I I .^■/' <^', yt. ^// p ^e-/,? y/^ // A^ c^ij^^. A MANUAL PSYCHOLOarCAL MEDICINE. V.-- /«0/lf PHOTOGRAPHS TAHEN IN THE DEVON COUNTY LUNATIC /^SYLUM. •; r dAscripbav .ntf tfu/Unt saau acusu iru the. Apperuiun I A MANUAL PSYCHOLOGICAL MEDICINE CONTAINING THK HISTORY, NOSOLOGY, DESCRIPTION, STATISTIC DLVGNOSIS, PATHOLOGY, AND TREATMENT INSANITY. aflit^ an giiptnbu- ol (Lasts. BY JOHN CHAEI.ES BCCKNILL, M.D. Loxd., rKLLunr or tui botal college or ratsicuxa, london ; rELLOw or imiebsitv college, lonuon ; ton .laSOCIATK or JIEDIrO-PStCUOLOOICAL AaS0CIAT10.> OF PARIS ; MEDICAL 8|;PEBIXIE> UF..\T OK THI DEVa:< COIXTT lUSATIC ASrLlM i AXUEDIIOU OF' lUE JOl BXAL OFMEMALSCIENCK ;' AND BT DANIEL HACK TUKE, M.D., MKUBrii II. int. uiilAL COLLKCB OF PHTSICIAXS, LOXDOX ; rOBMKRLT LECTURES ON PSTCHOLOblC MtUlCI.\t AT TUB lOBK 9CUOUL OP MEDICI.'OE, AND VIBITIXG MEDICAL OPFICKK TO THE lUBK BBTBEAT. SECOND EDITION, REVISED AND ENLA' CED. LONDON: JOHN CHURCHILL, NEW BURLINGTON STREET. MPCCCLXIl. 3IOL-Ua, r«c<^ Thi- Ritjht of Translation is reserved. -7^^ > ° ^ J. K. ADLABD, I'lUNTEK, BAKTUOLOMEW CLOSE. PREFACE. The Authors of the following pages have long felt the want of a systematic treatise on Insanity, adapted to the use of students and practitioners in Medicine. Numerous mono- graphs and works on limited portions of Psychological Medicine have appeared of late years. They are of great value to the specialist physician, but they do not meet the oft-repeated inquiry of the student and practitioner, — " To what systematic treatise on Insanity can I refer?" Dr. Prichard's excellent * Treatise on Insanity ' has undoubtedly been the one which hitherto has most nearly afforded the desired information ; but it was written a quarter of a century ago, at a time when the Treatment of Insanity bore an aspect entirely different to its present one ; and, moreover, it is now out of print. A knowledge of the nature and treatment of Insanity is now expected of every well-educated man. Tlie India Board require it of all persons to whom medical appointments arc given under their • new system of competitive examination. It is reasonable to expect that the good example thus set will be followed in other quarters; and a desire to obtain a competent knowledge of this important branch of medical practice has become far more general in tlic profession than it ever before has been. b VI PUr.FACE. The Authors arc aware that no amount of reading can render it safe to dispense with a clinical knowledge of mental disease. Their aim has hccn^ to sui)[)ly a text-book which may serve as a guide in the acqnisition of such knowledge^ sufficiently elementary to be adapted to the wants of the student^ and sufficiently modern in its views and explicit in its teaching to suffice the demands of the practitioner. How far the Authors have succeeded in their purpose^, it remains for their readers to determine ; of their shortcomings none can be more sensible than they are themselves. It only remains to add respecting this Work, that the Chapters on the History, Nosology, Description, and Statistics, namely, that portion of the Work from the commencement to page 300, are written by Dr. Tuke ; and that the Chapters on the Diagnosis, Pathology, and Treatment of Insanity, and the Appendix of Cases, from page 300 to the end of the Work, are written bv Dr. Buckmll. CONTENTS. CHAITER I. PAGE HiSTOBiCAL Sketch of Ixsanity among the Nations of Axtiqcitv, MAINLY IN BEGABD TO ITS EXTENT . . . .1 1. Inference to be drawn from the Condition of the Ancients in regard to Civilization. The Egyptians — Greeks — and Romans ; their Civilization consider- ably advanced, but defective, and probably less calculated than our own to favour Mental Disease (1 — 5). / Examples in Ancient History, of Persons who were Insane, or who feigned Insanity ; including References made to the Disease by Medical and other Writers. Feigned Madness of Ulysses, and David — Madness of Saul — Ajax — Orestes — Cassandra — Plato's Opinion of the Oracles — Power of Bacchus to induce Madness — Lycurgus, King of the Edoncs — The Daughters of Pra?tus — Athamas, King of Thebes — Medea — Question of Demoniacal Possession — Cambyses — Cleomencs, King of Sparta — Allusions to Insanity made by Pythagoras — Hippocrates — Diodes — Asclepiades — and the Roman Poets, Horace, Persius, Juvenal, &c. (5 — 18). CHAPTER II. Opinions of Ancient Medical Wuiteks on tue Tkeatment of the Insane . . . . , . .11) Treatment of Saul — Treatment pursued by Hijipocrates — Aristotle v — Diocles — iVsclepiades, the Founder of the Metliodici — His Dis- ciples, Titus and Themison — Celsus — Soranus — Cadius Aurcli- anus—Arcta'us— Galen (19— 2'J). CIIAITKU III. PAGE Modern Civilization in its IJeakino upon Insanity . 30 Observations on the Numbers of Insane, and on the Fallacies con- nectetl with the Inquiry (30). Number of Insane (and Idiots) in England, &c., at the Present Time (32). Impossible to compare this satisfactorily with Previous Statistics (33). Attempt to decide the Question, Does Civilization f\ivour the Gene- ration of Insanity ? by an Inquiry whether the Chief Causes of Mental Disease are present in greater force in Civilized than in i Uncivilized Society — Excess of Study — Emotional Sensibility — Grief, Anxiety, &c. — Political Excitement — Occupation, Agri- cultural and Manufacturing — Intoxicating Liquors — Uterine Disease — Intermarriage (33 — 45). See also Chapter VIl. Comparison of Number of Insane in Civilized and Uncivilized Countries at the Present Day (45). Summary of Conclusions (49). CHAPTER IV. Ameliouation of tue Condition of the Insane in Modern Times, especially in eeoaed to Mechanical Pestbaints Injurious Effects of Celsus' Teaching extended to Modern Times (51) Condition of Insane in England formerly — Foundation of Bethlem Hospital and St. Luke's — Interest in Insanity indicated by Works published in the 18th Century — Perfect — Arnold — Pargeter, &c.— Treatment of Insane as described by Dr. Browne —Establishment of the Retreat at York— Condition of the York Asylum— Evidence before the Committee of the House of Com- mons in 1815 — Subsequent Improvement in Asylums in conse- quence of Exposure at Y'ork and Rethlem Hosjiitals — Abolition of Instrumental Restraint at Lincoln — Dr. Conolly at Hanwell — Report of Commissioners, 1844— Many Asylums still Unreformed ^Subsciiuent History — Report of Commissioners on Instrumental Kcstraint in 1854 (51—68). Review of Legal Enactments in England in reference to the Insauo, from 171-1- to the Present Time (i) occurs for the first time among the threats uttered against future disobedience (Deut. xxviii, 28). Our English "mad" is by some Hebrew scholars derived from the Hebrew word for strength (mad), on account of the increased strength poss.jssed by the insane when excited. AMOiNG THE iNATlO.NS UF AMIQLITV. \'6 man presently falling down, he mentioned Solomon, and reciting the charms composed by him, he adjured the demon never to return more/' We have assumed, in these remarks, tiiat de- moniacal possession has an important bearing on insanity; because, amidst the conflicting hypotheses upon this question, we believe that one of two views must be adopted ; either of which equally warrants this assumption. Either those supposed to be possessed by devils were labouring under simple madness, the result of natural causes ; or they were madmen, the excit- ing cause of whose malady was the Evil One. In either case, the symptoms were those of madness. In the sixth century before the Christian era, history presents to lis a memorable example of madness, in the person of Cam- byses.* Herodotus thus refers to him : " It is indeed said, that Cambyses from his birth laboured under a powerful malady, called by some the sacred disease (epilepsy). No wonder, then, that, as his body was so much distempered, his mind should not be sound. The Persians had accused Cambyses of being insanCj in allusion to which, addressing Prexaspes, he says, ' Now yourself observe whether the Persians speak truly, or whether, in saying such things of me, they are not themselves insane ; for if I strike your son to the heart, as he stands there in the vestibule, it w^ill appear that the Persians have no ground for what they affirm ; but if I miss my aim, the Persians will prove they are in the right, and that I am not of sound mind.' So saying, he bent his bow^ and hit the youth, who fell dead. Cambyses then ordered the body to be opened, and the wound to be examined ; when the shaft was found in the heart. * There, Prexaspes,' said he, laughing, and in high glee, ' it is pi'oved to you that I am not mad ; but that it is the Persians w ho have lost their wits. Now tell me, did you ever know a man hit his mark so nicely ?' Prexaspes, perceiving that he had to do with a madman, and fearing for his own life, replied, — ' My lord, I really think that a god could not have shot better.' In a like temper, on another occasion, he seized twelve Persians of high rank, and buried them alive up to the head. From all these instances, it is evident to me that Cambyses was truly deranged ; • In the same century L. Junius Brutus feigned insanity, according to good authorities. Otliers have disputed it (ride Smith's ' Dictionary of Greek and Roman Biojrraphv,' Art. Bi-utus). 14 HISTORICAL SKKTCH OF INSANJTY for otherwise he certaiuly would not have attempted to make sport of thinnjs sacred, and of estabh'shed usages/' When deso- lating Egypt, he plunged his dagger into the sacred bull Apis. " After this brutal deed," says Grote, " Cambyses lost every spark of reason that yet remained to him, and the Egyptians found in this visitation a new proof of the avenging interference of their gods." To the example of Cambyses may be added that of Cleo- menes, king of Sparta, who is stated to have killed himself in a fit of madness, 491 b. c. To hira Herodotus thus refers. " The Lacedemonians, informed of the intrigues of Cleomenes, were inHuenced by their fears to place him again on the throne ; and they restored to him all his former prerogatives. But, presently after his return, he was seized with a frenzy, to which indeed he had before been liable. With his sceptre he would strike in the ■ face any Spartan he happened to meet. On observing this insane conduct, his family confined him in stocks. While so bound, it happened, that seeing himself left with a single attendant, he asked him for a knife ; the man at first refused, but being a helot, was at length intimidated by his threats, and gave him one. Cleomenes, seizing the weapon, began to hack his legs, making long gashes in the flesh ; from the legs he ascended to the thighs, and from thence to the hips and loins ; and then reaching the belly, made many deep incisions, and so died. The Spartans say, that Cleomenes contracted a great in- timacy with the Scythians, who came to Sparta on (state) busi- ness, — a too great intimacy, for he learned from them to drink unmixed liquors; and it was from this cause, as they believe, that he became mad." Herodotus also speaks of a large number of persons in Scythia being attacked with wolf-madness. Pythagoras, who is supposed to have lived in the sixth cen- tury before Christ, was acquainted with epilepsy; lience, it has been justly inferred, that he umst have been acquainted with madness, seeing that the former so frequently induces the latter. It is to the writings of Hippocrates, however, who flourished about a century later, that we naturally turn with the greatest interest, not only because two thousand two hundred years have rlapsod sinr-p ho lived, but bocauso so noule an observer, and AMONG THE NATIONS OF ANTIQUITY. 15 accurate a writer, was not likely to overlook any striking disease. He lived in the palmy days of Greece. " He had for his cotemporaries/' observes Dr. Adams, " Pericles, the fiimous statesman ; the poets .Eschylus, Sophocles, Euripides, Aristo- phanes, and Pindar ; the philosopher Socrates, with his dis- tinguished disciples, Plato and Xenophon ; the venerable father of history, Herodotus, and his young rival, Thucydides ; the unrivalled statuary, Phidias, with his illustrious pupils ; and many other distinguished names, which have conferred immortal honour on the age in which they lived, and exalted the dignity of human nature. ... If we may believe oriental chron- ology, Confucius and Zoroaster had gone off the stage of life only a* very few years before the dawn of this celebrated age of Grecian superiority in the arts and sciences." In one of his Aphorisms, Hippocrates appears to recognise the common observation of the comparative insensibility of the insane to pain. " Persons/' says he, " who have a painful aftection in any part of their body, and are, in a great measiu'c, insensible of the pain, are disordered in intellect." (Sect. ii, 6.) In another, he acknoAvledges the iuHuence of the sea- sons. "The diseases of spring are, maniacal, melancholic, and epileptic disorders," &c. (Sect, iii, 20.) In a third, the bene- ficial effect of the supervention of other diseases is referred to. " In maniacal affections, if varices or haemorrhoids come on, they remove mania." (Sect. ^^, 21.) "Dysentery, or dropsy, or ecstasy, coming on madness, is good." (Sect, vii, 5.) Dr. Adams states that by " ecstasy," commentators understand a violent exacerbation of the maniacal symptoms, which brings the disease to a crisis. Again, he defines melancholia, when he says that, " if a fright, or despondency, last for a long time, it is a melancholic aftection" (Sect, vi, 23) ; and tells how prog- nosis is affected by the age of the patient, in the aphorism that, " persons above forty years of age who are affected with phrcnsy, do not readily recover; the danger is less when the disease is cognate to the constitution and age." (Sect, viii, 82.) In the following remarkable passages, Hippocrates gives us his views of cerebral physiology, and of the pathology of insanity. "Men ought to know," he says, " that from nothing else but thence (the brain) come joys, despondency, and lament- ations. And by this, in an osprrial manner, wc acquire wisdom, 16 HISTORICAL SKETCH OY INSANITY and knowledge, and see and hear, and know what are foul and Avhat are fair, what are bad and what are good, what are sweet, and what unsavoury ; some we discriminate by habit, and some we perceive by their utility. By this we distinguish objects of relish and disrelish, according to the seasons; and the same things do not always please us. And by the same organ we become mad and delirious, and fears and terrors assail us, some by night and some by day; and dreams and un- timely wanderings, and cares that are not suitable, and igno- rance of present circumstances, desuetude, and unskilfulness. All these things we endure from the brain when it is not healthy, but is more hot, more cold, more moist, or more dry, than natural, or when it suffers any other preternatural and unusual affection. And we become mad from humidity {of the brain). For when it is more moist than natural, it is necessa- rily put into motion, and the affected part being moved, neither the sight nor hearing can be at rest, and the tongue speaks in accordance with the sight and hearing. As long as the brain is at rest the man enjoys his reason ; but the depravement of the brain arises from phlegm and bile, either of which you may recognise in this manner : Those who are mad from phlegm are quiet, and do not cry out or make a noise ; but those from"^bile are vociferous, malignant, and will not be quiet, but are always doing something improper. If the madness be constant, these are the causes thereof. But if terrors and fears assail, they are connected with derangement of the brain, and derangement is owing to its being heated. And it is heated by bile when it is determined to the brain along the blood-vessels running from the trunk, and fear is present until it return again to the veins and trunk, when it ceases. He is grieved and troubled when the brain is unseasonably cooled, and contracted beyond its wont. It suffers this from phlegm ; and from the same affection the patient becomes oblivious." {' The Sacred Disease ; Works of Hippocrates,' Sydenham Society.) Who does not read with interest the report which Hippocrates gives of a case of melancholia occurring in Thasus ? The patient, a woman, lived near the Pylades, upon the plain. She was "of a melancholic turn of mind, and from some accidental cause of sorrow, while still going about, became affected with loss of sleep, aversion to food, and had thirst and nausea." The AMONG THE NATIONS OF ANTIQUITV. 