ADDRESS 
DELIVERED BEFORE THE 
judical ^ocietg of fijo of ^nnsglcania, 
AT ITS 
\ 
ANNUAL SESSION, JUNE, 1869. 
BY 
JOHN CUR WEN, M.D., 
PRESIDENT. 
EXTRACTED FROM THE TRANSACTIONS 
OF THE MEDICAL SOCIETY OF THE STATE OF PENNSYLVANIA. 
PHILADELPHIA: 
COLLINS, PRINTER, 705 JAYNE STREET. 
1869. ADDRESS. 
Gentlemen of the Medical Society of Pennsylvania : 
The mind of man, to which he owes his supremacy as head of 
created beings, has ever been a mystery. Philosophers have specu- 
lated and theorized to account for its mode of action, and the 
various powers which it manifests; but, having pursued a wrong 
course in their investigations, they reached no clear and satisfac- 
tory conclusions. In consonance with the confused views enter- 
tained on the proper exercise of the mental powers in health were 
the speculations promulgated in reference to their disordered action. 
But within a comparatively recent period a truer course of investi- 
gation has been adopted, and some hope may be entertained of 
arriving at more enlightened and rational opinions. Careful obser- 
vation of the mental functions, and true philosophic reasonings on 
the facts and legitimate inferences and deductions from those facts 
have only been attempted within a recent period, and by this course 
alone may we hope to establish such a mental philosophy as will 
guide us in our investigations into disordered action. In exam- 
ining into disordered conditions of the mind, we must not allow 
the false lights of fancy to lead us from the true path, but, keeping 
truth constantly before us as a guiding star, allow each faculty of 
our minds that true balance and exercise which will conduct us to a 
true judgment in ?my particular case. The progress in the knowledge 
of mental disorders has been commensurate with the great advance 
which has attended the science of medicine generally. With the 
greater attention to physiology and the allied branches, men have 
given more careful study to those parts of the bodily organization 
which are concerned in mental manifestations. No question now 
arises that " the brain is the minister of the understanding," and 
that to its disordered condition are to be traced the deranged mani- 4 
festations of mind. It is useless in this presence to attempt to 
cite proofs of a fact which all educated men now admit. 
The reciprocal influence of bodily disorders on mental manifes- 
tations is also so fully admitted that no time need be spent in at- 
tempting to elucidate their true relations. The morbid feelings 
excited by disorders of the stomach, the liver, the kidneys, and 
particularly certain diseases of the nervous system, are daily before 
the mind of the profession, and need only be alluded to to produce 
a strong conviction in the minds of all who have witnessed them 
how great must be their agency in the production of mental de- 
rangement. Insanity is as clearly a disorder to be treated by all 
the appliances of medical art and science as any disease of the 
lungs and stomach. The metaphysics of the subject must be left 
to those who have an inclination to pursue that branch of scientific 
inquiry, but to us who are called to deal with the practical, and to 
rectify disordered or diseased conditions, the first inquiry must be, 
to w'hat is the condition before us, in any particular case, to be 
referred ? 
A careful and minute inquiry into the previous condition and 
character of the individual, his mental state and its peculiarities, 
the history of his parents, and, as far as may be traced, of his 
ancestors, in their peculiar mental and moral traits, will tend to 
throw a strong light on the character of the disorder to be treated. 
No one professes to doubt the influence of hereditary predisposi- 
tion in the transmission of various bodily disorders; but sufficient 
attention has not been given to tracing out the influence of peculi- 
arities of thought or feelings, of moral character and the various 
passions and affections of the parents on the offspring. If we 
give credence to the researches which, of late years, have established 
the connection between idiocy and imbecility, and the indulgence 
of the parents in intoxicating drinks, and we cannot deny their 
force nor their correctness, we must be prepared to admit that a 
certain degree of mental perversity and obliquity in the offspring 
is clearly to be referred to some violation of natural law in the 
parents; and the more attentively the subject is examined and 
reflected on, the less will men be able to escape the conclusion 
that there exists, what may be called, for want of a better term, an 
insane predisposition to disorders of the mental and moral powers; 
and, as all admit a strumous diathesis, why may not the same 
kind of arguments which prove that be applied to the proof of 
the other? True; the strumous diathesis shows itself in a more 
palpable bodily constitution, but will any one who has for years been 5 
conversant with the insane be willing to deny that similar disordered 
manifestations of the nervous system are not clearly to be traced 
in certain individuals or families ? There- can be no question of 
the greater prevalence of disorders of the nervous system within 
the last half century. With the greater disposition to these dis- 
orders, there has been found a gradual deterioration in the healthy 
condition and power of the nervous apparatus in the families of 
those who have suffered from various diseases clearly unmistak- 
ably nervous. This weakness of this part of the system makes it 
more readily subject to disease, and predisposes the individual to 
attacks from causes which would not influence a more robust con- 
stitution. In the same way, where insanity has once prevailed in 
either branch of the family, there is a greater likelihood to the 
return of this disease than where nothing of the kind has at any time 
existed. If to the liability to nervous disorders be added the heredi- 
tary predisposition to mental disorders by previous manifestations, 
or by marriage between parties subject to one or both of these 
characters, a condition of affairs is effected very favorable to the 
production, on the slightest provocation, of some disorder of the 
mind. To those who have seen much of the insane no class pre- 
sents more interesting subjects of study than those who possess 
what may be termed an insane temperament. With their natural 
character is mingled a disordered element, which renders them the 
wonder of their neighbors, the annoyance of their friends, and the 
dread and terror of their own families. Very commonly they are 
exceedingly nervous and irascible, are given to extreme, or even 
moderate, peculiarities of thought and feeling, look upon every 
subject in a different light from the generality of their neighbors, 
entertain absurd and often unfounded prejudices, are prone to do 
things in a manner different from everyone else, certain intellectual 
power may be brighter and more striking in their manifestations, 
their moral powers may be weakened or perverted so that they are 
incessantly rendering themselves liable to remarks by their actions, 
their singular exhibition of traits of character, or their open defi- 
ance of certain rules and principles. Some sickness or disease has, 
in some period of their lives, given a morbid bent to certain feel- 
ings, affections, or passions, which no future training or manage- 
ment appears able to conform to the healthy growth of other parts. 
