Some observations on Dr. Rush's work, on " the Diseases of the Mind." With remarks on the Nature and Treatment of Insanity. By George Hayward, M. D. [Extracted from the New England Journal of Medicine, &c] AMONG the improvements of modern medicine, we can- not boast the acquisition of any considerable ascendancy over the diseases of the mind. From the time of Hippocrates to the present day, embracing a period of more than two thou- sand years, we find accounts in the writings of eminent physi- cians, of mental derangement and its varieties, histories of individual cases, with enumeration of the exciling causes and remedies, and yet we are nearly as far, at the present time, from any plan of medical treatment that promises much suc- cess, as the ancients were at the commencement of the healing art. It is a well known fact, that most of the remedies that are now in use in Europe and this country, and which retain the greatest share of reputation, are precisely the same as were recommended by Aretaeus and Ceisus, eighteen hundred years ago.* Several causes have, no doubt, contributed to retard im- provement in the medical treatment of the insane. As one of these may be mentioned the fact, that physicians have not, until within a few years, been agreed as to the seat of insanity. The ancients were almost unanimously of opinion, that it arose from disease of the abdominal viscera ; and the term melan- choly (derived from two Greek words, meaning black bile) by which they distinguished one species, shows that they thought * In the thirtieth number of the London Quarterly Review, it is stated, that a remedy for madness, which some years since excited considerable attention in England, was supposed to consist in an " immersion of the patient's body in very hot water, and, at the same time, pouring a stream of cold water on the naked head." In a note, the reviewers observe, that this process is described by Ceisus in express terms, and quote, in proof of the assertion, the following sentence :—" Super caput aqua frigida infusa, demissumque corpus in aquam et oleum." But this is certainly a diffe- rent process, and there is nothing, in any part of that author's writings, that justifies the opinion, that he was acquainted with the remedy men- tioned iu the Review.— Vide Liber 3. cap: XV111. of hi; works. Halter's edition A 2 Diseases of the Mind. there was derangement in the secretion of one of those organs. It is evident, that while there was a doubt as to the seat of the disease, no curative plan could be adopted upon any sure or promising foundation. Another cause may be, that though pathologists of the pre- sent day are pretty well satisfied that in all cases of insanity, the brain, or its appendages, or both, are in some way disorder- ed, they pretend not to say precisely how, yet from the ex- treme difficulty that has attended all in\ estimations of the physi- ology of the mind, the subject seems to have been almost abandoned in despair by medical men. But though we cannot examine by our senses the faculties of the mind, as we do the organs of the body, nor understand the wonderful connexion of matter and of mind, and their constant action and reaction upon each other, yet much may be learnt by an accurate analysis of our own intellectual faculties and operations. An intimate acquaintance with the philosophy of the human mind, is indispensable to him who would hope to treat its diseases with success ; he might as well expect to un- derstand the pathology of the body, without a knowledge of its structure and functions in health. There is slill much obscurity relating to the phenomena of mind, as well as to the physiology of the brain ; though in re- gard to the first, the labours of Mr. Stewart in particular justify the hope, that much mote light may yet be thrown upon this interesting subject; and as to the second, whatever opinion may be entertained of the physiological researches of Drs. Gall and Spurzheim, yet their method of developing the brain may ultimately lead physiologists to a better knowledge of the functions of that 01 gan. Anolher cause, probably, of the repeated failure of almost every attempt to relieve insanity, is, that mankind have too often considered the disease beyond the controul of medicine, and the unfortunate patients have usually been abandoned to the care of ignorant or designing empirics; or when they have been placed under the direction of medical men, it is not in the early stages of their disease; it is, in fact, usually permitted to continue so long, that some organic changes are produced in the brain, before medical advice is obtained. Recent cases of insanity may be very often cured, while those of long standing are almost always hopeless. By a calculation that has lately been made in Great Britain, upon a large scale,* it appears, that of recent cases, seventy-six patients of every hundred were relieved, while there were only nineteen out of the same number, whose disease had been of long standing. Perhaps, * Vide Edinburgh Review, for August, 1817. Diseases of the Mind. 3 therefore, it would be adviseable to admit into public institutions at a lower rate, all patients whose disease was recent. This plan has been adopted at one asylum in Great Britain. Numerous treatises on mental derangement have appeared at different periods in Europe, but the work of Dr. Rush, which was published in 1812, is the only original one, that was ever printed in this country. From this circumstance, as well as from the fact of the alarming increase of insanity within a few,years, and