17 attack was acute, and passed away iu a few days, there being " about the crisis a copious menstruation." (' Epidemics,* book iii, case 11.) These are the most important, and nearly all the referenees made by Hippocrates to madness. It must be confessed that, on the whole, they are rather scanty, and would seem to indicate that he had not occasion to treat mental maladies to any very great extent. He distinguished, however, between mania (fiavia), melancholy {int\ayxo\ia.), and a state of dementia {■rrapdvoia). We have not cited any of the references made to insanity in the treatises 'DcMorbis,' on account of the doubtful authenticity of these books ; as, however, they are very ancient, it is interesting to observe how melancholy is here referred to. The writer describes " the anxiety of those who labour under it, their love of solitary places, their fears, the frightful dreams by which they are tormented, the malaise they suffer from when their stomach is empty, or too full. Trelat quotes from Hip- pocrates the following, Avhicli, however, we have not been able to find in his works. " A continual and unaccustomed irresolu- tion, a change in the voice, — especially if it becomes bawling and ill regulated, — a trembling of the tongue, a hesitation in the speech, announce alienation.'^ We might recognise here the symptoms of incipient general paralysis. Diodes (b. c. 300) discussed in his writings several points relating to some of the various forms of mental disease. Asclepiades, as we shall see, entered largely into the subject. The references made incidentally by the Roman poets to insanity are frequent. ]Many pages might be filled -with citations from Ovid, Plautus, Horace, Virgil, and others. The citizen of Argos, so graphically described by Horace, is a remarkable example of the presence of intellectual, without moral alienation of mind. Fuit baud ignobilis Argis, Qui se credebat miros audire tragoedos. In vacuo Iffitus scssor plausorque tbeatro ; Caetera qui vita; servarct uiunia recto More ; bonus sane vicinus, amabilis bospes, Comis in uxorcni ; posset qui ignoscere servis, Et signo la;8o non insanire lagena; : Posset qui rupeni ct putcuni vitare patcntem. 18 HISTORICAL SKETCH OF INSAMTV. The allusion to the treatment pursued in this case, by ex- pelling the bile and the disease together, is also of interest : Hie ubi, cognatoruni opibus curisque refectus, Espulit elleboro morbuin bilemque meraco, Et redit ad sese, &c. The Avell-known proverb, naviget Anticyram, referring to the hellebore for whieh this place was so famous, is to be found in the 'Satires^ of tliis poet. (Lib. ii, 3, 1(56. See also De arte Poetic, v. 300, Tribus Anticyris caput insauabile, &c., and Sat. iii, lib. ii, v. 82.) Lastly : the words, insanus, amens, delirus, demens, dementia, &c. are of frequent occurrence in the pages of Horace. Ovid refers to Antieyra : Littus ad Euxinum, si quis mihi diceret, ibis, Et metues arcu ne feriare Geta? ; I, bibe, dixissem, purgantes pectora succos ; Quiquid et in toto nascitur AnticjTa. The same poet, in his ' Metamorphoses,' makes several refer- ences to illusional forms of insanity. Persius, in his bold satire on Nero, coolly advises him to resort to the use of hellebore ! (See also Sat. v, ]00.) Qiiin tu igitiir summa nee quiequam pelle decorus Ante diem blando eandem jactare popello Desinis, Anticyras melior sorbere meracas ? And in the third satire he makes a passing allusion to the madness of Orestes : . . . dicisque facisque quod ipse Non sani esse hominis, non saniis juret Orestes. In Juvenal we find many allusions to the use of hellebore as a medicine for the cure of insanity, and to the celebrity of Antieyra. (Juv. Sat. xiii, 97. Sat. vi, 619, &c.) To these the reader is referred. CHAPTER II. OPINIONS OF ANCIENT MEDICAL WRITERS ON THE TREATMENT OF THE INSANE. Music is the first recorded remedy employed^ so far as we are aware, for the relief of madness. That ancient musician, of whom it has been said that he struck tones that were an echo of the sphere harmonies, " took a harp and played with his hand ; 80 Saul was refreshed and was well, and the evil spirit departed from him." (1 Sam. \x\, 23.) Music appears, also, to have been strongly recommended by Asclepiades. References to the treatment of insanity in the works of Hip- pocrates are few in number. The treatise concerning hellebore, ascribed to him, is not admitted among his genuine works by the learned Dr. Adams. Nor does it make any allusion to its administration in insanity. This, however, is distinctly referred to in the correspondence between him and Democritus. " I am persuaded," says the latter, ''that if to me you should give hellebore to drink as to the insane, it would be right that the insane should escape it ; and, according to your art, you would have blamed it as being itself the cause of madness. For helle- bore, when given to the sane, pom's darkness over the mind, but to the insane it is very profitable." (Works of Hippocrates, Frankfort edition, 1595.) Now, although these letters have been regarded as supposititious, there is considerable evidence in their favour ; at all events, their great antiquity cannot be disputed; and, as Dr. Adams observes, "that Hippocrates visited Abdera, and that he was familiarly acquainted with Democritus, are facts which the most sceptical critic will hardly venture to call in question.* • For the genuineness of the treatise professing to treat specially of insanity, und puhlishcd in some editions of the works of ni)>i>ocTatt'R, there appears to l>o no authm-itv. 20 ANCIENT MEDICAL WRITERS lu the doubtfully genuine treatise ' Of the Places in ;Man/ the writer says, " a draught made from the root of mandrake, in a smaller dose than will induce mania, should be administered to the suicidal maniac.'^ Also, in the work ' Of Diseases,' which, whether written by Hippocrates or not, is of great antiquity, the author prescribes for melancholy persons — a tranquil and regular life, tlic absence of all excesses, sobriety, a vegetable diet, food but little seasoned, continence, exercise short of fatigue and never in the sim, and bleeding. "When the head is gorged with l)lood/' says he, " patients are sometimes as if they were intoxicated ; it is then necessary to open a vein. But, then, we often make fruitless attempts to take away much blood, when there is but little in the affected organ.'' From the time of Hippocrates down to that of Asclepiades (the founder of the School of the Methodici), but little evidence is afforded of the treatment to which the insane were subjected. Aristotle and Diodes are, however, represented by Caelius Aurelianus ('De Morbis Acutis et Chronicis,' edit. 1709, Amsterdam,) as recommending the application of cold, from the belief that heat is the cause of the complaint. Asclepiades was certainly one of the most definite in his directions in regard to the treatment of the insane. As we have already said, he prescribed music. He especially recommended, according to Celsus, that the patient should abstain from food, drink, and sleep, in the early part of the day; that, in the evening, he should drink water ; that then gentle friction should be applied, while, later still, liquid food should be given, with a repetition of the frictions. B)^ these means, sleep was supposed to be induced. He regarded as worse than useless, the appli- cation of narcotic fomentations, referring specially to hyos- cyamus, mandragora, and poppies. Such reference to these remedies is interesting, as showing their use prior to the time in which he flourished. He directed that the patient should be placed in the light. To employ bleeding was, he thought, little short of murder. According to Caelius Aurelianus, Asclepiades ordered his patients to be chained. Feuchtcrsleben, in his ' Medical Psychology,' states, that Asclepiades recommends "that bodily restraint should be avoided, as much as possible, and that none but the most dangerous should be confined by bonds ; " referring to Celsus and Ciclius oy THE TREATMENT OF THE INSANE. 21 Aurclianus as his authorities for tlie opinions of Asclepiadcs (wliose works are lost) ; but neither of these writers appears to assert so much. The latter says, " Asclepiades ofliciis solitis amoveri jubet regrotantes, et vinculis constrinyi, et abstinentia ciborum niniia eocrceri, et siti alHei, turn vino corrumpi vcl in araorem induci." Thus, althougli he prescribed " vinum vel amor/' he scarcely merits the praise Avhich Feuchtcrsleben has bestowed upon him, when he observes, that he did not withhold his well-known motto, Cito tuto et jucunde, from the therapeutics of insanity. According to this writer, Asclepiades recommended that books should be read to the patient in an inaccurate manner, in order that he might be induced to correct the mistakes. His disciple Titus, also, enumerates stripes among the curative agents in the treatment of mania; and it would not be unfair, perhaps, to conclude that the practice was known to his master. Thcmison, another disciple of Asclepiades, and who is often regarded as the real founder of the School of the ^Icthodici, styled " phlcbotomotos " by Cailius, followed, to a considerable extent, in the steps of his predecessor ; but prescribed the bath and a more liberal regimen, and ordered astringent fomentations (constrictiva fomenta). The treatment recommended by the celebrated Celsus (who was bom about 30 b.c), in his chapter entitled, De tribus in- sania generibus, may next be considered. On the whole, the directions of this physician are harsh, and scarcely merit the praise which some authors have bestowed upon them. It is true, that he admits, in regard to those who ramble in their discourse, or attempt some trifling injury with their hands, that it is unnecessary to employ any rough, coercive measures. He deemed it proper, however, to subdue those who were more violent, by a very compulsory treatment, "lest they should injure themselves or others." Their audacity must be coerced, and they must be brought to submission by blows, as in the case of any one else who requires restraint. Excessive mirth must be checked by scolding. If conciliatory measures fail, patients must be cured l)y some kind of torment ; thus, should they be detected in falsehood or deceit, they must be lumgcrcd, or bound in chains, or flogged [fame, vhicuUs, plagis, coerceudus est). By these means, he assures us, they will before long, 23 AKCTENT MEDICAL WRITERS through the influence of fear, be thoroughly disposed to come to terms, to eat anything, and even their memory, he says, will thus be refreshed. For, to startle them suddenly, and greatly to terrify them, is profitable in this disease ; — anything, in short, by Avhich the mind is violently disturbed ! To close up all the avenues of pity, this humane physician also says, that you are not to Ijclicve any one who, thus subdued, while he is desirous of being released from his bonds, pretends that he is sane, however prudently and piteously he may converse, since this very deceit is the result of madness. On which enlightened prin- ciple, it is difficult to understand how Celsus himself (or any other sane man) would have escaped, had he once been so un- fortunate as to be suspected of insanity. Celsus by no means, however, overlooked all medical treat- ment. He approved of venesection, and of cupping applied to the head, which, he observes, will have the effect of inducing sleep. Should any syniptom render bleeding unsuitable, the next best remedy is abstinence, followed by an emetic and a purgative of white hellebore, and, if possible, the employment of friction twice in the day. He is here speaking of those cases in which sadness appears to be the result of black bile. No longer under the influence of apprehension from the violence of the patient, Celsus directs that fear should be removed from his mind, and cheerful hopes excited ; pleasure being sought in fables and sports, and whatever else may be conducive to health. Patients are to be judiciously encouraged in their several occu- pations, and their groundless fears are to be lightly reproved. Cold water is also to be poured upon the head of the patient, and his body immersed in water and oil. In maniacal cases, warm fomentations may be applied to the shaven head. When, in consequence, the febrile symptoms abate, we are to liaye recourse to friction ; but we miist use it more sparingly in those cases in which the patients are exMlaratcd, than in those in which they are depressed. In the maniacal paroxysm itself, however, Celsus had not much faith in medical applications ; indeed, he M'as afraid that by such means the fever would be increased. Therefore, in such cases, says he, do nothing with the patient but confine him. Severe as was Celsus upon the insane who were guilty of deception, he had no hesitation in employing similar means # ON THE TREATMENT OP THE INSANE. 23 towards the patient. AVc need not quan-cl with the direction, that, shoukl the patient refuse to swallow the doctor's favourite hellebore mixture, he is to be deceived by having it mixed in his food ; but Ave may well dissent from the propriety of another direction, namely, that, should it be necessary to inspire fear, and should the patient be a rich man, you are to announce to him the false intelligence of a lost estate. The good cflFect of a full diet, in some cases of insomnia, was very properly pointed out. Other somniferous remedies pre- scribed by Celsus were, friction, exercise after food and by night ; the sound of a waterfall ; but chiefly the rocking motion of a suspended bed. Nor were the soothing influences of music in melancholy overlooked. The mind was also to be called forth in some cases, by reading aloud ; and occasionally errors might be made, in order to elicit the critical powers of the patient. The next authority to whom Ave may refer, in point of time, is Soranus, avIio, according to Fabricius, was born at Ephesus, A.D. 98. The works of Soranus which have reference to insanity are lost ; the opinions expressed by CseHus Aurelianus are, hoAV- e\'er, attributed to him; but it is difficult to determine the extent to which he is a translator or an original writer."