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FROM THE AUTHOR'S PUBLIC AND PRIVATE PRACTICE : WITH

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PROFESSOR OF THE SCHOOL OF MEDICINE AT PARIS,

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PRINCIPLES OF A NEW AND MORE PRACTICAL NOSOLOGY OF MANIACAL DISORDERS

THAN HAS YET BEEN OFFERED TO THE PUBLIC,

EXEMPLIFIED BY

NUMEROUS AND

OF MALCONFORMATION OF THE SKULLS OF MANIACS

ACCURATE HISTORICAL RELATIONS OF CASES FROM THE AUTHOR'S PUBLIC AND PRIVATE PRACTICE : WITH PLATtS ILLUSTRATIVE OF THE CRANlOLOGY OF MANIACS AND IDEOTS.

BY PH. PINEL,

PROFESSOR OF THE

MENTAL DERANGEMENT D'STRIBUTED INTO DIFFERENT

SCHOOL OF MEDICINE AT PA

MELANCHOLIA, OR DELIRIUM UPON ONE SUBJECT

RIS,

'Senior "Physician to the Female National Asylum la Sat.petnere, late Physician to the Asylum de Bicetre, and Member of many learned Societi

FACULTY,

es.

TRANSLATED FROM THE FRENCH,

BY D. D. D AVI S

FIFTH SPECIES OF MENTAL DERANGEMENT,

,

IDEOTISM, OR OBLITERATION OF THE INTELLECTUAL

M. D.

PHYSTCTAN TO THE SHEFF-ELD GENERAX INFTRMARY.

SHEFFIELD :

PRIN

THE IMPORTANCE OF AN ENLIGHTENED SYSTEM OF POLICE

TED BY

FOR THE INTERNAL MANAGEMENT OF LUNATIC ASY-

W. r ODDj rOU MESSRS, CADELL AND DAVIES, STRAND, LONDON,

18Ub"

Digitized by the Internet Arciiive

in 2010 witii funding from

Open Knowledge Commons and Harvard Medical School

http://www.archive.org/details/treatiseoninsaniOOpine

Table of Contents.

General plan of the work, ,

PAGE

... I

14 16

SECTION I.

Periodical or intermittent insanity, • • . 7

Circumstances favourable to the author's researches upon the subject of insanity, ••• ^

Periods of accession of intermittent insanity, 10

Periodical insanity independent of the influence of the seasons, 12

The character of maniacal paroxysms not depending upon the nature of the exciting causes, but upon the consti- tution,,,..

Precursory symptoms of maniacal paroxysms,

Changes in the affections of the mind during paroxysms of insanity, . . 19

Different lesions of the functions of the understanding during paroxysms of insanity, 22

Maniacal paroxysms characterised by a high degree of phy- sical and mental energy, 27

Are all lunatics equally capable of supporting the extremes of cold and hui'ger ? SO

Debility, a frequent symptom towards the decline of mania- cal paroxysms ; and the danger thence to be apprehended, . . 34-

Are persons who have recovered from this disease subject to relapses, and what are the. preventatives^ ctf such relapses ? 37

VI

Are not mankcal paroxysms tlie effects of asalutasy reaction of the sysKta ? ............ 39

Tfeie great difficiukj of securing the concurrence cf all cJr- cumstances favourable to the cure of insaaky, wiiether in private asylums or in public hospitals, *. ...... 43

The Tariety and profundity of knowledge requisite on the |rart of the physician, in order to secure success in the treatment of insanity, .... .... ....4'5

SECTION II.

THE MORAL TREATMENT OF INSANITY.

Moral treatment particularly insisted upon by the ancients, 4§

Have the English published any new rules oe the mora! treatment of iiisanity ? ........>. ....40

The author*s inducements to study the principles of moTal treatment, ........,« ...... ..51

Candour in the exposition of facts, ...... 55

A case of insanity, in ivhich it is probable that moral treat- ment would have been attended with success, . . ,,56

The absence of the means of moral treatment in the above case to be highly regretted, .... .... 59

The estimable effects of coercion illustrated in the case of a soldier, .......... ...... ..,. 60

The advantages of restraint upon the imagination of maniacs illustrated, .... .... 6l

Intimidation too often associated with violence,, ... .... 63

Maxims of lenity and philanthropy applicable to the man- agement of lunatics, ............ ......66

A happy expedient employed in the cure of a mechanician, 68

Tiie treatment of maniacs to be varied according to the spe- dfic diaracter of their hallucination, . <> . . . , . . 73

VJl

PACE

A case of melancbolia, •with bigotry, ......•• 75

Insanity from religious enthusiasm extremely difficult ta cure, 78

The conduct of the governor of Bicetre, upon the revolution- ary orders he received to destroy the symbolic reprcstent- ations of religion, .... 79

Maniacal fury to be repressed ; but not by cruel treatment, 82

Tlie functions of the will exclusively diseased, 83

Violent paroxysms of insanity are generally the least danger-

86

A limited degree of liberty recommended to be given to madmen confined at lunatic institutions, . . .... 89

The most violent and dangerous maniacs described, with expedients tor their repression, ............ 92

The propriety of appearing to assent to the absurd proposi- tions and fanciful ideas of maniacs, 95

The necessity of maintaining constant order in lunatic asy- lums, and of studyiiig the varieties of character exhibit- ed by the patients, 99

An instance of violent mania cured by prudent and vigour- ous coercion, .... .... .... 1 03

The physical and moral qualities essential to the successful management of lunatic asylums, 1 07

SECTION III.

OF MALCONFORMATION OF THE SKULLS OF MANIACS AND IDEOTS.

Does insanity depend upon organic lesion of the brain ? . . . . 110

The periods of life most liable to insanity from moral causes, «11S

VIU

PAGE

The affections of the mind most calculated to induce insa- nity, .... .... 113

No facts, j'et clearly established, relative to the influence of the size and coniiguratioa of the cranium upon the fa- culties of the mind, .... 114

Do the best formed heads bear a proportion to the intellec- tual faculties ? .... .... 116

The advantage of assumin^^ for a standard of comparison, the beautiful proportions of the head of the Appollo, 11 f

Varieties in the dimensions of the head considered, 120

The htads of two female maniacs, the configuration of which lead to no evitient inference, 122

Malconformation of the cranium, the probable cause of ideotism from infancy, .... 124

The stupidity and degraded condition of an ideot of whose head I iiave given an engraving, 126

Various relations of the height of the head, to that of the whole body, .... ., .... 128

Relative proportions of different parts of the head with devia- tions from the standard dimensions, ........o... 129

Inferences from the foregoing anatomical researches, 131

SECTION IV.

MENTAL DERANGEMENT D'STRIBUTED INTO DIFFERENT SPECIES.

The principles upon which the author has founded his noso- logical distinctions of mental derangement, . , » » 134

FIRST SPECIES OF MENTAL DERANGEMENT.

MELANCHOLIA, OR DELIRIUM UPON ONE SUBJECT

EXCLUSIVELY.

FACE

The common acceptation of the term melancholia, 136

Mdancholia considered nosologically as a species of mental derangement, 141

Two opposite forms of melancholia with delirium, 142

May not melancholia of several years standing degenerate into mania ? .... 1 45

Melancholia with a disposition to commit suicide, 146

Specific character of melancholia, 149

SECOND SPECIES OF MENTAL DERANGEMENT.

MANIA WITHOUT DELIRIUM.

Madness independent of any lesion of the understanding, . . 150

An instance of maniacal fury without delirium, 150

Madness without deUrium, confirmed by a well established fact, 152

Another instance of mania without dehrium, ] 54

Specific character of mania without dehrium, isS

THIRD SPECIES OF MENTAL DERANGEMENT.

MANIA WITH DELIRIUM.

A paroxysm of periodical mania is a prototype of continued ^sanity, J,

PASE

Is mania With delirium commonly susceptible of a cure ? . . 3 58 Specific character of mania with dehrium, e.o... 159

FOURTH SPECIES OF MENTAL DERANGEMENT.

DEMENTIA, OR THE ABOLITION OF THE THINKIN© FACULTY,

The most striking features of dementia frequently obseiTable in insanity, ,, , 160

Dementia marked by ideas unconnected amongst themselves aad vv'ithout relation to external objects, . . . . 16!

A case of dementia well calculated to mark the distinction between that form of mental derangement and mania, . . 163

Specific character of dementia, , . . 164

FIFTH SPECIES OF MENTAL DERANGEMENT,

IDEOTISM, OR OBLITERATION OF THE INTELLECTUAL FACULTIES AND AFFECTIONS.

Definition^ causes and character of ideotism, .. .. 165

Intense emotions inductive of ideotism, l6^

Ideotism, the most common species of mental derangement in hospitals: sometimes cured by paroxysms of active mania, ...... .... .... 168

XI

PA6B

The leading features of the physical and mental character of the Cretins of Switzerland, .... .. I69

Specific character of ideotism, , , . , .... 1 72

Insanity complicated with epilepsy, 172

SECTION V.

THE IMPORTANCE OF AN ENLIGHTENED SYSTEM OF POLICE FOR THE INTERNAL MANAGEMENT OF LUNATIC

GENERAL PLAN OF THE WORK,

ASY- LUMS.

The advantages of a systematic distribution and a perfect in- sulation of the different species of mental derangement,. . 174

General considerations in regard to the distribution of pa- tients in lunatic hospitals into different classes, 175

The isiportance of frequently and variously repeated at- tempts to counteract the hallucination of melancholies, 177

The choice of a proper situation for melancholies recom- mended .. .. .... ..ISO

Coercion to be sometimes resorted to, in cases of melancho- lia with delirium, 182

How far may lenient measures suffice to calm the violence and fury of acute mania ? .... 184

Is close confinement requisite in all cases and throughout the whole term of acute mania ? I8S

Measures calculated to accelerate the reestablish ment of con- valescents, . . . . .... .... 1 89

An instance illustrative of the advantage of obtaining an inti- mate acquaintance with the character of tlie patient, .. I9I

Varieties of bodily exercises including laborious occupations, recommended for convalescents, .. I93

The propriety of engaging the attention of conv.J'scents in some interesting pursuit illustrated, I95

A case of convalescent insaiiify aggravated by neglect of en- couraging the patient's taste for the fine arts,. , . , 197

The apparently incurable nature of dementia, . . , . 200

The propriety of seperating ideots from the other classes of patients at lunatic asylums, 208

Epileptic maniacs to be secluded from the other patients of lunatic hospitals, .... . . . . . . 204

General police and daily distribution of the services in luna- tic asylumSj, . . . , . . . . 205

Conscientious attention to the preparation and distribution of provisions, .... .... .... ., 207

The fatal consequences of the scarcity of the year 4 expe- rienced at the lunatic hospitals, .... . . 209

The communications between maniacs and persons from without to be prudently restricte

PERIODICAL INSANITY INDEPENDENT OF THE INFLUENCE

d, .... . . 212

The English and the French agreed in regard to the utility of public asylums for lunatics, .... 214

Mechanical employment essential to the successful manage- ment otlunatic hospitals, .... .... .,., 2IS

SECTION VI.

OF THE MEDICAL TREATMENT OF INSANITY.

Are all medical books equally deserving of the cencures ©f

philosopheis ? .... .... .... 219

Are medical opinions founded upon obse

THE CHARACTER OF MANIACAL PAROXYSMS NOT DEPEND-

rvation ? 220

The cure of melancholia often extremely difficult, . . 22^

An attempt to cure a case of melancholia produced by a rnoral cause, .... .. •• •••• 224

The art of counteracting the human passions by others of equal or superior force, an important department in me- dicine, .... 228

XIU

The propensity to suicide accompanyingf some cases of me- lancholia, occasionally removed by a strong emotion, . ... 231

Is maniacal fury without delirium susceptible of cure with- out the use of pharmaceutic remedies ? . . . , 234?

The idea to be formed of demoniacal possession, . . 237

Can pharmaceutic experiments, without proper attention to the different species of mental derangement, contribute to the advancement of medicine ? 239

Inferences from the foregoing table, 241

Periodical mania with delirium and originating In a moral cause,

CHANGES IN THE AFFECTIONS OF THE MIND DURING

fiequently cured by moral and physical regimen exclusively, .... .... 242

The inconvenience of separating the treatment of maniacs upon their first attack from the assistance and attention which they require during their convalescence, 244-

A general method of a synoptic table calculated to exhibit the state and movements of a lunatic asylum, 248

The practice of bleeding in maniacal disorders, and the li- mits by which it ought to be restrained, .... 251

Circumstances calculated to

DIFFERENT LESIONS OF THE FUNCTIONS OF THE UNDER-

determine the use and effects of evacuants, . • 253

Of the value of antispasmodics as remedies for insanity,. . . . 257

The effects of the cold and warm bath, and especially of the bath of surprise, in the cure of maniacal disorders, .... 201

Mental derangement cured by a spontaneous eruption on the skin, .... ..,. 265

The difficulty and importance of deciding in some instances on the curability of insanity, 27 1

Of the discharge of convalescents, 276

Feitrned mania : the method of ascertainlnor it, 282

Circumstances to be adverted to in forming an opinion of the author's success in the treatment of mental derancrem.ent, . .287

INTRODUCTION.

OF all the afflictions to which human nature is subject, the loss of reason is at once the most calamitous and in- teresting. Deprived of this faculty, by which man is principally distinguished from the beasts that perish, the human form is frequently the most remarkable attribute that he retains of his proud distinction. His character, as an individual of the species, is always perverted ; some- times annihilated. His thoughts and actions are diverted from their usual and natural course. The chain which connected his ideas in just series and mutual subserviency, is dissevered. His feelings for himself and others are new and uncommon. His attachments are converted into aversions, and his love into hatred. His consciousness e.ven is not unfrequently alienated ; insomuch, that with equal probability he may fancy himself a deity, an em- peror, or a mass of inanimate matter. Once the orna- ment and life of society, he is now become a stranger to its pleasures or a disturber of its tranquillity. Impatient

XVI

of restraint, and dis

ARE ALL LUNATICS EQUALLY CAPABLE OF SUPPORTING

posed

THE EXTREMES OF COLD AND HUNGER?

to expend the unusual efferves- cence of his spirits in roving and turbulence, coercion of the mildest kind adds fury to his delirium, and colours with jealousy or suspicion every effort of friendly or pro- fessional interest in his fate. His personal liberty is at length taken from him ; and tciken from him perhaps by his nearest relative or dearest friend. Retaining his original sensibility, or rendered more acutely sensible by opposi- tion to his will and deprivation of his usual gratifications, co-operating with a morbid excitement of his nervous functions, he gives himself up to all the extravaoances of maniacal fury, or sinks inexpressibly miserable into the lowest depths of despondence and melanchol}'. If the former, he resembles in ferocity the tyger, and meditates destruction and revenge. If the latter, he withdraws from society, shuns the plots and inveiglements which he ima- gines to surround him, and fancies himself an object of human persecution and treachery, or a victim of divine vengeance and reprobation. To this melancholy train of 53'^mptoms, if not early and judiciously treated, ideotism, or a state of the most abject degradation, in most instan- ces, sooner or later succeeds. The figure of the human

XVll species

ARE PERSONS WHO HAVE RECOVERED FROM THTS DIS-

is no

EASE SUBJECT TO RELAPSES, AND WHAT ARE THE

w all

PREVENTATIVES OF SUCH RELAPSES ?

that remains to him, '* and like the ruins of a once magnificent edifice, it only serves to remind us of its former dignity and grandeur," and to awaken our gloomiest reflections — our tenderest resrret for the de- parture of the real and respectable man.

The history of this formidable disorder is necessarily and intimately connected with that of the human mind in general. The physical and metaphys

ARE NOT MANIACAL PAROXYSMS THE EFFECTS OF A

ical op

SALUTARY REACTION OF THE SYSTEM?

inions enter- tained of it by theologists and physicians of different coun-r tries bear due correspondence to the prevailing doctrines, prejudices, and fashions of their respective times.

However our thinking faculty may be connected with the operations of the body, the apparent remoteness of its nature, from the generally acknowledged properties of matter, have deterniined many philosophers, and especi- ally those of antiquity, to detach its history from the other pursuits of the naturalist, and to ascribe its phenomena to the agency of an indwelling principle, perfectly dis- tinct in its essence, and infinitely more exalted in its ori^ gin and destination. This opinion appears to have been

XVlll adopted by the earliest metaphysic'ans of E

THE GREAT DIFFICULTY OF SECURING THE CONCURRENCE

gypt, and to

OF INSANITY, WHETHER IN PRIVATE ASYLUMS OR IN

have been imbibed frptn that source by Pythagoras and Plato, yfho o-ave it importance and fashion in all the schools of Asia and Europe. It is, in '*-ed, an article of belief, which ap- pears to have accompanied the curiosity of philosophy in its earliest researches into the mysteries of natu e's laws and operations. Not content with examining the external and perceptible properties of the numero

THE VARIETY AND PROFUNDITY OF KNOWLEDGE REQUI-

us obj

SITE ON THE PART OF THE PHYSICIAN, IN ORDER TO

ects which surrounded him, man, certainly more conceited than judi- cious, as soon as he could think upon subjects not imme- diately connected with his animal wants, advanced in his enquiries beyond the boundaries of sense, and penetrated into the intricate and unknown regions of metaphysics and mythology^ The nature of the efficient cause of the world, and of the numerous orders of beings contain- ed in it, mocked his

MORAL TREATMENT PARTICULARLY INSISTED UPON BY

puny- comprehension. But what- ever he could not understand, he vested with imagi- nary properties, and designated by names which expres- sed the reverse

HAVE THE ENGLISH PUBLISHED ANY NEW RULES ON THE

of wha

MORAL TREATMENT OF INSANITY ?

t he clearly understood. Hence the crude speculations of the ancients relative to the ori- gin of the world and the essence of the divine mind. Theories of the divine mind or soul of the w^oxld, as it

xix

was then not uncommonly called, naturally led to enqui- ries of analogous curiosity and importance in regard to the various evils, disorders and diseases that were expe- riencird both in the natural and moral world. B}- s

THE AUTHOR S INDUCEMENTS TO STUDY THE PRINCIPLES

ome it was asserted, that spirit was in itself essentially pure, im- maculate, incorruptible, and therefore indestructible ; and that the human mind, being a part of the divine mind, was consequently not susceptible of disease nor im- perfection. Whatever was deemed unamiable or disor- dered, or imperfect in any order of living or thinking being, was attributed to the stubborn intractability and in- nate grossness of matter. The summit of human felicity and eminence of intellectual talent, were alike ascribed to the suitableness of the tenement of clay for its office, which admitted of the exertion and extension of the hea- ven-born principle which directed its motions. By other theorists, the origin of evil was accounted for by supposing an eternal evil principle coexistent with the good princi- ple, but inferior in its natural attributes and opposite in its moral

A CASE OF INSANITY, IN WHICH IT IS PROBABLE, THAT

qualitie

MORAL TREATMENT WOULD HAVE BEEN ATTENDED

s. This principle was likewise endowed, like the divinity, with the property of divisibility. It accordingly assumed as many different characters and

XX

functions as suited its power and inclination to do mis- chief. With these interesting but fanciful conjectures, was blended the celebrated doctrine of metempsychosis, or the translation of immortal souls through a succession of corruptible and perishable bodies. Thus was the universe peopled with invisible beings of diverse orders, and an easy commerce was supposed to be carried on between the ma- terial and spiritual worlds. At length the maji and meta- physicians of antiquity could talk of ideal forms,

THE ABSENCE OF THE MEANS OF MORAL TREATMENT IN

immutable essences, the nature of the divinity, the mysteries of theo- gony, the transmigration and community of spirits, pos- session by d

THE ESTIMABLE EFFECTS OF COERCION ILLUSTRATED IN

a:;mons, and other marvellous subjects equally beyond their comprehension, with as much familiarity as if they had been theorems of geometry or objects of actual sensation. From materials like these, it ^tas not difficult to deduce many plausible theories of

THE ADVANTAGES OF RESTRAINT UPON THE IMAGINA-

insanity. By those who contended for the essential purity of the thinking principle, Avhatever deranged its functions vv^as very con- sistently ascribed to the morbid influence of a gross and diseased body, and treated by hellebore and other evacu- ant remedies. Hellebore was, indeed, the grand specifie from time immemorial. The mode of selecting, prepar-

xxi

ing and administering that drastic vegetable, formed a complicated body of doctrine, (a) By the materialists, of whom there were not many among the physicians, and fewer among the priests of antiquity, disorders of the mind were treated after the same method. The rhytho- logists, who, on the other hand, maintained the existence of spirits of different orders and qualities, founded their theories of insanity upon the supposed intercourse that existed between the material and spiritual worlds. In

MAXIMS OF LEWITY AND PHILANTHROPY APPLICABLE TO

some instances, it was believed that the intellectual facul- ty was merely deranged by the malignant influence of a demon : in others, where the change of character was more evident and complete, an actual exchange of the indwelling soul was imagined to have taken place, and the maniac was consulted as the organ of an oracular spirit, or shunned as embodying an emissary of the evil princi-^ pie

A HAPPY EXPEDIENT EMPLOYED IN THE CURE OF A

. ' Hence the original propriety of the terrti alienation of the mind, which the moderns, however, have used im» properly, as they have only intended to express by it a de- rangement simply of the intellectual functions, llie treat-

(a) See the articles Ellebore and Eelleborisme in the Encyclopedia Methodique Francaise,

C

XXll

ment of insanity according to the theories of supernatural possession naturally devolved upon the priests, who pre- tended to have more interest with, and more power over the invisible world than the rest of mankind. We ac- cordingly find, that, in all countries remarkable for their superstition, the treatment of mental aflfections has been associated with the other duties of the sacerdotal office. *' At both extremities of ancient Egypt, a country that vi^as at that time exceedingly populous and flourishing, wer

TO THE SPECIFIC CHARACTERS OF THEIR HALLUCI-

e temples dedicated to Saturn, whither melancholies resorted in great numbers in quest of relief." {b) What- ever gifts of nature or productions of art were calcu- lated to impress the imagination, were there united to the solemnities of a splendid and imposing superstition. Games and recreations were instituted in the temples. The most voluptuous productions of the painter and the statuary were exposed

A CASE OF MELANCHOLIA, WITH BIGOTRY,

to public view. Groves and gardens sur- rounded those holy retreats, and invited the distracted de- votee to refreshing and salubrious exercise. Gaily decor-

(6) Nosograpie Philosophique par monsieur le Docteur Pinel, ^Tom. ii. J). 23.

XXIII

ated boats sometimes transported him to breath amidst ru- ral concerts the purer breezes of the Nile. In short, all his time was taken up by some pleasurable occupation, or rather by a system of diversified amusements, enhanced and sanctioned by superstition. The methods adopted by the priests of Besangon to cast out the demons which were supposed to possess the madmen and melancholies who resorted thither during the celebration of the feast of St. Suaire, bear great analogy to those of the Egyptian temples : but, as they were more calculated to excite sudden terror and temporary commotion in the syst

THE CONDUCT OF THE GOVERNOR OF BICETRE, UPON THE"

em, than

REVOLUTIONARY ORDERS HE RECEIVED TO DESTROY

to secure a permanent diversion of the imagination from the morbid trains of thinking, feeling and acting, which constituted the demoniacal malady, and which were particularly attended to by the priests of Saturn, they were more hazardous, and probably, upon the whole^ more imsuccessful in their application, (c)

The above speculations were, no doubt, modified into various shapes, and must be supposed in actual practice

(c) See p. 238 of the following work.

XXIV to have been frequently combined or confoun

MANIACAL FURY TO BE REPRESSED ; BUT NOT BT

ded in their application. The earlier philosophers of Greece, were not only initiated in the mystical learning of Egypt, where they generally received a part of their education, but were likewise emiiient for their knowledge of tlie art of medicine. Their acquaintance, imperfect as it was, with the physiology of the human

THE FUNCTIONS OF THE WILL EXCLUSIVELY DISEASED,

system, and their fami- liarity with the invisible powers which were supposed to molest the functions of the human soul, were calculated equally to give value to their physical remedies, and to inspire confidence in their religious and astrological ceremonies.

Such were the theories and treatment of insanity, ante- rior to that illustrious era in medical history, which com- menced with the father of the greek medical school, the Immortal Hippocrates. When that luminary of genius ap- peared above the horizon of medica

VIOLENT PAROXYSMS OF INSANITY ARE GENERALLY THE

l literature, the gen- uine processes of nature were more distinctly exposed, and an eternal wall of separation was raised between sci- ence and einpyricism, and between the dogmas of mytho- logy and metaphysics, and the legitimate inductions of

XXV

experiment and observation. Whether Hippocrates wrots professedly on the subject of insanity is not ascertained by his commentators. It is possible, that the extent of his enquiries and his numerous engagements in the practical part of his profession, especially in the treatment of fe- brile and inflammatory disorders, left hirn no opportunity to record his observati

A LIMITED DEGREE OF LIBERTY RECOMMENDED TO BE

ons upo

GIVEN TO MADMEN CONFINED AT LUNATIC INSTITU-

n mental ailments : or, it is not improbable, that his treatise upon that subject may have shared the fate of many others of his valuable writino-s. That he was not ignorant of the subject is not only pre- sumeable from his Ijabits of analysis and observation, but more certainly deducible from the opinion which tTie Ab- derites entertained of his skill, when they invited him over from Athens to see their fellow cit

THE MOST VIOLENT AND DANGEROUS MANIACS DESCRIB-

izen, the celebrated Democritus, whose mirthful and whimsical peculiarities gave rise to the suspicion that he was insane. There is^ indeed, one chapter upon the subject of melancholia, incor- porated with Galen's voluminous productions, which some of his editors have ascribed to the father of physic. That it was not however written by Hippocrates is evident, from its decided inferiority to his other and acknowledged works, both in respect to style and argument j not to mention the

references which are made in the course of the essay t6 the opinions of Hippocrates, as to those of a third or an absent person. If Galen himself, whose style indeed it does not much resemble, was not the author, the ascrip- tion of it to Possidonius or Ruffus must be acceded to. {d) However that may be, its intrinsick value is very moder-

THE PROPRIETY OF APPEARING TO ASSENT TO THE ABSURD

ate. It exhibits no clear view of the disorder of which it professes to treat. It confourids melancholia with other diseases presumed to originate from the same cause, de- tails improbable suppositions relative to the seat and prox- imate cause of the melancholic passion, and presents no rational indications of cure. The opinions of Hippocrates on the nature, causes and varieties of insanity, are more clearly inferred from some casual observations which he advances upon the subject in his excellent treatise upon epilepsy, {e) The principal object of the author in that little tract, appears to have

THE NECESSITY OF MAINTAINING CONSTANT ORDER IN

been

LUNATIC ASYLUMS, AND OF STUDYING THE VARIE-

to combat the prevailing

(d) Vid Galen De locis afFectis, Lib iii. Cap. vi. p. 152. Editio Basili-- ensis Lugdin, 1547. Multa ac fere omnia qua? hoc capite dicuntur in opiis- chIo de melancholia scripta sunt quod alii Hippocrati, quidara Galeno, noo>» nulli RufFo et Possidonio attribueruut.

(e) Hippocrates de morbo sacro.

opinion that epilepsy, whether combined with insanity or otherwise, was the positive and decided effect of inspiration j and the efforts, which he displays, of a masculine genius, ex- ertino- itself in a strain of bold and luminous argumentation against the arts of empyricism, the credulity of supersti- tion, and the prejudices of vulgar minds, are highly ho- nourable both to his judgement and his virtue. Hippo- crates was a firm believer in the doctrine of a divine pro- vidence. He did not, however, maintain it like most of hi

AN INSTANCE OF VIOLENT MANIA CURED BY PRUDENT

s contemporaries at the expense of the moral perfections of the divinity. In the strides of pestilence and the revo- lutions of states and empires, he saw the movements of deity, and adored the hand that swayed the awful sceptre. But any interference in the ordinary functions of the human System, in individual cases, was, in his estimation, unbecom- ing the exalted character of the Gods : and as the disorders, w hich it Avas the fashion to ascribe to supernatural agency, might be explained upon natural principles, it appeared to him unnecessary to admit the interposition of Mars, Hecate or Apollo. In furnishing the requisite explanation, he advances a theory of the proximate cause of insanity, which accords with the general principles of the humoral

XXVIll pathology, and which consequently maintained its place in the institutes of modern medical schools till towards the beginning of the last century. Its outlines are the follow-!- ing. The brain is the organ of the understanding. That o'! gan is susceptible of various states in respect both to consistence and temperature. It may be hotter or colder, harder or softer, more or less humid. Bile is the heatino-^ pituita the cooling principle. Froni the supposed analoo-y between the turbulence of the passions, and the rapid move- ments of the element of fire, the bile or the heating princi~ pie, either admixed in too great a quantity with the ge

SECTION III

ne

OF MALCONFOHMATION OF THE SKULLS OF

ral mass

DOES INSANITY DEPEND UPON ORGANIC LESION OF

of b

THE BRAIN ?

lood, or conducted to the brain in distinct Ves- sels, he deemed the proximate stimulant of that organ in mental derangement, accompanied by extraordinary tur- bulence and ferocity. The yellow bile he considered as the cause merely of irritability, high spirits and extrava- gance '; but when the black bile {/) ascended the

THE I'ERIODS OF LIFE MOST LIABLE TO INSANITY FROM

cham- bers of the thinking organ, it ro

MANIACS RECEIVED

used to exertion the darker passions of suspicion and jealousy and hatred and re-

(/) Quemadrndum, inquit, a

THE AFFECTIONS OF THE MIND MOST CALCULATED TO

lter. atrx bills succiis, qui ex praeassata fiava bile nascitur feriiia delirameata inducit modo sine febre, modo cum febre, Galen, Lib. 3, de locis affectis, cap. 7. . > •

XXIX venose. Pituita, on the other hand, possessed of quaUties diametri

NO FACTS, YET CLEARLY ESTABLISHED, RELATIVE TO THE

cally o

INFLUENCE OF THE SIZE AND CONFIGURATION OF

pposite to those of the bile, he supposed to operate as a sedauive principle, to diminisJi the energy of the sentient and intellectual faculties, and to act as the proximate cause of insanity, attended by great depression of spirits, by fears and: anxieties from i

DO THE BEST FORMED HEADS BEAR A PROPORTION TO THE

maginary

INTELLECTUAL FACULTIES ?

causes, or by silent solitude or muttering despair. Other nervous diseases, accompanied by delirium, are ascribed by the same author, to disordered states of the blood, to casual obstructions to the course of that fluid, or to an unusual determination of it to the parts primarily affected, (g) Such are the germs of a system of physiology, which grew up with the other productions of Grecian genius, (/z) whic

PARISON, THE BEAUTIFUL PROPORTIONS OF THE

h was cherished for many centuries in Italy and Ara- bia, which spread itself after the revival of literature over all the countries of Europe, and which, after havino- arriv- ed at a goodly old age, fell a few years ago by the re- morseless hands of modern theorists.

(g) Hippocrat. Sec. id. Lib. demorb. sacr. p. 301, et sequent. Edit Foes. Lib. quoque de his qua ad virgines spectant, p. 562.

(fi) Galen in apologia contra Julianum, Cap. iv. Idem method me Oend. Lib. ii. Cap. 8, Idem Lib. de cans. morb. c. 2.

XXX

However great the authority of Hippocrates in matteff of medical behef, wd find that the above theory of ner- vous disorders was not universally adopted by the physi- cians of Greece and Italy. The leven of superstition had been so intimately infused with the speculations of the times, that their most accurate medical writers ascribed some forms of insanity to supernatural influence. " De- orum afflatu hie furor provenit, qui cum remittitur hi* lares sunt et curis

THE HEADS OF TWO FEMALE MANIACS, THE CONFIGURA-

vacui tanquam Diis initiati." (i) It must, on the other hand, be confessed, that the example of the Sage of Cos, as he has been very deservedly called^ contributed not a little to rescue the art of healing from the hands of priests, itinerants and astrologers, who equally practiced it empyricaily, and to establish it on its only legitimate basis, the knowledge of the healthy and diseas- ed functions of the human body.

Aretaeus, the Cappadocian, whose works upon many subjects have been greatly admired, is the most ancient

(i) Aretffii de causis et notis diuturnor affect. Lib, i. Cap. vi. Edit. Venet Crasso Interprete.

xxxi

Greek author extant, who has treated professedly on dis- eases of the mind. His first tract, de melanchoUa, {j) contains a concise and elegant history of that disorder

THE STUPIDITY AND DEGRADED CONDITION OF AN IDEOT

; and without the affectation of a systematic arrangement, it exhibits a clear account of the supposed causes, symp- toms and varieties of the malady of which it professes to treat. Aretaeus adopted, with some modifications, the

VARIOUS RELATIONS OF THE HEIGHT OF THE HEAD, TO

phy- siological doctrines of Hippocrates, {/c) He appears not, however, to have been a stranger to the more metaphy- sical and less useful speculations of the methodists ; {I) at the same time, that his writings are principally valuable for the simple and unexaggerated facts which they con^ tain. A chapter by this aut

RELATIVE PROPORTIONS OF DIFFERENT PARTS OF THE

hor on

HEAD WITH DEVIATIONS FROM THE STANDARD

mania appears deserv- ing of a similar character. His rtiethod of treatment {m)

(j) Idem, Lib. i. t ap. v.

{k) In liis physiological opinions, Hippocrates was a dogmatist " Hanc," (scilicet sectam dogmaticam,) " Hippocrates Cous a Crotonieiisibus medi- cis, et Cyrenaicis, penes quos medicinam dim maxima exultam floruisse Herodotus est auctor, fortasse

INFERENCES FROM THE FOREGOING ANATOMICAL

acciptam, perfecit ac maxime excoluit." Prosper. Alpin. in medicina methodic. Cap. de vaiiis medicincc sectis.

(I) The founder of that sect was Themison of Laodicea, one of the most selebrated physicians of his day, and a disciple of Asclepiades.

(ot) Aretsei diuturnor. morbor, curativus, Cap. t.

3tXXli

accords with his theoretical principles, and serves to il- lustrate the influence of those principles upon his prac- tice. It is to be regretted, that a great part of his tract on the cure of melancholia(n) has been lo

SECTION IK

st

MENTAL DERANGEMENT DISTRIBUTED INTO

. In

THE PRINCIPLES UPON WHICH THE AUTHOR HAS FOUNDED

what r

HIS NOSOLOGICAL DISTINCTIONS OF MENTAL DERANGE-

e- mains of it, though very judicious so far as it goes, and as to physical means it comprehen 's a- most all the indica- tions which have ever been offered on the subject, we meet not with a single observation on the management or moral treatment of maniacs and melancholies.

Cornelius Celsus, a Roman physician of very genera! and extensive information, has left us a short but

MELANCHOLIA, OR DELIRIUM UPON ONE

very

THE COMMON ACCEPTATION OF THE TERM MELANCHOLIA,

valuable tract wpon mental disorders, (o) His precepts, which are not alloyed by any theoretical disquisitions, appear to be the dictates of observation and experience ; and what gives them an additional value, is, that they chiefly relate to the moral management of the insane. His nosological distribution of the different species of in- sanity is, however, unscientific and confused.

(n) AretEimorbor. cliutum®rcurativ. Lib. i. Cap. v. (o) Corn. Celsus de medicina, Lib, iii. Cap. 18.

xxxiii Coelius Aurelianus, greatly inferior to Celsus in ele- «^yanc3 and pur.ty of language, has rendered his section on mania valuable, by a more detailed account of the symp- toms, accessory circumstances and treatment of insanity(/>)

Alexander Trallianus wrote at a time when Galenism was spre

MELANCHOLIA CONSTDERED NOSOLOGTCALLY AS A SPECIES

ading its crude and complicated speculations over the world. He therefore occasionally adverts to the doctrines of the numerous sects which distinguished the profession of medicine in the fourth century, and speaks of Galen in terms of the profoundest veneration {q) Trallian, however, w^ho was a man of original genius, studied

TWO OPPOSITE FORMS OF MELANCHOLIA WITH DELIRIUM,

his profession analytically, and acquired his knowledge of human nature and human disorders by the same method, (r) and from

(p) Coelius Aurelianus de morbis acutis, Lib. 1

(y) Alexandri Tralliani libri du jd -cim Edit. Basilex, Lib. xii. p. 768.

(r) " Hicinqtiam auctor clarissimus, ut in arte medica cognoscenda ac facierida exreilentior fieret et c;>nsuinmatus, noii diu in patria sua Tralle, ci-

ING DEGENERATE INTO MANIA ?

vitate Lydis, alias celebri atque eruditissimis hominibus, liberal issimisque studiis affluenti permanendum. Sed omnes cunctae Grecias partes, Italiam

Galliam, Hispaniam peragrandas sibi esse censuit Post longas autem

perigrationes, ad scribendi studii\m se con'ulit, et experimenta qus longo usu atque pericUtatione ex morbis collegerat in commentarios redigenda pu- tavit." Vide Epistolam nuncupatoriam quam libris Tralliani duodeeim praeposuit Andernacus, Edit. Basilese.

XXXIV the same inexhaustible sources. In his tract de melancho« lia, (s) he does not altooretiser reject the irvAy oiBces of the bile ; but it is evid nt that his leading theorv of the proxima,te cause of inj-^aaity, was tha*: of an excessive de- termination of blood to the head. The remedies wiiich he recommends are simple, suit^ible and active.

Without entering upon a more minute detail of the ■writings of the ancients

MADNESS INDEPENDENT OF ANY LESION OF THE UNDER-

individually, which would be tedi- ous to most readers, a few general observations upon their treatises and merits collectively, in connectiou with the subject of the following work, will not, perhaps, be deem- ed uninteresting,.

It was believed by most of the physicians of antiquity, that jiiania and melancholia are only degrees or varieties of one and the same affection, {t) Both forms of mental derangement were distinguished from phrenitis, by the absence of fever. The diagnostic s3aijptoms between ma-

(.f) Lib i. Cap xvi. to Coelius Aurelianus, Aretaeys, Paulus ^gineta, Ti'alU^.

XXXV

ilia furibunda and the melancholic passion, were the same that are adopted by the nosologists of the present day. They afford the best rules, perhaps, that the nature of the subject will admit of, and are sufficiently discriminating for all useful and practical purposes. The seat of mental disorders was generally supposed to be the head, affected either originally or by consent with other distant and dis- ordered parts. A very common opinion prevailed among the Greek physicians, that the pyloric and cardiac ex- tremities

A PAROXYSM OF PERIODICAL MANIA IS A PROTOTYPE OF

of the stomach were in fault in all cases of disor- dered intellect. Tlieir theories on that subject are exceed- ingly weak, however accordant with their bilious patholoo-y of insanity, {u) The remarkable sympathies existing be- tween the functions of the brain and those of other viscera, and particularly the uterus, are noticed by several of the au- thors whom we have

IS MANIA WITH DELIRIUM COMMONLY SUSCEPTIBLE OF

already quoted. Of their numerous, doctrines relative to tlie proximate causes of maniacal dis- orders we shall only state the most remarkable. Those depending upon the supposed influence of Gods, demons or tlieir representatives have been already noticed, and require

(

FOURTH SPECIES OF MENTAL DERANGEMENT,

m)

DEMENTIA, OR THE ABOLITION OF THE

Vid. P

THE MOST STRIKING FEATURES OF DEMENTIA FREQUENT-

iosper Alpin. de mediciiia methodica, Lib. x, p. 615.

not to be enlarged upon. To enter upon the theories of ia- sanity, founded ujjon the supposed quaUties of the bile and p^tuita, with a minuteness commensurate to the extent o

DEMENTIA MARKED BY IDEAS UNCONNECTED AMONGST

f their iiafliuen.ce, for many ages, upon the practice of physi- cians, would be a task which it cannot be necessary nor Useful to undertake in an introduction to a modern practi- cal treatise. The various degrees of density, temp

A CASE OF DEMENTIA WELL CALCULATED TO MARK THE

erature,,

DISTINCTION BETWEEN THAT FORM OF MENTAL DE-

crassitude, colour, opacity, putrescency or any other qua- lities of the bihous humour which theorists might fancy^ aiid actually did fancy, must be supposed adequate to the explication of all the varieties of insanity which its his- tory presented : (v) but if ever deemed inadequate, it was only necessary to admingle with this humour a proper quaii= tit

IDEOTISM, OR OBLITERATION OF THE INTEL-

y of pituita, [w) or any other principle which circumstan- ces might require. In some cases it was supposed, that the bile was intermixed in a morbid quantity with the blood*

(v) "Ex yaria autem liumoris melancholici dispositone maxima deliriorum varietas emergit. Uncle alii se reges, principes, vates 5 alii viireos, testa* fragiles, grana tritici a gallinis devoranda; alii ceram igne liquabilem; alii se canes feles, lupos, cuculns, luscinias, g.:llos esse ptitant, horumqtie aut aliorum animalium voces imitantur.'" Riverii Praxis

IDEOTISM, THE MOST COMMON SPECIES OF MENTAL DE-

medica,

RANGEMENT IN HOSPITALS : SOMETIMES CURED BY

Lib i Cap xiv.

(w) "Respondemus varies esse melancholije gradus et varias humoris rae^- lancholici cum alis humoribus permixtiones indeque max'.mam deUrioruia varietatem emergere.'" Idem. Vide

THE LEADING FEATURES OF THE PHYSICAL AND MEN-

quoque Galeni, Lib. ii, De sympt. caus. Cap. 6.

XXXVll In others, that it was conveyed to the substance of the •brain by distinct vessels, and that it irritated, heated or ^ried up that organ, so as to render it incapable of per- forming its usual and healthy functions. Some again conjectured, that something like a blaze was kindled by -the same phosphorescent principle amongst the thoracic and abdominal viscera j which sent its dry dnd fuliginous ^umes to the brain, and there eXcited the commotions of insanity. *'Nonulli veterum, ut Diodes, quendam pylori affectum inflammationi persimilem banc" (soil, melan- cholicam) " passioneni retulerunt, qub vense calidiores red- ditse humore crudb a stomacho intempestive attracto ob- struantur ; qua obslructione, calore transpirari, hum- oreque moveri ventilarive neqii

THE IMPORTANCE OF AN ENLIGHTENED SYS-

eUntib

TEM OF POLICE FOR THE INTERNAL MA-

iis, fit

THE ADVANTAGES OF A SYSTEMATIC DISTRIBUTION AND

qiiaeda

A PERFECT INSULATION OF THE DIFFERENT SPE-

m in iis veliis alteratio, agitatioque ac veluti etiam exinde a calore 'fere igneo semiputrefactio, ex qua vapores excitantur ca- lidi, acres, adusti ; ex quibns juxta varias corporis partes in

GENERAL CONSIDERATIONS IN REGARD TO THE DISTRIBU-

quas

TION OF PATIENTS IN LUNATIC HOSPITALS INTO DIF-

ab hypochondriis attolluntur, vanse passiones ori- untur : si ad caput ferantur mentem turbant, melancho- liamque homini inducunt."(2^) The term vapours, as ex-

(a) Prosper. Alpin. de medicinametbodica, Lib. X. Cap. n.

xxxViii pressive of mental depression and solicitude, is evidently derived from this fanciful theory. The spleen was frequent- ly accused of harbouring the morbid operations of the me- lancholic humour : hence unhappy and fretful dispositions are called splenetic to this day. Though the influence of the bile upon the functions of the understanding was sel- dom lost sight of by any of the writers of antiquity, we nevertheless find, that it was not universally adopted to the exclusion of other and better founded explications. The doctrines of general and topical plethora, which are noticed by Hippocrates, are discussed at considerable leno-th by Alexander Trallianus, who adapts his indica- tions of cure, with great judgement, to the supposed na- ture and action of this offending cause.

The metaphysical doctrines of the Methodists embraced theories of all diseases, whether of the mind or of the body. What difficulties can, for a moment, baffle the in- genuity or impede the progress of a thorough bred meta- physician ? By some it was supposed, that insanity was the result of a morbid stricture of the brain, or of other parts conn

COERCION TO BE SOMETIMES RESORTED TO, IN CASES OF

ected or consenting with the functions of that

organ. This was the idea of Coelius Aurelianus, who re- probated the opposite theory of a morbid relaxation of some part or parts of the brain, as adopted by Mnaseus and others of that distinguished sect.

It is a circumstance deserving of remark, that some of the ancients advanced a metaphysical theory which meets the modern idea of an actua

THE VIOLENCE AND FURY OF ACUTE MANIA?

l derangement of the intelkct- nal and active faculties. The term diachisis, which they employed to express this fact, signifies primarily a solu- tion or separation of parts of any compound body, and, like the corresponding English term derangement, has been borrowed from the phenomena of physical or mecha- nical decomposition. This theory, granting in its favour its metaphysical postulatum, that the sentient and intel- lectual functions of the brain, have

IS CLOSE CONFINEMENT REQUISITE IN ALL CASES AND

each

THROUGHOUT THE WHOLE TERM OF ACUTE MANIA?

a separate and in- dependent existence, is objectionable, on the ground that it does not give us any clear and satisfactory idea of the proximate cause of insanity. As far as those ternas have been employed analogically and figuratively to express the absence of the usual harmony between the different func- tions of the mind, they may have answered a convenient and

xl

useful purpose. They are not words which can by any means be admitted as representatives of an actual physical fact.

On the subject of remote causes of maniacal disorders, the writers of antiquity have been exceedingly reserved. The important influence of the passions were generally considered in connection with morals exclusively. We, therefore, do not meet with, in the writings of any of the physicians of Greece and Rome, a detailed developement of the numerous predisponent and occasional causes of insanity more immediately depending upon the morbid excitement

AN INSTANCE ILLUSTRATIVE OF THE ADVANTAGE OF OB-

of the

TAINING AN INTIMATE ACQUAINTANCE WITH THE

active powers of the mind. Confining their attention to the physiology, history and causes of those disorders, they frequently overlooked even the more obvious exciting causes resulting from bodily diseases and inalconformations.

The symptomatology or general medical history of ma- niacal disorders, was carried by the ancients to a degree of correctness and extent, which has left little room for the display of

VARIETIES OF BODILY EXERCISES INCLUDING LABORIOUS

modern descriptive talent. It must, how- ever, be confessed, that in regard to nosological distribu-

xU

tion and nice delineation of specific and indiAridual cases of insanity, the best writers of antiquity have by no means distinguished themselves. Their nosology is, in a great measure, founded upon their proximate causes of insanity^ and not upon the great and leading varieties of the dis- order, as the different departments of the thinking and sentient faculties are affected by it. The Greek distribu- tion, which has been

THE PROPRIETY OF ENGAGING THE ATTENTION OF CON-

almost

VALESCENTS IN SOME INTERESTING PURSUIT

uni

ILLUSTRATED,

formly adopted by the moderns, of vesanious disorders into two species, viz. those of mania and melancholia, is imperfect, too general and not sufficiently discriminating.