the uncommon attention which it has lately ex- cited in this vicinity, it was thought that an abstract of its contents might be interesting, if not instructive, to some of your readers. In doing this, the writer has not confined him- self exclusively to the views that the author has taken of the subject, but has endeavoured to present, in as concise a manner as possible, the opinions of others, of equal eminence, on the nature and treatment of insanity. A few objections have been made to some parts of the work, because it was thought that the erroneous views of so distinguished a man, were particular- ly calculated to mislead ; and not from any want of respect for his character and professional acquirements. The writer of this remembers Dr. Rush, as an impressive, eloquent, and in- structive lecturer, and is fully aware hoiv much his labours advanced the cause of medical science in the United States. Though he may controvert some of his opinions, it does not lessen the respect he feels for his memory. The first chapter treats "of the faculties and operations of the mind, and of the proximate cause of intellectual derange- ment." The faculties, he says, "are understanding, memory, imagination, passions, the principle of faith, will, the moral faculty, conscience, and the sense of Deity." Though authors are not agreed, as to the precise number of the faculties of the mind, there are none in the list of Dr. Rush, except memory and imagination, that have ever been so considered by meta- physical writers. The faculties of perceiving, judging, re- membering, associating, and imagining, constitute the catalogue usually given. Some have added the faculties of conceiving, combining, and abstracting, though others have thought that these are rather the effects of the five principal ones. Con- science and the will have been called principles, because they have not the power, like the faculties, of modifying our per- ceptions or sensorial impressions. The moral faculty, sense of Deity, &c. are probably the result of a proper, and well directed exertion of our intellectual faculties. The remainder of the chapter consists of remarks upon the proximate cause of insanity. Dr. Rush endeavours to show, that it is not seated in the abdominal viscera, the nerves, or the mind, except through the medium of the body, and his obser- 4 Diseases of the Mind. rations on these subjects are interesting and conclusive. In attempting to establish his own theory, viz. that it is seated in the blood-vessels of the brain, he seems not to have been so fortunate. He does not say in precisely what state he considers the blood-vessels to be, though it may be gathered from his remarks generally, that it is that of increased fullness, or tur- gescence. It is a well known fact, however, that this takes place daily, in almost every individual, from violent exercise, or over-exertion of any kind, without producing the slightest symptoms of delirium, or any unpleasant effects whatever; and even where there is an increased determination of the blood to the head, sufficient to produce phrenitis, it either speedily ends in death, or yields to the depleting remedies, and if mania is the consequence, it is after the crowding of the blood-vessels has subsided. If the blood-vessels were the parts diseased, no matter in what way they are supposed to be affected, dis- sections would probably discover the same appearances in the brains of nearly all maniacal patients; but the testimonies of Bonetus, Morgagni, and Arnold, are sufficient to prove that the fact is far otherwise. In controverting this opinion of the au- thor, it is intended merely to say, that there seems not to be satisfactory evidence, that the proximate cause is in every in- stance seated in the blood-vessels, though there is no doubt that frequently an irregular and unhealthy action in them may pro- duce that state of the brain, which exists in insanity. What that precise state of the brain is, whether the whole, or a part only is affected, or what diseased action is going on in mental disease, it is impossible for any one to determine. New dis- coveries in morbid and healthy anatomy may hereafter eluci- date this dark and important subject. In the second chapter, the author gives an account of the exciting and predisposing causes of insanity. The exciting causes are divided into such as act directly upon the body, and such as act indirectly through the medium of the mind. In di- viding them in this way, he has followed the arrangement of Dr. Arnold, which is probably preferable to that of any other writer. The bodily causes are, 1, Those that are seated in the brain and its appendages. Under this head maybe mentioned a peculiar hardness of that organ, tumors, hydatids, and ex- crescences in various parts of if, disease of the pineal gland, extravasated blood, or water in the ventricles. 2. There are external causes that act mechanically on the brain. Such as exostoses, fractures, and depressions of the skull, concussion of the brain, and insolation or sun-stroke. 3. There are causes which produce insanity, by their influence on the brain, through the medium of the body in general. Such as fevers, inanition, excessive indulgence in venereal pleasures, and intemperance Diseases of the Mind. 5 m living. 