^ We cannot unite in the opinion expressed by Trelat, that he re- ceived from posterity all the honour Avhich was due to Soranus. A difterence of opinion exists, as to the interval which elapsed betAveen these tAvo Avriters, the confusion in part arising from there having been at' least four physicians of the name of Soranus. By some, Caelius is stated to have lived in the first century of the Christian era ; by others he is placed a century later. It has been thought that he was a cotemporary, or rival, of Galen, because that Avriter noAvherc alludes to him. In presenting the opinions of Cselius Aurelianns, we shall, to some extent, be supplementing what has already been said of the Greeks, inasmuch as they are, in a considerable measure, a reflection of the treatment pursued by them. It has been found impossible in all instances to distinguish ])etwcen his oaati opinions and practice, and those of the Greeks ; and, as regards the latter, to decide to Avhat period of Grecian history he refers. • Tlie passage which appears to support the former view, is as follows: — "Soranus vero ciijns ha?c sunt latinizanda suscepimus," 4c. 2t ANCIENT MKDICAL WRITERS Cselius regarded it as essentially necessary to place the maniacal in a room moderately light and warm, and to avoid every thing of an exciting character; pictures were not to be allowed; nor was the window to be too high^ nor was the room to be in the upper story, the reason being added, that many when seized with madness have thrown themselves out. The bed was to be firm, and so placed that the patient could not be disturbed by the sight of persons entering the room ; it was to be of straw, soft, and well beaten, but not broken. If the patient was in danger of injuring himself, soft wool, moistened, was applied to the head, neck, and chest. Thus, instead of having a padded room, Cjelius padded his patient. The duty of attendants, in regard to deception, is clearly laid down. They were to beware, on the one hand, of seeming to confirm the patient's delusions, and thus increase his disorder; and, on the other, they were to be careful not to exasperate him, by too much opposition ; but at one time by indulgent condescension, at another by insirma- tion, endeavour to correct his delusions. Should the patient attempt to escape, and be with difficulty restrained, or exasper- ated with seclusion, then, says Cajlius, with admirable percep- tion, you must employ more attendants. Let these, he adds, without the patient perceiving the real object in view, engage themselves in applying friction to his limbs. Further, should this treatment fail, and the violence be great, a ligature (ligatio) may be resorted to, being quietly applied, and the limbs pro- tected by wool. Should the patient ha.ve been accustomed to submission and reverence, this, he observes, will not require frequent repetition — for such repetition would induce contempt, and when patients do not yield to such a course of treatment, then it becomes necessary to subdue them by inducing fear or awe. Should the patient's eyes be affected by the light, they must, according to our author, be shaded ; but he adds, with great discrimination, in such a way that other parts of the body may not be deprived of light. We have already noticed tlic views of Asclepiades, regarding abstinence. Ciclius directed that abstinence from food might be carried so far as to induce slight hunger; adding, that the strength nuiy be reduced by l^lceding (but on no account from both arms), if the malady rccpiirt' it, even during such abstinence, should there be nothing present to contra-indieate it. The food was to be UN 11 IK TRKATMKNT OF TlIK JNSANK. '.T) light and digestible, as bread softened in warm water, or a preparation of wheat lightly boiled with honey, &c. Al- ternate days of fasting and feeding were likewise recom- mended. Should the disorder become stationary, Cielius advises the head to be shaved, and cujiping to be applied, first over the chest, then between the shoulders (" for these parts sympathise with the head"), and next to the head. A restless and sleepless condition was to be relieved by carrying the patient about on a litter or in a chair, or by the monotonous sound of running water. Fomentations, by means of warm sponges, were to be applied over the eyelids, with the idea of relaxing them, and in the hope of exerting a curative influence over the meninges of the brain. As reason returned, moderate exercise was strongly re- commended, — riding, walking, and exertion of the voice. The patient was to read compositions containing inaccuracies, in order the better to exercise the understanding j but Ciclius adds a cau- tion that this must not be too difficult, lest the patient be over- done with laborious mental exercise, which were as detrimental to the mind as immoderate exertion to the body. Theatrical entertainments were to follow for those labouring under melan- choly, and scenes of a solemn or tragic character were to counter- act excessive hilarity and excitement. "Oportet enim con- trarietate quadam alienationis corrigere qualitatem, quo animi quoque habitus sanitatis mediocritatem agnoscat." Subjects of disputation might be added as the patient recovered, conducted in a low tone of voice, the preference being given to narrative and demonstrative subjects. Further : individuals known to the patients were to be employed to converse with them, in a manner calculated to encourage and amuse them. These various mental exercises were to be followed by rubbing with oil, and a gentle walk. Here our author suddenly remembers, that much of the preceding treatment could not be carried out with the illiterate; for such, he prescribes questions, having reference to their par- ticular callings, — as on farming for the agriculturist, navigation for the sailor ; and for those ignorant even of these, questions of a general nature must be propounded. Shampooing, as well as inunction, was an important remedy with Civlius, including frictions of the head. The diet was to be improved as tiu- patient's health returned; wine being forbidden 2(5 ANCIENT MEDICAL WRITERS in the first instance, gradually allowed after the use of fruits, but then only of light quality. As the mind recovered its tone, the patient was allowed to go and hear the disputations of the philosophers, from the per- suasion that the passions of grief, fear, and anger, were thus dissipated. If, on the contrary, the patient relapsed, the former treatment was to be resumed, adding sternutatories, an emetic made from the root of white hellebore, &c. The ears were to be injected ^^ ith water containing a little nitre, honey, nettle-seed, or mustard; the rationale given being that even through the channels of the senses, a restorative virtue may be conveyed to the mem- branes of the brain, especially as patients are often affected Avith tinnitus aurium. Finally, the cure of the patient was to be established by travelling and sea voyages. After thus stating the mode of treatment which recommended itself to his judgment, Caclius proceeds to condemn the practice of some who had preceded him. Some of the ISIethodici, lie observes, have prescribed close confinement in a dark room, forgetting, that the patient's dislike to it may aggravate his dis- order, and that too much seclusion from the air causes dense bodies to perspire, and that the omission of ordinary occupations will aggravate cerebral congestion. He then denounces the ex- treme abstinence which was recommended in forgetfulness of the fact, that such a course disorders the bodily powers, and is one which the patient will be unable to bear. The supporters of such a regimen referred to the taming of wild beasts as ana- logous, and as a proof that madness may be thus repressed; but Caelius, anticipating the practice of the present day, retorts that they should have known better, from a consideration of the efi'cct of hunger upon the sane, in inducing rage. He does not hesitate to assert, that the starving system will induce madness rather than cure it. He then refers to a sul)jcct of especial interest to us in our time, and his observations are calculated to humiliate us, exhibiting, as they do, a far-seeing philanthropy which those who have treated the insane have, until very recently, failed to imitate. Ciclius observes, that they also order the patients to be bound with chains, Avithout any consideration that the bound parts must necessarily be chafed, and hoAv much more properly the patients might be restrained by tlie care of attendants than by senseless chains. ON TTIK TREATMENT Or TIIK INSANV.. 27 He is alike indignant against those wlio would coerce by flagellation, especially aljout the face and head, which, so far from relieving the disease, only induces swellings and sores ; in addition to which, the returning consciousness of the patient could not but be hurt by the sense of his wounds. Among the many strange and opposite modes of treatment to which, as if in despair, the insane have been subjected, intoxica- tion was not overlooked. Some, our author observes, recom- mend intoxication, since madness is often caused by it ; * and music, but without sufficient discrimination, since, injudiciously used, it may prove injurious. The pleasures of love, Avhich were prescribed by Titus and Themison, were strongly con- demned by Cielius, who regarded as impious and absurd, the attempt to indulge pi'opensities wMiich require restraint. In the chapter which treats of melancholy, Ctelius observes, that he would not bleed ; nor depress the patient by purging him with hellebore and aloes, but at once soothe and invigorate him by emollient and astringent applications. The exact period when Aretreus flourished is a matter of doubt. Dr. Adams regards him as cotemporary with Galen. He probably wrote about the time of Caelius Aurelianus ; but this remains doubtful, so long as writers differ as much as a century in assigning the date of the latter. Aretaeus only speaks of the cure of melancholy. Here he recommends bleeding from the right arm to relieve the liver; '^for this viseus," he observes, " is the fountain of the blood and the source of the formation of the bile, both which are the pabulum of melancholy." But he wisely adds, that as the blood is the pabulum of Nature also, venesection must be moderate, " lest she, too, be ejected from . her seat.'' After a day's fasting, two drachms of black hellebore were to be administered, in order to evacuate black bile. This purgation was followed by the bath, and cupping over the liver and stomach. The hiera from aloes he recommends to be given repeatedly, observing, that " this is the important medicine in melancholy, being the remedy for the stomach, the liver, and the purging of bile." After these remedial measures, which Arettcus characterises as " sufferings," the patient is to be re- cruited by frequenting the natural hot baths, the medicinal * "Alii inebriandos aiunt srprotantes, cum sirjie ex vinolentia furor atmie iiwania generetur." 28 ANCIENT MEDICAL WRITERS substances in which, as bitumen^ sulphur, and alum, he regarded as highly beneficial. Gentle frictions with oily liniments were also recommended, exercise, and a diet of eggs, fowls, hares, and the lean parts of other animals. AVe may conclude our reference to the practice of this phy- sician, with his remarks by way of excuse for failing to be suc- cessful in the treatment of all cases of melancholy. " It is impossible, indeed, to make all the sick well ; for the physician would thus be superior to God : but the physician can produce respite from pain, intervals in diseases, and render them latent. In such cases, the physician can either decline and deny his assistance, alleging, as an excuse, the incurable nature of the disease, or continue to render his services to the last." (' The extant works of Aretreus the Cappadocean,' 1856.) The celebrated Galen, of Pergamos, flourished at a period but little subsequent to Cffilius Aurelianus. He is said to have died at the age of ninety, a.d. 193. His treatment was based upon the humoral pathology, which was in such high repute among the ancients, and which exercised an almost universal influence on their practice. He lays it down that, if moisture produces fatuity, and dryness sagacity, just in proportion to the excess of moisture over dryness the sagacity will be diminished. Hence, he advises the practitioner to aim, above all things, at preserving a just medium between these opposite qualities. He recommends that, " should you be of opinion that the whole of the patient's body may contain melancholy blood," you are to employ venesection, especially from the median cephalic vein. He adds that, should the blood flowing from it not appear to be of a melancholy quality, the vein must immediately be closed; but that, should the contrary be the case, you are to abstract as much blood as the state of the patient and his habit of body will permit. If, however, madness arise from idiopathic disease of the brain, bleeding is by all means to be avoided. In forming an opinion on this subject, regard was to be had to the patient's constitution and temperament. The fat, the fair, and the flabby, were not to be supposed to possess any melancholy humour ; but the lean, dark, and hairy, and those in wliom the veins are large, are the most snl)jcct to its accnmulation. He gives a long enumeration of the kinds of food which induce melancholy, — as the flesh of ON THE TREATMENT OE THE INSANE. X!U oxeiij goats, but especially asses and camels, and also wolves, dogs, hares, and snails. Among vegetables, the cabbage only is mentioned. Thick and black wine was particularly to be avoided, " as from it the melancholy humour is made." This melancholy humour is spoken of by Galen as a condition of blood, "thickened, and more like black bile, which, indeed, exhaling to the brain, causes melancholy symptoms to affect the mind." We frequently also notice, he observes, that when yellow bile is contained in the stomach, the head is painfully affected ; but it immediately recovers when the stomach is relieved from bile by vomiting. In mild cases of insanity, Galen prescribed the bath and nourishing food. On the whole, we deem Galen a very inferior authority to Caelius Aurelianus, at least in regard to the practical treatment of the insane. His book, entitled ' De cognoscendis curandisque animi morbis,^ and consisting of ten short chapters, is a moral essay, and not a medical treatise. He treats of the method of con- trolling anger, and also the desires and appetites, by the exercise of reason, regarding insanity as the opposite of wisdom. "With Galen this sketch of the medical practice of the old physicians must close. The subject is far from being exhausted ; suflficient has been said, however, to enable the reader to com- pare ancient with modern methods of treating the insane. CHAPTER III. MODERN' CIVILIZATION l\ ITS BEARING UPON INSANITY. In the preceding observations avc have rapidly glanced at the evidences existing of the extent of insanity among the ancients, and have passed in review the treatment which they adopted in order to repress the violence of those labouring under mental disease. We now pass on to a somewhat similar inquiry in regard to the nations of modern times. On no subject has there been more absurd and illogical reasoning, or more hasty generalization, than on the proportion of the insane to the population, w^hether in regard to various countries, or in regard to the same country at different periods of its history. The most obvious essentials for making correct comparisons are constantly disregarded, notwithstanding which highly important inferences arc drawn Avith the utmost com- placency, and apparently in entire ignorance of the fallacy which underlies such loose and Avorthless calculations. Even up to the present time, and in scientific journals, we are presented with a list of the numbers of lunatics in various countries ; the conclusion being drawn that such numbers represent correctly the liability to insanity in these countries, — the difference some- times ranging between one in a thousand and one in 30,000 ! Generally, the only basis for such calculations is the number of patients in lunatic asylums ; yet it must be obvious that, in consequence of the very different provision made for the insane in different countries, such a basis as this is utterly fallacious. Eut there are other circumstances which vary most materially among different peoples, and which must l)e taken into account before we can arrive at anything like a satisfactory result ; yet these have again and again been entirely overlooked. For ex- cxamplc — the mortality of lunatics varies in the same country MODlillN CIVILIZATION, KTC. 31 at diflcreiit periods, and is greater in some countries than in others. Now let the reader suppose that there were a law in Scotland that every luuatie should be put to death when all means of cure had been resorted to for the space of five years, and suppose that no such law existed in England ; it must be evident that a return of the number of lunatics in the two countries would exhibit a far larger proportion in England than in Scotland ; while, at the same time, it is not less evident that precisely the same, or even a greater number, might become insane in the latter country than in the former. Although an extreme case by way of illustration is here supposed, the same error is in degree committed whenever the relative liability to insanity of two nations is endeavoured to be ascertained, witli- out an attempt being also made to ascertain the relative mor- tality of their lunatics. In other words, unless we can ensure an entire similarity in the various circumstances of two nations, or of the same nation at two different periods^ we must obtain statistical returns — not of the number of lunatics existing at any given period, but — of the number of cases occurring in a nation, as compared with the population. "The tendency to insanity in a class is expressed (as Dr. Farr observes) by the proportion that become insane.'