From the above sketch of the theories of insanity, which are to be found in the earlier Greek and Roman institutes of Physic, it may be perhaps presumed, that the treatment of this formidabl

A CASE OF CONVALESCENT INSANITY AGGRAVATED BY

e order of diseases was not very well un- derstood by the ancients. It however fortunately happens, that theory and practice are not, always and essentially, counterparts of each other. The same method of treat- ment may result from very different physiological and pa- thological views. The treatment of insanity by evacuants, for the purpose of expelUng the bile or Qther pecpant hu-

xlii ni6urs, according to the opinions of the ancients, was not less effectual in allaying the preternatural excitement of a dis- tempered brain, than a similar system of practice recom- mended by the moderns from other views of pathology and other indications of cure. Solid and liquid diet have each been recommended to the exclusion of the other, both by the ancients and the moderns; but upon different physiolo- gical principles, and to answer very different intentions in the treatment of the disorder.

The leading indication of cure by the ancients was eva- cuation by hellebore, which generally operated both as an emetic and a purgative. From the confident language that was made use of by the poets of antiquity, and by the physicians of the middle ages, relative to the antimaniacal efficacy of the hellebore, it has been believed by some, that the moderns are either ignorant of the real vegetable, so celebrated in former times, or have lost the art of pre- paring it after the ancient manner. In opposition to this mistaken idea it may be observed, that the medical authors of antiquity, whose testimony alone can be considered of any weight in this case, do not in a single instance express

xliii an empirical exclusive confidence in the virtues of any one remedy. Alexander of Tralle prefers, indeed, in a very de- cided manner, the substitution of other evacuants to the use of white hellebore, which he considered as a very uncer- tain and dangerous remedy .(r) Acrid and vesicating rubefacients were advised by the physicians of Greece to be applied to the crown and back part of the heads of maniacs at repeated intervals. Cupping of the temples, the extraction of blood by leeches, and general vensesec- tion, were remedies of insanity with which they were likewise well acquainted. Bathing was deemed by most of them a pov^^erful remedy in diseases of the mind, and was emplo^'ed in various forms, to meet different indi- cations, and in conjunction with other processes, chiefly unctuous, which were intended to act on the surface of the body. With respect to narcotics, it may be observed, that they were not favourite remedies among the ancients. Corn. Celsus (j/) informs us, that an infusion of the pop- py employed externally in the way of lotion to the head.

(x) Alexander Trallianus, Lib. i. p. 112. (y) Cora, Cels. Lib. iii. Cap. 18. ,

Was reprobaTe^ by his great master Asclepiades, as calcii^ lated to induce a dangerous lethargy. The means which ■Were generally recurred to, to procure slepp and to alle- viate pain, were the warm bath, friction, gestation, siis,- ]pensory beds, monotonous music, and such other methotJg' as were adapted to sooth the fedings and the senses. The Yules prescribed by the ancients, in respect to exercise and regimen, are for the most part tedious and unimportant ; arid in the great object of moral management they are all exceedingly deficient. Cornelius Celsus is the only an= cierit writer who has incorporated, with his other indica- tions of cure, any practical directions in regard to the mo- ral treatment of lunatics.

Such is a general outHne of the leading principles of the ancients, in respect both to their theories and treatment of mental disorders. To have engaged in a more minute analysis of them, would have rendered these introductory observations unnecessarily tedious. From what has been said, the intelligent reader will find no difficulty in ascer- taining the portion of merit due to their successors in the same route.

xlv

The Arabian physicians adopted the speculations of their Greek and Roman predecessors, exer-jising the right, no doubt, of modifying them according to circumstances, so as to render them accordant to their own prejudices and subservient to their temporary credit and consequence. The practical observation and beautiful simplicity of Are- taeus and Celsus we;e now lost amid the disputations of medical sectarianism and the farago of ridiculously compli- cated formulae. Among the productions of tiiese times, we do not, therefore, meet with any essays upon mental disorders which are not miserable compilations from the works of the ancients, obscured by false physiology and pharmacy.

The contests which succeeded in the latter centuries

between the Galenists and the Alchemists, caused much

wrangling and animosity in the medical schools on

the continent, without adequately contributing to the

progress of genuine medical science. The writers of

those times, such as Sennertus, Riverius, Plater, Heur-

nius, Horstius, Bonnetus, and manv others, who were

profoundly versed in the learning of the Arabians,

.f

xivi

devoted their time and their talents in the fabrication of medical cyclopsedias or systematic works, containing disquisitions upon all the diseases to which the human frame is subject. Those writers, among their other labour- ed and volmninous productions, have left some no con- temptible essays lipon the subject of the present work. Their theories of insanity are, for the most part, founded upon the supposed influence of four or five different prin-^ ciples in the human constitution, viz. the bile, the pituitsi, the element of fire, and what they called the animal spi- rits, and in some instances an insidious poison. In their indications of cure are enumerated, in different relations to the states and stages of the malady, almost all the arti- cles of their superbundant materia medica.

Van Helmont, equally celebrated for his genius "and ex- centricities, had the merit of being the first to emancipate the profession of physic from the shackles of Galenism, and to advance new and original ideas upon the subject of in- sanity. Upon applying the root of the monk's hood to the tip of his tongue, that father of modern medical analytical enquiry experienced new and indescribable sensations, which

xlvii

equally excited his astonishment and admiration. This curious circumstance, all the particulars and machinery of which are described at considerable length in the twelfth sec- tion of his works, (a) engaged his attention in a very high degree. He thought that he could trace great analogy be- tween the novel sensations which he experienced, and cer- tain symptoms which he had heard described of incipient insanity. Whether his sensations upon this occasion are to be classed among many other phantasms of his bril- liant imagination, or were actually excited by the poison- ous virulence of the vegetable which he had tasted, it is certain that the experiment led him to theorise upon the morbid hallucinations of the human mipxl, and to propose several important applications of the phenomena of strong impressions, as connected with the laws of association to the cure of insanity. Ilis treatment of mental disorders^ by prolonged and indiscriminate immersions in coid water, must, however, appear exceedingly repr^ehensible to a well-informed physician of the present day.

We now advance in our retrospect of insanity, to a pe* riod in medical history which cannot fail to engage the

(a) Van Halmont Opera omnia Hafn, 1707.

xlviii

warmest in'^errs'" ©f evf ry lover of the healing art — that period whic'.i wit i ssecl the exertion of the splendid talents of a Stahl and a Boer^-a'-^e. Under the direction of those eminent philosophers and phj^sicians, the science of che- mi'^try and physio ogv assumed a new aspect ; observation and analysis reco\'ered their primitive importance in the study of the hmnan frame, and the volume of nature was opened to the comtemplation of the naturahst,and contrast- ed with the literary productions of ages. But the ambition, by which these illu!!;trious rivals were equally distinguish- ed, of establishing their own peculiar doctrines to the exclu- sion of every other, and of erecting their reputation upon a brilliant universality of professional knowledge, render- ed it impossible for them to study individual diseases with the requisite attention and profundity. We, there- fore, look in vain in the productions of the Leyden school ■for instructions in the physiology and treatment of ma- niacal disorders. Whilst the most eminent professors of the first medical seminary in the world were thus ad- vancing in their career of theoretic glory with unparalelled rapidity, the unhappy lunatic was permitted, as in ages of utmost ignorance, to subsist on his bread and water, to lie

xlix on his bed of straw, chained to the wall of a dark and soUr tary cell, a being unworthy of solicitude in his fate, and a victim of an idle and interested liiaxim, that " Insanity is an incurable malady." The best information which, till of late years, could be obtained upon the subject, must have been extracted, with infinite labour and pains, from the musty and unwieldy volumes of the older systematic writers. Of all tiie disorders to which the human frame is unfortunately subject, it is somewhat remarkable, that the interesting malady under our present consideration has been most neglected. The treatises which have been pro- fesseily written upon it since the revival of literature in Europe, are all of them of late publication, and, with a few exceptions, are mere advertisements of lunatic es- tablishments under the superintendence of their respective authors. As exceptions to this remark, the essays of Monro, (^) Lorry, (c) Mead,(^) Faucett,(e) Greding,(/)

(6) Dr. John Monro's reply to Dr. Battle's treatise on madness,.

(c) Lorry de Melancholia et morb. melancholicis Lutetise Parisiorum, i765,

(d) Mead Prjecepta Medica Cap. iii. De Itisania. p. 67.

(e) Faucett tiber Melancholie Leipsick 1785.

(./) Greding's Vermischte &c, 1781.

1

i*argeter,(^) Femar,(/f) Haslam,(?) and, above all others, the inestimable work of the learned Dr. Arnold, (--J-) deserve to be mentioned. The psychological work of Dr Crich- ton,(/) exhibits some curious facts illustrative of the morbid influence of the passions upon the functions of the intel- lectual faculties. Dr. Cox's new publication (??z) is recom- mended to the perusal of the faculty, by what it contains up- on the moral and medical use of the swing in maniacal dis- orders. There is still another work of reputed value upon the subject, of which we have not been able to obtain a perusal, by a M. Dufours. Dr. Crichton speaks of it in the following terms. " The work ofM. Dufours is more scientific than that of Dr. Arnold, but it is extremely in- complete in what regards the diseases which disturb human reason. M. D, is a man who is evidently well acquainted

(g) Pargeter's observations on Maniacal disorders. 1792.

{h) Ferriar's Medical Histories and Reflections, Vol. i. p. 171, and Vol. 2, p. 88.

(i) Observations on Insanity with practical remarks by J.olin Haslam, late of Bethlehem hospital.

(k) Observations on the nature, kinds, causes, and prevention of in- sanity, by Thomas Arnold, M. D.

fl) An enquiry into the nature and erigin of mental derangement, &c. by A. Crichton, M. D.

(to) Practical observations on Insanity, by Joseph Mason Cox, M. D.

u

with the mind in its natural state, and, indeed", the greater part of the work is entirely taken up in psychological and physiological disquisition, the only diseases which he de- scribes being ideotism, mania, melancholy and hypochon- driasis. On these subjects he does not bring forward any thincr new." If M. Dufours advances nothing new on the subject of Dr. Arnold's treatise, he surely cannot with propriety be put in competition with him. The greatest number of the essays just quoted are pamphlets, contain- ing cases, general observations on the pathology, and sliort reviews of the usual remedies of insanity. With- out being contemptible, as those of certain empyrical ^\Tit- ers on the subject, whom we do not choose to injure by mentioning their names, indubitably are, they have not individually contributed in any great measure towards the elucidation of the theory, nor towards the successful treat- ment of mental indispositions. They have seldom exhibit- ed those nice delineations of the peculiar varieties of in- sanity, depending upon di-ersities of temperament, habits, intellectual abilitv, th?, ^acuit; s jjrincipallv affected, and bther causes, the knowledge of which would be highly advantageous in pr-actice. Without clear views of the no-

lii

sology of the disease upon which to establish their indi- cations, the professors of this department of the heaUng art have generally indul ged in a Wind routine of treatment, which has been more calculated to throw discredit upon its pretensions than to advance our knowledge upon certain and unquestionable principles. Dr. Arnold's nosology of insani- ty is the first work of the kind that has appeared in any coun- try, founded upon the basis of pneumatology. It might be deemed presumptuous in us to advance objections against a system of nosography no less distinguished for the great-^ ness of its object, than for the ingenuity and learning that are displayed in its execution. We cannot, however, help owning, that we are among some of the readers of that re- spectable author, who are of opinion, that his distinctions, to say the best of them, are unnecessarily minute. So nu- merous are his varieties, and distinguished from each other by such fine and evanesant shades of difference, that how- ever we may admire the skill of the psychological patho- logist in the discovery and detail of tiiem, we are firmly convinced, that nine-tenths of the faculty of physic will not be at the pains to make themselves practically acquaint- ed with them. Before the work is completed, it would be

iiii

equally uncandid and premature to add, that Dr. Arnold's treatise is not calculated, in any considerable degree, to benefit the practice in this department of physic. His views of the causes of insanity, whether proximate or re- mote, are ingenious and comprehensive, and have afford- ed fundamental principles for systematizers upon the same subject, of later date and of incomparably inferior ta- lents. (?7) Having said thus much, we take our leave of that veteran practitioner, by wishing him great success in the execution of his original undertaking. (<?)

In the present volume, the observations of an en- lightened foreigner are offered to the English public. Whatever other merit they may possess, the subject is con- sidered throughout in an easy, practical and interesting

(n) We have 'ik wise observed, with a mixture of contempt and indig- nation, that a ceitain publication of late appearance in this country, has be'^n introduced to the favour of the more ignorant part of the profession, partly by transcripts of cla^^sical and other quotations from the work of this eminent scholar and physician.

(o) " My next business," says Dr A ndd, " will be to turn my thoughts more imm<;di.itely to the peco.id a;id m^ re important |;art of my undertak- ing, The Cure of insanity; to wi'ich what 1 have hiiherio written on this disorder is pieparato y, and with ut which it can be out of little value." See Dr, Arnold's preface to the second edition of his Observations, p. 50.

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manner. Evidently acquainted witH the literary sources, from which others have borrowed with considerable repu- tation, he has chosen, in this essay, to report his own ob- servations, opinions and practice exclusively. The facts, therefore, with which the volume abounds, are generally illustrative of positions of his own, which are often original and always practical. His object has necessarily excluded many psychological and all metaphysical disquisitions. His methodical distribution is not established so much upon the principles of pneumatology as upon the striking differences of character exhibited upon a large scale, by persons labour- ins: under these formidable disorders. Though it has not been pursued to its remote branches, so as to exhibit the numerous varieties of maniacal diseases, with that scientific minuteness of which we suppose it capable, it, nevertheless, exhibits the great and boldly sketched outlines of a more practical system of nosology than we have yet seen upon the subject. But this volume is chiefly valuable for the great attention to the principles of the moral treatment of insanity which it recommends. Works of practical value, usually leave some one strong and permanent impression on the mind. The inestimable importance of moral ma-

Iv nao-ement is the great key note sounded by tlie present author almost in every subdivision of his treatise. This part of the subject is examined in all its bearings, and ac- companied by examples of the methods, for subduing the extravagances and arresting the hallucinations of the insane, which were adopted in the lunatic establishments over which Dr. Pinel so ably presided. To enter into a more particular detail of what the author has accomplished in this volume, and of what he has left for others or deferred to another opportunity, would be to anticipate the judge- ment of the reader. The subject is so abstruse and ex- tensive, that the expectation of any thing like a perfect treatise upon it, in the present state of our knowledge, could be formed, onl}'^ to be disappointed.

TRANSLATOR.

S/ieJ/eld, Oct. 28, 1806.

Treatise on Insanity.

GENERAL PLAN OF THE WORK,

N.

OTHING has more contributed to the rapid improvement of modern natural history, than the spirit of minute and accurate observation which has distinguished its votaries. The habit of analytical investigation, thus adopted, has induced an accuracy of expression and a propriety of classification, which have themselves, in no small degree, contributed to the advancement of natural knowledge. Convinced of the essential importance of the same means in the illustration of a subject so new and so difficult as that of the present work, it will be seen that i have availed myself of their application, in all or most of the instances of this most calamitous disease, which occured in my practice at the Asylum de Bi- cetre. On my entrance upon the duties of that hos- pital, every thing presented to me the appearance

A

2

of chaos and confusion. Some of my unfortunate pa- tients laboured under the horrors of a most gloomy and desponding melancholy. Others were furious, and subject to the influence of a perpetual delirium. Some appeared to possess a correct judgement upon most subjects, but were occasionally agitated by violent sallies of maniacal fury ; while those of ano- ther class were sunk into a state of stupid ideotism and imbecility. Symptoms so different, and all com- prehended under the general title of insanitj^, re- quired, on my part, much study and discrimination; and to secure order in the establishment and success to the practice, I determined upon adopting such a variety of measures, both as to discipline and treat- ment, as my patients required, and my limited op- portunity permitted. From systems of nosology, I had little assistance to expect ; smce the arbitrary distributions ofSauvages and CuUen were better cal- culated to impress the conviction of their insufficien- cy than to simplify my labour. I, therefore, resolv- ed to adopt that method of investigation which has invariably succeeded in all the departments of natu- ral history, viz, to notice successively every fact, without any other object than that of collecting ma- terials for future use ; and to endeavour, as far as possible, to divest myself of the influence, both of my own prepossessions and the authority of others^

With this view, I first of all took a general statement of the symptoms of my patients. To ascertain their characteristic peculiarities, the above survey was followed by cautious and repeated examinations into ,. the condition of individuals. All our new cases were entered at great length upon the journals of the house. Due attention was paid to the changes of the seasons and the weather, and their respective inflaences up- on the patients were minutely noticed. Having a pe- culiar attachment for the more general method of descriptive history, I did not confine myself to any exclusive mode of arranging my observations, nor to any one system of nosography. The facts which I have thus collected are now submitted to the con- sideration of the public, in the form of a regular treatise.

Few subjects in medicine are so intimately con- nected with the history and philosophy of the human mind as insanity. There are still fewer, where there are so many errors to rectify, and so many preju- dices to remove. Derangement of the understand- ing is generally considered as an effect of an organic lesion of the brain, consequently as incurable ; a supposition that is, in a great number of inslances, contrary to anatomical fact. Public asylums for maniacs have been regarded as places of confinement

for such of its members as are become dangerous to the peace of society. The managers of those in- stitutions, who are frequently men of httle know- ledge and less humanity, (a) have been permitted to exercise towards their innocent prisoners a most ar- bitrary system of cruelty and violence j while expe- rience affords ample and daily proofs of the happier effects of a mild, conciliating treatment, rendered effective by steady and dispassionate firmness. Avail- ing themselves of this consideration, many empirics have erected establishments for the reception of lu- natics, and have practiced this very delicate branch of the healing heart with singular reputation. A great number of cures have undoubtedly been effect- ed by those base born children of the profession; but, as might be expected, they have not in any degree contributed to the advancement of science by any valuable writings. It is on the other hand to be la- mented, that regular physicians have indulged in a blind routine of inefficient treatment, and have al- lowed themselves to be confined within the fairy cir- cle of antiphlogisticism, and by that means to be diverted from the more important management of

(a) The English legislature has taken some cognizance of the crying evils which formerly existed in this country, as they now do in France, from the indiscriminate toleration of empyrical lunatic establishments. More Jiowever might and ought to be done, T.

the mind. Thus, too generally, has the philosophy of this disease, by which I mean the history of its symptoms, of its progress, of its varieties, and of its treatment in and out of hospitals, been most strangely neglected.

Intermittent or periodical insanity is the most common form of the disease. The symptoms which mark its accessions, correspond with those of con- tinued mania. Its pai oxysms are of a determined duration, and it is not difficult to observe their pro- gress, their highest developement, and their termi- nation The present essay will* therefore, not im- properly commence with an historical exposition of periodical insanity. The leading principles of our moral treatment will then be developed. Atten- tion to tliese principles alone will, frequently, not only lay the foundation of, but complete a cure : while neglect of them rpay exasperate each succeed- ing paroxysm, til!, at length, the disease becomes established, continued in its form, and incurable. The successful application of moral regimen exclu- sively, gives great weight to the supposition, that, in a majority of instances, there is no organic lesion of the brain nor of the cranium. In order however to ascertain the species, and to establish a nosology of insanity, so far as it depends upon physical de-

6

rangement, I have omitted no opportunities of ex- amination afier death, 1, therefore, flatter myself, that my treatment of this part of the subject will not discredit my cautious and fn quenily repeated observations. By these and other means, which will be developed iti the sequel, I have been en- abled to introduce a degree of method into the ser- vices of the hospital, and to class mv paiieiits in a great measure according to the varieties and inve- teracy of their complaints An account of our sys- tem of interior police, will finish this part of the en- quiry. 1 he last section will comprehend the prin- ciples of our medical treatment.

In the present enlightened age, it is to be hoped, that something more effectual may be done towards the improvement of the healing art, than to indulge with the splenetic Montaigne, in contemptuous and ridiculous sarcasms upon the vanity of its pre- tensions. I flatter myself, that the perusal of the following work will not excite the sentiment of that celebrated censor of human extravagance and folly, when he said, *' that of whatever of good and salutary fortune or nature, or any other foreign cause may have bestowed upon the human frame, it is the priviledge of medicine to arrogate to itself the merit."

SECTION I.

PERIODICAL OR INTERMITTENT INSANITY.

1 . Nothing can place the slow progress of medi- cal science, in a more striking point of view, than histories of maniacal paroxysms, taken by different persons and at different periods of time. Aretaeus advanced little more upon the subject of intermittent insanity, than that, if well treated, it is capable of be- ing completely cured ; but, that the patient is sub- ject to relapses, from various causes, such as errors in regimen, sallies of passion, and the return of spring, Coelius Aurelianus [b] notices the redness and the fixed direction of the eyes, the distension of the veins, the heightened colour of the cheeks, and the increase of strength, which usually take place in fits of periodical insanity. Those writers, however, give us no instructions with respect to the causes of those

{b) Coel, Aureliaii. de morb. chronic. Lib. i. Cap. vi.

8

complaints, their peculiar symptoms, their succes«= sive periods, their varied forms, their duration, ter- mination and prognosis. It has always been more easy to compile than to observe ; to indulge in fruit- less theory, than to establish positive facts. Authors, therefore, without number, both ancient and mo- dern, have acquitted themselves in a manner worthy of this inglorious facility, and have been ever writ- ing what their predecessors had written before them. The particular histories, which we meet with in dif^ ferent works, are chiefly remarkable for a few un-= connected facts which they detail. The important method of descriptive history has been too much neg- lected. The great object of the physician and the author has almost uniformly been to recommend a favourite remedy,(c) as if the treatment of every dis- ease, without accurate knowledge of its symptomSg involved in it neither danger nor uncertaintyo

(c) In illustration of this assertion, the reader is desired to consult the practice of Dr. Laugther, Physician to the Lunatic Asylum, at Vienna, That gentleman is abundantly copious upon the subject of medicaments and cures, but miserably deficient in historical description and analytical enquiry.

(ililcUMSTANCES FAVOliRAfiLE TO THE AUTHOR'S RE- SEARCHES UPON THE SUBJECT OF INSANITY.

2. The Asylum de Bicetre, which was confided to my care during the second and third years of the republic, widened to a vast extent the field of en- quiry into this subject, which I had entered upon at Paris, several years previous to my appointment. The storms of the revolution, stirred up corresponding tempests in the passions of men, and overwhelmed not a few in a total ruin of their distinguished birth- right as rational beings. The local disadvantages of the hospital, perpetual changes in the administration of public affairs, and the difficulty of obtaining a va- riety of means that might have conduced to its pros- perity, were circumstances that frequently perplexed but were never allowed to dishearten me. For these serious inconveniences, I found ample amends in the zeal, the humanity, and intelligence of the keeper j a man of great experience in the management of the in- sane, and every way calculated to maintain order in the hospital. The advantages, which I have derived from this circumstance, will stamp a greater value upon my observations in the present treatise, than any attempts to discover or establish ne)v remedies.

B

to

For, in diseases of the mind, as well as in all other ailments, it is an art of no little importance to ad- minister, medicines properly : but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.

PERIODS OF ACCESSION OF INTERMITTENT INSANITY.

3. It is curious to trace the effects of solar in- fluence upon the return and progress of maniacal paroxysms. They generally begin immediately af- ter the summer solstice, are continued with more or less violence during the heat of summer, and com- thonly terminate towards the decline of autumn. Their duration is limited within the space of three, four or five months, according to differences of indi- vidual sensibility, and according as the season hap- pens to be earlier, later, or unsettled as to its tem- perature. Maniacs of all descriptions are subject to a kind of effervescence or tumultuous agitation, upon the approach either of stormy or very warm weather. They then walk with a firm but precipi-

11

tate step ; they declaim without order or connec- tion; their anger is roused by trivial or imaginary causes, and they express their feelings by clamor- ous and intemperate vociferation. We must not, however, extend this law of solar influence beyond its natural boundary, nor conclude that the return of maniacal paroxysms is universally dependent upon a high temperature of the atmosphere. I have seen three cases in which the paroxysms returned upon the approach of winter, i. e. when the cold wea- ther of December and January set in ; and their remission and exacerbation corresponded with the changes of the temperature of the atmosphere from mildness to severe cold.

It will not be improper to mention in this place two instances of insanity, the return of whose pa- roxysms occurred at very distant and unusual pe- riods of time ; — that of the first, after an interval of three years ; and that of the second, after an inter- val of four years. For several years they recurred in the summer season ; but the last attack in each instance, did not take place till towards the decline of autumn and the commencement of the cold weather. — Upon what then depends this nervous disposition of the sys- tem to be deranged at stated periods; a disposition that appears to be governed but imperfectly by general

^ ^^^Z^ ^.

12

laws ? What becomes of Dr. Brown's principles of medicine in relation to the action of cold and heat upon the human body, and of the character of a sthenic diathesis which he ascribes to insanity ?

PERIODICAL INSANITY INDEPENDENT OF THE INFLUENCE OF THE SEASONS.

4. I NOW proceed to describe the general pro- gress of periodical insanity. Among its various causes j exclusive of changes in the state of the at- mosphere, my experience leads me to enumerate as the most frequent ; undue indulgence of the angry passions ; any circumstances calculated to suggest the recollection of the original exciting cause of the disease i intemperance in drinking, inanition, &c. There are some instances of periodical insanity, which, in the present stai'e of our knowledge, we are not authorized to ascribe to the vicissitudes of the seasons, nor to any of the causes which have been just mentioned j but which appear to depend upon a peculiar idiosyncracy, the existence even of which^ we can infer only from its constant and regular ef«

13

fects. This form of the disease is much more diffi- cult of cure than the other; but, fortunately, much less frequent. From a general examination of the patients, at the Asylum de Bicetre, in the second year of the republic, which was undertaken for the purpose of ascertaining the relative number of each variety of the disease ; it appeared, that, out of two hundred maniacs, there were fifty-two of the class subject to paioxysms of insanity at irregular periods; and only six, whose periods of accession ob- served a regular intennission. Among the latter class, there was one, whose paroxysms returned regularly every year, lasted for three months, and ended to- wards the middle of summer. A second, was subject to extreme fury during fifteen days in the year, and was perfectly calm and in possession of his reason for the remaining eleven months and a half A third case, having one day of complete intermission, ap- peared to observe the type of a tertion fever. I shall be excused, if I mention three more cases, whose paroxysms invariably returned after an inter- val of eighteen months, and lasted precisely six months. The peculiar character of those unfortunate cases consisted in a few but well marked circumstances. Their ideas were clear and connected ; — they indulged in no extravagances of fancy; — they answered with great pertinence and precision to the questions that were proposed to

j^Af?t>

u

ih&k : ''but they w6 re under the dominion df a most ungovernable fury, -and of a thirst equally ungovern- able for deeds of blood. In the mean time, they were fully aware of their horrid propensity, but ab- solutely incapable, without coercive assistance, of suppressing the atrocious impulse. How are we to reconcile these facts to^ the opinion which Locke and Condillac entertained with regard to the nature of insanity, which they made to consist exclusively in a disposition to associate ideas naturally incompati- ble, and to mistake ideas thus associated for real truths?

THE CHARACTER OF MANIACAL PAROXYSMS NOT DEPEND- . ING UPON THE NATURE OF THE EXCITING CAUSES,

BUT UPON THE CONSTITUTION.

5. To believe that the different species of insan- ity depend upon the particular nature of its causes, and that it becomes periodical, continued or me- lancholic, according as it may have originated from unfortunate love, domestic distress, fanaticism, su- perstition, or interesting revolutions in the state of public affairs, would be, to fall into a very great

^w

13

error. My experience autliorizes me to affirm, that there is no necessary connection between the spe- cific character of insanity, and the nature of its ex- citing caused Among the cases of periodical ma- nia, which I; have seen and reporded in my journals, I find some which originated in a violent butmor; fortunate passion j others in an ungovernable ambi- tion for fame, power ,or glory. Many succeeded to reverses of fortune j others were produced by devo- tional phrenzy ; and others by an enthusiastic pa- triotism, unchastened by the sober and steady influ- ence of solid judgement. The violence of maniacal paroxysms appears, likewise, to be independent of the nature of the exciting cause ; or to depend, at least, much more upon the constitution of the indi- vidual,— upon /he diiferent degrees of his physical and moral sensibility. Men of robust constitutions, of mature years, with black hair, and susceptible of strong and violent passions, appear to retain the same character when visited by this most distres- sing of human misfortunes. Their ordinary energy is enhanced into outrageous fury. Violence, on the other hand, is seldom characteristic of the paroxysms of individuals of more moderate passions, with brown or auburn hair. Nothing is more common than to see men, with light coloured hair, sink into soothing and pleasurable reveries; whereas it seldom or never happens that they become furious or unman-

^A i^;2^ y--.*— - Z^,^.^ti^ ^^^

16

ageable. Their pleasing dreams, however, are at kngth overtaken by and lost amid the gloom of an incurable fatuity. It has been already observed, that people of great warmth of imagination, acute- ness of sensibility and violence of passions, are the most predisposed to insanity. A melancholy reflec- tion ! — but it is not less true than it is calculated to interest our best and tenderest sympathies.

I Cannot here avoid giving my most decided suf- frage infavourofthemoralqualitiesofmaniacs. I have no where met, excepting in romances, with fonder husbands, more affectionate parents, more impas- sioned lovers, more pure and exalted patriots, than in the lunatic asylum, during their intervals of calm- ness and reason. A man of sensibility may go there every day of his life, and witness scenes of indescrib- able tenderness associated to a most estimable vir- tue./^

PRECURSORY SYMPTOMS OF MANIACAL PAROXYSMS^,

6. The nature of the affections most calculated to give birth to periodical mania, and the affini-

17

ties of this complaint with melanctiolia and hypo* choiidriasis, warrant the presumption that its seat, primarily, is almost always in the epigastric region, and that from this centre are propagated, as it were by a species of irradiation, the accessions of msanity. An attentive examination of the circumstances pre- ceding the attack, will likewise afford a very striking support to the opinions of Lacaze and Bordeu, in regard to the very extensive influence which they ascribe to the functions of the epigastric region, of Vvhich Buffon has given us so excellent a description in his natural history/ ^All the abdominal system vs even appears to enter into the sad confederacy. The <^i^^^fu. ^ patient complains of a sense of tightness in the "^^-/i^l/^' gion of the stomach, want of appetite, obstinate cos- tiveness, and a sensation of heat in the bowels which obtains a temporary relief, from copious draughts of cooling liquids. He is subject to a kind of uneasi* ness which he cannot describe nor account for ; ex* periences a degree of fear that sometimes amounts to terror, and feels either little clispostion or ab- solute incapacity to sleep. Soon after, incohe- rence and incongruity of ideas are betrayed in his outward conduct, by unusual gestures and by ex- traordinary changes in the expression and move- ments of his countenance. He generally holds his head erect, and fixes his eyes and attent^ion upoQ

18

thfe heavens. He speaks with a deep hollow voice ; walks with a quick and precipitate step ; and stops suddenly, as if arrested by the most interesting and profound contemplations. Some maniacs are re- markable for great humour and merriment, which they express by fits of loud and immoderate laugh- ter. There are others, as if nature delighted in con- trast, whose taciturnity is perpetual, who express their afflictions by tears, or who sink without a tear under the distressing influence of solitary anxiety. The eyes, in some species of insanity, suddenly ap- pearing red and sparkling, the cheeks flushed, with a vigorous and rapid action of the muscles of the countenance, accompanied by an exuberant loqua- city, are certain presages of an approaching parox- ysm; and point out the urgent necessity of strict confinement. I remember a maniac who suddenly spoke with great volubility, laughed immoderately, and then shed a torrent of tears. Experience had taught me the value ,of a speedy seclusion ; for his paroxj/sms were extremely violent, and he broke into a thousand pieces whatever fell in his way^

Dreams of extacy and visions of heavenly plea- sure are the ordinary preludes to paroxysms of ma- niacal devotion : — as those of unfortunate love are preceded by similar interruptions of sound and health- ful sleep. The beloved object appears under the

19

form of an exquisite beauty, with every other ad- vantage, greatly exaggerated by the magic power of fancy. But the too happy dreamer, after an inter- val of more or less continuance of reason and calm- ness, awakes once more the noisy, the disconsolate, and the furious maniac.

CHANGES IN THE AFFECTIONS OF THE MIND DURING PAROXYSMS OF INSANITY.

7, He who has identified anger, with fury or tran- sient madness, (ira furor brevis est,) has expressed a truth, the profundity^ of which we are more or less disposed to acknowledge, in proportion as our ex- perience on the subject of insanity has been more or less extensive. Paroxysms of madness are gene- rally no more than irascible emotions prolonged be- yond their ordinary limits; and the true character of such paroxysms depends, perhaps, more frequently upon the various influence of the passions, than upon any derangement of the ideas, or upon any whimsi-^ cal singularities of the judging faculty. The terms mania and fury, are used synonymously in the works

20

of Aretasus and CaeliusAurelianus, who are acknow- ledged masters in the art of observation. It may, however, be observed, without disparagement to the authority of these venerated names, that such a latitude of meaning is incompatible with the snm- phcity and precision of descriptive language. We have occasionally seen cases of periodica] insanity, without fury, but scarcely ever without some change or perversion of tlie functions of the understanding, A man, rendered insane by events connected with the revolution, repelled with rudeness, a child whom at other times he most tenderly caressed. I have, likewise, seen a young man that was much attached to his father, commit acts of outrage, and even at- tempt to strike at him, when under the influence of this unfortunate disease, ^

I could mention several instances of maniacs, of known intregity and honesty during their intervals of calmness, tvho had an irresistible propensity to cheat and to ste^l upon the accession of their mania^ cal paroxysms. /-^^

Another maniac, who was naturally of a very mild and pacific disposition, appeared to be inspired by the demon of mahce and mischief during the whole period of his attaqk. His time and faculties were

■^ ■ . to'-. . : < -^ . ._ ■

21

then employed in the most mischievous activity; shutting up his companions in their own rooms, and seeking every means of insulting and quarrelling with them. Some are actuated by an instinc- tive propensity to commit to the flames every thing of a combustible nature; a propensity which, in most instances, must no doubt be ascribed to an error of the ima^inationr^ A madman tore and de- stroyed the furniture of his bed, (bed-clothes and straw,) under the apprehension that they were heaps of adders and coils of writhing serpents. But, amonffst madmen of this description, there are some whose' imaginatiops .are in no degree affected, but who feel a blind and ferocious propensity to imbrue their hands in human blood. I mention this cir- cumstance upon the authority of one of my patients, in whose veractiy I had the utmost confidence, and who during one of his lucid intervals confided to me the fatal acknowledgement.

To complete this account of automatic atrocity, I shall just mention the instance of a madman who directed his fury towards himself as well as against other people. He had taken off his own hand with a chopping knife, previous to his admission into the liospital; and, notwithstanding his close confinement, be made constant ejDTorts to mangle his own ihighs

X

?2

with his teeth, (b) This unfortunate man put aa end to his existence in one of his fits.

DIFFERENT LESIONS OF THE FUNCTIONS OF THE UNDER- STANDING DURING PAROXYSMS OF INSANITY.

8. In order to trace analytically, and to arrive at the sources of human knowledge upon the subject of perception, Condillac supposes an animated statue which he endovs/s successively with the functions of smell, taste, hearing, sight and touch, and refers to each its appropriate impressions and ideas. It can- not be doubted, that to consider the faculties of the mind separately, would equally contribute to facili- tate the study of pneumatolygy, as well as lead to very important knowledge, in regard to the nature and varieties of insanity. In some instances of

(b) A young man, ^s^ho had become insane in consequence of long con- tinued intoxication, made violent efforts to maim himself, and especially to pull out ^s right eye, which appeared to give him great offence and a slight degree of pain. Rest, temperance, seclusion, the application of half a do- zen leeches to the temples, and a few doses of opening medicines, restored him, in about a fortnight, to the full possession of his faculties. T.

23

mental derangement, all the powers of the mind ar« either absolutely enfeebled or more than usually ex- cited. In other instances, the change or perversion affects but one or a few of the intellectual faculties, while the others are found to acquire a new degree of developement and activity. It is not uncommon, to see maniacs absorbed by one idea exclusively. Thus occupied, they remain motionless and silent in a corner of their apartment, repel with rudeness the services that are offered to them, and betray, in all their features, the marks of a fixed stupidity. Others, during their paroxysms, are incessantly agi- tated : — they laugh, cry and sing by turns, discover a most versatile mobility, and are not able to fix their attention for a single moment..

I have seen some maniacs refuse nourishment from superstitious and other motives with a most invinci- " ble obstinacy. Terrified by the imperious and me- nacing threats of their guardians, they at length come to a kind of dilemma, whether to render them selves criminal in the sight of God, or to expose themselves to ill treatment. At last, they yield to fear and accept the proferred food. Thus do they prove themselves capable of drawing comparisons between two evils, and of choosing the least. There are others, however, who are not capable of institut- ing such comparisons, but are constantly rivetted to

24

one leading idea ; perhaps the original cause oxid

object of their hallucination. The faculty of judge- ment appears, in some instances of periodical insani- ty, to be entirely obliterated: — in others it is eminently vigorous and active. The patient re- plies to the enquiries of the curious with an air of moderation and calmness, and, in general, if not al* ways, with great pertinence and accuracy. But if he receive or imagine any offence, he throws him- self into the most violent fits of anger and fury 5 which, indeed, he will likewise indulge in whenever he finds himself at liberty from the confinement of his chamber, or the controul of his keeper, (c) This species of insanity is indeed so common, that I have seen eight instances of it in the asylum at one time. From its leading character it has acquired in France the name of folic raisonante. It would be endless to speak of the numerous errors of the imagination, the fantastic visions, and ideal transformations into

(c) The reader must recollect the deplorable excesses which were com- mitted by the maniacs, who, among others that were lodged in confine- ment, were so preposterously set at liberty on the 2d of September, iu the second year of the republic.

25

o-enerals, {d) monarchs and divinities, and such other illusions that form the characters of hypochon- driacal and maniacal affections. In insanity, which frequently is only hypochondriasis and melancholia in a state of high developement, we must expect to meet with similar exhibitions of a disordered fancy.

The faculty of memory is likewise variously affected. In some instances it is entirely abolished, inasmuch that the patient in his lucid intervals retains not the least recollection of his extravagant and inconsistent actions^ But, on the other hand, there are others, who can retrace with great accuracy all the circum- stances of the paroxysms,— all the absurd positions which they maintained, and all the violence of pas- sion in which they indulged. Thus situated they be- come gloomy and silent for many days ; they with- draw for retirement into the remotest, part of their house or chamber, and are penetrated with remorse

(d) I have seen, in the Asylum de Bicetre, four madmen, who believed |

themselves in possession of the supreme power in the state, and who assum- j

ed the title of Louis XVI. Another -who thought himself Louis XIV. flat- tered me with the hopes of being one day made his chief physician. The hospital was not less richiy endowed with divine personages ; insomuch, that some of our maniacs were named after their several countries, and were cal- led the God of Brittauny, the God of the Low Countries, &c.

'X^ ^^^^ ^^2L.

26

or repentance, as if conscious of being really charge- able witli folly, criminality or extravagance.

The faculties of reflection and reasoning are visibly impaired or destroyed in the greatest tium- ber of cases< But I have seen some, where either or both of those faculities have retained all their energy, or have recovered themselves speedily upon an object presenting itsc-lf calculated to at- tract and to fix the attention, I engaged a per- son of this class, naturally of excellent parts, to write a letter for me at a time when he was main- taining very absurd and ridiculous positions. This letter, which I have still by me, is full of good rea- soning and good sense. A silversmith, who had the extravagance to believe that he had exchanged his head, was at the same time infatuated with the chi- mera of perpetual motion. He got his tools and set to work with infinite resolution and obstinacy. It may be easily imagined that the discovery in ques- tion was not made. There resulted from it, how- ever, several very ingenious pieces of machinery — such as must have been effects of the profoundest com- binations. Do those facts consist with the doctrine of the unity and individuality of the seat and principle of the human mind ? If not, what then must become of the thousands of volumes which have been written on metaphysics ?

27

MANIACAL PAROXYSMS CHARACTERISED BY A HIGKt DEGREE OF PHYSICAL AND MENTAL ENERGY.

9. It is to be hoped, that the science of medi- cine will one day proscribe the very vague and inac- curate expressions of "imag;'es tracedin the brain, the unequal determhiation of blood into different parts of this viscus, the irregular movements of the ani- mal spirits," &G. expressions which are to be met with in the best writings that have appeared on the human understanding, but which do not accord with the origin, the causes, and the history of insanity. The nervous excitement, which characterises the greatest number of cases, affects not the system phy- sically by increasing muscular power and action only, but likewise the mind, by exciting a consciousness of supreme importance and irresistible strength. En- tertaining a high opinion of his capacity of resistance, amaniac often indulges in the most extiavagant flights of fancy and caprice ; and, upon attempts being made to repress or coerce him, aims furious blows at his keeper, and wages war against as many of the ser- vants or attendants as he supposes he can well mas- ter. If met, however, by a force evidently and convincingly superior, he submits without opposi- tion or violence. This is a great and invaluable se-

;^.-^.v <^^-t ;^ ,:^-w-^ ^ ^^^^

fi'C^ *-^-s^*

28

cret in the management of well regulated hospitals, I have known it prevent many fatal accidents, and contribute greatly towards the cure of insanity. I have, however, seen the nervous excitement in ques- tion, in some few instances, become extremely ob- stinate and incoercible.

A maniac, who had been calm for several months, was suddenly seized by a paroxysm of his unfortu- nate complaint. His eyes, darting and protuberant, expressed the commotions within -, — his face, neck and bosom, assumed a purple hue; — he thought, that he saw the sun at the distance of four paces ; — said, that he felt an indescribable motion in his head, analo- gous to that of gurgling or boiling. Upon the occur- rence of this symptom, it was his custom to warn his friends, of the necessity of a speedy confinement, as he no longer retained the command of his temper nor conduct. He continued throughout his paroxysm to be violently agitated ; supposed that he saw the sun by his side ; spoke with extreme volubility, and betrayed every symptom of disorder and confusion ia his ideas. It sometimes happens that the re- action of the epigastric region upon the functions of the understanding, is so far from oppressing or ob- scuring them, that it appears even to augment their vivacity and strength. The imagination is ex- alted to the highest pitch of developement and fe-

29

cundity. Thoughts the most brilliant and ingenious, comparisons the most apt and luminous, give to the maniac an air of supernatural enthusiasm and inspira- tion. The recollection of the past appears to unroll with great rapidity, and what had long been not thought of and forgotten, is then presented to the mind in glowing and animated colours.

I have frequently stopt at the chamber door of a literary gentleman, who, during his paroxysms, ap- peared to soar above the mediocrity of intellect which was habitual to him, solely to admire his newly ac- quired powers of eloquence. He declaimed upon the events of the revolution with all the force, the dignity, and the purity of language that the very interesting subject could admit of. At other times, he was a man of very ordinary abilities. (<?) The elevation of mind, produced by the nervous ex-

(e) A madman, that was cured by the celebrated Dr. Willis, has given us the following account of his own case :

" I always expected with impatience the accession of the paroxysms ; since I enjoyed during their presence a high degree of pleasure. They lasted ten or twelve hours. Every thing appeared easy to me. No obstacles p<esented themselves, either in theory or practice. My memory acquired all of a sud- den a singular dgree of perfection. Long passages of latin authors recurred to my mind. In general I have gtea' difficulty in finding rhythmical termi- nations ; but then 1 could write in verse with as much facility as in prose. I was cunning, malicious, and fertile in all kinds of expedients."

30

citement now under consideration, while it is as-^ sociated with the chimerical consciousness of pos- sessing supreme power or attributes of divinity, inspires the patient with the most extatic feel- ings, with a sort of inchantment or intoxication of happiness. A madmaUj who was confined at a pension-house in Paris, wtenever his insane fits came on, believed himself to be the prophet Maho- met. He then assumed a commanding attitude and the tone of an embassador from the most high. His looks were penetrating and expressive, and his gait was that of majesty. One day, when there was a heavy cannonade at Paris, in celebration of some political event, he seemed firmly convinced that it was intended as a tribute of homage to himself. He enjoined silence around him, could not contain his joy, and he resembled the ancient prophets in their pretensions and manners.

ARE ALL LUNATICS EQUALLY CAPABLE OF SUPPORTING THE EXTREMES OF COLD AND HUNGER?

10. A GREAT degree of muscular power, and a capacity of supporting with impunity the extremes of cold and hunger, are effects, or at least proper- ties of the nervous excitement of maniacs, that ai"e

31

W equally frequent and remarkable. This, however, like many other general truths, has been too fre- quently applied to all kinds and periods of insanity. I have seen some instances of muscular energy that impressed me with the idea of a strength almost su- pernatural. The strongest bands yielded to the ef- forts of the maniac, and the ease with which it was done, often surprised me more than the degree of resistance that was overcome. But this energy of muscular contraction is far from being common to all the species of insanity. In many instances, on the contrary, there is present a considerable degree of muscular debility. General propositions have, like- wise, been too often advanced in regard to the capacity of maniacs to bear extreme hunger with impunity. I have known several, who were voracious to a great degree, and who languished even to fainting from want or deficiency of nourishment. It is said of an asylum at Naples, that a low spare diet is a funda- mental principle of the institution. It would be dif- ficult to trace the origin of so singular a prejudice. Unhappy experience, which I acquired during sea- sons of scarcity, has most thoroughly convinced me, that insufficiency of food, when it does not altoge- ther extinguish the vital principle, is not a little calculated to exasperate and to prolong the dis-

32

ease. {/) One of the most dangerous symptoms in some cases of periodical insanity, is the obstinate re- fusal of food J a refusal, which 1 have known some maniacs persist in for four, seven, and even for fif- teen days together. To conquer so blind and so dangerous an. obstinacy, deserves the utmost atten- tion, address and sagacity on the part of the medi- cal and other attendants. It fortunately happens that patients thus affected will in general drink rea- dily and copiously ; a disposition which it is' the du- ty of the physician most freely to indulge. ^

The constancy and facility with which some ma- niacs support severe and long continued cold, appear to favour the supposition of a singular degree of in- tensity of the animal heat. It is not, however, very easy to ascertain this fact b3^the thermometer, as the experiment can be made and repeated with ac- curacy only during the intermissions o.f^^the disease.