4. Insanity is frequently produced by causes that primarily affect other parts of the body, and the disease is either suddenly or gradually conveyed to the brain by metasta- sis or sympathy. Madness sometimes is the consequence of a long continued disease of the abdominal viscera, and the reten- tion or suppression of any customary evacuation has been fol- lowed by mania. Several diseases, particularly gout, erysipe- las, and other affections of the skin, are oftentimes suddenly translated to the brain, and produce derangement of the intel- lectual faculties. The mental causes of insanity are, intense study, close ap- plication of the mind to any subject that requires long watch- fulness, and all the passions, when they are not well regulated, especially excessive joy, grief, disappointed love, religious fanaticism, avarice, &c. It appears, from the best authorities, that there are con- siderably more cases of insanity from mental than corporeal causes, though it would be difficult, perhaps, to say what pro- portion they bear to each other. This fact, which is noticed by Pinel and others, is confirmed by Dr. Rush, who ascertain- ed, that of fifty maniacal palients, the disease of only sixteen was produced by corporeal causes. The predisposition to a disease is that state of the body that renders it peculiarly liable to be affected by its exciting causes. The predisposing causes of insanity are either hereditary or acquired. It has often been observed, that the children of persons who have been insane, are more liable to attacks of delirium than others ; and it cannot have escaped the notice of any, that mania will oftentimes affect the members of the same family of successive generations. As children not unfrequently inherit from their parents a resemblance in the features of their faces and forms of their bodies, it appears equally natural that there should be a similarity in that peculiar structure and organization of the brain, upon which depends either its healthy or morbid actions- The disease does not, however, necessarily take place, though a predisposition may exist; it may be prevented, if the exciting causes are avoided. A predisposition also may be acquired, by a frequent or long continued exposure 1o the action of some of the exciting causes. As these have already been noticed, it is only necessary to refer to them here ; it may be remarked, however, that intemperance is probably the most frequent, as well as the most certain in its effects. The six next chapters, which are devoted to the considera- tion of the various forms and remedies of insanity, embrace the only subjects that remain to be noticed. It may be recollect- ed, that Dr. Rush, some years since, obtained considerable 6 Diseases of the Mind. notoriety, by an attempt which he made to establish the doc- trine of the unity of disease, as he termed it, in opposition to the commonly received nosological arrangement. In support of this he maintained, that all diseases consisted in morbid excite- ment, and consequently were not capable of division into classes and orders, like substances having permanent characters. It will be perceived at once, that he entirely overlooked the dif- ference that will necessarily exist in morbid affections, from the difference in the causes which produce them, as well as in the parts affected ; and though it may be admitted that all dis- eases consist in morbid action, it by no means follows, that all diseases are the same. Every nosological system is of course founded upon the fact, that among all diseases, there are certain points of resemblance, sufficiently strong to justify the arrange- ment of them under some general classes, and points of differ- ence so clearly marked, that they may be subdivided into orders, genera, and species. This has always been considered to be merely a matter of convenience, and no one probably but Dr. Rush, ever apprehended any practical danger from it. If it was necessary in every history of disease, to enumerate all the symptoms, instead of making use of one general term which embraced them, there would be no end to the labour it would occasion. Nothing however would be more absurd than to prescribe for a disease, after having been furnished only with the name, and whatever the author may have thought upon the subject, it may be doubted, whether any practitioner is ever governed in his prescriptions, except by the symptoms of the case before him. This notice has been taken of the subject, because there is frequent reference in the present volume to the doctrine of the unity of disease, and at the same time a disposition is shewn to add new names to the long catalogue already in the nosology. Madness, for example, is subdivided into mania, manicula, and manalgia, and the same thing the author has done in his other writings, with regard to hepatitis, and rheumatism. There really seems to be no use whatever in these minute divisions, and they appear particularly unreasonable when they are proposed by a man, who is continually declaiming against all classification of diseases. The division of madness into melancholia and mania, which was made by the early Greek physicians, has been adopted by almost every writer since their time ; though the two species do not seem to have characteristics so strongly marked, that they may be in every instance distinguished ; in fact they are often known to alternate with each other in the same individual. The ancients considered melancholy to be marked by the cir- cumstances of the absence of fever, and derangement of mind, Diseases of the Mind. 7 in relation to one subject, attended with fear and dejection; while mania was said to be delirium without fever, with fury and audacity. These definitions, or some of similar import, are given by Hippocrates, Aurelianus, Aretaeus, Galen, and others, and