tfW&SLj «►**? °*uii ?«**** *^\m *■& :«/./>V£^; f-^r *& £H NATIONAL LIBRARY OF MEDICINE Bethesda, Maryland Practical Observations ON INSANITY: Id which some suggestions are offered towards ar. IMPROVED MODE 05 TREATING DISEASES OF THE MIND, AND SOME RULES PROPOSED .vhich it is hoped may lead to a more humane and successful] Method of Cure. TO WHICH ARE SUBJOINED Remarks on Medical Jurisprudence AS CONNECTED WITH DISEASED INTELLECT. BY JOSEPH .'.rASON COX, M- i>- ~~""V-^i--/*'7". From the second corrected and enlarged London Edition PHILADELPHIA: FUflLISHED BY THOMAS DOBSON.AT THE STONE HOVi-E No. 41, SOUTH SECOND STREE I\ Fry and Kammerer, Trinicrs. 1811. ADVERTISEMENT. 1 HE author of the following pages having devoted himself exclusively and assiduously, for a series of years, to the care and cure of maniacal patients, in an establishment where persons of both sexes are received, has had ample opportunity of comparing the effects produced by different modes of treatment, and flatters himself he has advanced some steps to- wards improvement in this particular depart- ment of medical practice. Although the hints contained in these pages are derived from diligent observation, and an uninterrupted experience of many years, yet they are offered with a degree of diffidence which, it is hoped, will procure them a corre- spondent degree of candor and indulgence from the public. The observations are accompanied with cases: these, while they seem to illustrate IV the different modes of treatment, adopted in dif- ferent forms of insanity, will, it is presumed, be found to exhibit many striking and impor- tant facts connected with the history of mental derangement. Fishponds, near Bristol, Nov. 1st, 1805. PREFACE. IF the possession of reason be the proud attri- bute of humanity, its diseases must be ranked among our greatest misfortunes, since they sink us from our preeminence to a level with the brutes. Most of our formidable maladies are rare, but insanity is unfortunately not only fre- quent but said to be peculiarly endemical to England; nor are we left' to conjecture the causes. Early dissipation, unrestrained licen- tiousness, habitual luxury, inordinate taste for speculation, defective systems of education, laxity of morals; but more especially, promis- cuous intermarriages, where one or both of the parties have hereditary claims to alienation of mind, are sufficient to explain the lamentable fact. Where few or none of these causes exist, madness is a rare occurrence or wholly un- known; hence it appears that one of our great- A2 VI est infelicities arises from increased civilization and a more refined state of society.* The ample experience thus furnished by the frequency of occurrence might, a priori, be supposed to enable medical men to reduce the relief of mental diseases to a systematic cer- tainty; but unhappily, this is so far from being the case, that we seem to have lost what our ancestors knew,f and either the famed produc- * The report of our most respectable travellers and well authenticated history confirm this position. Diseases of the intellect never occur among the Indians. The Africans also are said to be free from them, both in their native country and when in a state of slavery. May not this exemption be owing to the absence of that sickly sensibility which so generally accompanies luxury and ease? It is certain they are subject to most diseases which attack Europeans, besides a number peculiar to themselves: and are exposed to the action of the usual predisposing and exciting causes of insanity. t Pliny in his Lib. 25, c. 5, p. 457, says, Nigrum Hel- lebovum purgatper inferna. Candidum autem vomitione, causas que morborum extrahit* quondam terribile postea tarn promiscuum, ut plerique studiorum gratia ad per- videnda acrius quae commentabantur, saepius sumptita- verint. Carneadem responsurum Zenonis Libris: Dru- sum apud nos constat hoc medicamento liberatum ct> Vll tion of Anticyra is degenerated, or we are ig- norant of the proper mode of its cultivation, preparation, or exhibition.* mitiali morbo in Anticyra Insula. Ibi enim tutissime sumitur, quoniam (ut diximus) Sesamoides admiscent. Horace, among other of the Latin Poets, refers to this celebrated plant as possessing the peculiar property of clearing the mental faculties, and particularly in his 2d Epistle, Lib. II. v. 136. Hie ubi cognatorum opibus curisque refectus Expulit Ellebro morbum btlemque meraco Et redit ad sese: Pol me occidistis, amici, Non scrvatis ait; —— Had the ancients been in possession of calomel and tartarised antimony, it is probable they would have pre- ferred them to helebore; for this celebrated root seems ■ to have possessed no specific virtue, no antimaniacal pro- perty, but to have acted on the stomach and bowels like the former. * See Lorry de Melancholia, Tom. 2, p. 201. Et certe quod historici est in curatione hujus morbi, eo majoris est ponderis, quod forsan in artis dedecus fatendum sit, nos in sanatione hujus mali, veteribus minus eruditos esse. Constat enim non solum ex medicorum monumen- tis, sed ex Libris etiam qui ad artem non pertinent. omnes fere melancholicos, aut a melancholia maniacos per artem sanatos olim fuisse. Sed ne diutius in ejus natura investiganda insudemus, facit gravissima Theo- phrasti autoritas qui earn helleborinem et nominat et Vlll The human mind has furnished a most am pie field for philosophic investigation; but its nature, faculties, and properties, as well as its diseases, are wrapt in such impenetrable ob- scurity, that the advantages gained have not been in proportion to the labour employed. Most medical writers, in detailing the morbid phenomena of the human mind, and the means of removing them, appear to have been more anxipus to display their own ingenuity in the result of their abstruse speculations than to fur- nish the inquiring student with a plain practical describit, verum ex ejus descriptione dubium est an eadem sit planta cum ilia quain nos sub eodem nomine noscimus etiam hodie. See Lorry, Tom. 2, pag. 291. With all due respect for Lorry, I cannot but conclude that a too great veneration for the ancients has induced him, without sufficient reason, to pay them a compli- ment at the expense of the moderns. Our medical forefathers were in the habit of confounding many distinct diseases under the head of mania; some of which their system of evacuation was well calculated to re- move. May not the more robust temperaments of their patients, in a disease not so complicated as it is in the present day, have contributed to their success? The nerve of an Ajax or Orestes must have contributed to form a very different system from that of some of the nervous puny class of patients of the present day. ix manual, to direct his judgment in the treatment of maniacal patients. To supply this desidera- tum, in some degree, is the principal object of the present work, in which all abstract reason- ing is purposely avoided, the result of my own observation and experience stated, and an at- tempt made to point out a rational and success- ful method of treating diseases of the intellect. Much still remains to be effected, and I fear ever will, while our knowledge is so limited re- specting the parts of the animal economy more immediately connected with the reasoning fa- culties. I would advise my brethren of the pro- fession to adopt every mode calculated to im- prove the treatment of insanity, and experience has taught me, that nothing is more important and useful than a judicious, well conducted case book, in which the history of every maniac subjected to our care should be minutely de- tailed, every symptom and peculiarity accu- rately noticed, as well as the methodus medendi. While we deplore the unsuccessful result of so many excellent investigations, established for the express purpose of increasing our know- ledge of mental diseases, we have particularly to lament that those of our anatomists have been X attended with so little advantage.* We are not only disappointed, but have been furnishedfrom this source with extraordinary and unaccount- able facts which might induce us to believe the brain in some instances had little to do with the intellect; thus the contents of the cranium of some madmen, and even idiots, have appeared on dissection free from disease, while the same parts in other individuals, who retained their intellectual faculties unimpaired to the last hour of existence, have been found universally dis- eased: and, indeed where certain peculiarities have been detected in and about the encepha- lon, it is impossible to determine whether they were the cause or effect of the disease. Infants * Reasoning a priori it might have been expected that much useful information would have accrued from such researches. Both ancients and moderns have diligently investigated the brains of maniacs, and the celebrated Haller (See Haleri Elem. Physiolog. Lib. xvii. Sect. 1. Tom. 5. p. 57J.) collected a great variety of histories of such dissections, hoping to procure some valuable infor- mation respecting the functions of the encephelon, from the appearance of its different parts after death, in sub- jects who had laboured under mental diseases during life, but he candidly acknowledges his disappointment. XI have been born without brain,* and adults al- most completely deprived of it by disease; the cranium of some animals has been found filled with bone, and that of others completely empti- ed of their contents, &c. yet the faculties said to depend on the integrity of this organ did not appear to suffer. From such singular facts we can account for some authors having assigned the seat of the soul to the stomach, plexus So- laris, &C. But waiving any discussion of such subjects, as being more curious than useful, I shall take it for granted that the brain and its emanation, the nervous system, are the parts most intimately connected with the intellect, and that some morbid changes of these exist in every case of insanity. * See New Abridgment of the Philosophical Transac- tions, Vol. IV. p. 149, and p. 372. Practical Observations ON INSANITY. WITHOUT any laboured Introduction, I shall immediately proceed to the HISTORY OF A MANIACAL ATTACK. The approach of insanity is generally very gradual, at first only observable in a change of habits, disposition, taste, and pursuits, gene- rally succeeded by hurried movements, a rapid succession of ideas, high spirits, acute -sensi- bility, mental irritation, unusual suspicion, list- ening to fancied whispers or obscure noises, pride, impatience of control, peevishness, rest- lessness, inordinate mirth or depression, (ac- cording to the temperament) occasional abstrac- tion: dreams of the most grotesque and unna- tural description deprive the patient of refresh- ing slumbers, and frequently whole nights in B 14 succession are passed without sleep; in some individuals, the mind is occupied by one im- pression, in others, agitated by an endless va- riety, sometimes the judgment is perverted, at others the imagination excited: the body also exhibits various accompanying peculiari- ties: the face is flushed or pallid, the eyes are prominent and animated, or sunk in the orbit and dull; frequently the features are sharpened, so as to render the expression unnatural: in general, the muscular powers are increased, as is the capability of enduring cold, hunger, fatigue, and long watching; at the same time the natural excretions, and particularly the al- vine, become interrupted. The utmost irre- gularity of appetite and passions usually takes place, and this more or less increases till the disease is established, and there is an absolute necessity for restraining the patient. Among the varieties of maniacs met with in medical practice there is one which, though by no means rare, has been little noticed by writers on this subject: I refer to those cases in which the individuals perform most of the common duties of life with propriety, and some of them, indeed, with scrupulous exactness, who exhibit 15 no strongly marked features of either tempera- ment, no traits of superior or defective mental endowment, but yet take violent antipathies, harbour unjust suspicions, indulge strong pro- pensities, affect singularity in dress, gait, and phraseology; are proud, conceited and osten- tatious; easily excited and with difficulty ap- peased; dead to sensibility, delicacy and refine- ment; obstinately riveted to the most absurd opinions; prone to controversy and yet incapable of reasoning; always the hero of their own tale; using hyperbolic high-flown language to ex- press the most simple ideas, accompanied by unnatural gesticulation, inordinate action, and frequently by the most alarming expression of countenance. On some occasions they suspect sinister intentions on the most trivial grounds, on others are a prey to fear and dread from the most ridiculous and imaginary sources; now- embracing every opportunity of exhibiting ro- mantic courage and feats of hardihood, then indulging themselves in all manner of excesses. Persons of this description, to the casual ob- server, might appear actuated by a bad heart, but the experienced physician knows it is the head which is defective. They seem as if con 16 stantly affected by a greater or less degree of stimulation from intoxicating liquors, while the expression of countenance furnishes an infallible proof of mental disease. If subjected to moral restraint or a medical regimen, they yield with reluctance to the means proposed, and gene- rally refuse and resist on the ground, that such means are unnecessary where no disease exists; and when, by the system adopted, they are so far recovered as to be enabled to suppress the ex- hibition of the former peculiarities, and are again fit to be restored to society, the physician and those friends who put them under the phy- sician's care, are generally ever after objects of enmity, and frequently of revenge. When the peculiarities and propensities of such patients are in themselves innocent and only occasional, though they approach ever so near the confines of insanity, there is no neces- sity for restraint or confinement: but when the suspicious traits are of an opposite description, and only the occurrence of some exciting cause wanting to render such persons extremely dan- gerous, then coercion becomes indispensably necessary. Insanity, more than any other complaint, seems to take entire possession of the whole 17 system, and almost secures it from other mor- bid attacks. Mead, (See his Monita, Page 72) I believe, was the first who made the ob- servation, and no fact in medicine is more com- pletely established. During the period of pre- vailing epidemics, maniacs, in their affliction, seem to possess nearly an immunity from these diseases; and where an exception to this rule has occurred, the original complaint has been removed by the attack of the new disease. From hence a degree of improvement has arisen in the methodus medendi, by the in- troduction of some new disease into the system of maniacs; as where the patient has not had the small-pox, this complaint may be commu- nicated by inoculation. Indeed a variety of means might be adopted to excite a new order of symptoms, creating considerable commotion in the animal economy, interrupting the morbid associations, and even occasioning temporary disease; and it is highly probable that, in a great proportion of human diseases, health is restored by temporary morbid changes and new specific actions, and that medical men sometimes ac- quire credit from even the effects of their blun- ders: this applies to the whole class of empirics, B 2 18 As connected with the History of Mania, it will be proper to notice some circumstances concerning the pulse: a variety of causes, both mental and corporeal, conspire to induce al- terations in the circulation of the blood, and it is very difficult to determine what is a frequent pulse, this being a relative term, unless we were acquainted with the healthy standard in every individual, as the range is often very considera- ble; in one man it shall be sixty, in another ninety.* But I would by no means convey an idea that the indications from this source are to be wholly neglected, but only that the minute attention to the pulse, which is neces- sary in other diseases, is not so in mania. The difference of sex, stature, temperament, age, position, and temperature, as well as the state of the mind, are among the principal circum- stances to which we must ascribe the variety exhibited in every disease. Striking and obvious peculiarities in the pulse are never to be neglected, even in mad- ness; but where these exist without concomi- * " Nisi pulsus cujusvis hominis antea innotuerit; ex 50la. ejus frequentia., febris certo discerni nequit. Burserii Inst. Med. Pract. Vol. I. p. 9. 19 tant symptoms, we may suspect natural idio- syncrasy: for Dr. Falconer* met with a case, wherein the pulse did not exceed 40 in a min- ute, attended with numerous and evident symp- toms of fever; and individuals in their highest health have had their pulse at 120 and 130, while that of others has been naturally full, low, or intermitting; and it is no uncommon occur- rence to meet with patients who possess the power of accelerating or retarding the pulse by the operations of volition. In many chronic af- fections the pulse is but little to be depended on; but with patients labouring under mental affections, whether of the melancholic or ma- niacal description, it is a peculiarity worthy of attention, which sometimes prevails, that the pulse generally differs in the radial and carotid arteries, and, when soft and weak in the former, is full and hard in the latter, though the number of pulsations in a minute be the same in both. Though the face be emaciated and look pale, this is not a proof that there is no morbid de- termination towards the head; since, notwith- standing these appearances, we often find the * See his Observations on the Pulse. '20 most unequivocal marks thereof, such as sense of fulness within the cranium, of heat about the scalp, acute sense of hearing, sensation of throb- bing, imaginary noises, fancied whisperings, with a protruded eye, and a degree of oph- thalmia. Having described the premonitory and con- comitant symptoms of a maniacal attack, it will next be proper to notice its duration and ter- mination. These are far from being uniform in every subject of mental disease, and the differ- ence arises from a variety of circumstances. In some maniacs there are very few intervals of calmness, in others the hallucination occurs only at stated or unequal periods. As the attack is often sudden, so is the cessation or remission. When the disease advances gradually, and almost imperceptibly, so as to take complete possession of the patient before any attempts are made for its removal, it is frequently of long continuance. Where the causes are acci- dental, or obviously corporeal, the cure of the mental malady generally advances as the bodily health improves. Sometimes madness subsides into incurable melancholy, and frequently these two states alternate with each other, but the 21 most hopeless sequela of disordered intellect is Idiotism. However violent the symptoms du- ring the existence of the disease, the mental powers seem seldom to suffer on its removal; and it frequently happens that the patient retains the most lively and accurate recollection of every circumstance that attended the very acme of the paroxysm. I have often observed in ex-. amining patients, whether convalescent or dur- ing a lucid interval, that many of the unnatural, peculiar, extravagant acts, which accompany the mental derangement, seemed to have origi- nated in, or arose from, impressions on the or- gan of hearing occasioning false perceptions. Fancied whispering and distant voices are fre- quent symptoms, and I think may, in some degree, be attributed to a morbid state of the auditory nerve, the proximity of the carotid arteries, and the redundant flow of blood to the head, in mania. Though mental diseases in general steal on the patient in the most gradual and almost imperceptible manner, yet they sometimes attack suddenly: in the former cases the causes are generally either obscure or pure- ly mental, in the latter most commonly corpo- 22 real. In every case relapses are to be expected, and precautions used in order to prevent them. OF THE REMOTE CAUSES. These may be divided into predisponent, and exciting, or occasional; but as there are several causes whose action, in producing in- sanity, is not confined to either of the above, but seems, by frequent repetition, not only to bring on the disease where the predisposition already exists, but also to form that peculiar state of the body, these may with propriety be ranked under either class, or form a distinct one of themselves. The predisponent are either Connate or Ac- quired: and first of the connate. At the head of the list must be placed hereditary affections; these often descend from sire to son, and are transmitted to successive generations. Certain temperaments have attended a whole progeny; the same habits of thinking, reasoning," and ex- pression, similarity of voice and gait, and a pro- pensity to particular studies, have run through whole families. These facts being indisputable, parity of reasoning allows the possibility of pre- 23 disposition to diseases being hereditary, and this may with propriety be termed connate. It is hidden among the arcana of Nature, beyond the reach of human comprehension, on what these hereditary peculiarities depend, though various, and some very ingenious, explanations have been attempted. That certain improved states of the intellect take place uniformly in certain circumstances of the animal economy, as if the first depended on the last, seems evinced by what is observed in rickets, scro- phula, mollities ossium, &c. where defect of conformation is compensated by mental acu- men. There cannot be a more unequivocal proof that such connate predisposing causes exist, than that the same powers,' acting on some individuals, produce no morbid change in the intellect, while in others predisposed, insanity uniformly follows their application. There is a connate predisposition, where cer- tain peculiarities are exhibited, which mark men as characters who delight in oddity, in singularity of manner, modes of thinking and reasoning, such as often accompany the differ- ent temperaments when they are exquisitely marked, (See Darwin on Temperaments,) when 24 extreme mobility of body and mind, or torpidity of either, takes place. Diseases of the intellect have been observed to attack those individuals, on whom the impression of an agent is never in proportion to the degree of the acting power; who are much affected by trifles light as air, or remain unmoved amidst the most tremendous shocks. Persons thus predisposed should care- fully avoid the exciting causes. Wherever sin- gularity of natural temper is strikingly obvious, there exists a connate predisposition to insanity: this may be difficult of explanation, but it is reasonable to conclude that where such pecu- liarities exist, analogous states of the organs of intellect are present. These causes may arise from a certain structure of the primary moving powers of the nervous system, as where it re- sults from hereditary taint; or be occasioned by the frequent or continued agency of causes tending to produce such peculiarity, such as habitual intoxication, protracted lucubrations, or the inordinate indulgence of any passion. The connate predisposing causes may be either corporeal or mental, or the latter may depend on the former, and vice versa. Among the acquired predisposing causes we may reckon 25 those induced by habit. This has been with propriety, termed a second nature; its influence over some individuals is very extensive, and few are insensible to its agency. A late eccen- tric philosopher (See Darwin on Generation) has started a very singular idea on this subject, that habits of acting and feeling in parents are imparted to the new embryon at the time of its formation, and attend the soul into future life. Whatever agitates the mind intensely, what- ever occupies it exclusively, always hazards its faculties, inducing a state favourable to the at- tack of mental disease. Riveted attention to one train of thought is a very frequent source of insa- nity; the unhappy effects of this dangerous prac- tice commence with the loss of volition, and an inability to abstract the mind from what so deeply occupies and interests it: the moment this ina- bility to abstract the attention takes place, rea- son totters on her throne, and instead of retain- ing universal dominion, becomes a slave, and is influenced by every trifling impulse. It is a curious fact, that a peculiarity somewhat ana- logous attaches to the senses of hearing, sight, and feeling; whatever has occupied either of them for a considerable length of time will seem C 26 to be present long after it is dismissed: thus the sensation of gyration after sailing, and the perpetual recurrence of tunes. A very fruitful source of acquired predispo- sition to diseases of the mind results from de- fective systems of education, as well as from the uncontrolled indulgence of certain tempers and dispositions, especially where these exhibit peculiarity bordering on the extreme, and are not subjected to wholesome restraint. Exces- sive venery, and the profuse and unnatural ex- penditure of the seminal fluid, may be enume- rated among the acquired predisposing causes of insanity. However unable we may be to ex- plain the action of inordinate sensual gratifica- tion, and of the baneful and detestable habit of monkish seclusion, in producing those effects which occasion the predisposition in question, they are a most prolific source of diseased intel- lect, and often induce that species of madness which resists the most judicious curative at- tempts, so that both mind and body fall a sa- crifice; the first losing all its faculties in idiot- ism, and the last all its locomotive powers in palsy. No habit, to which depraved human naturr 27 is prone, acquires such irresistible force by in- dulgence, and none entails more dreadful con- sequences on its votaries, whether we regard fame or fortune, health of body, or the faculties of the mind. From this lamentable habit, the finest forms and most transcendent mental en- dowments are frequently destroyed, and it is observed to have a direct tendency to increase that excess of circulation in the vessels of the brain, which I conceive to be so peculiarly calculated to produce insanity. In young ple- thoric subjects, the effects of these enervating indulgences on the mind are sometimes sud- den, and exhibited by marks of high excite- ment, which generally subside into torpid me- lancholy without a lucid interval: or should the unhappy patient have occasional returns of rea- son, these only render him a prey to more acute feeling, to the reproaches of a guilty conscience, and excite the wish to terminate a miserable ex- istence, and become his own executioner; as it is by no means unusual for the influence of this pernicious habit to terminate in suicide. The generality of such patients suffer excessively from violent pains in various parts, tormenting, tantalizing desires, depressed spirits by day, and 28 harassing dreams by night; the faculties of body and mind becoming gradually affected until they are ultimately destroyed. It has been generally supposed that the influ- ence of the heavenly bodies is connected with diseases of the mind, and that the periodical returns of their paroxysms are regulated by the moon, hence the term lunacy; but I am deci- dedly of opinion, after much attentive observa- tion, that the moon possesses no such power: in some instances, the accessions of violence or of tranquillity have observed a degree of regu- larity, and it has happened that the first have taken place during the wane of the moon, and the latter in her increment; but this being only a casual coincidence, it cannot establish any law. I will not deny that some peculiar influ- ence of the heavenly bodies may produce cer- tain changes in the animal economy both in a- state of health and disease, since the fact is es- tablished by the most respectable authority, (See Mead, Jackson, Lind, Cullen, Balfour, Grainger, &c.) especially as we frequently see persons of delicate constitutions becoming a / sort of animated barometer, and certain crises uniformly taking place in some diseases; but I 29 never could discover any such power peculiarly connected with madness. The idea of lunar influence in maniacal conv plaints was handed down to us by our fore- fathers, and is still very generally adopted. Cel- sus says, " Cui caput infirmum est, is, si bene concoxerit, leniter perfricare id manibus su is de- bet, nunquam id si fieri potest veste velare, aut ad cutem tondere: utileque lunam vitare, max- imeque ante ipsum luna solisque concursum. (See Cels. de Medicina, Cap. IV.) Among the acquired predisponent causes may be reckoned that state of the mind and body which is induced by the intemperate use of spirituous or fermented liquors producing intoxication. Drunkenness seems more imme- diately to affect the intellectual faculties, and in proportion to the degree of excess the effects are more or less obvious and extensive. The circulation of blood about the head is consider- ably affected by drinking intoxicating liquors to excess, as appears by the protruded eye, the suffusion of face, and turgescence of vessels; and thus a morbid state of distention is induced, which I have supposed intimately connected with the proximate cause of insanity. The ha- C2 30 bit of intoxication has a direct tendency to en. ervate the body and destroy the mental powers, and it is a singular and lamentable fact, that in this instance the sins of the fathers are some- times entailed on their innocent progeny, and drunken sires are frequently succeeded by in- sane children. The habitual application of this power to the system, like many others, not only induces a predisposition, but fresh indulgences may prove an exciting cause of mental disease. External heat, especially when applied to the uncovered scalp, has induced a predisposition to insanity, and in some cases has proved an exciting cause, as in coup de soleil. Various peculiarities of structure, and original malcon- formation of the parts more immediately con- nected with the organs of intellect, have pro- duced such states of the system as predispose to insanity. Intense study, neglect of exercise, and a se- dentary life have a similar tendency, as also certain chemical poisons. We come now to consider the exciting or oc- casional causes. These two are eiiher mental or corporeal; and many of those which induce a predisposition to insanity may, in certain 31 circumstances, prove exciting or occasional causes. Both the depressing and exciting passions have proved occasional causes of mental dis- eases. Perhaps it would not be far from a just con- clusion, and might direct to the most success- ful mode of practice, were we to conclude that all those causes of insanity which we have term- ed mental, particularly the various passions, induce the disease in a similar way with intense thinking confined to one subject. Slight desul- tory contemplations leave transient impressions, but deep continued study exhausts both body and mind. It has been supposed, and perhaps justly, that all our thoughts, sensations, and in- tellectual exertions, are accompanied with cor- respondent motions; close and severe thinking has a direct tendency to weaken, confuse, and destroy the intellect. Our own feelings, the ex- isting symptoms, and the appearances on dis- section, tend to confirm the opinion, that these effects are produced by that change in the cir- culation about the head which uniformly attends the action of such causes. Thus the various passions, according to their nature, degree of 32 action, and the subjects acted upon, prove the predisposing and exciting causes of insanity. Though the inspection of the brains of dead maniacs, has added but little to our knowledge of the various causes which induced the atten- dant symptoms, yet we know that very trifling ones, acting immediately on the organ of intel- lect, derange its functions; thus the pressure of a very minute exostosis from the inner table of the cranium, the distention of some of the finest vessels of the dura mater, and the extravasa- tion of a very small quantity of water or blood on the superficies of the brain, have produced the utmost confusion of ideas. I have found Religion and Love the most fre- quent among the exciting causes of madness: both may produce this dreadful effect by an in- tense and exclusive direction of the mind to one subject, by the action of opposing passions, such as hope and fear, or by rendering the sensibility morbidly acute; thus individuals, whose judg- ment is not proportionate to their feelings, are peculiarly liable to become insane from these sources. It may appear strange that religion, the great- est blessing bestowed by heaven on man, should 33 ever prove a cause of one of his severest cala- mities. I am well aware that very various and op- posite opinions are entertained on the subject of religion as the exciting cause of mental dis- eases; but many an unhappy instance has oc- curred in my practice, where the ignorant or injudicious zeal of Preachers has induced hy- pochondriasis, insanity of the most incurable species, and moping melancholy, often termi- nated by suicide.