With an average, or more than an average, amount of shrewdness 
and tact in their business and capacity for conducting their affairs, 
is blended a morbid perversity of will and an irregular action of 
mind which leads them to the assertion of the most extravagant 6 
notions, the commission of the most singular acts, and, at times, 
the perpetration of the most unnatural crimes. At one period they 
are morose, gloomy, and disposed to avoid every one and shut 
themselves up in gloomy seclusion ; then they are impulsive, cherish 
the most bitter and unfounded likes and dislikes, indulge in most 
fearful bursts of passion without adequate cause or provocation, 
and, having once taken offence at the most trivial circumstance, 
they dwell on it, brood over it, and magnify it until it becomes part 
of their disordered nature. 
Penurious or prodigal, bdhstful or taciturn, fearfully profane or 
austerely religious, everything by turns and nothing long, they 
live in the community a mystery to all until some fearful outbreak 
brings them under the cognizance of the law, which too often fails 
to recognize the connection of their crime with the disordered con- 
dition of their mind, and because they do not evince the legal and 
technical delusions, or the utter confusion of mind so commonly 
associated with mental disorders, they receive the full penalty of 
the offence claimed by the statute. In such persons an inquiry into 
their previous history will reveal some disposition to disorders of 
the brain or nervous system, or some definite outbreak of mental 
disorder in some earlier member of the family by whom it has been 
transmitted to those who exhibit this peculiar mental constitution. 
It should be the duty of the medical profession to endeavor to con- 
vince the community at large of the great importance of treating 
all such cases as those laboring under a disorder of the mental 
powers, which should claim their sympathy and indulgence, and 
not their scorn and reprobation; and also when such persons come 
before a court of justice to take the scientific view of their condi- 
tion and give such information as to their true state as will lead to 
their receiving enlightened treatment, in place of what is too often 
meted out to them, the vengeance of impulse and prejudice. In- 
sanity has too often been looked upon as a branch of medical sci- 
ence peculiarly difficult to diagnosticate, but with certain plain 
principles in the mind, and with the same application to the study 
of any case which would be given to any other intricate disease, 
every one can distinguish without special difficulty the great ma- 
jority of the cases which ordinarily occur. Cases unquestionably 
arise which baffle the most experienced, but so do they in the in- 
vestigation of every other disease, though this should not dis- 
courage any one from the diligent prosecution of the study. The 
first principle to be always borne in mind is that the individual, 
who is the subject of study and investigation, must be carefully 
compared with himself. The peculiar state exhibited at the time 7 
of the examination must be compared as accurately as possible with 
what the individual was known to be in full mental health. No 
imaginary standard must be set up to which every case is to be 
brought and judged, but the supposed diseased condition must be 
investigated in the light which may be derived from a diligent 
scrutiny into the state existing before the present peculiarities of 
thought, feeling, action, or conduct, were observed. In this man- 
ner where full information can be had, and, as a general rule, it can 
be obtained, an idea may be formed how far the state of mind under 
examination may or may not be a departure from healthy normal 
action. 
Inquiry into the previous mode of life, the general condition of 
the bodily system, the occupation or want of occupation, the con- 
nection by blood or marriage of the ancestors, and the previous 
existence of any mental infirmity or peculiar nervous affection, will 
tend to strengthen or invalidate the conclusion which may be 
formed. 