repeated by many modern authors. Dr. Ferriar has endeavoured to point out the difference between them, by saying, that " in maniacal cases, false perception, and conse- quently confusion of ideas is always a leading circumstance," while " the contrary state to false perception, an intensity of ideas constitutes melancholy." It must however have been noticed by every one accustomed to see insane patients, that these two forms of disease are continually running into each other, and that melancholic patients often become furious with- out any apparent cause, while the most violent maniacs have been known suddenly to be dull, quiet and dejected, though there was not the slightest return of reason. It must be confessed, that it would be extremely difficult, in the present state of our knowledge, to give an accurate and comprehensive definition of insanity, or to make an arrangement of its different species, that would embrace every variety. The attempt of Dr. Crichton is perhaps more deserving of notice than that of any other author, particularly his definition of intellectual disease, for his arrangement is liable to some objections. "All delirious people," says he, "no matter whether they be maniacs, or hypochondriacs, or people in the delirium of fever, or of hysteria, differ from those of a sound mind in this respect, that they have certain diseased percep- tions and notions, in the reality of which they firmly believe, and which consequently become motives of many actions and expressions, that appear unreasonable to the rest of mankind." He prefers the term diseased perceptions and notions, to that of false and erroneous perceptions, " first, because the ideas in all kinds of delirium whatever, arise from a diseased state of the brain, or nerves, or both, as will be satisfactorily proved ; and secondly, because the word erroneous does not describe any thing peculiar to delirium ; for every man, however sane or wise he may be, has some erroneous notions, in which he firmly believes, and which often seriously affect his conduct." He divides the exciting causes into four classes. 1. Physical, or corporeal causes. *2. Over-exertion of the mental faculties. 3. Disproportionate activity of some of the faculties; and last- ly, the passions, or their influence. He entirely disregards the ancient division of insanity, and proceeds to treat of delirium as arising from physical causes, and afterwards of the diseases of each of the faculties of the mind, and of those of the passions. It is extremely doubtful, whether at present this arrangement will be attended with any practical advantage. It supposes an s Diseases of the Mind. acquaintance with subjects, that are but obscurely known, and founds its divisions upon a minute and thorough knowledge of the physiology of the mind, which is far from being generally well understood. Dr. Arnold, in a work of much learning, and apparently the result of long and patient investigation, has taken a different view of mental disease. Adopting the opinion of Locke, that all our ideas are derived either from sensation or reflection, he calls those of the first class only, ideas, and those of the other, notions, and thence divides insanity into two kinds, viz. ideal and notional. " The first is characterized by a delirium, aris- ing from an error in the ideas of the person; and the second, by a delirium arising from an error in his notions." Ideal in- sanity is subdivided into four species, and notional into nine. The objections to this arrangement are so numerous, and pow- erful, that they will prevent it from ever being generally adopt- ed. It may be sufficient to observe, that the names and the definitions which he gives of the various species, do not point out diagnostic symptoms by which they may be discriminated, and it is hardly possible that this should be done, as the ar- rangement seems to have no foundation in nature. Dr. Rush has followed the track of most writers who have preceded him, and divided insanity into melancholy and mania, though he proposes to cail the first amenomania, and substitute the term tristimania for hypochondriasis. To this division it has already been objected, that it is not sufficiently definite, and the terms that the author has introduced are not at all cal- culated to elucidate the subject. It is to be hoped, that as more enlarged views are obtained of intellectual disease, a more precise and natural classification of its various forms will be the consequence. But this can only be done, by a better know- ledge of the physiology of the brain, and the changes that organ undergoes in mental derangement. With a view to this desirable object, the intimate structure of the brain should be studied with constant and unceasing diligence, and every new fact connected with its healthy or morbid anatomy, faithfully recorded. By observing every circumstance relating to its diseases, and carefully comparing the morbid appearances, upon dissection, with the symptoms during life, a correct theory of mental disease may perhaps be ultimately formed. At present, therefore, it will be most convenient to follow the common arrangement, with the belief, that, as our knowledge on these subjects is advanced, a more useful and natural classification will be established. The diseases of the mind assume such a variety of appear- ances, that it would be impossible to give an accurate account of all the symptoms, without very much exceeding the limits Diseases of the Mind. 9 of this article. The abstract which is presented is therefore short, and consists