.. — ^

(J) Before the revolution, the daily allowance of bread was only 1/5. The distribution was made in the morning. It wag^idevoured in an instant. The remainder of the day was spent in a delirium 'of hunger. In the year 1792, the allowance was increased to 2lh. and the distribution was made in the morning, at noon and at night, with some soup carefully prepared. This, no doubt, is the cause of tfTe difference of mortality observable on accurately consulting the register. Out of one hundred and te^j^maniacS received into the hospital in 1784, fifty-se^en died. The proportion in 1788, was ninety- five in oi]e hundred and fifty-one. On the contrary, during the second and third year of the republic, the proportion of deaths was as one to eight.

SB

In the month Nivose, (December and January,) of th^^ year S, when the thermometer marked very low degrees of atmospheric temperature, a ma- niac Cfmld not bear his clothes on, which were of flannel — so rapid was the evolution of the natural heat of the system, He sat up whole nights toge- ther ui his chamber, with no other covering than his shirt ; and, no sooner was the door opened in the morning, than he ran in that condition to the inte- rior court of the hospital, where he seized upon handsful of snow, and applied it to, and left it to melt on his naked bosom. This process appeared to give him unspeakable delight and satisfaction, (g) Such a propensity for applying, and capacity of re- sisting the effects of cold, are however, by no means universal. There are many, on the other hand, who are affected severely by cold, even during their ac- cessions. How common is it in the winter season to see the patients at lunatic hospitals crowd about the fire? Seldom has a whole year elapsed,, during which no fatal accident has taken place at the Asy- lum ye Bicetre, from the action of cold upon the es^^emities. y^

(g) Une sorte de delectation, et comnie on respireroit 1' air frais durant la canicitle. V%' ■

34

DEBILtTY, A FREQUENT SYMPTOM TOWARDS THE DE- CLINE OF MANIACAL PAROXYSMS; AND THE DANGER. THENCE TO BE APPREHENDED.

11. The singular reciprocities and correspond- ence between the active and the intellectual powers of the mind, are not less remarkable towards the decline and termination of maniacal paroxysms, than during their progress, I have known the patient, in some instances, forget his situation, and solicit per- mission to go to the interior court of the hospital at unseasonable hours and in improper states of mind. The keeper must, at those times, give evasive answers, direct the attention to other objects -, and, by such address as it is his peculiar duty to cultivate, avoid, as far as possible, every cause of irritation. But, there are some maniacs who are fully sensible of their situation j and who request, under the influence of that impression, that their confinement be prolonged -, frequently observing, that they still feel themselves under the dominion of their impetuous propensities. They speak with great coolness of the decreasing violence of their complaint; and prognosticate, of- ten with great accuracy, the happy time when it will be no longer necessary to bound their wishes

35

or to restrain their persons. The power of distin- guishing between these very nice and important varieties of the disease, can only be obtained by great skill, industry and experience. But, these are qualifications which the keepers and managers of lu- natic institutions ought eminently to possess.

Paroxysms of insanity, which continue with more or less violence during the whole of summer and the greatest part of autumn, seldom fail to induce a considerable degree of exhaustion. The high ex- citement, so lately characteristic of active mania, is now exchanged for a languor approaching to syn- cope, a general sense of lassitude, extreme confu- sion of ideas, and in some instances a state of stu- por and insensibility, or rather a gloomy morose- ness, accompanied by a most profound melancholy. The patient lies in bed extended and motionless, without a wish or an effort to leave it. His looks are altered and his pulse is feeble and depressed. It now becomes the duty of the keeper to redouble his vigilance. If the weather be very cold, there is the utmost danger to be apprehended. Artificial heat must be speedily applied, and what is generated by the natural processes of the system, must be confin- ed by an additional number of blankets or other clothing. Cordials and tonics are particularly indi-

36

cated, Should this sudden change take place in the night, it may be fatal before morning : — a circutn- stance which renders it a duty of seri6us and impor- tant obligation upon the directors of lunatic asylums, to furnish their respective institutions with faithful and zealous servants, who shall see the patients fre- quently in the course of the night, especially at the commencement of the winter season. Great atten- tion is paid to this branch of domestic police at the Asylum de Bicetre.

An Austrian prisoner was brought to the above hospital, who continued for two months in a state of violent and perpetual agitation, singing or crying without ceasing, and breaking to pieces every thing that came in his way. His appe- tite vvas so voracious that he ate 41b of bread daily. On the night of the third of Brumaire, (Oct. 25,) of the third year of the republic, the paroxysm sub- sided. In the morning he was observed to be in the full possession of his reason, but in a state of ex- treme debility. After breakfast he walked for a short time in the court. On returning to his apartment in the evening, he complained of a sense of chillness, which we endeavoured to remedy by increasing his bed clothing. The keeper on going his round, some hours afterwards, found this unfortunate man dead in

37

his bed, in the position in which he had left him. (h) Another poor man fell a victim on the same night to the severity of the weather, notw^ithstanding the frequent visits of the keeper.

ARE PERSONS WHO HAVE RECOVERED FROM THTS DIS- EASE SUBJECT TO RELAPSES, AND WHAT ARE THE PREVENTATIVES OF SUCH RELAPSES ?

l2. A WISE man is cautious how he becomes the echo of a commonly received opinion. He dis- cusses it freely, and adopts or rejects it on the evi- dence solely of facts. Such an opinion, is that which prevails in regard to the incurable nature of insanity. Such, therefore, are the tests by which it ought to be tried. It is of some importance to ascertain, how far this generally received notion accords with the

(h) 1 find by my memorandums, that the month Vendemiaire, (which includes the latter part of September and the principal part of October,) of the thiid year was temperate. On the 29ih of the same month, (Oct. 21,) the thermometer stood at eight degrees above the freezing point. On the Sd Brumaire, (Nov. 14,) the wind changed to the North, the cold was pierc- ing, and the next morning the quicksilver was scaicely one degree above the freezing point.

38

facts which have been observed in well regulated hospitals in England and France.

The acute sensibility which generally character- ises the temperaments of maniacs, and which ren- ders them susceptible of the liveliest emotions both of pleasure and pain, renders them likewise liable to relapses. But this consideration ought to operate upon such as are subject to this complaint, as an ad- ditional inducement to subdue their passions by the dictates of wisdom, and to fortify their minds by the precepts of enlightened morality. The writings of Plato, Seneca and other philosophers of antiquity, will be found of more eminent service in the pre- vention of insanity than any phannaceutical formulae of tonics and antispasmodics. Besides this treatment exclusively moral, it will be proper to use every means of prevention approved of by experience ; to adopt every necessary precaution, especially in the summer season ; to fix the attention upon some labo- rious o^ interesting occupation ; to suppress, during the patient's convalescence, all his whims and ca- prices, by inflexible firmness, without forgetting the general propriety of mildness both of tone and beha- viour; to proscribe intemperance of every descrip- tion ; to remove, if possible, eveiy cause of sadness or passion; and finally, a circumstance of great importance, to prevent his

89

from the hospital, {i) The experience of many years has convinced me of the utiHty of these pre- cautionary measures for diminishing the frequency of relapses.

It may here be observed, that out of twenty-five cures performed at Bicetre, during the second year of the repubhc, we have had but two instances of relapse, which were caused ; the one, by ennui and chagrin ; and the other, after five years* enjoyment of perfect health and reason, by the recurrence of a profound melancholy, — the original cause of the dis- ease.

ARE NOT MANIACAL PAROXYSMS THE EFFECTS OF A SALUTARY REACTION OF THE SYSTEM?

13. The celebrated Stahl, in his views and treat- ment of fever, soared above the petty province of

(i) When convalescents are prematurely dismissed from establishments *f this description, at the instance of vreak relations, relapses are to be appre- hended, and, in fact, frequently take place. The cure in these cases being imperfect, can reflect no discredit upon the principles of treatment; which, indeed, if attended to for a sufficient length ef time, may be eminently and permanently success/n?.

philopharmaceutic medicine to the general cohsider-^ ation of a principle of conservation, whose olhee it is to repel any attack upon the system injurious to its well being, or fatal to its existence. May not the same principle be applied to the theory of insan- ity ? In the beginning of this complaint an Unusual sensation is felt in the epigastric region, symptom- atic it would appear of some great commotion in the jcentre of the system ; which, upon repetition, is felt to ext:^d__j;S_fei;_asJbe 3bdominal_plexus, and to produce a spasmodic oppression of the prsecordia, heat of the bovveis and costiveness ./^CSoonafter, a general readtiM'ts''exciTed^"'s'tronger or weaker ac- cording to the sensibility of the individual. The face becomes flushed, the circulation quicker, and the epi- gastric powers appear to receive a secondary impulse very different from the first in its nature and effects. Muscular irritability is now greatly increased, and the understanding itself is involved in the movements which nature has established for throwing off the dis- ease. Several of the functions are either wholly or partially changed : — some times they are impaired, some times increased in their energy. In the midst of these disturbances the gastric and abdominal af- fections, after having continued some time, cease, A ealm succeeds and brings with it a recovery more or less permanent.

41

If the paroxysm has not arisen to the degree of energy necessary, the same circle of action is again repeated and continued periodically, diminishing gradually in violence, until a complete recovery is established. Out of thirty-two madmen, with irre- gular periodical insanity, twenty-nine were restored : some by a prompt suppression, others by a progres- sive diminution in the violence and duration of the paroxysms. The remaining three continued to be visited by fits of increasing violence, until nature, at length exhausted, gave up the dismal conflict. Is it not probable, that in those unfortunate cases, the general and salutary laws of the vis conservatrixj were impeded in their action by some organic lesion of the nervous system } We meet with analogous exceptions in fevers, botb of the intermittent and continued type, [k)

{k) It is ridiculous to speak of the numerous instances in which fevers terminate fatally, as exceptions to the generally salutary influence of the vis medicatrix naturx. If the vires nature be the great agents in exciting the commotions virhich constitute fever, as the Stahlian theory supposes; then are they to be deiirecated both by the phvsician and his patient, since ieath is incomparably oftener the effect of the fever than of its originally ex- citing cause ? It is a matter (if astonishment, that the fatality of fevers in every climate of the globe, has allowed so flimsy an hypothesis to fetter the minds and the practice of physicians for so many years. How many thou- sands of lives have been lost while the medical attendant has been indolentlj'. waiting upon the coctions and concoctions of the vis medicatrix natuxE : A day lost, is often life lost. See Currie's reports. T.

F

42

I might here enumerate many other incontestible facts in favour of the salutary effects of paroxysms of periodical insanity. A few shall suffice ■ — Five young men, between the ages of eighteen and twenty-eight, were admitted at Bicetre, whose in- tellectual faculties appeared really obliterated They continued in that state, some for three months, some for six, and others for more than a twelve-month. After those intervals of different duration, they were .severally attacked by a paroxysm of considerable vio- lence, which lasted from fifteen to twenty-five days; after which, they recovered the perfect use of their reason. It would, however, appear, that it is only during the vigour of youth, that the sj'stem is sus- ceptible of the reaction which has been described to any very salutary extent, since I cannot recollect more than one instance of a cure after the age of for- ty, during my official attendance at the Asylum de Bicetre.

I may now presume upon the reader's acquies- cence, when I assert, that paroxysms of active insan- ity are, in some circumstances, to be hailed as salu- tary efforts of nature to throw off the disease. It is only when periodical mania, whether regular or irre- gular, threatens, from the increasing violence and duration of the fits, to become fatal or to degenerate into continued insanity, that we ou^ht to seek the

43

aid of poweiful medicaments. Tiie remedies then to be used are the bath, shower bath, opium, camphire, and other antispasmodics, whose efficacy appear to be agreed upon, but whose operation still remains to be elucidated, notwitlistanding the briUiant theories of Dr. Brown.

THE GREAT DIFFICULTY OF SECURING THE CONCURRENCE OF ALL CIRCUMSTANCES FAVOURABLE TO THt CURE OF INSANITY, WHETHER IN PRIVATE ASYLUMS OR IN PUBLIC HOSPITALS.

14. We cannot help regretting the lot of the hu- man species, when we consider the frequency and the innumerable causes of insanity, together with the great variety of unfavourable circumstances to which lunatics are exposed, even in the best orga- nized institutions. To attempt the complete seclu- sion of a maniac at his own house, in the bosom of his family, is not desirable, because, not to mention many other reasons, it is seldom practicable : and, on the other hand, there are objections to the system of public hospitals, arising from the diffi- culty of commanding the services of able officers and faithful domestics. How many rare qualities, what zeal, what sagacity, the union of how much

44

firmness, with mildness of manners and unaffected goodness of heart, is it not requisite to possess, in order to manage, with complete success, such un- tractabie beings as lunatics generally are, — subject to so many odd fancies, ridiculous whims and transports of blind and ungovernable passions? In order to foresee the approach of their paroxysms, how neces- sary the united apphcation of vigilance and expe- rience(/). Constant_attention must be paid to the conduct of domestics, in order, frequently, to re- press their_cruelt^]and to punisli their^ negligence. lEvery cause, calculated!^ irrjtate^e temper, and to exasperate the delirious excitement, must^eaiauti- ously removed, llie state of debility and atony, whicirirequentTy succeeds to paroxysms of active in- sanity, must be sedulously watched and obviated with judgement and promptitude; and lagtly, every fa- vourable opportunity, presented during the intermis- sion, of preventing the accession of new paroxysms.

(7) It will not be improper to observe, that a decoction of endive, with a few drams of the sulphate of magnesia, is a highly efficacious preventative of paroxysms of periodical insanity. This remedy is to be given upon the first appearance of the precursory symptoms enumerated in page 17, and repeated for some time. In a few bad cases, where a flushed counten- ance and tensionof the veins announced an approaching explosion, I have prescribed copious bloodletting, which, however, I have never done during the paroxysm. During the intervals of this complaint, the best prophylae- .tics are exercise arid good diet.

45

or of connteratcting their violence, must be carefullj- seized and improved. These are the duties, and highly important they are, which pecuUarly belong to the governor. There are others, however, and they are certainly of no less importance, which as they are connected with the character and province of the physician, it is not my intention in this place to enlarge upon. Let it suffice to remark, that, the object to be obtained, deserves the united exer- tion of all the talents that can mutually consist and co-operate.

THE VARIETY AND PROFUNDITY OF KNOWLEDGE REQUI- SITE ON THE PART OF THE PHYSICIAN, IN ORDER TO SECURE tJUCCESS IN THE TREATMENT OF INSANITY.

15. The time, perhaps, is at length arrived when medicine in France, now liberated from the fetters imposed upon it, by the prejudices of custom, by interested ambition, by its association with religious institutions, and by the discredit in which it has been held in the public estimation, will be able to assume its proper dignity, to establish its theories on facts alone, to generalise those facts, and to maintain its level with the other departments of natural history.

The principles of free enquiry, which the revolution has incorporated with our national politics, have opened a wide field to the energies of medical philo- sophy. But, it is chiefly in great hospitals and asy- lums, that those advantages will be immediately felt, from the opportunities which are there afforded of making a great number of observations, experi- ments, and comparisons Such are the opportunities, of which my situation at the Asylum de Bicetre has put me in the possession. How far I have improv- ed them I leave to the judgement of the reader. My office is highly responsible and important, and in- volves in it various branches of knowledge, which are, too generally, neglected in the education of a physician. Amongst others of this class, the know- ledge of the hunian passions, which are to be studied in the lives of men distinguished for their love of glo- ry, their enthusiasm for letters, for the ime arts, for their monastic austerities, or for any great feature of character that has engaged their own passions or attracted the admiration of mankind, deserves pecu- liar attention.

In order to trace the numerous changes and per- versions of the human understanding with success.^ it will, likewise, be found advantageous to cultivate an intimate acquaintance with the writings of l.ocke and Condillac.

47

The history of insanity claims alliance witbrthat^of alf the errors and delusions of" ignorant credulity ; — with those of witchcraft, demoniacal possession, mi- i-aclesToi'acles and divination. As such, these are sub- jects by no means unvvorthy the consideration of a medical philosopher ; and, especially of him, whose peculiar office it is, to administer health and consola- tion to minds distressed and diseased. Information, from whatever source, merits acceptance , but occa- sionally it must be sought, where ordinary enqui- rers are either unable or too indolent to look for it.

Rosseau, in a fit of causticity and ill humour, in- vokes the goddess of medicine and intreats her to pay him a visit unattended by the physician. He woukl have rendered more service to humanity, if he had exalted his eloquent voice against presump- tuous empyricism, and called talent and genius to the study of a science of which it is of infinite impor- tance to acquire a profound and intimate know- ledge.

SECTION 11.

THE MORAL TREATMENT OF INSANITY.

MORAL TREATMENT PARTICULARLY INSISTED UPON BY THE ANCIENTS.

16. TO repeat the maxims which were delivered by the ancients upon the art of treating maniacs with kindness, firmness and address, can throw but- little light upon the moral management of insanity. Those precepts are only of partial utilit}^, as long as the nosology of the disease is not established upon clear and extensive views of its causes, symptoms and varieties. The influence of seasons and cli- mates, the peculiarities of temper, character and capacity of the individual, together with the pre- cise nature of the hallucination, are circumstan- ces which must never be omitted in the study and treatment of mental derangement. Luminous his- tories of the disease, and candid reports of the indin cation and application of remedies, whether success*-

49

ful or otherwise, from men of acknowledged sagaci ty and experience, and all with a reference to the circumstances above enumerated, might, perpi.aps, in time contribute to place this branch of the heal- ing art upon a level with its kindred pursuits.

HAVE THE ENGLISH PUBLISHED ANY NEW RULES ON THE MORAL TREATMENT OF INSANITY ?

17. English ph}'sicians give themselves credit for a great superiority of skill in the moral treatment of insanity; and their success, frequently under the veil of secrecy, has given a sanction to pretensions to which they have no just nor exclusive claims. I have for the last fifteen years paid considerable at- tention to the silbject, and consulted all the works which have appeared updn it in''the English language, as well as the reports which English travellers and physicians havie published, in regard to their numer- ous lunatic establishments. I have discovered no secret ; but, I approve of their general principles of treatment. Of the celebrated \Villis it has been said, that the utmost sweetness and affability is the usual expression of his countenance. But, when he looks

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a maniac in the face for the first time, he appears instantly to change character. His features pre- sent a new aspect, such as commands the respect and attention, even of lunatics. His looks appear to penetrate into their hearts, and to read their thoughts as soon as they are formed Thus does- he obtain an authority over his patients, which af- terwards co-operating with other means, contribute to restore them to themselves and to their friends.^* But Dr. Willis' general principles of treatment, are no where developed, and applied to the cha- racter, intensity and varieties of insanity. Dr. Arnold's work upon this subject, which he published in London, in 1786, is principally a compilation from different sources, — scholastic divisions, more calculated to retard than to accelerate the progress of science, (m) And as to Dr. Harper, who, in his preface, announces an intention of departing from the beaten path ; Does he fulfil his promise, {n) and is not his work more of a commentary upon the doctrines of the ancients than an original produc- tion upon mental indications? Again, I cannot

(m) Dr. Arnold's nosography of insaniiy, (for it is little more) is perhaps, the best ■work that has appeared xipon that subject. It is to be hoped, that in the edition which is now preparing for publication, he will favour the world with a full and candid exposition of his principles of treatment. T,

(rt.) A treatise oa the real cause and cure of insanity. Sec. London, 1789.

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h-^lp admiring the courage of Dr Crichton, who has lat; ly published two volumes upon maniacal and me- laacholic affections, merely upon the basis of some ing 'nious elucidations of the doctrines of modern phy- siology, which he extracted from a German journal, and which he accompanied by a description of the moral and physicial effects of the human passions, [o) I respect Dr. Fowler's little essay, upon his establish- ment in Scotland, for the pure and elevated princi- ples of philanthropy which it contains, and which are applied with great felicity to the moral treatment of insanity. But, I do not find that he has advanced any thing new upon the subject.

THE AUTHOR S INDUCEMENTS TO STUDY THE PRINCIPLES OF MORAL TREATMENT.

18- All civilised nations, however different in their customs, and manner of living, will never fail to have some causes of insanity in common ; and, it is natural to believe, that all will do their utmost to remedy the evil. Why may not

(o) An -enquiry into the nature and origin of mental derangement, &c. iouQon, 1799.

France, as well as England, adopt the means, from the use of which, no nation is by nature proscribed, and which are alone discovered by observation and experience ? But success, in this department of me- dical enquiry, must depend upon the concurrence of many favourable circumstances. The loss of a friend, who became insane through excessive love of glory, in 1783, and the inaptitude of phanmaceutic preparations to a mind elated, as his was, with a high sense of its independence, enhanced my admiration of the judicious precepts of the ancients, and made me regret that I had it not then in my power to put them in practice.

About that time I was engaged to attend, in a professional capacity, at an asylum, where I made observations upon this disease for five successive years. My opportunities for the application of moral reme- dies, were, however, not numerous. Having no part of the management of the interior police of that insti- tution, I had little or no influence over its servants. The person who was at the head of the establishment, had no interest in the cure of his vtealthy patients, and he often, unequivocally, betrayed a desire, that every remedy should fail. At other times, he placed exclusive confidence in the utility of bathing, or in the eiTicacy of petty and frivolous recipes. The administration of the civil hospitals, in Paris, open-

53

ed to me in the second year of the republic a wide field of research, by my nomination to the office of chief physician to the national Asylum de Becetre, which I continued to fill for two years. In order, in some degree, to make up for the local disadvantages of the hospital, and the numerous inconveniences which arose from the instability and successive changes of the administration, I determined to turn my attention, almost exclusively, to the subject of moral treatment. The halls and the passages of the hospital were much confined, and so arranged as to render the cold of winter and the heat of summer equally intolerable and injurious. The chambers were exceedingly small and inconvenient. Baths we had none, though I made repeated applications for them i nor had we extensive liberties for walking, gar-' dening or other exercises. So destitute of accommo- dations, we found it impossible to class our patients according to the varieties and degrees of their respec- tive maladies. On the other hand, the gentleman, to whom was committed the chief management of the hospital, exercised towards all that were placed ua- der his protection, the vigilance of a kind and affec- tionate parent. Accustomed to reflect, and posses- sed of great experience, he was not deficient either in the knowledge or execution of the duties of his office. He never lost sight of the principles of a most genuine philanthropy. He paid great atten-

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tion to the diet of the house, and left no opportunity for murmur or discontent on the part of the most fas- tidious. He_exercised„a strict disci pHne over the con-

duct of the domestics, and punished, with sev^ty, every instance otill treaTment, and every act of vio- lence, of which they were guilty towards those vvhom ifwas merely theJFHuty to~l;erve. He was both es- teemed and feared by every maniac; for he was mild, and at the sameT,imeiullexibl}' hiiii' In a word, he was master of every brariclfoF his art, from its simp- lest to its most comphcated principles. Thus was I introduced to a man, whose friendship was an in- valuable acquisition to me. Our acquaintance ma- tured into the closest intimacy. Our duties and inclinations concurred in the same object. Our conversation, which was almost exclusively profes- sional, contributed to our mutual improvement. With those advantages, I devoted a great part of my time in examining for myself the various and numerous aifections of the human mind in a state of disease. I regularly took notes of whatevei' appear- ed deserving of my attention ; and compared vvhat I thus collected, with facts analogous to them that I met with in books, or amongst my own memoran- da of former dates. Such are the materials upon which mv principles of moral treatment are foundt^l.

S5

CANDOUR IN THE EXPOSITION OF FACTS.

19 I cannot help congraltuating;- those Sfentle> men, who feel no difficulties in the treatmpnt of any disease to which the human frame is subject, and who are ever ready to entertain us with the relation of their incomparable successes. Ostentation, like this> is doubtless dictated by a spirit of empyricism, _uQ' wortliyTlie character of persons who have jll^^^j^ ^^- tained to public esteem snd celebrity. We are in- formed, that Dr. Willis cures nine lunatics out of tenV The doctor, however, gives us no insight into the nature and peculiarities of the cases in which he has failed of success , and if his failure in the case of the Queen of Portugal had not been made a subject of public notoriety, it likewise, would, probably, have been buried in the profoundest silence. He who cul- tivates the science of medicine, as a branch of natu- ral history, pursues a more frank and open system of conduct, nor seeks to conceal the obstacles which he meets with in his course. What he discovers, he feels no reluctance to shew ; and the difficulties which he cannot master, he leaves, with the impression of his hand upon them, for the benefit of his successors in the same rout. Impressed with the importance of this truth, I proceed to detail a case of insanity imsuccessfully treated.

'jhj^**-^^ -y^-^

^-^i^^i^^i^

S6

A CASE OF INSANITY, IN WHICH IT IS PROBABLE, THAT MORAL TREATMENT WOULD HAVE BEEN ATTENDED WITH SUCCESS.

SO, A YOUNG gentleman, twenty-four years of ^6, endowed with a most vivid imagination, came to Paris to study the law, and flattered himself with the belief that nature had destined him for a brilliant station at the bar. An enthusiast for his own con- victions, he was an inflexible disciple of Pythagoras in his system of diet : he secluded himself from society, and pursued, with the utmost ardour and obstinacy, his literary projects. Some months after his arrival, he was seized with great depression of spirits, fre- quent bleeding at the nose, spasmodic oppression of the chest, wandering pains of the bowels, trouble- some flatulence and morbidly increased sensibility. Sometimes he came to me in a very cheerful state of mind, when he used to say, " How happy he was, and that he could scarcely express the supreme felicity which he experienced." At other times, I found him plunged in the horrors of consternation and despair. Thus, most acutely miserable, he frequently, and with great earnestness, intreated me to put an end to his sufferings. The characters of the profoundest hypochondriasis were now become recognisable in his feelings and conduct. I saw tlje

57

approaching danger, and I conjured him to change his manner of life. My advice was unequivocally re- jected. The nervous symptoms of the head, chest and bowels continued to be progressively exasperated. His intervals of complacency and cheerfulness were succeeded by extreme depression and pusillanimity ai).d terror, and inexpressible anguish. Overpow- ered nearly by his apprehensions, he often and ear- nestly entreated me to rescue him from the arms of death. At those times I invited him to accompany me to the fields, and after walking for some time, and conversing together upon subjects likely to con- sole or amuse him, he appeared to recover the en- joyment of his existence : but, upon returning to his chambers, his perplexities and terrors likewise returned. His despair was exasperated by the con- fusion of ideas to which he was constantly subject, and which interferred so much with his studies. But what appeared, altogether, to overwhelm him, was the distressing conviction that his pursuit of fame and professional distinction must be for ever aban- doned. Complete lunacy, at lengtn, established its melancholy empire. One night, he bethought him- self that he would go to the play, to seek relief from bis own too unhappy meditations. The piece which was presented, was the " Philosopher without know- ing it " He was instantly seized with the most gloomy suspicions, and especially with a con-

H

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vfctlon,, that the comedy was written on purpose and represented to ridicule himself. He accused me with having furnished materials for the writer of it, and the next morning he came to reproach me, which he did most angrily, for having betrayed the rights of friendship, and exposed him to public deri- sion. His dilirium observed no bounds. Every monk and priest he met with in the public walks, he took for comedians in disguise, di>patched there for the purpose of studying his gestures, and of discovering the secret operations of his mind. In the dead of night he gave way to the most terrific apprehensions, — believed himself to be attacked sometimes by spies, and at others, by robbers and assassins. He once opened his windovv with great violence and cried out murder and assistance with all his might. His relations, at length, determined to have him put under a plan of treatment, similar to that which was adopted at the ci-de-vant Hotel Dieu 5 and, with that view, sent him under the protection of a proper person, to a little village in the vicinity of the Pyrenees. Greatly debilitated both in mind and body, it was some time after agreed upon that he should return to his family residence, where, on account of his paroxysms of delirious extrava^ ganee, succeeded by fits of profound melancholy, he was insulated from society. Ennui and insurmount- iable di.sgust with life, absolute refusal of food, and

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dissatisfaction with every thing, and every body that came near hisn, were amoag the last ingredients of his bi[ter cup. To conclude our affecting history : he one day eluded the vigilance of his keeper ; and, with no other garment on than his shirt, fled to a iieiglibouring wood, where he lost himself, and where, from weakness and inanition, he ended his miseries. Two days afterwards he was found a cor})se. In liis hand was found the celebrated work ©f Plato on the immortality of the soul.

THE ABSENCE OF THE MEANS OF MORAL TREATMENT IN THE ABOVE CASE TO BE HIGHLY REGRETTED.

21. What important services, a young man such as has been described in the above history^ might not have rendered to society, had it been possible to restore him to himself, and to the capa- cities of intellectual exertion, for which he was so eminently distinguished. In the treatment of his case, it is true, that I had it in my power to use a great number of remedies j but, my opportunities for the employment of those means that appeared, almost exclusively ap])licable, were altogether wanU ing. At a well regulated asylum, and subject to

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tliej2}ana£[gfflen1: pf ^ajyovgrnorj in everyjrgspect qualifiedjto,£X£ldse_qverhim an irresistible controul, and toiijterrupt or divert his chain of maniacal ideas, it is possible, andeven probable^tt^Ta cure'might haver^een effected. Of successful treatment in pa- rallel circumstances, there are numerous instances recorded in the registers of the Asylum de Bicetre.

THE ESTIMABLE EFFECTS OF COERCION ILLUSTRATED IN THE CASE OF A SOLDIER.

22. A SOLDIER, who for sometime had been insane, and a patient at the Hotel Dieu, was suddenly seized with a vehement desire to join his regiment. All fair means to appease him being exhausted, coercive measures became indispensible to convey him to his chamber, and to secure him for the night. This treatment exasperated his phrenzy, and be- fore morning he broke to pieces every thing that he could lay his hands upon. He was then bound and closely confined. For some days he was allow- ed to vent his fury in solitude : but he continued to be agitated by the most violent passions, and to use the language of imprecation and abuse against every body that he saw, but especially against the govern-

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or, whose authority he affected to despise. In about a week, however, he began to feel that he was not his own master ; and, as the governor was going his round one morning, he assumed a more submissive air and tone, and requested to kiss his hand. This small favour being granted, he said, " You have promised, upon my engaging to be peace- able and quiet, to permit me to go into the in^- terior court. Now, Sir, have the goodness to keep your word." The governor, with a countenance full of sweetness and affability, expressed the very great pleasure which he felt, congratulated him on. his returning health, and instantly ordered him to be set at liberty. Further constraint would have been superfluous, and probably injurious. In seven months from the date of his admission into the hos- pital, he was restored to his family and to his coun- try, and has since experienced no relapse.

THE ADVANTAGES OF RESTRAINT UPON THE IMAGINA- TION OF MANIACS ILLUSTRATED.

213. A YOUNG religious enthusiast, who was ex:- ceedingly affected by the abolition of tlie catholic re- ligion in France, became insane. After the usual treatment at the Hotel Dieu, he was transferred to

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the Asylum de Bicetre.. His misanthropy was not to be equalled. His thoughts dwelled perpetually upon the torments of the other world ; from which he founded his only chance of escaping, upon a con- scientious adoption of the abstinences and mortifi- cations of the ancient anchorites. At length, he refused nourishment altogether; and, on the fourth day after that unfortunate resolution was formed, a state of languor succeeded, which excited consider- able apprehensions for his life. Kind remonstrances, and pressing invitations proved equally ineffectual. He repelled with rudeness the services of the attend- ants, rejected with the utmost pertinacity some soup that was placed before him, and demolished his bed, (which was of straw,) in order that he might lie upon the boards. How was such a perverse train of ideas to be stemmed or counteracted ? The excitement of terror presented itself as the only re- sourse. For this purpose. Citizen Pussin appeared one night at the door of his chamber, and, with fire darting from his eyes, and thunder in his voice, com- manded a group of domestics, who were armed with strong and loudly clanking chains, to do their duty. But the ceremony was artfully suspended; — the soup ' was placed before the maniac, and strict orders were left him to eat it in the course of the night, on pains of the severest treatment. He was left to his own reflections.^ The night was spent, (as he afterwards

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informed me) in a state of the most distressing hesi- tation, whether to incur the present punishment, or the distant but still more dreadful torments of the world to come. After an internal struggle of many hours, the idea of the present evil gained the as- cendancy, and he determined to take the soup. From that time he submitted, without difficulty, to a restorative system of regimen. His sleep and strength gradually returned j his reason recovered its empire ; and, after the manner above related he escaped certain death. It was during his con- Yalescence, that he mentioned to me the perplexities and agitations which he endured during the nio-ht of the experiment.

INTIMIDATION TOO OFTEN ASSOCIATED WITH VIOLENCE*

524. In the preceding cases of insanity, we trace the happy effects of intimidation, without severity; of oppression, without violence ; and of triumph, without outrage. How different from the system of treatment, which is yet adopted in too many hospitals, where the domestics and keepers are permitted to use any violence that the most wanton caprice, or the. most sanguinary cruel-

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ty may dictate. In tliejvritings of the ancientSa and especiallyofCelsus, a sort of intermediate and con- ditional mode of treatment is recommended, found- ed, in the first instance, upon a system of lenity and forbearance ; and when that method failed, upon corporal and physical punishments, such as confine- nient, chains, flogging, spare diet,~&c. jp) PuBlic and private mad-houses. In more modern times, have been conducted on smiilar pnnciples. "

We are informed by Dr. Gregory, that a farmer, in the North of Scotland, a man of Herculean sta- ture, acquired great fame in that district of the Bri- tish empire, by his success in the cure of insanity. The great secret of his practice consisted in giving full employment to the remaining faculties of the lunatic. With that view, he compelled all his pa- tients to work on his farm. He varied their occupa- tions, divided their labour, and assigned to each, the post which he was best qualified to fill. Some were employed as beasts of draught br burden, and others as servants of various orders and provinces, l^ear was the operative principle that gave motion and harmony to this rude system. Disobedience

(p) Ubi perperam aliquid dixit aut fecit, fame, Trincnlis plagis coercen- dus est. Cels. Lib. iil. Can. 18,

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and revolt, whenever they appeared in any of its operations, were instantly and severely punished.

A system of management analogous to the above, was adopted in a monastic establishment in the South of France. One of the inspectors visited each chamber, at least, once every day. If he found any of the maniacs behaving extravagantly, stirring up quarrels or tumults, making any objections to his victuals, or refusing to go to bed at night, he was told in a manner, which of itself was calculated to terrify him, that unless he instantly conformed, he would have to receive in the morning ten severe lashes, as a punishment for his disobedience. The threat was invariably executed with the greatest punctuality; while good conduct, on the contrary, was not less equally and punctually rewarded. Those who were disposed to behave orderly, and to observe the rules of the institution, were admitted to dine at the governor's table. But, if any one abused this indulgence, he was immediately remind- ed of it, by a smart stroke over his fingers with a ferule, and informed, with an air of great gravity and coolness, that it became him to conduct liirn- self with more propriety and reserve.

It is painful to close this sketch by a reference to

an imperfection in the treatment of insanity, by

I

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one of the most successful practitioners of any age, I allude to the practice of the celebrated Dr. Willis. In the establishment under his direction in the vici- nity of London, it would appear that every lunatic is tinder the controul of a keeper, whose authority over him is unlimited, and whose treatment of him must be supposed, in many instances, to amount to un- bridled and dangerous barbarity : — a delegated lati- tude of power totally inconsistent with the princi- ples of a pure and rigid philanthropy.

MAXIMS OF LEWITY AND PHILANTHROPY APPLICABLE TO THE MANAGEMENT OF LUNATICS.

0,5. To apply our principles of moral treatment, with undiscriminating uniformity, to maniacs of every character and condition in society, would be equally ridiculous and unadvisfeable. A Russian peasant, or a slave of Jamaica, ought evidently to be managed by other maxims than those which would exclusively apply to the case of a well bred irritable Frenchman, unused to coercion and impa- tient of tyranny. Of the unhappy influence upon -the French character of needless and vexatious op-

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position, my experience has furnished me with too many instances, in the paroxysms of rage and in- dignation, which have been occasioned at the Asy- lum de Bicetre, by the thoughtless jests and bar» barons provocations of idle and unfeeling visitors. In the lunatic infirmary, which is insulated from the body of the hospital, and which is not subject to the controul of the governor, it has frequently happened that lunatics, who w^ere perfectly com- posed ancTin a fair way of recovery, have, in con- sequence of the silly raillery and rude brutality of their attendants, relapsed into the opposite cod» dition of violent agitation and fury. Maniacs, on on the other hand, who have been transferred from the infirmary to the asylum, and represented upon their arrival as more than commonly furious and dangerous, rendered so no doubt by severe treat- ment, have, upon being received with affability, soothed by consolation and sympathy, and encour- aged to expect a happier lot, suddenly subsided in- to a placid calmness, to which has succeeded a ra- pid convalescence/^ To render the effects of fear solid and durable, its influence ought to be associ- ated with that of a profound regard. For that pur- pose, plots must be either avoided or so well man- aged as not to be discovered ; and coercion must always appear to be the result of necessity, reluc-

tantly resorted to and commensurate with the vio- lence or petulance which it is intended to correct. Those principles are strictly attended to at Bice- tre. That great hospital is far from possessing such advantages of site, insulation, extent of liberty, and interior accommodations, as that of Dr. Fowler. But I can assert, from accurate personal knowledge, that the maxims of enlightened humanity prevail throughout every department of its management j that the domestics and keepers are not allowed, on any pretext whatever, to strike a madman ; and that straight waistcoats, superior force, and seclu- sion for a limited time, are the only punishments in- flicted. When kind treatment, or such prepara- tions for punishment as are calculated to impress the imagination, produce not the intended eflect, it fre- quently happens, that a dexterous stratagem pro- motes a speedy and an unexpected cure.

A HAPPY EXPEDIENT EMPLOYED IN THE CURE OF A MECHANICIAN.

Q6. a celebrated watchmaker, at Paris, (see page 26,) was infatuated with the chimera of per- petual motion, and to effect this discovery, he set

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to work with indefatigable ardour. From unremit- ting attention to the object of his enthusiasm coin- ciding with the influence of revolutionary distur- bances, his imagination was greatly heated, his sleep was interrupted, and, at length, a complete derange- ment of the understanding took place. His case was marked by a most whimsical illusion of the im- agination. He fancied that he had lost his head on the scaffold j that it had been thrown promiscuously among the heads of many other victims ; that the judges, having repented of their cruel sentence, had ordered those heads to be restored to their re- spective owners, and placed upon their respective shoulders ; but that, in consequence of an unfortunate mistake, the gentlemen, who had the management of that business, had placed upon his shoulders the head of one of his unhappy companions. The idea of this whimsical exchange of his head, occupied his thoughts night and day; which determined his relations to send him to the Hotel Dieu. Thence he wsS transferred to the Asylum de Bicetre. Nothing could equal the extravagant overflowings of his heat- ed brain. He sung, cried, or danced incessantly; and, as there appeared no propensity in him to commit acts of violence or disturbance, he was al- lowed to go about the hospital without controul, in order to expend, by evaporation, the effervescent excess of his spirits. " Look at these teeth," ha

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constantly cried ; — '' Mine were exceedingly hand- some;— -these are rotten and decayed My mouth was sound and healthy : this is foul and diseas- ed. What difference between this hair and that of my own head." To this state of delirious gaiety, however, succeeded that of furious madness He broke to pieces or otherwise destroyed whatever was within the reach ©r power of his mischievous propensity. Close confinement became indispen- sible. Towards the approach of winter his violence abated ; and, although he contniued to be extrava- gant in his ideas, he was never afterwards danger- ous. He was, therefore, permitted, when ever he felt disposed, to go to the inner court. The idea of the perpetual motion frequently recurred to him in the midst of his wanderings 3 and he chalked on all the walls and doors as he passed, the various de- signs by which his wondrous piece of mechanism was to be constructed. The method best calculated to cure so whimsical an illusion, appeared to be that of encouraging his prosecution of it to satiety. His friends were, accordingly, requested to send him his tools, with materials to work upon, and other requisites, such as plates of copper and steel, watch-weels, &c. The governor, permitted him to fix up a work-bench in his apartment. His zeal was now redoubled. His whole attention was .rivetted upon his favourite pursuit. He forgot his

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meals. After about a month's labour, which he sustained with a constancy that deserved better suc- cess, our artist began to think that he had followed a false rout. He broke into a thousand fragments the piece of machinery which he had fabricated at so much expense of time, and thought, and labour; entered on the construction of another, upon a new plan, and laboured with equal pertinacity for another fortnight. The various parts being com- pleted, he brought them together, and fancied that he saw a perfect harmony amongst them. The whole was now finally adjusted : — his anxiety was indescribable : — motion succeeded : — it continued for some time : — and he supposed it capable of con- tinuing for ever. He was elevated to the highest pitch of erijoyment and triumph, and ran as quick as lightening into the interior of the hospital, cryinc out like another Archimedes, "At length I r ave solv- ed this famous problem, which has puzzled so many men celebrated for their wisdom and talents " But, grievous to say, he was disconcerted in the midst of his triumph. The wheels stopped 1 The perpe- tual motion ceased ! His intoxication of joy was succeeded by disappointment and confusion. But, to avoid a humiliating and mortifyii g confes- sion, he declared that he could easily remove the impediment, but tired of that kind of em- ployment, that he^ra? determined for the future

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to devote his whole time and attention to his busi» ness. There still remained another maniacal im- pression to be counteracted ; — that of the imagina- ry exchange of his head, which unceasingly recurred to him. A keen and an unanswerable stroke of pleasantry seemed best adapted to correct this fart^ tastic whim. Another convalescent of a gay and fa* cetious humour, instructed in the part he should play in this comedy, adroitly turned the conversa* tion to the subject Of the famous miracle of Saint Denis. Our mechanician strongly maintained the possibility of the fact, and sought to confirm it by an application of it to his own case. The other set up a loud laugh, and replied with a tone of the keenest ridicule : " Madman as thou art, how could Saint Denis kiss his own head ? Was it with his heels ?" This equally unexpected and unanswerable retort, forcibly struck the maniac. He retired confused amidst the peals of laughter, which were provoked at his expense, and never afterwards mention- ed the exchange of his head. Close attention to his trade for some months, completed the restoration of his intellect. He was sent to his family in per- fect health ; and has, now for more than five years^ pursued his business without a return of his com- plaint.

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tkE^ TREATMENT OF MANIACS TO BE VARIED ACCORDING TO THE SPECIFIC CHARACTERS OF THEIR HALLUCI- NATION,

Q7. QfLall the powers of the human mind, that of the hnMo-inatioM appears to bejliejnost subject to iniarv>><The fantastic iHusions and ideal trans- formations, which are by far the most frequent forms of mental derangement, are solely_ascribf«hlia to lesions of this faculty. Hence the expediency of a great variety of schemes and stratagems for remoY^ing these prepossessions. Of the numerous illusions to which the imagination is subject, the most difficult to be eradicated are those origin- ating in fanaticism. My experience on this sub- ject agrees with the reports of Enghsh autiiors. How extremely difficult to level, with his real .situation, the ideas of a man swelled up wiih morbid pride, solely intent on his high des- tinies, or thinking himself a privileged being, an. emissary of heaven, a prophet from the Almighty, or even a divine personage. What measures are likely to counteract the influence of mystic visions or revelations, of the truth of winch he deems it blasphemy to express a doubt ?

An unfortunate beino:, under the influence of this variety of mental derangement, fancied that he saw

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devils constantly about him, and one day rushed up-: on a party of visitors as upon a legion of demons. A maniac of a milder temperament invoked^ with- out ceasing, his guardian angel, or rather one of the apostles, and discharged, with great rigour, the duties of mortification, fasting and prayer. I have sometimes amused myself by conversing with ano- ther victim of fanaticism, who, like the ancient dis- ciples of Zoroaster, paid divine homage to the sun ; prostrated himself, with great devotion, before its rising splendour; and during the remaining day consecrated to it, his actions, his pleasures and his pains, {q) With this harmless enthusiast may be contrasted, one subject to more dangerous propensities, who, during the day, was generally tranquil, but at night, fancied himself surrounded with ghosts and phantoms At different times he had imaginary conferences with good and bad angels, and, according to the respective influences of those delusions, he was mild or furious, inclined to acts of beneficence or roused to deeds of ferocity. The

(o) Some of those maniacs experienced a partial abolition of their mo- ral faculties,— sunk into a gloomy taciturnity, or mused in indolent reveries^ which sooner or later terminated in ideotism. One of them, in the ^yinter of the year 3 of the republic, spent with invincible pertinacity, several nights on his knees in the attitude of prayer. Tha consequence was, that a par- tial morti cation of his feet took place. To effect a cure I was obliged to tie lum down to his bed.

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Ibllowing relation will exhibit a picture of the hor- rible excesses to which maniacal fury may be unfor- tunately subject.

A CASE OF MELANCHOLIA, WITH BIGOTRY,

S8. A MISSIONARY, by his declamatory repre- sentations of the torments of the other world, so terrified an ignorant vine dresser, that he fancied himself irrevocably condemned to everlasting perdi- tion. To rescue his family from a similar fate, he sought by his own hand to give it the claim oi mar- tyrdom upon the mercy of heaven. The seducing descriptions he had met with in the lives of saints had impressed his mind with this dangerous preju- dice. He first attempted to discharge his murder- ous duty upon his wife -, but she fortunately made her escape ere the intention was executed. Two dear little infants, however, his own children, equally helpless and unsuspicious, fell victims to his cold blooded barbarity. For these acts of vio- lence, which he deemed so meritorious in the sight of God, he was cited before the tribunal : but, during his imprisonment and before his trial came on, he contrived to immolate one of his fellov^^ prisoners as an expiatory sacrifice to the God of free and disinterested mercy. His insanity having

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been proved in court, he was condemned to perpe- tual confi) jement in one of the cells at Bicetre. His lon^ confinement, co-operating in its influence with the idea, that he had escaped death, in defiance of the sentence which he supposed the judges to have pronounced upon him, aggravated his delirum, and countenanced his belief that he was invested with om- nipotent power, or, according to his own expressions, " That he was the fourth person in the trinity," (r) " That his special mission was to save the world

(»•) To correct bis dangerous bigotry, I shall just mention one out of many inefFecti;al expedients that were tried upon him. I, one day, ordered to be brought t: gether, him and an jther convalscent of a gay character. The latter couid recite, extremely well, the poems of Racine and Voltair. Iliad desired him to get by heart Voltair's poem on natural religion, and instruct- ed him to lay great stress on the following lines, as most applicable to my purpose—

Penses-tu que Trajan, Marc Aurele, Titus, Noms chef'ris, noms sacres que tu n' as jamais lus, De r UTiivers charmed bienlaiteurs adorables, Soient au fond des eufers empaled par les diables ; Et que tu seras, toi, de rayons couronne', D' un choeur de ch^rubins sans, cesse environne', Pour avoir quelque temps, charge'd' une besace Dormi dans V ignorance ou croupi dans la crasse ?

