.ni// .vM/,.,„/' ^i^ ;.,ai/.->^^W.. ..^\\i/., aV,/. •^'^..<^W■.\^f/-. .vm

r'^ •">^)"'' -^NM. ASM// kuA, .>>\\(/..'i\\(;.\!;v;.!

.V\\U// .a\U// ..WWU/ ,..\\\(/_. aU/', AWI/ .vWil/- ..ssxl/'. .,4(,,'
^.>\M/.. jW(//^.\\\i/., ,.\^\\;„ ..vs\I/...nv\//,.,a\\i/. aWHa .am/'

^^:^^^'::^;:;^:i^^U,^^^llu^,^^il:;w/•^^%w;-^^^;;;
i*;;*7',;ul.MV/::Aw/'l;xV//.}\\\'/AN\/\\(v(/i'.(s\/::UNv:v'/r,;

,.. ..HI/ ...su/ — .Al/ ,.w ..\\|/''. .AM/' '.AUJ.."...\i(/..-U(i
nM/. ..\W/, .Aid, AU/. ...ill/. ..A«/, .AUK, .AVli/, '.,A\(//!

'VaVU, _.«\l(-. ..\\U" ..iHili ,.aW «/ ^wii ,.M/' "il;

M„...JU., .,Al/. aH... ~a\(/. ...V\(/., ..Ai/- vW. ..A\l/,..(,,l

'.Al .A\Ui/, .A.WI/ .\Uw .A\t/. .All/. .All/ .\\t/, .A\l/ ..uV
;..,..\H;...\V,W,. ■.\\V. .i\UI/...vl\Mi. ,.>\\l/.. ..iM/.. ..,\\/, ..A,/.. '
|.^\Mi' ,.\\M/' .vWli, .-Ai/. . .AMI/ .A\,'.;. ii.i .-Au/ .Al/. 1

„...v\\\i//_.A\\\(/.. ..AU1/...AVI, »'Air., ..All, .lu, v7^ "i/;

l.n .1)11/ ..^11, ,Al|l, ,l\U^ -m../ A\M1. .AI/-Al(,,.M|,>

i/.Aui//.AVu/,Avur. ..v^u/ ..u/ /•■;;; "(y''5;"t:";

;..„i(..i\w/,. ..^\\\l.. .AVI/,. .i\i(/ . ..(\\w.. x\\(i/?^^x\\i/ x\v(/"'!

, . - .M/.,.A\\l/.-i

,-..i(,.»M'.^xi\/ .,\\i(/.,,,U(/ .i\\i/, .111/ -iiu/i/ ..\U'!

..Ai/..\\(// .vu//... vMiu. Aii/..Avy,A\v/ ii\v,/:.;-;\i/i,//i
; :.ii :->; ,vi(;'j'''ii/^'';i/^";:r ■■•*"-"</ ...u, ..xm,

, l!--^ ^ ^il/./ ..VU. aUI.' ..\W...xxj// ,, .,^1/, ,x\V/ AlAi'

^ v.niy ..vwi/ .. ,A\\i/ . ..Mfu\.Ui.. .x(\ii,;\\(u//,:"\l(„;;\^'r:

^;x:^/.c:^)^;iA/;)^'^;i;;^^'(;w:-:(,,,:-!-r'^u-l^
;%;-^p;\^;/^.-i^(,/;-l^(u-w/^,..,/^^^^.i^^^

i.W-.u/,A\iy^,K„A\U. '..\\U."-AM/- ...xvix. .\\i/.; ..i\,(/- ,ai/'

|::^i:.l;^I^':*^ii^'^(/!)^:w^!!((:lVfr:n^//!^l^l/;:!^l;:,^))!:^

MV AUl .illK/ .1X111/ ,..\ll/y. .i\V\ii' ■(\U/,,,.\IM/,. .,xMi,,.i

", .^»i/.,. A 1/ .. i« , A\/ .«( ..ii\/ -.11' ,iiM/.. /-^^ f , . A^\l/ ., , ..\\\i/ .. ,;<w

■,l..,xV<U,, ..All//.. ..sWWi/, ..x\\\/^, ,..\M(/. ..xx(A. ,„M|/„ ..,x\\//,l

v.Ai\'ii)7^;*'ivi,r;;^\\(u;;^^'>iu/,;^\':;^,,/:!^w^,,,-;»H^^,^u,,;

;:,?;Av\\/z^%\ti/;:^^:;vu./::v^;vw/.?^!^i,-^^i;;,,/<«^;;

w^V/,.^\\\(/-/ .,s\\\li, ,a\\\I/., ,a\\I/. ,.\\M/,, .x\\|/,,.cx\\j//i

;.;AMi/,:f;^\o/A'iw/r;V^:;uu/;V/iu/.r'.iiif/:)''.^ui/'^^^^Ai/:
;p;,\i' ^ Avu ^uu /' A^i/-/, ^►u/;;! w ^^ A^\^* :^^^^^^^^^

c

.22

J-^

^

^

€

^

A-^

ki

j^

13

-^

3

6

7

A.-nnvri', Smiih^. Cos J^it/v'-^

*

HARVARD UNIVERSITY f

Library of the Medical School ^

*

^
*

*

The Warren Library

Dr. John Warren

1753-1815

Dr. John Collins Warren

1778-1856

Dr. Jonathan Mason Warren

1811-1867

Dr. John Collins Warren
184.2— 1927

Dr. John Warren
1 874-1928

^<5>,^<<^#<4>=^<^>'^<<§>=^<<g>*^^<4>#^^

COUNT WAY LIBRARY OF MEDICINE

RC
3UO

S97
1833

RARE BOOKS DEPARTMENT