merely in a hasty sketch of an ordinary case of what is termed general madness. The patients, in the beginning of the disease, are usually wakeful, with a consider- able elevation or depression of spirits, and an evident incohe- rence in their language, and eccentricity in their deportment and manners. The countenance is continually varying, at one time flushed, at another, pale and lifeless ; the eye is sometimes unusually bright, and penetrating, at others, dull, heavy, and stupid. The appetite for food is for the most part increased, the bowels are cos'ive, the urine scanty and high coloured. The pulse is variable, sometimes hard and full, at others, prse- ternaturally slow, then small and quick, or frequent and de-- pressed. The senses of seeing and hearing are extremely acute, while there is a morbid insensibility to cold. Some- times the patients complain of pain, dizziness, and vertigo in the head, and are disturbed with uneasy sleep, and frightful dreams. Soon some extravagance will be discovered in their actions, and they take a strcng dislike to their connexions and friends. If nothing is done to allay these symptoms, the dis- ease shortly appears in its full force, and the palients become violent and impatient of restraint. The causes that have pro- duced their insanity, as well as their former habits and disposi- tions, usually give a complexion to their disease. It has, how- ever, been remarked, that the reverse is sometimes true, though by no means of so frequent occurrence. Insanity, in fact, ap- pears under such different aspects, that no two cases pre- cisely resemble each other; the few symptoms that have been enumerated, are only those of the most general kind. They are detailed by Dr. Rush, at some length, and with great accu- racy, though rather in a diffuse and desultory manner. There is, throughout the work, too great a disposition to draw general conclusions, from individual and insulated facts, and to erect a theory upon too feeble a foundation. Upon the prognosis of insanity, the author has made a num- ber of observations, and given several of " the signs of a favour- able or unfavourable issue." The disease yields more readily in the young than the old, in women than in men, in those who have not children, than in those who have. If gives way sooner when it is the consequence of corporeal, than of mental causes, and it is more difficult to cure, and more liable to return, when there is a hereditary predisposition, than under other circum- stances. Remissions, intermissions, and lucid intervals are favourable; so are abscesses in various parts of the body, warm and moist hands, when the patients have previously had cold ones. Madness, which succeeds an organic injury of the B 10 Diseases of the Mind. brain, epilepsy, chronic headach, palsy, and fatuity/is generally incurable ; while that arising from the common causes of fever, parturition and intemperance in drinking, usually yields to the power of medicine. These are among the most prominent and important circumstances, connected with the prognosis of mania. There is some degree of superstition, even among the well informed, in relation to insanity, and many writers on the sub- ject have attributed considerable influence to the moon, in heightening its paroxisms. This opinion, which was urivusally adopted by the ancient physicians, has found some advocates in modern times, though it is evidently losing ground. Dr. Rush made particular observation*, with a view of ascertaining if it was deserving credit, and concluded, " that the cases are few in which mad people feel the influence of the moon, and that when they do, it is derived chiefly from an increase of its light." As this opinion coincides pretty nearly with that of Haslam, and many accurate and intelligent observers, there can be no hesitation in admitling its correctness. The only subject that remains to be noticed, and which is perhaps more important than any that has been spoken of, is the moral and medical treatment of the insane. Within a few years, an entire revolution has been effected in the moral man- agement of this unfortunate class of patients. This is attribu- table, in part, to the pure and enlightened humanity of the Quakers in Great Britain, who first illustrated the good effects of a mild system, at their asylum at York, in England ; and more, perhaps, to that active benevolence, which forms one of the striking characteristics of the age. Until this period, ma- niacs were not unusually confined, without regard to the differ- ence of their cases, in damp, foul, and contracted cells, which were never visited by the rays of the sun, and hardly by the light of heaven. In these gloomy apartments, the unhappy sufferers were frequently chained to the floor, deprived not only of the amusements and comforts which their situation required, but even treated with brutal harshness. Many have lingered for years, afflicted with this awful visitation of heaven, but suffering still more cruelly from the inhumanity of man. Not a single effort was made for their relief, and for monlhsand years they were never cheered with the sight of a friend, nor gladdened by the voice of kindness or compassion. Happily our country has been a stranger to these iniquities, which were too long suffered to disgrace so many of the asylums of Europe. Until within a very short time, humane, sensible, and experien- ced writers, have recommended in many cases, a severe and rigorous discipline, and speak of chastising these unfortunate Diseases of the Mind. II beings, with the