Careful attention must be given not to confound causes with 
effects in tracing out the existence of insanity. Like every disease, 
the period of incubation may be of longer or shorter duration, from 
a few weeks to a long term of years; and the extreme difficulty of 
ascertaining the peculiar mental manifestations of any individual, 
adds greatly to the danger of confusion in such cases. In this way 
it is too often the case that relatives will assign as causes what are 
really and truly merely effects, and very diligent inquiry may be 
able to trace back a disorder which is looked upon as very recent 
to a period of months, or may be years, as in the celebrated case of 
Pinel, where the insanity had been gradually coming on for fifteen 
years. 
Cases are on record where the insanity was sudden and explosive, 
and passed away as rapidly as it came, but there was clearly in such 
cases some bodily disease or disorder giving rise to such sudden 
and violent excitement. 
These are the very rare cases in medical experience, and are not 
to be taken as guides or examples of what must ordinarily be looked 
for or expected. All cases must be subjected to the same rigorous 
scrutiny which would be given to any other bodily disorder where 
the cause was obscure, and such jealous care will often be rewarded 
by the discovery of conditions which will materially aid in the pro- 
per treatment of the disorder and its more prompt restoration. 
Attention must also be given to the great influence of moral 
causes in the production of physical disorders, and while we would 
not assign an undue importance to either physical or moral causes 8 
separately, it is a matter of very great moment to bear in mind 
that a moral cause acting steadily for many weeks or months will 
gradually undermine the health, and bring on such a state of physi- 
cal disorder as will require the utmost efforts of the physician to 
remove. The extreme difficulty of ascertaining the true state of 
the case in many instances should lead to more than usual diligence 
in the investigation, for the reason that the existence of a cause 
tending to produce extreme sleeplessness or some analogous condi- 
tion will baffle all the medical appliances which may be brought to 
bear upon the case. A removal from accustomed scenes, a change 
in certain matters in the household, or the introduction of some 
new occupation or pursuit to give another direction to the thoughts, 
may do more towards restoring the long lost and much to be desired 
sleep than any medicine in the pharmacopoeia. 
No one who will examine the tables of the cause of insanity in 
the reports of any of the hospitals for the Insane, will fail to be 
struck with the inaccuracy and incompleteness of those tables, de- 
rived as they are in the great majority of cases from the accounts 
of friends or relations, who have given little thought and attention 
to the matter, and who often seek to hide the true cause by the 
assignment of some other, or a total denial of any knowledge on 
the subject. 
It is earnestly to be desired that the members of the medical 
profession to whose care nearly all the cases of insanity are pri- 
marily given, would institute a more careful inquiry into the his- 
tory of each case, not only for their own benefit and satisfaction as 
a mental exercise and gratification, but in order to enable those to 
whom they are frequently so anxious to consign them to have a 
better knowledge of what they have to contend with and to correct. 
Too often the medical man thinks his duty discharged when he has 
recommended that the patient be sent to some hospital, forgetting 
that the physician, to whose care he thus consigns the patient, has 
not the means and opportunity of obtaining that minute knowledge 
of the causes which must have fallen to the lot of the physician 
under whose observation the individual may have been in health as 
well as in disease; and it must also be considered that friends are 
not so willing to impart facts of prime importance in relation to 
family matters to utter strangers as to those to whom they have 
intrusted the medical care of themselves or their families. Every 
physician in charge of a hospital for the insane will testify that he 
has often been led astray temporarily, or left to grope his way out 
to the clear light and understanding of a case, by the insufficiency 
of the history given of any particular case when placed under his 9 
charge, while his own efforts would have been lightened, and the 
restoration of the patient have been more promptly effected by 
light and information which might have been thrown upon the case 
by the original attending physician. 
Insanity is often at the commencement, and most generally in its 
course, essentially an asthenic disorder, requiring careful medical 
and hygienic treatment, but not necessarily requiring active stimu- 
lation. Success depends as much in the majority of cases upon 
the propei* attention to nutrition and other hygienic considera- 
tions as upon the administration of various articles of the ma- 
teria medica ; and it is because of the inability or unwillingness to 
carry forward properly such a course in a family who cannot or 
will not give attention to those measures, that it becomes necessary 
to place, the patient in a hospital for the insane, where the habit of 
regularity in all things is enforced by precept and example, and it 
becomes easier to fall in with the current than to go contrary to it. 
Medical treatment is unquestionably in most cases very much 
needed, and that treatment is directed to the removal of existing 
disorders, and the building up of the system by careful attention 
to all those matters which tend to impart vigor and elasticity to a 
frame debilitated by disordered functions and inattention to the 
proper wants of the economy. These measures may be briefly in- 
dicated to be the administration of such medicines as will give 
tone to the nervous syste.m, by producing sleep and increasing the 
nutritive functions, plain substantial diet regularly served, regular 
hours of rest, bathing, exercise in the open air whenever practi- 
cable and as much as is prudent and proper, and a diversion of the 
mind from self by any means which will effect that object in the 
most pleasant and agreeable manner. 