* Professors of this descrip- tion, with the very best intentions, too fre- quently make no allowance for the peculiarities of natural disposition, and impute to serious conviction and celestial influence what more properly belongs to incipient disease; but while symptoms of insanity are sometimes mistaken for serious impressions, real religion is too of- ten considered as. an unequivocal mark of mental derangement, simply because those, * It has been hinted by some of the author's friends, whose opinion he highly respects, that the singling out the conscientious exertions of any class of christian mi- nisters as exciting causes of insanity is objectionable, and calculated to cast an oblique reflection upon religion, than which nothing could be further from his intention. 34 who thus decide, possess no sympathy with such feelings; as Festus said to Paul, thou art beside thyself, much learning doth make thee mad; when he replied, I am not mad, most no- ble Festus, but speak forth the words of truth and soberness. Nothing is more calculated to depress hope, and induce despondency, than the indiscrimi- nate practice of minutely describing, in the most glowing colours, the effects and conse- quences of sin, the horrors of hell, and the suf- ferings of the damned; dwelling more on the judgments than on the mercy and goodness of the Deity: inordinate fear acting on weak minds having a direct tendency to confuse the intel- lect. I by no means wish to condemn any form of religious opinions, but only the manner of exhibiting them; for I am fully convinced that a very injudicious mode of enforcing and dis- playing truth may unite with real piety, and produce the effects I deplore. Cowper beauti- fully says, True piety is cheerful as the day, Will weep indeed, and heave a pitying groan, For other's woes, but smile upon her own. 35 It is true that the cheerful, though not the benevolent, effect of religion is sometimes ob- scured and counteracted by the peculiarity of natural temperament, or the particular state of the mind; and thus it becomes a painful, an- xious apprehension rather than a consolatory hope. The hardened and impenitent, whose moral sense seems either depraved or annihilated, it must be admitted, require all that is terrific in description to produce any effect; the most convincing arguments, the most energetic lan- guage are indispensably requisite to attract at- tention; but still no address from the pulpit should present images of terror only, or be more calculated to excite fear and dread than hope and consolation; but while describing the fatal consequences of sin, it should hold up to view the pleasures of piety, should contrast the joys of the righteous with the horrors of the wicked, and make it plainly appear to the conviction of the meanest capacity, that no one ought to despair, and that hope is admissible in every case. Love when directed to a proper object and regulated by reason, may be justly esteemed 36 one of our most grateful and interesting pas. sions; but no one is so liable to vicissitudes and extremes, takes more complete possession of the human heart, or has been productive of such prodigious effects; while history, ancient and modern, furnishes the most convincing proofs of its having been a frequent source of diseased intellect. Disappointment, Jealousy, and particularly Seduction, as consequences of this passion are too often the cause of insanity of the most deplorable species. In men, disappointed love may induce this effect by driving its victim to various kinds of dissipation, such as intoxica- tion, excessive venereal gratifications, or soli- tary indulgences, which debilitating both body and mind, have a direct tendency to produce mental diseases. The corroding suspicion that constitutes the passion of jealousy is also a very common ori- gin of madness, and unhappily its subjectsare too frequently stimulated to the commission of the most atrocious crimes, the consciousness of which assists in the subversion of the rational faculties. The detestable crime of Seduction is ano- 37 ther very fertile source of insanity, its cruelty and criminality must strongly impress every heart in which humanity is not wholly oblite- rated. The common consequences of seduction are the fear of discovery, consciousness of guilt, and the reproaches of the world. The fe- male sufferer sinks to despondency while ex- periencing the neglect of the inhuman being in whom she confided: her tenderness is thrown back on her own heart, with no eye to pity, no ear to listen to her tale of wo. Can we wonder if women suffer the loss of reason in such distressing circumstances? Perhaps the most disinterested affection has been the original cause of their deviation from the path of virtue, and thus tenderness became the in- strument of their ruin: for in proportion to the sensibility, consciousness of shame, and re- maining virtue of the victim, may we appre- hend the degree of morbid effect on the intel- lect. S ometimes the iniquitous seducer him- self falls a sacrifice to his infamy, if he be not a practised 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 sufferingfrom remorse. D 38 Perhaps I have already said too much on this subject, I will only add that several in- stances have come to my knowledge, in which it appeared, that the opposition of love and pa- rental duty was the exciting cause of insanity. This has most frequently occurred among fe- males, whose love seems to possess more ten- derness and less passion than that of the other sex. The corporeal occasional causes of madness are as varied and numerous as the mental; and as was observed above, many of them, by their frequently repeated action on some systems in- duce a predisposition. Excessive venereal in- dulgences, intoxication, heat, previous fever, suppressed evacuations, repelled eruptions, old sores and drains dried up, injuries done to the head, profuse haemorrhages, painful protracted parturition, tumours, and peculiarity of shape of the parts about the brain, are the principal among many other corporeal exciting causes of mental disease. Frdm the foregoing observations .it will be easy to perceive that ruqst qfjhe causes enume- rated, whether mentaj or corporeal, have a direct or indirect tendency to induce an increased cir- 39 culation in and about the brain; and though,"as is observed in another part of the work, nature has guarded against an occasional or tempora- ry circumstance of this kind, yet it seldom takes place to any considerable degree, or for any length of time, without prejudice to the intellec- tual faculties. The effects of an increased force or unnatural quantity of blood sent to the head are sometimes wholly mental, at others solely corporeal. In the first instance they are marked by grotesque and incongnjous catenations of thought, varying ad infinitum, while the senses of sight, hearing, and feeling are morbidly af- fected: transient clouds, floating insects, crim- son flashes, &c. obscure vision; voices and noises harass the hearing; a sense of universal or partial formicatio, local or general contrac- tion of the scalp, and the various muscles con- nected with it, as well as a great number of other fancied sensations, prove a morbid state of feeling, all of which catch the attention, and furnish a fruitful source of intellectual wander- ing, and this varies according to the intensity of impression, the constitution of the patient or the predominant passion. The corporeal effects of an inordinate determination towards the 40 head are a suffusion of the face, accompanied by an increased dilatation of the pupils and eye- lids, while the vessels of the adnata are loaded with blood, and the whole orb protruded. In many cases there is a staring wildness or an in- creased brilliancy, with a contraction of the whole features, giving an unnatural expression to the countenance not easily described. In a few instances, I have observed the retina almost insensible when no other symptom of anesthesia was present; and on submitting the pupils to a similar degree of light, they have contracted unequally. These are rare but ominous occur- rences, and always render the prognosis unfa- vourable. A thousand facts conspire to prove the re- markable reciprocity of action that subsists between the mind and body. A great variety of causes, both mental and corporeal, contribute to produce peculiarities of mind and manners which border closely on insanity. Were I disposed to speculate on this in- teresting and curious part of my subject, I might remark, as a satisfactory proof, that cer- tain important changes, being once introduced into a class of individuals, may be transmitted 41 from father to son; the circumstance of all the different races of men descending from our first parents, whether we suppose them to have been white or black, exhibiting such a curious variety, whether we regard Colour, shape, tem- per, constitution, Sec. Hence it is obvious that certain plvysical causes have conspired to pro- duce these effects, which are uniformly propa- gated, though moral ones may at the same time be supposed to contribute somewhat to their production. OF THE PROXIMATE CAUSiv All inquiries respecting the proximate cause of mania are involved in such a cloud of ob- scurity that I forbear to enter upon a topic, on which I could offer nothing but vague conjec- ture and speculation. It is true that many have attempted to account for the production of in- sanity from the morbid appearances observed on dissection, but these appearances vary ex- ceedingly in different cases; and even where they are the most marked and constant, the} serve to denote the progress and ultimate ef- fects, rather than the actual condition wherein D2 42 the disorder consists. We only know, for cer- tain, that, in the majority of maniacal persons that have been opened after death, more or less organic injury of the brain has been discover- ed, and that the said organic injury seems to be, for the most part, the consequence of an inordinate determination of blood to the head, a fact of extreme importance in a curative point of view. However difficult to explain what the mind is, how it acts on the body and is acted on by it, by what medium its volitions are conveyed and impressions received, and limited as our knowledge of it is, both in a healthy and dis- eased state, I am induced to believe that in every case of insanity, be the remote causes what they may, the proximate cause resides in the brain; and that it consists in some morbid changes of the circulation of the blood, destroy- ing that healthy state upon which the integrity of its functions depends; that there generally exists a degree of plethora about the heads of maniacs, and frequently when the other parts of the system are in a state of exhaustion and debility. 43 OF THE PROGNOSIS. Authors agree that most cases of insanity- are curable in the earlier stages of the disease, and that the probability of recovery diminishes as the length of its duration increases. The chances of recovery are against those madmen who can trace their indisposition to a lunatic ancestry. When the causes are accidental or obviously corporeal, a favourable termination may be expected. Where the subjects of hallu- cination vary, and the mind is not obstinately fixed on one topic, and where remissions and lucid intervals take place, hope may be indulg- ed; as also in those cases where the natural dis- position is not materially changed, and the mind can be easily diverted from the deranged train of thought, where a succession of ideas occupy the mind, and these are of a gay and interesting complexion. The insanity subsequent to par- turition is generally curable, if the curative at- tempts be rational, which is not always the case.* Where the disease arises from religious * Car dans la manie, comme dans beaucoup d'autres maladies, s'il y a un art de bien administrer les medi- 44 enthusiasm, from the mind's being intensely impressed with tenets of the most pernicious tendency, the probability of cure is not flatter- ing. Paralysis, hemiplegia, and diseases of this class supervening, may be reckoned among the unfavourable occurrences: in these cases the system is rendered insensible to the action of medical agents, and the unhappy patient too frequently sinks into fatuity, a state which does not admit of even a ray of hope, and to which death itself is preferable. In every instance of insanity the prognosis must be doubtful; but I think it may generally be favourable where the action of the heart and arteries is preternatu- rally increased, though there be no other symp- tom of pyrexia; perhaps this circumstance often arises from debility, when bark and a generous diet restore reason. If the pulse continue per- fectly natural, it is an unfavourable symptom, more so than if unnaturally slow, as in the lat- ter case we may reasonably suspect some une- qual pressure on the brain, not wholly out of the reach of remedies. What Celsus says of an camens, il y a un art encore plus grand de savoir quel- quefois s'en passer. See Traitfe sur la Manie par Mons Pinel. 45 acute disease may apply in forming a progno- sis of madness; " quo vetustior est longus au- tem, quo recentioreo facilius curatur." When the original cause of the disease is obscure or obviously mental, and where intense application has been directed to only one subject, such as love and religion, the prognosis will be dubious. It may be esteemed a favourable circum- stance when the countenance frequently exhi- bits changes of expression, is now flushed and then pale; and unfavourable when the patient, previous to his maniacal affection, shall have been subject to violent occasional or periodical pains in the head; and especially if these have been confined to the region of the cerebellum. It seldom happens that insanity terminates fa- tally; but this is always to be suspected when the symptoms of furor are incessant and ex- cessive, and when all the means employed fail to produce any remission, as also when any vi- olent unnatural motions of the head and eyes take place and continue for any length of time; when the latter squint, are alternately opened and shut, look wild, staring, glassy, bloodshot, or suffused with tears, are not sensible to vivid rays of light thrown upon them; when drastic 46 remedies fiil to produce any effect, and when rubefacients, blisters, and the most acrid sina- pisms, neither vesicate the cuticle, nor even in- crease the heat or circulation about the parts to which they are applied. Those maniacs who are most susceptible of fear, as they are more easily managed, and with whom this passion can be medically employed, most frequently recover; though, in fact, there are very few patients of this description, who, with very little address, are not easily awed, as madmen are generally cowards. The more distant the peculiarities of the patient from his natural habits and disposi- tion, the less hope of cure, and vice versa. Rich citizens who, from a bustling active course of life, retire into the country to enjoy the otium cum dignitate, frequently become hypochon- driacal or mad, and are with difficulty cured. Though individuals of every temperament be- come insane, it has been observed that those of the sanguine more frequently recover. OF THE DIAGNOSIS. The distinction of insanity from other dis- eases, whether we view it as a medical or juri- 47 dical question, is of the highest importance. Prima facie no difficulty would seem to exist, but experience proves the contrary; and where the most respectable opinions are in opposition, the greater caution and diligence are necessary to determine the point. Among medical authors and nosologists, ei- ther the definition of fever is defective or that of insanity. Delirium sine febre (See Cullen) is certainly not a proper definition of madness, since we so frequently meet with cases of men- tal alienation, in which the most unequivocal and obvious characteristics of pyrexia are pre- sent. It is not every slight perturbation of mind, or confusion of thought, that constitutes insa- nity, even where fever does not exist. As the features of mankind differ so do their mental peculiarities. Idiosyncrasies of mind exist as well as of body. In some exquisitely marked temperaments, the characteristic traits nearly approach those of diseased intellect, and it often requires the nicest discrimination to determine where the former end and the latter begin. Madness is always to be considered as a chro- nic disease. It often exists without intermission for years, and yet has neither injured the sys- 48 tem nor deranged any of its functions; other disorders, which in any degree resemble it, are, for the most part, acute. In some of the most prominent features, Delirium makes the nearest approaches to madness, and marks of fever ob- tain in both. Delirium in every case is a symp- torn depending on previous acute disease. The best distinguishing marks arise from the differ- ent states of the intellect when under the influ- ence of the two diseases. In delirium the patient is not conscious of surrounding objects, such as bed, chamber, 8cc. nor does he know his attendants, unless excited by some violent stimulus, and this conscious- ness is very transient, as he soon relapses into his former state;while the madman knows every thing about him, but reasons falsely and ab- surdly respecting them, and, as Doctor Darwin observes, (See Zoonomia) the voluntary powers of his'mind are intensely exerted on some par- ticular object of his desire or aversion; he har- bours a suspicion of all mankind that they mean to counteract his designs, and while he keeps his intentions and the motives of his actions profoundly secret, is perpetually studying how he may acquire the object of his wish, and pre 49 vent or revenge the injury he suspects. In most maniacs there exists a peculiar predominant idea or class of ideas; upon topics connected with these, some can reason with propriety, though it generally happens that the accustom- ed trains of thought are excited by the most loose and distant catenations. In delirium, the ideas seem totally unconnected, and no sort of consistency is ever observed; as in drunkenness so in delirium, there are more evident marks of diseased action in the system, particularly in the yessels about the head, than in madness. What has been said of delirium will apply more par- ticularly to pbrenitis; in both the most unequi- vocal marks of fever accompany the confusion of ideas, as does also a morbid state of some of the functions: both are in general acute tempo- rary affections, attacking with violence and soon terminating; but these observations will not ap- ply in mania. Insanity is easily distinguished from all those other complaints which affect the intellect, and are accompanied by an abolition more or less complete of the external and internal senses, such as apoplexy, carus, cataphora, coma, &c. There would be little difficulty in distinguish- E 50 ing mania from idiotism, if the latter did not sometimes supervene as a sequela of the for- mer, though it is seldom so complete as in those cases following epilepsy, or where the party is an idiot from the birth, as in some of the inha- bitants of the Alps, the Cretins and Goitres, who seem only impelled like animals by appe- tency, and seldom exhibit more reasoning pow- ers than the brute creation: but maniacs will always reason, and sometimes right, though upon false principles, while the expression of the features in idiots and madmen is very strik- ing and peculiarly characteristic. The accuracy of a diagnosis is never more necessary than when insanity, for particular pur- poses, is feigned; but the consideration of this subject must be left to another part of the work. Hypochondriasis exhibits symptoms very similar to this disease, and, when it happens in a strongly marked melancholic temperament, is with difficulty distinguished from melancholia, to which it is often converted. But in most cases of hypochondriasis, though there exist a peculiar state of mind, a seriousness, gloom and listlessness to motion, with groundless fears; and though, as in madness, there be no fever, 51 yet there is no defect of judgment, nor injury of the reasoning faculty. Much difficulty would attend the diagnosis between mania and melancholia; but consider- ing them as only modifications of the same dis- ease, the attempt is unnecessary. The observations on granting certificates and on medical jurisprudence, might be properly introduced here, but I prefer adding them in the form of an appendix. OF THE METHOD OF CURE. In every case of disease, a careful and mi- nute investigation is indispensably necessary, but more particularly where the mind is disor- dered; as it frequently happens that the best information we can procure from the patient, or his friends, is incomplete or erroneous; one of the characteristics of madness being an at- tempt to deceive. We propose to arrange all the varieties of mental indisposition under the two divisions of Mania and Melancholia. It must indeed be ad- mitted that these are only modifications of the same disease; but their characteristic symptoms 52 are so opposite that the distinction is admissi- ble, although it may happen that each will re- quire the same management. The medical and moral treatment of maniacs, in general, must necessarily vary, but there are some few rules that apply in all cases. The first attention of the practitioner is to see that the proper means of securing the patient be at hand; or if he be under coercion, he is to determine, from the symptoms, the propriety of continuing or of1 removing it. His next care should be directed to the causes which are supposed to have given rise to the insanity, then inform himself whe- ther any peculiarities, natural or acquired, exist, either of body or mind; if the patient be subject to sudden variations of temper, fits of any kind, such as epilepsy, and convulsions, headache or hernia; marking the leading features of the dis- ease, the subject of the hallucination, the idea that most frequently occupies the mind of the maniac, and determining whether it should be eombated or indulged in order to second his curative attempts; as also whether the patient is most disposed to injure himself or his atten- dants, cautiously seeing every dangerous wea- pon removed from the apartment, and that he 53 be furnished with every necessary comfort. Should no alarming or prominent symptom forbid, the maniac may be allowed to remain in his new situation, or under any new circum- stances that may have been adopted, some hours before any medical plan be entered on. As it frequently happens that insanity, if not occa- sioned, is continued by the very means adopted for its removal; as where a system of evacua- tion is persisted in when the symptoms of ex- citement result only from exhaustion, it is an object of the first importance to ascertain whe- ther any medical or even moral means are ne- cessary, instances having often occurred in which every symptom of mental derangement has gradually disappeared, as the vessels be- came filled, the strength recruited, and the health reestablished. As most patients of this description, previous to their being submitted to restraint or medical assistance, have been ex- posed to causes that disorder the primae vias and chylipoetic viscera, where a certain degree of torpor is almost uniformly occasioned, whereby their natural healthy functions are impeded, and a fomes of irritation often accumulated, it may be laid down as a general rule, with very few E 2 54 exceptions, to commence the plan of cure by emptying the stomach and bowels by varied means suited to the case, for even the existence of diarrhoea is not an unequivocal proof that purging is not necessary; as indigested sordes, or indurated faeces, may occasion it. Though the diet must be regulated by the symptoms, yet a system of regularity, of fixed periods for meals, Sec. should be invariably observed in every instance. The various means to be adopted in attempt- ing the cure of insanity, for the sake of method, may be divided into moral and medical. Under the first may be ranked management, which is of the highest importance in the treatment of maniacs, in almost every case is indispensable, and has succeeded when the most active means have failed. The art of management results from experience, and the natural endowments of the practitioner: it partly consists in address, and is principally displayed by making proper impressions on the senses. It cannot be too fre- quently repeated that, even in the medical ma- nagement of maniacs, the physician should ne- ver forget that sympathetic tenderness which the sufferings of humanity claim; he should* 55 only take care that this be not so far indulged as to diminish his steadiness and presence of mind: for the furious madman, as well as the mise- rable melancholic, is frequently sensible to tender impressions, and "Gentleness of beha- viour makes the approach of a physician be felt like that of a guardian angel sent to afford ease and comfort, while the visits of the rough and unfeeling resemble those of a minister of vengeance and destruction." It is impossible to exhibit a set of invariable rules for this de- partment of our curative attempts: the methods had recourse to, and the conduct both of me- dical and other attendants, must be regulated by the circumstances of the case. In some cases, recourse must be had to the most ex- treme measures, for the security of the party and the restraint of fury; in others, the most opposite methods are indicated. Most maniacs being artful, and their minds intensely fixed on the accomplishment of any Vild purpose conjured up by the disease, physicians should be constantly on their guard: their grand ob- ject is to procure the confidence of the patient or to excite his fear. The first may be obtain- ed by very varied means: I have seen the most 56 furious maniacs in consequence of being libe- rated from their shackles by my direction, and under my own immediate inspection, so at- tached and devoted to me as never again to re- quire coercion. Fear is excited by firmness, and menaces producing strong impressions on both mind and body, while confidence often results from soothing and gentleness; and I am decidedly of opinion, and I am fully convinced by much observation and experience, that more will be gained by these than by their opposites. Maniacs, of almost every description, are sen- sible to kindness and tenderness, and, in ge- neral, are to be managed and controlled with more facility by these than by harsher means, which ought never to be had recourse to but in cases of absolute necessity. Whatever me- thods are adopted in order to excite either fear or confidence, deception is seldom ad- missible; no promise should remain unfulfilled, no threat unexecuted. Though I have only mentioned the employ- ment of fear in maniacal management, yet the whole range of passions might be occasionally resorted to with advantage; and were these un- der our control, or could their action be regu.. 57 lated, or their effects limited, there can be no doubt of their being very powerful agents in restoring diseased intellect. As every object has its associated trains of ideas, it should be an invariable rule, in the management of maniacs, to remove from their senses those that have even the slightest con- nection with the mental derangement. Reason- ing with maniacs is generally useless; but the ideas that partake most of the hallucination, may be sometimes very efficaciously combated by a few selfevident arguments or proposi- tions often repeated; but the talking at will be found more efficacious than talking to a pa- tient.* Whoever has studied human nature, either as a physician or philosopher, must be convinced, that from the peculiar organization of the animal economy there exists a recipro- city "of action between the mind and body, that all the ideas and motions of man result from sensation and reflection. If this be obvious in common life, how forcibly is it exemplified in maniacs. There are a thousand circumstances, which tend to diversify the effects produced by the * See Case I. ¥»* 58 same causes on the minds and manners of men; and it is obvious that those peculiarities which are the most prominent must be attributed to the influence which circumstances have on the system; and which, both in sound and diseased intellect, almost uniformly depend on tempera- ment: There cannot, perhaps, be a more strik- ing proof and example of the mind's affect- ing the body than blushing; or of the body's affecting the mind than is exhibited in drunk- enness. In the former of these cases, the in- fluence may be carried to such a degree as to produce not only bodily disease but even death; and in the latter, not only temporary derange- ment but permanent insanity. Habitual intoxication is a frequent cause of madness of the most incurable species; and passions uncontrolled and inordinately indulg- ed have a similar tendency. Were I t3 eiitc fully into this interesting part of my subject, 1 might investigate the laws and rules by which the animal economy is governed, with respect to the action of the passions and other powers, but this is foreign to my purpose. The conscientious physician, when in the execution of his duty he is attempting the re- 59 moval of these deplorable maladies, is under the necessity of occasionally deviating from the accustomed routine of practice, and, in some cases that have resisted the usual methods, is warranted in adopting others that have any, though it be only the slightest plausibility, or that promise the smallest hope of success. Thus the employment of what may be termed pious frauds: as when one simple erroneous idea stamps the character of the disease, de- priving the affected party of the common en- joyments of society, though capable of reason- ing with propriety, perhaps with ingenuity, on every subject not connected with that of his hallucination, the correction of which has re- sisted our very best exertions, and where there is no obvious corporeal indisposition, it cer- tainly is allowable to try the effect of certain deceptions, contrived to make strong impres- sions on the senses, by means of unexpected, unusual, striking, or apparently supernatural agents; such as after waking the party from sleep, either suddenly or by a gradual process, by imitated thunder or soft music, according to the peculiarity of the case, combating the erroneous deranged notions either by some 60 pointed sentence, or signs executed in phos- phorus upon the wall of the bed chamber, or by some tale, assertion, or reasoning; by one in the character of an angel, prophet, or devil: but the actor in this drama must possess much skill, and be very perfect in his part. I might refer to a number of cases where such decep- tions were had recourse to, with very varied results. However ludicrous such expedients may ap- pear, they are not only admissible, but some- times indispensably necessary; as in those cases where life is hazarded from a mistaken notion of a bone or stone impeding deglutition, and preventing the passage of food; or where a frog, snake, or toad, &c. is believed to inhabit the stomach, and the maniac refuses to take nou- rishment from some erroneous reasoning: in the first instance we are warranted in even in- flicting a superficial wound across the throat, and exhibiting a bloody bone or stone as the successful result of the operation; or where the imaginary culprit is situated in the stomach, one of the species should be secretly conveyed into the receptacle, as if removed by the action of violent vomiting, as in the well-known in- 61 stance of the cobbler supposed to be swallowed and brought up by means of an emetic, poetic- ally described by Westly.* Every fraud or deception that had been found necessary in the treatment of the patient, should be carefully concealed from him, even after his recovery, as the knowledge could be attended with no possible advantage, and might prevent the renewal of confidence in his physician, and the repetition of similar means in cases of re- lapse. * See Case II. F CASES. CASE I. Mr.----, aged 50, naturally of a cheerful, lively disposition, always elated and depressed by trifles, of the melancholic temperament, became gloomy, dejected, and silent, from the impression of an idea excited in the course of his reading that he had sinned against the Holy Ghost. Removal from the objects he had been accustomed to was the first proceeding, and he was then consigned to the care of an expe- rienced attendant. All the attempts, moral and medical, produced no alteration in the state of his mind; hope was annihilated, he believed himself shut out. from mercy, and that his case was beyond the reach of Omnipotence. No ar- guments nor reasoning directed to him availed; and, having studied the subject, his observa- tions were often very acute. The impossibility 63 of his having committed this sin, was often ar- gued with a third person, in his hearing; he was always extremely attentive, and sometimes very much interested. A few sentiments on the sub- ject were afterwards committed to writing, and passed from one person to another in the pre- sence of the patient; these excited his curiosity, and he expressed an anxious desire to see them, which was acceded to on his promising to com- ply with certain requisitions; and as he had a high sense of honour, and a sacred regard for truth, he never deceived me. After repeated conversations, managed as above, he was more open to conviction, he employed new terms to express the deranged idea, and, soon after, his implicit belief of it wavered; at length he doubted, and at last was convinced of his error. I advised a long journey, in an open carriage, to occupy his mind and exercise his body; pre- scribed some light reading, and his carefully avoiding all abstract moral questions, and dis- puted doctrines. 