same indifference as they do of the other remedies. Even Cullen maintains the propriety of resorting to " stripes and blows," to gain an ascendancy over their minds, and Dr. Willis, it is believed, approved of a method not very different. Upon the first decisive symptoms of insanity, the patients shook! be removed from home, and placed under the care of strangers. This is necessary, in order to break up their old associations, and to obtain that controul over them, which their situation requires. At the first visit of the medical attendant, he should convince them, if possible, of the folly of resistance, by showing them that it is in his power to restrain their great- est violence, and punish their excesses. Dr. Rush thinks that they may be awed, by looking them steadily in the face, and constantly endeavouring to catch their eye; he has, perhaps, attriouted more power to this than it possesses. The manners and language of the physician should always be gentle, dignifi- ed, and affectionate. He should never condescend to trifle, or notice their rude and insolent remarks, except in the way of reproof. He should conscientiously fulfil every promise, and pay, in every instance, the strictest regard to veracity, in all statements he makes to them. If maniacs have been once de- ceived, they will never confide again in the same person. In those cases where they are violent, they may be prevented from injuring themselves or others, by a strait waistcoat, or by hand-cuffs, made of leather, to which cords may be attached. This is now considered preferable to any other method. Se- verer means are hardly ever required ; the cold shower bath, or the tranquillizer, mentioned by Dr. Rush, or the sudden immersion in cold water, or the denial of certain favourite amusements, may be employed as punishments, if the patients are perverse and troublesome. In violent paroxysms, they should be kept in dark apartments, and in an erect position. " The duration, however, of such a degree of violence as to render restraint necessary, is fortunately very short; never, says Mr. Bakewell, extending to a month together. Of sixty patients in the Retreat, the average number under restraint at any one time, was not more than two." Vide Edinburgh Re- view, for August, 1817. Their diet is to be regulated, in great measure, by the state of the system ; it should, however, be mild, simple, and not very nutritious. Exercise, and even labour in the open air, are useful to maniacs. It is important to employ all in some kind of occupation, who are not prevent- ed by the violence of the disease, and this should be, as far as is practicable, adapted to their former mode of life. In publick hospitals, there are generally a sufficient number of patients, 12 Diseases of the Mind. who are able to cultivate an extensive garden, besides assisting in the work of the house. Most writers, of late, have insisted upon the importance of classing the subjects according to the stale of their disease, and of allowing various kinds of amuse- ments to tho*e who are capable of enjoying them. It may be observed aUo, that great advantage has been supposed to have been derived, from requiring a regular attendance upon devo- tional exercises daily, as well as on Sundays, of all who are peaceable in their deportment. The subjects of an asylum should rarely be visited, except by the physician and attend- ant ; the presence of strangers often increases their disease, or at least retards the cure. Relapses have taken place, from the exposure of patients to company, before their health was perfectly re-established. Though the medical remedies are not so much to be depend- ed on in the treatment of insanity, as the moral management, they should never be neglected. One of the most powerful and valuable of these is blood-letting. The propriety of it is to be determined by the state of the system, and it is particularly indicated in all recent cases, where there is frequency, strength, and fullness in the pulse. In cases of this sort, Sydenham con' siders the use of the lancet highly important, and advises to draw blood, not only from the arm, but from the jugular vein. It is not unusual in mania, especially from corporeal causes, to meet with a depressed pulse, arising from what Dr. Rush terms suffocated excitement; if venesection is performed, under these circumstances, the pulse rises, and frequently a cure is effected, if a large quantity of blood is drawn. There seems to be no remedy so well calculated as this, to diminish excessive arterial action in the brain, and the propriety of its use in many cases of mania, is rendered evident, by the delicate structure of that organ, and the injury it would sustain by a long continued ple- thora of its vessels, as well as from the benefit maniacal patients have frequently experienced, from spontaneous haemorrhages. In the recent affections of young subjects, when blood-letting is employed, it should be copious, and its good effects are increas- ed by compelling the patients io stand while the operation is performed, so as to produce fainting, and afterwards confining them to diluting drinks, and a low and spare diet. This, how- ever, is proper only in those of a plethoric habit. There are cases also where there is congestion upon the brain, and at the same time general debility ; it is then that topical bleeding is indicated ; this can be done, by opening the temporal artery, or external jugular vein, or by applying cups, or leeches ; perhaps the last is most convenient, and equally efficacious with others. Diseases