Certain forms of mental disorder come so prominently before 
the physician in the regular practice of his profession, that it may 
not be amiss to make special reference to them, in order to enable 
the practitioner more readily to detect them, and to avoid errors 
which might arise from confounding them with diseases requiring 
essentially different treatment. Acute mania may be confounded 
with some of the acute inflammatory affections of the brain, or 
with delirium tremens, but a careful reference to certain particulars 
will lead to a correct diagnosis. In acute mania, no unusual heat 
of the scalp will be found, no pungent burning so unpleasant to the 
touch, no special fever or great excitement of the whole arterial 
system, but, on the contrary, the skin will have a tendency to dry- 
ness, often cool, the restlessness will be of a type far different from 
the excessive jactitation in acute inflammatory affections, the pulse 10 
will be more natural and rarely much accelerated, and in particular 
the eyes will be free from that intense glitter and fierce expression 
so very characteristic of inflammation of the brain, the counte- 
nance will be more variable and free from that fixed expression of 
anguish and distress so noted and so constant in all the forms of 
high inflammation of any of the cerebral organs. From delirium 
tremens it may be distinguished by the knowledge of the previous 
course of life of the individual, and by the essentially different 
forms of the delusions. 
But there is one form of disease which is so peculiar that it might 
readily be confounded with infla mation, and its prompt diagnosis 
is extremely important, as the course of treatment to be pursued 
must be decided on promptly and carried out energetically, or 
death will soon close the scene. This is that affection known to 
American alienists as " Bell's disease," from its first accurate de- 
scription by that able and accomplished physician, Dr. Luther V. 
Bell, and called by English writers, "typhomania." In this there is 
excessive restlessness, incessant loquacity, the most remarkable 
incoherence of thought and expression (tireless babbling as it is 
expressed by the French), the pulse is rapid, weak, and very com- 
pressible, so as almost to be stopped, the skin is cool and also the 
scalp, and as a general rule dry, except after violent exertion, and 
often even then, the tongue and mouth very dry from the incessant 
talking, and the attention can scarcely be attracted long enough to 
obtain an answer to any question. In ordinary cases of acute 
mania, or in inflammatory disorders, the attention may be arrested 
so long as to obtain answers to questions, or to change the current 
of thought, but in this it seems as if the individual was so impelled 
to give utterance to the words that crowd his mind that he had not 
time to stop for any purpose. The resemblance of this condition 
to the symptoms of acute meningitis or cerebritis as laid down in 
the books will mislead any one who will not give earnest heed to 
its peculiar diagnostic symptoms, the freedom from all feverish 
heat, the peculiar weakness and softness of the pulse, and the 
physical state of depression of the whole system. The treatment 
is the direct reverse of any inflammation, so that the demand for a 
distinct and clear diagnosis is much more imperative. This dis- 
order requires very judicious stimulation and food, promptly and 
regularly given, and careful watching of the effects. With cautious, 
well-directed stimulation, the pulse will diminish in frequency and 
increase in volume, the excessive restlessness will abate, and the 
extreme loquacity gradually disappear, and in a few days the 
patient looks up with an expression of countenance the direct 11 
reverse of that in which he was first seen, and calm, gentle sleep 
gives hope for the future. 
The necessity of caution in diagnosis and prognosis is taught by 
other forms of the disorder which have disappointed the expecta- 
tions and set at naught the calculations of many experienced phy- 
sicians. The first is that form known as recurrent mania. An 
individual labors under high maniacal excitement with great bois- 
terousness of manner and language, is mischievous, destructive, 
and fearfully violent in denunciation. Under the influence of a 
gentle purgative, and some opiate or sedative treatment and care- 
ful watching, the excitement passes off in a few days, and the 
patient seems to be himself again, and you are congratulating 
yourself, and probably the family and friends, that the disease has 
been so readily cured, and you are astounded when you are again 
called, in a short time, to find your patient in a great excitement, 
probably greater than before. Herein lies the great peculiarity of 
this disorder, the high excitement disappearing in a few days, or at 
most weeks, a period of apparently entire restoration and healthy 
exercise of the mental powers, and in a shorter or longer period, a re- 
turn of the excitement continuing longer, in all probability, than 
at first. The striking point in this disease is the interval of appa- 
rent soundness in the mental condition, varying from one or two 
weeks to several months, but always pursuing the same uniform 
course and sometimes ending after one or two such attacks in res- 
toration, or degenerating into that form termed paroxysmal mania 
in which the excitement returns every month or every two months,, 
and is the most intractable form of the disorder to be met with, 
continuing in this form often during the life of the patient, or end- 
ing in hopeless dementia. 