^* In our own countiy there are two reasons why the proportion of the insane to the population appears to be greater than was formerly the case. The first is, that the disease is recognised as such to a far greater extent than formerly ; and the second is, that we know, to a much greater extent than heretofore, the number of the insane throughout the country. In the short period of nineteen years, the estimated proportion of the insane in England rose from 1 in 7300 to 1 in 709 ; a difterencc which led to the belief in the frightful increase of insanity, but which by no means warranted such a conclusion. The knowledge of an evil, and the existence of that evil, are two widely difl"erent things. Insanity may or may not have increased; but our increased knowledge of its extent is no proof that it has. Again, • See also some excellent observations by Dr. Tliurnain on this subject, ' Statistics of Insanity,' p. 171. He suggests that ultimately we may be able to employ a still more stringent test of the liability to insanity in any community — viz., the proportion out of e(iual numbers living, of the same sex, and at each period of life, who become for the first time insane. 32 MODKllN CIVILIZATION it is obvious that, should there be a larger number relieved by treatment and discharged from asylums for the insane, there will be a larger number of recurring cases. It follows, there- fore, that if in the estimate of those Avho become insane these recurring cases are included, the simple circumstance of curing a greater number of patients will be the very means of making it appear that a greater number of persons are attacked by in- sanity, — a greater number than would appear to be the case under more unfavourable cii'cumstances. Let us endeavour to form some conception — however far re- moved it may be from mathematical accuracy — of the number of the insane (including idiots) among some of those nations which we regard as civilized. In the United States of America, the number of insane has been recently (1860) estimated at one in 738. In France the number of lunatics and idiots has been estimated at one in every 795. In Norway the proportion has been reckoned at one in 551. Dr. Jacobi estimates the number of insane in the Rhenish Provinces at one in 666. In England and Wales we find, from the Reports of the Lunacy Commissioners and Poor Law Board, that there were, on January 1st, 1861 : — In Asylums and Hospitals: INSANE. Private, 5,116 1 Pauper, 19,718 J 2i,83J. Single (Private) Patients * 119 In Workhouses t 8210 Paupers with their friends, or elsewhere t 5989 Total ... ... ... 39,152 If, then, we take the population of England and Wales at the time ofthe census of 1861 (males 9,758,852, females 10,302,873, total 20,061,725), we find that there was, at the above date, one * We believe that this return (Lunacy Report, 1861, p. 68) does not com- prise a tithe of the actual number. t These are the returns for Jan. 1, 18G0. The Poor Law Board has not yet published the exact numbers in workhouses, &e., for Jan. 1, 1861. The amount of pauper insanity (out of Asylums) is therefore probably under-estimated. It may here be stated that the Poor Law Board possesses no return for 108 parishes, having a population of 1,324,833 souls. IN US HKAlUN(i I I'ON I N SAN IT V. '^'^ lunatic or idiot to 'A2 persons. Distinguishing the sexes, we find the proportion among males to be one to 51-7, and among females one to 483. In these calculations, however, it must be remembered, that no account whatever is taken of the number of insane persons not reported to the Lunacy and Poor Law Commissioners. This number can of course only be guessed at. We cannot doubt, however, that were it fully known, it would, when added to the number ah-eady ascertained, exhibit a pro- portion of at least one insane (or idiotic) person to every 300 of the population. The Kcport of the Scotch Lunacy Commissioners of 1861, enables ns to form some (though doubtless an imperfect) idea of the proportion of insane in that country. The population of Scotland in 1851 was 2,888,712, and the number of ascertained insane in 18G0 (Jan. 1,) was 8084 — being a proportion of one in 344 ; and although it is true that the population has increased since 1851, and that this must be estimated; it is also true, as stated by the Commissioners in 1857, that this source of error is at least compensated for by the imperfection of the return of the number of lunatics. We are not aware of any reason why there should be a larger proportion of insane persons in Scotland, than in England and Wales ; and we have little doubt that further investigation will not only show that there are at least as many insane in the ' latter as there are in the former, but that there exists a still higher proportion in Scotland itself than that which has just been stated. This anticipation appears to derive additional support from the results of the census of the insane and idiots in Massachusets, in 1854. From this it appears, that there was at that period one lunatic in every 427, and one idiot in every 1031< of the popula- tion — being a proportion of both, of one in every 302. In the county of Franklin (population 31,735) the proportion was one in 229, and in Duke's county so high as one in 159. To compare the present extent of insanity, as indicated by these statistics, with the extent of insanity a century ago, would be a vain attempt. The means for making such a comparison do not exist. So far, however, as wc regard ourselves as more civilized than our forefathers, so far the inquiry is affected by our conclusion regarding a question we shall now enter upon, 3 34 MODERN CIVILIZATION namely, icln'tlnr cirilhutioii favours or opposes the increase of insanity — uhether, in fact, the barbarian or the civilized man be the more likely to fall a victim to mental disease. This question may conveniently be regarded from two different points of view. Apart from the information to be derived from actual observation or statistical inquiry, it is manifestly very important also to inquire, whether the most frequent causes of insanity are to ])e found in greater force in civilized countries than in those which are not civilized. There is no sufficient evidence to show that the brain, so long as it is not deprived of the ordinar}^ range of exercise and stimulus which existence in the world necessarily presupposes and ensures, has any tendency, from the want of systematic cultivation, to be- come diseased, however true it may be that moderate use de- velops and strengthens it. On the contraiy, from every analogy we should predicate, that the healthy condition of this organ would be endangered in proportion to the amount of work to which, beyond the limit referred to, it is subjected. The mental faculties are the thinking man's tools, constantly in use, and often necessarily subject to very rough usage, but still oftcner to unnecessary wear and tear — their employer not unfrequently totally unaware that, in producing certain results, he is using any tools whatever. If the above position be well founded, the inference would seem clear, that the liability to mental disease is greater (other things being equal) in a civilized and thinking people, than in nomadic tribes, or in any race whose intellectual faculties are but little called into action. Knowledge brings with it its miseries as well as its blessings. The tree in the Gai'den of Eden, which was " a tree to be desired to make one wise," was nevertheless the tree of the knowledge of evil, as well as of good. The tragical termination of the author of the ' Old Red Sandstone,' speaks loiully in confirmation of this. The fatal effects of an over-worked brain would not have occurred, had he not substituted head-work for manual labour. " He has not wrought out his way," \\Tites one who knew him well, " from the stone-mason's quarry to so distinguished a position in science and literature, without a life of incessant and wearing mental toil. In fact, he had worked much too hard and constantly; and, although a man of sturdy physique, his brain was unable to stand the stress of his will, and the strain of his perseverance." IN ITS HEARINU UPON INSANITY. 35 It is not asserted, that the course of life which this gifted man pursued did not add immensely, on the whole, to his happiness. All that is here contended for is, that, had he not pursued that course, he would have been less likely to fall a victim to the particular disease of insanity. Civilization, with its attendant knowledge and education, creates social conditions, and offers prizes dependent solely upon intense intellectual competition, unparalleled in any former age, and of course unknown among barbarous nations, which of necessity involve 7'isks (to employ no stronger term) which otherwise would not have existed. " Oh, sons of Earth ! attemj)t ye still to rise. By mountains piled on mountains, to the skies ? Heaven still with laughter the vain toil surveys, And buries madtnen in the heaps they raise." It may seem opposed to the importance which is here attached to overtasking the brain, that among the causes of insanity, as tabulated in our asylum reports, excess of study forms an in- significant item. Thus, in 472 cases in which the cause was traced by Esquirol, in 13 only is it referred to excess of study. But, even if this proportion be generally true, it is not to be forgotten that there are circumstances almost necessarily associ- ated with it (excessive study) which are recognised by all as frequently productive of mental disease. Loss of sleep, by which the nutrition of the cerebral tissue is necessarily interfered with, is one of the most important of these. The health is, moreover, injured by the various attendants on sedentary employments, and it cannot be expected that the brain should escape without a certain amount of injury. Besides, in many an over-stimu- lated child, or over- worked student, there may be only sown the seeds of future mental disease. Other circumstances may cause the seed to germinate, and be regarded as the cause, instead of merely the occasion. From these and other considerations, it is evident that ex- cess of study may lay the foundation of many of those cases of insanity, in which statistics recognise only loss of rest and numberless other secondary causes. Moreover, it must be borne in mind that excess of study is only one division of the intel- lectual strain to which civilized men are subjected. Intense application to business is another of great importance. 3G MODERN CIVILIZATION N It is sometimes remarked, in opposition to the view wliieh is here taken, that our asylums are peopled with inferior, rather than highly intellectual minds. But this circumstance (if true) does not really militate against such a view, inasmuch as it is obvious that excess of study will be very likely to derange the former class, and leave the latter comparatively uninjured. We do not refer here to inferior minds in the lower walks of life, for they of course will not have been subjected to this cause of mental disease. ]Moreover, the number of men of genius who, like Kant, have become insane, are by no means few. Although, however, civilized society offers a striking contrast in regard to excessive intellectual exertion, to those which are sunk in barljarism, there is another point of contrast as remark- able, and which is to a much larger extent the generator of mental disease. No one word conveys an adequate idea of this altered condition. There is an acuteness of sensibility, a susceptibility of the emotions, an intense activity of the feelings, which would seem to be peculiar to highly ci\alized life. The observation has, indeed, been made, that savage nations never shed tears, and rarely ever laugh. It would seem obviously to follow, from this cultivated condition of the higher sentiments, that external circumstances are much more likely to produce an impression upon them, to excite or depress them, and thus induce a shock under which the mind at last succumbs. Dr. Guislain forcibly observes, that " the people of European civili- zation, and of North American civilization, are, as it were, in a state of continual intoxication — intoxication of the emotions — intoxication of personal dignity — intoxication arising from con- stantly renewed impressions. It is not thus with those nations which most closely approach a state of nature ; men who live far from the tumult of what we call the world." " The charac- teristics of such nations are — less affection, uniformity of man- ners and habits, the unchangeable character of social institutions, wants much more limited, the being inured to privations, a life in accordance with the instincts ; a savage life, which enables them to support pain, to fortify themselves against sufl'ering, to brave peril, and to contemplate death itself with courage and tranquillity of mind. Among such there is much more resignation, less inquietude, dread, or apprehension. . Such primitive people consider a display of the moral feelings. IN ITS BEARING UPON INSANITY, 37 oratorical gesticulation, the gaiety so characteristic of Euro- peans, as so many proofs of madness. But we develop among ourselves a refined sensibility unknown among barbarous nations." It might be expected, then, that modern civilization would induce more insanity, not only or chiefly because there is more study, or purely intellectual labour, but because there is more emotion, and especially painful emotion, called forth. And this is entirely consistent with the position which we are disposed to take, that disease of the organ of the mind would be likely to increase in proportion to the work to which, beyond a certain limited point, it is subjected ; the emotions being as much a component part of the mind as the pure intellect. To speak of civilization and the over-tasking of the intellectual powers as synonymous, is incorrect, and has often led to con- fusion as to the real question at issue. Civilization involves the over-tasking of the emotions, as well as, and often inde- pendently of, the intellectual powers. Regarding the causes of insanity under the division of moral and physical, it has generally been thought that the former con- siderably preponderate. Thus fear, grief, reverses of fortune, speculation, domestic trouble, pride, ambition, great successes of any kind, religious fanaticism, are all frequently productive of mental disease. And can there be any question as to whether the several sources of insanity which have been enumerated are more frequent among civilized than uncivilized nations ? Bar- barians know little, comparatively, of the over-tasking of the emotions to which we have referred. The loss of friends, the prospect of death, are with them matters of superficial and temporary concern; not of profound sorrow or anxious antici- pation. Several years ago, an Esquimaux and his wife were exhibited in this countr3^ On the voyage homeward the wife was taken ill and died. Such an event would have risked the mental cquilil)rium of an Englishman ; but not so with the unimpassioued, matter-of-fact Esquimaux, who only considered how he could best repair his loss, and within a few days after his arrival at home provided himself with another wife ! Dr. Kane says the Esquimaux weep for their dead according to system, and do the same for the failure of a hunt or the death of a dog. He speaks of their " quiet stoicism " and that " apathetic fatalism which belongs to all lowly cultivated races." 