of the Mind. 13 It ought however to be observed, that Pinel is strongly op- posed to blood-letting in almost all cases of insanity, and says that it has rarely been practised at the Salpelriere, since he has had the charge of the hospital; that he has scarcely ever known any good effects from it, but has seen idiotism follow copious bleeding. He does not, however, give any information con- cerning the state of the patient's system, in those cases where the effects are prejudicial, nor say any thing as to the force or frequency of the arterial action. Although his opinion is en- titled to respect, it should not be admitted, in direct opposition to what appears to be the fair deduction of reason, as well as the experience of Sydenham, Rush, and other enlightened men. There can be no doubt as to the propriety of treating insanity as we do other diseases, according to the symptoms of each case, for surely no one will pretend, that of ail the reme- dies that have been tried, any one of them is entitled to the character of a specific. Cathartics have been long known to be useful, in the various forms of madness. In those cases where blood-letting is used, the saline purgatives are preferable, and Cullen recommends the tartrite of potash, or soluble tartar, as more useful than any other. When cathartic medicines are given to carry off the contents of the intestines, and at the same time to promote the secretion of bile, and the other fluids that are poured into the intestinal canal, the submuriate of mercury is the most effica- cious. This class of medicines, however, is used in various cases of mania, with a view of producing a determination of blood to the abdominal viscera, and thereby relieving the brain from congestion, if that state of the organ should exist; on this account aloes, which stimulates the rectum, gamboge, scam- mony and other drastic medicines have been employed. Ma- ny authors are of opinion, that the hellebore,* which is so repeatedly spoken of by the ancient poets and physicians, as a remedy, and almost a specific for madness, owes its reputation entirely to its cathartic properties. Dr. Arnold, however, be- lieves, that the moderns are either ignorant of the plant former- ly used, or the manner of using it, or in other words, that they have lost the art of helleborism, as it has been termed. Van- Swieten, the celebrated commentator on Boerhaave, speaks of * Modern botanists are of opinion, that the black hellebore of the an- cients, is the Helleborus Niger, orOrientalis, and the white, the Veratrum Album; the first is an active cathartic, the other an emetic. These are the same properties that the ancients ascribed to the two species then in use, as may be seen by referring to the 25th Book of Pliny's Natural His- tory. The plant is sometimes spoken of by the old writers, under the name of Helleborus, and at others, Veratrum ; the chapter, however, in the works of Hippocrates de usu Veratri, is supposed to have been written since his time. 14 Diseases of the Blind. the remedy as if it was well known, though he prefers mercu- rial purges to it. Cullen, Rush, and others, mention it as a drastic cathartic, but do not intimate that the plant is not known at present, or that the knowledge of its use is lost. Pi- nei expresses no doubt as to our acquaintance with the remedy, but is strongly opposed to the administration of it, for he says it someti nes produces hypercatharsis, obstinate vomiting, con- vulsions, inflammation of the intestines, and even death. Simi- lar effects are ascribed by Pliny, to the injudicious use of the , white hellebore, but many practitioners at the present day, are in the habit of using both species, in moderate doses, in ihe form either of extract, or tincture, not only without producing any unpleasant symptoms, but oftentimes with the most decided advantage. Ceisus directs the administration of cathartics of black hellebore, when the patients are sad and dejected, and emetics of the white, when they are too much exhilarated. If they refuse to take the medicine, he says it can be mixed with bread, and that they are easily deceived in this way; probably he used the extract. This writer, in common with many oth- ers, speaks so strongly of the good effects of hellebore in mania- cal cases, that it surely deserves a trial; and it may be satisfac- tory to state, that experiments are now making on the subject, at the Asylum at Glasgow, in Scotland. Within a short time, a physician, whose name, were it men- tioned, would give weight and authority to any statement, inform- ed the writer of Ibis article, that he had found, that the white hellebore oftentimes diminished the frequency of the pulse, with not so much certainty as digitalis, though in many cases it de- cidedly produced the effect. This is evidently an argument in favour of its use, in some forms of mania. Physicians are not agreed as to the value of emetics in the treatment of insanity. From the determination which they create towards the skin, some have supposed them useful, while others maintain that these good effects are more than counter- balanced by the increased impetus of blood to the head, which they produce. The remedy is not so popular as it formerly was, though a Mr. Hill, in England, has lately spoken favour- ably of it. Dr. Ferriar strongly recommends the administration of the tartrite of antimony, in small doses, in certain stages of insanity, sufficient only to excite nausea, and thinks that by its use he has relieved several patients. All his opinions are entitled to respectful