Still another form is that termed by the French folie circulaire, 
but first clearly and • accurately described by that very able and 
distinguished writer on the Jurisprudence of Insanity, Dr. Isaac 
Ray. " Its characteristic feature is that of excitement alternating 
with depression, the two conditions varying considerably in differ- 
ent cases, in point of intensity, and also-as well as the intervening 
interval-in point of duration. The general traits of the first 
mentioned condition are an unusual flow of spirits, great self-con- 
fidence, sanguine anticipations of the future, restlessness both of 
body and mind, and untiring loquacity. Usually these traits are 
only strong enough at first to modify the ordinary character of the 
individual, without raising the slightest suspicion, and not uncom- 
monly giving the impression that the person has been indulging 
too freely in drink. Sooner or later, they become more strikingly 12 
developed, and exert an unmistakable influence upon the conduct 
and discourse. He engages in enterprises, moral, social, or com- 
mercial, either manifestly beyond his means, or in one way or an- 
other inappropriate to his condition. Especially is he bent on 
speculation, and nothing comes amiss capable of gratifying this 
passion. Whether it be a farm or a ship, a mill-privilege or a city 
lot, a parcel of trumpery jewelry, or the odds and ends of a two- 
penny auction, he is equally ready to buy, and equally sanguine of 
getting a good bargain. He is constantly yielding to some new 
fancy, and ardently prosecuting some of the countless schemes that 
swarm in his teeming brain. He frequents company either above 
or below his own grade, while, perhaps, he amazes and mortifies his 
friends by the levity of his manners, if not the laxity of his mor- 
als. His movements are abrupt, rapid, and unseasonable. He is 
fond of taking long journeys, and horseflesh suffers under his hands. 
He sleeps much less than he usually does, and is fond of being up 
at night roaming about the house or neighborhood. He is always 
ready with plausible reasons for his strangest conduct sufficient to 
silence, if not to satisfy, any troublesome inquirer, while his dis- 
course is entirely free from delusion, or obvious incoherence. With 
all this there is generally an utter disregard of the feelings of others, 
an imperious and even tyrannical deportment towards those who 
are dependent upon him, and a disposition to trample upon all 
domestic conveniences and proprieties. The slightest attempt to 
restrain or control his movements, or even to administer advice, is 
met by the fiercest hostility, and any intimation of mental infirmity 
provokes his hottest wrath. 
To this the state of depression presents a complete contrast, every 
trait here mentioned being replaced by its opposite. Seldom speak- 
ing except when spoken to, and apparently absorbed in his own 
gloomy reflections, he is silent and quiet in the midst of company, 
and, as if overwhelmed by a sense of inability, he reluctantly en- 
gages in any occupation beyond the most ordinary routine, and 
often is scarcely persuaded to perform the most necessary duties. 
All nature without and within him is shrouded in gloom, a terrible 
evil seems to be impending over him, the future reveals not a single 
gleam of hope, and were he called on to lay down his life, he would 
hardly hesitate to obey. His conduct during the excited state is 
now viewed in its true light, and is the subject of bitter reflections. 
He wonders that he should have done such things, and, in some 
instances, begs his friends to keep him in future from similar exhi- 
bitions by seasonable measures of restraint. With the mental de- 
jection, there is often some bodily ailment, and he loses both flesh 13 
and strength. Either this or a total paralysis of the will may keep 
him in bed much of the time, and incapacitate him for the slightest 
effort. In point of duration the two states are generally equal as 
compared with each other in the same case, though varying in dif- 
ferent cases, from one month to a couple of years. In point of 
severity, too, they are subject to the same rule. The interval be- 
tween these two conditions, when the individual appears to be 
perfectly rational and natural, also presents the same kind of uni- 
formity, in the same case, and the same kind of diversity in different 
cases. In many, and perhaps the majority of cases, it has no 
appreciable duration as a distinct condition, the periods of excite- 
ment and depression passing into each other, with scarcely an in- 
terval between." 
Much has been said of the peculiar appearance of the eye in the 
insane, and in no symptom are people more positive than in this, 
but like every other exclusive symptom it is exceedingly deceptive 
and unreliable. There is, however, an entire change in the whole 
countenance of the individual so striking that in many cases the 
whole aspect of the person is changed, and in this change the eye 
bears its part and adds to the peculiarity. On what exactly this 
change of expression in the countenance depends might be difficult 
to state, but it is clear that, as in health, the emotions, passions, 
and feelings are indicated by the peculiar expression of the fea- 
tures, except in some impassive beings who never manifest any emo- 
tion ; and as joy, hope, love, fear, distrust, or aversion will vary 
the expression, so may the different disordered manifestations be 
imaged forth in the same way. 