When he came to those line;, and especially the concluding ones, the fa- natic could no longer contain his rage. He eyed the oratoi with looks of fury, loaded him with the most insulting epiihets, and invoked the Almigh- ty vengeance to send down five from heaven, to consume a blasphemer, his blasphemy and philosophy together. He then precipitately withdrew to hig own apartment. This experiment was never repeated, as it appeared more calculate^ to ag-gravate than to moderate his maniacal impressions. ^

P it— —

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by the baptism of blood, and that all the potentates of the earth, united in hostile alliance against him, could not take away his life." His derangement was con- fined to the subject of religion, for upon every other, he appeared to be in perfect possession of his reason. After the expiration often years of his solitary con- finement, his apparent calmness and tranquillity de- termined the governor to grant him permission to mix with the other convalescents in the inner court. Four years of freedom and of harmlessness seemed to confirm the propriety of the expieriment, when, all of a sudden his sanguinary propensities returned. On the tenth of Nivose (Christmas eve) of the year 3, he formed the atrocious project of making an ex- piatory sacrifice of all his fellow tenants of the asy^ lum. For this purpose he got a shoemaker's knife, and seized for execution the moment when the gov- ernor was coming down stairs to go his round. Hav- ing stationed himself to advantage, he aimed at that gentleman a fatal wound ; but fortunately the in- strument grazed his ribs, without producing any se- rious injury. It is shocking, however, to relate, that he killed two maniacs who were then on the spot, and would have persisted in his bloody career, until he had accomplished the whole of his purpose, had he not been speedily arrested by superior force. It is scarcely necessary to add, that his confinement was now made absolute and irrevocable.

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tNSANITY FROM RELIGIOUS ENTHUSIASM fiXTR^MELY DIFFICULT TO CURE.

99' To say that the attempts, which have been made in England and France, to cure the insanity of devotees, have been generally ineffectual, is not pre- cisely to assert its incurability. It certainly is not impossible, that, by a judicious combination of mo- ral and physical means, a cure might, in many in- stances, be effected. My plan would have been, could the liberties of the Bicetre have admitted of it, to separate this class of maniacs from the others ; to apportion for their use a large piece of ground to till or work upon, in the way that mine or their own inclination might dispose them ; to encourage em- ployments of this description, by the prospect of a moderate recompense, want or more exalted mo- tives; to remove from their sight every object ap- pertaining to religion, every painting or book cal- culated to rouse its recollections 3 to order certain hours of the day to be devoted to philosophical read- ing, and to seize every opportunity of drawing apt comparisons between the distinguished acts of hu- manity and patriotism of the ancients, and the pi- ous nullity and delirious extravagances of saints ajid anchorites ; to divert their minds from the p.6-

Cutiar object of their halluoination, and to fix theif interest upon pursuits of contrary influence and ten- dency .7^

THE CONDUCT OF THE GOVERNOR OF BICETRE, UPON THE" REVOLUTIONARY ORDERS HE RECEIVED TO DESTROY THE SYMBOLIC REPRESENTATIONS OF RELIGION.

SO. In the tliird year of the republic, the direc- tors of the civil hospitals, in the excess of their revo- lutionary zeal, determined to remove from those pi ices the external objects of worship, the only re- maining consolation of the indigent and the unhap- py. A visit for this purpose was paid to the hospi- tal de Bicetre. The plunder, impious as it was and detestable, was begun in the dormitories of the old and the infirm, who were naturally struck at an in- stance of robbery so new and unexpected, some with astonishment, some wi.h indignation, and others with terror. The first dav of visitation beins: alrea- dv far .^pent, it was determined to reserve the luna- tic department of the establishment for another op' portunity. I was present at the time, and seized tho occasion to observe, that the unhappy residents «>f that part of the hospital recjuired to be trtiate^

u^

with peculiar management and address ; and, that it would be much better to confide so dehcate a bu- siness to the governor himself, whose character for prudence and firmness was well known. That gen- tleman, in order to prevent disturbance, and per- haps an insurrection in the asylum, wished to ap- pear rather to submit to a measure so obnoxious than to direct it. Plaving purchased a great num- ber of national cockades, he called a meeting of all the lunatics who could conveniently attend. When they were all arrived he took up the colours and said, ** Let those who love liberty draw near and enrol themselves under the national colours." This invi- tation was accompanied by a most gracious smile. Some hesitated 5 but the greatest number complied. This moment of enthusiasm was not allowed to pass unimproved. The converts were instantly inform- ed, that their new engagement required of them to remove from the chapel the image of the Virgin, with all the other appurtenances of the catholic worship. No sooner was this requisi- tion announced than a great number of our new re- publicans set off for the chapel, and committed the desired depredation upon its sacred furniture. The images and paintings, which had been objects of re- verence for so many years, were brought out to the court in a state of complete disorder and ruination. Consternation and terror seized the few devput but

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impotent witnesses of this scene of impiety. Murmurs, imprecations and threats expressed their honest feel- ings. The most exasperated amongst them prayed that fire from heaven might be poured upon the heads of the guilty, or beUeved that they saw the bottom- less abyss opening to receive them. To convince them, however, that heaven was deaf equally to their imprecations and prayers, the governor order- ed the holy things to be broken into a thousand pieces and to be taken away. The good-will and attachment, which he knew so well how to conciliate, ensured the execution of this revolutionary measure A great majority immediately seconded his wishes. The most rigid devotees, who were comparatively few in number, retired from the scene, muttering imprecation, or agitated by fruitless fury. I shall not enquire into the propriety of so harsh a mea- sure, nor how far its universal enactment might consist with the principles of a wise and enhghteiied administration. It is very certain, that melancholia or mania, originating in rehgious enthusiasm, will not admit of a cure, so long as the original impressions are allowed to be continued, or renewed by their appropriate causes.

MANIACAL FURY TO BE REPRESSED ; BUT NOT BT CRULL TREATMENT.

31. The lesions of the human intellect simply, embrace but a part of the object of the present treatise. The active faculties of the mind are not less subject to serious lesions and changes, nor less deserving of ample consideration The diseased affections of the will — excessive or defective emo- tions, passions, &c. whether intermittent or con- tinued, are sometimes associated with lesions of the intellect. At other times, however, the understand- ing is perfectly free in every department of its exer- cise. In all cases of excessive excitement of the passions, a method of treatment, simple enough in its application, but highly calculated to render the disease incurable, has been adopted from time im- memorial : — that of abandoning the patient to his me- lancholy fate, as an untameable being, to be im- mured in solitary durance, loaded with chains, or otherwise treated with extreme severity, until the natural close of a life so wretched shall rescue him from his misery, and convey him from the cells of the mad-house to the chambers of the grave. But this treatment convenient indeed to a governor, more remarkable for his indolence and ignorance than for his prudence or humanity, deserves, at the

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present day, to be held up to public execration, and classed with the other prejudices which have d< 'graded the character and pretensions of the human species. To allow every maniac all the latitude of personal li- berty consistent with safety ; to proportion the de- gree of coercion to the demands upon it from his extravagance of behaviour ; to use mildness of man- ners or firmness as occasion may require, — the bland arts of conciliation, or the tone of irresistible autho- rity pronouncing an irreversible mandate, and to proscribe, most absolutely, all violence and ill treat- ment on the part of the domestics, are laws of fim- damental importance, and essential to the prudent and successful management of all lunatic institutions. But how many great qualities, both of mind and bo- dy, it is necessary that the governor should possess, in order to meet the endless difficulties and exigei^- des of so responsible a situation !

THE FUNCTIONS OF THE WILL EXCLUSIVELY DISEASED,

3^. CoNDiLLAc has displayed equally his saga- city and profundity in the application of the princi- ples of analytical enquiry, to the developement of certain mental emotions, such as inquietude, desire.

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the passions which depend upon agreeable of disagree- able sensations, &c. But, connectedwith the history of the affections, there are important factswhich it is the exclusive province of medical philosophy to unravel and to expose, (s) It is for the scientific physician particularly to define the limits of those principles in their respective states of health, disease or convales- cence ; to ascertain the circumstances by vi?hich they are impaired in their action, or carried beyond their natural excitement , to trace their influence upon the moral and physical constitution, and to point out the various diseases which they may gene- rate or exasperate. That the functions of the will are absolutely distinct from those of the understand- ing, and that their seat, causes and reciprocal de- pendencies are essentially different, can admit of no doubt. To bring proofs therefore in support of a truth universally admitted is unnecessary : but, to illustrate the fact, I will just cite one instance of the exclusive ^ lesion of the functions of the will. It is that of a maniac whose symptoms appear totally inexplicable upon the principles of Locke and Coiidillac. His insanity was periodical.^ His paroxysms generally returned after an interval of several months. The first symp- tom was a sensation of great heat in the umbilical

(s) See Crichton on the influence of the passions.

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region, which was felt to ascend progressively to {he chest, neck and face. To this succeeded a flushed countenance, wildness of the eyes, and great disten- sion of the veins and arteries of the head. No soon- er was the brain itself invaded, than the patient was suddenly seized by an irresistible propensity to com- mit acts of barbarity and bloodshed. Thus actuated^ he ftilt, as he afterwards informed me, a contest ter- jible to his conscience arise within him, between this dread propensity which it was not in his polver to subdue, and the profound horror which thg blackest crime of murder inspired. ~ The memory, the ima^ gination, and the judgement of this unfortunate man were perfectly sound. He declared to me, very solemnly, during his confinement, that the murder- ous impulse, however unaccountable it might ap- pear, was in no degree obedient to his will ; and that it once (t) had sought to violate the nearest relationship he had in the world, and to bury in blood the tenderest sympathies of his soul. He fre- quently repeated those declarations during his lucid intervals ; when he likewise avowed to me, that he had conceived such a disgust with life, that he had several times attempted to put an end to it by sui- cide. " What motive," he would say, " can I have

(0 In the case of his wife.

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to murder the governor, who treats us all with so much kindness; nevertlseless, in my moments of fury, my propensity acknowledges no respect for his person, for I would then plunge my dagger in his bosom, as soon as in that of any other man. It is to avoid the guilt of murdering my friend, that I am induced to attempt my own life." It is easy to see, that pa^ roxysms of this nature admit not of the application of moral remedies. The indication must, therefore, consist in their prevention by evacuants^see page 44,) or suppression by antispasmodics. ^

VIOLENT PAROXYSMS OF INSANITY ARE GENERALLY THE LEAST DANGEROUS.

S3. In periodical mania, as in other acute diseas- es, the apparent violence of the symptoms is often less to be dreaded than a deceitful calm, — the fore- runner frequently of tempestuous passions or other more durable indispositions. It is a general pro- perty of such paroxysms as are distinguished by more than usual extravagance, to diminish gradually in their intensity, until at length no vestiges of their in- fluence are to be traced, either in the conduct or in the state of the feelings.

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A maniac, under the influence of the most outra* geous fury, shall be guilty of every extravagance, both of language and action ; — his excitement shall continue for several months ; — a dose or two of an- tispasmodics shall serve to calm the tumult, and even to produce a total cessation, at' least, of the most violent symptoms: but, we likewise know, that a certain and permanent cure may be obtained by what the French call the method of expectation, which consists solely in delivering up a maniac to the efforts of unassisted nature. His tumultuous ef- fervescence is allowed upon this plan to subside by evaporation, and no more coercion is employed than what is dictated by attention to personal safety. For this purpose the strait-waistcoat will be generally ibund amply sufficient. Everycause of irritation, real or imaginary, is to be carefully avoided. No oppor- tunity of discontent must be allowed to exist, and when discovered must be immediately removed. Improper application for personal liberty, or any other favour, must be received with acquiescence, ta- ken graciously into considerc^tion, and withheld un- der some plausible pretext, or postponed to a more convenient opportunity. The utmost vigilance of the domestic police will be necessary to engage the ex- ertions of every maniac, especially during his lucid intervals, in some employment, labourious or other- wise, calculated to employ his thoughts and atten-

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tion. That this view of the subject is equally simple and just, would appear from the circumstance, that some maniacs, who had been thrown into a kind of imbecility and ideotism by the excessive use of the lancet, have been roused from their lethargy by a paroxysm of active mania, and left, in about a fort- night or three weeks, in the full possession of their faculties.

A young soldier was dispatched from the army of la Vandee to Paris, in a state of great fury, and submitted to the usual treatment of the Hotel Dieu. Venaesection was repeatedly resorted to. After one of those operations it unfortunately happened, that the bandage was displaced Great hasmorrhage took place, and the patient sunk into a state of syncope, which lasted for some time. He was transmitted to Bice- tre, in a very debilitated condition. The sphincter ani had lost its power, his tongue had forgot its move- ments, his face was deadly pale, and all the functions of the ^understanding were obliterated. His father came to see him in this melancholy situation, was greatly aifected as may be supposed, and left some money towards the amelioration of his condition. Wholesome food, and gradually increased in quan- tity, contributed by slow degrees to strengthen him, and to rouse his dormant faculties. The usual pre- cursory symptoms preceded the explosion of an

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active paroxysm. His countenance was flushed, his eyes were wild and prominent, attended with febrile excitement, extreme agitation, and at length com- plete delirium. Thus raised to maniacal consequence, our hero sallied forth to the interior court of the hos- pital, and provoked and insulted every person that he met with as he went along. But as he abstained from active violence, his personal liberty was not abridged. He continued for twenty days in a state of delirious excitement, when a calm succeeded, and the dawn of reason faintly glimmered above the tempest. Moderate employment and regular exercise, co-oper- ating with the energies of nature herself, restored him, in a short time, to the full enjoyment of his intellec- tual faculties. To secure, however, a solid and per- manent cure, he was detained for six months after his recovery ; and towards the decline of autumn he was restored to his family.

A LIMITED DEGREE OF LIBERTY RECOMMENDED TO BE GIVEN TO MADMEN CONFINED AT LUNATIC INSTITU- TIONS.

34. In lunatic hospitals, as in despotic govern- ments, it is no doubt possible to maintain, by unli-

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mited confinement and barbarous treatment, the appearance of order and loyalty. The stilhiess of the grave, and the silence of death, however, are not to be expected in a residence consecrated for the recep- tion of madmen A degree of liberty, sufficient Jo maintain order, dictated not by weak but enlighten- ed humanity, and calculated to spread a few charms ever the unhappy existence of maniacs, contributes, in most instances, to diminish the violence of the symptoms, and in ^^^^j^lILJ!'^!!!^!^!^^^ '"^r^plnin*' altogether. Such was the system which the govern- oT~^>t iiicetre endeavoured to establish on his en- trance upon the duties of his present ofllce. {u) Cru- el treatment of every description, and m all depart- ments of the institution, was unequivocally proscrib- ed. No man was allowed to strike a maniac even in his own defence. No concessions however hum- ble, nor complaints nor threats were allowed to in- terfere with the observance of this law. The guilty

(w) Frequent attendance upon lunatic institutions can alonegive an ade- quate idea of the difficulties of the service. New aversions or offences to en- countei, dangers unforeseen to incur, perpetual clamours or insulting voci- ferations to listen to, and violence frequently to repel, are the leading cha- racters of the scene that is daily presented at these melancholy habitations. The duties of the governor are evidently commensurate with his utmost abilities, which, indeed, ought to be distinguished no less by their variety than by their eminence.

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Was instantly dismissed from the service. It mi^ht be supposed, that to support a system of manage- ment so exceedingly rigouroas, required no little sa- gacity and firmness. Tlie method which he adopted for this purpose was siuiple, and I can vouch my own experience for its success. His servants were generally chosen from among the convalescents, who were allured to this kind of employment by the prospect., of a little gain. Averse from active cru; 1- ty fromllie recollection of vvbat they had themseh es experienced i — disposed to those of humanity and kindness from the value, which for the same reason, they could not fail to attach to them ; habituated to obedience, and easy to be drilled into any tactics which the nature of the service might require, such men were peculiarly qualified for the situation. As that kind of life contributed to rescue them from the influence of sedentary habits, to dispel the gloom of solitary sadness, and to exercise their own faculties, its advantages to themselves are equally apparent and important. What I had done at Bicetre, pre- vious to the late change in the administration, com- prehended but a small part of my plan towards ex- tending its liberties and multiplying its conveniences, for laborious and other exercises.

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THE MOST VIOLENT AND DANGEROUS MANIACS DESCRIB- ED, WITH EXPEDIENTS FOR THEIR REPRESSION.

3S. The madmen most remarkable for their ac- tivity and turbulence, most subject to sudden explo- sions of maniacal fury, and most difficult of manage- ment at lunatic hospitals, exhibit almost all the ex- ternal characters, which Cabanis, in his general considerations upon the study of man, has described with so much truth and eloquence as peculiarly characteristic of the sanguine temperament, iv): " A bold and well marked physiognomy; brilliant expres- sive eyes ; a yellow or dark complexion ; face re- markably thin ', jet black hair and frequently curl- ed ; a strong athletic person, with the bones project- ing, but seldom fat ; strong, quick and hard pulse. These men are perpetually hurried away, sometimes on the buoyant streams of imaginatinnj and at

otbers on the torrents of passioiil Their purposes are formed rashly, and executed with violence and impetuosity. Their diseases even participate in the violence of their temperament." We may easily

(v) This memoir is inserted among the papers of the national institute for the year 6 of the republic.

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imagine how dangerous madmen of this tempera- ment are, when we consider that their strength and audacity are frequently increased by the influence of their unfortunate maladies The great'secret of mas- tering maniacs of this character, without doing them injury or receiving violence from them, consists ingo- ing up to them boldly and in a great body. Convinc- ed of the inutility of resistance, and impressed with a degree of timidity, the maniac thus surrounded will often surrender without further opposition or reluc- tance. An instrument of offence will, however, sometimes arm him with extraordinary resolution. A madman shall be suddenly seized with a parox- ysm of phrenitic delirium, with perhaps a knife, or a stone, or a cudgel in his hand at the time. The go- vernor, ever faithful to his maxim of maintaining order without committing acts of violence, will, in defiance of his threats, march up to him with an in- trepid air, but slowly and by degrees In order not to exasperate him, he takes with him no offen- jsive weapon. As he advances he speaks to him in a firm and menacing tone, and gives his calm advice or issues his threatening summons, in such a manner as to fix the attention of the hero ex- clusively upon himself. This ceremony is continu- ed with more or less variation until the assistants

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have had time, by imperceptible advances, {w) to surround the maniac, vi^hen, upon a cer'ain signal being givtn, he finds himself in instant and unex- pected confinement. Thus a scene which threaten- ed so much tragedy, generally ends in an ordinary event. Disturbances will occasionally interfere with the tranquillity of all institutions, where the pas- sions are licentiously gratified Lunatic estab- Jishments are peculiarly liable to such commotions. The prevention^ of con'^piracies and tumults by an- ticipation, is always pieterable to their suppression by violence or actFve contestr-^^eifher will trcquenfe-

(iv) The situation of the madman at the time must determine the cho ce of different means of arrest. A piece of iron of a semicircuhir form, with a longhandle attached to it, and adapted hy its convexity in the middle for its intended purpose, is sometimes found of great service in the mastering of maniacs, by forcing them up to awall, and incapacitating them in that position for Usi.-g their hands. In other cases, when with impunity they can be more nearly approached, a piece of cloth thrown over their face so as to blind them will enable their keepers to secure them without much difficulty. By harm- less methods of this description, a maniac may be sufficiently repressed,- -wit]!- out subjecting him to the danger of a wound or the indignity 6f a blow. Of this mode of coercion, the predecessor of the present governor of Bicetre adopted entirely the reverse. During his superintendence the refractory were abandoned to the unrestrained cruelty of the domestics. Consistent withtlieir policy, the graat object was to bring the unruly maniac to the gniund by a bru- tal blow : wjien one of the other keepers or servants in-^tantly j umped upon him, ahd -detained bim in that position, until he was secured, by pressing his knees against his chest and stomach — a process by which that important part was frequently cru^^hed and injured. I cawnot speak without horror of the bar- barous methods for the repression of maniacs, which are still emjiloyed at some hospitals, and which I know to be in too many instances the cause of a pr^. mature death.

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ly require such a varip-ty and combinationjof, sures as the o-reatesr sao^acity and longest experj^ace cansupply/^ Lunatics, even during their lucid in- tervals and convalesce ice, are disposed to be pas- sionate upon very slight causes. Quarrels amongst the patients — specious complaints of injustice — the sight of a sudden seizure by a maniacal paroxysm— any ooject, real or imaginary, of murmur or di^con- tent, may become a source of great disorder, and be communicated, like a shock of electricity, from one end of the hospital to the other. Meetings are cal- led, parties are formed, and commotions stirred up as in popular insurrections, which, if not suppressed in their very commencement, may be succeeded by very unpleasant and possibly by disastrous or tatal consequences. Upon the appearance of tumults of this kmd, I have more than once seen the governor of Bicetre brave with wonderful courage the violence that threatened him, move about and mingle m the effervescence with the rapidity of thought, seize the most mutinous, and provide for their instant securi- ty, and thus, in a very short time, restore tranquil- lity to the institution.

THE PROPRIETY OF APPEARING TO ASSENT TO THE ABSURD PROPOSITIONS AND FANCIFUL IDEAS OF MANiACS.

36. Other secrets, not less calculated to put an end to disputes and quarrels among maniacs, to

overcome their resistance and to maintain order ie hospitals, are tliose of not appearing to notice their extravagance, of avoiding every expression of re- proach, of assenting to tlieir opinions, and giving them impulses with such address as to impress them with the conviction that tljiey originate with them- selves. In all these respects, the governess of the Asylum de Bicetre is uncommonly well qualified for her office. I have seen her, with astonishment, go up to the most furious maniacs, and by soothing | conversation and artful proposals abate their fury^ and prevail upon them to take nourishment when it had been obstinately refused from every other hand.

A maniac, reduced to extreme danger by stubborn abstinence, threw himself into a great passion, and repelled the victuals which the governess had brought him, with rudeness and abuse. Dexterous by na- ture, and rendered still more skilful by experi- ence, she veered about in a moment, acquiesced in his purpose, and even applauded his delirious con- duct. She then skipped and danced, told droll things, and at length made him laugh. Availing herself of this favourable moment , she persuaded him to eat, and thus saved his life.

Three maniacs, who all believed themselves to be sovereigns, and each of whom assumed the title of

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Louis XVI. were one day disputing their respective rights to the regal office and prerogatives, with more warmth than appeared consistent wiih their mutual safety. Apprehensive of consequences, the gover- ness went v;p to one of them and look him a httle aside : " How happens it," said she, addressing him with great gravity, " that you should think of disputing with such fellows as those, who are evi- dently out of their minds : we all know well enough that your majesty alone is Louis XVI." Flattered by this attention and homage, this gentleman immediately withdrew, looking at his rival dispu- tants as he retired with ineffable disdain. The same artifice succeeded with a second, who left the other in undisputed possession of his honours. In a i'ew minutes no vestiges of the quarrel remained.

I remember to have admired, on one occasion parti- cularly, the fertility in expedients for mastering mani- acs possessed by this valuable woman. A young man, who had been calm for several months and at liberty in the interior court, was suddenly seized by a paroxysm of his complaint. He stole into the kitchen, took up a knife and some vegetables which he began to chop, and insisted upon enter- ing in defiance of the cook and other servants, vvho attempted to impede his progress and to dis-

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arm bim. H^ jumped upon the table and threaten- ed to take off the head of the first man that dared to approach him. The governess, with more recol- lection than fear, instantly changed her mode of at- tack, and appeared very much to disapprove of the assault upon him. " Be quiet," said she, " why prevent so strong a man from giving me that assist- ance which he is so capable of?" She then addres- sed herself to the madman with great good hu- mour, desired him to go to her, to receive pro- per instructions in the business of preparing the ve- . ge tables, and congratulated herself on having in him an assistant so well disposed and so able to serve her. The maniac, deceived by this innocent stratagem, complied with the invitation, and fell to work with great satisfaction. But, as he was receiving his instructions, and the governess took care to in- struct him with the knife in her own hand, he was surrounded by the domestics, taken without difficul- ty or danger, and instantly carried away to his chamber. I might defy the most skilful of either sex, and the most conversant in the management of maniacs, to seize with more firmness and prompti- tude a method better adapted for disarming a raving madman. y~

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THE NECESSITY OF MAINTAINING CONSTANT ORDER IN LUNATIC ASYLUMS, AND OF STUDYING THE VARIE- TIES OF CHARACTER EXHIBITED BY THE PATIENTS.

37. The extreme importance which I attach to the maintenaiice of order and moderation m iu'-a^ic institutions, and consequently to the physical and moral qualities requisite to be possessed by their go- veruors, is by no means to be wondered at, since it is a fundamental principle in the treatment of ma- nia to watch over the impetuosities of passion, and to order such arrangem.ents of police and moral treat- ment as are favourable to that degree of excite- ment which experience approves as conducive to recovery. Unfortunate, indeed, is the fate of those maniacs who are placed in lunatic hospitals, where the basis of the practice is routine, and that per- haps under the direction of a governor devoid of the essenti?! principles of morality; or where, which amounts to the same thing, they are abandoned to the savage and murderous cruelty of underlings. Gieat sagacity, ardent zeal, perpetual and indeta- tigable attention, are essentia! qualities of a governor whovvishes to do his duty, in its various departments of watching the progress of every case, seizing the pecu- liar character of the hallucination, and meeting the numerous varieties of the disease depending upon

100

temperament, constitution, ages and complications with other diseases. In some unusual or difficult cases, it requires great consideration to decide upon thetreat- ment or experiment most eligible to be attempted, (x) But in the greatest number of instances, especially of accidental mania originating in the depressing pas- sions, the experience of every day attests the value of consolatory language, kind treatment, and the revi- val of extinguished hope. Severity in cases of this des- cription can answer no other purpose than those of

(x) A man, formerly attached to the household of a prince, who became insane, partly from the subversion of Jiis old political associations, and partly from reverses of fortune, was buoyed up, especially when the subject of the revolution was mentioned, by extravagant notions of his own consequence. Excepting during the influence of occasional paroxysms of delirious efferves- cence to which he wasljable, he was silent upon the subject of his hallucination anrl paid proper attention to the external forms of politeness and good breeding, which had been habitual to him. Whenever his opinions were contradicted, he retired, with a cojol but respectful bow, to his own room, without shew- ing any further signs of disapprobation. His prevailing idea was that of his omnipotence, and whenever he wished to appear veiy great, he boasted of his power as being adequate to the execution of his unbounded wishes or ut- most vengear.ce. There was, likewise, another idea which frequently pos- sessed and disturbed him •• — it was the loss of the army of Conde, of which, he was a warm admirer, and which, according to him, was destined to ac- complish the purposes of the eternal. To produce any impression upon the imagination of a madman of this character, either by fair means or by those of decided coercion, appeared next to impossible. About six months, however, after his arrival, he was guilty of a misdemeanour, — thai of great impertineirce to the governor, which might have authorised such a punishment as would have convinced him that his power was totally chimerical. But, as his rela- tions proposed to withdraw him from the asylum in a few days thereafter, it 'c.-as thought ineligible to attempt it.

101

exasperating the disease, and of frequently render- ing it incurable. >^

A youn,^ man, already depressed by misfortune, lost his father, and in a few months after a mother, whom he tenderly loved. The consequence was, that he sunk into a profound melancholy 5 and his sleep and appetite forsook him. To these symptoms suc- ceeded a most violent paroxysm of insanity. At a lunatic hospital, whither he was conveyed, he was treated in the usual way, by copious and repeated blood-letting, water and shower baths, low diet, and a rigorous system of coercion; Little or no change appeared in the state of the symptoms. The same routine was repeatedj and even tried a third time without success, or rather with an exasperation of the symptoms. He was at length transferred to the Asylum de Bicetre, and with him the character of a dangerous maniac. The governor, far from placing imphcit confidence in the accuracy of this report, al- lowed him to remain at libeity in his own apart- ment, in order more effeciuaily to study his charac- ter and tlie nature of his derangement. The som- brous taciturnity of this young man, his great de- pression, his pensive air, together with some broken sentences which were heard to escape him on the subject of his misfortunes, afforded some insight in- to the nature of his insanity. The treatment most

suitable to his case was evidently to console him, to sympathise with his misfortunes, and, after having gradually obtained his esteem and contidence, to dwell upon such circumstances as were calculated to cheer his prospects and to encourage his hopes. These means having been tried with some success, a circumstance happened which appeared at once to give countenance and efficiency to the consolatory conversations of the governor. His guardian, with a view to make his life more comfortable, now thought proper to make small remittances for his use ; which be promised to repeat monthly. The first payment dispelled, in a great measure, his melancholy, and encouraged him to look forward to better days. At length, he gradually recovered his strength. The signs of general health appeared in his countenance. His bodily functions were performed with regularity, and reason resumed her empire over his mind. His esteem for the governor was unbounded. This pa- tient, who had been so egregiously ill treated in ano- ther hospital, and consequently delivered to that of Bicetre as a furious and dangerous maniac, is now become not only very manageable, but, from his affectionate disposition and sensibility, a very inte- Festing young man.

103

AN INSTANCE OF VIOLENT MANIA CURED BY PRUDENT AND ViGOUROUS COERCION.

38. " In the moral treatment of insanity, hmatics are not to be considered as absolutely devoid of rea- son, i: e, as inaccessible by motives of fear and hupe, and sentiments of honour . ... In the first instance it is proper to gam an ascendancy over them, and after- wards to encourage them." (?/) Those general pro- positions are doubtless very true and very useful in their apphcation to the treatment of insanity. But to have inculcated them with proper effect, they ought to have been accompanied and illustrated by appropriate examples. On this point, however, the English choose to be hileiu. That being the case, I shall add to tlie preceding histories a single example, which, I presume, will convince the rea- der that tlie secret is not unknown in France.

A gentleman, the father of a respectable family, lost his property by the revolution, and with it all his resources. His calamities soon reduced him to a state of insanity. He was treated by the usual rou- tine of baths, blood-letting and coercion. The symp- toms, fa • from yielding to tliis treatment, gained

(j/) Encyclopzedia Bntannica.

•

104

ground, and he was sent to Bicetre as an incurable maniac. The governor, without attending to the unfavourable report which was given of him upon his admission, left himahttle to himself, in order to make the requisite observations upon the nature of his hallucination. Never did a maniac give greater scope to his extravagance. His pride was incom- pressible and his pomposity most laughably ridiculous. To strut about in the character of the prophet Maho- met, whom he beheved himself to be, was his great de- light. He attacked and struck at every body that he met with in his walks, and commanded their instant prostration and homage. He spent the best part of the day in pronouncing sentences of proscrip- tion and death upon different persons, especially the servants and keepers who waited upon him. He even despised the authority of the governor. One day his wife, bathed in tears, came to see him. He was violently enraged against her, and would probably have murdered her, had timely assistance not gone to her relief. What could mildness and re» monstrance do for a maniac, vvho regarded other men as particles of dust ? He was desired to be peaceable and quiet. Upon his disobedience, he was ordered to be put into the strait-waistcoat, and to be confined in his cell for an hour, in order to make him feel his dependence. Soon after his detention, the governor paid him a visit, spoke to him in a friendly

tone, mildly reproved him for his disobedience, and expressed his regret that he had been compelled to treat him with any degree of severity. His maniacal violence returned again the next day. The same means of coercion were repeated. He promised to conduct himself more peaceably ; but he relapsed again a third time. He was then confined for a whole da}^ together. On the day following he was remarkably calm and moderate. But another ex- plosion of his prciud and tuihulent dii^position mg-dq the governor feel the necessitj^ of impressing this ma-^ niac with a deep and durable cotiviction of his de- pendence. For that purpose he ordered him to im- mediate confinement, which he declared should likewise be perpetual, pronounced this ultimate determination with great emphasis, and solemnly assured him, that, for the future, he would be in- oxorable. Two days after, as the governor was going his round, our prisoner very submissively petitioned for his release. His repeated and earnest solicitations were treated with levity and derision. But in consequence of a concerted plan between the governor and his lady, he again obtained his liberty on the third day after his confinement It was granted him on his expressly engaging to the governess, who was the ostensible means of his en- largement, to restrain his passions and by that means to skreen her from the displeasure of her husband

o

h

106

for an act of unseasonable kindness. After this, out lunatic was calm for several days, and in his moments of excitement, when he could with difficulty sup- press his maniacal propensities, a single look from the governess was sufficient to bring him to his recol- lection. When thus informed of impropriety in his language or conduct, he hastened to his own apart- ment to reinforce his resolution, lest he might draw upon his benefactress the displeasure of the governor, and incur, for himself, the punishment from which he had but just escaped. These internal struggles between the influence of his maniacal propensities and the dread of perpetual confinement, habituated him to subdue his passions, and to regulate his conduct by foresight and reflection. He was not insensible to the obligations which he owed to the worthy managers of the institution, and he was soon disposed to treat the governor, whose au- thority he had so lately derided, with profound es- teem and attachment. His insane propensities and recollections gradually, and at length, entirely dis- appeared. In six months he was completely restor- ed This very respectable gentleman is now inde- fatigably engaged in the recovery of his injured for- tune.

107

THE PHYSICAL AND MORAL QUALITIES ESSENTIAL TO THt 6UCCESSFUL MANAGEMENT OF LUNATIC ASYLUMS.

39. I HAVE given a sufficient number of ex- amples to illustrate the importance which I attcich to the moral treatment of insanity. The credit of this system of practice has been hitherto almost ex- clusively awarded to England. Though it be a de- partment of experimental medicine that is least un- derstood, I trust, that what has been advanced in this section will rescue France from the imputation of neglecting it. For my ability to use, with any degree of propriety, this language of competition, I am indebted to a fortunate concurrence of circum- stances. Among these may be first enumerated, the eminent qualities, both of body and mind, of the go- vernor of the Asylum de Bicetre. He possesses the principles of a pure and enlightened philanthropy. His attention to the arduous duties of his office is in- defatigable. His knowledge of human life and of the human heart is accurate, extensive, and easily appli- ed to the frequent and urgent demanc|s that are made upon it. His firmness is immoveable, his courage cool and unshrinking. As to his physical properties, he is manly and well proportioned. His arms are ex- ceedingly strong. When he speaks in anger or dis- pleasure, his countenance expresses great decision

108

and intrepidity, and his voice is that of thunder. Act-^ ing in concert with a gentleman of such a character, X had great opportunities afforded me of deriving from my situation every possible professional advantage. Of the knowledge to be derived from books on the treatment of insanity, I felt the extreme iiisuffici- ency. Desirous of better information, I resolved to examine for myself the facts that were presented to my attention ; and forgetting the empt}' honours of my titular distinction as a physician, I viewed the scene that was opened to me with the eye of com- mon sense and unprejudiced observation. I saw a great number of maniacs assembled together, and submitted to a regular system of discipline. Their disorders presented an endless variety of character : but their discordant movements were regulated on the part of the governor by the greatest possible skill, and even extravagance and disorder were mar- shalled into order and harmony. I then discovered, that insanity was curable in many instances, by mildness of treatment and attention to the state of the mind exclusively, and when coercion was indispensible, that it might be very effectually applied without corporal indignity. To give all their value to the facts which I had the opportu- nity of observing, I made it an object of interest to trace their alliance with the functions of the under- standing. To assist me in this enquiry, 1 atten-

109

tively perused the best writers upon modern pneu- matologv, as well as those authors who have written on the influence of the passions upon the pathology of the human mind. The laws of the human econo- my considered in reference to insanity as well as to other diseases, impressed me with admiration of their uniformity, and I saw, with wonder, the resources of nature wheu left to herself, or skilfully assisted in her efforts. My faith in pharmaceutic preparations was gradually lessened, and my scepticism went at lens:th so far, as to induce me never to have re- course to them, until moral remedies had completely failed, [x) The success of this practice gives new support, were it necessary, to the following maxim of Dr. Grant : — " We cannot cure diseases by the resources of art, if not previously acquainted with their terminations, when left to the unassisted efforts of nature '*

(z) Dr. Ferriar, an English physician, has published a work entitled medical histories and reflections, in which hs exhibits the effects ©f certain medicami-nts, which he has employed in cases if insanity; such as tartar- ized antimony, c mphor, opium, bark, &c Of what value are experiments of this kind, when it is ascertain d, that insanity, especially if originating in accidental causes or in a gr^-at vividness or intensity of the passions, may be cured without any medicaments whatevt-r ? Such inaccuracy is altogether avoided in my infirmary practice, as I n^ver give any medicine, excejjting in cases of regular intermi'tent insanity, religious melancholy, and delirium with a total obliteration of the faculties of judgement and reasoning. These are species of the complaint, which, according to my experience, never yield to moral remedies. But, the exposition of these facts is reserved foj another Eartoithirtyesktise,

SECTION III

OF MALCONFOHMATION OF THE SKULLS OF MANIACS AND IDEOTS.

DOES INSANITY DEPEND UPON ORGANIC LESION OF THE BRAIN ?

40. IT is a general and very natural opinion^ that derangement of the functions of the understand- ing consists in a change or lesion of some part of the head. This opinion is, indeed, countenanced by the experimental labours of Bonnet, Morgagni, Meckel and Greding. Hence the popular prejudice that insanity is generally an incurable malady, and the custom very prevalent of secluding maniacs from society, and of refusing them that attention and assist- ance to which every infirmity is entitled. But the numerous cures which have been performed in Eng- land and in France; the fully established success of the moral treatment in a great variety of instances ; nu- merous results of dissection which have shewn no or-

Ill

ganic lesion of the head ; and lastly, the observations^ of Mr. Harper, who considers insanity as an affec- tion purely nervous, appear to establish a contrary opinion. («) A principal object of my researches for the last six years has been to rescue this important subject from the charge of inaccuracy. 1 shall re- port, at another time, the result of my observations upon the particular condition of the brain, meninges and other parts of the bodies of persons who have died insane. But, in the present section, I shall confine myself to the consideration of malcon- formations of the cranium.

(a) It is marvellou;; that Mr. Harper's speculations should have been cited by a gentleman of Dr. Pinel's good sense, as a authority for any opi- nion depending solely for its support upon facts and experiments. Nevet ■wa-:a poor author so completely involved by paradoxes of his own creation, nor more unfortunate in his attempts to clear his way out of them As an instance ot his prompous ob curity, the readei is requested to pTuse the following definition. " I will, therefore, take upon me to define and pro- nounce the proximate cause and spec fie exi tence of insanity to be a posi- tive, immediate discord in the intrinsic motions and operations of the mental faculty, exerted above the hsalthfr.l equilibrium, its exact seat to be jn the prime movement, and its precise extent just as far as the neivoBj power conveys its influence," T,

112

THE I'ERIODS OF LIFE MOST LIABLE TO INSANITY FROM

MORAL CAUSES.

41. The following table, by exhibiting the periods of life most exposed to moral influences, will furnish very strong presumptive evidence for the infrequency || of malconformation of the brain or of the cranium.

TABLE.

MANIACS RECEIVED

AT

BICETRE.

In 1784

1785

1786

1787

1788

1789

1790....,

1791

1792

In the nine last months of 1 the year 1 of the republic j

In the year 2

15

20

30

40

50

0

to

to

to

to

to

tf>

-?o

30

40

50

60

;o

5

33

31

24

11

6

4

39

49

25

14

3

4

31

40

32

15

5

12

39

41

26

17

7

9

43

53

21

18

7

6

38

39

33

14

2

6

28

34

19

9

7

Q

26'

32

16

7

3

6

26

33

18

12

5

1

13

13

7

4

2

3

23

15

15

9

6

110 134

127

142

151

132

103

9S

98

40

71

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THE AFFECTIONS OF THE MIND MOST CALCULATED TO INDUCE INSANITY.

42. The known tendency to mental derangement at those periods of life which are most exposed to the inQuence of strong passions, agrees with the uni- form experience of hospital observations and prac- tice. Among the lunacies confined at Bicetre, dur- ing the year 3 of the republic, whose cases 1 parti- cularly examined, I observed that the excitmg causes of their maladies, in a great majority of instances, had been very vivid affections of the mind, such as ungovernable or disappointed ambition, religious fanaticism, profound chagrin, and unfortunate love. Out of one hundred and thirteen madmen, with whose histories I took pains to inform mvself, thiitv- four were reduced into this state by domestic mis- fortunes ; tvventy-four by obstacles to matrimonial connrcti 'US which they had ardently desired to to rm; thirty by events cwinccted with the revolution, and twentv -five by religions fanat icism It is well known, that certain professions conduce more than others to insanity, which are chitflv thoise in which ihe imagination is unceasingly or ardently engaged, and not moderated in its excitement by the exer- cise of those functions of tne uuderbiandmg which

114

are more susceptible of satiety and fatigue. In con- sulting the registers of Bicetre, we find many priests and monks, as well as country people, terrified in- to this condition by the anticipation of hell torments: many artists, painters, sculptors and mu.^icians : some poets extatized by their own productions : a great number of advocates and attorneys. But there are no instances of persons whose professions require the habitual exercise of the judging faculty; not one naturalist, nor a physician, nor a chemist, and, for the best reason in the world, not one geo- metriciauo

NO FACTS, YET CLEARLY ESTABLISHED, RELATIVE TO THE INFLUENCE OF THE SIZE AND CONFIGURATION OF THE CRANIUM UPON THE FACULTIES OF THE MIND.

43. From the above data, and they agree with the reports of all other luratic hospitals, the clear and unavoidable inference is, that lesions or deformi- ties of the skulls of manaics which cannot be acquir- ed in adult age, and after the complete ossific?tion of the bones of the head, are very rare, if ever oc- curring causes of accidental insanity. It, therefore, ynay not be undeserving an attempt to establish this fact by accurate researches and dissections.

115

Greding, {h) a German author, who has bestowed great hibour upon investigaiions of this khid, ob- serves, that, among one hundred maniacs, he found three with exceedingly large and two with equally small heads. He talks likewise of certain skulls that were remarkable for their thickness, for small and contracted frontal bones, and for compressed temporal bones. Some heads were m )re than com- monly spherical, others oblong. But as tliis author took no accurate means for ascertaining the dimen- sions of the skulls which he examined, and conse- quently could obtain no data of comparison and pro- portion among them, it is evident how vague and indeterminate his results must necessarily be. Be- sides, there are forms of skulls which are common to many descriptions of people of the soundest un- derstandings. To avoid false reasoning, and to dis- tinguish between a determinate cause and forms purely accidental and co-existent, it is necessary to conduct the investigation upon the principles of ac- curate analysis and abstraction. How far I have myself succeeded in this department of the enquiry, I must beg the reader to judge when he has perused the sequel of the present section.

(b) See medical aphorisms on melancholy and other diseases connected, with it, by Dr. Crichton, London.

116

DO THE BEST FORMED HEADS BEAR A PROPORTION TO THE INTELLECTUAL FACULTIES ?

44. It is a very genera] opinion, that mental de- rangement depends upon lesion^, of the head, and es- pecially upon irreguhirities and disproportions of the cranium. It would be an interesting speculation to determine how far the best proportions of the head are to be considered as external indications of the excellence of the intellectual faculties. That master- piece of ancient sculpture, the head of the Pythian Apollo, (c) might be taken for a prototype. Next in order, might be placed the heads of men most suitably organized for the successful pursuit of the arts and sciences, and progressively downwards every successive degree of malconformation of the

(c) " Of all theproductioub ot'art -s^hich have escaped the ravages of time," says Winki^'lmaii, <" thd statue of Apollo is beyond dispute the most as- tonishing. The artist has conceived his image after an ' ideal model, and has used no materials but what were necessary to execute and to represent his conception, its h-ight is above that of life, and its attitude is lull of majes- ty. At the s ght of this prodigy, I am disposed to forget the world. I put myself in a more majestic attitude in o.der to contemplate it with dignity. From admiration 1 sink mto extacy." Of this statue, which ha> lately be- come by conquest the property of France, and wlii h is now placed in the museum at Paris, 1 am not a if ss passionate adn irer than Winkelman But I wish to refer to it in this place with all the coolness of reason. Under that impression, I beg to add my humble opinion to that of many better judges, that its head unites the best proportions and the most harmonious lines that are possible to be met with in the most perfect configurations of life.

117

head, with its corresponding intellectual capacity, to absolute ideotism and imbecility. But observation is fai' from confirming these specious conjectures. We soiTiJ'times meet with the best possible formed heads associated with a very contracted discernment, or even with absolute insanity; while singular varie- ties of conformation are united to every attribute of talent and genius. It would, therefore, be no less curious, than conducive to the progress of science, to establish some facts as results of new and accurate researches; to examine the varieties of conforma- tion of the head that are inditferent or equally fa- vourable to the free exercise of the functions of the understanding ; to mark particularly the deformities of the cranium, that are co-existent with manifest lesions of those functions ; and lastly, to ascertain the species of mental derangement depending upon the want of symmetry of the cianium, or upon the smallness of its dimensions, in comparison with those of the whole body.

THE ADVANTAGE OF ASSUiMING FOR A STANDARD OF COM- PARISON, THE BEAUTIFUL PROPORTIONS OF THE HEAD OF THE APOLLO.

45. Camper, in his physignomonical researches, in order the better to seize the characteristic and

118

constant traits of the human countenance in diffe- rent climates, hasconfried his attention to what lie calls the fascial line. The object of my present in- vestigation refers more inmediately to the configur- ation and dimensions of the cavity of the skull. My enquiries, therefore, have necessarily taken a diffe- rent direction. I have examined the relation of the height of different skulls, with their depth in the direction of the great axis of the cranium, and with their breadth at the anterior and posterior part of the same horizon. I have marked the want of sym- metry in the corresponding parts, and compared, in the living subject, the bulk of the head, or rather its perpendicular height with that of the whole stature. In order to attain to some degree of accuracy in my investigation, I have taken for my standard, the ad- mirable proportions of the head of the Apollo, as they are given by Gerard Audran. [d) But many ob-

(rf) I shall confine myself to mark the proportions of the statue of the Apollo Belvidere, and of those parts of it which more immediately suit my purpose.

The height of the head is divided into four equal parts.

The first part, from the crown of the head to the roots of the hair on the forehead.

The second, from the top of the forehead to the j unction of the frontal and nosal bones.

The third, from the origin to the basis of the nose.