attention. Blisters to the head, are less used now than they were some years since, though they are frequently applied to the back of the neck, arms, ankles, and other parts of the body. It is pro- Diseases of the Mind. lb bable, that in cases where there is active inflammation, either on the brain or its membranes, they would have a tendency rather to increase than diminish it, from their contiguity o the diseased parts. In recent cases, therefore, where the arterial action is great, cold applied to the head in the form of water, snow, or ice, or that produced by the evaporation of alcohol, or ether, is preferable to vesication. Dr. Willis, who acquir- ed great celebrity in England, by relieving the king, some years since, preferred, it is said, blistering the ankles in madness, and it is well known, that many of the most eminent of the French physicians, do not think it safe, even in pneumonic inflamma- tion, to vesicate immediately over the parts affected, but make the application to the arms, or to some place even more remote from the disease. In chronic inflammation of the brain, how- ever, the whole external surface of the head may be blistered with great advantage, and setons and issues in the neck have been found beneficial. The effects of mercury have been tried in some cases of in- sanity, until a slight salivation was produced, and in a few in- stances the practice has been advantageous. It is probable that small doses of calomel, or the blue mercurial pill, might be administered with benefit to melancholic patients, in whom the functions of the liver were deranged; and perhaps it would be justifiable to resort to some preparation of mercury in cases of obstinate chronic mania, with a view of exciting a new action in the system. Contradictory and opposite statements have been made upon the virtues of musk, opium, digitalis, and camphor, in the treat- ment of mental diseases. This fact is sufficient to show, that none of them have any thing like a specific operation, and that though they may sometimes be beneficial, at others their effects are injurious. The propriety of their use is always to be determined by the state of the system. If may be remark- ed with regard to opium, that where it is administered to mani- acs to procure sleep, it should be given in large doses, and at short intervals, otherwise it only increases their wakefulness. A combination of bark with opium has been found beneficial in some melancholic cases, where there was debility of the stomach with indigestion and loss of appetite. All authors are agreed, that baths, either of cold, temperate, or warm water, are beneficial in the various forms of madness. Dr. Ferriar recommends cold baths in melancholy, and warm in mania, while Pinel prefers the temperate in both cases. The present opinion seems to be, that the warm bath is one of the most powerful means that are used in the treatment of insanity. From the good effects that Dr. Cox, and others have ascribed 16 Diseases of the Mind. to the use of the swing, it is certainly deserving a trial; it is, no doubt, upon the same principle, that benefit has been derived from Dr. Rush's tranquillizing chair. The most important medical remedies of insanity have thus been noticed, but it is only with a proper combination of these, with judicious moral management, that any considerable degree of success can be anticipated. There are several other chapters in the present volume, on fatuity, derangement of the will, principle of faith and memory, and on dreaming, night mare, and somnambulism ; but as these are rarely, if ever, subjects of medical treatment, it is not im- portant to take any further notice of them. Though the present volume contains many useful facts and cases, and some ingenious practical suggestions, it has added nothing to the well earned reputation of the author. There is not a sufficiently clear and connected view of the causes, na- ture, and treatment of insanity, to render it valuable to physi- cians, and it contains so many crude, theoretical views, that it cannot be any considerable use to students. Perhaps it is a little too much encumbered with technical phraseology to be very interesting to general readers, though they no doubt will consult it more frequently and with more pleasure than profes- sional men. Notwithstanding the imperfect view that has been taken in this article, of the nature and treatment of mental disease, an apology is perhaps due for the length to which it has been ex- tended; if so, it may be found in the importance of the subject, and the interest it has so recently excited among us. " Of the uncertainties of our present state," says a celebrated moralist, " the most dreadful and alarming is the uncertain continuance of reason." It is not wonderful, then, that so much zeal has lately been displayed in relation to the establishment of an asylum for the insane. It is a concern that equally interests all the members of the community, and every one must have witnessed with de- light, the pure, zealous, and signal benevolence, which our citi- zens have manifested. It is gratifying to think, that they can now lay claims to higher distinction, than they ever could have done before, by their earnestness in the cause of afflicted hu- manity. An institution founded for such laudable objects, and placed under the care of so many able and enlightened direct- ors, will, with the blessing of Heaven, greatly contribute to ameliorate the condition of a distressed and suffering portion of our fellow beings. . Boston, January, 1818. "2*'10 U is