Another form of mental disorder may claim a few words from 
the importance not so much of its diagnosis as of properly direct- 
ing its treatment. No cases are more perplexing than those attended 
with great depression and delusions which seem to take away all 
hope and courage, and cast the individual into the very abyss of 
despair. These cases require all the tact, energy, and perseverance 
of the physician, and claim, at the same time, all the sympathies of 
his heart, the best directed efforts of his-skill, and the full ex- 
ercise of his mental powers. In most of those cases will be added 
the strong temptation to suicide, and to avert this no watchfulness 
can be too strict. In all such cases with an habitual tendency to 
depression of spirits, even in health, will be associated some morbid 
affection to the removal of which all the applications of medical 
and hygienic science must be directed. 
In late years a form of mental disorder has attracted very general 
attention, to which it seems proper in this place to refer in general 14 
terms: the general paralysis of the insane, or, as now called, general 
paresis. A great deal has been written within the last few years on 
this disorder, and to those who feel inclined to pursue the study 
more fully, the many articles in the English, French, and German 
Psychiatric Journals, may be recommended. One or two points 
only need be noticed here. The disease is characterized by delu- 
sions of immense wealth or unbounded possessions, with a peculiar 
impediment, or hesitation, or stammering in talking, among the 
very earliest symptoms, and also an irregular contraction of the 
pupils of the eyes, and an unequal movement of the lower extre- 
mities, often from the very first, though only to be recognized by 
very strict examination. The disease is confined almost exclusively 
to males, very few cases among females having been reported. Much 
dispute has arisen on the etiology of the disease, but it may be 
referred, as a general rule, to excessive indulgence, and to various 
circumstances which tend to deprave the physical constitution, and 
from these conditions maybe inferred the almost utter hopelessness 
of the disease. 
The general principles of treatment in different mental disorders 
will be modified by peculiarities in the constitution of the individ- 
ual, and the condition which may be presented at the time. These 
general principles are divided into two classes, medical and moral, 
and to a proper combination of these two, all success in the man- 
agement of the insane must be attributed. The essentially chronic 
character of most mental disorders requires great patience and 
perseverance on the part of the physician, notwithstanding the con- 
stant discouragements to be met with, and the pleas to be trying 
some new remedy, and the truth must be steadily inculcated, that 
a speedy restoration must not be looked for, but that chronic dis- 
orders can only be cured by steady perseverance in that course 
which has been found most serviceable in such cases. 
As would be inferred from the asthenic character of the disorder, 
an unusual tendency to constipation exists in nearly all cases, vary- 
ing from the mildest to the most intractable form, which must be 
met and managed, not so much by violent medicines, which only 
add to the mischief, but by a judicious combination of medicines, 
food, exercise, and the inculcation of regular habits. The great 
sleeplessness so characteristic of insanity must also be overcome in 
the same way, not by a routine treatment of sedative medicines, or 
one medicine in particular, but by such diversity of mental and 
bodily exertion as will bring on that moderate degree of fatigue 
which will induce sleep. A general tonic treatment will also be 
indicated to brace up the debilitated nervous system,' and add 15 
strength and energy to the enfeebled powers, ana this can usually 
be effected by the regular exhibition of the different preparations 
of iron and such vegetable tonics as may be found most useful, 
conjoined with such sedatives as may aid in carrying forward the 
object to be attained. But our efforts must not be directed to 
medical care alone, since as the disorder has, in the great majority 
of cases, been induced by irregular habits and modes of life, we 
must endeavor to correct these, and bring the individual back to 
that regular and systematic exercise and manner of life, which will 
enable all the functions to exert their proper influence, and have 
their proper action and development. For this purpose hygienic 
measures must be resorted to and regularly and systematically car- 
ried out. Meals at regular hours of good, plain, well-cooked, and 
easily-digested food, exercise of different kinds, in-door and out- 
door, bathing, the enforcement of regular periods for retiring at 
night and rising in the morning, and whatever else of this nature 
may aid in the object to be sought. But even these will not en- 
tirely fulfil the desired end. Dr. Samuel Johnson, in his character 
of the insane astronomer, has shown the influence of too great ab- 
sorption of the mental powers by one engrossing pursuit, and the 
relief and restoration obtained from the extravagant fancies and 
delusions by a variety of agreeable and entertaining objects and 
conversation. On this principle the moral treatment of the insane 
is founded. To furnish every means by pleasant and varied read- 
ing, games of different kinds, illustrations of physical science, em- 
ployment in every way in which the individual can be induced to 
engage, the direction of the attention to objects of interest and 
curiosity by exhibitions of the magic lantern, and, in fine, anything 
which will tend to arouse the latent energies, attract the different 
feelings or interest the mental faculties pleasantly and profitably, 
all are among the class of things included under the general term, 
moral treatment. One individual may be reached by one method, 
another must be approached by a different course, but the aim must 
be so to combine all the resources which can be made available for 
the grand purpose towards which all should tend, the restoration 
of the mental faculties to their normal condition. 