1 have every reason to believe that the plan being rigidly observed, was com- pletely successful. 64 CASE II. Mr.----, aged 40, of a spare habit and me- lancholy temperament, remarkable for having acquired general and almost universal know- ledge, and always possessing singular equani- mity, had injured his health by too close at. tention to extensive mercantile concerns. At length he was observed to be very attentive to every feeling, of which he made minute de- scriptions to his family; this increasing, he be- came a prey to empiricism, read several ridicu- lous popular pamphlets, and was soon worked up to a belief that his body was universally dis- eased; pills, potions, powders, unctions, lotions, and mercurial girdles, were employed and dis- missed in succession: Perkins's Metallic Trac- tors, for a time, amused him, till it was proved to the patient, and to the friends who witnessed the experiments, that these expensive baubles possessed no more properties than a rusty nail, which indeed had been satisfactorily ascertained by Dr. Haygarth, and others, some years since. All the fears of the patient became, at length, concentered in one, from which no arguments 65 could divert him, he believed all his sufferings arose from repelled itch; a formal consultation of medical men was therefore determined on, who, having previously agreed on the propriety of humouring the patient, professed to be una- nimously of opinion that this apprehension was just; a medical plan was laid down, some ru- befacient application to different parts of the body occasioned crops of eruptions from time to time, which were washed with some simple preparation. This farce continued a few weeks, and the patient at length was perfectly restored to health and reason. CASE III. Mr. ----, aged 25, of fair complexion, though his hair and eyes were dark, of exem- plary morals, and most amiable manners; fond of anatomy, and had dissected some few ani- mals; very desultory in his studies, but had read several medical authors with much atten- tion, and was in the constant habit of quacking himself. Though no apparent alteration took place in his countenance, yet he constantly complained of his health, to which all his at- F2 66 tention was confined, till at length, he was ren- dered absolutely incapable of all exertion both bodily or mental. After the repeated and anx- ious inquiries of his friends, it was discovered that he believed himself affected with syphilis, contracted, not by any unfortunate connection, but from sitting on the same seat after an in- fected person. Deaf to all reasoning and every attempt to prove the extreme improbability of the disease being propagated in such a way, his case was referred to some medical man of his own proposing of whom he had read or heard; and he being previously instructed, pro- nounced it venereal, sent a prescription, which very soon dissipated the absurd idea, and re- stored him to himself, his friends, and family, CASE IV. Mr.-------, aged 36, of ^fuli habit, melan- cholic temperament, extremely attached to literary pursuits, and subject to depression of spirits without any obvious cause. His lucu- brations were sometimes extended through whole days and nights in succession, and at these periods he was very abstemious, drank 67 only water, and avoided animal food; his friends remonstrated with him on the hazard of such proceedings; and his house-keeper being ur- gent for his adopting some plan that had his health for the immediate object, the idea struck him of her having some sinister design, and that she intended to destroy him by means of a succession of poisoned shirts, under the bane- ful influence of which he believed himself then suffering. No arguments availed, and all rea- soning was ineffectual, the hallucination there- fore was humoured, a suspected shirt was ex- posed to some simple chemical experiments, continued, repeated, and varied with much ce- remony, and the result so contrived as to prove the truth of the patient's suspicions; the house- keeper, notwithstanding all her protestations of innocence, was served with a pretended war- rant, and in the presence of the patient, hurried out of the house by the proper officers, and secluded from his observation for a time, while he supposed she was in gaol expecting an ignominious death. After this preface, a formal consultation was held, certain antidotes prescribed, and after a few weeks he perfectly recovered; a new plan of life and regimen were 68 adopted, and he has ever since continued to enjoy mens sana in corpore sano. I might select a great variety of cases very similar to the above, as—where the patient be- came insane from the idea of an earwig having entered the cranium, and traversing the brain, created strange confusion among its parts,— where insects were supposed to have intruded themselves into some of the cells of the bones of the face, by means of the aroma of flowers —where the parties believed themselves be- witched, enchanted, a prey to sprites, devils, hobgoblins, &c; others—where the patient imagined himself under the influence of magic spells, and vows; in all which it was absolutely necessary to humour the insane idea. But very distressing cases occur where the patient re- fuses food from some of the most absurd no- tions; and in order to prevent total exhaustion, and consequent death, the most consummate art and address are necessary. In these cases all the reasoning of the patient must be fully entered into, his fancies and wishes complied with as far as practicable and prudent, keeping the object of supporting life constantly in view; threats, promises, solicitations, indulgences, 69 deprivations, and varied reasoning must be had recourse to according to the nature of the case. CASE V. Mr. ----, aged 50, melancholic tempera- ment, spare diet, subject to bilious attacks, after running the medical gauntlet with little relief, though in fact afflicted widi no obvious bodily indisposition. After hearing his state- ment detailed with minuteness peculiar to pa- tients of this description, who seem almost uniformly to want language adequate to de- scribe their meaning, and an examination man- aged with a design to make a strong impres- sion, it was pronounced, with much solemnity and apparent anxiety, that his disease was in the bladder and kidneys, and consisted of uni- versal ulceration of these parts; but as, from their situation, it was impossible to exhibit them to the senses, it was purposely suggested that, if this were to be done, much hazard and danger would necessarily result, yet that hope might be indulged if it could be proved that the suspected cause was the just one. In order to ascertain this momentous fact, it was pro- 70 posed to pass a bougie up the urethra; this was effected with much formality, and attaching great importance to this very simple process, after allowing the instrument to remain for some time, it was returned loaded with the mucus from the glands of the part, and this being called pus was deemed the proof positive required. A course of remedies consisting of simples was now adopted, and a regimen rigidly pursued for a length of time, which ultimately terminated in complete reestablishment of health and intellect. Similar deceptions, varied according to cir- cumstances, are the only efficacious modes of combating many other hallucinations resulting from notions founded only in imagination; as where the patient suspects himself affected with certain loathsome diseases, such as itch, syphi- lis, scrophula, &c. labouring under the influ- ence of poison secretly administered by the most unnatural and improbable means of ma- gic, witchcraft, and evil spirits; these and simi- lar fancied causes have contributed to produce that species of mental derangement not curable by the common methods, in which no obvious corporeal indisposition exists, nor consequently 71 any indications to direct the practitioner. In all such cases the deranged ideas must be hu- moured, contrary to the established rule in the more common ones. CASE VI. Mrs.-------, aged 50, illiterate and natu- rally gloomy, of the melancholic temperament, strongly marked, meagre habit, and from her infancy subject to inequality of spirits, and rigidly religious. Her moral conduct had been exemplary, yet she became dejected, looked miserable, often sighed and wept, and yet would assign no cause. She became perfectly inac- tive, inattentive to her domestic duties, and could only be induced to read a certain descrip- tion of books, the sense and meaning of which she strangely perverted. At length her ideas became confused, and were uniformly directed in one train; she believed herself lost beyond redemption, and had no other prospect present- ed to her mind but the horrors of the damned, and the flames of hell; these haunted her inces- santly, deprived her of ease by day and rest by night: hope being extinguished and life a bur- 72 then, she made many attempts to destroy her- self. For months no sort of change took place. Her apartment was decorated with pictures re- presenting the portraits of saints, burnings of Smithfield, the sufferings of our Saviour, &c. the patient was surrounded with bibles and prayer-books, and she received the constant visits of some itinerant preachers, who employ. ed their utmost zeal and exertions in the hope of dissipating her distressing ideas, but with- out success. In this state she was committed to my care. I immediately removed her books and pictures, and suffered no one to visit her r>ut an attendant and myself: allowed no rea- soning on religious topics, and only a little light reading. Having been very irregular in her diet, her tongue foul and breath offensive, an active antimonial emetic commenced my method of cure; this brought away a vast quan- tity of bilious undigested sordes, and produced some very offensive evacuations from the bow- els. A certain hour for rising and going to bed was observed, and exercise in the open air gradually increased, which some days was ex- tended even to fatigue: still religion was the subject of her musings and soliloquies, her 73 ideas confused and incoherent, but her looks became more natural, and she could be occa- sionally diverted from the favourite topic. Va- rious remedies were administered, with very little relief, for several weeks, and then for two or three weeks following all medicine was sus- pended; the curative attempts confined to amus- ing and interesting the mind, to light nutritious diet, and to constant exercise. Under this plan she obviously improved, but she grew thin and complained of weakness; a more generous diet was then adopted, two glasses of wine every day, with some preparations of steel, and an occasional aperient to obviate costiveness; she at length began to think more rationally on se- rious subjects, and even to converse with pro- priety on them. t\ plan for the management of both mind and body was laid down, calculated merely to restrain the propensity to inaction, and to vary the subject of pursuit.—This finally succeeded. CASE VII. Mr.------, aged 40—his* case was very similar to the former, in its most striking fea- G 74 • tures, during the first weeks of his indisposi- tion. A more wretched or distressing picture of human infirmity can scarcely be imagined. At length all the symptoms that characterize religious melancholy were suddenly converted into those of mania furibunda.—He who was before silent, motionless, and almost senseless as a statue, now raved and swore, displayed the most surprising exertions of strength, and required three or four stout men to restrain his violence and secure him: his mind underwent a change equally striking; all was joy and hap- piness, and the countenance expressed the ut- most gaiety and pleasant feeling.—Ideas the most extravagant and wild now occupied his attention, and schemes equally so became the subject of frequent reasoning and calculation, There existing no contra-indication, a varied antiphlogistic plan was adopted, all stimuli Were abstracted, and sometimes light excluded: this in a few weeks perfectly succeeded. The conversion of religious melancholy into furious madness is a frequent occurrence, and is generally followed by recovery. This has suggested the propriety, in some cases that have resisted more common methods, of pro- 75 ducing a degree of excitement, by various means, such as keeping the patient, for days in succession, in a state of intoxication, which has often occasioned an alleviation of symp- toms, and sometimes restored the sufferer to reason. The religious insane are commonly despondent, though there are exceptions, yet in none of these do we scarcely ever find any indication to direct the curative attempts, and I have frequently observed with astonishment, in such cases, that however the body may be affected by medical, moral, or mechanical means, the mind undergoes no changes, or if occasionally diverted or distracted from the subject of its melancholy musings, it reverts to the same point, like the needle to the pole. As the gloomy insane devotee conceives him- self justly abandoned to despair, not a ray of hope enters his beclouded mind; he places no confidence in the mercy and goodness of God; nor, though he admits the truth of the doctrine of the atonement, will allow its possible effi- cacy in his case. The merest peccadillos of his earliest youth are generally aggravated into the most atrocious crimes, and accusations Of conscience incessantly haunt him. If we may judge from the language and the figures drawn 76 by patients of this description, to convey an idea of their feelings and sufferings, they must be exquisite: they are almost uniformly in the habit of quoting scripture very accurately to elu- cidate their positions, but as uniformly pervert its real meaning; delighting to dwell on the gloomy side of subjects, they disregard the brighter. Thus on my asking a miserable desponding fa- natic, who believed himself out of the reach of even Omnipotence, if the arm of the Lord was shortened that it could not save? he immediately retorted, " is his power diminished that he can- not destroy?" Though reasoning with such patients is sel- dom effectual, it should always be had recourse to when other means have proved unsuccessful, as instances have occurred in which convic- tion has flashed on the mind, and corrected its wanderings from a single argument. Selecting the mollia tempora fandi, we should preface our arguments with insisting on being heard without interruption, and then endeavour to suit them to the erroneous ideas adopted by the patient: and as his mind is generally tor- mented and terrified by a sense of the enormity of his offences, and the apprehension of the ef- 77 fects of God's wrath and displeasure, we might expatiate on the merits of Christ and the ef- ficacy of his atonement, endeavour to dissi- pate fear, and excite hope by quoting appro- priate parts of scripture, such as the parable of the labourers in the vineyard, in which it appears, that those who were hired at even the eleventh hour received the same wages as those who had borne the burthen and heat of the day; as also the account of the thief who was cruci- fied with our Saviour. I have met with some miserable individuals, whose defective reasoning turned entirely upon having committed the unpardonable sin; in these cases it is necessary to oblige the patient minutely and accurately to describe his idea of the exact nature of the crime, and afterwards to confute his arguments by proving their ab- surdity and impossibility. I have had a great number of cases of reli- gious melancholy, which exhibited but very little variety except in their termination; but I could select many to show the propriety of adopting the means proposed, were it not that they would swell this tract beyond all reasona- ble bulk. G2 78 Perhaps the most successful moral means re- sult from exciting new mental affections that have a tendency decidedly to correct erro- neous ideas, to call up new trains of thought, destroy ihe links of morbid association, and break the force and effects of vicious men- tal habits, which frequently have very exten- sive influence in the animal economy, producing many of those periodical and irregular effects erroneously imputed to other causes. We are such slaves to habit, that when it is strength- ened by frequent repetition, its dominion re- mains even in the absence of the causes that occasioned it. The mental indications are as various as the forms and causes of insanity; but the employ- ment of remedies, acting on the mind primari- ly should be regulated by the prominent features of the disease: some maniacs require threats, others soothing; the eccentric vagaries of this class to be humoured, the simple erroneous idea of that to be combated; while the hope of efficacy, in a great degree, will depend on the nature and duration of the insanity, the age and peculiarities of the maniac. It would be ex- tremely useful could we lay down certain 79 rules for the moral management of insane pa- tients of every description; but this is not pos- sible, it must depend on the existing symp- toms and circumstances of each case. There are few instances where the insanity has such a decided character, as to admit the application of fixed rules. In most of those cases which ma}r be termed religious madness, it might seem reasonable to apply similar means; but such a plan is fraught with extreme hazard. In some it is absolutely necessary to deprive the patient of books, particularly of his bible; and never to allow any reasoning on the subjects that harass and occupy the mind; as where the sense of authors, and passages of scripture are perverted, and the intellect has become bewil- dered by diving deep into polemic philosophy, and the patient delights to wander in the mazes of speculative religion, is sceptical or dogmati- cal, where he believes himself the Deity, our Sa- viour, an apostle, &c. or possessed of superna- tural powers.* In others the subject must be * The Author recollects a singular instance of a de- ranged idea of a maniac being corrected by a very sim- ple stratagem. The patient asserted that he was the Holy Ghost; a gentleman present immediately exclaimed, you 80 more delicately handled; the deranged idea may be calmly combated by a few mildly op- posing arguments, often repeated; hope should be elevated, and some rays of light diffused through the gloomy prospect. From hence it is obvious that there are two classes of the reli- gious insane, one self-conceited and confident, the other humble and despondent. With the first, it will be always necessary for the physician and attendants to look to their own safety, being deemed heretics and reprobates by the patients, in whose opinion no crime attaches to their in- jury or destruction: with the last, the attention must be directed to the patient, who being a prey to the most miserable feeling and des- pondency, is too frequently disposed to suicide; and to accomplish this dreadful purpose will sometimes employ the most consummate art, and elude the strictest vigilance. the Holy Ghost! what proof have you to produce? I know that I am, was his answer; the gentleman said how is this possible, there is but one Holy Ghost, is there? how then can you be the Holy Ghost and I be so too. He appear- ed surprised and puzzled, and after a short pause said " But are you the Holy Ghost?" When the other observ- ed, did you not know that I was? his answer was, I did not know it before, why then I cannot be the Holy Ghost, 81 The Cure of these deplorable diseases, being that part of my treatise which I consider by far the most important, and intending it to be more practical than speculative, I hope to be excused if I descend to minutiae in a matter of such moment. Some physicians have laboured to prove that insanity is uniformly produced by a mental cause, or that it is in general dependent on no bodily one; but their arguments are certainly inconclusive, and I am more disposed to sub- scribe to the converse of the proposition, that madness is always accompanied by corporeal disease, though this may not be obvious to the senses in every case. It is possible the occa- sional causes may be either mental or bodily, but it will be most rational as well as useful in practice to believe the proximate cause of the latter description. In attempting the cure of insanity, we cer- tainly ought, if possible, to inform ourselves of the remote causes, and carefully to collect the most minute particulars connected with the history of every case. In a great variety of ma- niacs, the employment of medicine is either improper or impracticable; and here our cura- 82 tive attempts must be confined to what is called management, which often, claims a considera- ble share in removing mental derangement. Strong coercive measures are seldom necessa- ry in the earlier stages of the disease, though much address is requisite to secure tranquil- lity and obedience; but more is always to be done, as before observed, by firmness and ten- derness than by violence and harshness. That there are cases perfectly unmanageable with- out bodily restraint, and all the different means of security, must be acknowledged: and others, where, from the nature of the complaint, and its peculiarities, as connected with the tempe- rament, and the prominent symptoms, such restrictive means are absolutely necessary; for it often happens that the silent moping melan- cholic, as well as the furious maniac, is artfully lulling suspicion, brooding mischief, and has all the faculties of his soul intently bent upon injur- ing himself or others. It would be impossible to point out the modes of management exactly suited to the various species of madness we meet with in practice. I will dierefore content myself with detailing what may be requisite in the two opposite states of insanity, Mania and 83 Melancholia. In the first, where there are symp- toms of high excitement, and the natural dis- position and temper are very materially altered; where audacity, indelicacy, and fury alternate, with raving, vociferation, and impatience of- control, we must have recourse to the best me- thods of restraint, and perhaps every other must yield to the improved strait waistcoat, assisted by other means of coercion.* i The furious maniac, after being well secured, should be kept quiet, and all stimuli abstracted, excepting, perhaps, light, concerning which I have not been able to form a decided opinion; as total darkness generally tends to aggravate all the symptoms, by exciting fear, dread, and apprehension, it will be, obviously, improper in some cases to have recourse to it, but in others it will be necessary on purpose to pro- duce these effects. In a considerable proportion of insane patients, confinement to an airy quiet apartment, from whence previously every dan- gerous or missile weapon has been removed, is all that is necessary. Whenever coercion is in- * The author conceives he has made improvements in these mechanical contrivances, of which he may at some future time publish a description with engravings. 84 dispensable, great advantages would arise were it employed under the immediate inspection of the physician, who should give directions and see them executed, but not assist: he should issue his orders and see them obeyed; never threaten, without executing; should be firm yet tender, and never permit himself to be alarmed, agitated, or ruffled. Corporeal punishments, such as stripes, are in no case necessary or admissible.* Thus far the attention has been directed to the management of the body in mania, it must now be directed to that of the mind. It has been a very general, but erroneous idea, that the subjects of hallucination should be uniformly humoured and attended to, in order to dissipate or correct them; that the fear of exciting madmen by contradiction indicates * The furious maniac being once restrained, it may be expected that I shall point out some rules for his re- lease; this, however, is a matter of much difficulty, and it is only by close observation and long experience that we can ascertain when a part or the whole of the coer- cion should be discontinued. His promises can seldom be depended upon. The liberation must, however, in all cases be gradual. 85 the necessity of acquiescence with their eccen- tricities, and the propriety of reasoning with them on the topics of their alienation; but such a practice is often productive of an aggravation of the symptoms, and onty admissible either for the purpose of gaining some important ob- ject, or where it makes part of the curative system, as in Case V.* * I am aware that a degree of confusion and contradic- tion appears to exist in the observations and directions respecting the practice of opposing or humouring the deranged ideas of different maniacs. The subject has oc- cupied much of my attention, but I find it extremely difficult to give such rules and directions as may not mislead the inexperienced practitioner. The remarks upon this part of the former edition of this work, in a criticism of a very respectable periodical publication, seem so judicious, and for the most part, so entirely accord with my own ideas, that I shall take the liberty of transcribing some of them. « If we may pre- sume to generalize for ourselves, from considering the nature of the hallucination in the few cases which Dr. Cox has related, we should conclude that the instances in which the idea may be humoured with success, are those which bear a great affinity to hypochondriasis, or which are in fact hypochondriasis in an extreme degree. The insanity in these instances we believe, with Dr. Crichton, originates in some obscure and uneasy corpo- H 86 The business of managing the alienated mind is a very difficult branch of the curative art, for real sensation, which excites the imagination to those very unaccountable conceptions which constitute the disease. Strong impressions on the senses may in these cases counteract the tendency of those feelings__We can here oppose sensation to sensation; clear and dis- tinct sensation to that which is obscure: the latter of course yields to the former, and without the train of imaginary evils to which it gave rise. If a person be- lieves himself to be affected with the itch, as in the se- cond case related by Dr. Cox, the production of a crop of eruptions on the skin by some application, and the apparent cure by other applications excites a palpable sensation which the imagination cannot easily distort; and that which was obscure is no longer attended to. But in other cases, where the disease is more purely men- tal, is independent of sensation, and the mere result of strong and repeated impressions on the mind (such are instances of religious insanity) to accord with the insane idea, and to permit it to be cherished, is but to respect the impression, and to add to its intensity; no counter- acting object or sensation can be employed; and decep- tion is impossible. Hence the only successful attempt to cure must be the contrary of the former; it must consist in removing every thing which, by association, can in- duce the recurrence of the insane idea; in preventing all reasoning on the subject of it; and in pressing upon the attention every variety of topic that may interest the 87 which very few rules can be laid down. Dr. Lorry, (See De Melancholia, Vol. II. page 382) speaking on the subject, says, " praecipue vero preceptoris hasc esto cura, ut studeat qua parte ad furorem inclinet animus illi commis- sus, hancque praecipue temperare studeat, non minas aut verbera intentando, sed oppositarum virtutum laudibus, sed avertendo ab iis quae possunt propensioni pondus addere. In hoc vero ars consistit ut vis illata non sentiatur ne indo- cilis animus negata occulto ardore concupis- cat." In every case, as much liberty and exercise in the open air should be allowed as is consist- ent with safety; and when coercion is employ- ed, the degree of it should be uniformly pro- portioned to that of the disease. The management of melancholies turns mind. Case V. of Dr. Cox affords a pointed illustration of this doctrine." (See Critical Review for July, 1805.) I would only observe on this criticism that, contrary to the principle laid down of " preventing all reasoning, &c," I have met with some few cases of religious me- lancholy in which reasoning produced the most obvious advantages after other more common and probable means had failed. 88 principally upon the prevention of injury to themselves: with patients of this description coercion is seldom necessary, excepting with the above intention; and, in general, a plan very opposite to that adopted with the furious maniac is to be pursued. The utmost sympa- thy and feeling is to be uniformly observed in the conduct of the physician and attendants, who should employ all their exertions to amuse the mind, and divert the thoughts from the gloomy subjects which occupy it, by endea- vouring to interest and excite new and pleasing ideas. It sometimes happens that after the most acute and ingenious reasoning has failed, and every attempt to make any impression on the diseased intellect has been unsuccessful, the talking to a third person in the presence of the patient, artfully opposing his erroneous opin- ions, and pointing out the absurdity and im- possibility of truth and reality in the ideas he maintains, quoting instances, and citing cases as additional proofs, has been productive of happy effects.* A great part of the successful management * See Case I. 89 of the insane is such as cannot be minutely de- scribed, for as the existing symptoms differ, so must the methods to be adopted; but let it be indelibly impressed on the physician and attendants, that all the fury, disposition to mis- chief, attempts to injure, and all the noise and exertions of maniacs, as well as their abuse, keen, sarcastic, cutting observations, &c. are the result of disease, and ought to be al- lowed for accordingly, and imputed to this source; that any virulence of expression should never be regarded by the attendants or physi- cian; nor injury or violence inflicted on them be resented or returned; unnecessary severity is unmanly and highly criminal. In most instances, maniacs, notwithstanding the apparent ungovernable fury and impatience of control, are easily curbed, and fear as easily induced. A firm, resolute demeanor, stern as- pect, an assumption of authority, giving orders and seeing them executed, uniformly decided measures, a scrutinizing look fixed on the pa- tient's eye, will, in general, excite dread or confidence, respect and compliance: and the procuring of these effects is a material point gained, which is seldom lost again, unless by H 2 90 the mismanagement and improper conduct ol the physician. The promises of a maniac who can reason at all may sometimes be attended to, and the word of honour is seldom broken, if solemnly given at those periods when the more violent and dangerous symptoms have subsided. Deception, unless this makes part of our attempts to relieve, should never be ad- mitted in the management of the insane; if once detected confidence is lost, and with it very frequently our hopes of cure. All our mea- sures respecting them should be decided, and though mildness, yet firmness, should attend their execution; no point should be abandoned which our judgment approves: for an effect or impression once produced is generally lasting, and a repetition of disagreeable means seldom necessary. Our curative attempts may often be very much assisted by artfully engaging the mind in some pursuit, occupying the body in any em- ployment which requires attention, and yet does not occasion fatigue; attaching importance to.certain trifling engagements, such as weaving bobbin, knotting thread, knitting, netting, and 91 various other modes, which it is not necessary to enumerate. The power of harmony over some constitu- tions is not easily described or conceived. I have seen it rouse from a most lethargic state, and divert the mind from the subject of its deepest contemplation. In a military maniac, I once witnessed the notes of a shrill fife, managed with some address, first awaken attention, then occasion interest, as was obvious by his anima- ted looks and by his beating time; till at length, by varying the air according to the effects, it pro- duced the most pleasing sensations, and brought back, as he afterwards informed me, some very impressive recollections, excited an entirely new train of thought, and seemed to correct the er- rors of intellect: though he had not left his bed for weeks, nor spoken a single word during that time, and had been supported entirely by force, he now arose, dressed himself, and with- out any other remedy but gentle tonics, re- turned to his former habits of neatness and ra- tionality; advancing gradually to perfect reco- very. Unfortunately he relapsed a-year or two afterwards, and I fear is now incurable. 