38 MODERN CIVILIZATION " Miserable, yet happy wretches!" he exclaims, ''-without one thought for the future, fighting agaiust care wheu it comes unbidden, and enjoying to the full their scanty measure of present good." AVhat, indeed, can be a greater contrast than that which is presented by the untutored savage, on the one. hand, and the member of a civilized community, on the other ? The former passes his time chiefly in the open air, engaged in huntiug and other pursuits, requiring much physical and but little mental exertion ; never exhausts his brain by thinking, sutffns very slightly from grief and sorrow, and knows little of the anxieties and sufferings connected with poverty. The latter, very generally, is obliged daily to infringe more or less the laws of health. lie is subjected to " the steady, soaking intoxication of habitual over-work." If the brain demands rest, that rest is denied, and the brain is, perhaps, goaded on by alcoholic stimulation. The very same person is possibly, also, the subject of ever-present anxiety and apprehension, in consequence of a precarious income. In a highly civilized com- munity, the highest standard of intellectual attainment is con- stantly presented to the aspirations of its members ; and minds, without reference to calibre, promiscuously enter the lists of an unequal contest. From these and other points of difference, we think we do not rashly draw the conclusion, that there are reasons for expecting a greater susceptibility to mental disorders among the civilized than the uncivilized nations of the world. Political commotions, also, may here be referred to as a cause of insanity l)ut little known, or at least less felt, in uncivilized nations. In England, in Ameiica, and still more in France, they have had their share in adding to the number of inmates of our asylums. Dr. AVebstcr attaches much importance to both political and religious movements^ and instances the effect produced by the Crusades, the Reformation in Germany, the Low Countries and Britain, the civil wars of England, and the domination of Puritanism under the Long Parliament and Cromwell ; as also the Revolutions in France. " The influence of our political misfortunes," observes Esquirol, " has been so great, that 1 could illustrate the history of our revolution, from the taking of the Bastile to the last appearance of Buona- parte, })y describing in a series, the cases of lunatics whose mental derangement was in connection with tlie succession of events." IN ITS BKARING UPON INSANITY. 39 In opposition to the view that civilization would .seem in many respects to favour the development of insanity, it has been asserted by many writers that there is a larger number of pauper lunatics in the agricultural than in the manufacturing counties. Assuming this, however, to be the case, the inference which has been drawn by no means necessarily follows. In the agi'icultural districts (which are by these writers taken as the representative of savage life), there are to be found, as well as in the manufacturing districts, many of those very elements of modern civilization which are not found to the same extent in savage life ; such for instance as the excessive use of alcoholic liquors, and the hard struggle to obtain an honest livelihood. Drink, and waut, and consequent domestic suffering, produce their certain effects in the generation of insanity, in agricultural as well as in manufacturing districts. It should, besides, first be shown by those who make this comparison, for this purpose, that there are not in other respects any essentially dissimilar conditions in the two districts. Indeed, Sir Andrew Halliday, in whom this statement originated, himself attributed the fact, in part, to the circumstance of the women in agricultural dis- tricts labouring in the field during pregnancy. And Dr. Prichard suggests that the hard labour and low diet to which the males are subjected, may have an infiuence on the offspring propagated by them. But we do not think this line of argument need be further pursued. The fact, we believe, is quite otherwise than stated ; that is to say, although there may be more pauper lunatics in the one group of counties than the other (even in proportion to the population) , there are not more than we should expect when we consider the relative amount of pauperism (from other causes as well as insanity) in the respective groups. Instead of taking the proportion of pauper limatics to the pauper population in the respective counties, an estimate has been made of the proportion of pauper lunatics to the total population of the county. In the agricultural group, the pro- portion of pauper lunatics to the general population was found to be 1 in 820, while in the manufacturing it was only 1 in 1200. It must, however, be clear, that in those counties where pau- perism is the greatest, there will in all probability be a larger number of pauper limatics in proportion to the general popu- 40 MODERN CIMJJZATION Ifttioii. For example, if we take Lancashire and Cheshire as manufacturing:, and Essex, Suflblk, and Norfolk^ as agricultural counties, avc find that the proportion of paupers to the popula- tion is (Jan. 1, 1861) in the former S'S^ per cent., and in the latter G-93 per cent.'^ In the agricultural counties, therefore, the proportion of paupers is more than double that which exists in the manufacturing counties, and consequently, there may be absolutely more pauper lunatics ; but it by no means follows that there are more pauper lunatics in proportion to the pauper population, nor, indeed, that there are more lunatics in the former group than in the latter. If, then, we work the proportion in accordance with the above prmciple {i. e. proportion of pauper lunatics to pauper popula- tion), we shall find that in Lancashire and Cheshire the pro- portion is 41 insane, and in Essex, Suffolk, and Norfolk, 28 insane to every 1000 paupers (on the 1st of January, 1861). And taking the two groups of counties selected by Sir Andrew Ilalliday, we shall find that the proportion of paupers to the general population is much higher in the agricultural than in the manufacturing counties. That the greater amount of pau- perism in the agricultural group is not earned by insanity — that the ranks of the paupei^ are not swelled by additional lunatics — is proved by the following statistical results. If, instead of cal- culating the proportion of pauper lunatics to the general popu- lation in the two groups, we ascertain the proportion of pauper lunatics to the number of paupers relieved, we shall find that in the agricultural, the proportion on January 1st, 1859, was 31, * We may hero observe, that we do nut forget it may be objected, that, inas- much as the mere cireuuistance of becoming insane frequently involves pauperism, we cannot arrive at any just estimate by a consideration of the varying extent of pauperism in different counties; it is clear, however, that the proportion of luna- tics to paupers is comparatively so small, that the deduction of the total number of the former would not materially affect the relative number of the latter in the several counties. Further, it may be here stated, that the proportions of pauper lunatics to paupers, subsequently to be given, cannot be taken as rigidly correct, because we fear that some diversity of practice exists on the part of those who make the returns. Our i)resont object, however, is gained if we succeed in fhowing that there are no certain data on which to base the inferences that have hitherto been drawn, and that it is useless to compare together agricultural and manufacturing counties to detorminc the question at issue. Except for this pur- pone, the figures possess little or no intrinsic value. IN ITS BEARING VPON INSANITY. 41 and in the manufacturing 36 per thousand, the greater propor- tionate number of pauper lunatics being in the manufacturing districts. In the " Metropolis " the proportion is, at the present time, the highest, viz., 41 per 1000. We see no reference either, to another important source of fallacy, in the calculations of those who have compared together the manufacturing and agricultural statistics of insanity. The mortality in large towns is greater than in rural districts. In a county, therefore, like Lancashire, the existing number of luna- tics would appear to be smaller, than in a county in which the inhabitants live mostly in the country or small villages. Agri- cultm-al labourers are long-lived ; and therefore lunatics accumu- late among them, who would have died if resident in the manufacturhig districts. Neison estimates that the mortality of the toAvn exceeds, at the ages between thirty and thirty-five, that of the rural districts, by nearly 15 per cent. Such arrangement of counties, however, as would show their relative condition, in regard to learning, would appear to be more important in the present inquiry, than the distinction between agricultural and non-agricultural shires. Now, if we take the group of counties in which the largest* number, according to the [ Vital Statistics ' of ISIr. Neison, signed marriage certificates with marks; and that in which the number signing with marks was at least 25 per cent, below the average, we shall find that the proportion of pauper lunatics to the number of paupers on January 1st, 1859, was greatest in the more educated counties, viz., 31-9 to 29'2 per 1000. In the foregoing calculations idiots are included in the returns. The proportion which they bore on the 1st of January, 1859, to the non-idiotic insane was as follows, in the districts enumerated. The " Eastern " or agricultural group (Essex, Suffolk, and Norfolk), 30- 7 (idiots), to 69-3 (lunatics), per 100 insane paupers : the " North-western,'' or manufacturing group (Lancashire and Cheshire), 28-2 to 71 '8 per cent. At the same date the proportion of idiots to the pauper popu- lation was — in the " Eastern " group, 8-2, and in the " North- western" 103 per 1000. In North Wales, however, which is mainly agricultural, the proportion of idiots to pauper popu- lation is higher, namely, 13'5. It has been stated bv several writers on the Continent, that 42 MODERN CIVILIZATION their statistics distinctly exhibit a larger amouut of lunatics in cities than in country districts. We have no facts which would afford the means for an exactly similar comparison. It will be seen, however, that so far as the agricultural and manufacturing districts are analogous, the contrast (though pointing in the same direction, when the pauper, and not the general population, is made the basis of calculation,) is not so great in our own country as on the Continent. There may be, therefore, some disturbing inllucnccs at work in England which prevent the difference being greater than it otherwise would be. For, while in Ghent (according to Dr. Guislain), there is one lunatic in 302 inhabitants, the rural population around has but one lunatic to HOO ; and in one of the departments of France (Meurthe) there is only one lunatic in 1460 inhabitants, while in the town of Nancy, in the same department, there is one in 500. * " Examine the elements of insanity in our asylums," observes a French writer, "and you will find two thirds of them made up of the inhabitants of our towns, and scarcely one fourth by the country population. And wherefore? Because, in proportion as you remove from the great centres of activity, the suljjccts of conversation are contracted and circumscribed, and you will hud the country people almost exclusively engaged in the sanu' circle of ideas, having reference chiefly to their interests and their property." Dr. Parchappe admits the fact, but is disposed to attribute the difference to the drunkenness and demoralization which, as he believes, are more prevalent in city than in country life. Such statements as those of Dr. Guislain can scarcely be called in question, coming as they do from such high authorities ; at the same time, seeing that in regard to the statistics of England and Wales, we are not in a position to point to such striking results, we do not found any conclusions upon them, but rather confine ourselves to the I)ro()f already adduced, that no evidence exists (such as has again and again been brought forward), which militates against our position that modern civilization tends, cceteris paribus, to increase^ the amount of mental disease; and to the fact, that so far as the evidt iico afj'ordcd by Jiyures is worth anything, it tells in our favour. To recapitulate. Tbe agrieidtural and manufacturing dis- tricts cannot be taken, the one as the representative of savage, IN ITS BEARING UPON INSANITY. 43 aud the other of civilized society. But, even if they are so taken, statistics indicate less insanity in the pauper class of the former than in that of the latter. Further, if we take those counties in which there is most, and those in which there is least ignorance, as bearing more closely upon the present inquiry, although from the impossibility of excluding all disturbing in- fluences, such grouping of counties is liable to fallacy, we find more insanity among tlie paupers of the latter than among those of the former.* The causes which have now been considered in reference to this question, belong all of them to the moral class. Of those which are properly physical, the most important for considera- tion is intemperance. It is probable that all nations, in some form or other, make use of stimulants ; at the same time, those which are employed in Europe would appear to be decidedly more extensively injurious to mental health. Thus we shall see that in China, and among the Mussulmans in Egypt, by whom opium is so much used, there is comparatively little evi- dence of mental disease ; and that travellers attribute the immu- nity enjoyed by the former to the (formerly) limited use of alco- holic drinks. When we reflect on the very large number of cases of insanity more or less connected with functional or organic disease of the uterus, and remember that among barbarous nations these dis- orders are unquestionably of less frequent occurrence than in civilized society, we shall not fail to recognise in this difference, one reason why more mental disease might be looked for in the one condition of society than in the other. Parturition itself, according to the general testimony of travellers, interferes much less, and for a shorter period, with the healthy action of both body and mind among savage nations, than among the luxurious daughters of artificial life. There are several other important * There are various reasons why there should be, as iiulicateil by tlie Lunacy Reports, an apparently greater increase of pauper than private lunatics. And so far as the increase is rejil, we would observe that the i)resent contlition of our labouring classes is not only consistent with, but is usually attached to an advanc- ing civilization. It is not, as some assume, a condition of barbarism, but one of the complex unfavourable elements of a civilized nation. \\\\\\e, therefore, civili- zation favours mental disease by inducing among the educated classes undue intellectual ellort, it prrinry of fsmnns witli lircthron and sisters. IN MODERN TIMES. 