The fourth, from the bottom of the nose to the anterior and infeiior part •f the chin.

119

stacles oppose the application of mathematical prin- ciples to subjects of this nature. Nothing, indeed, appears less capable of precise admeasurement than the cavity of the cranium. At the basis there are many irregular eminences and depressions. The upper part presents the general appearance of one half of an ellipsoid, whose convexity differs at diffe- rent parts. Hence it results, that a section of the cranium, parallel to its base, presents but a distant resemblance to an ellipsis, and, consequently, af- fords no data for accurate admeasurement. We are, therefore, confined to mechanical means as the best we can apply for ascertaining the dimensions of the cranium. To obtain a standard position for all heads, I placed, afier the manner of Camper(c'),

The eye seen in front from the external to he internal canthns is half a part. The space between the eves ha'f a part.

The breadth of the head in the direction of the temples is two parts and one eigth ; but above the ears, in the^sanie line, is about two parts.

From the most projecting point of the frontal bonebetv/een the eyebrows to that of the occipital bone, is about three parts and two thirds.

The height of the whole statue Is seven heads, three parts and a half} i. e. the h.-ad is a little more than one eigth of the whole height.

Note. For the other dimensions of the A pr.Uo Belvidere, the English reader may consult a volume entitled, notes by Sir Joshua Reynolds, upon Fresnoy's art of paintiiig, page 78. T,

(e) Dissertation Physique sur les differences que presententles traits du ■iisage, &c. Uetiecht, 1791.

120

a prop under the foramen magnum of the occipital bone, of such a height that the extremity of the nasal apophysis and the upper margin of the t^eatus auditorius externus were in a Hne parallf^l with the plane of the horizon. I then constructed an instru- ment in the form of a parallelopipedon, vA'hose sides admitted of varying the dimensions without destroy- ing the figure, so as to be adapted to heads of diffe- rent capacities. The upper plane, which I placed on the crown of the head, was loose, and b}^ means of a level kept in a horizontal position. By this contrivance, the respective distances of the different planes gave the most accurate results which it was possible to obtain of the three dimensions of the head. On the living subject, 1 made use of a cali- ber compass. By these means I compared skulls of different forms and capacities.

VARIETIES IN THE DIMENSIONS OF THE HEADCONSIDEREDo

46. A PERPETUAL source of error in the anatomi- cal and physiological researches of Greding, has been to consider as causes of insanity, certain va- rieties of conformation of the cranium, which may, in some instances, co-exist with this malady, but

Foiff J2iK

Pll.

Treatud nn J/isamti/.

121

which are also discoverable after death, in persons who have never experienced it. To avoid erroni- ous conclusions of that nature, I have measured and excUTiined a i^reat number of skulls in different museums. I have also taken, by means of a cali- ber compass, the dimensions of the heads of different persons of both sexes, who had been, or who were at the time in a state of aisanity. I generally observ- ed, that the two most striking varieties, tlie elon- gated and the spheroifLd skulls are fjund indiffe- rently and bearing, at least, no evident relation to the extent of the intellectual faculties. But I have likewise observed, that there are certain malcon- furmations of the cranium connected with a state of insanity, especially with ideotism or idiopathic fatuity. Ill order to represent those truths more forcibly and clearly, I have made drawings of cer- tain heads, which, upon comparing their respective configurations, appear to me, to establish the theory of a connection between an imperfect structure of the cranium and an imperfect operation of the in- tellectual faculties. Of the head of an ideot, who died at the age of forty-nine, the remarkable pro- perty was length. With that I contrasted the cra- nium of a person possessed of a sound understand- ing, who died when hr was twenty years of age, and whose head was equally remarkable for its ro--

122

tundity. At the end of the same plate is the repre- sentation of an extremely irregular head of a per- son who died at the age of nineteen in a state of complete ideotism. At the beginning of the second plate I have given a lengthened cranium. It is that of a maniac of forty-two years of age, who was com- pletely cured about seven years ago To contrast with this, I have given the very round skull of a young man who died at twenty-two, and vv^hom I can af- firm to have been endowed with a perfectly sound in- tellect. I have concluded my sketches with the drawing of the head of a young man two and twenty years of age, a complete ideot, which is remarkable for its extreme want of symmetry and disproportion of its dimensions. The two heads at the end of the plate will form the principal subject of my anatom- ical discussion.

THE HEADS OF TWO FEMALE MANIACS, THE CONFIGURA- TIONS OF WHICH LEAD TO NO EVIDENT INFERENCE.

47. The anatomical examination of the heads of two female maniacs, of whom one died at the age of forty-nine, and the other at that of fifty-four, would appear to confirm the opinion which I have

123

already advanced, that intense menial affections are the most ordinary causes of insanity, and that the heads of maniacs are not characterised by any pe- culiarity of conformation that are not to be met with in other heads taken indiscriminately. Of these heads, the form of the one is elongated, of the other, shortened. The flattened forehead of the one, which appears to form an inclined plane, and the perpen- dicular elevati(m of the other, are varieties which are often observable, but which admit not of any induction favourable or otherwise, in regard to in- tellectual capacity. This observation, however, does not apply to the skull represented by figure 5 and 6, plate II, of which I obtained possession at the death of a girl of nineteen, who was an ideot from her birth. The length of this head is the same as that of the two other maniacs ; but its height is one cen- timetre above that of the second, and two centimetres above that of the first ; whilst its breadth is less : — ■ a form which gives to this head a disproportionate degree of elevation and lateral depression very com- mon to ideotism from the birth. I have marked both appearances in two young ideots who are now alive : and they are said to prevail amongst the Cretins of the Pays de Vaud.

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filALCONFORMATTON OF THE CRANIUM, THE PROBABLB CAUSL OF IDEOTISM FROM INFANCY.

48. I HAVE considered the above cranium in another point of view. 1 have contrasted it with another well formed skull, and I have caused a cor- responding section to be made of both in the direct tion of the most projecting part of the frontal bone and the angle of the lambdoidal stature. - I have hence obtained means of comparison between the two irregular ellipses which results from those sec- tions. I have observed, that in the well formed skull, the two demi-ellipses are disposed symmetri- cally around the principal axis, so that the conjug- ate diametres drawn from the anterior left side to the posterior right side, are evidently equal. On the contrary, in the ill constructed skull, the two demi-ellipses are not placed in a symmetrical order on the two sides of the principal axis; but that which is on the right takes a more prominent curve to the anterior side, whilst on the posterior it is flat- tened, and that on the left side the anterior curve is flattened, and the posterior more projecting. This difference, which is apparent at first view, is still more manifest on measuring the conjugate axes; since that which goes from right to left measures twenty-two centimetres, and that which goes from

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left to right measures only seventeen. {/) I have found the same pccuharity of structure in the head of a child eigliteen months old. The difference of the conjugate axes in this case was even a centime- tre and a half. Was this child doomed to live an ideot ? This is a question which the immaturity of its mental faculties rendered it impossible to deter- mine. Another defective structure of the head that I am describing, which must not be omitted, was that of the thickness of the skull. It was every where double the ordinary density. From the ex- traordinary thickness of this skull, it would be easy to calculate how mnch the internal capacity of the cranium was diniinished, if its figure had been a re- gular ellipsoid; since it would only be neces^sary to determine the solid dimensions of a figure formed by a revolving ellipsis whose great and small axes would be known, . But the irregularity of form of the cranium precludes the adoption of such a method of admeasurement.

The malconformations of the cranium of the above ideot : — the depression of the si les, the n'ant nf cor-

(/) For a tibleof th; nevr French mea^ur s, -Aith the.r re'ation'-- to the old m'a^uros of th.it Coun-iry, and the present m-asure-; of this conntrj', see awork late y pub'ished by the Rev. T. Gabb,e'iutled, Finn Pyramid is, &c. Lond n lsf)6, page r 3. And also a hi'^i ry lately pub'ishs'! of the metro- polis of Fraiice, emitkd, Paiis as it was, and Paris as it is. Ad locum. T.

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respondence between the right and left side, and its praeternatural thickness, must evidently diminish the capacity of the receptacle of the brain. But we must beware of drawing inferences hastily. I shall, therefore, confine myself to historical facts, without absolutely deciding that there is an imme- diate and necessary connection between ideotism and the various structures which I have described. This young woman was in a state of complete fatu- ity from her infancy. She uttered, at intervals, some inarticulate sounds; but she gave no indications of intelligence nor of moral affections. She ate when food was presented to her mouth, appeared to be 'insensible of her existence, and had every appear- ance of an automaton. She died last year of the scurvy. Upon dissection we found a large collection of blood effused upon the brain, which, together with ihe disease, had so altered its appearance that we could form no conclusions as to its softness or spe- cific gravity.

THE STUPIDITY AND DEGRADED CONDITION OF AN IDEOT OF WHOSE HEAD I HAVE GIVEN AN ENGRAVING.

49. On a first view of this ideot, figure 5, plate II, what appears most striking is the extremely dis- proportionate extent of the face, compared with the diminitive size of the cranium. No traits of ani-

127

mation are visible in his physiognomy. Every line indicates the most absolute stupidity. Between the heio-ht of the head and that of the whole stature, there is a very great disproportion. The cranium is • greatly depressed both at the crown and at the tem- ples. His looks are heavy and his mouth wide open. The whole extent of his knowledge is con- fmed to three or four confused ideas, and that of his speech to as many inarticulate sounds. His ca- pacity is so defective, that he can scarcely guide the food to his mouth ; and his insensibility so great, that he is incapable of attending to the common calls of nature. His step is feeble, heavy and tottering. His disinclination to motion is exces- sive. He is totally insensible to the natural pro- pensity for reproduction ; — a passion so strong even, in the Cretin, and which gives him a deep consci- ousness of his existence. This equivocal being, who seems to have been placed by nature on the very confines of humanity, is the son of a farmer, and was brought to the hospital de Bicetre about two years ago. He appears to have been impressed from his infancy with the above characters of fatu- ity.

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VARIOUS RELATIONS OF THE HEIGHT OF THE HEAD, TO THAT OF THE WHOLE BODY. .

50. The extreme disproportion between the lieight of tiie head, and that of the whole stature of the above ideot, was strikingly aparent at first view. But to determine its size with more preci- ijion it was necessary to take the dimensions of the head with a caliber compass ; to examine its height in relation to that of the \vhole body ; and after- wards to compare this relation, with that of the best proportioned statures. I found that the height of his entire stature was eighteen decimetres, and that of his head only eighteen centimetres. The proportion, therefore, between the height of the head and that of the entire stature is as one hundred and eighty, to eighteen, i. e. The head is only one tenth of the whole. The maniac on the contrary, of whose head I have given an engraving, figure 1, plate ii, and v\ho had been subject only to periodica} attacks of insanity, is characterized by much better propor- tions between his head and entire stature. The di- mensions of his whole stature were seventeen deci-^ metres, and of his head twenty-three centimetres, i. e. The proportion of one to the other was as one hundred and seventy to tv\enty-three, or 7 7^ to 1, The whole stature is seven and a half times the

Jiz^e 328.

Pl.U.

TreotUif on IiutiuiUi/.

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liead, which approaches much nearer to the propor- tions of the Apollo. How diminutive then is the head of the ideot c<^mpared with his whole stature, being only one tentii ot its height? — a striking dis- proportion, and such as I have never observed amang a very great number oi heads whose dimensions I have taken. Nothing, on the contrary, is more common than to meet with heads which, from their relation to the above standard, would appear too ad- vantageously proportioned, as the stature, to be in just proportion, should be considerably greater. This conformation affords a presumption in favour of the intellectual faculties : but, as we more commonly form our judgement of the man from his conduct and conversation, this indication is neglected.

RELATIVE PROPORTIONS OF DIFFERENT PARTS OF THE HEAD WITH DEVIATIONS FROM THE STANDARD DIMENSIONS.

5 1 . The ancient artists, who were equally re- markable for the delicacy of th? ir touch and their acuteness of observation, could not fail to discover those proportions of the head which are the essen- tial constituents of beauty. They have, consequent- ly, divided those of the Apollo into four parts by

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hOri^otital planes at equal distances. One of those parts begins at the foots of the hair on the forehead, and extends to the crown. The form of the head of the maniac, figure 1, plate ii, varies no more than weH proportioned lieads in general from thiis standard, since the whole height of his head is twen- ty-three centimetres, and that of his face seventeen centimetres. Subtracting one from the other, we obtain a remainder of six centimetres, vvhich, com- pared with the whole height, gives a proportion very nearly approaching that of one to four, as in the head of the Apollo. The height of the head of the ideot, on the contrary, is eighteen centimetres, and his face fifteen. On subtraction we have a dif- ference of three centimetres, which is only one sixth of the height, and which shews how much the vault of the cranium is flattened, and, consequently, its capacity diminished. This diminution is still more strikingly apparent if we examine the human skull in another point of view. In well formed heads, a hori- zontal section of the cranium made in the direction of the squammous margin of the temporal bones, gives an irregular ellipsis of such a form, that the double or- dinate passing at the anterior portion of those bones,is much shorter than that passing through the posterior part. The head of the maniac, fig. 1 and 2, platen, approaches in those respects to the proper proportions, for the posterior double ordinate is longer by two cen-

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timetres than the anterior. On the contrary, those two Hues are about equal in the head of the ideot, as I have ascertained by a cahber compass ; so that the section of this cranium would give a figure very nearly approaching that of a regular ellipsis. Hence it is evident how much the posterior lobes of the brain must be diminished in bulk by this singular conforma- tion. We must not, however, decisively conclude, that this defect of capacity of the cranium is the sole and exclusive cause of the imperfect developement of the mental faculties.

INFERENCES FROM THE FOREGOING ANATOMICAL RESEARCHES.

52. The two ideots, the conformation of whose skulls I have described in pages 122 and 128, notwith- standing their respective differences present a general resemblance; that of a great diminution of capacity of the cranium, with an almost total obliteration of the affections and intellectual faculties. Has then the physical condition of the head any immediate influ- ence on that of the mind ; and may the one be con- sidered as the efficient cause of the other ? I am cautious how I decide ^ and I confine myself to mark the line which separates truth from probability. The

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varieties of form ; the exact determination of mea- sures; and the relative proportions of the parts, are the only subjects which I profess to discuss. The rest I leave to the wide field of conjecture, which, in other words, is a species of vesania common enough in the world, but which has not yet been recognized at the Petites Maisons.f^) The anatomy and patho- logy of the brain are yet involved in extreme ob- scurity. Greding, dissected two hundred and six- teen maniacal subjects, and he details all the pecu- liarities which he observed in the meninges, the sub- stance of the brain, the ventricles, the pineal gland, and the cerebellum. But as those maniacs died by disorders unconnected with their mental ailments, we can form no just conclusions from the morbid apear- ances which presented themselves. Many varieties of structure might likewise accidentally co-exist with the lesions of the mental functions, without having any immediate connection with them. The same may be said of the experiments of a similar nature, by Haslam in England, and Chiaruggy in Italy. 4 have attended at thirty-six dissections in the hos- pital de Bicetre; and I can declare, that I have ne- ver met with any other appearance within the cavity of the cranium than are observable on opening the bodies of persons who have died of apoplexy, epilep-

(A) The Petites Maisons at Paris, is an institution similar to our Bedlam,^

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sy, nervous fevers, and convulsions. (^) From such data, what light can be thrown on the subject of" in- sanity? In one of my dissections, indeed, I recol- lect to have found a steatomatous tumor about the size of a pullets egg in the middle of the right lobe of the brain: but the disease in that instance was not insanity but hemiplegia. What a field would have been opened for hypothesis and comment, had this person been likewise affected with insanity ? Bat, also, what an additional motive for circumspec- tion and reserve in deciding upon the physical causes of mental alienation ?

(g) Before I piacticed medicine at the hospitals, I f mcied that consi- derable light might be thrown upon insanity, by examining the morbid state of the brain and its membranes : but now lam convinced, that inferences from dissections are WfU founded only when the maniac has died during a paT.x- ysm of his complaint, a circumstance which rarely occurs. It more frequent- ly happens, that the patient sinks after the termination of a paroxysm t'rom the state of languor and debility which succeeds. In these cases 1 have most frequently found an effusion of lymph in one or both ventricles. When lunatics, on the contraiy, die of adventitious disorders, it must evidently appear that conclusions from the morbid condition of the parts are very equivocal : but I resen'e for another occasion the exposition and details of my anatomical resea.ches in regard to insanity, having confined myself in this section to the consideration of the form, and proportions of theiireacl.

SECTION IK

MENTAL DERANGEMENT DISTRIBUTED INTO DIFFERENT SPECIES.

THE PRINCIPLES UPON WHICH THE AUTHOR HAS FOUNDED HIS NOSOLOGICAL DISTINCTIONS OF MENTAL DERANGE- MENT.

53. The terra mental derangement is sufficient- ly well adapted to express the various lesions of the hiiman understanding. But to obtain accurate knowlecjlge of this subject, we must not remain satis- fied with general expressions however suitable and comprehensive. For this purpose we must examine the different species of derangement analitically, con- sider them separately, and thence deduce the princi- ples both of medical treatment and hospital police. I shall not take upon rtie to discuss the arbitrary dis- tributions of nosologists, as in most instances, they are far from being the result of accurate observation and experience. That a better system of methodi- cal distribution upon this important subject is a de- sideratum, is sufficient inducement for me to engage

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in the attertipt. One of the greatest difficulties which I have experienced in the choice and prepara- tion of materials for the present volume, has been the want of proper terms, to express certain facts, and to describe, with a suitable degree of minute- ness, the various lesions of the intellectual and ac- tive faculties. Tlie greek language, so rich and expressive as it is, furnished Hippocrates with a suf- ficient variety of epithets for describing all the kinds of delirium symptomatic of acute diseases. But the history of insanity, being inseparable from that of the human understanding, is necessarily found in a very imperfect state in the writings of the ancients. I have, therefore, felt the necessity of commencing my studies with examining the numerous and im- portant facts which have been discovered and detail- ed by modern pneumatologists. Upon that basis alone, must be established any system of nosology founded in nature, of a disease affecting either pri- marily or secondarily the faculties of the human mind. The powers of preceplion and imagination are frequently disturbed without any excitement of the passions. The functions of the understanding, on the other hand, are often perfectly sound, while the man is driven by his passions to acts of turbu- lence and outrage. In many lunatics, a periodical or continued deljrium are united to extravagance and fury. Again, instances are not unfrequent of ac-

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tual dementia or tnental disorganisation, where the ideas and internal emotions appear to have no connection with the impressions of sense, and to succeed each other without order, and to vanish without leaving any traces of their existence. A still more deplorable condition is that of a total ob- literation of the thinking faculties, or a privation more or less absolute of all ideas and emotions : in other words, a state of complete ideotism.

FIRST SPECIES OF MENTAL DERANGEMENT.

MELANCHOLIA, OR DELIRIUM UPON ONE SUBJECT EXCLUSIVELY.

THE COMMON ACCEPTATION OF THE TERM MELANCHOLIA,

54. The symptoms generally comprehended by the term melancholia are taciturnity, a thoughtful pensive air, gloomy suspicions, and a love of soli- tude. Those traits, indeed, appear to distinguish the characters of some men otherwise in good health, and frequently in prosperous circumstances. No- thin «•, however, can be more hideous than the

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figure of a melancholic, brooding over bisjmagJJi- ary misfortunes. If moreover possessed of power, and endowed with a perverse disposition and a sanguin- ary heart, the image_is rendered still more repulsive. Tiberius ancTCouiTSl. are singular instances of this unhappy temperament. Gloomy taciturnity, aus- tere moroseness and gravity, the mequalities of a mind abounding with acrimony and passion, love of solitude, and the timid embarassment of an artful disposition, betrayed, from early youth, the melan- cholic temperament of Louis. Between the cha- racter of this prince and that of Tiberius, there are several striking traits of resemblance. Neither of them distinguished himself in war, excepting during the effervescence of yoiuh. Imposing bur ineffec- tual preparations, studied delays, illusive projects of military expedition.", and negociations conducted on the principles of intrigue and perfidiousness, dis- tinouished their future Lves. Before the commence- ment of their respective reigns, they passed sever- al years in inglorious banishment, amidst the lan- guors of private life ; the one in the Isle of Rhodes, and the other in a retired province of Belgium. The profound dissimulation, the chaiactenstic in- decision, and equivocal answers of Tiberius upon bis succession to the throne of Augustus are well known. Louis, throughout the whole of his life.

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was in like manner a model of the most refined and perfidious policy. Each of them a prey to dark suspicions, sinistrous prognostications and terrors ever new and imaginary, which increased with their advancing lives, they at length sought re- tirement from the effects of their tyranny ; the one, in the chateau de Plessis-les -Tours ; and the other, in the Island of Caprese, on the coast of Campania, where they respectively buried themselves in unman- ly and unlawful pleasures. The biography of per- sons of distinguished talents and reputation, affords many instances of melancholies of a \ery opposite character, who were remarkable for their ardent en- thusiasm, sublime conceptions, and other great and magnanimous qualities. Others, occupying a less exalted station, charm society by the ar- dour of their affections, and give energy to its movements by their own impassioned turbulence and restlessness. Melancholies of this class are remarkably skilful in tormenting themselves and their neighbours, by imagining offences which were never intended and indulging in ground- less suspicions. It is \ery common for physi- cians to be consulted by persons of this temper- ament for nervous palpitations or aneurism of the heart. Some fancy themselves under the influence of hydrophobic madness. Others believe that

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they have all the diseases which they read of in me- dical books. I have known many who had had the venereal disease, torment themselves, upon the ap- pearance of the least indisposition, with the belief that the virus of sip'nilis was still operating ; and they have gone for advice to every empyric that flat- tered their creduhty.

Profound melancholia is frequently succeeded by actual derangement of the intellect. A lady, highly respectable for her talents and dispositions, seduced by the prospect of improving her rank and fortune, married a neighbouring gentleman, who was in a state of dementia. The desire of making herself agreeable in her family, united to a dis- position truly amiable, enabled her for a long time to support the irksomeness of the connection. But the impassioned extravagances of her husband, and the disturbances which he made in the family and neighbourhood, admitted of no respite to her anx- iety. 1 he education of her two children, whom she tenderly loved, and the constant attention which she was disposed to pay to their health and improvement, were the only circumstances that served to palliate the severity of her disappointment, or to tolerate the in- sipidity of her existence. But they were not sufficient to arrest the progress of her melancholy. Her in>

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agina^^ion daily suggested new causes of solicitude and apprehension. Some misfortune or other arri^^- ed every day of the week, but especially, as she sup- posed, on Friday. Hence she fancied that Friday was a day of ill omen and ill luck. She, at length, carried this notion so far, that she would not leave her room on that day. If the month began on a Friday, it rendered her extremely fearful and mis- erable for se\eral days. By degrees, Thursday, being the eve of Friday, excited similar alarms. If ever she heard either of those days named in com- pany, she immediately turned pale, and was con- fused in her manner and conversation, as if she had been visited by some fatal misfortune. Some months after the revolution it was determined to take my advice on her case. Conjoined to such moral manage- ment as her situation appeared to require, I advis- ed a few simple and suitable remedies. The changes of 17t^9, succeeded by reverses of fortune, and the eventual emigration of the family, put it out of my power to learn the sequel of her history. But, I am disposed to think, that a new chain of ideas, change of scene and climate, and, perhaps, depressed cir- cumstances, have long since dissipated her apprehen- j sions and her melancholy.

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MELANCHOLIA CONSTDERED NOSOLOGTCALLY AS A SPECIES OF MENTAL DERANGEMENT.

55. Melancholics are frequently absorbed by one exclusive idea, to which they perpetually recur in their conversai ion, and which appears to engage their whole attention/^ At other times, they observe the most obstinate silence for many years, and friendship and affection are refused participation in their secret. On the contrary,, there are some who betray no extraordinary gloom, and appear pos- sessed of the soundest judgement, when an unfore- seen circumstance happens and suddenly rouses their delirium.. A commissary, one day, visited the hospital de Bicetre, for the purpose of dissmising such of its tenants as were supposed to be cured. Amongst others, he put some questions to an old vine dresser, who replied to him with great propriety and coherence. Upon which, the officer prepared the pro- ces verbal for his discharge, and according to custom, gave it him to sign. But, Vvhat was his surprise when he saw the old man sign himself christ, and indulge in all the reveries suggested by that delusion.

Any cause of fear or terror may produce a habi- tual susceptibility to those emotions, and, by under- mining the constitution, may induce dangerous debili- ty and death. I have known two Austrian prisoners

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of war, fall victims to their apprehensions. The object of then' terror was the guillotine.

A certain sourness of disposition, and a surly misanthropy of character, appear to determine some maniacs to shut themselves up in their own chambers, and to treat, with great rudeness and abuse, any person that should offer to molest their solitude. Fanatics, belonging to this class of mad- men, often fancy themselves inspired and under di- vine requisition to perform some sacrificial act or acts of expiation. Those deluded and dangerous beings can commit most barbarous homicides in cold blood. An old monk, driven to a state of insanity by religious enthusiasm, believed that h^ had one night seen the virgin in a dream, and that he had received from her an express order to put to death a person of his acquaintance, whom he accused of infidelity. This projected homicide would, no doubt, have been executed, had the maniac, in consequence of betraying his purpose, not been timely and effec- tually secured.

TWO OPPOSITE FORMS OF MELANCHOLIA WITH DELIRIUM,

56. Nothing appears more inexplicable, at the same time that nothing can be more certain, than

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that melancholia with delirium, presents itself in tw« very opposite forms. Sometimes it is distinguisned by an exalted sentiment of self-importance, associ- ated with chimerical pretensions to unbounded power or inexhaustible riches. At other times, it is charac- terized by great depression of spirits,- pusillanimous apprehensions and even absolute despair. Lunatic asylums afford numerous instances of those opposite extremes. The steward of a gentleman of fbrtune,> lost his property by the revolution; and for his attach- ment to the old regime, he was committed to prison, where he was detained for some months. Overwhelm- ed by apprehensions for his life, which he perpetually harboured, and which the violence of the times were too mucli calculated to excite, he at length became insane. In that situation he was transmitted to the hospital de Bicetre, where he soon complimented himself with the title and prerogatives of the king of France. A jurisconsulte, deprived by requisition of an only son, for whom he entertained a most tender affection,, yielded to a grief so poignant that it terminated in insanity ; upon which, he assum- ed the character of the king of Corsica. A native of Versailles, ruined by the revolution, was soon after extatized by the fantastic illusion of being the sover- eign of the world On the other

hand, there are instances of profound and distres- sing melancholy, being exasperated into active

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madness, without any change in the object of the hallucination. A simple timorous man, made use of some expressions of dissatisfaction with the go- vernment, in the second year of the republic. He was threatened with the guillotine. The conse- quences were, ihat he lost his sleep, was exceeding- ly perplexed, and forsook his ordinary employment. Soon after, he was confined in the Asylum de Bi- cetre. The idea of his ignominious death perpetu- ally haunted him, and he daily solicited the execu- tion of the decree which he fancied to have been pas- sed against him. His mind was thoroughly unhing- ed and deranged. All my attempts to restore him proved unsuccessful.

It has not been without emotion, that I have seen many an interesting victim of sensibility and affection, sink under the loss of a near and dearly beloved relative, into a most distressing state of delirious melancholy. A young man,^ who had lost his reason amid the pangs of disappointed love, was influenced by so powerful an illusion, that he mistook every female visiter for his dear Mary Ade- leine, the object of his unfortunate attachment. To hear his tender and impassioned addresses to every fak" stranger that he met with, was calculat- ed to soften the hardest heart.

U5

MAY NOT MEL\NCHOLTA OF SEVERAL YEARS STAND- ING DEGENERATE INTO MANIA ?

57. Melancholia remains often stationary for several years without any change in the object of its dehriun, and without any other alteration of the moral and physical functions. Some melancholies of this class, have been c:)nfiiied at the Asylum de Bicetre, for twelve, fifteen, twenty and even thirty years; and, • throughout the whole of that period, their hallucination has been confined to one subject. The functions of their monotonous existence chiefly consisted in eating and sleeping: and they have gene- rally withdrawn from society to associate with phan- toms of their own creation. B.it Home of them who were endowed with a greater mobility of character, from constantly seeing the extravagances of thfir more furious associates, became themselves decided maniacs. Others, after the lapse of some years, and from no evident cause, have undergone a thorough re- volution of character. The object of their hallucination has changed, or it has excited their interest in a new direction. A majuac of this description was under my care for about twelve years For the first eight, he was perpetually haunted with the fear of being poisoned. He supposed that his relations wished to disown him, and to deprive him of his property.

T

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He was exceedingly reserved in bis conversa- tion ; but what he said upon every subject, except- ing that of his hallucination, was perfectly connected and correct. The idea of the poison made him ex- tremely suspicious, and he durst not eat any victuals but what were cooked at the usual kitchen. Towards the eighth year of his confinement, his delirium suddenly changed its character. He then became a mighty potentate, sovereign of the world, equal to the creator, and supremely happy.

MELANCHOLIA WITH A DISPOSITION TO COMMIT SUICIDE-.

58. " The English," says Montesquieu, " fre- quently destroy themselves without any apparent cause to determine them to such an act, and even in the midst of prosperitj^ Among the Romans sui- cide was the effect of education j it depended upon their customs and manner of thinking: with the English it is the effect_jof^ disease, and depending upon the_pbysical condition of the system .*^/t The propensity to this horrid deed as existing independ- ent of the ordinary powerful motives to it, such as the loss of honour or fortune is by no means a dis- ease peculiar to England : it is far from being of rare occurrence in France.

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In a periodical journal of some time past, I pubi- lished a case of this kind, of whicii the following his- tory contains an abridged account. A young man, twenty-two years of age, was intended by his parents for the church. He disliked the profession exceed- ingly, and absolutely refused to take orders. For this act, at once of integrity and disobedience, he was forced to quit his father's house, and to exert his inexperienced energies for a precarious subsists ence. He turned his thoughts to several different employments -, and, at length, he went to reside with a family, where he was treated with great kind- ness, and where he appeared to enjoy a degree of tranquility. His enjoyment, however, was not of long continuance ; for his imagination was again as- sailed by gloomy and distressing reflections His life became gradually more and more burdensome to him, and he considered of different methods of put- ting an end to it. He one day formed the resolu- tion of precipitating himself from the top of the house : but his courage failed him, and the execu- tion of the project was postponed. Some days after, he took up a pistol with the same design of self-destruc- tion. His perplexities and terrors returned. A friend of this unhappy youth, called upon me one day to inform me of the projected tragedy. We adopted every means of prevention that prudence could sqg-

14S

^est : but the most pressing solicitations and frieiid* liest remonstratices were in vain. The propensity to suicide unceasiiigly haunted him, and he precipi* tately (juirted the family where he had experienced so many proofs of friendship and attachment. Fi* nancial considerations prohibited the suggestion of a distant voyage, or a change of chmate. I, there- fore, advised as the best substitute, some constant and laborious employment. The young melancho- lic, sensihly alive to the horror ot his situation, en- tered fiilly into my views, an4 procured an engage- ment a' Bled harbour, where he mingled with the other labourers, with a full determination to deserve his stipulated wages. But, completely fatigued and exliausted by the exertion of the two first days of his engagement, he was obliged to have recourse to some other expedient. He entered into the employ of a master ma^on, in the neighbourhood of Paris, to whom his services were peculiarly acceptable, as he devoted his leisure hours to the instruction of an only son No situation, apparently, could have been more suitable to his case, than one of this kind, admit- ting of alternate mental and bodily exercise. Who'e- somefood, comfortable lodgings, and every attention due to misfortune, seemed rather to aggravate than to divert his gloomy propensities. After the expiration of a fortnight, ht; returutd to his friend, and, with

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tears in his eyes, acquainted him with the internal struggles which he fek, and the insuperable disgust with life, which bore him irresistibly to self-distruc- tion. The reproaches of his fnend affected him ex- ceedingly, and, in a state of the utmost anxiety and despair, he silently withdrew, probably to terminate a hated existence, by throwing himself into the •Seine.

SPECIFIC CHARACTER OF MELANCHOLIA.

59. Delirium exclusively upon one subject: no propensity to acts of violence, independent of such as may be impressed by a predominant and chimeri- cal idea : free exercise in other respects of all the faculties of the understanding : in some cases, equa- nimity of disposition, or a state of unruffled satisfac- tion : in others, habitual depression and anxiety, and frequently a moroseness of character amounting even to the most decided misanthropy, and some- times to" an invincible disgust with life.

SECOND SPECIES OF MENTAL DERANGEMENT.

MANIA WITHOUT DELIRIUM.

MADNESS INDEPENDENT OF ANY LESION OF THE UNDER- STANDING.

60. We may very justly admire the writings of Mr. Locke, without admitting his authority upon subjects not necessarily connected with his enquiries. On resuming at Bicetre my researches into this dis- order, I thought, with the above author, that it was inseparable from delirium ; and, I was not a little surprized to find many maniacs who at no period gave evidence of any lesion of the understanding, but who were under the dominion of instinctive and ab- stract fury, as if the active faculties alone sustained, the injury.

AN INSTANCE OF MANIACAL FURY WITHOUT DELIRIUM.

61. The following relation will place in a conspi- cuous, point of view, the influence of a neglected or

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ill directed education, in inducing upon a mind na- turally perverse and unruly, the first symptoms of this species of mania. An only son of a weak and indulgent mother, was encouraged in the gratifi- cation of every caprice and passion, of which an untu- tored and violent temper was susceptible. The impe- tuosity of his disposition increased with his years. The money with which he was lavishly supplied, re- moved every obstacle to his wild desires. Every in- stance of opposition or resistance, roused him to acts of fury. He assaulted his adversary with the audacity of a savage; sought to reign by force, and was perpetually embroiled in disputes and quarrels. If a dog, a horse, or any other animal ofiended him, he instantly put it to death. If ever he went to a fete or any other public meeting, he was sure to ex- cite such tumults and quarrels, as terminated in ac- tual pugilistic rencounters, and he generally left the scene with a bloody nose. This wayward youth, however, when unmoved by passions, pos- sessed a perfectly sound judgement. When he came of age, he succeeded to the possession of an extensive domain. He proved himself fully com- petent to the management of his estate, as well as to the discharge of his relative duties ; and he even distinguished himself by acts of beneficence and com- passion. Wounds, lavV-suits, and pecuniary com- pensations, were generally the consequences of his

J52

unhappy propensity to quarrel. But an act of no* toriety put an end to bis carreer of violence. En* jaged at a woman, who had used offensive language to him, he precipitated her into a well. Prosecution was commenced against him, and on the deposition of a great many witnesses, who gave evidence to his furious deportment, he was condemned to perpetii* al confinement at Bicetre.

MADNJESS WITHOUT DELIRIUM, CONFIRMED BY A VTElilf ESTABLISHED FACT.

62. A FULLY developed case of this species of mental derangement will clearly establish its claims to nosological attention.

A mechanic, confined at Bicetre, was subject, at irregular intervals, to paroxysms of maniacal fury, unaccompanied by any lesion of the intellect. The fn-st symptom which manifested itself was a burning heat in the abdominal region ; which was accompani- ed by great thirst and costiveness. It extended itself, by degrees, to the chest, neck, and face, of which it heightened the complexion. Vv'hen it reached the temples, it beame still more intense, and produced violent and accelerated pulsations of the arteries of those parts. At length, the brain itself was affected^

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when the maniac was seized by an irrestible propen- sity to sanguinary deeds : and could lie have posses- sed himself of an instrument of offence, he would have sacrificed to his fury the first person that came in his way. In other respects, however, he enjoyed the free use of his reason, even during his paroxysms. He answered wirhout hesitation the questions that were proposed to him, and evinced no incoherence in his ideas, nor any other symptom of delirium. He was deeply conscious of the horror of his situation, and was sfung with remorse, as if he had been real- ly accountable for his furious propensities. Before his confinement at Bicetre, he was one day seized by a furious paroxysm at his own house. He in- stantly gave warning of it to his wife, to whom he was tenderly attached, and advised her by an immediate flight to avoid certain death. At Bicetre he exjDC- rienced similar accessions of periodical fury, and his propensity to acts of atrocity was sometimes di- rected even against the governor, to whose compas- sionate attention and kindness he never appeared insensible. These internal conflicts, in which he shewed him.self to be possessed of sound reason, and at the same time, to be actuated by sanguinary cru- elty, occasionally overwhelmed him with despair, and he often sought to terminate by death the dread- ful struggle. He one day seized the cutting knife of the hospital shoemaker, and wounded himself

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deeply in the right breast and arm. The conse- quence was a violent haemorrhage. Close confine- ment, and the strait-waistcoat were employed to prevent the execution of his bloody project.

ANOTHER INSTANCE OF MANIA WITHOUT DELIRIUM.

63. At a period of the revolution, which it is to be wished could be effaced from the annals of our history, a case of mania without delirium, gave rise to an extraordinary scene at the Asylum de Bicetre. The Brigands, after the massacre of the prisons, broke like madmen into the above hospital under pretence of emancipating certain victims of the old tyraimy, whom it had endeavoured to confound with the maniacal residents at that house. They prc- ceeded in arms from cell to cell, interrogating the prisoners, and passing such of them as were mani- festly insane. A maniac, bound in chains, arrested their attention by the most bitter complaints which he preferred with apparent justice and rationality. " Is it not shameful," said he, " that I should be bound in chains and confounded with madmen ?** He defied them to accuse him of any act of im- propriety or extravagance. " It is an instance of the most flagrant injustice." He conjured the strangers to put an end to such oppression, and to

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become his liberators. His complaints excited, amongst the armed mob, loud murmurs and impreca- tions against the governor of the hospital. They im- mediately sent for that gentleman, and, with their sa- bres at his breast, demanded an explanation of his con- duct. When he attempted to justify himself, they im- posed silence upon him. To no purpose did he adduce, from his own experience, similar instances of mani- acs,(//) who were free from delirium, but at the same time, extremely dangerous from their outrageous passions. They answered him only with abuse j and had it not been for the courage of his wife, who pro- tected him with her own person, he would have been sacrificed to their fury. They commanded him to release the maniac, whom they led in triumph, with reiterated shouts of Vive la Republique. The sight of so many armed men, their loud and confused shouts, and their faces flushed with wine, roused the madman's fury. He seized, with a vigorous grasp, the sabre of his next neighbour, brandished it about with great violence, and wounded several of his li- berators. Had he not been promptly mastered, he would have soon avenged the cause of outraged hu- manity. The savage mub then thtuight proper to lead him back to his cell, and, with shame and reluctance, yielded to the voice of justice and experience.

(h) See similar cases recorded by Dr. Rowley, in bis treatise on madness and suicide, page 155, et seq. T.

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SPECIFIC CHARACTER OF MANIA WITHOUT DELIRIUM.

64. It may be either continued or internaittent. No sensible change in the functions of the under- standing ; but perversion of the active faculties, marked by abstract and sanguinary fury, with a blind propensity to acts of violence.

THIRD SPECIES OF MENTAL DERANGEMENT. MANIA WITH DELIRIUM.

A PAROXYSM OF PERIODICAL MANIA IS A PROTOTYPE OF .COJJTINUED INSANITY.

^5. An accession of periodical mania resembles continued madness in all its characteristic properties, its duration excepted ; and it is impossible to con- vey a clearer idea of the one, than by recording the various circumstances of the other. With respect to their predisponent causes ; the varieties of their extravagance and fury ; the lesions of one or more of the functions of the understanding ; and the pro- digious number of objects, towards which their de^ lirium may be directed, there is a perfect analogy between them. Both may be excited by intense or vehement passions ; by exalted and furious enthu- siasm, or by whatever strong ernotions that may ori-

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ginate in fanaticism or chimerical delusion. Deliri«* ous insanity is sometimes distinguisiied by a gay and jovial humour, venting itself in hvely and incoherent sallies, or in petulant and absurd propositions ; at other times, by gigantic pride and fantastic preten- sions to dignities and grandeur. I was frequently fol- lowed at Bicetre by a general, who said that he had been just fighting an important battle, and had left fifty thousand men dead on the field. At my side was a monarch, who talked of nothing but his subjects and his provinces. In another place, was the prophet Mahomet in person, who denounced vengeance in the name of the Almighty. A little further, was a sovereign of the universe, who could, with a breath, annihilate the earth. Many of them seemed to be occupied by a multiplicity of objects wliich were pre- sent to their imagination. 1 hey jesticulated, de- claimed, and vociferated incessantly, without appear- ing to see or to hear any thing that passed. Others, under illusive influence, saw objects in forms and co- lours which they did not really possess. Under the influence of an illusion of that kind, was a maniac, who mistook for a legion of devils, (/) every assem- blage of people that he saw. Another maniac, tore his clothes to tatters, and scattered the straw on which he lay, under the apprehension that they were

^i) gee pagis 76 and 74.

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Jieaps of twisted serpents, {k) Delirium sometimes continues with a degree of furor for a long series of years. At otlier times, it is constant, and the pa- roxysms of fury recur only at certain inrervals, or from tlie coincidence of some accidental cause. As life advances, the disease commonly subsides nr^o a settled calm : but sometimes the accessions of fury become more frequent, which is a fatal prognostic.

IS MANIA WITH DELIRIUM COMMONLY SUSCEPTIBLE OF

CURE ?

66. Prejudices which are very commonly en- tertained, and which operate in too many instances to the abandonment of maniacs to their melancholy fate, are those of considering their disorder as incur- able, and of referring it to an organic lesion of the brain, or some other part of the head. I can affirm, that in the greatest number of anatomical facts which I have been able to collect on mania with delirium, almost all the results of my dissections, compared with the previous symptoms, favour the opinion, that mania, especially of this species, is a nervous jnalady. Mr. Harper, asserts, " That no morbid affection, general or local, nor any physical change

(k) Seepages,!.

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or effect, that may exist in the habit considered as a mere corporeal system, can possibly constitute or even create insanity.'^/). However that may be, there is in maniacs every appearance of a strong ner- vous excitement. That an increased developement of vital energy takes place upon the accession of this disease, is apparent from their perpetual agitation, their impassioned cries, their propensities to acts of violence, their constant wakefulness, their wild looks, their strong venereal appetite, their petu- lance, their quick replies, and their consciousness of physical and mental superiority. Hence, it is not to be wondered at, that proper attention to mental and corporeal regimen seldom fails to effect a cure.

SPECIFIC. CHARACTER OF MANIA WITH DELIRIUM.

67. Mania with delirium is either continued or intermittent, with regular or irregular returns of the paroxysms. It is distinguished, both in respect to the functions of the mind as well as those of the bo- dy, by a strong nervous excitement ; and marked by the lesion of one or more of the functions of the un- derstanding, accompanied by emotions of gaiety, of despondence or of fury.

'/) See note, page 111.

FOURTH SPECIES OF MENTAL DERANGEMENT,

DEMENTIA, OR THE ABOLITION OF THE THINKING FACULTY.

THE MOST STRIKING FEATURES OF DEMENTIA FREQUENT- LY OBSERVABLE IN SOCIETY.

68. The extreme volatility, thoughtless absence, extravagant improprieties, and wild excentricities which constitute the character ofMenalcus, in the work of Bruyere, chap. 1 II, are far from forniing one of those pictures of the imagination, which exist only in romances. A medical observer, will often see in society, the incipient traits of dementia, of which the finished forms are to be met with in hospitals. A man, who bad been educated in the prejudices of the ancient noblesse, was advancing, about the com- mencement of the revolution, with rapid strides to- wards this species of mental disorganization. His passionate effervescence and puerile mobility were excessive. He constantly bustled about the house, talking incessantly, shouting and throwmg himself into great passions for the most trifling causes. He

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teased his domestics by the most frivolous orders, and his neighbours by his fooleries and extravagan- ces, of which he retained not the least recollection for a single moment. He talked with the greatest volatility of the court, of his periwig, of his horses, of his gardens, without waiting for an answer or giv- ing time to follow his incoherent jargon. A woman of great sensibility, (?/z) whom considerations of rank had united to his destenies, fell a victim, in conse- quence of the unhappy connection, to the most pro- found and desperate hypochondriasis.

The childishness of old age, which is frequently accelerated by excessive pleasures, bears a close ana- logy to the case which we have just described : but it is not accompanied by any effervescence of the passions.

DEMENTIA MARKED BY IDEAS UNCONNECTED AMONGST THEMSELVES AND Wtn-IOUr RELATION TO EXTERNAL OBJECTS.

69. The dementia of which we are treating, is generally accompanied by a turbulent and ungo- vernable mobility, by a rapid and unconnected suc- cession of ideas, wliich appear to be generated in

(m)^ See page la9.

W

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the mird, without exciting their correspondent ex- pressions upon the organs of sense, and by passion- ate emotions which seem to be felt and to be forgot- ten, without reference to external objects. An ar- dent, but ill informed patriot, and one of the warm- est partizans of the celebrated Danton, was present at the sittingof the legislative body, when the writ of accusation was pronounced against that deputy. He withdrew in consternation and despair j shut him- self up in his own apartments for several days, and surrendered himself to the influence of the most gloomy ideas. " What! Danton, a traitor!" re- peated he without ceasing, " then is there no man to be trusted: the republic is lost." His appetite and sleep forsook him. Complete insanity ensued. Having undergone the usual treatment at the ci-de- vant Hotel Dieu, he was transmitted to Bicetre. He passed several months in the infirmary of this hospital, in a state of tranquil reveriesm, uttering in- cessantly, half expressed and unconnected sentences. He spoke alternately of daggers, sabres, dismasted vessels, green meadows, his wife, his hat, &c. He never thought of eating but when the food was ab- solutely put into his mouth, and in respect to his functions he was almost levelled with an automaton.

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A CASE OF DEMENTIA WELL CALCULATED TO MARK THE DISTINCTION BETWEEN THAT FORM OF MENTAL DE- RANGEMENT AND MANIA.