92 The concord of sweet sounds, however pro- duced, may be often very usefully employed in the treatment of maniacs: it has hushed con- tending passions, allayed irritation, collected the wandering thoughts, and induced sleep. Where the patient has been a performer, if there exists no bodily indisposition that contra- indicates, the playing on his instrument should be always allowed, as it innocently employs both mind and body; and where the partiality for music is considerable, the indulgence or deprivation may make part of a system of re- wards and punishments. Some few instances have occurred in my practice, where the patient, who, before his mental malady, possessed the most exquisite skill on various instruments, and the most profound knowledge of music as a science, has lost both while under his hallucination, as was proved by repeated expe- riment; but as his health and intellect improv- ed, his musical powers returned. I once had the care of a professor whose talents seemed improved by mental derangement: all the facul- ties of his mind were riveted upon his profes- sion, though he frequently reasoned on this and every other subject absurdly. His ideas, as ex- 93 ecuted on the violin, were wonderfully strik- ing, singular and original; but the labour and practice some passages occasioned were attend- ed by profuse perspiration, and often followed by exhaustion and syncope. A few very eccen- tric and beautiful variations of some popular English airs, two or three of which were com- posed in the very acme of maniacal paroxysm, I have still in my possession, which have been much admired by amateurs, and require very superior talent to execute accurately. I am sor- ry to add, of this extraordinary genius, that though he perfectly recovered, and continued in possession of all his faculties for many months, he relapsed and is since dead. From the few experiments I have made, I am confident the concord of sounds, in some cases, and the dis- cord of jarring instruments, in others, might be very usefully employed in the rectification of some alienated minds. The study of thorough bass and counterpoint is well calculated for the amusement and employment of patients, musi- cally mad, under proper restrictions, and in particular circumstances. Hence I am decided- ly of opinion that music, as a mean in the treat- $4 ment of many diseases, is undeservedly des- pised and neglected. There is a charm, a power that sways the breast, Bids every passion revel or be still; Inspires with rage, or all our cares dissolves, Can sooth distraction and almost despair: That power is Music:— Music exalts each joy, allays each grief, Expels diseases, softens every pain, Subdues the rage of poison and the plague; And hence the wise in ancient days adored One power of Medicine—melody and song. Armstrong, m. d. In the medical management of the insane, it is an object of the first importance, when symp- toms of high excitement take place, to ascer- tain whether the disease be of the sthenic or asthenic kind; as rage, fury, and every species of violence accompany these two opposite states. The distention of vessels may be either tonic or atonic, and derive its origin from dif- ferent sources; the first from tenseness and ri- gidity, with partial or general plethora of the system, when the circulating fluids are vio- lently propelled in order to overcome the resist- ance; and the other from debility and relaxation 95 of the coats of vessels, when these yielding too easily, admit a more than ordinary proportion of contents. In the treatment of such cases, the physician must be directed by his knowledge of the remote or occasional causes. It may be difficult to point out with accuracy all the diagnostic marks of those cases in which the irritability and fury are the result of atony; but the more prominent features may be easily ascertained. Thus, where all the usual atten- dant symptoms of mania furibunda follow dis- eases that have been attended with extreme ex- haustion of the system, where an abstemious and evacuating plan has been rigidly pursued, and great prostration of strength has followed, where painful protracted parturition is succeed- ed by insanity, where debility and emaciation exist, notwithstanding the attendant fulness of the pulse, where paleness and trembling of the extremities, partial and fetid diaphoresis take place, where impeded respiration follows trifling exertions, and syncope violent ones, and where no alleviation of any of these symptoms is pro- cured by the antiphlogistic plan: in all these, and other similar cases, we may reasonably sus- pect, that the appearance of high excitement 96 results from atony, and this should direct our practice; for here I suspect that deviation from the healthy distention of the vessels of the or- gans more immediately connected with the in- tellect, which I have laid down as the proximate cause.* Diet is an object of very considerable mo- ment in attempting the cure of the insane. The quality is not of so much consequence as the quantity, either as to fluid or solid ingesta. The almost total abstinence from liquids, as recom- mended by some practitioners, has, I believe, been seldom carried to any great extent in the treatment of maniacs; and as this system, rigid- ly pursued, occasions the intolerable sensation of thirst, were any advantages to result, would it not be reasonable to impute the good effects to this painful impression, which forcibly af- fecting the stomach arrests the attention: though it must be allowed that no plan can be more reasonable, where the vessels are loaded, with an obvious determination towards the head, than abstraction of fluids, and a very limited quantity as part of the diet. So long as * See Cases VIII, IX, and X. 97 symptoms of irritation or violence exist, it has been usual to pursue the antiphlogistic plan; but where these obviously arise from atony or debility this must be highly improper, as they are only to be removed by a generous diet, bark, port wine, &c* Another very improper practice in the dietetic management of the insane is almost universally adopted, that of plying them with caudles and broths, teas and ptisans, deluging the stomach with warm thin fluids: these impair the powers of the chylopoetic vis- cera, induce flatulency, and tend to generate or accumulate viscid phlegm, the presence of which deranges every healthy process, and has more connexion with the state of the intellect than will be readily admitted. In the majority of cases the diet should be of the most nutri- tious kind, administered in small quantities, and often: the various leguminous productions, and the culinary preparations from them, are generally improper, as also the whole tribe of fermented liquors: pure water with the occa- sional mixture of distilled spirits is the best beverage. * See Cases VIII, IX and X I 98 It often happens, from various causes, but most frequently from some mistaken idea or secret vow, that maniacs refuse food; in such cases, rich soups, jellies, and the like, are in- dispensably necessary, and must be introduced by force; but new milk alone, combined with other nutritious substances, or loaded with ani- mal gluten, has been found to preserve life longest, either by the mouth or clysterwise. In every instance> much advantage arises from a system of regularity; the hours of leaving and retiring to bed, of meals and exercise, &c. should be punctually observed; as very trifling means, acting uniformly and constantly, are often productive of considerable advantages, and none should be neglected that have any claim to attention; for though relief does not speedily follow our best exertions, we should ever indulge hope and persevere in the use of various methods while the shadow of probable success remains. Many hopeless cases undoubtedly arise from topical mechanical causes within the brain: whatever increases the bulk of its contents, obstructs or impedes the circulation, in a htony case such as the cranium, may be reasonably 99 conceived equal to the production of deranged intellect; and that this does sometimes take place, both as cause and effect, dissection and accidental modes of relief* have unequivocally proved, though the Creator has so admirably provided for the preservation of the integrity of the more noble organs. Where such causes are suspected to be present from certain ap- pearances about the head, complaints of fulness. partial, flying painful affections about this part, occasional squinting, dilatation of the pupil, regular periodical returns of insanity, where the usual means have failed, are we not war- ranted in having recourse to desperate ones, and may not relief arise from the application of the trephine to various parts of the cranium? by removing portions of which, may not a greater degree of expansion be allowed to its contents, and thus contribute to the rectification of their impaired functions? The medical philosopher, in his study of hu- man nature, must have observed the sympathe- tic correspondence of action between the mind and body, which is uniformly present in health * See Cases XII, and XIII. 100 anddisease, though varying with circumstisnces. The different passions, according to their na- ture, the degree or intensity of application, and the sensibility of the party, exhibit certain cha- racteristic expressions of countenance, and pro- duce objjybus changes, actions, or motions in the animal economy.* Music has been found to occasion all these actions,changes, and move- ments in seme susceptible systems; and where one passion morbidly predominates, as fre- quently happens in mania, those specie's of sim- ple or combined sounds which excite an oppo- site passion may be very usefully employed. If then such effects can be produced by such a power, acting on a mind only endued with its healthy proportion of susceptibility, what may we not expect where the sensibility is morbidly increased, and where the patient is alive to the most minute impressions? Cases frequently oc- cur where acuteness of sensibility and extreme delicacy exist to such a degree, that most of the more common, moral, and medical means are * Omnis enim motus animi suum quendam a natura habet vultum et sonum et gestum et ejus omnis vultus, omnesque voces, ut nervi in fidibus ita sonant, ut a motu animi quoque sunt pulsae. Cic. de Oratore. 101 contra-indicated; here relief may be frequently administered through the medium of the senses: the varied modulations, the lulling, soothing cords even of an eb'lian harp have appeased con- tending passions, allayed miserable feeling, and afforded ease and tranquillity to the bosom tor- tured with real or fancied wo; and I can easily imagine, that jarring discord, grating harsh rending sounds, applied to an ear naturally mu- sical? would uniformly excite great commotion. Under circumstances calculated to assist this action, by producing unpleasant impressions through the medium of the other senses, as when screeches and yells are made in an apart- ment painted black and red, or glaring white, every man must be painfully affected; the ma- niacal patient, however torpid, must be roused; or, on the contrary, where an opposite state ob tains, extreme sensibility and impatience of powerful impression, there much may be ex- pected from placing the patient in an airy room, surrounded with flowers breathing odours, the walls and furniture coloured green, and the air agitated by undulations of the softest harmony. Much of this may appear fanciful and ridicu- lous, but the inquiring practitioner will find, on 12 102 making the experiment, that it deserves his se- rious attention; and no means are to be despised which are capable of arresting the attention, changing the trains of thought, interesting the affections, removing or diminishing painful sensations, and ultimately rendering both mind and body sensible to impressions, and all this has been effected by music. Every individual is not capable of accurately estimating the ex- tensive powers of this agent; but I would ask the musical amateur, or the experienced pro- fessor, if he has not frequently felt sensations the most exquisite and indescribable; if he have not experienced the whole frame trilling with inexpressible delight, when the tide of full harmony has flown on his ear; and the most wretched miserable feeling, universal horripi- latio and cutis anserina, from the grating crash of discord? All the varied sensations, from tran- sport to disgust, have been occasioned by the different movements in one piece of music. I might amuse my readers with a great variety of instances, where persons have been very sin- gularly affected by means of music, and where its powers have extended to the brute creation, but this I purposely avoid. 103 CASE VIII. -----—, aged 19, temperament not very exquisitely marked, but rather choleric; fair skin, dark hair and eyes, of most accomplished manners, very superior literary acquirements, and amiable disposition. A tender attachment to a worthless object, at length diminished her natural vivacity, she became pensive, and fond of solitude. One of those accomplished villains, who so frequently practise their successful sys- tems of seduction, after securing her confi- dence, had at length triumphed over her too susceptible heart, rioted in the possession of her charms, and then basely deserted her. I cannot pretend to pourtray what beggars de- scription; but a more interesting or distressing case can scarcely be imagined; suffice it to say, the period of gestation passed without any pe- culiar corporeal indisposition, but the unhappy patient pined in secret, her vivacity and spirits, like her deceitful lover, abandoned her, and her countenance exhibited the most striking traits of guilt and despondency. A protracted and painful parturition reduced her delicate frame 104 to extreme debility and emaciation, while her ideas became confused and her mind obviously diseased. Her days and nights were passed in alternate raving, vociferations and incoherent murmurs. Though the countenance assumed the common marks of facies hippocratica, the eyes shone with an unusual brilliancy, and with that peculiar expression which so fre<$uendy accompanies insanity. A regimen, composed of nutritious soups, vegetable and animal jel- lies, was gradually changed to full generous diet. A slight infusion of the bark was succeed- ed by a strong decoction, and the same in sub- stance: the mind was kept interested by change of scenery and varied pursuits: the sympathy of kind friends, and the consolations of religion, brightened her future prospects, and elevated her hopes. Under this system, both mind and body daily acquired strength, and at length health and reason were perfecdy reestablished. CASE IX. -------, aged 30, sanguineous temperament, of a delicate irritable habit, subject to transient head-aches and slight febrile attacks, the mo- 105 ther of four children. Nothing unusual oc- curred during her periods of gestation; indeed her health rather improved while pregnant; but she uniformly suffered successively in parturi- tion: the milk, which at first was copious, ge- nerally disappeared the second or third day, and then the usual marks of insanity took place. Her ideas passed in rapid succession, linked by nothing like rational or natural association, and tinctured by no one particular character, which is, I believe, almost uniformly the case in puerperal mania. Her volubility, exertions, and want of rest, almost exhausted the vital functions; but by adopting the same plan as in the last case, it produced the same happy effects on both mind and body. CASE X. Miss-----, aged 22, sanguine temperament, very delicate habit, seldom enjoying robust health, particularly partial to botany and draw- ing, which she sometimes pursued inordinately, rambling over hills, and scrambling up rocks, from morning till night, in quest of plants, and to procure favourite points of view for sketch- 106 ing; often regardless of weather or food, and sometimes debilitated and exhausted even to fainting. Such a process, with such a frame, could not be long persevered in with impunity; at the close of one of the hottest days in July, after a long ramble over rugged steeps, preci- pices and mountains, in one of the most ro- mantic parts of North Wales, a peasant found her, seated on a hillock, exhibiting all the usual symptoms of furious madness, surrounded by fragments of plants and drawings, making the most frantic gesticulations, vociferating with great vehemence, and spouting parts of Shak. $peare. With great difficulty she was conveyed home, where she continued for some time with all the peculiarities attendant upon the wildest phrenzy excepting fever. She was bled, purged and vomited in succession, deluged with saline juleps, broths, and ptisans, without any allevi- ation; in this situation I was consulted; and re- flecting on the history of the case, the attend- ant symptoms, and the plan that had been adop- ted without relief, I was induced to employ an opposite one. A more nutritious diet was gra- dually adopted, a pleasing change was speedily observed, and, with the assistance of port wine, 107 gentle exercise, and without the aid of any other medicine, besides the bark, she perfectly recovered in the course of one month. I could detail a great number and variety of cases very similar to the above in point of treatment and termination, though the remote causes in the majority were different. Insanity, in many instances, derives its origin from de- bility and exhaustion, when it is accompanied with audacity, fury, impatience of control, and this whole class of symptoms; and when the causes, prima &cie, do not seem calculated for their production; thus the indulgence of one train of thought, protracted, though varied stu- dies, the incessant action of one depressing or exciting passion, such as grief and joy, Sec. these and similar powers acting on some sys- tems, deprive the patient of rest or sleep, and render him inattentive to the common calls of nature; and, under such circumstances food is seldom taken regularly, of a proper quality, or in sufficient quantity. In such cases, evacuating medicines, and a debilitating plan, frequently fail, and the regulation of the mind, particularly removing as much as possible what makes the strongest impression on it, and a tonic invigo- rating plan as often succeed. 108 CASE XI. Mr.----, a very respectable tradesman, aged 40, of the melancholic temperament, subject to autumnal intermittents, which were always with difficulty removed, naturally ingenious, and indefatigable in whatever he undertook, pursuing it with an ardour that scarcely allowed any interval for sleep; a perplexing, intricate, anxious business occupied his mind for weeks in succession, till at length he could think of nothing else, all his faculties were intensely ri- veted on this subject; and, if disturbed by either the common calls of nature, or the soli- citations of his friends, he became angry, and frequently furious, till at last nothing could ex- ceed his violence. All his symptoms were the common ones of mania furibunda, alternating with gloom and taciturnity, which seemed al- most uniformly a state of exhaustion from the previous excitement. A whole year elapsed with very little alleviation, when he gradually improved, without my being able to impute the mitigation of his symptoms to any one re- medy; he was judged proper for a trial in a 109 Common room, with some convalescents, where bis only gratification was to irritate his com- panions, exciting squabbles amongst them, and amusing himself with various species of mis- chief, when any opportunity offered. While playing one of his tricks with another patient, a scuffle ensued, and before the attendants could effectually interfere, he received a violent blow on the temple, which, for a time, deprived him of sense and motion; some prompt measures soon restored him, and, though he complained of unusual sensations about the back part of his head, and a concussion of the brain had certainly been the effect of the blow, he gradu- ally improved, was soon conscious of his im- proper conduct, allowed he had been the ag- gressor, reasoned rationally on all the attendant circumstances, and at length lost all his com- plaints of both mind and body, and, I have no doubt, owes his restoration to the accident; for though a casual observer might have pronoun- ced him convalescent, yet there were certain peculiarities remaining, connected with his mental indisposition, which I have always found very difficult to remove; and indeed it is a fact which every medical man, conversant in such K 110 cases, must have observed, that where the de* viation from rationality in maniacs is but tri- fling, there the prognosis must be dubious, and there is always much more hope where, with symptoms of high excitement, the ideas exhi- bit the utmost confusion. Dr. Gregory, in his lectures, mentioned a case, where a gentleman subject to periodical alienation of mind submitted to be trepanned, and never afterwards experienced any return of his mental malady.* * (See explanation of a Criticism on the system of Dr. Gall, by J. L. Moreau de la Sarthe.) " Instances have been known in which blows on the head, shocks, the operation of trepanning, and different injuries of the brain, have entirely annihilated or suddenly developed certain faculties. Thus Fabricius de Hilden mentions a young man who by a fall on the head was rendered com- pletely silly; and Haller an idiot whom a wound in the head restored to his understanding. It is well known, that to the operation of trepanning, Father Mobillon owed a sudden increase of his intellectual faculties."—It is said that a son of the late celebrated Dr. Priestley was restored to reason from idiotcy by a fall from a window. Ill CASE XII. -------, aged 30, the history of whose case I was never acquainted with, had been for years insane, by accident fell backwards down stairs, and was taken up apparently dead, but by open- ing the jugular, and employing the more com- mon means, signs of life returned. Upon ex- amination, it was soon discovered that the skull was fractured, and that there was a necessity for trepanning, which operation was very skil- fully performed when he was in a state of al- most complete insensibility; he remained in this state for some weeks, when the wounds assum- ed a very promising appearance, and the looks a degree of intelligence which had never till then been observed since the first attack of his insanity; occasional rays of rationality appeared, and though he seemed averse to conversation, and his ideas flowed very slowly, yet they were not tinctured by any singularity as formerly. Exercise in the open air, improved du t, and interesting amusements were now adopted, and with the best effects; for though he became debilitated and emaciated, and the style of his i 112 observations and his address were considerably changed, he gradually advanced to con vale- scence and recovery. CASE XIII. Mr.------, an ingenious mechanic, aged 26, sanguineous temperament, prone to exces- ses, especially in sacrificing at the shrines of both Venus and Bacchus; subject to spasmo- dic affections and profuse perspirations on the most trifling exertions, after a week of constant riot and intoxication became insane. Nothing unusual occurred in the symptoms, excepting his extreme impatience of control and coercion; and to procure his liberty all the faculties of both body and mind were incessantly directed. His mechanical skill was most ingeniously ap- plied, and his success in removing bolts, locks, &c. was inconceivable. The art he employed to lull suspicion, and the means he had recourse to for the accomplishment of his ends, some- times succeeded: he one night opened the roof of his chamber and scaled the top of the house, but, by some accident he fell from a wall ten feet high, bruised his head, and fractured the tibia of his right leg: he was discovered writh- 113 ing in agony; and, with professions of com- punction and repentance, prayed the assistance of the surgeon, who was instantly summoned. The necessary process of reducing the fracture was attended with much pain, which was not very manfully borne by the patient; but, though only the day before the accident he was most furiously insane, no marks of the disease were now obvious, nor could a trace of mental ali- enation be discovered in any movement or ob- servation; and, strange to tell, he submitted to every thing proposed during two months con- finement on account of his leg, which at length perfectly recovered, and no return of his for- mer complaint took place. He now became a very reformed character, is a great comfort to his friends, and a valuable member of society. In the medical treatment of maniacs, it is to be observed, that difficulties exist peculiar to this class of diseases. It frequently happens that the patient cannot be induced to take what the best skill and judgment have prescribed, without having recourse to a system of forcing, or spouting, as it is called, a practice never ad- missible but in cases of the most extreme ne- cessity. Maniacs in general are very insensible K2 114 to the acHon of powers applied to the body, whether internal or external; from hence arises the impossibility of ascertaining the dose of medicines. The mind intensely occupied, is with difficulty distracted from the subject of its musings, which apparently absorbing all its powers, extends its insensibility through the whole animal economy: by means of this want of sympathy the body becomes equally steeled against impressions; in such cases our curative attempts should be confined to exter- nal corporeal agents, blisters, sinapisms, heat, cold, swinging, Sec. and the use of medicines, particularly those of an active drastic nature, should be suspended till new indications war- rant their employment; since it has happened that their accumulation in the system, and their consequent combined action have proved fatal. In speaking of antimaniacal remedies it can- not be too often enforced, that no system is more reprehensible than that which pursues a blind indiscriminate routine of practice in every case of derangement. This is more frequent than, in the present enlightened age, would be credited, though it is fraught with such perni- cious consequences; not only in many instances 115 terminating the disease fatally, but almost al- ways rendering the complaint permanent from neglecting the proper means in its earlier stages. Another difficulty attending the medical treatment of insanity arises from the impossibi- lity of accurate information from the pulse; me- dical men in general, I believe, begin to be con- vinced that the pulse will not always furnish, even in other diseases, an accurate criterion of the state of the system, or indeed of the circu- lation, but in madness we can seldom derive any important knowledge from this source; The pulse, in some maniacs, is affected by the most trifling causes, in others it suffers little variation, however violent the attendant symp- toms; but whenever it exhibits very sudden and considerable changes, without any obvious causes or corresponding symptoms, sudden death frequently closes the scene. I have often suspected that some maniacs possess a faculty like Spalanzani, of regulating the action of the heart by the powers of volition, increasing or diminishing it by means of the exciting or depressing passions; and I have met with some instances where the patient appeared to resist the usual action of remedies at will: these pecu- liarities are not easily explained. But recurring 116 to the pulse, it should be laid down as an inva- riable rule that, in the treatment of maniacs, the utmost caution is necessary in drawing infer- ences from this source. I might have extended my observations on this part of my subject, but it is difficult to be minute without being tedious; I shall therefore proceed to the consideration of individual means in our attempts to relieve diseases of the intellect. VOMITING. Though some physicians, reasoning more from theory than practice, have reprobated the employment of this remedy in diseases of the mind, experience has convinced me that it takes the precedence of every other curative mean. I will acknowledge that, reasoning a priori, the beneficial effects of vomiting militate against my supposed proximate cause; and it seems often contra-indicated, especially where there exists an inordinate determination of blood to the brain; but I am confident that in the majority of insane patients, there is no reasonable ground of apprehension from the employment of reme- dies of this description, and much for hope. 117 When obvious and unusual plethora obtains, and vomiting is indicated, venesection and other evacuating means should precede it. Of all antimaniacal remedies, emetics have stood the test of ages, having been almost constantly employed from the days of Hippocrates to the present time. In almost every species and degree of these complaints, from the slightest aberration of intel- lect that accompanies hypochondriasis to the ex- treme of mania fyribunda, emetics have proved a most valuable and efficacious remedy. Their action is not simply confined to the stomach and first passages, it extends through the whole system, afiecting all the vital and animal func- tions, agitating every part of the animal eco- nomy, and uniformly relieving the oppression not only of the body, but of the mind. There never was a more mistaken idea than that vo- miting, being an unnatural, is a dangerous process. The human stomach has suffered its almost incessant action, for weeks in succes- sion, with impunity. The most delicate sub- jects have experienced not only nausea, but sea-sickness during the whole of a long voy- 118 age without injury, and indeed with advan- tage. Saburra in the stomach and bowels has often seemed the sole of cause mental indisposition; and the removal of it by vomiting has effected permanent relief: how frequently do we see all the faculties of the soul when impaired and op. pressed by a loaded stomach, instantly relieved by the evacuation of its contents? This viscus, in maniacs, is generally diseased, and disposed to collect and retain indigested viscid sordes, and the most judicious medical treatment will be inefficacious if we lose sight of this fact. It frequently happens that almost the whole of the first passages are lined with mucous, phlegm; and till this be removed, remedies are useless. I will admit that from existing symptoms, in many cases of insanity, the employment of vo- mits is contra-indicated; so they certainly are in haemoptysis and other haemorrhages, as well as in phrenitis; and yet Dr. Bryan Robinson employed them with advantage in these com- plaints. Contrary to expectation, vomits fre- quently produce a diminished action of the heart and arteries, even during their operation. I feel every disposition to allow full credit 119 to an author of the present day, for the very valuable information contained in a late inge- nious publication on the subject of insanity, yet every physician, who has devoted his at- tention to this branch of the profession, must differ from him when he treats of vomiting. In all the various stages and species of mental indisposition, I have employed emetics with advantage, and can confidently assert from many years experience and observation, that no sort of risk is attached to their use, that I never witnessed any consequence bordering on para- lysis, and, for the reasons above assigned, they are indispensably necessary in almost every case of mental derangement. In a variety of instances, a single emetic has, in a very won- derful manner, removed every symptom .of mental affection;* in some their exhibition has *---------, aged 40, dark hair and eyes, though fair skin, following a profession that confined him most part of the day within doors, and in one position: naturally of a gay, cheerful disposition, but subject to dyspepsia and headache. Without any obvious causes he neglected his business, though his family depended on it for sup- port; became irritable and quarrelsome: his habit of so- briety and industry gave place to tippling and idleness, though he would occasionally exhaust himself with fatigue: 120 been repeated for several days *in succession; bu4.it is a fact, perhaps not generally known, that though maniacs bear and require medi- not being conscious of indisposition he refused remedies, till, on my visiting another patient in his neighbourhood, I accidentally saw him amusing himself by leaping through the doors of my carriage with the utmost velo- city; struck with the oddity of the circumstance, I made inquiries- concerning him, and learnt the above particu- lars, and prevailed on him to take an antimonial emetic, which restored him without any other remedy. I have at this time a servant, who was formerly a patient, whose mental disease was wholly removed by an emetic; who is still subject to aberrations of mind, which are uni- formly corrected by a few grains of emetic tartar. My recollection furnishes a variety of cases, where the state of the intellect seemed regulated by that of the stomach. In many of these there existed an unnatural tendency to the accumulation of viscid indigested matter in the stomach, the quantity of which occasioned all the variety from depressed spirits to absolute insanity. In all simi- lar cases emetics are indispensable, and generally re- lieve. I have at this moment a patient under my care who had been formerly insane, and was at length perfectly cured, and continued well for some years, he then relapsed. I saw him a few days since, when his mind was strangely affected, but by the action of a single emetic he became perfectly clear, and so continues. 