53 ill London, a large building was erected in 1G75, in Moorfields,* where the Hospital stood until 1814. There was, in a short time, accommodation for 150 patients; whereas, in the old building, there were usually but 50 or 60. In the rules made March 30, 1677, to which it is interesting to refer, it is ordered inter alia, that such of the lunatics as are fit should be per- mitted to walk in the yard till dinner-time, and then be locked up ill their cells ; and that no lunatic that lies naked, or is in a course of physic, should l)e seen by anybody without an order of the physician. It is further humanely ordered, that no officer or servant shall beat or abuse any lunatic, nor employ any force to them, but upon absolute necessity for the better governing of them. Dr. Tyson, who was physician to Bethlem from 1684 to 1703, informs us that, *^ as to the care and ciu'c of the pa- tients, here is, undoubtedly, the greatest provision made for them of any public charity in the world; each having a convenient room and apartment to themselves, where they are locked up at night, and in it a place for a bed ; or if they are so senseless as not to be fit to make use of one, they are every day provided with fresh clean straw. Those that are fit for it, at convenient liours have liberty to walk in the long galleries, which are large and noble. For the summer time, to air themselves, there are two large grass-plats — one for the men, the other for the women ; in the wnnter, a stove for each apart, where a good fire is kept to warm them ; in the hot w^eather, a very conve- nient bath place, to cool and wash them; wliich is of great service in airing their lunacy, and is easily made a hot bath for restoring their limbs when numb, or cleaning and preserving them from scurvy, &c. Their diet is extraordinary good, and proper for them, which every week is viewed by a committee of the governors. . . . There is nothing of \dolence suffered to be offered to any patient, but they are treated with all the care and tenderness imaginable. If raving or furious, they are confined from doing themselves or others mischief; and it is to the credit of the hospital, that in so great a number of lunatics that are constantly kept there, it is very rare, in many years, any one patient makes away with himself. . . . The time of cure is un- certain : some have been cured in a month, others in two or * "The jfatc or entrance is all of stone, with two ti^jures of a distraclpd man xr\<\ woman in chains over the gate." — Sfri/pe't Sloue. 54 CONDITION OF TlIK INSANE three, and some continue distracted many years. '^ This was written early in the eigliteenth century. In 1734 considerable additions were made to Bethlem ; and, in consequence of its still proving inadequate to meet the de- mand, St. Luke's Hospital was established in 1751, by volun- tary subscription. It was situate on the north side of Upper Moorfields, in a locality called Windmill Hill.* From this period to the latter part of the eighteenth centuiy but little progress was made in the treatment of the insane, and in the condition of the houses where they were received ; in- deed, as respects Bethlem, it is probable that its state had retrograded rather than advanced. In the middle of the cen- tury (1755) a work was published, the title of which appears significant ; this was, ' Folly Predominant ; Avith a Dissertation on the Impossibility of Curing Lunatics in Bedlam.' From time to time, during this period, a work made its appearance on the subject of Insanity, Thus, in 1700, Hcrwig published his ' Art of Curing Sympathetically or Magnetically ; with a Dis- course on the Cure of ISIadness •/ and five years later, Fallowes enlightened the world with his ' Method of Curing Lunatics,' Blakeway wTote in 1717, and Frings in 1746, Batty MTote his treatise on madness in 1757. But none of these works de- served or gained much reputation. Perfect, whose first Avork on the subject (' Methods of Cure in some particular Cases of Insaiiity') was written in I778,t made some valuable contribu- tions to the knowledge then possessed regarding insanity. His treatment appears to have consisted chiefly in venesection, emetics, setons, digitalis, antimony, and electricity. Dr. T. Arnold published the first edition of his excellent 'Observa- tions on the Nature, Kinds, &c., of Insanity,' in 1782. This work, however, contains little or nothing in regard to treat- ment. A few years afterwards (1789), 'A Treatise on the Ileal Cause and Cure of Insanity ' was published by Harper, which, although it possesses no merit, has the honour of having • St. Luke's n(»\v stands on a site tornu'rly known as The Bowling Green, Old Street Uuiul. It was commenced in 1782, the expense (£50,000) being defrayed by voluntary subscription. It w:is opened January 1, 1787, the number of patients being 110. t The same author wrote 'Address to the Public on Insanity,' 1781; 'Select Cases of lns;initv,' 1787 ; and 'Annals of Insanity,' 1801. IN MODhK.N TIMl-'.S. uO been criticised by Pincl. In 1790 appeared ' Obsonatinns on the General and Improper Treatment of Insanity/ l)y Faiilkner ; and the ' Observations on Maniacal Disorders/ by Pargctcr, in 1792. But none of these writings appear to liave exercised any material effect in ameliorating the condition of the insane in England. This, nnfortunately, is but too correctly described in the following graphic skctcli from the pen of Dr. W. A. F. Browne : " The building was gloomy, placed in some low, con- fined situation ; without windows to the front, every chink barred and grated — a perfect gaol. As yon enter, a creak of bolts, and the clank of chains, are scarcely distinguishable amid the wild chorus of shrieks and sobs which issue from every apartment. The passages are narrow, dark, damp, exhale a noxious effluvia, and are provided with a door at every two or three yards. Your conductor has the head and visage of a Carib ; carries (fit accompaniment) a whip and a bunch of keys, and speaks in harsh monosyllables. The first common room you examine — measuring twelve feet long by seven wide, with a window which does not open — is perhaps for females. Ten of them, with no other covering than a rag round the waist, are chained to the wall, loathsome and hideous ; but, when addressed, evidently retaining some of the intelligence, and much of the feeling, which in other days ennobled their nature. In shame or sorrow, one of them perhaps utters a cry ; a blow, which brings the blood fi'ora the temple, the tear from the eye — an additional chain, a gag, and an indecent or contemptuous expres- sion, produces silence. And if you ask where these creatures sleep, you are led to a kennel eight feet square, with an iniglazed air- hole eight inches in diameter; in this, you are told, five women sleep. The floor is covered, the walls bedaubed, with filth and excrement ; no bedding but wet decayed straw is allowed ; and the stench is so insupportable, that you turn away and hasten from the scene." (' What Asylums were, are, and ought to be.') " Among the ])ad, the York Asylum," observes Dr. Conolly, " was the worst." This institution was founded by general sub- scription, in 1777, and had for its object the decent maintenance and relief of such insane persons as were in low circumstances. Up to the year 1791, no suspicion in regard to the comfort of the ])atients was felt. " In this year, however," proceeds Dr. f'oiioUv, " some meniljcrs of the Soeictv of Friends sent one of 56 CONDITION OF THE INSANE their family, a lady, for care, to that asylum. The rules of the asylum forbade her friends to see her she died some- thinj^ wron{ij was suspected ; and from that day the Society of Frieflds determined to establish an institution in which there should be no secrecy. William Tuke was the great founder of the new asylum ; ai^ from the first, he and his friends pursued, in their institution, those principles which are noAv universally acknowledged." '' By a singular and interesting coincidence," writes Dr. Thurnam, "it was in the spring of 1792, the very year in which the celebrated Pinel commenced the amelioration of the treatment of the insane in France, by the truly courage- ous act of unchaining fifty supposed incurable and dangerous lunatics at the Bicetre, that the establishment of the Retreat (at York) was proposed by the late AVilliam Tuke."* " Each," it is observed in the '■ American Journal of Insanity,' " each perceived the wretchedness, the misery, the sufierings of the insane around him. Each was moved to compassion. Each resolved to cfi'ect a reform in their treatment. Each succeeded. This recognition of services to humanity is due to each. To each we freely accord it." A visit to St. Luke's Hospital, for the purpose of obtaining useful information, had the eflFeet of stimulating the mind of the projector of the new asylum, in his effort to ameliorate the condition of the insane. He saw the patients miserably coerced, — not entirely from intentional cruelty, but from the conviction of the superiority of such a course of treatment over any other. Among them was a young woman, whose condition especially arrested his attention, and excited his compassion. She was without clothing, and lay in some loose, dirty straw, chained to the wall. The form of this unhappy patient haunted him afterwards, and redoubled his exertions until his plans were carried into practical effect. f The new institution was to be " in an airy situation," and to have " a few acres for keeping cows, and for garden ground for the family, which will afford scope for the patients to take exer- • liorn 1732, died 1822. A sketch of his life will be fciiiul in the 'Journal of Psychological Medicine,' Octoher, 1855. t A few years after, this patient hecanic an inmate of the York Hctreat; and wo find its founder observing, in a letter written to a friend, "She has got settled, and »j)iiears more comfortable than at St. Luke'.s." IN MODERN TIMES. 57 cise, whcu that may be prudent and suitable." The prospectus expresses tlie desire to introduce ''cheerful and salutary amuse- ments;" and another paragraph speaks of the \vish " to cherish in their patients the strengthening and consolatory principles of religion and virtue." The institution was called The Retreat, by wliich " it was intended to convey the idea of Avhat such an institution should be — namely, a place in which the unhappy might find a refuge ; a quiet haven in which the shattered bark might obtain the means of reparation or of safety." The first Report speaks of the introduction of suitable employment, in order " to relieve the languor of idleness, and prevent tlie in- dulgence of gloomy sensations 3" and alludes to the custom of forming tea-parties, at which the oflfieers entertained their guests — the patients. Into these plans, Jepson (appointed to superintend the institution at an early period of its history) most heartily entered, and largely contributed, by his benevo- lence and skill, to the success of the institution. The managers of the Retreat did not at once perceive how- far the lunatic might be permitted to enjoy liberty, or to what extent his feelings and better nature might be eflectually ap- pealed to. But no chains of any kind, no hobbles, leg-locks, or liandcuflFs, were employed from the opening of the establish- ment. A patient was admitted who had been for twenty years chained, and naked. "With the exception of the occasional use of arm straps, no personal restraint was employed from the moment of his admission. He was soon induced to wear clothes and adopt orderly habits. Another patient had nearly lost the use of his limbs from similar usage, and, for some time after his admission, it was i\ecessary to lead him about like an infant. He was foimd to require no restraint, and was, after a while, able to walk without assistance. When one of his friends visited him, and asked him what he called the place, he replied, with great earnestness, " Eden, Eden, Eden ! " The two modes of restraint resorted to, were either the strait waistcoat, or a belt to which the arms were attached so as to prevent mischief, but allowing of considerable motion. AVIien the waistcoat was employed, it was solely for the purpose of ])revcnting what was regarded as dangf^ous violence, and was not a})plicd as an instrument of suffering and punishment. It Mas reserved to otliers to sliow, that even the strait waistcoat 58 CONDITION OF THE INSANE is not essential to the safe custody of the insane; at the same time, the restraints above referred to were not to be compared with the chains for which they were substituted. " Certainly," observes Dr. Conolly, " restraint was not altogether abolislicd by thcni (the early managers of the Retreat), but they undoubt- edly began the new system of treatment in this country, and the restraints they did continue to resort to were of the mildest kind." In the general arrangement of the house, in the size of the rooms, and especially in the avoidance of a gloomy prison- like aspect, they anticipated, to a remarkable extent, the principles now admitted in reference to the construction of asylums for the insane. They entirely discarded the practice, then common in even the very best asylums, of having apertures guarded by strong iron bars and shutters (in the place of glazed windows) in the cells of the poorer patients. These shutters, when closed, of course excluded both light and air. Iron sashes, glazed, were employed throughout the Retreat. Little was known of the experiment which was being tried at the Retreat, until, in 1798, Dr. Dela Rive visited the house, and, astonished and delighted with what he witnessed there, published some account of it in a periodical.