70. In order to mark, with the greater precision, the characteristic properties of dementia, it will be of advantage to consider them in contrast with those of mania. In mania, there are important lesions of the powers of perception, imagination and memory: but the faculty of judgement, and the association of ideas remain. The maniac, who believed him- self to be the prophet Mahomet, and blended this idea with every action and every thought, retained his faculty of judging ; but he combined two discord- ant ideas : therefore, his judgement was unsound. In this point of view, what would become of the greatest part of the world, if every act of erronious judgement entitled the judge to an apartment in the Petites Maisons ? In dementia, there is no judge- ment either true or false. The ideas appear to be insulated, and to rise one after the other without connection, the faculty of association being de- stroyed. An example will illustrate my position. It is that of a person whom I had frequently the opportunity of seeing. His motions, his ideas, his broken sentences, his confused and momentary glimpses of mental affection appeared to present a perfect image of chaos. He came up to me, looked

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at me, and overwhelmed me with a torrent of words, without order or connection. In a moment he turn- ed to an )ther person, whom in his turn lie deafened with his unmeaning babble, or threatened with an evanescent look of anger ; but, as incapable of de- termined andcoi.t nued excitement of the feel .ngs as of a just connection of idfas, his emotions wer^ the effects of a momentary elfervscence, which was im- mediately succeeded by a calm. If he went into a room, he qnicklv displaci dor overtuinedtbefurniture, without manif; sting any direct intention. Scarcely could one look off, before he would be at a consider- able distance, exercising his vert>atile mobility in some other way. He was quiet only when food was presented to him. He rested, even at nights, but for a few moments. X

SPECIFIC CHARACTER OF DEMENTIA.

71. Rapid succession or uninterrupted alterna- tion of insulated ideas, and evanescent and uncon- nected emotions. Continually repeated acts of ex- travagance : complete forgetfulness of every previ- ous state ; diminished sensibihty to external impres- sions: abolition of the faculty of judgement : perpet- ual activity.

FIFTH SPECIES OF MENTAL DERANGEMENT.

IDEOTISM, OR OBLITERATION OF THE INTEL- LECTUAL FACULTIES AND AFFECTIONS.

DEFINITION, CAUSES AND CHARACTER OF IDEOTISM.

721. Ideotism, which by the author of the Sy- nonym es Francois is defined to be a defective percep- tion and recognizance of objects, is a partial or to- tal abolition of the inttUectual and active faculties. This disorder may originate in a variety of causes : such as excessive and enervating pleasures ; the abuse of spirituous liquors ; violent blows on the head ; deeply impressed terror ; profound sorrow ; intense study ; tumors within the cavity of the cra- nium ; apoplexy ; excessive use of the lancet in the treatment of active mania. The greatest number of ideots are either destitute of speech or are con- fined to the utterance of some inarticulate sounds. Their looks are without animation ^ their senses stu- pified; and their motions heavy and mechanical. A young sculptor, eight and twenty years of age, in confinement at Bicetre, had been reduced to this

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state by excessive intemperance and venery. He re- mained almost always motionless and silent. At inter- vals his face would be distorted by a silly and stupid laugh. His features were devoid of expression. Every trace of his former condition was effaced from his me- mory. He shewed no symptoms of hunger; and even eating appeared to be a motion purely mechanical. He passed the whole of bis time in a lying position. At length, he sunk under a fatal hectic. Ideots con- stitute the greatest number of patients at lunatic hospitals ; and their pitiable condition, has in two many instances, originated in severity of treatment experienced at other places. In cases of congenite ideotism, there is often a malconformation of the cra- nium. In the third section, I have cited two remark- able instances of this kind.

INTENSE EMOTIONS INDUCTIVE OF IDEOTISM.

73. The feelings of individuals endowed with acute sensibility, may experience so violent a shock, that all the functions of the mind are in danger of being suspended in their exercises or totally abolish- ed. Sudden joy and excessive fear are equally capa- ble of producing this inexplicable phenomenon. An engineer, proposed to the committee of pubHc safe- ty, in the second year of the republic, a project for

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a new invented cannon, of which the effects would be tremendous. A day was fixed for the experiment at Meudon ; and Robespierre wrote to the inventor so flattering a letter, that upon perusing it, he was transtixed motionless to the spot. He was shortly afterwards sent to Bicetre in a state of complete ideotism. About the same time, two young con- scripts, who had recently joined the army, were cal- led into action. In the heat of the engagement, one of them was killed by a musket ball, at the side of his brother. The survivor, petrified with horror, was struck motionless at the sight. Some days af- terwards he was sent in a state of complete ideotism to his father's house. His arrival produced a similar impression upon a third son of the same family. The news of the death of one of the brothers, and the de- rangement of the other, threw this third victim into a state of such consternation and stupor as might have defied the powers of ancient or modern poetry to give an adequate representation of it. My sym- pathetic feelings have been frequently arrested b}- the sad wreck of humanity, presented in the appear- ance of these degraded beings : but it was a scene truly heartrending to see the wretched father come to weep over these miserable remains of his once enviable family.

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IDEOTISM, THE MOST COMMON SPECIES OF MENTAL DE- RANGEMENT IN HOSPITALS : SOMETIMES CURED BY PAROXYSMS OF ACTIVE MANIA.

74. Ir is to be regretted, that this species of mental disorganization, as it is most common, es- pecially in lunatic asylums, is for the most part in- curable. At Bicetre it constitutes one fourth of the ■yvhole number of patients. The cause is suificient- ly obvious. This great hospital is considered as a place of retreat for the incurable, and for such as have been exhausted by severity of treatment else- where. It frequently happens, that out of the great number that are sent thither, many are previously re- duced to such a state of weakness, atony and stnpor, that they die in a few days after their arrival. Some of them, however, with the gradual reestablishment of their strength, recover their intellectual faculties. Others are greatly relieved, but are subject to re- lapses on the accession of warm weather. Many, especially young people, after having reaiained se- veral months or years in a state of absolute ideotism, are attacked by a paroxysm of active mania, of twenty, twenty-five, or thirty days' continuance. Such paroxysms, apparently from a reaction of the system, are, in many instances, succeeded by per- fect rationality. This truth is illustrated by a case which has been slready detailed in pages 88 and 89-

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THE LEADING FEATURES OF THE PHYSICAL AND MEN- TAL CHARACTER OF THE CRETINS OF SWITZERLAND.

^5. The most numerous class of patients at lu- natic hospitals is undoubtedly that of ideots j who, when viewed collectively, exhibit every degree and form of stupidity. This state of degradation and nihility, is strongly marked in the Cretins of Switzerland. Those monuments of imperfect reproduction of the human species, exhibit, from their earliest years, unequivocal indications of their future destiny. A swelling of the throat, about the size of a nut ; a tumescent distortion of the face j the diminutive size of their heads and hands ; defec- tive sensibility to the variations of the atmosphere ; difficulty in sucking, apparently from an imperfec- tion of the instinct ; general insensibility ; extreme- ly slow and incomplete developement of the power of articulating sounds, confined as it is to the enunciation of vowels; clumsiness of all their move- ments in proportion to the increasing size of their bodies, are characteristics of their earliest infancy. At ten or twelve years of age, their intellectual powers are so little developed, that they are unable to convey the food to their mouth or to masticate

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it ; and their mechanical existence is preserved by thrusting the aliment down their throats. As they grow up, their efforts to walk are feeble and clumsy; and if constrained to move, they never do it cheer- fully, but always with an air of surly dissatisfaction, w^hich maternal tenderness alone can tolerate. Their diminutive heads are always depressed on the crown and the temples, and the occiput is less than ordi- narily protuberant. Their eyes are small, sometimes sunk, sometimes prominent, but always fixed and doll. Their chests are broad and flattened ; their fingers long and delicate, with the articulations of the joints indistinctly marked. The soles of their feet are broad, and the foot itself generally distorted. At the age of puberty, which arrives at a very late period, the organs of generation are developed to an enormous size : hence their extreme salacity and propensity to onanism. It is at this period, that they begin to walk ; but even then, their powers of locomotion are very limited, and are roused to action only by the desire of gratifying hunger, or of basking before the fire, or in the sun. Their bed is the end of a long and laborious journey to them, to which they retire with pendant arms and tottering steps. In walking, they keep their eyes fixed on their object, and pursue the rout most familiar to them, regardless of obstacles and

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dangers. Arrived at their full growth, which is gene- rally from thirteen to sixteen decimetres, their skin be- comes brown; their sensibility continues blunt, which is indicated by great indifference to the action of cold and heat, or even to blows and wounds. They are generally both deaf and dumb. The strongest and most pungent odours scarcely affect them. I know a Cretin, who devours raw onions, and even char- coal with great avidity. A striking proof of the coarseness and imperfect developement of the organ of taste. Their organs of sight and feeling are equal- ly limited in their operation. Of affections, they seem wholly destitute : they discover no signs of gratitude for kindnesses shewn to them, nor any attachment to their nearest ralatives. In a word, they appear almost totally insensible to objects which excite the interest of mankind, and even to the wants which more immediately affect the func- tions of life. " Such," says Fodere, " is the phy- sical and moral existence of the Cretins for a long series of years. Endowed with a sort of vegetative life, they arrive at extreme old age, without expe- riencing the difficulties incident to humanity."

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SPECIFIC CHARACTER OF IDEOTISM.

76. Total or partial obliteration of the intellec- tual powers and affections : universal torpor : de- tached, half articulated sounds ; or entire absence of speech from want of ideas : in some cases, transiei^t and unmeaning gusts of passion.

INSANITY COMPLICATED WITH EPILEPSY.

77. To the preceding species of insanity might be subjoined, mania complicated with epilepsy : a variety of the disorder, that we frequently meet with in hospitals, and which, in the present state of our knowledge, is almost always incurable. But, as those cases are in general no more than combinations of epilepsy, with the third species of mental derange- ment or mania with delirium, or, perhaps, more frequently with the last species or ideotism, I shall here simply advert to the circumstance.

Insanitydoes not in general preserve the same cha- racter throughout the whole of life. The different spe-

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cies are mutually interchangeable. Melancholia is not unfrequently exasperated into mania. Mania is depressed into ideot ism ; and ideotism is in its turn exalted to mania, as a first step towards the re- covery of reason.

The proportion subsisting between the different species of mental derangement, in respect to numbers, appears very deserving of remark. Out of two hundred patients confined at Bicetre, when I took my last survey, there were twenty- seven melancholies, fifteen maniacs without deli- rium, eighty maniacs with delirium including both the continued and intermittent varieties, eigh- teer^ affected by dementia, and sixty ideots.

It is now time to conclude the nosological part of the present treatise. It is to be hoped, that our system of classification, independent of its methodical clear- ness and discrimination, will contribute towar<{> the establishment of proper, rules for the internal govern- ment of lunatic hospitals, and serve to discover or confirm some general indications of tieatnienr ; which, in order to avoid empyrical experiments, oiigiit to le respectively adapted to each species and variety if mental derangement.

SECTION V.

THE IMPORTANCE OF AN ENLIGHTENED SYS- TEM OF POLICE FOR THE INTERNAL MA- NAGEMENT OF LUNATIC ASYLUMS.

THE ADVANTAGES OF A SYSTEMATIC DISTRIBUTION AND A PERFECT INSULATION OF THE DIFFERENT SPE- CIES OF MENTAL DERANGEMENT.

78. A LUNATIC hospital ought to unite the advan- tages of site, to those of an extensive inclosure, and a spacious and commodious building. If, in the erection of such an edifice, its compartments have been so ar- ranged as not to admit of insulating in a great measure different classes of patients, so as effectually to pre- vent their reciprocal communication ; and, at the same time, to facilitate the labours of the governor, physician or other assistant officers, it is defective in a most important circumstance. Such a distribution of the patients ought to be obtained in houses of this kind, as would, at one view, exhibit the respect- ive measures to be adopted for cleanliness, regimen iand moral management, and enable their officers

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to foresee and to calculate the wants of each class, and to make ample observations upon the symptoms and peculiarities of every case. Possessed of oppor- tunities of this kind, an enlightened physician, from the facts that would be daily presented to him, would be able to deduce many valuable practical results ; to distinguish accurately between all the species and varieties of insanity ; and finally, to establish such a system of treatment, as would be likely to meet the majority of cases.

GENERAL CONSIDERATIONS IN REGARD TO THE DISTRIBU- TION OF PATIENTS IN LUNATIC HOSPITALS INTO DIF- FERERT CLASSES.

79. It is much easier to make a distribution of the patients into distinct classes, than to construct an edifice that would correspond with that distribu- tion, and, in every respect, be adapted to fiilfil its in- tended object. A plan for an erection of this kind, ought invariably to be submitted to the inspection and approbation of some enlightened members of the faculty. Such an edifice completed, it will re- main for the physician to make a general inspection of the patients to be confined in it ; to observe carefully and minutely the symptoms of every case ;

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to distribute them into distinct classes, and assigtt for them such situations as will best contribute to counteract their maniacal illusions, and to facilitate the measures of the interior police. For melancho- lies, ought to be allotted a part of the establishment commanding open and cheerful scenery, and adjoin- ing to the grounds or gardens, where it is intended to engage them in the pleasing exercises of horticul- ture. The most furious and extravagant maniacs, it will be proper to confine in the most retired part of the building, where their cries and bowlings will not reach beyond the gloom and secrecy of the place, and where no external object can be presented to excite or to aggravate their fury. Those subject to periodical mania, may, during their lucid intervals, be liberated from their gloomy residences, and be per- mitted to associate with the convalescents. In or- der to avoid relapses, and to effect a permanent and perfect cure, the insulation of periodical maniacs is an important object in every well regulated hos- pital. The spectacle of degradation and nullity, presented by dementia and ideotism, ought never to be exposed to the observance of the other classes of maniacs. These subjects will be further enlarged upon in the sequel.

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fttE IMPORTANCE OF FREQUENTLY AND VARIOUSLY RE- PEATED ATTEMPTS TO COUNfERACf THE HALLUCI- NATION OF MELANCHOLICS.

80. " It is probable," says Montaigne, " that the credit of visions and enchantments and other supernatural influences, is for the most part, to be ascribed to the power of the Imagination over the unenlightened minds of the vulgar." This judicious remark, will more especially apply to the fantastic illusions, the gloomy suspicions, and groundless fears of melanchoKcs. Impressio^is of this kind, rooted in the temperament and matured by habit, are exceed- ingly difficult of removal. How are we to combat the prejudices of a contracted mind, that takes for reality every chimera of its own creation?

Some melancholies are perpetually haunted by the dread of treachery and inveiglement, and are jealous even of the kindnesses that are intended or shewn to them. Others, exalted in their imagination to gran- deur or pov>'er, are roused to indignation by the most distantoffer of advice,or theshghtest resistance to their supreme commands. There are yet others, who spend whole nights in contemplation ; who speak perpetually under the supposed influence of inspira- tion; meditate upon acts of expiation and pennance, or enjoin upon themselves a system of the most ob- tinate and rigorous abstinence. Some fancy them-

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selves under a sentence of condemnation, for crimes pmiishable by death, and strive to anticipate its ex- ecution by the most nivincible rejection of food. A ^patient at the hospital of Bicetre, who believed himself one of the victims of the revolution, inces- santly repeated that he was ready to submit to his fate. He refused to lie down on his bed, and re- .mained stretched on a damp pavement, which threatened to deprive him of the use of his limbs. The governor, m vani, employed the lenient mea- sures of remonstrance and intreaty, and found himself compelled to have recourse to more coercive steps. The madman was confmed to his bed with cords : but this severity of treatment he resented by the most obstinate rejection of all sustenance. Ex- hortations, promises and threats were used in vaiuo For four successive days he adhered most rigidly to his system of abstinence. He then was seized with a most vehement thirst, and he drank copious and frequently repeated draughts of cold water ; but he still obstinately refused broth, and every other liquid or solid nutriment. Towards the tenth day of his fast, he was reduced almost to a skeleton, and he exhaled an extremely fcEtid odour. He continued to adhere pertinaciously to his usual beverage, and his case, to all appearance, became hopeless. About the twellth day, it was announced to him by the at- tendant, that since he persisted in his refractoriness.

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he should for the future, be deprived of his usual al- lowance of cold water, in place of which should be substituted meat broth. . For some time he wavered between two opposite impulses ; the one, a consum- ing thirst which irresistibly impelled him to swallow any liquid whatever; the other, his firm and unchang- ed resolution to accelerate by fasting the period of his death. His raging thirst at length prevailed and he drank copiously of the broth. By way of recom- pence he was immediately restored to the free use of cold water. The powers of his stomach being in some degree restored, an agreeable sensation suc- ceeded, and the same evening he again consented to take of the broth. On the following days he by degrees acceeded to the use of rice, broth and other more solid nutriments. He gradually recovered his foraier health. I shall take a future opportunity to point out the means which I adopted to dispel his illusive and gloomy apprehensions. (/z)

(nj Melancholies somothnes reject food with such invincible obstinacy as to induce extreme exhaustion and death. A case detailed by Mr. Has- 1am, in his "Observations on insanity,"' pngeG?, will sufficiently illustrate my position. " 1. H. a ma.n, twenty eight years of age, was admitted a patient" (of Bethlehem Hospital ) " in May, 1795. He had been disordered for about two months before he came to the hospital. No particular cause was stated to have brought on the complaint. It was most probably an hereditary affec- tion, as his father had been several times insane, and confined in our hospi- tal. During the time he was in the house, he was in a very low and melan- cholic state ; shewed an aversion to food. His obstinacy in refusing all nourish- ment was very great, and it wa^ with much difficulty forced upon him, He

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THE CHOICE OF A PROPER SITUATION ^OR MELAl^CHOLlGS

RECCOMMENDED.

81. An intimate acquaintance with human na- ture, and with the character in general of melancho- lies, must always point out the urgent necessity of forcibly agitating the system j of interrupting the chain of their gloomy ideas, and of engaging their interest by powerful and continuous impressions on their external senses. Wise regular ions of this nature, are considered as having constituted in part the celebrity and utility of the priesthood of ancient Egypt. Efforts of industry and of art ; scenes of mas^nificence and grandeur-, the varied pleasures of sense; and the imposing influences of a pompous and my^sterious ji^->er,stition, were, per- lmps7never devoted to a more laudable purpose. At tRTftrexTreniTtles ot aiicreHTEgypt, a country which was at that time exceedingly populous and flourish- ing, were temples dedicated to Saturn, whither me-

(Eontiuued in this state, but becaiie daiy weaker and more emaciated until August 1, w'nen he died. Up ii opening the head, the pericranium was found loosely adherent to th? skull. The bones of ihe craniim were thick. The pia mater was loaded witli blooH/and the mudvillary substance, when cut into wa.> full of bloody points. The pinea gland contained a la- ge quan- tity of gritty matter, which u, on examination was found to be ihosphate of lime The consistei ce of the brain was natural. He was opeued^-wenty fptir hours after death,"

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lancholics resorted in crowds in qnest of relief. The priests, taking advantage of their credulous confi- dence, ascribed to miraculous powers the effects of natural means exclusively. Games and recreatijjns of all kinds, were instituted in these temples. Vo- luptiTOLls paiiitinp^idTiiiages were every where ex- posed to public view. The most enchanting songs, and sounds the most mHodious, " took prisoner, the captive sense." Flowery gardens and groves, disposed with taste and art, invited them to refresh- ing and salubrious exercise. Gaily decorated boats sometimes transported them to breathe, amidst ru- ral concerts, the purer breezes of the Nile. Some- times tliey were conveyed to its verdant isles, where, mider the symbols of some guardian deity, new and ingeniously contrived entertainments were prepared for their reception. Every moment was devoted to some pleasurable occupation, or rather to a system of diversified amusements, enhanced and sanctioned by superstition. An appropriate and scrupulously- observed regimen ; repeated excursions to the holy places ; preconcerted fetes at different stages to excite ancTkeep uptHeirmtenest_on^ ot+jer

advantage of a similar nature, that the experienced priesthood couTd invent or command, were, in no small degreeTcalcuiated to suspend the influence of pain, to calm the mquietudes ot a morbid mind« and to operate^ salutary_ changes in the various func-

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tions of the system, [o) Those ancient estabhsh- ments, so worthy of admiration, but so opposite to the institutions of modern times, point out the ob- jects to be aimed at in every asylum, pubUc or pri- vate, for the reception of melanchohcs.

COERCION TO BE SOMETIMES RESORTED TO, IN CASES OF MELANCHOLIA WITH DELIRIUM.

82. The hfe of man may so abound with cala- mitous events, which may immediately affect his honour, his existence, and even all that lie holds most dear to him, as to induce extreme depression and anxiety, an unsurmountable disgust with life, and a strong propensity to terminate it by sui- cide. The progress of these unhappy impressions is rapidly accelerated by the influence of an acute sensibility, an ardent imagination and a fatal dispo- sition to prognosticate and exaggerate evil. " My blood runs in waves and torrents of despair," said a wretch, whose history is detailed by Crichton. ** This morsel of bread, which I water with my tears, is ail that is left for me and for my family; and still Hive: I have a wife depending upon me, and a child who

^oj See an excellent work by the same author^ entitled iRosographie Philosophique. Tom. ii page 28,

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has to reproach me for its existance. It is every man's duty to accommodate himself to his situation: reason commands it, and rehgion must approve of it." This unfortunate man, wlio was distinguished by correct morals and an enlightened understand- ing, took advantage of his wife's absence to put an end to his existence. A diseased temperament, a serious lesion of one or more of the viscera, a gra- dual exhaustion of the energies of the system, may so aggravate the miseries of life as to hasten the period of voluntary death. But, how are we to account for the irresistible propensity to suicide, which sometimes exists independent of any appar- ent mental or physical ailments. ? A melancholic, whose case I published in Fourcroy 's medical journal, of 1 792, once said to me ; " I am in prosperous circumstances ; I have a wife and a child who con- stitute my happiness ; I cannot complain of bad health ; and still I feel a horrible propensity to throw myself into the Seine." His declaration was too fatally verified in the event. I was once consulted upon the case of a young man, twenty-four years of age, in full vigour and health, who was torment-^ ed by periodical accessions of those gloomy feelings and propensities. At those times he meditated his own destruction. But on a nearer view of the fatal act, lie shrunk back into himself and recoiled with honor from its execution. Without relinquishing

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his project, he never bad the courage to accomplish it. It is in cases like these, that energetic measures of coercion, and the effectual excitement of terror, should lend their aids to the powers of medicine and regimen.

fe[OW FAR MAY LENIENT MEASURES SUFFICE TO CALM THE VIOLENCE AND FURY OF ACUTE MANIA?

83. To detain maniacs in constant seclusion, and to load them with chains ; to leave them defenceless, to the brutality of underlings, on pretence of danger to be dreaded from their extravagances : in a word, to mle them with a rod of iron, as if to shorten the term of an existence considered miserable, is a system of superintendence, more distinguish- ed for its convenience than for its humanity or its success. Experience proves that acute mania, es- pecially when periodical, may be frequently cured by measures of mildness and moderate coercion, con- joined to a proper attention to the state of the mind. The character of a superintendent, who is in the ha- bit of discharging the important duties of his office, with integrity, dignity and humanity, is itself a cir- cumstance of great weight and influence in a luna- tic establishment. As instances of the truth of this

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remark, may be cited the names of Willis, Fowler, Haslam ill England; Dicquemare, Poution, Pussin in France; and the keeper of the madhouse at Am- sterdam, (p) A coarse and unenhghtcned mind, considers the violent expressions, vociferation and ri- otous demeanour of maniac^ as malicious and inten- tional insults. Hence the extreme harshness, blows and barbarous treatment which keepers, if not cho- sen with discretion and kept within the bounds of their duty, are disposed to indulge in towards the unfortunate beings confided to tlieir care. A man of better feeling and consideration, sees in those ef- fervescences of a maniac but the impulses of an au- tomaton, or rather the necessary effects of a nervous excitement, no more calculated to excite anger than a blow or a crush from a stone propelled by its speci- fic gravity. Such an observer, on the contrary, is dis- posed to allow his patients all the extent of liberty con-

(p) A maniac, in the vigour of life, and remarkably strong, who had been brought lo-that establishment, bound hand and foot in a cart, had so terrified lii^ conductors, that none of them had courage enough to go up to him and unbind him for the puipose of conveying him to his apartment. The keeper, having dismissed his attendants, talked for some time to him, gained his confidence and baviig untied him, prevailed upon him to suffer himself to be conducted to the apartment -which ^ad been prepared for him Every successive day he acquired a greater ascendancy over him, and having obtained hi^ entire confidence, he had the satisfaction to perceive the gradual return of his reason. This man was in a short time restored to the bospin of his family, of which he constitutes the chief happiness.

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sistent with their own safety and that of others ; [q] He conceals with great address the means of con- straint to which he is compelled to resort ; yields to their caprices wim apparent complacency ; eludes with dexterity thfeir inconsiderate demands ; sooths with coolness and kindness their intemperate pas- sions ; turns to advantage every interval of their fury; and meets with force their otherwise incoercible ex- travagances.

IS CLOSE CONFINEMENT REQUISITE IN ALL CASES AND THROUGHOUT THE WHOLE TERM OF ACUTE MANIA?

84. Dr. Ferriar observes, that in their pa- roxysms of violent fury, maniacs ought to have their arms and legs effectually secured -, but that we should only have recourse to those measures where it is impossible to avoid them. It is that gen-

CqJ During my official attendance at the hospital de Bicertre, I had a favourable opportunity of comparing the respective merits of the mild and severe systems of treating the insane. When the furious and extravagant maniacs were perpetually chained down in their cells, as they where when I entered on the duties of that office, they were incessantly and ravingly agitated ; cries, howlings and tumults echoed, at all hours, throughout the melancholy mansion. But since the strait-waistcoat as been substituted for chains, and limited liberty for absolute confinement ; the exhalation of their harmless effervescence during the day, has at night been succeeded by a state of comparative calmness and tranquility.

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tleman's practice in cases of refractory conduct, to confine the offenders to their apartments, where, with their windows closed, they are left in darkness, supplied only with water gruel and dry bread, until they shew signs of repentance, which is seldom long delayed. But before the adoption of that decided measure, he always tries the means of mildness and remonstrance : " For in general," adds the same author, " lunatics have a deep sense of honour, which is more efficacious than coercion in reducing them to propriety of conduct.

Close confinement, solitude, darkness and a spare diet, may no doubt be recurred to occasionally, and for a short time, as a punishment for the improper demeanour of maniacs. But when the paroxysms are of long duration or the disorder of a continued form, restriction in the article of food might be ex- ceedingly prejudicial.

A state of dependence and constraint may greatly accelerate the cure of a madman who is elated to improprieties of behaviour, by imaginary con- sequence, or by the recollection of dignities and power once possessed. A person of high rank be- came insane. To effect and expedite a permanent cure, unlimited power in the choice and adoption of curative measures were given to his medical

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attendant. The in ignla of his order were imme- diately removed. Separated from his family and acquaintance, he was conveyed to a lonely paiace, wliere he was shut up in a solitary chamber, the floor and walls of which, that he might not hurt himself, were covered with matting. He was then informed, that he was no longer a personage of distinction, and that, for the future, he would tind it his interest to be docile and submissive. Two of his strongest pages, were commissioned to at tend to his wants, and to shew him every act of kindness consistent with his situation; but, at the same time, to convince him that he was entirely dependent upon them. In his presence they observed the strictest silence : but, whenever occasion required it, they discovered to him how much they were his superiors in strength. In a paroxysm of furious dehdtium, he once received his physician's visit with boisterous rudeness, and he even threw at him the contents of his chamber uten- sils. Upon this, one of the pages entered the room, and without saying a word, seized the maniac by the waist, disgustingly filthy as he was, threw him forcibly on aheap of matting, undressed him, wash- ed him with a sponge, changed his clothes, and, looking sternly at him, left the room, to resume his post. Lessonsofthisdescription, repeated at intervals for sctme months, followed up by other methods of treatment, produced a solid and permanent cure.

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MEASURES CALCULATED TO ACCELERATE THE REESTA^B- LISHMENT OF CONVALESCENTS.

85. Periodical maniacs and convalesrenfSj sn far as they are more promisinir cases, require more than ordinary atr.entioa on the part of the snperiiy tetident. To avoid all occasional exciting causes of relapses, a part of the hospital should be appropriat;;^ ed exclusively tor their use, and accommodated for such amusements or exercises as may be required to engage, develope, strengthen or divert their morbid faculties. They mast not only be subject to stand- ingTules of management, applicable to all or to a majority of cases ^ but the pecuhariugsixf eadixase must be vvatcJi£d>-sUtd;ed-aiid- tfeat-ed-with such as- siduity and adclre^ss^s nicf^ P^'^^PiQiglg' speedy and permanent cure. But to govern men of great pene- tration and irasciblity, such as maniacs most general- ly are, will require, on the part of the superintend- ent, a combination of the rarest talents. I have already developed those maxims at considerable length, in the second section of this work. I shall merely in this place illustrate their importance by an appeal to their successful application at one of the most extensive essablishments, in Europe — that of Bethlehem Hospital.

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"It should be the great object of the superintendent to gain the confidence of the patient and to awaken in him respect and obedience: but it will readily be seen, that such confidence, obedience and respect, can on- ly be procured by superiority of talents, discipline of temper and dignity of manners. Imbecility, miscon- duct and empty consequence, although enforced by the most tyrannical severity, may excite fear j t>ut this will always be mingled with contempt. In speaking of the management of insane persons, it is to be understood, that the superintendent must first obtain an ascendancy over them. When this is once eftected, he will be enabled on future occasions to direct and regulate their conduct, as his better judge- ment may suggest. He should possess firmness, and when occasion may require, should exercise his au- thority in a peremptory ritanner. He should never threaten but execute; and when the patient has mis- behaved, should confine him immediately

When the patient is vigorous and powerful, two or more should assist in securing him. By these means it will be easily effected ; for where the force of tlie contending persons is nearly equal, the mastery can- not be obtained without difficulty and danger." The same author proscribes, with equal justice, all cor- poral punishment and violence : for he adds, " If the patient be so far deprived of understanding as to be insensible vv'hy he is punished-, such corrections

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setting aside its cruelty, is manifestly absurd. And if his state be such as to be conscious of the impro- priety of bis conduct, there are other methods more mild and effectual." (r)

AN INSTANCE ILLUSTRATIVE OF THE ADVANTAGE OF OB- TAINING AN INTIMATE ACQUAINTANCE WITH THE CHARACTER OF THE PATIENT.

86. A MAN, in the vigour of life, confined at Bicetre, fancied himself to be a king, and always spoke with the voice of command and authority. He had been for sometime at the Hotel Dieu, where blows and other indignities, received from the keep- ers, had greatly exasperated his fury. Thus render- ed suspicious and unmanageable, it was extremely difficult to fix upon a proper method of treating him. To have recourse to coercive means might still fur^ ther aggravate his disorder, whilst condescension and acquiescense appeared likely to confirm him in his chi- merical pretensions. I determined to wait the further developement of his character, and take advantage of any favourable circumstance that might happen. I was not long kept in suspence. He one day w^'ote a letter to his wife full of passionate expressions, accusing her with great bitterness of prolonging

(r) Observations on Insanity, by Mr. Haslam, late of the Bethlehem iiospital, pages 122--. — 125,

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his detention, in order to enjoy her own entire liberty. He moreover threatened her with all the weight of his vengeance. Before this letter was sent off, he gave it to read to another paiient, who re- proved his passionate conduct, and remonstrated with him in a friendly manner, for endeavouring, as he did, to make his wife miserable. This remon- strance was kindly received. The letter was not sent, and anodier, re})lere with expressions of es- teem, was subbtituted in its place. Mr. Pussin, the governor, saw in the etfects of this friendly advice, the evident symptoms of a favouraMe change which was about to take place. He immediately availed himself of the occasion, and went to the maniac's apart m€^nt, where, in the course of conversation, he led him b\ degrees to the principal subject of his de- limim. " If you are a sovereign, observed the go- vernor, why do you not put an end to your deten- tion; and wherefore do you remain here, confound- ed with man sacs of every description ?" He repeated his visits daily, when he a?^sumed the tone of friend- ship and kindness. He endeavoured from time to time to convince him of the absurdity of hispreten= sions, and pointed out to him another maniac, who had for a lons^ time induleed in the conviction that he was invested with sovereign power, arid on that account, was now become an object of derison. The maniac was soon shaken in his convictions. In a

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short time he began to doubt his claim to sovereignty; and, at last, he was entirely convinced of his preten- sions being chimerical. This unexpected revolution was accomplished in the course of a fortnight, and after a few months' longer residence in the house, this respectable husband and father was restored to his family.

VARIETIES OF BODILY EXERCISES INCLUDING LABORIOUS OCCUPATIONS RECOMMENDED FOR CONVALESCENTS.

87. Convalescent maniacs, when, amidst the lan- guors of an inactive life, a stimulus is otfered to their

natural propensity to motion and exercise, are ac- tive, diligent an 1 methodical. Laborious or amus- ing occupariojis arrest their del rious wanderings, prevent the determination of blood to the head by rendering the circulation more uniform, and ^ "^ii2Li!BiSli^iL-5HliL--'y * ''^•^' > i n cy sleep , I was one day deafened by the tumultuous cries and riot- ous behaviour of a maniac. Em])loyment of a ru- ral nature, such as 1 knew would meet his taste, was procured for him. From that tune I never ob- served any confusioif nor extravagance in his ideas. It was pleasing to observe the silence and tranqii'lity which prevailed in the Asylum de Bicetre, when near- ly all the patients were supplied by the tradesmen of Paris with employments which fixed their atten-

A a

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tion, and allured them to exertion by the prospect of a trifling gain. To perpetuate those advantages, and to ameliorate the condition of the patients, I made, at that time, every exertion in my power to obtain from the government an adjacent piece of ground, the cultivation of which, might employ the convalescent maniacs, and conduce to the reestablishment of their health. The disturbances which agitated the coun- try in the second and third years of the republic, pre- vented the accomplishment of my wishes, and I was obliged to content myself with the subsidiary means which had been previously adopted by the governor; that of choosing the servants from among the conva- lescents. The same method is still continued at the mad-house at Amsterdam, [s) The accomplish- ment of this scheme would be most effectually ob- tained by combining with every lunatic asylum, the advantages of an extensive enclosure, to be convert-

(?) "It is remarkable," saysThouin, "that inahouse containing so many residents there shouM be £0 few hired servants. I never saw more than foar or five permanent domestics there. All the others are taken from among the convalescents, who, impressed by respect for the governor, are eager in the offer of their services to those who stand in need of them. Havr ing themselves experienced similar attentions from their predecessors, they are the more zealous in the fulfilment of this duty. Servants of this descrip- tion are never wanting, as there are almost as many able convalescents as there are patients who require their assistance. This economical practice is adopted in all the hospitals of Holland. Hence it happens, that maniacs are there better treated and at much less expence of officers and servants than ji) the hospitals of this country."

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ed into a sort of farm, which might be cultivated at the expence of the patients, and the profits of which might be devoted to their support. A prin- cipal hospital of Spain, presents in this respect an excellent example for our imitation. The maniacs, capable of working, are distributed every morning into separate parties. An overlooker is appointed for each class, who apportions to them all, individually, their respective employments, directs their exertions, and watches over their conduct. The whole day is thus occupied in salutary and refreshing exercises, which are interrupted only by short intervals of rest and relaxation. The fatigues of the day prepare the labourers for sleep and repose during the night. Hence it happens, that those whose condition does not place them above the necessity of submission to toil and labour, are almost always cured; whilst the grandee, who would think himself degraded by any exercises of this description, is generally incurable.

THE PROPRIETY OF ENGAGING THE ATTENTION OF CON- VALESCENTS IN SOME INTERESTING PURSUIT ILLUSTRATED,

88. At the commencement of convalescence, and upon the dawn of returning reason, it frequently hap- pens, that the taste of the individual, for his former

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pursuit of science, literature or other subjects un- folds itself. The first ray of returning talent ought to be seized with great avidity by the governor, and tenderly fostered, with a view of i avouring and ac- celerating the developement of the mental faculties. Numerous facts might be mentioned to coniirm the importance of this maxim.

An old literar}'^ gentleman, whose incoherent and incoercible loquacity I could sometimes with difficul- ty follow, was at intervals subject to a rude and gloomy taciturnity. If ever a piece of poetry which at any time had given him great satisfaction, recurred to his memory, he would become immedi- ately susceptible of close attention, and his judge- ment appeared to recover its usual vigour. At those times, he would compose verses not only accurate m point of order and method, but enriched with ap- propriate images, and happy sallies of humour and fancy. As I could only bestow a few occasional hours upon experiments of this kind, it is not very easy to determine the quantum of benefit that might have resulted from the continued or frequently re- peated application of the same means.

A musician, who had become insane in consequence of the revolution, wasdeprived of the powerof connect- ing his ideas, and he mingled with his unmeaning mo-

nosyllables the most absurd and fantastic gestures. Upon the commencement of his convalescence, he once expressed himself as if he had a confused recollec- tion of his favourite instrument. I took an earl j oppor- tunity to send to his friends f#F his violiifi. It seem- ed to have a very soothing effect upori him, and he continued to amuse himself with music for several hours every day for eight months, when his recovery was rapidly advancing. Bat about that time, was admitted into the asylum, another maniac, who was exceedingly furious and extravagant. Frequent ren- counters with this new comer, who was permitted to ramble about the garden without restraint, again unhinged the musician's mind, and overwhelmed its returning powers. The violin was forthwith destroy- ed ; his favourite amusement was forsaken ; and his insanity is now considered as confirmed and in- cural)le. An instance equally distressing and re- markable of the contagious influence of acts of mani- acal extravagance upon the state of convalescents; and a strong proof of the necessity of insulation !

A CASE OF CONVALESCENT INSANITY AGGRAVATED BY NEGLECT OF ENCOURAGING THE PATIENT's TASTE FOR THE FINE ARTS'.

89. The gloomy and irritable character of ma- niacs, even when convalescent, is well known.

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Endowed, in most instances, with exquisite sensibi- lity, they resent with great indignation the sHghtest appearances of neglect, contempt or indifference, and they forsake for ever what they had before adopted with the greatest ardour and zeal. A sculptor, a pupil of the celebrated Lemoin, was de- feated in his endeavours to be admitted a member of the academy. From that moment he sunk into a profound melancholy, of which the only intermissions consisted in invectives against his brother, whose parcimony he supposed had arrested his career. His extravagance and violence rendered it necessary to confine him for lunacy. When conveyed to his apartment, he gave himself up to all the extrava- gances of maniacal fury. He continued in that state for several months. At length a calm succeeded, and he was permitted to go to the interior of the hospital. His understanding was yet feeble, and a life of inactivity was not a little irksome to him. The art of painting, which he had likewise cultivat- ed, presented its renascent attractions to him, and he expressed a desire of attempting portrait paint- ing. His inclination was encouraged and gratifyed, and he made a sketch of the governor and his wife. The likeness was striking; but incapable of much application, he fancied that he perceived a cloud before his eyes. He allowed himself to be discour- aged by a conviction of his insufficiency to emulate

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the models of fine taste, of which the traces were not yet effaced from his memory. The talent which he had discovered, his disposition to exercise it, and the probability of rescueing for his country the abili- ties of so promising a youth, induced the board of Bicetre to request of him a pledge of his genius ; leaving to him the choice of his subject, that his im- agination might not be cramped. The convales- cent, as yet but imperfectly restored, shrunk from the task which was thus imposed upon him; re- quested that the subject might be fixed upon, and that a correct and proper sketch might be given him for a model. His application was evaded, and the only opportunity of restoring him to himself and to his country was thus allowed to escape. He felt exceedingly indignant ; considered this omission, as an unequivocal mark of contempt; destroyed all the implements of his art; and with angry haughtiness declared, that he renounced for ever the cultivation of the fine arts. This impression upon his feelings so unintentionally communicated, was so profound, that it was succeeded by a paroxysm of fury of se- veral months' continuance. To this violence again succeeded a second calm. But now the brilliant intellect was for ever obscured, and he sunk irreco- verably into a sort of imbecility andreverieism, bor- dering upon dementia. I ordered him to be traiis- fered to the hospital infirmary, with a view of try-

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;jng th^ effects of a few simple remedies, combined with the tonic system of regimen. Familiar and consolatory attentions to him, and such other assist- ance as his case appeared to suggest, were recurred to, more as they were dictates of humanity than as probable means of recovery. His taste for the fine arts, with his propensity to exertion of any kind, Jiad for f ver disappeared. Ennui, disgust with hfe, his gloomy melancholy and apathy made rapid pro^ gress. His appetite and sleep forsook him, and a colliquative diarrhea put an end to his degraded ex- istence.

THE. APPARENTLY INCURABLE NATURE OF DEMENTIA.

90. The intellectual faculties and affections are so exceedingly weakened and disordered in this va- riety of mental derangement, as to resist the powers both of pharmaceutic medicaments and moral regi- men. The ideas received by the external senses, if any, are feeble and fugitive. Incessant wanderings incapacitate the patient for attention to present ob- jects, while he appears to retain no consciousness of the past. The faculty of judgement is lost or want- ing; the aflections are vanished or never existed. May dementia, from an occasional cause, be proper- ly identified with that originating in old age ; and

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are they not equally incurable ? All the facts that I am acquainted with appear to countenance this melancholy truth. An old maniac, in an advanced state of convalescence, who was employed in the service of the hospital, abused the liberty which that situation procured for him, and was guilty of re- peated acts of intemperance, both in drinking and venery. The consequences were great debility and languor. His mania never returned j but he sunk into a state of complete dementia. I attended him for a long time at the hospital infirmary, and tried various remedies, both physical and moral, that ap- peared at all suitable to his case : but, nothing seemed to produce any decided effect. Ascites su- pervened in the course of a few months and carried him off.

Curative measures are equally useless in cases of dementia originating in enthusiasm o«^-<iny other extatic emotions, as Tissot has ably shewn in his " Essay on the diseases of literary and sedentary persons." Forestus, mentions an instance illustra- tive of the same fact. A young man was sent to the University of Louvain, to study theology. Pie studied hard and lived low. His intellect was short- ly affected, and he gra'lually sunk into complete de- mentia. What appeared most remarkal)le in his

case was, that he repeated almost incessantly the

Bb^

202

words " Biblise sunt in capite et caput in bibliis," %

As he was going home to his friends he precipitated himself into a well, which he found on the road.

THE PROPRIETY OF SEPARATING IDEOT8 FROM THE OTHER CLASSES OF PATIENTS AT LUNATIC ASYLUMS.

87. To be an ideot, is to be almost levelled with an automatonj_tQ._be depriyed of i5p or to re-

tain the power merely of pronouncing inarticulate sounds : to be obedient only to the instinct ot want, aiTd'soriietlmes to be insensible even to thaLL-lo be incapable of feeling, attending;_to or gratifying with- out assistance the appetite for food : to remain mo- tionless in the-«^ame~^laee-and positionlbr several days together, without discovering one single ex- presilfWrefllreFoFtTiougKrbTalfection: to be at other times subject to sudden, furious and evanescent tran- sports of passion. Such are the circumstances charac- teristic of ideotism. They seldom admit of redress by the best possible superintending police. Hu- mane attention to their physical wants and comforts, is in general the utmost that can be devised or done for those unfortunate beings. Their passive obedi- ence and degradation expose them to inattention, and frequently to cruel treatment on the part of the

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keepers and servants. It is for the governor to be their protector and guardian. Those who are sub- ject to sudden and furious passions, for the most trivial causes, and are incapable of suppressing their emotions, from the great imbecility of their intellects, require his particular attention.

The natural indolence and stupidity of ideots, might in some degree be obviated, by engaging them in manual occupations, suitable to their re- spective capacities. With an able active man at their head, ideots are capable of being drilled into any sort of service where bodily strength alone is requi- site. The new plantation at Bicetre was made al- most altogether at their expence.

Another object of particular attention on the part of the governor, regards the management of acci- dental ideotism. This form of mentaL^^^rangement is very commonly induced by a too debilitating treat- ment of acute mania, and is again removed by the recurrence of a paroxysm of raving madness. Such paroxysms, therefore, are to be welcomed as salutary efforts of nature to raise the degraded intel- lect to its natural level. By promoting such efforts by tonics, good diet and humane treatment, ideots are not unfrequently restored to their priviledges and estimation in society.

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EPILEPTIC MANIACS TO BE SECLUDED FROM THE OTHER PATIENTS OF LUNATIC HOSPITALS.

88. Few objects are f(Uind to inspire so much horror and repugnance amongst maniacs in general, t ban the sight ot'~epite|3iic fits. TEe^Teither reti re from the scene greatly terrified, or go up to the pa- tlentiH "arvtsfent passion, ~ancl if not prevented, as- saiftnilm with furious and fatal blows. Hence it ought to be a fundamental lav/ in all lunatic asylums, to insulate epileptics with great care, and to appor- tion for their exclusive use a part of the establish- ment, which cannot be visited or seen into by the other classes of lunatics. The mere sight of epilep- tic convulsions has excited similar convulsive allec- tions in spectators of acute sensibility.

Numerous facts attest, that mania, complicated with'epilepg,^^, IS ahTTo^THHrays an incurable malady. Ilmirot" therefore, much surprised, that cases of that Ascription are not adnilssible at Bethlehem hospital in I-ondon.

Epilepetic maniacs seldom arrive at advanced age. It appears from my journal, that out of twelve cases of this description, who were at Bicetre in the second year of the republic, six died in the course of eighteen months, from the extreme violence and frequency of

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their paroxysms. The duties of the superintendent, in respect to this class of maniacs, consist in guarding them against falls and bruises, obviating all causes of strong or intense emotions, preventing errors in re- gimen and diet, and perscribing exercises suitable to their inclinations and capacities.

GENERAL POLICE AND DAILY DISTRIBUTION OF THE

SERVICES IN LUNATIC ASYLUMS.

89- The natural propensity of maniacs to in- dulge in passionate emotions, to murmur at trifling inconveniences, and to represent circumstances which they fancy in any degree objectionable in co- lours the most unfavourable, and exaggerated, must render necessary the strictest discipline and order in every department of their management. Hence the measures, for securing order and regularity in the services oF tlie institution, which were adopted at the Asylum de Bicetre, during my professional at- tendance upon it. The different rooms were open- ed in the morning at five o'clock in the summer, at half past seven in the winter, and between those hours in the intermediate seasons. Great attention was paid to the cleaning out of the chamber utensils, as well as the rooms and courts. To assure himself that nothing had been omitted or neglected, the go- vernor paid a forenoon visit to all the rooms. Break-

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fast was served soon after the hour of getting up. The hour of dinner was eleven o'clock precisely. The rooms were set in order, and examined in re- spect to cleanliness after every meal. The third, and last portion of bread, was distributed with broth or some other mess, at four or five o'clock in the af- ternoon, according to the season. Tiie patients* apartments were shut up for the night at a given hour, when the bell was rung. To allay the fury of the raving, to administer to the wants of the needy, and to prevent the accidents to which a house of that description was peculiarly exposed, a watchman was commissioned to go round the hospital every half hour till midnight. From twelve o'clock till morn- ing, another keeper fulfilled the same duty. In the morning, the servants entered again upon their re- spective duties. Their industry was a condition of their service ; and, in order to be able to put an end speedily to any tumult or confusion that might hap- pen, their presence at all hours of the day was in- dispensably exacted. The servants were under spe- cial injunction not to lay violent hands on a maniac, even in their own defence. A system of tactics, carried on by signs, was adopted, in order to secure the momentary seizure and effectual arrest of the raving and furious madmen. In a word, the ge- neral gove rnment of the hospital, resembled the su- perintendence of a great family, consisting of tur-

207

bulent individuals, whose fury it should be more the object to repress than to exasperate, to govern by wisdom rather than to subdue by terror.