121 cines in increased doses, yet by giving a com- mon dose of opium going to bed, on the night previous to an emetic next morning, a dimin- ished quantity of the vomiting ingredient will produce very considerable effects. As was observed in a former part of this treatise, cases will occur in which there exists no obvious curative indication to decide the path for the practitioner; but he will seldom err by evacuating the stomach and bowels by an emetic, which, as said before, has been often found to bring aboura cure without any other assistance. It may be difficult to explain how the cure is thus effected; and this indeed may be said of various other remedies, but I am , here stating only the result of experience. Could vomits be dispensed with in mania, they are of the highest value in melancholia, as they not only evacuate the stomach, but rouse the languid torpid system, agitate the whole frame, shaking all the viscera, removing obstruction, &c; their efficacy in ascites proves their power over the absorbent vessels, which are often much diseased in affections of the intellect. Having said thus much on the subject of vomiting in madness, it may be necessary to ob- L 122 serve that the means used to promote it must be adapted to the age, state, and other circumstan- ces of the patient. Here we have a decided ad- vantage over our forefathers, with whom this was a favourite remedy, but who had a very scanty list of articles possessing an emetic property, and these were of the most drastic nature. In almost every case where these remedies are to be employed, the various preparations of anti- mony are to be preferred, and of these the anti- monium tartarizatum has superior claims; this, when recently prepared, pure and crystalized, according to the formula first given to the world by the justly celebrated Dr. Jenner, is almost tasteless and colourless in solution, and consequently may be easily disguised: which is a consideration of consequence in the medi- cal treatment of maniacs. The vinum antimonii, either prepared by infusing the glass of anti- mony in white wine, or by dissolving the ant. tartar, in it, is another very valuable prepara- tion, and as the medicated quality of the liquid is not obvious to the senses it may be often exhibited without suspicion. By a similar pro- cess other fluids may be impregnated with the virtues of antimony, but more particularly ci- 123 der. In athletic, and more robust patients, the vitrum antimonii finely levigated, and given in the form of a bolus, is a most powerful, and often very efficacious remedy; especially if taken on going to bed, conjoined with a grain of opium; or administered at an early hour be- fore getting up, and suffered to remain as long in the stomach as the nausea excited will allow, before its action is assisted by tepid fluids; when it often cleanses the first passages com- pletely, removing what less active means had left behind. With a similar intention the union of calomel with the antimonium tartarizatum, in the proportion of one of the first to two of the last, has been found equally efficacious in more delicate subjects, and these have super- seded the necessity of the frequent repetition of milder means. The materia medica furnishes a list of other emetics, but the majority of these are inadmissible or inefficacious in the treat- ment of maniacs. Ipecacuanha, for instance, where the mind is affected, and the sensitive powers of the body diminished, often produces only nausea, and sometimes its action is wholly resisted, though administered in large and re- peated doses: when combined with antimonium 124 tartarizatum, it only increases the bulk without adding to its virtues. With sqme practitioners the asarabacca has been esteemed a valuable antimaniacal emetic, but I never could discover its superior claims. The various preparations of mustard, squill, &c. are too mild and uncer- tain to be admissible in these complaints. Cases do sometimes occur in which emetics cannot be administered internally, when recourse must be had to external application: thus strong so- lutions of ant. tartar, in boiling water, when the heat is sufficiently diminished, may be rub- bed on the region of the stomach, or a cata- plasm of tobacco leaves applied to this part; either of which generally affects the stomach very considerably. The inexperienced practi- tioner may conceive any remedy might be in- troduced per annum, but in making the expe- riment he will find that the power of maniacs over the sphincter muscles is often insurmount-, able. Though from what has been said on the subject of emetics I am a strenuous advocate for their use in diseases of the intellect, it will be necessary to bear in mind that circumstances may exist where the use of them would not .only be injudicious, but might be attended with 125 serious, alarming, or fatal consequences: thus in cases where the vessels of the head are un- usually distended, in subjects of an apopletic make; where there is inflammation of any of the more noble viscera, but particularly where the patient is afflicted with hernia of any kind, as was observed before. In addition to what is advanced above, re- specting the more common and general effects of emetics, it may be observed that they not only relieve, by their removal of obstructions,. spasm, irritation, Ike. but often produce a very surprising alteration in the mind itself, in some instances lessening the number of deranged ideas, in others changing them entirely. When administered in doses calculated only to excite nausea, they seem to call off the mind from its hallucination, and to concentrate its attention on die unpleasant sensations occasioned in the stomach. From the similarity that exists be- tween maniacal and convulsive affections, and the well known efficacy of vitriolated zinc in the latter, it has been very usefully employed in the former. Combining the valuable proper- ties of a tonic, sedative, and emetic, it is found to allay irritability without debilitating; and in L 2 126 all those cases which have undergone unmer- ciful evacuation, such a remedy is generally indicated. DIGITALIS. This has an undoubted claim to rank next to emetics as a remedy in madness; indeed, I am of opinion no case ought to be deemed in- curable till it has been submitted to a trial of this very powerful medicine, and its employ- ment has been persisted in till some effects are produced. Before we advert to the characteristic pro- perties of this valuable plant, it may be proper to premise, that there are few instances of this complaint in which its use is contra-indicated, but that it most frequently succeeds where the derangement of the intellect is accompanied, and, in a degree, regulated by an accelerated circulation without any other symptom of py- rexia. The difficulty of ascertaining "the dose of so powerful a remedy in mania might be deemed an objection, but this equally applies to its administration in other diseases: begin- ning with a few drops of the tincture or half a grain of the powder, gradually increasing the 127 quantity, will obviate all danger, though some cases resist its action to a wonderful degree. I had a patient, two years since, whose system was kept saturated, as it were, with digitalis, for weeks successively, whose mental wander- ings seemed regulated by the state of the cir- culation; when the pulse were at 90 he was constantly furious, at 70 perfectly rational, at 50 melancholic, and at 40 half dead: this man was at length perfectly cured by such a dose of this remedy as kept the pulse pretty uni- formly about 70, and yet he had sometimes taken three drachms of excellent tincture of digitalis three or four days following. Its power over the heart and arteries is one of its most valuable properties; and yet there can be no doubt that by its injudicious use the pulse may be gradually reduced to the total extinction of the vital principle. Its efficacy in mental dis- eases may also be very justly attributed to the nausea it occasions; which, as was observed before, wonderfully contributes to influence . and rectify the intellect; and this effect is not transient, as when produced by other articles of the materia medica, but will sometimes re- main for a length of time after the remedy is 128 discontinued, and yet it possesses the peculiar property of arresting the action of the heart, and occasioning nausea without impairing the vi- gour of the system. It may be laid down as a rule resulting from observation and experience, that in the medical treatment of maniacs, the doses of every actiye remedy should uniformly be regulated by the degree of disease present, the age and constitu- tion; a greater or smaller being necessary as the mind deviates more or less from the standard of rationality. It is much to be feared that the virtues of this inestimable plant will sometimes be brought into disrepute from being injudiciously employed, as the bold, incautious practitioner may make it the instrument of murder, or the timid declare that it is inert. Our very best medi- cines are well known to be insidious poisons when improperly administered. It may be necessary to add, that much of the efficacy of digitalis will depend on its preparation: this does not arise wholly from its pharmaceutical management: we should be careful to select healthy luxuriant plants in full bloom, in the middle of a fine day, from elevated gravelly situations, rejecting 129 every defective leaf, cutting out the middle rib of each, culling those only that are unspotted and of one uniform green; nor is this all, for much care is still necessary in the processes of drying, and preserving the leaves after being selected. They should be exposed to the action of a low degree of heat, either in a hothouse, or in the sunshine^ and as much as possible of the colour and smell of the plant should be re- tained.* When reduced to a fine powder, it must be kept in close corked phials for use. No part of the kingdom furnishes this beautiful plant in greater perfection than the neighbour- hood of Bristol. In my own fields it flourishes most luxuriantly. I have frequently gathered single plants, with lateral shoots, upwards of six feet in height, and hung with upwards of two hundred bells. This plant is very scarce in the vicinity of London, and other herbs, such as the verbascum, are mistaken for it. An in- stance of this occurred lately to a physician of the author's acquaintance. Having occa- sion to call at an apothecary's shop, and seeing some large fresh verbascum leaves on the * See Withering on the Fox-glove. 130 counter, he asked what they were designed for? the reply was, they are very fine specimens of the famed digitalis or fox-glove. Without making himself known, he assured,him he was mistaken, and that those leaves were a very inert.plant called verbascum. Can we be sur- prised that so many complaints are made res- pecting the great uncertainty of this excellent remedy, when such plants as the verbascum are prepared and sold instead of it? BLEEDING. Since in most cases of mental disease there exist symptoms of high excitement, the use of the lancet would seem generally indicated; but unless there be obvious plethora or evident de- termination and congestion about the head, bleeding may increase rather than diminish the disease; when this evacuation is determined on, it may be effected either by leeches, cupping, venesection in the foot, arm, or neck, or by arteriotomy: in the performance of this last, on the temples, the artery should not be divided, though this may be done with impunity, but a longitudinal incision should be made in it with 131 a lancet or scalpel, from whence the quantity of blood i quired may be procured; but it should be an invariable rule to secure the vessel by a ligature; and indeed it is never safe to trust even a wounded vein to a common bandage in maniacs. PURGING. This is a very necessary, and generally an in- dispensable operation. As maniacs are frequent- ly and almost uniformly costive, this should be constantly obviated, and the more gentle ape- rients first employed; selecting the article of the materia medica best calculated to produce the degree of effect required. Purging was a favourite remedy among the ancients, whose practice, in diseased intellect, appears to have been very simple, though successful, consisting for the most part of evacuations by the stomach and bowels, procured principally by the most drastic medicines; but more particularly by the different species of hellebore. When remedies of this description are required, I have pre- , ferred those of the saline class; and no prepa- ration exceeds the kali tartarisatum; but the particular article, must be left to the judgment 132 ©f the practitioner. When a more active purga- tive is required, calomel is the best, though where uterine obstruction or suppressed haj- morrhoids are the cause or consequence of in- sanity, aloetic preparations are to be preferred. As spontaneous diarrhoea often proves a solution of mental diseases, where there is florid health, and the natural functions are regular, a system of evacuation by the bowels may be instituted: this generally mitigates if it does not remove the symptoms of violence and irritation; and, it must be granted, that there is no more pow- erful or convenient mode of emptying the ves- sels than by purging. This makes part of what is called the antiphlogistic regimen, which, though often indiscriminately had recourse to, is sometimes very prejudicial, and has been known to remove the symptoms of excitement only by the extinction of life. The use of pur- gatives is improper where general debility pre- vails, where there is any tendency to anasarca, where delicacy of the system is accompanied by irritability of the bowels, and where the pa- tient is much emaciated. iJ.'J BATHING. The external application of cold to the head in madness is a very rational remedy, and has been often employed, with advantage, to ap- pease irritation and fury, and to induce sleep. The modes of application may differ according to the degree of cold required, or the effect in- tended. In some cases, in which only partial application of cold is required, simple ablution of the head with cold water, or wrapping wet cloths round it, frequently renewed as they get warm, are the most convenient methods. In others where the application is intended to be general, the common cold or shower baths are preferable.* In some instances? the clay cap is a very convenient and efficacious mode of ap- plying cold; but where an intense degree is re- quired, it may be easily procured by means of • The French physicians are said to have employed, with much advantage, a small stream of cold water, fall- ing from a great height on the shaved heads of maniacs. I can easily conceive such a remedy capable of producing a strong impression, but I have not yet had an opportu- nity of ascertaining the fact in my own practice. M 134 i-cther poured on the bald or shaved scalp; and the evaporation may be increased by means of a stream of air, directed to the part by a pair of bellows. If some advantage has resulted from the partial application of cold in maniacal affec- tions, much more has attended the general im- mersion of the body in cold water, which, in my opinion, deserves to be placed high in the list of antimaniacal remedies, as it is one of those powerful means which are seldom contra- indicated, and may always be employed without hazard, if the system be not too much reduced and debilitated by previous evacuation, ex- hausted by violent ravings and continued ex- ertions, or if some lsesion of the structure be not either obvious or suspected. The very best effects have followed the severest cold bathing, even when the pulse has been much reduced in force, and the heat much below the natural standard; for it is uniformly observed that maniacs are very insensible to external impres- sions, and retain heat with great tenacity.* Our knowledge of the extent of the powers of this * See Currie's Medical Reports on the Effects of Water. 135 remedy remains still very limited, whether we view it as a simple mean or in combination with others. I have had more experience in its employment since publishing the first edition of this work, but am still unable to lay down any fixed and positive rules for its manage- ment; though from various trials and much attentive observation, I am decidedly of opin- ion, not only that no remedy is more likely to succeed in affections of the mind, but also that in order to secure its successful application, no remedy requires more experience and skill. It is often indicated in very opposite circumstan- ces, thus as a sedative to diminish the violence of reaction, and as a tonic to remove debility. In these cases the effects depend entirely on the degree of cold applied, and the duration of the application. In a very great proportion of maniacs there exists the most unequivocal proofs of partial plethora, as has been already observed in various parts of this work, and that this mor- bid, unnatural state of the circulating system is confined to the head, the vessels of which appear universally swollen, the superficies red, and the action of the heart and arteries obvious ■ 136 ly increased; here cold bathing, properly em- ployed, after evacuating remedies, has instant- ly restored rationality; the natural balance of the circulation seems to have been suddenly recovered, the temperature and pulse reduced, and such a contraction produced of the vessels, vwhich seemed before so overloaded, that pale- ness of the superficies has succeeded the pre- vious redness. As cold bathing has so decided a tendency to diminish the action of the heart and arteries when long continued, it is more particularly indicated in those cases where the injury of the intellect is accompanied with much external heat, particularly about the head, which is a very frequent symptom, and when the patient cannot be induced voluntarily to take remedies prescribed, or will not submit to the various means proposed; for though the cold bath, ac- cording to the experiments of Dr. Stock,* do not diminish the number of pulsations, it cer- tainly renders the action obviously weaker. * See Medical Collections on the Effects of Cold as a Remedy in certain Diseases, by John Edmonds Stock, M. D. 137 The employment of the cold bath was a fa- vourite remedy among the ancients, who carri- ed it sometimes to a very dangerous extent; and even so late as the days of Boerhaave we have the most vague directions for its employ- ment; such as keeping the patient immersed till he is almost drowned, or while the atten- dants could repeat the Miserere. Though it may be difficult to decide when long continued bathing promises most success, yet in almost every desperate case it may be resorted to with safety: but it is a matter of doubt with me whether the effects of this remedy, thus appli- ed, may not frequently be imputed to fear or the nisus of resistance. Many instances certainly have occurred, in which either from accident or design maniacs have been immersed in cold water till the vital powers were nearly extin- guished, and in one or two cases, till respira- tion and animation were, for a time, completely suspended, and the intellectual disease has been either obviously mitigated or totally annihilated by the occurrence. The mode recommended and so successfully practised by Dr. Currie of Liverpool is very far preferable, that of suddenly immersing the ma- M2 138 niac in the very acme of his paroxysm; and this may be easily accomplished, if the patient be previously secured by a strait waistcoat, and fixed in a common Windsor chair by strong broad straps of leather, or web girth. But the common shower bath answers every intention, when the patient will submit to its application, or where, from his violence, the employment of this mode is impracticable, the same advantages may be gained from pouring the water on him by means of a common watering-pot, when he is secured in a chair fastened to the floor. This is another of those remedies which requires judgment in its employment, and should not be indiscriminately had recourse to. In melancho- lic patients, where the symptoms occasionally approximate to violence, the cold bath may be useful. It is a singular circumstance, that the two opposites of warm and cold bathing should often produce effects very analogous: the for- mer is more general in its application, and the party may be exposed to its action for hours in succession, not only with impunity, but with obvious advantage. Where rigidity of fibre, any degree of spasmodic stricture, exhaustion and debility, are accompanied by mental irrita- 13"9 bility, vociferation, and violence, no remedy promises more than the warm bath. This is often very successfully employed while a stream of cold water is directed on the head. The warm bath, when heated to about 90 of Farenheit, may be classed with the most valuable remedies in diseases of the intellect: it is eminently calcu- lated to restore that regularity and balance of the circulating system which is so frequently destroyed in maniacal affections; is particularly opposed to that unnatural dryness of the sur- face and obstruction of the pores, those bilious and dyspeptic symptoms which frequently ac- company the lower degree of mental indisposi- tions, and is often more willingly submitted to than the cold bath, and equally invigorating and tonic. Should a relaxing and debilitating effect be intended from this remedy, a few degrees of additional heat may be communicated to the bath, and its application be longer continued. In delicate female maniacs, in whom, from va- rious causes, the system is much reduced, when violence and fury threaten the extinction of life, and internal remedies are obstinately refused, the warm bath is admirably calculated to ap- pease the tempestuous commotions of mind and 140 body. Where an unusual degree of heat exists, whether partial or general, the warm bath has 'feeen known to reduce it more speedily and ef- fectually than the cold. Cases of the most dis- tressing nature sometimes occur, in which all kinds of sustenance are obstinately rejected by the maniac, who is intent upon self-destruction; after every other method has been attempted in vain, the warm bath, of either the simple ele- ment, or composed of water gruel, or milk and water, has contributed to support life for a con- siderable time; for though the administration of clysters may be impracticable from the vo- luntary and insurmountable contraction of the sphincter ani, the patient possesses but little power over the absorbents of the surface; and yet I would not positively deny that the mind has any influence over the skin, since we ob- serve that various passions diminish the sensa- tion of cold in some instances, and occasion cutis anserina in others, and the experience of every man proves that whenever the mind is intensely engaged the sensations are wonder- fully diminished. The astronomer, intent on the objects of his sublime science, it is said, neither feels nor is injured by the damps or the 141 chillness of the night; and in some species of madness, where the ideas of imagination are too vivid to admit the impression of sense, cold is resisted to an extraordinary degree. I knew an instance of a young woman, previously of the greatest delicacy of frame, struck with madness, lie all night on a cold floor with hardly the co- vering that decency requires, when the water was frozen on the table by her, and the milk that she was to feed on was a mass of ice.* Of a similar nature is the vapour bath; but the pediluviumis most frequently had recourse to, and may produce very beneficial effects in various ways. With maniacal patients I have sometimes impregnated the water with rose- mary and other aromatic herbs, which, being grateful, engaged their attention, and appeared to amuse them; they have often attributed the good effects of the remedy solely to the herb, and willingly submitted to its repeated employ- ment from this stratagem alone. * See Currie's Medical Reports, Vol. I. Appendix, No. II. page 40. 142 BLISTERS. These have been often employed, and some- times with obvious advantages, whether applied with the intention of keeping up a discharge, or only of exciting temporary inflammation. I have proved the propriety of Dr. Monro's ob- servation on this subject, that they are never useful when applied to the head itself; but to the calves of the legs and to the feet, in the form of sinapisms, they are frequently a powerful and efficacious mean. There are however cases where their employment on any part is inad- missible, as where any degree of salacity pre- vails, which is a very common attendant upon maniacal affections. CAMPHOR. This has always been with me a dubious re- medy. It is difficult to decide when is the pro- per period for using it, and still more so to as- certain the dose. I have seen it in small quan- tities convert mild melancholia to mania furi- bunda; and have often found it produce no 143 other effects, in doses of 20 or 30 grains, than those of the common terebinthinate prepara- tions of the shops. Like many of the remedies deemed sedative, camphor often excites and stimulates. It has the reputation of quelling the passions and curbing venereal propensities; but I have never witnessed its producing such ef- fects. However prepared, whether alone, or in combination with nitre, vegetable acids, foetid gum, &c, I have never observed any perma- nent good effects from its use. It may be added to the list of nervous antispasmodic medicines, more calculated to obviate unpleasant symp- toms than to effect the cure of insanity. In small doses it is generally inert, in larger pre- judicial, and in enormous ones has a tendency to increase the derangement it was intended to remove, and has been known actually to ex- tinguish life itself. OPIUM. From the soporific tranquillizing properties of this valuable drug it might seem indicated in maniacal affections; but I have tried it alone to an almost incredible extent, without per- 144 eeiving any, even temporary, much less per- manent advantage from it. Opium often in- creases the heat and irritation it was meant to allay, constipates the bowels, and tends to pro- mote rather than diminish that determination towards the head which is always injurious. A dose of opium, as mentioned above, adminis* tered going to bed, previously to taking an emetic in the morning, has been found to ren- der a smaller quantity of the vomiting ingredi- ents sufficiently efficacious. With digitalis it has been useful in maniacal cases, especially where this powerful remedy has a tendency to run off by the bowels. Combined with antimo- ny, in repeated small doses, it has been pro- ductive of very good effects, but only by re- lieving the more obvious symptoms without correcting the aberrations of the mind. With bark, in hysteric melancholic insanity, where universal laxity of fibre prevails, it has been beneficial. With concentrated vegetable acid it has produced a soothing tranquillizing effect, which was easily kept up by small repetitions for a length of time, and, in some instances, with very considerable advantage; but whether this arose from any salutary, impression on the 145 nervous system, or from impeding nutritious absorption, it is difficult to decide. Dissolved in a strong tincture of tobacco, and applied externally to the region of the stomach, it has allayed the violent nauseating effects of other remedies, particularly digitalis, contrary to what might have been suspected a priori: and this same solution applied to the bald or shaved head has removed pain and checked the wan- derings of the mind. With aether united to al- cohol, and rubbed on the bare scalp, it has been productive of similar good effects, as also when applied to the same part in form of a plaster. Hyoscyamus, aconitum, datura, cicuta, and other articles of this class, have been em- ployed as antimaniacal remedies, but seldom with any flattering success. The first has cer- tainly superior claims to notice; and from the testimony of Drs. Stork, Home, A. Fothergill, Monro, and others, has been employed with advantage. As it rather relaxes than constipates the bowels, and possesses very considerable narcotic powers, it is preferable to opium in some cases of insanity; but the inspissated juice or extract requires much nicety in its prepara- tion, as well as care in its preservation, even N 146 after the most successful pharmaceutical man- agement: for its virtues are soon dissipated by careless keeping, and being a remedy seldom employed, it can as seldom be had at the shops in a state of proper preservation. As it is a very powerful medicine it should be cautious- ly administered in every case, beginning with small doses, gradually increased to such an ex- tent as to produce some obvious effects, the first of which is generally a degree of stupor or dizziness. It may not perhaps be generally known that the extract of hyoscyamus is not so well preserved, so as to retain its properties undiminished in the consistence of a rob, as it is commonly met with in the shops, as when exsiccated to a hard extract, that may be easily rolled into pills. When opium disagrees, or costiveness contra-indicates, the hyoscyamus may be advantageously employed, and though it may not radically remove the wanderings of mental disease, it will be found to soothe and calm commotions both of body and mind. The aconite has been extolled by some phy- sicians, but it is too uncertain in its action; like other diaphoretics, it is apt to constipate the bowels, an effect always to be guarded against 147 in diseases of the mind; joined with antimoni- als it has occasioned profuse perspirations, and where the evacuation by the skin is intended, a combination of this kind may produce the effect. Hemlock, gradually introduced, has cer- tainly been of seuvice in some cases of insanity, by diminishing irritation and excitement, and causing sleep; but some systems resist its in- fluence for a length of time, and others are not affected unless when it is administered in enor- mous doses. When opium has disagreed, the cicuta has'been often conjoined or substituted with evident advantage. There is another class of remedies called nervous, or antispasmodic, which, from the analogy between maniacal and convulsive af- fections, seem often indicated in the former; these will often subdue certain prominent symptoms, such as pains in the head, consti- pation, irregular spirits, &c. which frequently accompany some of the milder species of in- sanity, but they often heat and irritate. When epilepsy is accompanied by mental delusions, the cuprum ammoniacum and zinc have been beneficial, mitigating the epileptic paroxysms and diminishing the affection of the intellect. 14a Some of the preparations of iron have ccr tainly advanced convalescence to the perfect reestablishment of health; and where diseases of the mind are accompanied by debility and relaxation they have proved eminently useful. The continued use of Fowler's arsenical solu- tion in such cases might contribute to recruit the system and restore reason. Though we are unwilling to allow this powerful medicine any specific antimaniacal property, yet it may be expected to produce very important changes both in body and mind by means of its tonic po\. er. Musk, though highly extolled, I have never seen relieve a single maniac by removing any of the characteristic symptoms of this com- plaint, though, in combination with some of the other powerful antispasmodics, it has con- tributed to diminish the hallucination, altering the subjects of the mental attention by its se- dative and diaphoretic powers. It frequently happens that maniacs of the melancholic temperament are torpid and appa- rently insensible to every agent; their mental faculties seem immovably fixed, as if some vow bound them to apathy; they resist and re- sent every attempt to attract and arrest their 149 attention. In these cases stimulants of various kinds have been found expedient, and often very beneficial; but diey must be used with great caution and judgment, particularly those applied about the head; such as volatiles, er- rhines, and sternutatories. Medicines of this class, which are more usually applied external- ly, have been directed internally with great ad- vantage; thus mercury, squills, mustard, horse- radish, and cantharides. As to the first, it may be pronounced a doubtful remedy in mania, hav- ing been too frequently a remote cause of the disease; though some cases do occur in which it may be very usefully employed, whether ad- ministered with the intention of simply acting on the bowels or to produce ptyalism. Stimulants, possessing a diuretic property, have been very advantageously employed in affections of the mind; among others canthari- des, though a dangerous and violent remedy, have been, occasionally, highly beneficial, when the whole animal economy seemed steeled against the effects of others: the dose at first should be small, and then gradually increased, watching carefully the effects as they arise, that N2 150 the medicine may be suspended on the first ap- pearance of any that are unfavourable. As a degree of paralysis of the bladder some- times takes place in various affections of the mind, occasioned by inattention to the stimu- lus of the urine, and the consequent over dis- tention; this part should be frequently exam- ined, as by neglecting it irreparable mischief often ensues. The haemorrhoides being a frequent accom- paniment of insanity, the state of the rectum should be particularly attended to, as trouble- some sinuses, scirrhus, and even sphacelus, have succeeded neglected piles. There often exists a very intimate connection between the hemorrhoidal veins and intellect; the loss of a very small quantity of blood from these has been followed by the dispersion of gloom and a new train of ideas. Among the stimulants used in paralytic af- fections, accompanied by mental derangement, recourse has sometimes been had to electricity; but I have never seen any lasting advantages follow its application, excepting in those ma- niacal cases which arise from uterine obstruc- tion. 151 Among the valuable antimaniacal remedies may be reckoned permanent artificial drains, such as caustics, issues, and setons; the last of these are best, being managed with the greatest facility; and the least liable to be injured or destroyed. There are few cases of mania where these may not be usefully em- ployed, excepting where derangement is ac- companied by considerable debility; they have indeed been eminently successful in various instances, where the loss of reason has suc- ceeded painful unnatural parturition with re- trocession, or disappearance of the milk, as im- proved health and intellect have taken place while the discharge was profuse. Where this complaint arises from repelled eruptions, dry- ing up of old ulcers, curing haemorrhoids, and the like, setons seem more particularly indi- cated; perhaps it would be immaterial where the seton is inserted, if some advantages did not arise from its being placed between the shoulders, where the patient cannot easily de- stroy or injure it; and in maniacs it is always advisable to inclose at least an inch of skin be- tween the two orifices, and the extremities of the riband or cord should be fastened or sewed together. 