* He observes, that the house " does not present the idea of a prison, but rather that of a large rural farm. It is surrounded by a garden. There is no bar nor grating to the windows. . . The chief part of the moral treatment (in addition to the internal arrangements of the building) consists in the use of agreeable remunerative means. As soon as the patient is quiet, they remove him from restraint — permitting him to go out of his room and to walk in the open air in a large court, surrounded by a wall; if he con- tinues better, he is preferred to a chamber on the first floor, which is a kind of honourable promotion, and serves to encourage the cxertise of self-restraint. These rooms are large, and more agreeable than the lower ones, and are provided Avith more furniture, and are altogether the picture of neatness. . . As soon as the patients are well enough to be employed, tiiey • ReiiiiMished nmler the title ' Lettrc addressee aux Kedaeteurs de la Hiblio- theijue Britannique sur un iiouvel establisseiiicnt pour la guerison des Alienes." Pinel refers to it on several oceasions, in his well-known work imblislied three vears afterwards. IN MOUKKN TI.MKS. 59 endeavour to make tlieiu work. The women are employed in the usual female occui)ations. The men are engaged in straw and basket-work, &e. The superintendent had made an experi- ment a few days before, wliieh had answered very well. The institution is surrounded by some acres of land, wOiieh belong to it. He had undertaken to make the patients cultivate this laiul, ginng to each a task apportioned to his strength ; he found that they were fond of this exercise, and that they were much better after a day spent at this work than wlieu they had remained in the house, even when they had had the liberty of taking a walk." In 1810, Stark, in his ' Remarks on the Construction of Public Hospitals,' observes : — " In some asylums which I have visited, chains are affixed to every table, and to every bed-post; in others, they are not to be found within the walls. At the Retreat, they sometimes have patients brought to them frantic and in irons, whom they at once release, and, by mild argu- ments and gentle arts, reduce almost immediately to obedience and orderly behaviour. It is a government of humanity and of consummate skill, and requires no aid from the arm of violence and the exertions of brutal force.'' * These and other testimonies to the practice pui'sued at the Retreat, did not fail to attract the attention of medical men and philanthropists ; and the numerous inquiries made respecting it led (twenty -one years after its projection) to the publication of an account of the institution, and of the methods of treatment adopted in it. (' Description of the Retreat, containing an ac- count of its origin and progress, the modes of treatment, and a statement of cases,' by Samuel Tuke, 1813.) This publication drew the attention of the public still more to the treatment pursued at the Retreat, and produced a much greater effect than- could have been anticipated. The physician of the York Asylum took offence at the following passage, which was by this sensitive officer supposed to have reference to his own asylum : — " It deserves inquiry whether the extensive practice of coercion which obtains in some institutions, does not arise from erroneous views of the character of insane persons, from indifl'erence to their comfort, or from having rendered coercion necessary by * It is curiotis, tliiit Stark liiniself is iinxions not to be Hiip|)osc(l to imply, by these olisdviitions, that he- iijiprovcd dI' the total aliolition of chains. (Loe. cit.) 00 CONDITION Ol' THE INSANE previous unkind treatment." A long controversy ensued in the local papers, during which a case of gross ill-treatment in the asylum came to light ; the indefatigable Godfrey Higgins — a name ever to be remembered — unrelentingly investigated and substantiated it ; the public were thoroughly aroused ; a com- mittee of inquiry was formed ; the most fearful abuses were dis- covered, and nearly every officer and servant dismissed. It is foreign to our purpose to enter into the details of the fearful dis- closures which were made. Let it suffice to present the follow- ing summary from the 'British and Foreign Medical Review/ vol. ix, p. 146 : — " The York Asylum was, for the long period of thirty-seven years (1777 — 1814), the scene of every abuse that rapacity and inhumanity could crowd into a single institution. The mere recital, at the present day, would exceed belief. Suffice it to mention, that among the instances of mismanagement gradually brought to light, were the most aggravated neglect of all medical and moral treatment ; every species of cruelty ; much gross immorality ; every practicable variety of shabby embezzle- ment and peculation ; false reports, in which especially the deaths were concealed, even so many as 100 at a time ; the occa- sional disappearance of patients supposed to have been murdered outright and returned in the reports as dead, or removed, or cured; and, as a grand and appropriate ^wa/e, a very strong suspi- cion of the building itself being Milfully set on fire, in the hope of destroying some of the books or patients." Then followed the appointment of the Comuiittcc of the House of Commons, in 1815. From the evidence given before this memorable Committee, notwithstanding the equivocation and evasion which marked many of the replies, it is not difficult to form an estimate of the state of the English asylums generally, more especially the York Asylum and Bethlcm Hospital. Nor was the condition in which they were found at that period, alone revealed; their past condition was, at the same time, rendered manifest. A miserable and empirical routine marked the treatment. To the question, " Has there not been a rule in the hospital, for a certain number of years, that, in certain months of the year, particular classes of the patients should be physicked, bled, bathed, and vomited, at given periods?" the reply from Beth- lcm was in the affirnuitive. Twice in the year tlio patients, IN MUDEIIN TIMKS. 61 with few exceptions, were bled. " After tliey have been bled," said the pliysician, iu evidenec, "they take vomits onee a week, for a certain number of weeks; after that, wc purge tlie patients. That has ])een the practice, invariably, for years — long before ray time." In regard to the means of coercion employed, it was stated that the patients "are generally chained to the wall with manacles." "When inquiry was made regarding the use of strait waistcoats, it was replied, "I do not believe there are any strait waistcoats in Betlilem now, or very few indeed ; they generally use ii'ons." The objection to strait waistcoats was, that the patients " could not help themselves in strait waist- coats ; they are so excessively long in the hospital -without being seen by anybody, in a dark place ; in winter, from four o'clock to six or seven in the morning. If they were in a strait waist- coat, they could not assist themselves the least in the world." AVhcn, in the following year, the head-keeper of Bethleni Hospital was asked, " Was it not the practice in old Bethlem, — not in the late gallery, but in the gallery pulled down, — for ci.i;ht, ten, or more patients to be fastened to the tables, almost in a state of perfect nakedness ?" he replied, " Yes ; they used to think they tore their clothes all to pieces ; some of them would do that." " In point of fact, were they not fastened to the tables, sitting, in a state of perfect nudity?" Answer: " They used to be so at the table; they were chained all round." In regard to the apparatus so ingeniously cruel, by which one of the patients (Xorris) was chained ten or twelve years, Haslam, the apothecary at Bethlem, when asked, " Do you think that his confinement in that manner, during the whole of that period, Mas necessary ?" replied, "' Decidedly." The matron of Bethlem Hospital (who was elected January, 1815) gave evidence that, when she was appointed, tliere Mere about tM'enty patients under personal restraint out of between fifty and sixty patients. " The custom when I first went was only to get them up three days of the week — never on meat days : they lie in bed four days in the week." She also stated, that one of the female patients had been chained for eight years, but had not required restraint since she had been there. But Bethlem was far from being the only place where patients were treated like wild beasts. Mrs. Mary Iluinieres, formerly 62 lONDITIOX OF rUV. INSANE housekeeper in a private asylum at Bethnal Green, gave evidence to an attendant " kicking the patients and thumping them sadly ;" and " heating one in his shirt with a pair of hoots, in a most dreadful manner." She named a female patient who, when in a state of irritation, " was confined in a place in the yard which was originally a pig-sty ; it Avas run np high on purpose for her ; I have seen her confined there for three weeks together. Slie has been ironed there in the crib with wrist-locks, and leg- locks, and a chain two or three times across her body." An iron bar was placed between her legs when she walked about, to prevent her escaping. " It was confined to each ankle, with a chain coming up between her legs, which Avas attached to her handcufls." But, in addition to this frightful restraint, we are informed that an attendant, at the instance of the proprietor, would, " at sundry times," lock her down in her crib with wrist-locks and leg-locks, and horsewhip her. " I have seen the blood follow the strokes." Yet this patient is described as very harmless ; " you might sit and talk to her when she was in the highest state." Such were the terrible revelations which the inquiries of this Committee elicited. But it must be borne in mind that, although that management of the insane, which consisted so essentially in mechanical restraint, had, in some instances, its origin in cruelty and recklessness, its general use arose from the idea impressed upon the keepers of asylums — no less by the highest authori- ties than by a venerable antiquity — that it was the necessary and best mode of treatment. It Avas connected with a theo- retical ignorance of the nature and pathology of insanity, and M'ith a practical want of acquaintance with the tendencies and capabilities of tlie insane. If, then, to determine the condition of the moral management of the insane in England, during the period extending from 1792 to 1815, we review the then existing asylums, we shall find : first, a total absence of moral management in the greater number of asylums (as in the hospitals of Bethlem and York) ; secondly, a very high degree of moral management, in which mechanical restraint was rarely employed, and then only of the mildest kind (as at the Retreat) ; thirdly, a considerable amount of moral government, but combined with the extensive use of meehanieal restraint, — not from cruelty, —but from igno- IN modi: UN TI.MKS 63 ranee. Under the first class, wc meet with eliains, stripes, and a filthy condition of the person of the hmatic. In the second, we find the waistcoat, or arm-straps, occasionally resorted to in extreme eases ; but the chief reliance placed upon moral means, persuasion, gentleness, and sympathy. In the third class, we see the' waistcoat, leg-locks, coercion-chairs, &c., in constant use — many patients being never free from mechanical restraint. It cannot be doubted, that the exposure of the abuses existing in the York Asylum, in Bethlem, and in other institutions for the insane, awakened the public mind, and aroused strong suspicions as to the probable condition of similar institutions. Hence arose an increasing desire for improvement on the part, not only of the public, but also of medical men engaged in the treatment of mental diseases. Old asylums were remodelled, the whip and chain discarded (though, as we shall see, not universally), and milder modes of coercion introduced. New asylums were erected, superintended by men of intelligence and humanity, who, recognising the supreme importance of moral and medical treatment, endeavoured to ameliorate the condition of those placed under their charge. The aspirations of the French and English Reformers of 1792 were being realised. We wiU now pass on to that important stage of asylum his- tory, wlien the experiment of the entire abolition of mechanical restraint was to be tried. The scene of this experiment was the Lincoln Asylum. How gradual its introduction was, the following table will show : — Year. Total number in the House. Total number Rcstniini'd. Total number of instances of Restraint. Total number of hours under Restraint. 1829 72 39 1727 20,424 1830 92 54 2364 27.1131 1831 70 40 1004 10,830 1832 81 55 liOl 15,671i 1833 87 44 1109 12,003i 1834 109 45 647 6597 1835 108 28 323 2874 1836 115 12 39 834 1 1837 130 3 28 Here we observe that, in 1829, more than half the number of the inmates were subjeeted to mechaiiieal restraint, while, in 64 CONDITION OF THK INSANE 1836, out of 115 patients, only 12 were so confined; and that, in 1837, there were only two out of 130.* The total disuse of mechanical restraints followed. They were, however, resorted to on one or two occasions subsequently. In connexion with the foregoing, it must be mentioned, that the entries of the visitors and the reports of the physicians alike agree in describing the condition of the patients as much im- proved, the quiet of the house increased, and the number of accidents and suicides materially reduced in number. It would appear that the mitigation of restraint, as evidenced by these minutes (which commence with 1819), "was ever the principle,'' to use Mr. Hill's own words, " pressed upon the attention of the Boards of the Lincoln Asylum, by its able and humane physician. Dr. Charlesworth, — at whose suggestion many of the more cruel instruments of restraint Avere long since destroyed, very many valuable improvements and facilities gradually adopted, and machinery set in motion, which has led to the unhoped-for result of actual abolition, under a firm determi- nation to work out the system to its utmost applicable limits." Mr. Hill became house-surgeon in 1835; and it will be seen l)y the table already given, that the amount of restraint (whicli, in consequence of Dr. Charlesworth's exertions, had already remarkably decreased) became less and less under the united efforts of these gentlemen, until the close of the year 1837, when restraint was entirely abolished ; and while, on the one liand, as Mr. Hill frankly acknowledges, " to his (Dr. Charles- worth's) steady support, under many difficulties, I owe chiefly the success which has attended my plans and labours ;" wliile Dr. C.'s great merit, both before and after Mr. Hill's appoint- ment, must never be overlooked, it is due to the latter gentle- man to admit, that he was the first to assert the principle of the entire abolition of mechanical restraint, as is stated in the ' Fourteenth Annual Report of the Lincoln Asylum ;' Avhich report is signed by Dr. Charlesworth himself. For a time there were, certainly, some drawbacks to the suc- cess of the Lincoln experiment, from the serious physical effects (such as broken ribs, &c.,) which occasionally resulted from the struggles between attendants and patients ; and it is • ' A Lecture on the Management of Lunatic Asylums,' &r.,by Robert Gardiner Hill. I'lil.lisli.'d Ai.ril, 18:jn. (Delivt'red .luue 21, 1838.) Appendix C. IN modi: K.N TI.MHS. f.") ])r()ljal)le tliat^ liad not the experiment been carried out on a nuicli larger scale at Ilanwell by Dr. Conolly, with far greater success, a reaction would have ensued, of infinite injury to (lie cause of the insane. Dr. Conolly went to Ilanwell in 1839; and in the first of an admirable series of reports written by him, we read: ''T]\c article of treatment in which the resident physician has thouglit it expedient to depart the most widely from the previous prac- tice of the asylum, has been that which relates to the personal coercion or forcible restraint of the refractory patients. . . . By a list of restraints appended to this report, it will be seen that • the daily number in restraint was in July so reduced, tliat there were sometimes only four, and never more than fourteen, at one time [out of 800] ; but, since the middle of August, there ha.s not been one patient in restraint on the female side of the house ; and since September 21, not one on either side. . . . For patients who take oft' or destroy their clothes, strong dresses are provided, secured round the waist by a leathern belt, fastened by a small lock. . . . No form of strait waistcoat, no hand-straps, no leg-locks, nor any contrivance confining the trunk or limbs, or any of the muscles, is now in use. The coercion-chairs (forty in number) have been altogether removed from the walls. . . . Several patients formerly consigned to them, silent and stupid, and sinking into fatuity, may now be seen cheerfully moving about the walls or airing courts ; and there can be no question that they have been happily set free from a thraldom, of which one constant and lamentable consequence was the acquisition of uncleanly habits." In a later report (October, 184- 1) Dr. Conolly observes, "After five years' experience, I have no hesitation in record- ing my opinion, that, with a well-constituted governing body, animated by philanthropy, directed by intelligence, and acting by means of proper officers (entrusted with a due degree of authority over attendants properly selected, and capable of exercising an efficient superintendence over the patients), there is no a.sylum in the world in which all mechanical restraints may not be abolished, not only with perfect safety, but witli incalculable advantage." The subsc(iuent experience of this asylinu lias, in the estima- 5 66 CONDITION or THK INSANE tion of Dr. Conolly, only confirmed the trutli of tlic above statements."