The pathology of mental disorders cannot yet be said to have 
been settled in a satisfactory manner, or even so as to claim a par- 
tial assent to its truth. It is true certain diseased manifestations 
have been found in those dying from different forms of mental dis- 
orders, but there has been no special condition recognized which 
could be said to be significant of any particular disease. It is per- 
haps not surprising that in a disease where the symptoms are more 16 
those of disordered function than of diseased action, this condition 
should be so uncertain, and so little positively settled on a basis as 
fixed as in diseases of the lungs. While we may not be able as yet 
to trace any special difference in the diseased condition of the brain 
in mania, or in melancholia, yet we must hope that the investiga- 
tions, which are now going forward in the hands of earnest patholo- 
gists, will produce some definite and satisfactory result. 
The researches of Lockhart, Clarke, and others, in the minute 
anatomy of the brain, point out the source to which we must look 
for our knowledge on these points, and should those researches be 
verified and confirmed by subsequent investigators in the same 
field, we may earnestly hope that a way may be opened which will 
lead us through the mazy labyrinth in which we have for long 
years been groping out into the clear field of scientific truth and 
positive knowledge in mental disorders. 
Many interesting points in mental medicine cannot now be dis- 
cussed, but it seems proper to state distinctly the views on some 
disputed subjects, held by those whose long experience and acknow- 
ledged ability in this particular branch of our profession entitle 
their opinions to be received with deference and respect; and the 
most knotty of these points, and that on which most misappre- 
hension prevails, is that of the so-called moral insanity. 
The mind of man is acknowledged by all who have treated of the 
subject to be formed of two different classes of powers or faculties: 
the intellectual, comprising the memory, the judgment, the imagina- 
tion, and the reason; and the moral, classed as the affections, pas- 
sions, emotions, etc., and that the proper healthy action of mind, 
and its true and regulai' development is found, when these powers 
are carefully and thoroughly trained and kept in due subordina- 
tion, so that the intellectual shall not be advanced at the expense 
of the moral, nor the moral be cultivated to the neglect of the intel- 
lectual. All will admit that this distinction is not so carefully ob- 
served in practice as it should be; but it is too often the case that 
the intellectual are highly and urgently stimulated, while the moral 
are left in the background, or attain undue, unnatural prominence, 
by neglect to educate them properly; and the more baleful passions 
gain the ascendency and control, and direct the individual. No 
one will for a moment deny that the intellectual powers by them- 
selves may, at any time, become disordered, while the moral powers 
may not appear to be in the least disturbed; but this is not the 
usual result. In the same way we can readily imagine that the 
moral, emotional, or affective powers (for each of these terms is 
used to express the condition referred to) may also become disor- 17 
dered, so that the individual will be guided to an entirely different 
line of conduct from what he was previously accustomed to pursue, 
and the intellectual faculties may not appear to be involved. But 
the rule to be observed in deciding on these cases is the same as 
that previously laid down in reference to the general diagnosis of 
insanity, that the individual must be compared with himself as he 
was in a previously healthy state, and not with some imaginary 
moral standard set up by the person making the examination. 
A man has always led a correct, moral life, has been honest and 
truthful in all his relations, has been scrupulously exact in his 
dealings with his fellows, kind and indulgent in his family, pleasant 
and agreeable as a neighbor, and in all the various relations of life 
has been considered correct and honorable. 
Such a man is attacked with some fever, or experiences some re- 
verse of fortune, which so acts on him as to injure his health, and 
it is perceived before long that he has become irascible and quarrel- 
some, that he no longer attends to his duties as a husband, a father, 
or a neighbor as he had done, that he is not careful to observe that 
decorum in the family of which previously he had been such a strict 
exacter, that he engages in foolish and improper enterprises and 
speculations, that he no longer observes that honor and scrupulous 
regard to truth which he had before exhibited, that, in a word, his 
whole conduct and manner are the precise reverse of what he was 
before: while at the same time his conversation betrays no inco- 
herence in his ideas, he gives utterance to no foolish expressions or 
delusions, but is sharp, shrewd, and apparently very exact in most 
of his business arrangements. 
Will any one deny that here is not a disordered condition of the 
moral powers with no observable derangement of the intellectual? 