152 SWINGING. This is both a moral and medical mean in the treatment of maniacs. It may be employed in either the oscillatory or common, or the circu- lating form. The first, or oscillatory, is too ge- nerally known to require a description: the se- cond, or circulating; is easily constructed by suspending a common Windsor chair to a hook in the ceiling, by two parallel ropes attached to the hind legs, and by two others passing round the front ones joined by a sliding knot, that may regulate the elevation of the patient when seated, who, besides being secured in a strait waistcoat, should be prevented from falling out of the chair by a broad leather strap, passed round the waist and buckled behind to the spars, while another strap to each leg may fasten it to the front ones of the chair. The patient thus secured, and suspended a few inches from the ground; the motion may be communicated by an attendant turning him round according to the degree of velocity required. But a more complete rotatory swing may be very easily con- trived, of which I cannot convey a more accu- 153 rate idea than in the words of Dr. Darwin, with whom I believe the idea first originated. "Let one end of a perpendicular shaft, armed with iron gudgeons, pass into the floor, and the other into a beam in the ceiling, with an hori- zontal arm, to which a small bed might be rea- dily suspended." To this perpendicular shaft a ehair may be fixed, and the patient secured in it as above described. A considerable improve- ment to this swing is a strong rod of iron, fixed to the upper extremity of the perpendicular shaft, and to that of the horizontal arm at the foot of the bed, which may be easily«so contrived as to be shortened or lengthened, and thus to regulate the elevation of the l^ed. The neces- sary motion may be given by the hand of the attendant pushing or pulling the extremity of the projecting arm, with greater or less force, each time it circulates, but by a little very sim- ple additional machinery any degree of velocity might be given, and the motion communicated with the utmost facility. Thus by means of the chair or the bed, the patient may be cirtulated in either the horizontal or perpendicular po- sition. 154 On persons in health these swings produce only the common effects; but in proportion to the degree of motion communicated, and sooner by the circulating than by the oscillatory, and in the horizontal than in the perpendicular po- sition. Independent of these more obvious ef- fects in some maniacal cases, swinging, often repeated, has had the singular property of ren- dering the system sensible to the action of agents, whose powers it before resisted.* One of its most valuable properties is its acting as a mechanical anodyne. After a very few circum- volutions, I have witnessed its soothing lulling effects, tranquillizing the mind and rendering the body quiescent; a degree of vertigo has often followed, which has been succeeded by the most refreshing slumbers;f an object this the most desirable in every case of madness, and with the utmost difficulty procured. Maniacs in ge- neral are not sensible to the action of the com- mon oscillatory swing, though it affords an ex- cellent mode of secure confinement, and of harmless punishment; and I have met with a few instances where the circulating, in both the * See Case XIV. f See Case XV. 155 horizontal and perpendicular positions, produ- ced no effect. The valuable properties of this remedy are not confined to the body, its powers extend to the mind.* Conjoined with the pas- sion of fear, the extent of its action has never been accurately ascertained; but I have no doubt it would afford relief in some very hope- less cases, if employed in the dark, where, from unusual noises, smells, or other powerful agents, acting forcibly on the senses, its efficacy might be amazingly increased. The employment of such Herculean remedies requires the greatest caution and judgment, and should never be had recourse to but in the immediate presence of trie physician. The debility arising from swing- ing is never to be dreaded, it is generally ac- companied by sleep and the sense of fatigue, while the slumbers thus procured surpass those induced by opiates, as much as the rest of the hardy sons of labour surpasses that of the pam- pered intemperate debauchee. Where insanity attacks patients of delicate habits, with previous consumptive or pulmonic symptoms, swinging has been found particularly beneficial.f I have * See Cases XVI, and XVII. t See Case XVIII. 156 sometimes seen a patient almost deprived of his locomotive powers, by the protracted action of this remedy, who required the combined strength and address of several experienced at- tendants to place him in the swing, from whence he has been easily carried by a single person; the most profound sleep has followed, and this has been succeeded by convalescence and per- fect recovery, without the assistance of any other mean.* One of the most constant effects of swinging is a greater or less degree of ver- tigo, attended by pallor, nausea, vomiting, and frequently by the evacuation of the contents of the bladder. As in Tsome maniacal cases, the mental alienation seems dependent upon, or re- gulated by the action of the heart, when ration- ality returns, if the puxaC be reduced below the usual standard, and departs again, as it ad- vances above this standard, the swing, from the powers it possesses over the circulation, has been known to produce the most beneficial ef- fects. Though we cannot accurately explain in what way the best remedies promote relief in madness, yet we have the most unequivocal * See Case XV. 157 proofs that those which occasion a degree of vertigo, often contribute to correct the morbid state of the intellect, and no one of them is so well calculated to produce this effect as the swing. Madmen are never so easily made giddy as people in their senses; yet scarcely any, even of them, can resist the action of a continued whirling with increased velocity. The vertigo, as was observed above, may be produced by means of the swing, from its effects on the sense of sight, though it may be attributed with grea- ter probability to feeling or consciousness, even in maniacs, when they are not insensible to the impression of the process; and this opinion seems confirmed from the circumstance that vertigo is produced by the circular motion even in the dark. Perhaps the appearances which usually accompany vertigo may contribute to explain its nature. The singular and unusual motion of swinging, when continued with in- creased velocity, induces first paleness, then nausea, and then alternately an obvious change in the circulation, and giddiness: these changes necessarily result from an impression made on those organs of sensibility, the brain and ner- vous system, and prove that the remedy acts on O 158 the seat of the disease; though the proximate cause cannot be satisfactorily ascertained. In some cases, where the animal frame is easily. influenced by the vertiginous motion, both the vital and animal functions are consi- derably affected, as well as the internal and ex- ternal senses. When vertigo is either symptomatic or idio- pathic it is usually accompanied by nausea; and as the swing generally produces this effect, and as vomiting is often indicated, and the patient refuses to take any remedy, our mechanical apparatus is of the highest importance in such cases: indeed it often possesses superior ad- vantages, as we can regulate the action on the stomach, producing either temporary or con- tinued nausea, partial or full vomiting. The sickness produced resembles that occasioned by sailing, than which perhaps none is more severe: and though in long voyages the most delicate systems have borne it for weeks toge- ther, no ill consequences have accrued, as was observed before. When full vomiting has fol- lowed the use of this remedy it has often suc- ceeded in bringing away viscid accumulated sordes and tenacious phlegm, with which the 159 first passages of maniacs so frequently abound, and indigested matters, which appear to have been long pent up, though the most active drastic evacuating remedies have been employ- ed, and apparently with considerable effect. As vomiting has been long esteemed among the most successful remedies in madness, if the swing produced only this effect, its properties- would be valuable; but though it can be em- ployed so as to occasion the mildest and most gentle effects, yet its action can be so regulated as to excite the most violent convulsions of the stomach, with the agitation and concussion of every part of the animal frame; thus rendering the finest Msystem of vessels pervious, or, in other words, removing obstructions, and alter- ing the veryaiature and quality of the secretions. The impressions made on the mind by the recollection of its action on the body is another very important property of the swing, and the physician will often only have to threaten its employment to secure compliance with his wishes, while no species of punishment is more harmless or efficacious.* * See Case XIV. 160 Though much of the beneficial effect of the swing may be justly ascribed to its action on the stomach, yet more of it may arise from its power over the circulation. CASE XIV. Mr.----, aged 34, naturally of a gloomy, morose, reserved disposition, had been indul- ged in every wish of his heart from his infancy, became suspicious, revengeful, and impatient of control; had been engaged in a business which occupied his thoughts, with scarcely any bodily exercise: a series of disappointments and losses at length deprived him of reason: after being treated in the most judicious man- ner, without success, he was consigned to my care. I found all the peculiarities of his tempe- rament increased by his indisposition, the coun- tenance approached to saturnine blackness, the eyes, suffused with bile, were immovably fixed on the ground, the limbs seemed deprived of their locomotive powers, the action of the lungs, and the circulation retarded, the tongue parched, and the whole man resembled an au- tomaton, seldom exhibiting any marks of ex- 161 istence but from the deepest sighs. His whole system was steeled against impressions, and he must have sunk to the grave but for the address of his attendants. All the more common means had failed, and he obstinately resisted medi- cine; I therefore adjudged him a fair case for the swing, into which he was placed two hours after he had taken a pint of thick water gruel and new milk, pulse 80, breathing twenty in- spirations in sixty seconds, had had no alvine evacuation for six days, nor made any water for the last 24 hours, skin dry but cool, eye-lids half closed, the face vacant and of a murky hue: he made some resistance to being placed in the chair, but when properly seated and secured, he was at first turned round very gently, and after a few revolutions, he appeared to experience some unpleasant sensations, his attention was roused, and he made some violent but unavail- ing struggles; the motion being increased he became pale, and begged the operation might be discontinued, promising compliance with my wishes as to food, medicine, &c. I therefore directed his immediate liberation; he complain- ed of giddiness, nausea, seemed exhausted, and had nearly fainted; being laid on a bed, I found 02 162 his pulse 60, the inspirations fifteen, the ex- pression of features changed, the extremities and superficies cold; he soon fell into a pro- found sleep, which continued three hours; but on waking I found him in mind and body just as before the swing was employed, all his pro- mises were forgotten, and he refused both food and physic; next day the swing was repeated as before, when similar effects were soon excited, and by increasing the velocity the nausea ad- vanced to vomiting, when the swing was sud- denly stopt very unexpectedly to the patient, who appeared roused and alarmed, intreated to be relieved, and repeated his former promise. I again complied, and he was taken out of the swing in the most helpless state imaginable, was put to bed, where he soon fell asleep, and did not awake for six hours, when he reluctantly acquiesced in my proposal to take a mercurial purgative, a very small dose of which procured some copious alvine evacuations, though he had before taken three times the quantity in dis- guise without effect, and he now began on a light nutritious regimen, with gentle exercise in the open air; but his former mental peculia- rities soon after returning, the swing was pre- 163 pared, and the necessary steps taken for its em- ployment, but rather than repeat the ride in the whirligig, as he termed it, he submitted entirely to my wishes, and, with some occasional re- turns of obstinacy and disinclination to persist in the remedies I prescribed, I had the pleasure to see him gradually improve till he advanced to perfect reason. CASE XV. Mr.-------, aged 40, of a florid complexion, very muscular, but of rather a mixt tempera- ment, became gradually depressed, then unu- sually gay and flighty: previous to these symp- toms he had been eccentric, ingenious, and good tempered, remarkable for an accurate retentive memory, and for feats of the palestra. A tender attachment was the supposed cause of his in- disposition, though this was not obvious in the bent or train of his deranged thoughts. For six weeks he had resisted all attempts to introduce medicines, his appetite was voracious, days and nights passed in alternate struggles from coercion and violent vociferation. Judging from all the circumstances no hazard could attach 164 to the employment of the swing, this was de- termined on, but a strong party were necessary to place him in it. The first five minutes pro- duced no kind of change, except that the no- velty seemed to amuse; but, on increasing the motion the features altered, and the counte- nance grew pallid; the urine passed; complain- ing of sickness, he prayed to be released; after a few rapid gyrations, more vomiting succeed- ed, his head fell upon his shoulder, and bjs whole system seemed deprived of vigour and strength; from the swing he was carried to his bed by a single attendant, where he immediate- ly fell asleep; after sleeping nine hours without intermission, awoke calm and refreshed, and by persevering in the use of much exercise in the open air, an occasional purgative, and a light nutritious diet, he soon became convalescent, and advanced to the perfect enjoyment of health and reason; has never exhibited any mark of his deplorable malady since. CASE XVI. Mr.-------, aged 26, accustomed to an ac- tive life, used violent exercise occasionally, be- 165 ing addicted to field amusements, prone to ex- cessive drinking, and to other intemperance, was attacked with a fever of the inflammatory type; during which he wras delirious, but the disease soon yielded to the common mode of treatment, and both mind and body were per- fectly restored. With returning health he re- lapsed into his former pursuits, and it was ob- served that a small quantity of stimulating po- tation affected his reason, and that in his cups he exhibited peculiarities never noticed before his late indisposition; his ideas were of the most grotesque complexion, linked by the strangest associations; while he sometimes reasoned with much acuteness on the most absurd and false principles. When not under the influence of liquor his spirits were often irregular, eleva- ted, and depressed by the merest trifles, and many parts of his conduct and conversa- tion were marked by peculiarities that bor- dered closely on insanity; at length he wit- nessed some legerdemain tricks which he could not comprehend, and these took full possession of his mind for days and nights in succession, from which nothing could divert him; his whole soul seemed occupied with one train of ideas, and reason wholly abandoned the mind. 166 In this state he continued six months with lit- tie change, though the very best exertions had been employed for his relief, and in this state he was committed to my care. No means I could devise procured any relief, and remedies, in increased doses, produced but little effect. I then had recourse to the swing, which occa- sioned a degree of fear and unpleasant sensa- tion, accompanied by vertigo; and sometimes violently affected the stomach and increased the secretions of the intestines and kidneys; yet no other permanent advantage resulted but that of rendering the patient more orderly and quiet. CASE XVII. Mr. ----, aged 22, with every mark of the sanguine temperament, had been a lounger from his youth, and would never be induced to fol- low any prescribed rules or pursuit for any length of time; eccentric and volatile, always gay and joyous; poetry, music, love and revelry made up the checquered tissue of his life, and, without any obvious cause he became furiously insane, and, contrary to the common issue of mental diseases, with symptoms of high ex- 167 citement, his mind continued wild and con- fused, with hardly a moment's lucid interval, notwithstanding all the usual means had been exhausted on him. He was submitted to the swing repeatedly, and would be sometimes considerably affected by it; but it was uniform- ly observed that he seemed gratified by the motion, and amused himself with the arms of the chair, pulling the suspending cords in time to his song: no nausea, vertigo, or other effect was produced, but as soon as any degree of fear|was excited or the attention called back to the swinging, he appeared to suffer unplea- sant sensation; and on the days this was most obvious his system was more easily affected by exercise, food, and remedies. Under this , united plan of swinging and physic he certainly is improved, so that I think the prognosis fa- vourable.* * I am sorry to add that my hopes were disappointed, this patient continuing far from well. 168 CASE XVIII. Miss-----, aged 25, of a very delicate frame, highly nervous sensibility, long neck, flat chest, fair complexion, light hair and eyes, blue veins, and possessing most of the other marks of the sanguine temperament, had laboured under some pulmonic affection, which exhibited the usual characteristic symptoms of ulcerated lungs; without any obvious cause became un- usually talkative, uttered some very strange ideas, and, at length, from confused thought, became completely insane, with hardly a mo- ment of lucid interval. During this new acces- sion the pulmonic affection disappeared, all the symptoms gradually retiring, there was daily an acquisition of strength, with improved looks as to health, but the features exhibited what we have before mentioned, that peculiarity of expression which is not to be described. AH the usual remedies, first of the stimulating, and then of the debilitating kind, procured no re- lief; and, there being no contra-indication, the circulating swing was had recourse to, at first every other day for ten minutes; but as she 169 appeared gratified by the motion, no effect was produced: at length it was repeated daily for fifteen minutes, with gradually increased velo- city, when considerable nausea, pallor, and ex- haustion supervening, its use was suspended for a day, and she dreaded its repetition, which however was again adopted, every other day, when the former effects were obvious in a few minutes, and full vomiting always succeeded, with all the usual subsequent consequences and symptoms, particularly fatigue and refresh- ing slumbers, which had been denied her for weeks, though the materia medica had been ransacked for anodynes. In the intermediate day a more generous diet and tonic plan were had recourse to, with constant exercise in the open air, and as she became more disposed to reasoning and to conviction, the mind was kept amused, the lucid intervals became longer, and the topics of delusion diminished in absurdity and number, till reason again re- sumed her sway, and both mind and body be- came perfectly reestablished; and have con- tinued so ever since, without a return of any one of the former pulmonic symptoms. P 170 CASE XIX. Mr.----, aged 22, of the choleric tempe- rament, partaking of both the sanguine and melancholic, but the usual marks of the latter predominating; naturally grave, silent, and par- tial to solitude, gloomy and reserved; had passed the usual routine of a classical educa- tion, with the character of plodding industry, but exhibiting no coruscations of genius. His life was a model of probity and virtue, being rigidly regular in the performance of all his duties, but more particularly his moral and reli- gious ones, tremblingly alive to the slightest de- reliction. He professed some peculiar religious tenets, but believed every word of the scrip- ture to be dictated and written by Divine in- spiration, and these were the subjects of his daily study. After having been for some time considerably affected by an unguarded expres- sion, uttered by a rash conceited teacher, who possessed more zeal than prudence, he became gloomy and depressed, till his life was such a burthen to him that he seemed bent on destroy- ing himself, and was only deterred by a sense 171 of the criminality and sinfulness of suicide. After reading that part of the New Testament which mentions the cutting off a hand, or pluck- ing out an eye, the idea of castrating himself rushed into his mind, and with a pair of small scissars he very completely performed the ope- ration; the surgeon when called in found him in a state of syncope from the haemorrhage, and by the most judicious treatment healed the wounds in a few weeks, but the mind continu- ed impressed with the most miserable ideas, and nothing but eternal perdition was ever in his view; in this state he was consigned to my care. He was perfectly silent, his eyes shut, averse to motion, and inattentive to the com- mon calls of nature. No solicitations could in- duce him to utter a word, to move, to eat, or drink, and his design was to deprive himself of life by starving, every other mode being de- nied him: with the assistance of some experi- enced attendants, his amazing resistance was overcome, and he was forced to take a suffi- cient quantity of nutritious fluid; this process was continued with very little variety, and with constant resistance for six weeks; the trouble and anxiety his obstinacy occasioned is not to 172 be described, all our efforts appeared unavail- ing, and I was, at times, afraid that we must abandon him to his fate: our exertions however were unceasingly continued, and with the food some evacuating medicine was occasionally in- troduced; and, at the expiration of two months of struggle, the eyes were sometimes observed half open, and a degree of new expression ap- peared in the countenance, which was one of the most incurious and vacant that can be im- agined: soon after, the resistance to food was not so great, and we sometimes gained a word or a single syllable by way of answer to ques- tions. Being so averse to speech, pen and ink were furnished, and when unobserved he wrote detached parts of scripture and sentences ex- pressive of miserable apprehensions, from hav- ing incurred the displeasure of the Deity, being excluded from hope and mercy, and numbered with the reprobate; and yet he retained such a reverence for the Deity, that he never used the letter /, because it made a part of one of his titles, the Great I Am: his mind was over- whelmed with gloom and despair, and it was too obvious that opportunity alone was wanting to terminate his wretched existence. The sys- 173 tem of forced feeding continued: when being furnished with the bible, his reading was con- stantly confined to the Leviticus, and though he refused to reason on what so occupied his attention, he made me sensible, by writing, that he wished to comply with some of the ce- remonies prescribed by the Levitical law, par- ticularly to make sin offerings; I paid little at- tention to so useless and impracticable a pro- posal, but his determined obstinacy was insur- mountable, and I began again to fear that he would fall a victim to it, when he proposed complying with some of my earnest solicita- tions if I would allow him certain ablutions be- fore and after meals, and with this I judged it best to comply; day after day he was accord- ingly plunged into a cold bath, and a very spare diet was, in consequence, adopted voluntarily, but the quantity of nutritious ingesta gradually diminishing, and it being too obvious that self- destruction was still uppermost in the mind, the bathing system was abandoned, and spout- ing again became absolute^ necessary; but the resistance never diminished, and it is not easy to conceive the difficulties we had to surmount, so that it became almost a dubious point to P 2 174 decide whether duty enjoined persisting in this terrible process or resigning him to his fate; but I was determined to try the effects of the circu- lating swing as a last resource, into which he was placed as an inanimate lump, with his eyes shut; after a few circumvolutions one eye was observed to be occasionally opened, and at length both, a degree of alarm seemed next excited, then nausea, and retching to vomit; the motion was then suspended, and he was consulted as to his unwillingness to com- ply with my requisitions, but he still refusing, the gyrations were renewed, when the former effects were soon obvious, and the motion be- ing increased, full vomiting ensued; he now begged to be liberated, and promised com- pliance with my wishes; he was taken out, put to bed, and slept for some hours, when food was offered, but, as usual, refused; he was re- minded of his promise, and threatened with an immediate repetition of the swing; this suc- ceeded, and for some days the prognosis seem- ed more favourable, but the reluctance to eat- ing returned, and recourse was again had to the swing, two or three times, with the former success, till at length he yielded entirely to my 175 wishes, and by very simple management, both mind and body were at length perfectly re- stored, and I have the pleasure of knowing that he continues well, and I am confident owes his life and reason to the swing. CASE XX. Mr.----, aged 25, of a full plethoric habit and sanguineous temperament, became sud- denly insane without any obvious cause; his case exhibited nothing new or interesting, being accompanied by the more common character- istic symptoms of mania furibunda, which at length yielded to a system, the rationale of which turned on the abstraction of stimuli; but I men- tion it as one in which the swing was repeat- edly employed as a moral mean, by way of punishment, and to induce a compliance with the remedies prescribed; and though there was a necessity for its repeated use, I never saw a patient more easily or powerfully affected by it, and though he always earnestly solicited for release and suffered so much, his obstinacy and perverseness were to be overcome by no other mean; his dread of the swing was extreme, and 176 yet he would not yield to my wishes till it was employed; once he seemed impressed with the idea of its proving fatal, and previous to his being placed in the chair, as if going to be led to execution, he exclaimed in the most pitiable accents, " hear the last words, dying speech, and confession of-------," Sec. I could detail other cases where considerable relief was pro- cured by swinging, in a few instances the pa- tients resisted its action entirely, in others no advantage accrued, though the usual effects were produced, but not a single instance do I recollect of any permanent unpleasant conse- quence resulting from its employment. The effects of the rotatory motion, on diffe- rent subjects, frequently vary according to the position and other circumstances. CASE XXI. Miss-------, aged 18, sanguineous tem- perament, subject to catarrh and slight pulmo- nary affections from the most trifling causes; such as reading a damp newspaper, touching linen before it was ironed, and the momentary partial application of cold air; hectic emaciated 177 habit, and pulse seldom below 80; a stranger to robust health, subject td irregularities both with respect to the periodical visitations and alvine evacuations. Without any obvious cause her spirits were depressed, the expression of her countenance unnatural, and from being of the most accommodating amiable temper she became peevish, rude and morose. By the most gradual steps alienation of mind succeeded. In the earlier stages of the mental affection there were lucid intervals, when she was conscious of her indisposition, and could reason with much propriety on its nature as well as on most other subjects. Though the return of insanity observed no regularity or exactness, yet the intervals became rapidly shorter and less obvious, till at length no ray of reason could be observed for days and weeks in succession. Sometimes one single idea seemed to take en- tire possession of the mind, on which she never reasoned, but repeated it in the same words in- cessantly for hours in succession; at other times the most grotesque and incongruous imagery crowded on the intellect, occasionally accom- panied with frantic gesticulation and violent vociferation. The best medical skin and all 178 that the fondest affection could procure, had failed, before she was consigned to my care, without any expectation of relief, but in order to secure her every comfort, an experienced nurse, and the constant attention of a medical man. Had my judgment dictated any new re- medies their exhibition would have been imprac- ticable, indeed every probable medical mean had been employed without success, and as the body seemed to improve as the mind became affected, the application of the rotatory motion, in different positions and circumstances, was determined on. The swing was first applied in the upright position between breakfast and dinner; previous to any preparation for the em- ployment of our remedy, as the patient reclined horizontally in bed, the eyes shone with brilli- ancy and expression, the countenance was suf- fused with a slight blushy the skin was moist, the pulse 84, and the inspirations 18 in 60 seconds. The exertions necessary for the employment of the swing, and the resistance of the patient, had increased the inspirations to nearly double the former number, the pulse were upwards of 100, and the skin bathed in perspiration. No 179 trace of reason appeared in her conversation, which was incessant; but it was observed that her ideas were unconnected with surrounding objects, being excited entirely by her own imagination; that they exhibited no sort of connexion, were the most opposite and incon- gruous that could be conceived, and passed in rapid succession. The motion was at first com- municated almost imperceptibly, and very grad- ually increased, while the patient sat erect against the circulating pillar. For five minutes no effects were obvious, but the pulse, heat and inspirations were reduced to what they were at the first examination of them; in five more the ideas were observed to flow less rapidly, though equally outre; and now the eyes became less expressive, the countenance pale, and some tremulous motions appeared about the lips: on suddenly suspending the motion, a degree of alarm seemed excited, some surrounding objects attracted her atten- tion, though she reasoned absurdly about them: no change of this kind had been observed for weeks before; as she seemed considerably ex- hausted and to suffer some uneasiness, she