CONSCIENTIOUS ATTENTION TO THE PREPAR.ATION AND DISTRIBUTION OF PROVISIONS.

90. The perpetual agitation of maniacs, espe- cially during their paroxysms of extravagance and fury, and their increased strength and temperature, are sufficient to account for the voraciousness of ap- petite, for which madmen are remarkable, and which is sometimes so great, that they will consume about (t) two kilogrammes of bread daily. One of my first objects, or rather what I considered as one of my most sacred duties, as senior physician to the Asy- lum de Bicetre, in the second and third years of the republic, was, immediately upon my appointment, to inspect the management and services of the kitchens. It was not long before I discovered that the lunatic department, was, in this respect, much better conducted than the other departments of that great hospital. I am happy to have it in my power to add this tribute of justice to what has been alrean

lb. oz. dwts. fn^T. (t) A kilogramme is equal to 2 : 8 : 12. 12-02. Troy. T.

208

dy said, (section ii.) in regard to Mr. Pnssin's nu- merous qualifications for the office of governor. In order to make up for any accidents or neglect that might happen in the order of laying in provisions ; so as to be able, without a possibility of failure, to administer to the urgent and unforeseen wants of the maniacs, he took great care to have eatables of some kind at all times in reserve. He saw that pot herbs of every description were taken up in the proper season, and dried or preserved in stone pots for winter con- sumption. The remaining provisions of the meat day, whether meat, gristles or marrow bones, were carefully laid by for the purpose of enriching the soups and pottages of the other days. The usual careless method of boiling meat for soup or other purposes, that of submitting it to the action of brisk ebullition for a long time, which renders the fibrinous part hard and tough, and prevents the disengage- ment of the gelatine, was carefully prohibited. The broths and soups were always prepared early on the day of their distribution, and proportioned, in re- gard to quantity, to the wants of the hospital. The boiling was continued only so long as to disengage what is called the scum of the pot, or the most con- cressible part of the meat. The fire was then in part removed, and a sort of oven was constructed with bricks round the bottom of the kettle. The meat was thus submitted to constant and uniform heat of a few

209

degrees below the boiling temperature for four hours and a half, so as to render the fibrinous part pulpy and tender, and gradually to dissolve the gelatine in the liquor. Pottage thus prepared could not fail to be rich and wholesome. By such a system of cu- linary management the lunatic patients were provid- ed with excellent fare at little expence.

THE FATAL CONSEQUENCES OF THE SCARCITY OF THE YEAR 4 EXPERIENCED AT LUNATIC HOSPITALS.

91. I LEAVE to the historian of the revolution to paint, in its proper and odious colours, that most barbarous and tyrannical measure which deprived in- firmaries and hospitals of their valuable endowments, and abandoned the diseased and the infirm to all the vicissitudes of public fortune, h is sufficient for my present object to mention a few fact s of which I have been myself an eye witness, and of which the recol- lection cannot but be painful to a man of any sensi- bility. To meet the well ascertained wants of the Hospital de Bicetre, it was determined, by the Con- stituent Assembly, to increase the allovvance of bread to one kilogramme daily. For the two succeeding years, I witnessed, with great satislact ion, the ope- ration of that salutary measure. I then ceased to be physician to that hospital. But, during one of my

friendly visits, (4th Brumair, year 4,) which I occa-

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sionally paid to my old insane acquaintances, I learned that the usual allowance of bread had been reduced to seven hectogrammes and a half (v) per day. A great number of the old convalescents had relapsed to a state of raving madness, and were com- plaining, loudly and bitterly, that they were about to be starved to death. But, this system of retrench- ing was afterwards carried to still greater lengths^ the allowance being gradually reduced to five, four, three and even to two hectogrammes of bread, with a small supplement of biscuit, which frequently was far from being of a good quality. The con- sequences were such as could not have escaped at- tention. Upon enquiring into the state of the insti- tution, it appeared, that in the short space of two months (Pluviose and Ventose, year 4,) the total number of deaths, in the lunatic department alone, had been twenty-nine, while during the whole of the year 2, twenty-seven only died. A similar, but a still more deplorable result, was obtained from a sur- vey of the same kind, which was made of the state of the Hospital de la Salpetriere. In the month of Brumair, (Oct. and Nov.) of the year 4, there were no fewer than fifty- six deaths, which more imme^^ diately were occasioned by the e^lxtreme frequency of colliquative diarrhea and dysentery. I was com-

oz. dwts. gr. (r) A hectogramme is equal to 3:4: 8'40. Troy.

211

missioned by the administration, to enquire into the cause or causes of a mortality so unprecedented. Having paid due attention to the diseases which pre- vailed at the time, I drew up the following report.

" My opinion is, that the mortality in question is principally to be ascribed to the scarcity of pro- visions which prevailed last spring and summer, and which was chiefly felt in the lunatic department of the hospital. Before the first of Germinal, (^ March 22,) every patient v;as allowed a pound and a half of bread daily, with a hundred livres to find soup for the whole hospital. On the first of Germinal the livres were withheld ; and on the 15th of the same month, the daily portion of bread was reduced to one pound. From the loth to the 30th, it was twelve ounces. On the 8th of Floreal, (April 28,) it was reduced to eight ounces. Till that time it had been the custom to allow some sea biscuit with the soup. A reduction of two hundred pounds of bread in the daily allowance for the whole hospital, brought the ordinary quantity for each individual to six ounces. When the biscuit was withheld on the 1st Thermidor, (July 20,) the twelve ounce portion was again restored. The voracious appetite of lunatics of both sexes is a well knov\'n symptom of their ma- lady j but the allowance of provisions was reduced more in that department of the hospital than in any

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Other, The Gonceqnences were a colliquative diar- rhea and faial dysenteries. Brumair 27> yc«:ir 4."

We should not have hfid to lament the above me- lancholy events, had the resources of the hospitals been fixed and invariable.

THE COMMUNICATIONS BETWEEN MANIACS AND PERSONS FROM WITHOUT TO BE PRUDENTLY RESTRICTED.

92. It is a great solace in almost all human in- firmities, to receive the consoling cares and good of- iices of friends and relatives. Those endearing at- tentions are still more estimable in infirmaries and hospitals where the sufferer finds himself separated from his family, and often subject to the controul of unfeeling domestics and attendants. Is there any good reason for making exceptions to this indulgence in cases of insanity ? It is found by experience, that maniacs are seldom or never cured as long as they are kept at home, subject to the influence of family intercourse. It is a maxim of Dr. Willis not to per- mit any visiters into his establisliment, excepting very rarely, under certain restrictions, and, by way ot recom|.ence or encouragement, tor good conduct. It is observed, that persons from a great distance, whose insulation is on that account most complete, are soonest and most easily cured/ No person can

£-i^

213

obtain admission into Bethlehem hospital without a recommendatory note from a governor. The rela- tions of patients are entitled only to two visits a week The necessity of restricting, in a similar manner, the visits of strangers and other curious people into luna- tic hospitals, is very much felt in France. To be in- troduced into the Hospital de la Salpetriere, as into Bethlehem, requires an express permission. It is much to be lamented, that prudent measures of this kind have never been attended to at the Asylum de Bicetre, where visits from strangers are without li- mits or restrictions. To see the unfortunate beings there confined, already too much the objects of pity, made the sport and the spectacle of the unfeeling and the mischievous, calls no less for redress than for sym- pathy. I recollect to have once-seen a madman, who, towards the decline of a maniacal paroxysm, was .excited to great fury and violence by provocations which he received at the window of his apartment from an unfeeling by-stander, who treated him with contemptuous merriment. He relapsed into the state of acute mania which he was in, when he entered the house, and continued in that state for more than a twelve month. A stranger, who was a merchant, and who had become insane from the loss of his property, was transmitted into the Asylum de Bicetre, after having undergone the usual treat- ment at the Hospice d'Humanite. He was put upon

214

moral regimen exclusively. His convalescence made such rapid progress, that in my repeated conversa- tions with him a short time after his admission, I could not perceive the least confusion nor incoherence in his ideas. But this favourable state of things was in a few hours completely reversed. He learned that his partners were actually dividing amongst them some of his moveables : and a woman had the imprudence to pay him a visit in a garment which he could not fail to recognize as belonging to himself. This threw him into absolute consterna- tion and despair, which terminated shortly after in complete dementia. His case is now considered as incurable.

THE ENGLISH AND THE FRENCH AGREED IN REGARD TO THE UTILITY OF PUBLIC ASYLUMS FOR LUNATICS.

93. It is pleasing to observe so great a conform- ity of opinion, founded as it appears to be upon the results of observation and experience, prevail in England and France on so important a subject as the utility of public and private hospitals. It is be come an established maxim in both countries, that insanity is much more certainly and effectually cured in places adapted for their reception and treatment, than at home amidst the various influences of fami- ly interests and intercourse. " Confinement," says Mr. Haslam, (page 133) " is always necessary in

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cases of insanity, and should be enforced as early in the complaint as possible. By confinement is to be understood, that the patient should be removed from home. During his continuance at his own house, he can never be kept in a tranquil state. The interrup- tions of his family, the loss of the accustomed obe- dience of his servants, and the idea of being under restraint in a place, where he considers himself the master, will be constant sources of irritation to his mind. It is also known, from considerable experi- ence, that of those patients, who have remained under the immediate care of their relatives and friends, very few have recovered. Even the visits of their friends, when they are violently disordered, are pro- ductive of great inconvenience, as they are always more unquiet and ungovernable for sometime after- wards. It is a well known fact, that they are less disposed to acquire a dislike to those who are stran- srers, than to those with whom thev have been inti- mately acquainted ; they become, therefore, less dangerous, and are more easily restrained. It frequently happens, that patients who have been brought immediately from their families, and who have been said to be in a violent and ferocious state, become suddenly cairn and tractable when placed in the hospital. On the other hand, it is equally cer- tain that there are many patients, who have for a length of time conducted themselves in a very order-

fl6

ly ihaliher under confinement, whose disorder speedi- ly recurs after being suffered to return to their fa-^ iniHes. When they are in a convalescent state, the occasional visit of their friends are attended with tnanifest advantage. Such an intercourse imparts consolation, and presents views of future happiness and comfort."

MECHANICAL EMPLOYMENT ESSENTIAL TO THE SUCCESS- FUL MANAGEMENT OF LUNATIC HOSPITALS.

94. It is nojongei: a, prohlejn to be solved^Jmt the result of the most constaniL^nd unaniDaouE_ex- penen(ce7~tHar~m all public asylums as well as in prisons and hospitals, thejurest, and, perhaps, the only niethod^f securing health, good~"5rdcr, and gooTmaimersTis to carry mto decmedandhabitual execution the natural law of bodily labouTi^saxaa- tributive and esseiitial to human happiness.'^This truth is especially applicable to lunaticasylums : and I am convinced that no useful and durable establish-

ments of that kind can be founded excepting on the tasis ofinteresting andTTaborious employment. I am very sure that few lunatics, even in their most lurious state, ought to be~vvithou"rsome"active occu- \ pation. The "sceiie whTcbTTs pre^entedln our na- tional establishments by the insane of all descriptions and character, expending their eflervescent excite- ment in antics and motions of various kinds, with- out utility or object, or plunged in profound melan-

117

choly, inertia and stupor, is equally affecting, pic- turesque and pitiable. Such unrestrained indul- gence of the natural propensities to indolence, to un- productive activity, or to depressing meditations, must in a hiofh dearree contribute tp ai^Q^rayate the existnig eviL-'VLiaborious employment, on the_other 7

hand, is not a little calculaj3jto^imtJ.he^ mfanatics from their usual morbid channel^ to fix their attention upon more_pleasing objects, and by exercise to strengthen the functions of the_under- standing. Where this methodfis adopted, little dif- ficulty is experienced in the maintenance of order, and in the conduct and distribution of lunatics, even independent of many minute and often ineffec- tual regulations, which at other places are deemed indispensibly necessary. The return of convales- cents to their primitive tastes, pursuits, and habits, has always been by me considered as a happy omen of their final complete re-establishment. To discover those promising inclinations, a physipian can never be^oo vigilant ; nor to encourage them, t6o~stud^ious of the means of nT(TLiTgenc^r~~7iii enviable-example is presentedTo~uFlnThis respect by a neighbouring nation. In a city of Spain, Sa- ragossa, there is an asylum, which is open to the diseased, and especially to lunatics of all nations, go- vernments, and religions, with this -imple inscrip- tion, uRBis ETs oRBis. Manual labour has not been

c^

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the sole object of solicitude on the part of its found- ers. They have, likewise, joughLan__.anlidQJ£_J^ the wanderings of thediseased imaginaUon_Jn_the charms of agriculture, a t^aste for which ^is so ge- neral, that it is commonly considered as an insting::^ tivFprinciple of the human breast. In the morning majTbeleen the numerous tenants of that great in- stitution, distributed into different classes and award- ed their respective employments. Some are kept in the house as dpmesjtics of various j^rd^is-^n^^ ces : others, w6rk at differ ent_trades^ in shops pro- vided for the purpose/' "The greatest number set out, in"~drfFefenFdivisions7 under the guidance of intelli- gent overlookers, spread themselves over the exten- sive inclosure belonging to the hospital, and engage, with a degree of emulation, in the soothing and de* lightful pursuits of agriculture and horticulture. Having spent the day in preparing the ground for seed, propping or otherwise nursing the rising crop, or gathering the fruits of the olive, the harvest or the vintage according to the season, they return in the evening calm and contented, and pass the night ill solitary tranquillity and sleep. Experience has uniformly attested the superiority of this nicCthod of managing the insane. The Spanish nobless, on the contrary, whose pride of birth and family presents unsurmountable obstacles to a degradation so bles- sed and salutary, seldom recover the full and healthy poijisession of a deranged or lost intellect. yV

/ ,^^uc.e.n^^ ^^^j ^^^2-^-^ ^iSL^jJ^ O-J^ ^

(^',

SECTION VL

OF THE MEDICAL TREATMENT OF INSANITY.

ARE ALL MEDICAL BOOKS EQUALLY DESERVING OF THE CENSURES OF PHILOSOPHERS ?

95. " Books on medicine," says Montesquieu, " those monuments of nature's frailty and art's re- sources, when they treat of diseases, even the most trivial, would convince us that death was really at the door : but when they speak of the virtues of re- medies, they place us again in marvellous security as if we were immortal. "/^^ This satyrical remark, so applicable to an immense number of medical writ- ings, which adorn or surcharge our libraries, is very apt to recur to my memory when I read in works on mania, of the " intemperies of the brain, the preparation of the humours before their evacuation, the seat of the peccant matter, its pretended revul- sion, repulsion, &c." Are not the reflections of the above philosopher, and others of a similar cast, justified by the enormous catalogue of powders, ex- tracts, juleps, electuaries, draughts and epithems.

220

which are recommended in books as remedies of great virtue in cases of insanity ? But what are we ta think of the practice of repeated blood-letting, which is so universally the fashion of the present day, without attention to the distinctions of the exciting causes, the varieties of sex or of individual constitu- tion, and the different species and periods of the complaint ? Let not the results of experience and observation be confounded with the errors of a doc- trine depending for its support upon prejudices, hy- potheses, pedantry, ignorance, and the authority of celebrated names.

ARE MEDICAL OPINIONS FOUNDED UPON OBSERVATION ?

96. Wearisome treatises, useless compilations, a scholastic dialect, and the furor of explaining every recurring fact, have characterized the progress of almost all the sciences. Modern physics, the an- cient doctrines of Aristotle, and the fanciful theories of Decartes, are examples perhaps equally illustra- tive of this truth. No wonder then if medicine be, in some degree, chargeable with similar incumbran- ces. It would however appear, that this science has, from its origin, been more or less distinguished for its habits of observation and analysis. The great father of the healing art, was an eminent observer

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of nature, and a faithful reporter of what he saw of her laws and operations. The writings of Arit^eus, Celsus and Caelius Aurelianus, upon tlie subject of msanity, are deserving of a similar eulogium : and if certain authors of a later date, such as Forestus, Horstius, Plater, Valeriola, &c. were stripped of their scientific explications and phaimaceutic details, their works would contain many valuable facts upon this unhappy malady. The observations and essays which are to be met with in periodical works and papers of academies are still more valuable, inas- much as they are more accurate, both in respect to observation and treatment. Ferriar in England, and Laughter in Germany, have made trials of some simple remedies, which sufficiently indicate, that they are on the right path, that of analytical enquiry, to useful and definite conclusions. Attach- ing, as I do, little importance to pliarmaceutic pre- parations, and all-sufficiency in curable cases to phy- sical and moral regimen, I intend not to devote many of my pages to the exclusive consideration of drugs and medicaments. My objects more especially are, to give due importance to the history of mental de- rangement ; to discriminate accurately between the difterent species of the disease, so as to avoid for- tuitous and ineffective treatment; to furnish precise rules for the internal police and government of charitable establishments and asylums ; to urge the

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necessity of providing for the insulation of the dif- ferent classes of insane patients at houses intended for their confinement j and to place first, in point of consequence, the duties of a humane and enlight- ened superintendency, and the maintenance of order, in the services of hospitals. The remedies which I prescribe are simple, and such as have been ratified by experience. I have endeavoured to at- tend to the stages and species of the disorder most adapted for medical treatment, and most promising of success. I reserve for extreme cases, and such as hold out little prospect of a cure, the employment of certain active remedies, which, in other circum- stances, I should consider either as unnecessary or dangerous.

THE CURE OF MELANCHOLIA OFTEN EXTREMELY DIF- FICULT.

97- Treatises upon melancholia and hypochon- driasis are full of anecdotes more or less interesting of melancholies under the influence of a morbid im- agination, and of ingenious expedients which have been devised to dispel their fantastic illusions. Such narratives we might, perhaps, be disposed to con- sider as frivolous tales, if hospitals did not abound with numerous and striking examples of similar eases. It is the extreme intensity of one exclusive

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idea, absorbing all the faculties of the understand- ing, that constitutes melancholia and that renders the treatment of it so peculiarly difficult. If we feign assent to the absurd propositions of a melan- cholic, he is rivetted still firmer to his convictions. If contradicted, he throws himself into furious pas- sions. Does his mental affection deppncl npon any physical^jangement .?Alt occasionally yields to the operation of evacuants, but the disorder is more fre- quently aggravated by the debility which succeeds upon such evacuations. Melancholia, with great atony and depression, can only be treated with pro- priety by tonic remedies, and especially by bark and opium, after the manner of Dr. Ferriar. (w) X When originating in the suppression of any cuta- neous eruption or discharge, the cure is to be at- tempted by the introduction of a seton or some other drain. Dr. Ferriar was consulted by the friends of a young gentleman who had fallen into a state of profound melancholia, (vol. i. page 181). In answer to the enquiries which he made rela- tive to the cause of the disorder, he learned that every spring the patient had for several years been sub- ject to a herpetic eruption upon the back part of his neck, extending to his right shoulder ; and that upon its failing to appear, he had once before been in a melancholic state. The eruption had then

(w) Medical Histories and Reflections, Vol. i. page 177.

$$4

disappeared. A seton was ordered to be placed at the nape of the neck. To the suppuration whichtook place, in about three or four days after the introduc- tion of the silk, a discharge of foetid matter succeeded. From that time the patient's mind became more and more confirmed. With the assistance of exercise, sea bathing, and a tonic regimen, he soon recover- ed completely.

AN ATTEMPT TO CURE A CASE OF MELANCHOLIA PRODUCED BY A MORAL CAUSE.

98. The fanciful ideas of melancholies are much more easily and effectually diverted by moral reme- dies, and especially b}^ active employment, than by the best prepared and applied medicaments. But relapses are exceedingly difficult to prevent upon the best founded system of treatment. A working man, during an effervescent period of the revolution^ suffered some unguarded expressions to escape him, respecting the trial and condemnation of Louis XVI. His patriotism began to be suspected in the neighbourhood. Upon hearing some vague and ex- aggerated reports of intentions on the part of go- vernment agents to prosecute him for disloyalty, he one day betook himself in great t rem our and conster- nation to his own house. His appetite and sleep

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forsook him. He surrendered himself to the influence of terror, left off working, was wholly absorbed by the subject of his fear; and at length he became fully im- pressed with the conviction that death was his una- voidable fate. Having undergone the usual treat- ment at the Hotel Dieu, he was transferred toBicetre. The idea of his death haunted him night and day, and he unceasingly repeated, that he was ready to submit to his impending fate. Constant em- ployment at his trade, which was that of a tailor, appeared to me the most probable means of divert- ing the current of his morbid thoughts. I applied to the board for a small salary for him, in consider- ation of his repairing the clothes of the other pa- tients of the asylum. This measure appeared to engage his interest in a very high degree. He UU' dertook the employment with great eagerness, and worked without interruption for two months. A fa- vourable change appeared to be taking place. He made no complaints nor any allusions to his suppos- ed condemnation. He even spoke with the tenderest interest of a child of about six years of age, whom it seemed he had forgotten, and expressed a very great desire of having it brought to him. This awaken- ed sensibilit}- struck me as a favourable omen. The child was sent for, and all his other desires were gra- tified. He continued to work at his trade with re-

E e

226

newed alacrity, frequently observing, that his child, who was now with him altogether, constituted the happiness of his life. Six months passed in this way without any disturbance or accident. But in the. very hot weather of Messidor, (June and July) year5, some precursory symptoms of returning melancholy began to shew themselves. A sense of heaviness in the head, pains of the legs and arms, a silent and pensive air, indisposition to work, indifference for his child, whom he pushed from him with marked coolness and even aversion, distinguished the pro- gress of his relapse. He now retired into his cell, where he remained, stretched on the floor, ob- stinately persisting in his conviction, that there was nothins: left for him but submission to his fate. About that time, I resigned my situation at Bicetre, without, however, renouncing the hope of being useful to this unfortunate man. In the course of that year, I had recourse to the following expedient with him. The governor, being previously inform- ed of my project, was prepared to receive a visit from a party of my friends, who were to assume the cha- racter of delegates from the legislative body, dispatch- ed to Bicetre, to obtain information in regard to Ci- tizen , or upon his innocence, to pronounce upon

him a sentence of acquittal. I then concerted with three other physicians whom I engaged to personate this deputation. The principal part was assigned to

227

the eldest and gravest of them, whose appearance and manners were most calculated to command atten- tion and respect. These commissaries, who were dressed in black robes suitable to their pretended office, ranged themselves round a table and caused the melancholic to be brought before them. One of them intorrogated him as to his profession, for- mer conduct, the journals which he had been in the habits of reading, and other particulars respecting his patriotism. The defendant related all that he had said and done; and insisted on a definitive judgement, as he did not conceive that he was guilty of any crime. In order to make a deep impression on his imagination, the president of the delegates pronounced in a loud voice the following sentence. " In virtue of the power which has been delegated to us by the national assembly, we have entered pro- ceedings in due form of law, against Citizen — ■ — : and having duly examined him, touching the mat- ter whereof he stands accused, we make our declara- tion accordingly. It is, therefore, by us declared, that

we have found the said Citizen a truly loyal

patriot ; and, pronouncing his acquittal, we forbid all further proceedffigs against him. We further- more order his entire enlargement and restoration to his friends. But inasmuch as he has obstinatelv re- fused to work for the last twelve months, we order his detention at Bicetre to be prolonged six months

228

from this present time, which said six months he is to employ, with proper sentiments of gratitude, in the capacity of tailor to the house. This our sentence is entrusted to Citizen Poussin, which he is to see executed at the peril of his life." Our commissaries then retired in silence. On the day following the pa- tient again began to work, and, with every expression of sensibility and affection, sohcited the return of his child. Having received the impulse of the above stratagem, he worked for some time unremittingly at his trade. But he had completely lost the use of his limbs from having remained so long extended upon the cold flags. His activity, however, was not of long continuance ; and its remission concurring with an imprudent disclosure of the above well in- tended plot, his delirium returned. I now consider his case as absolutely incurable.

THE ART OF COUNTERACTING THE HUMAN PASSIONS BY OTHERS OF EQUAL OR SUPERIOR FORCE, AN IMPOR-

TANT DEPARTMENT OF MEDICINE.

99- The doctrine in ethics of balancing the pas- sions of men by others of equal or superior force, is not less applicable to the practice of medicine, than to the science of politics, and is probably not the only point of resemblance between the art of govern-

229

itiir mankindand that of healing their diseases. The difference, if there be any, is ni favour of medicine, which considers men individually and independent of social institutions, but notwithstanding, can, in many instances, apply no other remedies than those of not thwarting the propensities of nature, or of counterbalancing them by more powerfid affec- tions, (x) A young man fell into melancholia and asthenia in consequence of a disappointment in love. Ariteus, whose advice was taken upon his case, could prescribe no other remedy than that of pos- session. Oribasis recommends the union of the sexes as a valuable remedy in cases of melancholia. Fo- restus supposed that severe restrictions upon the sex- ual propensity, might, in some instances, produce mental derangement. To arrive at the knowledge of such a cause of the malady, when it is the patient's interest and inclination to impose upon the medical attendant, requires, however, great address and saga- city. Galen (j/) and Erasistratus ( 2) have given ex-

(x) If man's physical functions are capable of any chang.> or amendment by physical means, the author's proposition is inaccurate. The difference must surely be in favour of the science of politics, which in its remote influ- ence, consists in governing the passions of men exclusively. A case of me- lancholia originating in deficient excitement of the stomach or any other viscus is to be treated, at least, in the first instance, by physical remedies. T.

(y) Lib. de precognitione ad posthumus. Cap. 6.

(s) Valer. Maxim. Lib. 5, Chap. 7.

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amples of this kind, which are so striking and so well known, that it is only necessary to mention them. The spasmodic affections of women depend ahuost uni- versally upon some concealed or suppressed exertion of the passions. The case of a disgraced courtier, who in consequence became melancholic, was designated by an ingenious physician " recoiled ambit ion. "(fz) The presentation of a captain's commission to the soldier who first mounted the assault upon the tak- ing of the Bastile, and who was afterwards confined as a maniac at Bicetre, would have been a treat- ment much more suitable to his case than bathinsr and pumping.

A new passion is sometimes generated by some fa- vourable circumstance, in consequence of which me- lancholia may be cured. A rich merchant met some inconsiderable reverses of fortune. His imagination was however so deeply impressed, that from that time he believed himself to be a ruined man, and that he had no other prospect than that of dying by hunger. No exertions were spared to convince him that he was still in possession of a very large fortune. The rich contents of his bureaus were displayed in his presence : but these he believed to be only false ap- pearances, and bis prevailing idea of extreme poverty

(a) " Ambition rentree."

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continued to haunt and distress him. It was at the period of the disturbances excited in Germany by the reformation. What the advice and medicines of Forestus failed to produce, was effected by ardent zeal for the catholic religion. The melancholic ex- erted himself night and day, both^y conversation and writing in defence of the rituals of the Romish church. It was not long before he was completely cured of his melancholia.

THE PROPENSITY TO SUICIDE ACCOMPANYING SOME CASES OF MELANCHOLIA, OCCASIONALLY REMOVED BY A STRONG EMOTION.

100. Experience has established the effect of some simple remedies in preventing the return of paroxysms of melancholia with a propensity to sui- cide. But it has likewise, and not unfrequently evinced their insufTici^ncy, and at the same time the influence of a strong and deeply impressed emo- tion in producing a solid and durable. change. A man, who worked at a sedentary trade, came to consult me about the end of October, 1783, for dyspepsia and great depression of spirits. He knew of no cause to which he could ascribe his in- disposition. His unhappiness at length encreas- ed to such a pitch that he felt an invincible pro-

232

pensity to throw himself into the Seine. Unequivo- cal symptoms of a disordered stomach induced me to prescribe some opening medicines, and for some days occasional draughts of whey. His bowels were effectually opened, and he suffered but little from his propensity^ self-destruction, during the remain- der of the winter. Fine weather appeared to re- store him completely, and his cure was considered as perfect. Towards the decline of autumn, how- ever, his melancholia returned. Nature assumed to him a dark and dismal aspect, and his propensity to throw himself into the Seine returned with redoubled force. The only circumstance that in any degree restrained the horrid impulse, was the idea of leaving unprotected a wife and child, whom he tenderly loved. This struggle between the feel- ings of nature and his delirious phrenzy was not per- mitted to continue long ; for the most unequivocal proofs soon after appeared of his having executed his fatal project.

A literary gentleman, who was given to the plea- sures of the table, and who was lately recovered from a tertain fever, experienced in the season of autumn all the horrors of the propensity to suicide. He weigh- ed with shocking calmness the choice of various me- thods to accomplish the deed of death. A visit which lie paid to London, appears to have developed, with

933

a new degree of energy, his profound melancholy and his immovable resolution to abridge his term of life. He chose an advanced hour of the night, and went towards one of the bridges of that capital for the purpose of precipitating himself into the Thames. But at the moment of his arrival at the destined spot, he was attacked by some robbers. Though he had little or no money about him, he felt extremely in- dignant at this treatment, and used every effort to make his escape ; which, however, he did not ac- complish before he had been exceedingly terrified. Left by his assailants, he returned to his lodgings, having forgot the original object of his sally. This rencounter seems to have operated a thorough revo- lution in the state of his mind. His cure was so complete that, though he has since been a resident of Paris for ten years, and has subsisted frequently upon scanty and precarious resources, he has not been since tormented by disgust with life. This is a case of melancholic vesania, which yielded to the sudden and unforeseen impression of terror. I shall add another case of melancholia, accom- panied by a propensity to suicide, which yielded to a remedy of an analogous nature. It is that of a watchmaker, who was for a long time harrassed by the propensity in question. He once so far gave way to the horrid impulse, that he withdrew to his house in the country, where he expected

F f

234

to meet no obstacle to the execution of his project. Here he one day took a pistol and retired to an ad- joining wood, with the full intent of perpetrating the fatal deed : but missing his aim, the contents of the piece entered his cheek. Violent haemorrhage ensued. He was discovered and conveyed to his own house. During the healing of the wound, which was long pro- tracted, an important change took place in the state of his mind. Whether from the agitation produced by the above tragic attempt, from the enormous loss of blood which it occasioned, or from any other cause, he never afterwards shewed the least inclina- tion to put an end to his existence. This case, though by no means an example for imitation, is well calculated to shew that sudden terror or any other lively or deep impression may divert and even destroy the fatal propensity to suicide.

IS MANIACAL FURY WITHOUT DELIRIUM SUSCEPTIBLE OF CURE WITHOUT THE USE OF PHARMACEUTIC REME- DIES ?

101. In the practice of physic, there are no re- strictions upon the employment of superfluous reme- dies, and there are too many pretenders to the art, who avail themselves of such a system of empyricism in its fullest extent. The methods of treatment too frequently adopted in cases of insanity, of whatever species, or from whatever cause, consist in the re- peated use of bathing and blood-letting, and in the

235

exhibition of antispasmodics in large doses. This bhnd routine has been followed even where experi- ence has hidicated the almost infallible sufficiency of moral and physical regimen. I have found mania- cal fury without delirium, which in France is called folie raisonnante, whether continued, periodical, or subject to irregular returns and independent of the influence of the seasons, the variety of the disorder most unyielding to the action of remedies. A mad- man of this description condemned himself to the most absolute conhnement for nearly eight years. During the whole of that time he was exceedingly agitated. He cried, threatened, and, whenever his arms were at liberty, broke to pieces whatever came in his way, without manifesting any error of the imagination, or any lesion of the faculties of perception, judgement and reasoning. Other mad- men, subject to periodical accessions of extreme vio- lence, are frequently sensible of the impending pa- roxysm, give warning of the necessity of their im- mediate confinement, announce the decline and ter- mination of their effervescent fury, and retain dur- ins: their lucid intervals the recollection of their ex- travagances. An important matter for considera- tion, and calculated to throw light upon the treat- ment of this disorder, is that of the different dura- tion of the lucid intervals, which in some are very short, and in others protracted to a considerable lenf^th. J have known intervals of calmness of eigh-

236 .

teen months' continuance, alternating with parox-* ysms which lasted for six months. In three differ- ent cases, this succession was continued till the death of the patient. A fourth sunk into continued ma- nia from distress of mind. A maniac, who was not delirious, but subject to the influence of blind rage, enjoj'ed a state of tranquillity for eleven months and a iialf of the year. During the remaining fortnight, be was under the dominion of ungovernable fury, which was directed against his own person.

Notwithstanding this variableness in the duration of the paroxysms and intervals of periodical mania, a gloominess of disposition and excessive irascibility, are common characteristics of them. Such maniacs are equally artful and malicious ; at other times they are actuated by blind end savage ferocity. It is in this variety of the disorder, which has hitherto been considered as incurable, and which has commonly terminated in premature death, that medicine should avail herself of her most powerful resources. Opium, camphire in large doses, sudden emersion in cold water, blisters, the moxa, and copious bleedings, are the remedies to be resorted to. I have not hi- therto been able to ascertain the decided effects of opium and castor, I hope, however, soon to have it in my power, from more conclusive experiments, to establish a systematic treatment of this formidable disorder.

237

^HE IDEA TO BE FORMED OF DEMONIACAL POSSESSION.

102. The credit attached to the impostures of demoniacal possession in the writings of Wierus are not to be wondered at, when we consider that his works were pubhshed towards the middle of the seventeenth century, and bear as much reference to theology as to medicine. This author, whose errors admit of some palliation in consideration of the in- fluence of popular prejudices, appears to have been a great adept in the mysteries of exorcism. He re- cords, with great solicitude, the gifts of demoniacal prediction, the perfidious and malicious tricks of the devil under the human figure, and the forms of celebrated characters which in different places he assumed to shew himself upon the earth. " When a man," says the judicious Dr. Mead, " rends his clothes and walks naked, strikes ail who come in his way with terror, inflicts severe wounds on his own person; when he is so fiirious as to burst the strong- est chains ; when he haunts the most gloomy soli- tudes, or wanders among the tombs, and cries out that he is possessed by the devil, there can be no dif- ficulty in ascertaining the nature of his disorder." Can we suppose the demoniacs, whose histories are recorded in theological writings, to be any more than extravagant maniacs ? (r) We need only visit a lunatic asylum in order to appreciate justly the

(c) See Farmer on Demoniacs, -where this view of the subject is ably de- fended. T.

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nature of their pretended inspiratioR. In a word, demoniacs of all descriptions are to be classed either with maniacs or melancholies. What more cal- culated to excite in weak minds such chimerical fan- cies than mania without delirium, conjoined to and chiefly consisting in a propensity to acts of maniacal extravagance ? To punish the misconduct, however extravagant, of a man, who avows his inability to go- vern his own actions, would be cruel : attempts to rectify errors, the absurdity of which he is ready to acknowledge and lament, would be attended with little advantage. Strong antispasmodics, the charms of music, or the excitement of profound emotion, are the only remedies adapted to effect any dur- able change. Such are the means which priests^ of all ages have adopted with equal avidity and ad- dress. Such, among others, were those which were practiced annually at Besancon, during the celebra- tion of the feast of Saint Suaire, famed for the great number of madmen, or demoniacs as they were called, who resorted thither to be cured. In the presence of an immense crowd of spectators, who were ele- yated on a spacious ampitheatre, the pretended de- moniacs were brought forth, guarded by soldiers, and agitated by all the movements and distortions characteristic of raving madness. The priests, in their official habiliments, proceeded, with great gravity, to their exorcisms. From a distant part of the church, and concealed from view, were heard

239

tneioclious notes of martial music. Upon a certain sisrnal, a flas: stained with blood, with the name of Saint Suaire inscribed upon it,^ was brought out three different times, and hoisted amidst the accla- mations of the astonished multitude, and the roar- ing of cannon from the citadel. Upon the minds of the credulous spectators a solemn impression was thus produced, and they cried out, with the utmost excess of enthusiasm, miracle ! miracle ! This pompous spectacle was exhibited once a year by the priests, to shew their power over denionomania. There were some maniacs who were actually cured by the impression produced by these rituals of fan- tastic solemnity. Enlightened medicine knows how to appreciate religious ceremonies of this description, at the same time, that it admires the address of priests of all ages, in conciliating the respect, and in making impressions upon the minds of the laity.

CAN PHARMACEUTIC EXPERIMENTS, WITHOUT PROPER ATTENTION TO THE DIFFEPs.ENT SPECIES OF MENTAL DERANGEMENT, CONTRIBUTE TO THE ADVANCEMENT OF MEDICINE ?

103. From the history of the abw^e variety of mental derangement, a variety so difficult to cure by ordinary means, and upon which so many expe- riments are yet wanting, I am naturally led to the consideration of the most celebrated medicaments of

240

ancient and modern times. Amongst those may be enumerated, hellebore, evacuants and antispasmodics. It must, however, be acknowledged, that the treat- ment of insanity, hitherto directed without due at- tention to generic and specific distinctions, has seme times been superfluous, rarely useful, and frequently injurious. No writer has yet distinguished the varieties of mental disorders which yield to the action of phar- maceutic remedies or to other skilfully applied means, from those depending upon organic lesions, which are beyond the resources of art, ahd which are seldom affected even by the operations of nature To open a new field of enquiry, more fixed as to its hmits ; and to illustrate the subject by less equivocal experiments, I shall throw into the form of a table the results of my observations for a whole year, represent- ing the cures winch were effected at Bicetre, in- dependent of pharmaceutic preparations. To give an idea of the species of mania which are most fatal, I shall afterwards sul join some remarks on the deaths which took place in the course of the same year, as well as on other obst inate cases. From a simple ex- position of facts after this manner, a correct judge- ment may be formed of the active treatment of ma- nia by repeated bleeding and the cold bath, so much in vogue at the Hospice d'Hun^anite, whence luna- tics are transferred to the hospitals de Bicetre and de la Salpetriere, and in fact constitute the greatest nurxiber of their patients.

" J.kn3T'^.3L GENERAL TABLE

OF CASES OF INSANITY CURED AT THE ASYLUM DE BICETRE, IN THE SECOND YEAR OF THE REPUBLIC, BY

>■'--: .; :-] , REGIMEffiAND. EXERCISE EXCLUSIVELY.

PERIODS OF

ADMISSION,

Vovember, 1790

.July, 1792

Xovember, 1 790 Frimaire, year 2

Pluviose, 2

Ventose, 1

Do

Germinal, ]

Do

Floreal, 1

Messidor, 1

Vendemaire, . . . .2

Do

Messidor, 2

Thermidor, .... 2

Do

Thermidor 2

Do

ENGLISH

CALENDAR,

DAYS INCLUSIVE

Nov. 22, Dec. 21 Jan. 21, ..Feb. li) Feb. 20, March 2i Do

Mar. 22, April 20

April 21, May 20 June20, ..July 10 Sep. 23, ..Oct. 22

July 20, Aug., 18

PROFESSION.

Gardener

Mason's Labourer

Soldier

Do

Do

Do

Do

Tailor

W aterman

Tailor

Labourer . . . . . .

Shopkeepeiii^.. . . .

Labourer t^u . . . Tanner . ,. ;uv'.. . t)o... .,.,.. .,.„...,.,. .

Hairdresser^-. . . . .

Soldier ........

Do

Disappointment in 7 love. j

Excessive -Labour . . Consequence of T acute fever C Do

Terror

F.xcessive ambition . . Do

Loss of property . . . .

.Jealousy

Distress of mind . . . . Heat of the sun . . . . Loss of property . . . . Distress of mind . . . .

Do

Do

Terror

Excessive ambition . . Terrorexcitedbvthe ^ (lischarcrp ofartillei v ^

Periodical mania with delirium

Do

Accidental de- ^

mentia f

Do

Periodica! with del Do

1 mania ? ■liiium J

Melancholia . . . ,

Periodical mania 7 with delirium J

Melaiicliolia . . . .

!'eriodical mania > with delirium J Convalescent i

from acute mania )o

}o.....

odical mania 1 ith delirium (

Periodical mania " with (

RELAPSES

WHERE THEY

OCCURRED

Two relapses on seeing the beloved object

rlelapsed for a fortnight

Three relapses One relapse from prema- ^ ture dismission j

Relapsed after his dismission

Relapsed three times be- 7 fore his dismission J

at^^SJI aS3T ■^

J

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INFERENCES FROM THE F0:R.EG0ING TABLE.

104. The inferences from the facts exhibited in the|foregoing table, relative to the active treatment of mania, by repeated bleeding and the cold bath, are simple and obvious. Among the great number of maniacs which are annually transferred to Bice- tre, after having undergone the treatment in ques- tion, (see page Q20,) we only received four conva- lescents in the second year of the republic, who did not afterwards relapse or otherwise change their cha- racter. Mast of the others,^ during their detention at the hospital, experienced one or more paroxysms of acute mania, more or le^s violent, of longer or shorter duration, and were cured solely by moral regimen and discipnne. Out of the number total, eighteen maniacs who were cured, seventeen expe- rienced no relapses, having, in all cases where no obstacles to it were presented by weak or obstinate relations, been detained for several months on trial after their re-establishment. One instance of relapse after dismissal, which was rather to be expected, oc- curred in a case of melancholia excited by jealousy. I might have noticed other cures of maniacs who bad been admitted into the hospital for three, four, five or even seven years previous to the date of my ap- pointment. Those are convalescents, who, som^

with a view to a little gain, others for the purpose

G g

242

of confirming their re-establishment, have devoted themselves for some time to the services of the insti- tution. The respective ages and professions of the cured are marked in the table, and require no par- ticular observations. It is equally obvious and to be lamented, that unhappy dispositions and violent passions are the most ordinary causes of insanity. Another truth not less important, and evident on a view of the above table, and which directly tends to impose restrictions upon the prescription of medica- ments, is, that the most turbulent and furious mad- men, when their disease is periodical, and when their paroxysms correspond with the changes of the sea- sons, are in general most perfectly and permanent- ly cured. Their restoration is best accomphshed by regimen alone : an expedition to Antycira will not in general be found necessary.

PERIODICAL MANIA WITH DELIRIUM AND ORIGINATING IN A MORAL CAUSE, FREQUENTLY CURED BY MORAL And PHYSICAL REGIMEN EXCLUSIVELY.

105. From the history of several madmen who have been cured for some time, and who have been since employed in the services of Bicetre, it ap- pears that their disorder, in almost every instance, originated in profound mental afftctions, such as terror, or distress from domestic calamities. In the

243

greater iiumber its character was that of periodical fury with dehrium. The medical treatment which had been employed, appears to have produced little effect ; the cure having in general been operated by ^oral or physical regimen during the paroxysm, or by exercise and laborious occupations during the lu- cid intervals and convalescence. I observe similar results in nine instances of cures which wefe per- formed during the first six months of the year 3. In all of them the occasional causes, species of the complaint, and remedies employed were the same. In this number, there were not any cases of con- tinued mania, of mania without delirium, of i^aania complicated with epilepsy, of. dementia, nor of ideot- ism. [d) From the necrology of Bicetre, in the se- cond year of the republic, it appears that the most frequent causes of death were accidental diseases un- connected with mania, such as phthisis, dysentery scurvy, inanition from the rejection of food; or else mania complicated with epilepsy, wounds from acci- dents, extreme debility supervening upon the de- cline of a paroxysm towards the end of autumn. Out of twenty-seven maniacs, who died in the hos- pital during the year 2, five were carried off by fits of epilepsy of extreme violence, three by attacks of

(d) I here, exee^ some very rare instances of accidental ideotism, men- tioned in a former part of this volume, which were cured by a critical maniaoiil

paroxysm.

244

ajpoplexy, two by the scurvy, seven sunk in a state of complete exhaustion immediately upon then' arri- val, three in consumption, tvv^o by inanition from the obstinate refusal of food, two by dysentery, and two by accidents, the one from a blow received i^^ a quarrel, the other from bruises and contusions received previous to the date of his admission.

The cases which are given in the table and which are vouched for their accuracy, shew, that of the live species of insanity to be met with at hospitals, one only, that of periodical mania, is remarkable for the frequency and facility of its cures. Melancholia, continued mania, dementia and ideotism are more unyielding, and mania complicated with epilepsy is seldom or never cured. Such at least, during a stormy period of the revolution, are the results which I obtained at Bicetre.

THE INCONVENIENCE OF SEPARATING THE TREATMENT OF MANIACS UPON THEIR FIRST ATTACK FROM THE ASSISTANCE AND ATTENTION WHICH THEY REQUIRE DURING THEIR CONVALESCENCE.

106. In medicine, as well as in most other pur- suits, there is generally a course to be followed, equally simple, natural and confornmble to sound reaspn, and as conducive to the progress of science

245

as calculated to promote the happiness of the human species. It might be supposed that such would be the rout which would be most generally and eagerly taken. This, however, is far fisom being the case. Sometimes from ignorance and want of reflection, afc other times from attachment to habits already fcftm-i ed, or a superstitious regard for opinions and cus-. toms of celebrated men or of other times, it unfor^ tunately happens, that the indirect road and the most beset with embarrassments and impediments, is too commonly pursued. This reflection is pecuharly applicable to the public asylums for insanity estab- lished at Paris. Nothing can be more simple than to place establishments of this kind under the super- intendency of men who, from their information, hu- manity and dignity of character and manner, are qualified for such a trust. Such a system of police as has already been recommended, would equally facilitate and give effect to the duties of the physi- cian. Co-operating with a governor of ability and experience, he would have it in his power to dis- tinguish accurately and practically between the different species of the disorder, and to determine in what cases to trust to the unaided operations of nature, and when to have recourse to the mosC active and diversified measures. It is of great importance that a physician to a lunatic asylum should be acquainted with the history of every case

from its commencement, so as to be able to follow up the treatment adopted in the first instance, or to vary, suspend and intermit its employment according to circumstances. I need not mention the essential propriety of registering in a journal provided for that purpose, all the new facts or changes which occur during the progress of each case, from its commence- ment to its termination, whether it has terminated in a complete restoration of intellect, in incurability, or death. Of this system of uniting method to ability, the opposite has been adopted from time immemo- rial. The Great Hospice d'Humanite, or the late Hotel Dieu, is now left, it is to be hoped, the soli- tary patron of the treatment of maniacs by bathing, pumping and repeated bleeding. When the disor- der proves obstinate, or begins to yield to the opera- tion of these remedies or to that of nature, the patient is forthwith transferrc^dtoBicetre, as incurable or con- valescent. Whether his malady has been cured, con- tinues obstinate, has changed its character, or termi- nated in death, are circumstances which are never known at the Hospice d'Humanite. The physician of Bicetre, on the contrary, a stranger to what has pas- sed during the early treatment of the case, and other- wise deprived of the means of adhereing to it when approved of, is left to the empyrical administration of remedies, or obliged to remain an idle spectator of the resources or insufficiency of nature for the ac-

247

«omplishmcnt of a cure. Such is the situation in which I have been placed as physician in chief of Bicetre, during the second and part of the third year of the repubhc. It has made me very circum- spect in the use of medicaments. I was, hkewise, deprived of the only guide that could direct me in the classification of my patients, according to the spe- cies of their disorder. In my co-operation with Mr. Poussin, a governor of equal zeal and intelligence, my principal attention was directed to the history of periodical and continued mania, to the determi- nation of the different species, and to the organic lesions by which the complaint might be rendered incurable. The trial of some simple remedies, or the vigorous employment of such as are already in established use, was adopted temporarily in expec- tation of other and happier times, when the institu- tion might be more favourably organized, for unit- ing, in harmonious and successful combination, the advantages of the medical treatment in all its bran- ches. In the mean time, it will be proper to offer some remarks upon the experiments and practice of ancient and modern physicians, upon my own views of the administration of medicines, (e) and especially

(e) Ihad made obsei-vatiotis upon this formidable disorder for the space of five years, previous to my appointment to the office of physician to Bicetre j and had communicated to tlie society of medicine a memoir containing many- facts upon the subject, which will be found in the present treatise.