and if the moral powers may be and frequently are thus disordered, 
have we npt an insanity of the moral powers as fully developed as 
in others we have an insanity of the intellectual? It is to be care- 
fully observed that this condition is not a steady growth from bad 
to worse, from a bad life and depraved habits to one much worse, 
but it is a total change of the whole conduct and character, that 
the man is as much the opposite of his former self in all his moral 
relations as it is possible for him to be, and that he now manifests 
traits of character and a course of conduct which no one who knew 
him before would ever have believed him capable of exhibiting. No 
evidence of delusion or other impairment of the intellectual facul- 
ties can be clearly discerned, unless we take it as an evidence of 
intellectual weakness that the man cannot see the exceeding incon- 
gruity between his present course of conduct and that which for- 18 
merly rendered him so much honored and respected by a large 
circle of friends and acquaintances. In truth, no one can discern 
any true delusion in such cases in their earlier stages, though such 
delusions may arise in course of time; but we are not justified in 
claiming the existence of such to establish a theory: but we must 
regard the case in the light we have at the particular time we are 
examining it, or are called to give testimony on it in a court of 
justice. We will thus be led to admit distinctly a disorder of the 
moral powers, which may be called moral, emotional, or affective 
insanity, as the views of the person may dictate. Our clear duty 
as medical men, seeking only the truth, is to take the facts of the 
case as wTe find them, and decide in accordance with those facts 
and the best information on the subject we can obtain. We can- 
not be justified, and do our duty conscientiously to the community 
and to ourselves, if we allow any special theory to turn us from 
the true course indicated, and yield to prejudice or clamor. 
But it is urged there is a large class of cases manifesting a dis- 
position to various misdemeanors and violations of the law from 
homicide to larceny, from the penalties of which it is sought to re- 
lieve the individual by the plea of insanity, and thus open a way 
to excuse all who have committed crime. The abuse of any good 
thing is no argument against its proper and legitimate use, and 
thus the abuses' of the plea of insanity are no valid reason for the 
rejection of what rational medicine and sound philosophy alike 
dictate to exist, and require to be treated as disease. There are 
undoubtedly cases which seem not to manifest any mental disorder, 
but where the whole life and conduct is a series of moral disorders 
and incongruities. In these cases, traceable by rigidly strict and 
diligent examination to some physical disease or disorder, shown 
by the peculiarities of conduct and character, there will almost in- 
variably be found some morbid irritation, some arrest qf develop- 
ment or improper indulgence in some vice, some want of the economy 
which will be evidence of the disordered condition of some organ, 
the healthy action of which is necessary to the proper exercise of 
the moral or mental powers, or the result of a proper insane tem- 
perament. 
The great difficulty is in obtaining proper information in relation 
to the previous history and character of such cases, which will lead 
to the formation of a correct judgment, for they are too often 
looked upon as simply depraved, and no attention given to the ex- 
amination of those states by which the true condition of the indi- 
vidual may be clearly and distinctly ascertained. Our duty is un- 
questionably to vindicate the majesty of the law, and maintain it 19 
in the proper exercise of all its powers ; but that does not forbid, 
but rather demands of us to give earnest heed to the careful and 
accurate examination of all those cases where pleas of insanity are 
presented, that the truth may be fully elicited, and justice done by 
the punishment of those who are really guilty, and the prompt med- 
ical hygienic treatment of those who are suffering from some dis- 
ordered bodily organ, or are the prey of some appetite which they 
need proper assistance to enable them to overcome. 
In this connection it may not be amiss to urge upon the mem- 
bers of the profession extreme caution and reserve when called 
upon to testify in court in cases of insanity. It is too often the case 
that counsel will endeavor to confuse the medical witness, and to 
draw him into an argument on some disputed point, or to give an 
opinion on some supposed case, particularly on the subject of moral 
insanity. The true practice in all such cases is to refuse to go 
beyond the plain facts of the case, and to avoid all argument or 
discussion which is attempted only to place the witness in a false 
position, and invalidate his testimony, and in taking this position 
the medical man will be sustained by the court. 
It is important for every medical .man to impress upon all those 
with whom he may be called upon to consult or to advise, the great 
necessity of early treatment in the first stages of mental disorders. 
Not that it is absolutely necessary that every case should be sent 
at once to some hospital, but that in the great majority of cases 
such a resort is the best means for promoting the restoration of the 
patient; and, when once placed under such treatment, to allow them 
to remain until the physician pronounces them fully restored. In 
at least three-fourths of all cases placed under treatment in hos- 
pitals within the first six months of the outbreak of the disorder, 
restoration may be confidently expected; all delays beyond that 
period are fraught with danger; and after two years very few 
cases ever entirely recover. And in regard to the continuance of 
sound mental health after restoration, it may be safely asserted 
that, with proper care and caution to avoid exciting causes, the 
majority will continue in the enjoyment of those faculties with 
which they have been endowed. 
In the arrangement of the studies of those from whom the ranks 
of the profession are to be recruited too little attention has been 
given to the subject of mental disorders, and it is time that our 
medical schools should supply this desideratum, by providing for a 
full course of lectures on mental disorders and the jurisprudence 
of insanity. 
No one can feel too grateful to an overruling Providence for the 20 
continued and uninterrupted use of all his mental powers, and it 
should be the earnest effort of every one so to order his own course 
of life, and to aid others to direct' theirs that he and they may at 
all times be prepared to render their full tribute of gratitude and 
praise to Him from whom all these and all other blessing have been 
derived, and to whom they must render an account for the right 
improvement of all He has intrusted to their keeping.