was liberated from her shackles and placed in bed, 180 when it was found the inspirations were redu- ced to 16, the pulse to 65; she slept for some hours, skin dry and cool, but, on awaking, no sort of improvement or alteration had taken place with respect to the mental indisposition. A few days after, the patient was submitted to a repetition of the above process, with this dif- ference, that as in the former trial she had breakfasted, in the second it was employed early in the morning before any food had been received into the stomach: after a very few circumvolutions a degree of change was ob- served, both as to the appearance of the fea- tures and the mind: the former expressed ap- prehension, while the ideas, though confused, did not seem to crowd so rapidly, though obviously excited by the imagination: in five minutes symptoms of nausea took place, with __an increased flow of saliva and urging to vomit: the pulse were reduced 20, and the in- spirations 4 in 60 seconds, the loquacity was interrupted, and surrounding objects, though they must have appeared indistinct and * on- fused from the gyration, attracted the atten- tion, and became the subject of conversation; an attendant was called by name, her person 181 character dilated upon, parts of her dress oc- casioned the most singular trains of thought: the furniture of the apartment, and the machine itself, were noticed, but reasoned about very absurdly. On suspending the motion, both mind and body in a tew seconds resumed their former morbid peculiarities, and upon renew- ing the whirling, nausea and vomiting were excited, as were the ideas by surrounding ob- jects. These changes were repeatedly renewed by the same means, and though fatigue and re- freshing slumbers uniformly followed the em- ployment of the swing, yet week after week elapsed with very little variety: at length the motion was obliged to be continued longer, arid its velocity increased before the effects were produced; but she was almost constantly so im- pressed with dread, or so miserably affected by the nausea, that she uniformly intreated to be liberated, and violently resisted the repetition of the remedy. The uterine obstruction, that had resisted the usual means for such a length of time, was, in a degree, removed; but this was attended with extreme prostration of strength, pains in the back, of which she herself com- plained, and lividity of countenance. She now Q 182 became more orderly and accommodating, but was perpetually musing or talking on subjects that were furnished by her bewildered imagi- nation. The circulating machine was had re- course to only once in five or six days, though compliance was frequently procured by a threat of employing it; a new system of diet and ex- ercise was therefore adopted, accompanied with pediluvium and aloetic remedies, corrected by columbo and aromatics, and, when the next period of the catamenia was expected an in- creased dose or two of these medicines, warm fomentations of the lower extremities and ute- rine region were daily had recourse to, and happily succeeded. A degree of improvement, both as to body and mind, immediately fol- lowed; the former acquired an increase of strength, and the countenance became more healthy and natural: the mind only exhibited occasional remains of indisposition, though it seemed often disposed to revert to some former absurd trains of thought, from which it was, at first, difficult to abstract it, but afterwards she was easily diverted from these, and was occasionally interested in some new pursuits; every attention was paid to prevent a relapse, 183 and to continue the regularity which had for- merly been so long solicited in vain; at several subsequent periods of expectation the usual means were had recourse to, and with success, though both mind and body underwent obvious changes during these visitations, but these be- came gradually less apparent; and at length both health and reason were fully reinstated, and I have no hesitation in asserting that she was in- debted to the above mechanical remedy for both. The results of these different cases, and much attentive observation of the effects of the rotatory swing in many others, convince me that the quantum of effect produced depends entirely on the state of the nervous system, and that the sensibility is the medium of its action. Hence we may satisfactorily explain how it happens that, in one instance, the remedy pro- duces violent effects, in a second, very mode- rate ones, and in a third, little or none: as also how to account for its affecting one man after a few revolutions, and another, not till after a lengthened application; how, in one case, a very gentle circumgyration will produce very con- 184 siderable effects, in another, the most violent, as well as long continued, rotation is necessary to bring about any. But I never could explain the circumstance of one patient being most easily affected in the horizontal, and another in the perpendicular position, though the majority of individuals are soonest sensible of its influ- ence in the former. The various peculiarities and changes, both mental and corporeal, pro- duced by this mode of swinging, must also be attributed to the state of the sensibility, joined to the sympathy or reciprocity of action that subsists between the mind and bodv, each be- coming in its turn the agent, and the subject acted on; as when fear, terror, anger, and other passions excited by the action of the swing, produce various alterations in the body, and where the revolving motion, occasioning fa- tigue, exhaustion, pallor, horripilatio, vertigo, &c. effect new associations and trains of thought. The varied action of the swing, depending on the state of the sensibility, not only differs in different persons, but in the same person at different times. Hence also we see why the ef- fects of this remedy are, in some instances, so 185 transient, and, in others, remain so long, though it generally happens that where they are easily excited they soon disappear, and vice versa. In a few instances the long continued gentle application of the circulating motion has ap- peared to correct the deviation of the sensi- bility from its healthy standard; as where it has been painfully acute, in some delicate hys- teric subjects, or in those cases which have undergone unmerciful evacuation, producing exhaustion, emaciation, and debility. In other instances, where the sensibility has been less acute, and below par, the rapid rotation has increased it; this may explain the cause of the swing's almost uniformly rendering the system sensible to impressions, whose powers it had before resisted, regulating and diminishing the action of the heart and arteries, rendering the expression of the countenance of maniacs more natural, unloading the vessels of the brain, and by diminishing the morbid determination to- wards the head, inducing new trains of thought, and effecting the temporary and occasionally the permanent restoration of the reasoning faculties. It is found by experiment that in order to produce the desired effect from the Q2 186 swing, in different patients, the velocity of the rotation must be regulated according to the state of the nervous system; but there have been some on whom it was found practicable to produce sensations both agreeable and dis- agreeable, to continue either of these or alter- nate them at pleasure. In every case it appear- ed that suddenly stopping the machine, when in full gyration, occasioned a very violent shock both to mind and body, as the sudden and unexpected suspension of the motion has a tendency to excite fear or terror. From the variety of cases I have here select- ed some idea may be formed when this me- chanical remedy may be resorted to with the prospect of success; I may however add, that it always promises very considerable relief where the wanderings of the intellect are attended with increased arterial action unaccompanied by any other symptom of fever. It has been conjectured that the heart naturally possesses a greater proportion of irritability, and conse- quently of sensibility, than the other less noble viscera, rendering it alive to all the finer feel- ings and impressions; this being morbidly in- creased in mania, and the sw ing possessing the 187 property of diminishing it, may be esteemed an additional proof that the sensibility is the medium of its agency. I may be too sanguine from having so fre- quently witnessed its amazing efficacy; but I suspect its employment might be so contrived as to supersede the necessity of distant jour- neys, and dangerous voyages, to procure change of air, and the effects of sailing, by only apply- ing it in an apartment the air of which has been modified by a simple pneumatic process. In all pulmonic phthisical affections, where some of the most distressing symptoms seem to arise from hectic heat and Tapid circulation, relief may very reasonably be expected from the em- ployment of the swing, as also in cases of rup- tured bloodvessels, epistaxes, hasmoptoe, &c. Before I dismiss the subject it may be neces- sary to observe that the repeated violent and long continued application of the swing has, in some instances, produced little or no effect; when this is the case it should be applied to the patient in different positions, the time of day be varied, and the state of the stomach, as to fulness or emptiness, altered; but I have never 188 known it fail when a degree of nausea had been previously excited by a grain or two of vitriol of zinc or emetic tartar; or when a moderate dose of opium had been taken going to bed, and the swing applied the next morning before breakfast. I will only add that we often meet with maniacal patients with whom nothing can be done which even the best judgment dictates; as they resist every remedy, strive against every shackle and mean of coercion, use the most violent gesticulations, and rend the air with vociferations. In all such cases there is the most imminent danger, not only of permanent men- tal disease, but also of extinction of life itself; and I am confident that numbers of unhappy maniacs have sunk to death under such deplo- rable circumstances, who might have experi- enced the most essential relief from the use of the swing; for, be the party ever so furious, he may be easily subjected to its action, and in no situation could he be more secure, while an ir- resistible power is applied whose effects can be regulated without hazard. But there is a class of maniacs, who, b nt on suicide and having been prevented from accomplishing their pur- pose by other means, have effected it by star- 189 vation, in spite of every caution that could be devised: for such cases the swing offers a der- nier resort, the effects of which, judiciously regulated, have counteracted the horrible pur- pose; as rather than submit to its repeated ac- tion, such patients have been induced to take food, and thus life has been preserved, when all the hopes of their friends and physician had been given up.* It sometimes happens that insanity arises from causes obviously mechanical within the cranium, where no permanent relief can be ef- fected, and where the symptoms are aggravated by indulging in improper habits and resisting other remedies; here the swing may be most efficaciously employed both as a moral and a medical mean. This observation will apply to some cases of epilepsy, the paroxysms of which have been rendered more mild and less frequent by the daily use of the swing. In one, more particularly, its employment obviously render- ed the sensibility more natural, and the system more susceptible to powers whose agency it had before resisted; and whenever the paroxysms * See Case XIX. 190 were found to observe any regularity in their return, the timely employment of the swing pre- vented the attack, and even suspended it when the usual precursory symptoms were present. I must however allow that in epilepsy no per- manent advantage has resulted from using the swing; but I have had few opportunities of judging fairly, the majority of epileptic cases that have occurred in my practice, since the adoption of this remedy, having been of long standing, accompanied by obvious derange- ment of mind, they were consequently almost hopeless. Since publishing the former edition I have been constantly in the habit of employing the swing, and am not only confirmed in my first opinion of its safety and utility, but convinced of its efficacy in the most hopeless cases: while I am gratified by the concurrent testimony of several medical gentlemen who have favoured me with the successful result of their trials with this remedy. I acknowledge my having been disappointed in some dreadful cases where re- lief could hardly be expected; but in others, al- most hopeless, it has produced very surprising ©hanges. In one most miserable patient, who 191 had interested me very much and occupied my unremitted attention for months, the applica- tion of swinging, in the perpendicular position, produced the most complete revolution in the mind; changing the whole train of ideas, indu- cing the catamenia which had been long ob- structed, altering the state of the circulation and the expression of countenance. The removal of uterine obstructions is a frequent effect of the swing; especially if applied about the period when, if it observed its wonted regularity, it might be expected, and if assisted by the more common emmenagogues. I now find that the perpendicular position is best calculated for violent cases, and the hori- zontal for opposite ones, and that in both the motion should be communicated in the most gradual way, and be progressively increased to the degree of velocity required. 192 Having thus gone through the principal antimaniacal remedies, I will proceed to some othe.a which have been resorted to in particu- lar cases. Every medical man knows that cer- tain changes take place in diseases which may, according to Dr. Ferriar, be very properly term- ed conversions; as where the remote causes, still acting, have obliterated one disease and generated another: were such changes always within our power we might hope to relieve many dreadful complaints by exchanging them for less formidable ones; but though this is not the case, yet from this discovery we deduce what must be esteemed a very important object in the treatment of maniacs. A-> insanity often suspends and sometimes terminates other dis- eases, such as phthisis, ascites, fever, &c, so various other complaints which have been at- tended with violent symptoms have removed affections of the mind. How these changes are brought about it may be difficult to decide; but I am of opinion that some very important in- ferences may be drawn from a knowledge of the fact in the treatment of insanity. Perhaps it would be too much to say that every mean em- Dloyed for the removal of mental diseases, whe- 193 ther moral or medical, when successful, relieves by introducing some important change into the general system; but certain it is, that if any con- siderable commotion, any violent, new, action can be excited in maniacal complaints, by what- ever means, the mental derangement is often considerably relieved if not permanently re- moved; thus smallpox has dissipated the most obstinate melancholia, and where affections of the intellect have resisted common remedies I should place considerable hopes on inoculation, had the party not previously had the smallpox, taking care by proper medicines and manage- ment to increase the symptoms that usually at- tend this disease to such a degree that the whole system should be considerable affected without endangering life. Itch, too, has been known to bring about the same happy effect, the cure of insanity, but probably in a very different way from smallpox; though on a principle of the first importance in the treatment of maniacs, by abstracting atten- tion from the wanderings of deluded imagina- tion, exciting new ideas by the means of strong impressions made on both mind and body: and in the instance of itch, by the irritation excited R 194 on the surface. I should therefore have no scru- ples, in some cases, in communicating this very troublesome1 disease, especially as it involves no danger, and its removal is always in our power. As diseases of the intellectual faculties often follow repelled eruptions, drying up of old sores, habitual drains, &c, it is reasonable to expect advantage from the reestablishment of these, and perhaps there is no more manageable or efficacious mode of exciting new eruptions than what is furnished in an unguent formed of some simple ointment, loaded with crystalized emetic tartar, reduced to an impalpable powder and applied to any part of the surface, though it has succeeded best when rubbed on the newly shaved scalp, where a smaller or larger crop of eruptions, very similar to those of smallpox, may be speedily excited. Blisters, issues, se- tons, &c, will be proper substitutes for the old drains. Independent of the other valuable pro- perties of fox-glove, tobacco, and similar me- dicines, may we not reasonably impute much of their antimaniacal power to the distressing affections they occasion in the stomach? in fact, to their excitement of a species of new disease 195 in the system? After every probable remedy has failed, instances have been known of sue-. cess following such a mode of management, composed of moral, medical and physical agents, as ultimately brought about a complete change of the system, both solids and fluids: on this principle alone we may perhaps explain the frequent cure of maniacs which has been known to take place by a removal from accus- tomed objects, rigid regularity with respect to diet, &c, and the lengthened employment of some simple alterative. I have thus completed my intention of giving a Practical Treatise on the subject of Insanity. Should the performance, however imperfect, in any degree tend to alleviate the sufferings of humanity, I shall be fully compensated for the labour which it has occasioned me. APPENDIX. I. On the Mode of granting Certificates. II. On Medical Jurisprudence in Cases of Insa- nity. ON each of these very important subjects, as connected with insanity, a volume might be written, and appears to be necessary; but con- sistently with the plan I have laid down, I can only offer some general rules and hints to the consideration of the younger and inexperienced classes of medical men, to direct them not only in their decisions as to the existence of insanity, but also in furnishing a legal instru- ment for the friends of the party to act upon, and to regulate their conduct in courts of judi- K2 198 cature, where the cases involve a suspicion of insanity. I. OF CERTIFICATES. My principal motive for touching on this sub- ject in a Tract professedly medical, is to obviate the facility with which a legal instrument may be procured, that can deprive an individual of liberty, at least for a time, and tarnish his repu- tation for ever.* The law as it now stands, assigns too much * In a former edition of this work I was led into a mis- take with respect to the Act of Parliament, the wording of which is rather obscure, and as it prescribes no parti- cular form of certificates, I shall add some which have had the sanction of legal opinion. Form of the Certificate from the Physician or Surgeon. I of in the county of Physician or Surgeon, do hereby certify that I have seen of in the county of that he is disordered in his intellects, that he is proper to be, and that I have advised his being, sent to some house licensed for the reception of lunatics. Witness my hand and seal this day of one thousand eight hundred and 199 power to the inferior classes of the profession, for, as these are not, and cannot be accurately defined, ignorant or interested persons may be procured to second the views of the unprinci- pled relations or guilty criminals.* It is much more easy to object to existing laws than to improve them; but as those which relate to the subject in question are peculiarly defective, and often involve consequences of such high impor- tance, they certainly demand revision. The difficulty of decision, in many cases, and the extreme delicacy and caution indispensably Form of the Certificate from the Friend of the Patient. I of in the county of do hereby certify that by the advice of Physi- cian or surgeon of in the county of I have directed of in the county of to be sent to the house of at in the county of being a licensed house for the reception of lunatics. Witness my hand this day of one thousand eight hundred and * The author has witnessed shameful abuses of this power, and remembers an instance where a son of Escu- lapius signed a certificate Sarjeant instead of Surgeon. 200 necessary in all, show the absurdity and danger of entrusting every description of medical men with such powers over the liberty of indi- viduals. Whenever a physician, surgeon, or apothe- cary, is consulted on the subject of granting a certificate of lunacy, divesting his mind of all prejudice, he should reflect on the importance of the duty that devolves on him, and the great responsibility that attaches to his decision. He should viewT the assigned proof of defective in- tellect in every varied point of light, and recol- lect that hallucinations, confusion of ideas, pe- culiarity of manner, and even defects of judg- ment sometimes accompany certain bodily in- dispositions, and therefore do not constitute insanity, these may be only symptomatic and temporary. Where the symptoms are at all equivocal, a certain period should always be allowed to elapse that the alleged proofs may be exhibited again and again. He should inform himself of every interesting particular connect- ed with the history of the case, and of the to- pics on which the mind wanders; and in exa- mining the suspected party, should artfully re- 201 cur to these without betraying any intention of doing so. He should never decide from first appear- ances, and should always recollect that pecu- liarities exist which border very closely on in- sanity, which may be owing solely to the in- fluence of some passion, or impression on the mind, arising from natural constitution, the influence of medical or moral systems rigidly pursued, &c. In most instances the diagnostic marks of diseased intellect are too decided and glaring to admit of doubt; but it is in others, where they are not so, that there exists such a necessity for mature deliberation and patient in- quiry; in the examination of which all the acts that appear tinctured with the suspected mala- dy, should be minutely attended to, and this should be done prior to our interview with the patient: we should investigate the motives that might possibly have induced them, and accu- rately ascertain whether they result from any rational cause, defective reasoning, or disorder- ed intellect. Our inquiries should extend to all the possible motives that could influence the friends in seeking a certificate of lunacy; we should also learn from them if any corporeal 202 indisposition existed, particularly of the erup- tive kind, prior to the exhibition of the mental, one; whether the party descended from lunatic parents, had been subject to any periodical eva- cuations, which have not observed their wonted regularity, and particularly if at any former pe- riod other symptoms of fever, besides quick pulse, ever attended the aberrations of intellect. When any suspicion is excited in the patient, that proofs of his mental indisposition are re- quired, the difficulty of decision has been great- ly increased, as madmen are always vigilant and on the alert to prevent detection; and some of them reason so plausibly and pathetically, and play so successfully on the feelings of bystan- ders, that the presence of insanity is doubted, the belief staggered, and decision postponed till some new act of atrocity or insanity renders confinement indispensably necessary.* The ap- • Dr. Gregory, in his lectures, relates two cases which immediately apply to this part of the subject. He was sent by the lords of sessioa to examine three ladies in one family, who were all insane. They came to him se- parately, and each gave him so true and lamentable an account of the others, and reasoned so sensibly and pa- thetically on the subject, that the first and second decei- 203 parent rationality of a person, suspected to be insane, when submitted to examination, ought not to bias our judgment any more than the prevalence of the more common symptoms of madness, as the first may be the effect of a mo- mentary lucid interval, and the last be occasion- ed by passion, intoxication, &c. Deceived by such appearances what dreadful errors may be committed; the most dangerous persons may thus be let loose upon society, and the most innocent be unjustly secluded from it. Though so much difficulty attends forming a definition of insanity, more attaches to a juridical deci- sion, especially if it were expected that medical men should determine on all cases which may be termed moral ones, when actions are com- ved him, but as they each told the same tale, he at length discovered all were affected by the same mental malady. The other case was a patient whom the doctor attended, who told so plausible a tale to his friends, and some ma- gistrates who were present, that they were induced to order the strait waistcoat to be taken off, hardly allowing the doctor, at his earnest entreaty, sufficient time to es- cape. The instant the maniac was freed from his shackles, he flew at his friends with a violence that endangered their lives. 204 mitted of the most absurd, injurious, or attro- cious nature, only to be tolerated by the cer- tainty of madness. Amidst the immense variety exhibited in mental disease, none is more wrapt in obscurity than where the hallucination turns upon one point only, where certain modes of thinking result from defective education, and where the mind as it were preys on itself, is denied the consolation of friendly communica- tion or sociable intercourse, is never subjected to wholesome discipline, seldom relieved by agreeable avocations or varied pursuit, when compunctions of conscience incessantly haunt the harassed sufferer, and imperious circum- stances oblige him to play the consummate hy- pocrite; this is not an ideal case, many very si- milar have occurred in my own practice. The casual observer, examining some insane patients, would be more disposed to admire their acute reasoning, sallies of wit and origi- nality of thought than lament a hopeless dis- ease. The ingenuity and sophistry occasionally employed by maniacs exceed what an inexpe- rienced person could conceive; and yet these are tne cases which demand the strictest scru- tiny and most prompt measures. In every du- 205 bious case we should take into account the na- ture and degree of the mental indisposition, the extent of the deviation from the natural accus- tomed habits of thinking and acting. Where the very lowest degrees of mania tranquilla only have appeared, and but little danger is to be apprehended from a repetition of the symptoms, and where these arise from some obvious cause, though a certificate should be required, the granting it ought to be delayed, and more fre- quently be dispensed with entirely. As men are endowed with various degrees of intellect, and as almost every individual has his peculiarities, it is often difficult to determine where these end and insanity begins, and what in one would be termed aberrations of the mind, in another might be called the coruscations of genius. " Cujusque morbi tanta est magnitudo quan- tum a naturali statu recedit, quantum vero re- cedat is solus novit qui naturalem habitum ad amussim tenuerit." Some individuals possess transcendent mental faculties and yet seem des- titute of common sense: however paradoxical this may appear, such instances are common. These exhibit peculiarities of thought and man- ner easily mistaken for insanity. S 206 It should be laid down as an invariable rule among physicians, that no man be deemed in- sane till proved so by his actions: the singula- rity of a man's modes and bent of thinking should not condemn him as a maniac, but his acting on them: on the other hand, the greatest care and caution are necessary in forming a judgment, where, from bad habits indulged, depraved moral sense, unrestrained passions, 8tc. a person may be hurried on to the most atrocious acts of madness; whereas, if the rudi- ments of the disease had been detected in time, and a certificate granted, these consequences might have been prevented. I would particu- larly guard my medical brethren against a hasty decision, where a certificate is requested in ner- vous gloomy hypochondriacal cases, especially where an exquisitely marked melancholic tem- perament obtains; in these, reason seems fre- quently but little disturbed, and yet they often terminate fatally by suicide. Patients of this class practise the most refined deception. Phy- sicians, the most experienced in the manage- ment of the insane, have been the dupes of their cunning and art. It is impossible to conceive, much less describe, the various means maniacs 207 have recourse to for the accomplishment of their purposes.* \ There is a class of individuals, who though they can hardly be termed insane, yet whose conduct argues a great degree of depraved reason and of very defective moral sense, and who occasionally exhibit all the more common symptoms of disordered intellect,—I refer to habitual drunkards. The recurrence to exces- sive drinking, especially ' when the baneful ef- fects have been frequently experienced, is a species of infatuation closely allied to madness, * The author had a gentleman sometime since under his care, who being denied the use of pen, ink, and pa- per, had recourse to the following means for the accom- plishment of his wish to send a letter to the editor of a certain provincial paper, offering himself a candidate for a seat in parliament; he tore out a blank leaf from a large bible, made a pen with a straw by means of a bit of glass, ink from a solution of soot in cherry juice, and wafer from chewed bread, which last being neatly ma- naged received an accurate impression of the family arms from his seal. The letter thus prepared he got con- veyed to the neighbouring postoffice by means of an orange girl, to whom he presented it with a shilling in- closed in a cover, on which was written « to be put into the postoffice immediately," and this he effected, while his servant was buying fruit at his elbow. 208 and as the detestable practice is an act of voli- tion, man being a free agent and accountable for his conduct, the law has wisely determined that drunkenness should be no extenuation of guilt, and it is to be lamented that the law has not also permitted the granting certificates of lunacy in such cases.* The experience of every physician proves the truth that insanity is a fre- quent sequela of intoxication; and it is matter of regret that while we witness the gradual de- struction of the best constitutions, the daily injuries done to the noblest mental faculties, health and reason sapped, and the devastating cause of all constantly repeated, we cannot in- terpose a legal order for confinement. The ef- fects of different intoxicating liquors on dif- * Since publishing the first edition of this work, I have learnt that an institution for the moral recovery of drunkards has actually existed on the other side of the Tweed, not however on such a plan as to render it useful to the lower classes of society, among which the baneful habit of intoxication now more particularly prevails; but confined to such people as could be maintained there at their own expense, till discipline and new habits had reformed their propensities, and restored strength to the frame.—See Edinburgh Medical and Surgical Jour- nal for April, 1805. 