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Upon the system of management adopted at the Asy- lum de Charenton, of the state of which, as a mem- ber of a commission appointed by the school of medi- cine, I sometime ago drew up an accurate report.

A GENERAL METHOD OF A SYNOPTIC TABLE CALCULATED TO EXHIBIT THE STATE AND MOVEMENTS OF A LU- NATIC ASYLUM.

107. I SHALL take for an example the synoptic table adopted at the Asylum de Charenton, whichi was submitted for inspection to the committee ap- pointed by the school of medicine, to make a re- port of the state of that establishment. The medi- cal department is occupied by Citizen Gastaldi, a physician of reputation, and the domestic superin- intendency by Citizen Coulomner, a gentleman of great intelligence and of pure and disinterested phi- lanthropy. The table submitted to our inspection, contained the cases of ninety-seven patients, and ex- hibited the state of this institution during the seventh and for ten months of the eight year of the republic. It was divided into sixteen columns, disposed in the foliowins: order : — 1st, the initials of the name of the patient : 2nd, the date of his admission into the hos- pital : 3rd, his temperament : 4th, his trade or pro- fession : 5th, period of his attack : 6th, the excit- ing cause, when that could be learned : 7tb5 the

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particular species of the disorder : 8t^i, the treat- ment in general which had been adopted : 9th, the period of detention after convalescence or re-estab- lishment, with a view to guard against a relapse : 10th, the date of the cure when performed: 11th, patients not cured or deemed incurable : 12th, the date of the death when it occurred : iSth, the cause of the death, whether natural or foreign to insanity: 14th, memoranda of patients on the medical estab- lishment : 15th, relapses after dismission : l6th, mis- cellaneous observations.

From the above table it likewise appeared, that the insane were divided into five different classes, agreeably to the general distribution which I have myself adopted at Bicetre, viz. melancholia, either simple or complicated with hypochondriasis, mania- cal fury without delirium, mania with delirium, de- mentia, ideotism. The column of occasional causes, whether periodical or moral, of mental derangement, ogives likewise a result analogous to what I have ob- tained at Bicetre. Out of seventy-one cases, whose causes could be clearly ascertained, five were occa- sioned by excessive pleasure, seven by disappointed love, thirty-one by distress from domestic misfor- tunes, one by terror, one by metastasis of the milk, one by onanism, one by the retrocession of psoric or herpetic matter, and five from^ hereditary predis*

H h

^50

position. The column representing the medical treatment, shews with what sagacity and skill it had been varied, according to the strength, habits and character of the patient, or according to the nature of the exciting cause, the species of the disease or its periods. Dr. Gastaldi, in different cases had re- course to avacuants, emetics, purgatives, bleeding ^ to baths, pumping, diluents, blisters, amusements^ select reading, consoling advice and conversation, exercise, mechanical employment, restorative regi- men and antispasmodics.

It is well kown, that the local advantages of that hospital are extremely well calculated to give effi« ciency to the medical treatment, as well as to the hu- mane and enlightened superintendency exercised over it by the governor. A spacious and commodi- ously arranged house, convenient apartments and adapted to the insulation of the different classes of mq,niacs, proper baths and pumps, a reservoir of cold water for what is called the bath of surprise, an enclosed ground for the culture of vegetables, private walks, an open terrace commanding an ex- tensive horizon, and lastly, its vicinity to the Marne, are the enviable advantages enjoyed by the Asylum de Charenton ; and they appear to extend the fame otherwise well deserved of those who are at the head of it. It may not be improper before we con-.

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elude this chapter to observe that out of ninety-sevqu patients there occurred but fourteen deaths in the course of twenty-two months. The number of cures were thirty-three, that is to say, about one third of the whole number ; a report agreeing nearly with that of Bethlehepi hospital. (/)

THE PRACTICE OF BLEEDING IN MANIACAL DISORDERS AND THE LIMITS BY WHICH IT OUGHT TO BE RE- STRAINED. ,

108. The blood of maniacs is sometimes so la- vishly spilled, and with so little discernment, as to render it doubtful whether the patient or his physician has the best claim to the appellation of a madman. This reflection naturally suggests it- self upon seeing many a victim of medical presump- tion, reduced by the depleteing system of treatment to a state of extreme debility or absolute ideotism. At the same time, I do not wish to be understood as altogether proscjibing the use of the lancet in this formidable disorder. My intention is solely to depre- cate its abuse. A young Swiss, vvhose case is detailed by Van Swieten, took a sea voyage during a very hot

(/) Mr. Haslam observes, that hi a period of about ten years, the num- ier of patients at Bethlehem hospital, had been about 1664; that out of that number, 574 had been cured, and that 1090 had been discharged uiicur- ed. Haslam's Observatigns on Insanity, page 112.

959.

season, and, when he came on shore, drank wine to great excess. It is not at all to be wondered at, that his cure was readily effected by repeated bleed- ing. Insanity, consequent upon the suppression of periodical or habitual discharges of blood, will doubt- less frequently yield to an artificial evacuation of the same fluid, procured either by general venaesectiou or topically by leeches and cupping, [g] A parox- ysm of mania is sometimes preceded by symptoms of its approaches which cannot be mistaken ^ such as heightened complexion, wildness and prominence of the eyes, exuberant loquacity. In such cases, the experience of hospitals authorizes the free use of the lancet. It is a well established fact, that paroxysms of madness thus anticipated, are in many instances prevented by a copious bleeding. On the other hand, I feel it my duty to abstain from this practice after the actual explosion of a paroxysm of irregular periodical insanity, as I am confirmed in the opinion that nature alone is adequate in this stage and form of the disorder to the performance.of a solid and permanent cure. It frequently happens, that bleeding, practiced as it is* without rule or bounds, is found to exasperate the complaint, and to cause periodical and curable ma- nia to degenerate into dementia or ideotism. In melancholia, whether simple, or complicated with

{g) Mr. Ha hm prefers to geaeral bleeding, the application of six or eight cupping glasses to the head.

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liypochondriasis, bleeding is still less to be recom- mended. The character of that disorder is dejection . Its appropriate remedies are tonics. Further expe- riments on this subject are only justifiable in the most hopeless and obstinate forms of insanity : such as re- gular periodical mania, inveterate continued mad- ness, and madness complicated with epilepsy, or marked by a disposition to apoplexy. Out of four- teen patients who died at Charenton, ten were car- ried off by fits of apoplexy. Is it not probable that a fatal termination of this kind might be frequently prevented by a copious bleeding from the vessels of the feet ?(^)

CIRCUMSTANCES CALCULATED TO DETERMINE THE USE AND EFFECTS OF EVACUANTS.

109. The use of hellebore in maniacal diseases ; the choice, preparation and administration of that vegetable; the preliminary remedies and precautions adopted to promote its action and to prevent its pernicious effects, formed among the ancients a re-

(A) Had the author prescribed blood to be taken from the temporal artery, from the jugular, occipital, frontal, angular or nasaV interual veins, or by cupping from the vessels of the scalp, his suggestion would haTe been valuable. Founded as it is, solely, upon the exploded theory of revulsion, and calculated to excite false confidence in a very ineTective method of deple- tion, it is equally injudicious and dangerous. T.-

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ar body of doctrine. Experience proved that this drastic sometimes produced violent hypercathar- sis, obstinate vomiting, convulsions, inflammation of the intestines and even death. The reader is re- ferred for a detailed account of this subject to the articles EUebore and Elleborisme in the Encyclope- dic Methodique. Whether we consider its empyrical administration or the unfounded theories and super- stitious fancies which in some instances sanctioned its employment, the disuse into which this remedy is fallen, ought to cause little regret. The history and distinctions of the disease were neglected through excessive and infatuated attention to the re- medy. The science of medicine, enlightened by the acquisitions of chemistry and botany, is now hap- py in the possession and choice of purgatives and emetics, the effects of which are more determined, and not succeeded by any dangerous consequences. It has been remarked, when speaking of paroxysms of periodical mania, (section i.) that they are gene- rally preceded by costiveness and great sensibility of the intestinal canal. If at an early period of this precursory stage of the disorder, the bowels are set at liberty by a purgative salt, dissolved in a decoc- tion of endive, the unfavourable symptoms are not unfrequently removed, and the threatened explosion of a paroxysm is prevented. This is a fact so well known at the Hospital de Bicetre, and established

965

xipon the evidence of so many successful experiments, that a maniac, affected by these intestinal symp* toms, is immediately upon his admission put upon the use of an opening medicine, prescribed accord- ing to this formula, (see note, p. 44.) Paroxysms of insanity, especially such as have no regular type, and correspond with the changes of the seasons, are by this method not unfrequently prevented. I have, also, often remarked, that a spontaneous diarrhea supervening in the course, or towards the decline of a maniacal paroxysm, has had all the characters of a critical evacuatian. My experience agrees with the observations of English practitioners on the same subject. <* Diarrhea," says Mr. Haslam, '' very often proves a natural cure for insanity. The number of cases which might be adduced in confirm- ation of this observation is considerable ; and the speedy convalescence after such evacuation is still more remarkable." Dr. Ferriar likewise mentions a case of insanity which was cured, as it appears, principally by the use of tartar emetic, which ope- rated for some days as a purgative. " A robust woman, about twenty-five years of age, who had been insane a few years before, had now relapsed into a state of furious mania. Her tongue was foul, and her pulse quick. She took emetic tartar, in sufficient doses, to support a constant slight nausea, and had a bhster applied about the same time to the

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crown of her head. In a day or two she appear-* ed more composed, and as she found further reUef from the continuance of the mediqine, it was given for a week together. At the end of that time she was sensibl}^ calmer, though there was yet no appear- ance of recovery. I then dropped the medicine, put her on a course of whey and on low diet, and kept her t)owels freely open with magnesia. This method was continued for fifteen days. She was then ordered in addition an opiate every night at bed time, and was occasionally purged by black hellebore. Signs of recovery began to appear under this method ; she became dull, and at last tractable and quiet. Her yeason returned gradually, and after being com- pletely rational for more than a month, she was dis- charged cured, at the end of four months from the time of her admission." (/) In another respect, however, my observations do not agree with those of English writers. In Er^ gland, cathartics are pre- scribed in small doses. In France, to produce the requisi|e effect, they must be administrated in much larger quantities. This difference in the effects of medicines may, perhaps, depend upon the nature of the exciting cause of the disorder, which in the former country is commonly intemperance in drink- ing J. while in the latter, insanity is almost always

(i) Medical Histories and Reflections, VoL 1, page 172.

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©ccasioned by vivid or profoimd mental emotions. I have as yet been able to obtain but very imperfect results from tiie use of evacuants in cases of melan- cholia with sallow complexion, and other characters which constitute the atrabilious temperament of the ancients. Those patients are, in general, so suspi- cious and untractable, that I have never been able to subject any of them, even in the infirmary, to a regular and methodical system of treatment. As to the employment of evacuants in the most obsti- nate forms of the disorder, in which alone they are perhaps applicable, suchascontinuedmaniaor insanity complicated wiih epilepsy, accurate and judiciously planned experiments are yet wanting.

OF THE VALUE OF ANTISPASMODICS AS REMEDIES FOR

INSANITY.

110. Dr. Laugther, physician to the lunatic asylum at Vienna, lays great stress upon views of the nature and treatment of insanity, which, in the present treatise, are considered of very inferior im- portance. The principal attention of that gentleman appears to be directed to pharmaceutic experiments. The internal police and discipline of hospitals, the historical study of the symptoms of insanity and its classification into distinct species, the distri- bution of maniacs into classes, their insulafion in

I i

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lunatic establishmeiats, together with anatomical and pathological researches, are estimated by Dr. Laugther much below their real value. He admits only of the general distinction of maniacal and melan- cholic delirium, without however adopting any dif- ference in their treatment. The remedies to which he has recourse are not numerous, and consist in emetics, diluent and acidulous drinks, blisters, bleed- ing and narcotics. Of the narcotic class, opium is the principal, and is administered at bed-time as a soporific. When the disorder proves obstinate and threatens to become chronic, he adopts, as he exr presses himself, " with promptitude" a more effi- cacious method. It is with this intention that he prescribes antispasmodics. He then cites six cases of lunacy, which, however, he does not discrimin- ate, in which he tried the effects of musk, in doses of from fifteen grains to a scruple, in the form of boluses, with the syrup of kermes. Diaphoresis was at the same time promoted by other subsidiary means. This remedy was continued for three months with- out any sensible effect from it, but that of impreg- nating the whole hospital with a strong disagreeable odour. The use of musk was then succeeded by that of camphor, whose effect, in the opinion of Dr. Laugther, depended upon its being combined with the acid of vinegar, in the form of a mixture. He then was led to try the effects ©f distilled vine-

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gar, which he administered after dinner, in the quan- tity of an ounce and a half daily, in doses of a table spoonful every quarter of an hour. Nine maniacs were cured under this treatment in the course of one, two, or at furthest three months. It is easy to see how imperfect experiments of this description must be, and how little they can contribute to the ad- vancement of medicine, when made without atten- tion or reference to the specific character of the dis- order. The apparent difference in the experience of different physicians, in regard to the virtues of camphor, renders it very necessary to advance be- yond the generic character of insanity to the con- sideration of those of the different species. Dr. Kenneir, in the Philosophical Transactions, [k) men- tions four cures of insanity which he effected by means of camphor. Dr. Ferriar, on the other hand, asserts that he employed that substance in all kinds of doses without success. In regard to the virtues of camphor simply. Dr. Laugther appears to entertain the same opinion. These contradictory opinions can only be reconciled by supposing that the remedy was employ- ed in essentially different varieties of mental disor- ders. To obtain certain and definite results, the above experiments must be repeated^ with proper attention to the specific distinctions of insanity.

.{fc) Abridged from the Transact. Philosoph-. Med. et Chirurg. Paris, 1791.

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It is only by adopting the same plan of medicinal arid nosological analysis unitedly, that we can ac-» curately ascertain the antimaniacal powers of opium. Tralles gives no favourable, at least, no decided opi- nion on the sanative effects of opium in diseases of the mind. Dr. Ferriar's report, is not more favour- able, though he tried opium alone in several cases, and in some in considerable doses. I recollect one case, if it may be considered a fair one, that would appear to confirm these reports. A young maniac, who was subject to fits of epilepsy, was seized by that disorder in ^ very aggravated form. The pa- roxysms were violent, and the intervals between them exceedingly short. It is a fact established by expe- rience, that this is one of the most certain symptoms of approaching death, I took advantage of the inter- vals, short as they were, to give him some opium. In the first instance, I gave him two decigrammes, (about gr. 1 --) of opium. In a short time I gave him four decigrammes more. The next fit was not distinguished by any diminution in the violence of its symptoms. On the fifth day the patient expired in dreadful convulsions. On opening the cranium, about two ounces of serum, tinged with red blood, was found in the ventricles of the brain. No decid- ed inference can be deduced from this case, either for or against the antimaniacal powers of opium. I greatly approve of Dr. Ferriar's method of combin-

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hig the use of bark and opium, in cases of melan- cholia with great atony and depression, as well as in accidental idealism consequent upon a too active treatment of mania. In page 178, vol i. he details the case of '^ a woman, sixty years of age, who labour- ed under a complete derangement of her intellect. Her aspect was extremely dejected, and her skin was yellow. Her pulse was low and languid. She was ordered two drams of the electuarium peruvianum, and two grains of opium, morning and evening. For some days little alteration was perceived, but in about a fortnight from her admission she was well enough to be allowed the liberty of the gallery." In two months, after having had a slight swelling of the legs, wliich was removed by friction with flower of mustard, she was dismissed cured.

THE EFFECTS OF THE COLD AND AVARM BATH, AND ESPE- CIALLY OF THE BATH OF SURPRISE, IN THE CURE OF MANIACAL DISORDERS.

111. A YOUNG gentleman, twenty-two years of age, of a robust constitution, was deprived of part of his property by the revolution. He gave way to melancholy, began to look forward to futurity with extreme despondency, and lost his sleep. He was, at length, seized by violent maniacal fury. He was

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put upon the treatment for acute mania, in the town of his department. With his hands and feet tied he was suddenly immersed in the cold bath. Notwithstanding the violence with which he resisted this treatment, it was practiced upon him for some time. His delirium chiefly consisted in supposing himself to be an Austrian general, and he common- ly assumed the tone and manner of. a commander. During the process of bathing his fury w£is greatly exasperated by the mortifying consideration that his rank was neglected and despised. His disorder be- coming more and more aggravated by this method, his relations came to the determination to convey him to Paris to be under my care. Upon my first in- terview with him he appeared exceedingly enraged. To conciliate his favour and obtain his good opinion, I felt the necessity of assenting to his illusive ideas. The bath was never mentioned to him. He was treated with mildness and put upon a diluent regi- men, with the liberty of walking at all hours in a pleasant garden. Tlie amusement which he derived from this liberty, exercise and familiar conversation, in which from time I engaged him, gradually induc- ed a state of calmness, and towards the end of a month he was not remarkable either for haughti- ness or indifference. In about three months his de- lirium had completely left him. But towards the autumn of that year, and the spring of the succeed-

26S

ing, some threatening symptoms of a return of his^ disorder betrayed themselves in his manner and con- duct. His looks became more animated, and he was unusually petulant and loquacious. In those circumstances I ordered him a gentle purge to be re- peated at intervals, vidth frequent draughts of whey. He was continued upon this plan for a fortnight. I then advised him to take the warm bath. Not to rouse his former repugnance to bathing, this indica- tion was suggested to him as a practice merely agreeable and conducive to cleanliness. By those means his paroxysm were prevented. To ascertain, however, the permanence of his cure he was detain- ed at my house for a twelve month. Upon his de- parture he returned into the country, where, for the last two years, he has been occupied partly by liter- ary pursuits, and partly by those of agriculture. No symptom of his delirium has since appeared.

^ Cold bathing," says Mr. Haslam, " having for the most part been employed in conjunction with other remedies, it becomes difficult to ascertain how far it may be exclusively beneficial in this disease. The instances in which it has been separately used for the cure of insanity, are too few to enable me to draw any satisfactory conclusions. I may, how- ever, safely affirm, that in many instances, paralytic affections have in a few hours supervened on cold

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bathing, especially when the patient has been in a furi- ous state, and of a plethoric habit.'* Dr. Ferriar ap- pears more decidedly favourable to the practice ot' bathing. In cases of melanchoHa he advises the cold, and in mania the warm bath. The only case, however, which he adduces in support of the practice must be acknowledged to be equivocal, inasmuch as it was treated, especially in its advanced stages, successively by opium, camphor, purgatives and electricity. Ge- neral experiments of this nature are, perhaps, more calculated to perpetuate than to dissipate uncenain- ty. The real utility of bathing in maniacal disorders, remains yet to be ascertained. To establish the practice upon a solid foundation, it must be tried with constant and judicious reference to the different species of insanity. A raving female maniac was put upon the use of the warm bath. She bathed tw^enty-five times, great debility w^as the immediate consequence, and her mania was shortly after suc- ceeded by dementia. I am led to suppose, that the warm bath maybe resorted to with more probability of success, as a preventative of approaching mania- cal paroxysms.

It has been said, that the bath of surprise has been found a valuable remedy in some cases of insanity which had resisted the effects of the warm bath, the cold shower bath, and other remedies. This supe-

§65

fiority of the unexpected application of cold water, has been ascribed to an interruption of the chain of dehrious ideas, induced by the suddenness of the shock, and the general agitation of the system ex- perienced from this process. It is well known, that the enthusiast Van Helmont, has made some valu- able remarks upon the durable effects of sudden im- mersion in cold water in some cases of mental de- rangement. His practice was to detain the patient in the bath for some minutes. It may be proper to observe, that this method, however successful in some instances, might in others be extremely dangerous, and that it can only be resorted to with propriety in cases almost hopeless, and where other remedies are ineffectual ; such as in violent parox- ysms of regular periodical mania, inveterate con- tinued insanity, or insanity complicated with epi- lepsy.

MENTAL DERANGEMENT CURED BY A SPONTANEOUS ERUPTION ON THE SKIN.

112. All men of sense are agreed in the opi- nion that the art of medicine consists not in multi- plying medical formulae, but in prescribing a few select and active remedies judiciously, in combining skilfully the resources of moral and physical regimen, so as gradually to induce a favourable change in the

character of chronic £^ilments, and in assisting na>

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26^

tu''e in her efforts to restore the disordered frame to its pristine health and vigour. Phj^sjcians, both an- cieut-and modern, have observed that msanity bome- times terminate in varicose sw< Ihngs, in haemor- rhoi jal evacuations, in dysentery, in spontaneous h^morrage, ui uitermittent fever But these favour- able terminations, whether slow and gradual, or by sudden and unexpected paroxysnis, seldom occur amid the vapours ot an inddent and sedentary life, Qn the other hand, they are generally promoted by methods judiciously adapted to the particular spe- cies and stage of the disorder ; such as bodily exer- cise, music, reading, change of residence, travelling. A case peculiarly illustrative of the value of those means of recovery, is recorded by the judicious Val- leriola. Observ Med lib. 4. " A young man fell in- to a state of insanity in consequence of unsuccessful love. H s relations, who were greatly distressed on his account, conjmed his physician to employ in his behalf every measure which his experience and judgement could suggest. The removal of the patient to a dis- tance from the scenes and objects with which the im- age of the beloved object was associated, was imme- diately judged necessarv He was conveyed to a bouse in the country, delightfully situated and com- manding a very agreeable prosj^ect. Fme gardens, an extensive paik, Li aniitul meadows, large basons oi ivaier aiid purim^ streams surrounded this charm-

ing abode. The air was perfumed with the odour of roses and citrons, and other aromatic plants. The walks were diversified, the ordinary society of the patient were numerous, but consisting of relations and select friends. His time was principally occu- pied by interesting and varied amusements. His delirium appeared, in some degree, to yield to these measures ; but his distressing recollections plunged him occasionally in the most acute and maniacal misery. It was thought proper to remove him still further from home, and he was conveyed to an agree- able market town at some distance, where every care was taken to meet the indications of the phy- sician, and to second the effects of the medicines which he had prescribed. But the patient's consti- tution appeared to be undermined by an insidious hectic fever. Recourse was then had to opiates at night, and to a tonic restorative diet, conjoin- ed with pediluvium, warm ablutions, and pumping upon the head. Music and readnig were on some days introduced during the process of lathing. By these means the delirious paroxysms gradually dimi- nished in their violence, reason resumed her empire, and at length the patient's health and strength were completely restored.

To exhibit the efficiency of unassisted nature in cases of insanity originating even in a natural or physical cause^ I must beg permission to add the

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two following cases. A yoong irsaii, attached to the hunt in the time of the late monarchy, was com- missioned by his employers to rub a mangy dog with mercurial ointment. By that sort of exercise, which of itself was not calculated to excite much envy, he contracted himself the disease which he had under- taken to cure in his canine friend. Acrop of unusually small eruptions appeared in a short time afterwards on his hands and other parts of his body. Having done his duty towards the dog, he had now to turn his medicinal skill towards his own person. He rub-' bed himself with the sulphur ointment, and was shortly cured of his cutaneous affection. But soon after he fell into a state of insanity. Sometimes he was extravagant in his conduct, exuberant in his language, and unconnected in his ideas. At other times he observed a profound silence, and appeared exceedingly dejected. The ordinary treatment at the Hotel Dieu, although it was continued for two months, produced no change. He was then con- veyed to the madhouse of Fabourg Antoine, where, in the winter of 1788, I had the opportunity of see- ing him. Upon his admission to that institution, the usual indications of relaxants and purgatives, with opiates at night, were resorted to. He soon became more tranquil. In the spring he was put on the use of the warm bath, with the inspissated juice of ves;€tables. In the course of the summer he be-

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came subject to an erratic inflammatory affection of the skin. An inflamed tumor appeared on the small of the leg. Poultices were applied to it. But instead of coming to a head, it terminated by resolution in the course of four or five days. The same affection shewed itself successively in large phlegmons upon the arms, legs and thighs, which, however, after a slight suppuration dried up and disappeared. The chest was likewise affected by oppression, difficulty of breathing, and other symptoms similar to those of astmah. During those affections of the chest, the head was sensibly relieved. Eight months elaps- ed amid these alternations, without any durable or remarkable change in the functions of the under- standing. As he was one day taking the warm bath, a swelling was observed on the right parotid gland. On the following day this tumor was inflamed and hard to the touch. Emollients were applied. Upon ascertaining the nature of its contents, by a fluctu- ation which could not be mistaken, an incision was made into the tumor on the seventh day after its appearance. A copious evacuation of purulent mat- ter succeeded the operation, and the wound con- tinued to discharge more or less for three weeks, when it healed and cicatrised. The efforts of nature were not equivocal in this case, inasmuch as the epoch of a complete re-establishment of the intellect, corresponded with that of the maturity of tjtie sup-

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purative process. The patient was in due time dis- missed cured. I saw him four years after the date of his discharge in the full enjoyment of his health, both of body and mind.

I have known another instance of nosological con- version not inapplicable to my present purpose. It was a case of melancholia which terminated in jaun- dice. A jeweller was attacked by a paroxysm of in- sanity, for which there appeared no evident cause. He was conveyed to the institution of Faubourg Anto- ine, where I was requested, amongst others to call and see him. This was in the year 1786. The character of his delirium was that of mildness and harmlessness. He walked almost always in the garden or in his own. room, when it was his custom to mutter to himself with generally a smile upon his countenance. He answered with great propriety to the questions which were put to him, took his victuals with ordinary relish, and was quiet at night. Paroxysms of profound melan- cholia occurred every spring and autumn. For six weeks or two months he was remarkable at those seasons, for his repulsive manners and taciturnity i. The features of his countenance were altered, and his complexion became sallow. Upon the appear- ance of these symptoms he was ordered opening me- dicines, the inspissated juice of plants, and the cold bath, in the forms both of immersion and pumping.

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Those remedies appeared only to produce a tempor- ary relief, and they were continued for five years without any perceptible, or, at least, durable change in the state of his mind. In October, 1791, he was suddenly attacked by a jaundice, which, as it did not originate in any evident cause, could only be as- cribed to a salutary effort of nature to remove the mental indisposition. The only remedies which were employed were diluent drinks, acidulated with the juice of the citron. In the course of about two mouths the jaundice disappeared; when the patient was likewise restored to the perfect use of his rea- son.

THE DIFFICULTY AND IMPORTANCE OF DECIDING IN SOME INSTANCES ON THE CURABILITY OF INSANITY.

1 13. The possibility of curing insanity in a given case, is one of those questions, the solution of which may not only be difficult and complicated, but may involve in it very important considerations connect ed with family interest and happiness. Experience has doubtless proved to the satisfaction both of Eno--

o

lish and French practitioners, that religious melan- cholia, mania complicated with epilepsy, ideotism, and regular periodical mania, are seldom known to tenninate in any other way than by death. But are we authorised by the solemn dictates of medical jurisprudence, to pronounce over any of those cases

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the sentence of absolute incurability ? In cases, even of irregular periodical mania, in which there are so many chances in favour of a cure, how many circumstances are there which may contribute to disappoint expectation ? Medical certificates, in- volving the fate of property, titles, conjugal or other relations, are instruments evidently of serious im- portance in society; and, therefore, deserving of adequate legislative provision in every country.

A farmer, deprived by the conscript act of a fa- vourite son, gave .way to profound sorrow, passed many sleepless nights, and, at length, shewed every symptom of insanity. Another son, who was left, shut him up in bis chamber, seized upon his proper- ty, treated him with great harshness, and by that means exasperated his poor father's fury to the ut- most pitch of maniacal violence. An order of trans- fer to Bicetre was shortly obtained and executed. His disorder continued exceedingly violent during the prevalence of the hot season. But towards the decline of autumn a calm succeeded, which lasted throughout the winter. To meet the symptoms of an incipient nervous excitement, which appeared in the ensuing sprmg, some opening medicines were prescribed, which prevented the explosion of the threatened paroxysm. In the autumn I judged that he might have been sent to his family with perfect

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isafety. I, therefore, wrote a letter to his son ex- pressive of my opiniorl, which, however, has never been replied to, to this day. After that I sent two successive letters by post to the municipal offi- cers of the place where he resided ; which likewise were never noticed. A persoa, who took great in- terest in the fate of our unfortunate patient, was then entrusted with a third epistle, containing my declaration of the farmer's perfect sanity, and the urgent propriety there was of restoring him to the possession of his property. This remonstrance was heard, atid, in defiance of the influence exercised by the son over the municipal officers, the old gentle- man was, at length, reinstated m his farm. In the course of the ensuing year, he paid me a visit and brought me a large basketful of fruit, as an expres- sion of his gratitude. It may be easily supposed, that this visit could produce no other than a pleasur- able impression on my feelings.

To seize the true character of mental derange- ment in a given case, and to pronounce an infal- lible prognosis of the event, is often a task of par- ticular delicacy, and requires the united exertion of great discernment, of extensive knowledge and of incorruptible integrity. Ihe following are cases of insanity of which the claims it requires little sagacity to determine.

S74

A gardener, who had been married for some years^ was tormented by jealousy. The object of his suspicions was a priest, who, as he fancied, received more favours from his wife than his official indulgences entitled him to. The husband sought to drown his feelings in the pleasures of the bottle ; which, however, contributed to hasten the fate which his jealousy alone would probably have induced upon him too soon. He fell into a state of furious insanity. Having undergone the ordi- nary treatment at the Hotel Dieu, he was transferred to Bicetre. He continued subject to paroxysms of his disorder for several months : but during the lucid in- tervals which he had, he appeared to be in perfect possession of his reason, and he was made to take a part in the domestic services of the institution. His habit of drinking became more inveterate, and in every instance of excessive indulgence that way, he became a prey to his original jealousy in all its vio- lence. In those circumstances his wife sued for a divorce. This measure I might have opposed, on the ground that there still remained some hopes of the husband's recovery. But the probability of a relapse from the influence of the first cause of his disorder, to the operation of which he would at home be pecu- liarly exposed, together with the danger to be ap- prehended from his violence when intoxicated with strong drinks, for which his propensity was very

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great, determined me, without hesitation, to advise the prolongation of his confinement.

An old shop-keeper, whom false calculations had rendered unfortunate, fell into a state of insanity. His delirium was confined to one subject ; which was that of enriching himself by the chances of bil- liards. The least opposition to this idea made him frantic. The fiill exercise of his reasoning faculties, which on every other subject he was capable of, btli which was not sufficient to obtain from me a favour- able attestation, encouraged him to make perpetual coniplaints, and to petition the executive body and the ministry for his enlargement, on the pretext that he was the victim of an unaffectionate wife, whom he took frequent occasion to abuse and to threaten. Repeated interviews with him gave me an opportunity of discovering the peculiar character of his delirium, and of observing his violent and im- placable disposition. I communicated the whole history of his case to the constituted authorities, to- gether with my appreliensions of the danger which might result from his enlargement. This effectually put an end to his intrigueing applications. The de- mentia of old age at length united itself to his ori- ginal disorder. He was about seventy years of age. In my general report, I advised his confinement for an indefinite space of time.

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.OF THE DISCHARGE OF CONVALJESCENTS.

114. A PHYSICIAN to a hospital is not priviledg- ed like a court physician, to reside in a palace or to aspire at the sources of favours and dignities and richeso But, has he, likewise, the affronts of the courtier to put up with, and plots and intrigues to anticipate ? Or is he under the necessity of sub- mitting to the caprices of others, or of being direct- ed by the impulse of a power foreign to his own will ? On the other hand, if well informed, and actuated by a desire of doing good, he may exer- cise in his province an irrestistible ascendency. His thoughts require no disguise, as they are always di- rected to a laudable object. To alleviate the weight of misfortu'ie, and to dry the tears of the distressed constitute at once his duty and his pleasure. In giving his opinion of the state of a convalescent, he is not shackled by the cabals of bulletins, nor by the inflj.ence of opposite and contending interests. Wnen iie judges that his patients may be safely re- stored to their friends and to society, he gives his absolute and unequivocal opinion accordingly, point- ing out' the mea ures necessary to be observed or ladopted by way of precaution.

Extrpuie sensibility generally characterises maiiiaCs in a state of convalescence , especially those who are

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but imperfectly restored. A fright, a transport of passion, great distress of mind, hot weavher, intem- perance, or a sudden change of condition from a state of detention and constraint to that of inde- pendence and Hberty, may produce commotions in the minds of convalescents of which inotiier circum- stances they would not be susceptible, and renew paroxysms of mania of which the habit had for some- time been suspended. A grenadier of the French guards, who was one of the foremost in mounting the assault upon the taking of the Bastille, was so intoxicated with the exploit, that he gave way to boundless ambition. But upon the disappointment of his hopes he fell into a state of the most violent maniacal fury. He was admitted into Bicetre, where he continued in the same state for four months. At length a calm succeeded, and his mo- ther imprudently demanded his discharge before his sanity was complete and confirmed. After his re- storation to his friends, he was shortly seized by a paroxysm of iiis disorder, which rendered it neces- sary to bring him back to the hospital. The same imprudence was repeated twice with the same result. The mother, then rendered wiser by experience, no more sought his liberty prematurely. Two years elapsed, during which he v/as perfectly calm and rational, beibre it was thought safe to give him his discharge. He was dismissed from- the hospital at

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the beginning of winter, and he has since experienc- ed no relapse.

The heat of summer, sometimes the cold of win- ter, but not often, may occasion the recurrence of paroxysms of irregular periodical mania. To have recourse, therefore, at those times to some appropriate preventatives, it is scarcely necessary to advise. Mild relaxants are most applicable to those cases, administered either internally in the way of medicine, or applied in the form of the warm bath to the surface.

An industrious farmer, who fell into a state of insani- ty from the action of a burning sun in the hot season of harvest, was cured after a residence of about one year at Bicetre, and sent to his family with the ex- press advice to take, towards the spring of every year, some opening medicines, diluent drinks, and the bath occasionally. For two years these precau- tions were punctually observed. For two years, therefore, no symptom of a relapse appeared. But in the third year the measures advised were neg- lected. After having undergone the usual treat- ment at the Hotel Dieu, this victim of his own im- prudence was transmitted, for the second time, to Bicetre. His insanity continued exceedingly vio- lent for five months. After a very slow recovery he

^79

was discharged cured. The experience of his past imprudence rendered it unnecessary to lay much stress upon the use of the means which he had for- merly employed with so much advantage.

One of the advantages peculiarly estimable of well regulated hospitals, is the means possessed by them of making deep impressions on the minds of maniacsj and of convincing them that resistance to a force at once intended and calculated to master their extravagances, and to keep them in respectful submission would avail them nothing. This idea, which they never ought to be allowed to loose sight of, is well adapted to exercise the functions of the understanding, to arrest their delirious wanderings, to habituate them gradually to self government, which is the first step towards recovery If premature- ly discharged and allowed to return to their family, their consciousness of independence, and the liberty which they possess of indulging all their whims and caprices, are found, in too many instances, to excite their passions, to raise the tone of their mind, and finally, to induce a relapse of their disorder. I was one day solicited and pressed to sign the dis- charge of a convalescent. It was in the spring of the year. The following were my motives as they afterwards appeared in the report, for my non- compliance with the request.

'^ t have carefully examined A. B. who is detain* ed a patient at the Lunatic Asyhim de Bicetre. Al- though he appears at this time perfectly possessed of his reason, I do not think it would be prudent to grant him his liberty. For the first three months of his confinement at the hospital he has been in a state of delirious fury, and he was not calm till the beginning <5f last wintei'. To ascertain his permanent reeovery, he must undergo the trial of tlie hot weather of sum- mer. It may be reasonably presuiried, if he enter- ed at this time upon the possession of his property, that the joy of recovering his liberty, and of see- ing his relatious and friends, would be too much for Mm in his present unconfirmed state of health, and might possibly occasion a relapse. I am, therefore, of opinion, that his discharge ought to be delayed till towards the end of autumn.

Bicetre, Germinal 15, (April 5,) year 2." P.

As the public safety ought to be conscientiously studied and provided for, I grant no attestations of cures without due examination of the state of the applicant, and without stating the circumstances upon which I found my opinion. To give the reader an idea of my method, I shall subjoin two examples.

"I certify, that I. R. aged twenty-two years, and detained as a lunatic at the Asylum de Bicetre,

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may be regarded as cured of his disorder ; since, for

the space of one year, he has shown no symprom .)f

a deranged intellect, even during the hot weather

of summer.

P.

Bicetre, Fructidor 10, (Aug 28,) year 2.'*

" I certify, that T. D. aged twenty-one years, detained as a lunatic at Bicetre, has for the last four months manifested all the signs of a perfect re- establishment of his reason. His cure is attested with more confidence, inasmuch as his derangement supervened on an acute disorder When admitted to the hospital he was in a state of great depression. Flis convalescence advanced by slow but certain steps, until at length he was completely restored.

P.

Bicetre, Fructidor 20, (Sep. 7,) year 2."

Experience has ascertained the permanency of cures operated by a jaundice, by phlegmon ic erup- tions, by varicose swellings, by haemorrhoidal eva- cuations, b} quartan fever, &,c. Critical maniacal pa- roxysms taking place during a state of dementia or ideotism have been atteiirled with the same effect. The physician may feel a degree of confidence in giv- ing his attestation to the probable permanency of

cores operated by critical solutions of acute disorders.

M m

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FEIGNED MANIA : THE METHOD OF ASCERTAINING IT.

1 15. Mania , as well as demoniacal possession, epilepsy, catalepsy and other nervous disorders, may be counterfeited^ either from views of interest or from worse motives. To distinguish between the dexterous imitations and the real disorder, is a pro- vince of medical jurisprudence, equally delicate, dif- ficult and important. I do not here speak of un- skilful pretensions and rude artifices calculated to impose only on simple and credulous people, such as Wierus quotes ; (/) but of insanity counterfeited on a great scale, and amidst enlightened characters, as in the example quoted by Dehaen (wz) of a woman, who, in consequence of attestations given in her fa- vour by certain well informed ecclesiastics, passed for a demoniac, and who after her admission into the hospital of Vienna was convicted of imposture. A guilty prisoner sometimes counterfeits insanity in order to escape the vengeance of the law, preferring confinement in a lunatic hospital to the punishment due to his crime. At other times genuine insanity supervenes in the course of a long and involuntary detention in a place of confinement. Those are cases which it is the important province of the physician to distinguish and to ascertain.

(I) Historia festiva figmenti femiuce demoniacce Wieri, Op. Med. p. 344. (w) Dehaen Meth. Med Tom. 15.

28S

A man, forty-five years of age, confined in the fe- lon department of Bicetre, on account of his political opinions, was guilty of numerous acts of extrava- gance, made many absurd speeches, and at length succeeded in obtaining his removal to the lunatic de- partment of the same place. This happened before my appointment- la the course of some months after my entrance upon the functions of my office, I de- termined to examine carefully into the history and state of his malady, in order to ascertain accurately the class of the disorder to which his case belonged^ For this purpose I frequently visited his chambers. At every visit he exhibited some new antic. Sometimes he wrapped up his head in cloths or blankets and refus- ed to reply to my questions. At other times he pour- ed fourth a torrent of unmeaning and incoherent jargon. On other occasions he assumed the tone of an inspired or affected the airs of a great personage. The assumption of so many and opposite characters, convinced me that he was not well read in thehistory of insanity, and that he had not studied the charac- ters of those whom he endeavoured to counterfeit. The usual changes in the expression of the eyes and other features, characteristic of a nervous maniacal excitement, were likewise wanting. I sometimes listened at the door of his chamber in the course of the night, when I invariably found him asleep, which agreed with the report of the hospitcil watch-

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man. He one dav escaped from his chamber while it was cleaning and setting in order, took up a stick and applied it, with great effect, to the hack of a domestic, in order to impress him and others with the idea of his violence and his fury All tliese facts, which I collected and compared m the course of one month, appeared to characterise no decided variety of mania, but rather a great desire of counterfeiting it. I was no longer the dupe of his artifices; but as he had been sentenced to be coafined on account of political matters, I adjourned my report of him, under pretence of wishing to learn some new facts. The 9th of Thermidor (July 28) succeeding put an end to the prosecution which had been commenc- ed against him.

In Vendemaire, (Sep. and Oct.) of the year 3, a young man, of tweniy-two years of age, confined in the prisons of Bicetre, was brought to the infirm- ary of the same establishment. He was exceedingly dejected and silent durmg my first visit to him. As I i'onud him free fr.)m fever, I merely prescribed a light diet, persuaded that his disorder consist- ed in great depression and distress of mind On the succeeding days I observed but little change in the state of his symptoms He still persisted in his si- lencp, even wh< n questions were put to him. Hq sometimes sighed deeply, and moaned pitepusly.

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He had little appetite, no sleep, and, according to the report of the attendants, was subject in the night to nervous agitations of extreme violence. He fre- quently got out of bed, walked about the ward, and was obliged to be re-condncted to his couch, as il out of his mind. Two m >iiths after ius admission into the infirmary, and during one of my visits, he advanced with an air of wildness, and forcibly seized one of the attendants with the intention apparently of throw- ing him down His looks were wild and fixed. He wished to be informed relative to some particulars connected with a certain female of his acquaintance. He sighed profoundly. Such was the sensibility of his epigastric region, that he could scarcely bear the weight of his bed-clothes. Being desired to as- certain the nature of his disorder, I felt no hesita- tion in pronouncing his state to be that of decided insanity, consequent either upon disappointed love, or upon the depression of mind occasioned by his confinement, or, perhaps, upon the united influ- ence of those two causes. His conveyance to a lu- natic asylum was, at length, decided upon, and all judicial proceedings against him were withdrawn.

It may be thought astonishing, that in an object of so much importance as that of ascertaining the actual existence of mental derangement, there is yet no defi- nite rule to guide us in so delicate an examination. In.

f 86

fact, there appears no other method than what is adopted in other departments of natural history: that of ascertciining whether the facts which are observed belong to any one of the established varieties of mental derangement^ or to any of its comphca- tions with other disorders. I could here quote seve- ral examples of cornplicated mania illustrative of my position. I shall confine myself to one, that of a young woman, twenty-eight years of age, with white hair, and little expression in her countenance. Her state of derangement, it is supposed, originally de- pended uponafright which her mother receivedduring her pregnancy. She remained like a statue, constant- ly in the same place. She could not speak, notwith- standing that her organs of speech appeared perfect in their conformation. It was with great difficulty that she was taught to enunciate the vowels e, o. Of af- fections she appeared not to possess any ; a circum- stance that might have disposed a nosologist to refer her case to the species ideotism. But there were two or three acts that she could perform, which appear- ed to indicate that her ideotism was not complete. She was subject almost every morning to a parox- ysm of great fury. If any one attempted to con- fine her in the strait-waistcoat she was violently en- raged, and could use her teeth and nails with great violence and effect : but as soon as she was actually seized, her paroxysm ceased, she submitted without

287

further resistance, and shewed every sign of repent- ance. Does not this case, at least in its paroxysms, present the character of" maniavvitiiout dehrium ?

CIRCUMSTANCES TO BE ADVERTED TO IN FORMING AN OPINION OF THE AUTHOR's SUCCESS IN THE TREAT" MENT OF MENTAL DERANGEMENT.

116. Before we conclude, it may not be im- proper to advert to certain circumstances which ought not to be overlooked, in judging of the success of our labours and researches on the subject of the pre- sent treatise. It is necessary to mark the point from which we set out, that at wiiich we have ar- rived, and the circumstances by which we were guid- ed in our hospital duties. The maniacs of either sex, who were admitted at Bicetre and Saltpetriere, whether as convalescents or incurables, had at other places previously to their admission into those hos- pitals, undergone the u.->ual system of treatment, by bleeding, bathing and pumping. Among the facts which were most constantly observed, are to be enumerated the permanent recovery of some, the death soon after their arrival of others, and the recur-< rence of paroxysms which in some instances termin- ate in complete re-establishment, but most frequent- ly in a state of incurable dementia. Establishment

288

of this kind Reldom afford an opportiinity of drawing up CO rect tables of their mortahty, of determining accuiaiely the proportion of the cases that are cured, and of fixing with precision the conversions which oc^ur among the different species of insanity. I have, therefore, devoted my principal attention to such objects as were within my power ; to the study of tiie different species of insanity, to the examina- tion of the effects of certain remedies, and to the de- termination of principles of moral and physical re- gimen at lunatic asylums To have surmounted many of the prejudices and other obstacles which present themselves in the organization and discipline of hospitals, is a merit which we hope it will be deemed no arrogance to lay some claim to. The fundamental principles advanced in this treatise will enable us, at a future period, to erect a superstruc- ture for the reception and treatment of lunatics, superior to any of the boasted establishments of neighbouring nations. For the accomplishment of these our earnest wishes, we look up to the councils of a firm government, which overlooks not any of the great objects of public utility.

THE END.

SHEFFIELD : PRINTED BV W. TODD, MARKET STREET,

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