209 ferent persons would furnish considerable in- formation, and a source of amusement to the curious philosopher. Some are excited by them, others depressed, this man is rendered bright, that man dull; in some the animal economy seems insensible to the rude attacks, while the intellects are strangely confused; in others both mind and body suffer equally. In many the effects of such excesses are tempo- rary and are speedily and completely dissipated, till the cause is again applied. In a few, the intervals between the paroxysms of drunken- ness are not accurately defined, when insanity and inebriety are strangely intermixed, and these generally become martyrs to their vice, or sink into lethargy, apoplexy, insanity, or idiotism. In one class of drunkards miserable feeling urges to the repetition of the baneful practice; in another, different passions are ex- cited, or such a morbid irritability as carries them beyond restraint and renders them equal to any act of violence and absurdity; and both these are peculiarly liable to become perma- nently insane. In such cases the judgment of a medical committee should be required, though thcv must be deemed proper subjects for a S2 210 certificate of lunacy, and unless the destructive habit has been too long persevered in, or has made very serious havock in the system, a tem- porary suspension of it, to be obtained only by confinement, promises the most probable means of cure. There are other cases in which medical men are applied to for certificates, where, though they have no doubt of the existence of insanity and cannot legally refuse furnishing the document required, yet it ought not to be im- mediately acted upon. I refer to those instances in which aberrations of intellect have followed febrile diseases, especially where these have been accompanied by excessive evacuation and consequent prostration of strength; as also where insanity is a sequela of very painful protracted parturition; since in these and simi- lar cases reason frequently returns as the health and strength improve. The same may be said of those cases where mental alienation seems to result from the sudden or powerful action of any of the exciting or depressing passions, such as terror, grief, joy, &c. or of wounds and contusions about the head, or the action of narcotic or other poisons. From what has been said above, it will be 211 obvious that the utmost experience, address, skill, and probity are indispensably connected with a medical man's duty in the business of granting certificates of insanity; and yet the existing laws empower any man who chooses to call himself a physician, surgeon, or apothe- cary, however incompetent and unprincipled, to furnish these important instruments. I am, however, decidedly of opinion that as too much caution cannot be employed in every case of suspected mental disease, and more particu- larly in those doubtful ones where the nicest discrimination is necessary, and where persons of the best abilities may fall into an erroneous judgment, one medical person should not be deemed competent to furnish a certificate of in- sanity in any case; butthat the concurring opinion of two, at least, should always be required, and when any doubt remains, a committee consist- ing of an unequal nu mber of men of respectability in their profession, should be absolutely and indispensably necessary, the majority of whom should decide; and that it be deemed illegal to furnish a certificate of insanity without re- peated interviews, where the symptoms are at all equivocal. 212 The legislature has wisely established the necessity of a certificate for the legal confine- ment of a maniac, but none for his liberation, and to prove his recovery; though this in my opinion, is equally necessary, and should always be furnished by the medical person to whose care the patient hasbeen consigned, who had wit- nessed the symptoms of the disease, his progres- sive convalescence, and ultimate recovery; should be dated, signed, and sealed by him: and no person should be deemed perfectly compos mentis, proper to be at large, to mix again with society, and transact any important business, till he had undergone an examination in the presence of his friends, particularly on those points which were the basis of his hal- lucination; nor till he is able to reason calmly and dispassionately on the subject of his indis- position, and has exhibited no mark of diseased intellect for at least one month previous to the period of his examination. Here again the me- dical profession have very extensive powers delegated to them, and equal judgment is ne- cessary to ascertain this point; as it oftens re- quires the nicest discrimination to decide whether patients who have apparently recovered 213 their reason, have retained it a sufficient length of time, to render it safe for their restoration to society and their usual pursuits. " For after recovery from a state of insanity, the mind is-, for a time, as weak as the body is after violent diseases. As in the latter instance patients can- not immediately return to the exercise and diet requisite in times of health, without imminently endangering a relapse; so in the former they cannot be admitted to those objects they were accustomed to behold before their mental de- rangement, without hazarding an equal or greater degree of danger. 11. OF MEDICAL JURISPRUDENCE, 50 FAR AS RELATES TO CASES OF INSANITY. Judicial opinions are seldom requisite in the more common and glaring instances of mad- ness; but in those where the reasoning facul- ties have been disturbed from different causes, the mind debilitated, and its powers impaired; where the symptoms of mental disease are equivocal, and where imperious circum- stances require an accurate estimate of the integrity and capacity of the intellect. Thus to 214 determine the capability of persons to hold certain offices, execute trusts, deeds, &c; to exculpate or criminate the perpetrators of atro- cious acts, by deciding the state of the mind at the time of their commission; to assist the coroner in forming his verdict in cases of sud- den or violent death, &c. It is next to im- possible to detail the variety of cases in which a physician may be required to give his judg- ment and opinion in a court of judicature, and equally so to lay down a system of rules that shall infallibly direct to an accurate deci- sion; though the want of such a code must be ever deplored, while instances occur which prove that the guilty have escaped, and the in- nocent been condemned and executed; that individuals have been secluded from society, who would have been valuable members of it, and madmen permitted to rove abroad to the annoyance of their sober neighbours and the exposure of themselves, who should have been under constant restraint: so difficult is it, in some cases, to determine whether the mind is sound or not. There are various diseases inci- dent to the human body, such as fevers, vio- lent headaches, hypochondriasis, and epilepsy, 215 which disturb and confuse the intellect, render- ing it incapable of steady attention, accurate thinking and sound judgment; and similar effects have been produced by external injuries about the cranium, intoxicating liquors and certain poisons; these and various other causes have contributed to debilitate and obscure the mind, without completely perverting it, or oc- casioned a partial derangement, confined to a single subject, which is frequently found to exist with general intelligence and superior mental powers.—Hence the greatest difficulty some- times arises to the medical jurist, when all his address, skill, and experience are incompetent to decide the question, whether insanity be present or not. Though many ingenious argu- ments have been offered to prove that insanity has no lucid intervals, a multitude of facts have occurred in my own practice, and crowd on my recollection, that induce me to controvert the assertion. In criminal cases to establish such a law would be most humane and merci- ful; but viewed in other points, as connected with jurisprudence, it would be cruel and un- just In those cases more particularly which observe periodical returns with some degree 216 of regularity, the intervals are marked with sobriety and steadiness, the mind seems to en- joy all its faculties, the intellect to be perfectly clear, not only capable of estimating the moral- ity of actions, but of giving legal evidence, making bargains, executing deeds, disposing of property, Ike. In every case, at all suspicious, common prudence will dictate the propriety of caution; but if we are ever to judge of men's minds by their actions, the same criterion is certainly admissible here, all circumstances being equal. Though it must be allowed that thought, design, and contrivance are in them- selves no proof of sound mind, yet it must also be admitted that when they are not tinctured with any prevailing hallucination or mark of mental disease; whenever the furious maniac of yesterday is to day calm and collected, can rea- son with the utmost propriety, and thinks as the generality of mankind on the same subjects; is conscious of his late indisposition, and can talk with philosophic coolness of its nature, &c. are we not warranted in deeming this a lucid interval? Or are we to refuse to give credence to the opinions, or to admit the evidence of a man who is only so partially insane that, if 217 kept clear of the subject on which his de- rangement turns, he will exhibit all the usual marks of a sound mind, whose decisions defy refutation, whose sentiments command confi- dence and respect, who is equal to all kinds of business, to unravel intricate accounts, who can call up all his powers of reasoning and recol- lection, and employ them to the best purposes? Patients of this description frequently occur in practice, I have several at this moment un- der my care; and it is a painful consideration that they form a class the most hopeless and most frequently incurable. One very interest- ing case I recollect of a patient, who, with an unusual proportion of natural endowment and great cultivation of mind would pass whole months without exhibiting a shadow of de- rangement, and yet on one point he was uni- formly defective, and his reasoning betrayed the most unequivocal proofs of mental disease; yet, would it not be unjust and unreasonable to deny to this man a lucid interval, and should he not have been deemed guilty if he had commit- ted any act, not connected with his particular hallucination by the most remote catenation, which amounted to the breach of any existing T 218 law, even though the offence were of so cri- minal and capital a nature as to endanger his life? As he was certainly capable of thinking and reflecting, reasoning and judging, and sub- ject to like passions with other men, though it be granted a degree of mental alienation ex- isted, confined within very narrow limits, he certainly ought to be reckoned accountable to the criminal code. Were we to deny the exist- ence of lucid intervals, how difficult it would be to determine when a cure took place; for though every mark of disease had long sub- sided, the patient, as being liable to relapse, might be said to enjoy no lucid interval, never to be convalescent or perfectly recovered. Those most conversant with diseases of the mind must be convinced that the greatest pro- portion of them are only partial, and conse- quently admit of lucid intervals. Perhaps it ■would be too much to assert that the majority of the wisest and best men that ever lived were subject to some degree of occasional alienation of mind; and yet it must be obvious to the most casual observer, that the highest order of intel- lect is generally accompanied by peculiarities that border closely on mental derangement. 219 History records a number of very interesting cases of excellent men, whose reasoning on some subjects betrayed marks of insanity, and yet whose general deportment was exemplary: would it be deemed inaccurate, in such in- stances, to denominate the periods between the recurrence of such morbid peculiarities, lucid? or would it not be infinitely more so, were we to pronounce men insane, when, perhaps, upon making the experiment, it would be impossible to prove them so? What very perplexing ques- tions, in a court of judicature, might arise out of such cases! In some instances the faculties so far from being weakened by the disease are really sharpened and improved by it. Hence again much difficulty may arise in forming a medical decision. When irregularities, mis- chievous or atrocious acts, have been commit- ted by a person subject to returns of partial in- sanity, it often proves a perplexing as well as painful duty to the physician to decide on the innocence or guilt of the person accused, espe- cially where any doubt exists whether these acts were perpetrated during a maniacal paroxysm or in a lucid interval. Man, being a free agent, is certainly account- 220 able for his actions, some of these are criminal or innocent according to the animus with which they were committed; and, as has just been observed, where any degree of mental de- rangement is suspected, the presence or ab- sence of it, at the time of the commission of improper acts, must decide their nature. In all juridical investigations of this kind, however varied the circumstances, all the collateral in- cidents should be carefully collected and accu- rately examined; and the physician should en- deavour to inform himself at what period the last appearance's of insanity took place, whether the acts complained of could be traced to sinis- ter motives or malevolent passions, and were such as might have actuated any individual of sound mind when unrestrained by principle, education, or moral sense. When no reason can be assigned for the commission cf atrocities, or where the cause alleged is not proportionate to the effect produced, where no plea or excuse is offered in extenuation of guilt, no appear- ances of compunction, no accurate recollection of the attendant circumstances, and no attempt to escape justice, we are warranted in imputing the acts to mental derangement. But where, on 221 the contrary, the crimes committed seem in- duced by a sudden gust of anger, revengo^ma- lice, &c; where they are the result of'delibera- tion, and exhibit decided proofs of reflection, art, and design; where attempts are made to conceal the acts, or escape the punishment due to their guilt, there is sufficient reason to deter- mine them proper objects for the vengeance of the law. The decision in such cases should not be biased by the appearance of the parties at the moment of examination, though in the first instance the person accused should be free from every symptom of disease, and in the last should be violently insane. The indiscriminate refusal to admit lucid intervals in any case of even par- tial insanity, would at once decide the nature of crimes committed under the above circum- stances, to be the result of disordered intellect: but we have the sanction of the first law autho- rities for the admission of the evidence in both civil and criminal cases of persons subject to occasional returns of insanity, and it would be unjust and irrational to refuse it. I subscribe to the position that, at a given moment, a man is or is not insane, but only in the same way as I would allow a patient has ague, even in the T 2 222 periods of its intermission. It certainly is a very wonderful fact that those parts of our frame more immediately connected with, or contri- buting to, the formation of ideas, should, at one moment, exhibit such high degrees of morbid action, and, in the next, appear to possess all the healthy state of their functions and properties; indeed that thought and intellect, once deran- ged, should ever again be rectified. Reverting to the subject of lucid intervals, it must be ac- knowledged that cases may occur where cri- minal acts happened at the time of the accession of mental disease, when the perpetrator, though at the moment of examination he is perfectly compos mentis, must be demed innocent; or vice versa, he might have been calm, clear, and rational, at the time, and become actually in- sane since, from the horrors of conscience, re- morse, or miserable feeling; but here the offen- der must be deemed guilty. Medical jurisprudence forms a neglected part of a physician's education,* though there is no branch of science more necessary or im- * Since writing these sheets, the work of the late Dr. Percival, entitled Medical Ethics, has appeared, which, however excellent, is far from complete. 223 portant, since we see such powers delegated to us by the laws of our country, and questions occur so enveloped in obscurity. Very perplexing cases have occurred where culprits have feigned diseased intellect; either for the accomplishment of wickedness or to skreen themselves from condign punishment. But the most consummate art and hypocrisy will be necessary to enable the impostor to play his part with even a tolerable degree of success. Here the experience and discriminating powers of the physician will effectually assist the judg- ment, as his knowledge of the genuine symp- toms and most frequent accompanying peculi- arities, modes of reasoning, talking, acting, &c. is superior to that of the novice who undertakes to exhibit them; for however accurately he may imitate the frantic ravings of delirium, he can- not assume that consistency of erroneous rea- soning, that peculiarity of look, that character- istic expression of countenance, which uni- formly accompanies the genuine disease, and which, though not to be satisfactorily described, will often determine the question when every other mark is equivocal. Should it happen that after the most minute, attentive and repeated 224 examination, circumstances exist which involve great suspicion and a degree of doubt, no final decision should take place till the party shall have been placed in a room alone, in such a si- tuation as to allow the observance of his coun- tenance and conduct, without his knowing or suspecting an eye was upon him; no method is better calculated to detect imposture. Some- times proposing painful operations, nauseating remedies, active medicines, blisters, clysters, &c. has induced the pseudo-maniac to throw off the imposture; and when other proofs are wanting to confirm our opinion of die presence of mental disease, the capability of resisting the action of certain agents, such as heat, cold, hunger, thirst, drastic remedies, watching, fa- tigue, &c. is decisive. It is the duty of every medical man, consult- ed on legal questions, to divest his mind of all prejudice, and his system of all theory; to di- rect his unbiassed judgment to ascertain the important point required; and, in cases of sus- pected insanity, to compare the reported history of them with the then existing symptoms; to inform himself as accurately as possible, among other interesting particulars, of the natural tem- 225 per and disposition of the suspected party; to compare these with the peculiarities which re- semble or approximate to insanity, making an allowance for lucid intervals, consummate art, &.C., where the characteristic features of the disease are not strongly marked, and where they are, recollecting the possibility of their arising from other diseases, or of their being feigned. Unless in those instances where prompt decision is indispensably necessary, a regular system of examination should be uniformly established; where difficulty or doubt prevails, the party should be subjected to reiterated and attentive observation in every possible situation and circumstance: every movement, every look, every word should be sedulously noticed, the subjects of conversation varied, and without apparent design, be directed to those topics on which he is reported to wander. He should be required to commit his thoughts to paper, to pen his ideas on a given subject, and it should be ascertained whether he exhibits any pecu- liarity in shaping his letters, writes faster or slower than he was accustomed to, previous to the suspicion of mental affection. We meet with no cases in legal medicine 226 more important, or of more difficult or nice de- cision, than those in which professional testi- mony is required concerning the capacity of individuals to conclude contracts, execute leases, deeds, trusts, make wills, &c. where the intellectual faculties seem weakened by violent or protracted disease, impaired or al- most annihilated, on approaching dissolution, harassed by distressing impressions, or dis- turbed by exciting or depressing passions. Here the physician is sometimes immediately required to give an opinion whether the mind is capable of deliberating and deciding justly and rationally, as the withholding his judgment might be attended with consequences as unfor- tunate as the giving an unjust or improper one. To lay down rules to direct in forming deci- sions under all the various circumstances that may occur is next to impossible, the judicious conscientious physician must be left to employ the talents nature has endowed him with, as- sisted by all the information which his reading, reflection and experience can furnish. THE END. The following useful HINTS which were pub- lished in the Eclectic Repertory, may be con- sidered as a valuable sequel to the preceding work. HINTS ON THE TREATMENT OF INSANE PERSONS. The following general hints on the treat- ment of insane persons have been chiefly drawn from the experience of The Retreat, near York (Eng.) The compiler however is fully aware, that after all which can be learnt from others, much must remain for experience to teach. The modes of insanity, and consequently its treat- ment, will be found to vary, in no small degree, with all the varying characters, manners, and habits of the human mind; and therefore the object, to which those concerned in the esta- blishment of lunatic institutions ought most peculiarly to direct their attention, is the selec- tion of a manager who possesses, in addition to other qualifications, a natural quickness of perception, and tendency to observe the varie- ties of mind, which will enable him to perceive 228 with readiness, and apply with address, such moral treatment as the different cases may re- quire. Medical Treatment. It must be confessed, that the experience of the Retreat has not thrown much light on the medical treatment of insanity. It has however led the manager to believe, that but little is to be done by its aid, and convinced him of the folly as well as cru- elty of forcing upon the patient a large quantity of nauseous draughts, at a time when probably his aversions are more thanusually strong, and when he is with difficulty induced to take the food necessary for his support. The use of medicine is however far from abandoned at the Retreat. In all cases where the disease has supervened, or is attended by any obviousbo.- dily disease, however slight, advantage may be reasonably expected from the removal of such complaint. The warm bath has been much used at the Retreat for several years in all cases of melan- choly, with the happiest effects. Indeed there has not been any recent case in which it has been employed without relieving or removing the complaint. The patient usually makes use 229 of the bath eveiry other day, and continues in it about twenty minutes, at a temperature of about eighty-five degrees. The time of conti- nuance is gradually advanced to nearly an hour, and the temperature to about ninety-six de- grees. The difficulty of obtaining sleep for maniacal patients, and that opium, though taken in large doses, frequently produces no effect, is well known. It suggested itself, however, to the sensible mind of the superintendent, that all animals in a natural state, repose after a full meal, and, reasoning by analogy, he was led to imagine, that a liberal supper would perhaps prove the most effectual anodyne. He therefore caused a patient, whose violent excitement of mind indisposed him to sleep, to be supplied free.y with meat, or cheese and bread, and good porter. The effect answered his expectation, and this mode of obtaining sleep has since been generally successfully employed. In cases where the patient is averse to take food, porter alone has been employed with great advantage. Medical attention to the general bodily health, during convalescence, and in the lucid intervals of the patient, is of great importance. The re- U . 2m turn of the disease may frequently be suspend- ed, if not prevented, by this kind of attention. The operation of cupping, applied to the head, temples, or neighbouring parts, has very fre- quently been attended with great advantage, where any pain or heat has been felt in the head. General bleeding and other evacuations have been found injurious at the Retreat, and are therefore not used; except where their neces- sity is indicated by the state of the bodily habit. Air and Regimen. The situation of the Re- treat is high, and affords a very dry air, which there is reason to believe is of very great im- portance to lunatics, but more especially for those of the melancholy class. All the patients should, as much as their cases will allow, be exposed to the open air, and particular care should be taken that their different apartments be well ventilated. A cheerful, pleasant scenery, in a retired si- tuation, seems a desirable appendage to a dry and healthy site for the building. A single range of rooms, with a gallery opening to the external view, is much preferable to a range of rooms on each side of a gallery. For though 231 the exclusion of much light, in some violent cases, is found desirable, this is not a general circumstance. Every appearance of a place of confinement should be studiously avoided. The window frames at the Retreat are cast iron sashes of a full size, with panes too small to ad- mit of a patient's escape through them. Sepa- rate wards for the men and women patients, and the different descriptions of each sex, are also very essential. The regimen of lunatics should be regulated by a consideration of the nature of the disease, and the state of the bodily habit. The experi- ence of the Retreat has fully convinced the manager of the general impropriety of reducing the patient, however violent, by a low diet, or violent evacuations. The following is the general diet of the pa- tients, viz. Breakfast. Milk and bread, or milk por- ridge. Dinner. Pudding and flesh meat six days in the week; fruit, pudding, and broth one day. In the afternoon. The men have bread and beer, th/; women tea or coffee. 232 Supper is generally the same as breakfast; sometimes bread, cheese, and beer. The parlour patients, when sufficiently well, partake of whatever comes to the superin- tendent's table, and some are supplied from it in their own apartments. Moral Treatment. It will naturallv occur to most persons, that the first objects to which the attendants upon lunatics ought to apply, is to obtain their entire confidence and good opi- nion, and for this purpose, it is necessary to treat hem with uniform kindness, and never to deceive them, either by promises or threats. The idea, which has too much prevailed, that it is necessary to commence an acquaintance with lunatics by an exhibition of strength, or an appearance of austerity, has been found, at the Retreat, extremely erroneous, and to be a part of that cruel system, dictated perhaps by timidity, which has so long prevailed, and un- happily still prevails, in many of the receptacles for the insane. Perhaps, in general, much fa- miliarity, when a patient first enters the house, would have a tendency to lessen that authority which it is in some cases necessary for the at- tendant to posses^ and exert; but, let it be re- 233 membered, that in most instances of mental depression, the behaviour, though it ought to be firm, cannot be too kind, conciliating, and tender. There may, however, be particular cases, in which the attendant may, perhaps with advantage, assume a distant and/somewhat im- portant manner; but it must be done with ex- treme judgment, as the observation of maniacs is frequently morbidly acute. It rarely happens that all the faculties are de- ranged at the same time, and the moderate ex- ertion of those which remain sane, is calculated to correct and strengthen those which are dis- eased. The patient on all occasions should be spoken to and treated as much in the manner of a rational being as the state of his mind will pos- sibly allow. By this means, the spark of reason will be cherished, and that painful feeling of de- gradation, which must be felt in a greater or less degree by all who recover the loss of their ra- tional powers, and which cannot fail materially to depress them, will be greatly lessened. Du- ring the state of convalescence, attention to this hint is peculiarly important, and the great- est advantage has been found to arise at the Re- treat from introducing the patients who appear U2 234 to be recovering into tlie society of the super- intendent and the other rational parts of the family. This liberty is afforded to the poor as well as the more opulent patients, as it has been found very materially to accelerate the recovery, if indeed it be not essential to it. Of the modes of employing the minds of maniacs, those are to be preferred, which are accompanied by bodily action, which are of the amusing kind, and are most opposite to the illusions of their disease. When the patient is himself inclined to any particular employment, if not very unsuitable, it should be seized as a favourable circumstance, and carefully encou- raged. Conversation with those who can condescend to their weaknesses, and walks into the country, under suitable care, have been found of essen- tial benefit to the different classes of patients. The salutary effects of air and exercise, the va- riety and beauty of the objects of nature and rural life, as well as the subjects of conversa- tion which these excite, have a strong tendency to still the effervescence of an overheated ima- gination, and to inspire the anxious and melan- choly mind with tranquil and pleasing emotions. 235 The experience of the Retreat has fully shown that, in melancholic and hypochondriac cases, close confinement is of all things the most un- suitable. Hence we may explain, why so few cases of melancholy are cured in lunatic asy- lums in general, and hence, happily, we may also> in great measure explain, who so many labouring under these most affecting complaints haye been restored, by their treatment at the Retreat, to their families and society. Several of the convalescents are made use- ful in assisting the attendants, and the females in general are employed in needle work, where they can be safely intrusted with the necessary implements. The use of books and pen and ink are generally allowed, and the indulgence has been found generally beneficial. Jt must however be allowed, that a suitable mode of employing the men patients is still a desideratum. The principle of honour is often very strong in the minds of lunatics. I have known patients, who were under a voluntary engagement of good behaviour, hold a successful contest, for a considerable length of time, with the strong wayward propensities of their disorder, and 236 even conceal all marks of aberration of mind. The attempt is highly beneficial to the patient, and ought to be sedulously encouraged by the attendant. Several of the patients are permitted to at- tend the meetings in the city, and all who are suitable are assembled together on a first day afternoon, when the superintendent reads to them some chapters of the Bible. A profound silence ensues, during which, as well as the reading, it is curious to observe the order with which the patients conduct themselves, and control their different propensities. In cases where the patient is disposed to be violent, ad- vice given in a friendly manner is very often successful in preventing the necessity of harsh measures, which ought never to be employed without absolute necessity, and then with ob- vious marks of regret on the part of the atten- dant. It is proper however to observe, that no advantage has been found to result from rea- soning with maniacs on their particular hallu- cination. One of the distinguishing marks of insanity is a false conception, which of course occasions an incapacity of conviction. The at- tempt therefore generally irritates the patient, 237 and rivets the false perception more strongly on his mind. When a patient proves refractory, and co- ercive measures are indispensable, it is advi- sable to have an ample force employed, as it prevents in general any attempt at resistance; but where such force cannot be obtained, and the case is urgent, courage and confidence will generally overcome the violence of the patient, for there are hardly any instances in which maniacs have displayed true courage. The su- perintendent of the Retreat was one day walk- ing, in a field adjacent to the house, with a pa- tient who, when opposed, was apt to be vindic- tive. An exciting circumstance occurred; the maniac retired a few paces, and took up a large stone, which he held up as in the act of throw- ing at his companion. The superintendent in no degree ruffled, fixed his eye upon him, and in a resolute tone of voice, at the same time marching towards him, commanded him to lay flown the stone. As he approached, the hand of the lunatic gradually sunk from its threaten- ing position, and dropped the stone to the ground. He then submitted to be quietly led to his apartment. One motion of timidity on the 238 part of the superintendent might have cost him his life. Modes of coercion. Kind yet firm treatment has been found to supersede the necessity of much coercion of any kind. Neither chains nor corporal punishments have ever been allowed on any pretext at the Retreat. The strait jacket, or a belt round the waist, which has straps that confine the arms close to the side, are the only instruments of coercion made use of when the patient is not in bed; when it is found necessary to confine the patient in a recumbent posture, the superintendent has invented a mode of fast - cning, which allows a change of posture, and the bending of all the joints of the body. If in any instances chains are necessary for the confinement of lunatics, it is much to be feared that the highest pitch of maniacal fury has been excited by the cruelty or improper treatment of the attendants, very few of whom are fit to be intrusted with much power. It should therefore be as limited as it can be with safety, that they may be obliged to use every means, to govern rather by esteem than severity, and avoid every thing likely to exasperate the patients. Taken apart, leaves deaeldlfled with magnesium bicarbonate* Folds reinforced A leaves mended* Reseved on linen cords with new all-rag end paper signatures A hand sewed headbands* Rebound la quarter Russell's oasis moroeoo with hand marbled paper sides A vellum oorners* Leather treated with potassium lactate A neat's foot oil A lanolin* , Ootober ltf1*. LI-ecO-M'^ Carolyn Horten A Assoo* ■430 West 22 Street Now York, N.Y. 10011 X* N BINDERY 9-70 C 977 p /*?//