^ Thus, then, whatever view may be taken of the question of mechanical restraint, it cannot be denied that, simply as an experiment, the course now pursued at Hanwell, for twenty-one years (not to mention many otlier asylums), is one of very great interest, and has at least afforded additional proof of the possi- bility of managing the most refractory patients without personal restraint. Into the proceedings of other lunatic asylums, in regard to • the disuse of restraints (Northampton, Lancaster, &c.), we do not enter, inasmuch as it would require far more space than would be consistent with the design of the present work, to do full justice to this part of the subject. To the sustained zeal and humanity of the Medical Superintendents of asylums, the pro- gress made at this period, in the adoptioii of enlightened prin- ciples of treatment, must be mainly attributed. While, however, the moral management of the insane was progressing in the majority of establishments for their care, the condition of other asylums was bad in the exti'eme. One is described by the Commissioners, in their Report of 1811, as "deficient in every comfort, and almost every convenience. The refractory patients were confined in strong chairs, their arms licing also fastened to the chair. One of these — a woman — M'as entirely naked, on both the days the Commissioners visited the asylum, and, without doubt, during the night. The stench was so offensive, that it was almost impossible to remain there." In another asylum, " in the small cheerless day-room of the males, with only one (unglazed) window, five men were restrained by leg-locks called hobbles, and two were wearing, in addition, iron handeufts and fetters, from the wrist to the ankle ; they were all tranquil. Chains were fastened to the doors in many places, and to many of the bedsteads." Of another house, the Commissioners report : — " In one of the cells for the women, the dimensions of which were eight feet by four, and in which there was no table and only two wooden seats, we found three females confined. There was no glazing to the window, and the floor of the place was perfectly wet with urine. • The reiull parturc from a somid mental status, as e\liil)iti'(l in incipient dementia. To comprehend the natural history of unsoundness of mind aright, botli methods of inquiry ought to be pursued. "We do not speak here of the pathological changes accompanying these states, but only of the mental phenomena. AVe now proceed with Idiocy — a condition of defective de- velopment {i^ioQ, privatus), in which the subjective symptoms of the patient are ascertainable in only a very limited degree. Syx. Idiotie (Fr.) ; Idiotismo (Ital.); Gefi'hllosif/keit (Ger.). A'ogel, Sauvages, and others spoke of idiocy under the terms, fatiiitas, imhecil/ifas, amentia. Esquirol was the first medical writer who very clearly defined the term, and, unlike Piuel, restricted it to a congenital defect. " Idiocy," he observes, " is not a disease, but a condition in which the intellectual faculties are never manifested ; or have never been developed sufficiently to enable the idiot to acquire such an amount of knowledge as persons of his own age and placed in similar circumstances with himself, are capable of receiving. Idiocy commences with life, or at that age which precedes the development of the intellectual and aftective facul- ties, wliich are from the first, what they are doomed to be during the whole period of existence.'^ Subsequently, he says, "de- mentia and idiocy differ essentially ; otherwise, the principles of every classification are illusory. ... A man in a state of de- mentia is deprived of advantages which he formerly enjoyed. He was a rich man, who has become poor. The idiot, on the contrary, has always been in a state of want and misery." This is the definition of idiocy usually adopted. Happily, however, the education of this unfortunate class has, in modern times, so far modified its correctness, that it would no longer be right to speak of the faculties of the idiot being doomed to remain stationary, or to say (as Esquirol pi'oceeds to do), " the condition of a man in a state of dementia may change — that of the idiot is ever the same." "We shall only, therefore, adopt Esquirol's description, so far as it represents idiocy as a con- genital deficiency of the mental powers. Lord Coke's definition is substantially the same as Esquirol's; "one who from his nativity, by a perpetual infirn)ity, is non compos mentis." Another legal definition of the word is contained in the fol- 92 IDIOCV, CRETINISM, AND IM BKCILITY. lowing : " he that shall be said to be a sot and idiot from his birtli, is such a person who cannot count or number twenty, and tell who was his father or mother, nor how old he is, so that it may appear tliat he hath no understanding or reason ■what shall lie for his profit, or what for his loss ; but, if he have sufficient understanding to know and understand his letters, and to read by teaching or information, he is not an idiot.'' ^ Dr. Prichard defines idiocy as " a state in which the mental faculties have been wanting from birth, or have not been mani- fested at the period at which they are usually developed. Idiocy is an original defect, and is, by this circumstance as well as by its phenomena, distinguished from that fatuity that results from disease, or from protracted age." Guislain's definition of idiocy, in his ' Lemons Orales,' is as follows : — " Partial or com- plete deficiency of the mental faculties, accompanied generally by a defect in the power of locomotion ; a malady belonging to a congenital condition." " Most modern authors," he else- where observes, " have made idiocy a distinct genus. I do not sec the necessity for establishing this distinction. On this account, I include it in the genus amentia, dementia, verecordia, fatttifas." We shall, however, follow Esquirol and Prichard in the use of the word, in distinguishing it from dementia, of which it is not merely the congenital form. So much for the definition of Idiocy. We will now consider its characters. These vary according to the degree in which the cerebro-spinal system is involved. In the lower forms of idiocy, the functions of organic or vegetable life are ill per- formed ; the idiot is below the plant ; nutrition is most im- perfect, and the power of reproduction null. He would perish but for the assistance of others. The functions of animal life are likewise, to a greater or less extent, impaired ; he may be scarcely alive to external impres- sions, or possess the power of executing spontaneous acts ; in the lowest type, he may be blind, deaf, and dumb; the dejec- tions are involuntary ; he is, indeed, nothing more than " a living, dead man." " La degradation des facultes intellectuelles," says Guislain, " atteint un degre qui fait descendre I'homme au-dessous de I'animal, qui Ic met mcme plus bas que les plantes, * 1 Fitzlierbert, ' Xatura Hrovinni,' 58:1, cd. iri.">2 ('i-Hert by Ray). IDIOCY, CRETINISM, AND niHECILITV. 93 vii que toutcs les fonctioiis sunt tcllcmeiit reduites quo, sans rassistauce d'une autre personne, certains idiots seraicnt dans rimpossibilite de pourvoir j\ leur nourritvire/' The degraded condition of the idiot is very clearly displayed in his vacant stare, in the thick everted lips, the slavering mouth, the irregular and decayed teeth ;* the gums often swollen, the frequent strabismus, the ill-formed, generally large ears, and the absence or defect of one or more of the senses — sight, hearing, speech, taste, or smell. His staggering walk is also very striking ; yet he seems as if he must be in motion, if he is on his feet ; and, even if seated, he often has a difficulty in balancing himself. There is a general want of symmetry ; the limbs are frequently contracted or paralysed ; the fingers are long and slender ; the grasp of the hand feeble or powerless, while the extremities are often cold and bluish from imperfect circulation. Psychologically, we may regard the idiot, with M. Seguin, as badly served by imperfect organs (mal ser\'i par des organes imparfaits) ; the instincts limited, but imperious ; the sensations determining in him the exercise of attention, comparison, judgment, memory, foresight, and will; in a word, differing from every one else, in that he wants that synergetic action of the faculties, and that spontaneity, from which springs free moral agency. Esquirol based his division of idiots upon the power of speech they possess. In the first degree of idiocy, properly so called, the idiot, according to him, uses merely words and short phrases ; idiots of the second degree, articulate only monosyllables or certain cries ; finally, in the third degree of idiocy, there is neither speech nor phrases, words nor monosyllables. Doubtless these divisions are mainly true to nature and practically useful ; it seems, however, more in accordance with our present know- ledge of the nervous centres, to regard the varioiis stages of idiocy, according to the degree in which the rcHcx and volitional functions are manifested ; and, occasionally, we meet with idiots who can talk, but who, in other respects, belong to a very * Mr. Hutthiiison, whose laborious investijrations have cstablishiHl the existence of a very important relation between the character of the teeth anil hereditary syphilis, exaininctl, in company with the writer, the teeth of the iiliots at the Earlswood Asylum, but did not find the characters referred to, in any considerable number of cases. 94 IDIOCY, CRETINISM, AND IMBECILITY. low type. The parrot can be tauglit to articulate, but, iu intel- ligence is far below the elepliant, which cannot. AVe might, from this point of view, speak of three classes of idiots. First, those who exhibit nothing beyond the reflex movements known as the excito-motor. Secondly, those whose reHex acts are consensual or sensori- motor, including those of an ideo-motor and emotional cha- racter. Thirdly, those mIio manifest volition — whose ideas produce some intellectual operations, and consequent will. This arrangement Avill be found to accoi'd, in great measure, with that adopted by Georget, although lie employed different modes of expression. He has four classes ; but if we withdraw the fourth, which refers more especially to imbeciles, we have the three following : first, those who have no mental existence, who cannot attend to any of their wants, and Avould certainly die if we did not take care of them; second, those who have some sensations, shun the cold, and give notice that they require food, but do not attach themselves to anvthing, and would never go in search of victuals, all their actions being Avithout reflection or object; third, those who are conscious of some of their sen- sations, who recognise the persons and objects by which they are surrounded, and are susceptible of attachment to those who do them good ; they employ signs more or less expressive, and make known their wants either by gestures or cries, or even by Mords badly articulated. As an illustration of the first class, we may refer to a very interesting case mentioned by Dr. Carpenter, in his ' Human Physiology' (1th edit., p. 360), on the authority of the late INIr. Wallis, of Hull. Although reared to the age of ten years, tliis idiot never, from the time of his birth, exhibited any distinct indication of consciousness ; there was no apparent malformation of the brain, yet no movements were ever Avitnessed which seemed to proceed from any higher centre than the medulla oblongata. Food had to be carried back into the pharynx, in order to be grasped l)y the constrictors.* An idiot boy at the Asylum for the West Riding of Yorkshire, aged twelve, swallowed " W'c iinderstniid this idiot is dend, witlKnil :\u\ :nitoi>sv linving Itecn nindp. IDIOCV, CRETINISM, AND IMBKCILITY. 95 his food -without mastication. It returned from the stomach, however, was chewed, and re-swallowed. An example of a very low form of idiocy has been given by Pinel, in his 'Traite ^Medico-philosophiquc sur I'Alicnation ;Mcntale,' but it is, in some respects, of a higher grade than the preceding : " One of the most singular and extraordinary cases which has ever been observed/' says he, "is that of a young female idiot, eleven years old, whose skull I have figured, and who, in the form of her head, her tastes, her mode of li^'ing, seemed to approach to the instincts of a sheep. For the two months and a half she was at the Salpetrierc, she exhibited an especial repugnance to meat, and ate, with avidity, vegetable substances, such as peas, apples, salad and bread ; she only drank water, and manifested, in her way, a lively appreciation of all the care which the attendant took of her. These demon- strations of feeling were confined to the expression of these two words, be, ma tante ; for she could not utter any other words, and appeared entirely silent, solely from wanting ideas ; otherwise her tongue seemed to possess all its mobility ; she was accustomed to exercise alternate movements of extension and flexion of the head, in supporting it (like a sheep) against the breast of her nurse, to testify her gratitude. Her back, loins, and shoulders were covered with long flexible hairs, from one to two inches in length, and which resembled wool in texture. In making efforts to get out of the bath, she would repeat, in an acute tone, be, be, be. She would not sit, but lay on the ground, " Ic corps roule, et etcndu sur la terre, tl la maniere dcs brebis." It is observable that many idiots whose mental power is ex- tremely deficient, have excelled in musical talents. In the instance of Quenau, an idiot at the Salpetriere, it was necessary to dress her ; when she attempted to speak, she uttered a hoarse cry, or a sort of articulate, jerking grunt, which she continued till she was understood. She comprehended, by means of a gesture, what was intended to be communicated to her, pro- vided it had reference to nothing beyond the most common wants of life. Yet this idiot was a musician. Dr. Peacock has recorded in the Pathological Society's 'Reports,' for 1858-9, the case of a boy, eleven years of age, which possessed many points of interest. He was born at the 96 IDIOCY, CRETINISM, AND IMBECILITY. full period, but his mother, in the fifth month of her pregnancy, received a severe shock, after ^yhich her abdomen did not in- crease in size. His parents were intelligent, and no member of the family was known to have been insane or imbecile. He was blind, micro-ccphalous (the anterior fontanelle closed at birth) ; had convulsions during dentition; could not utter articulate sounds, or stand unassisted ; the left arm was paralysed when about five. He distinguished his parents ; his sense of hearing ■was acute ; he could only swallow his food when cut into small pieces ; and passed his evacuations in bed. The thighs were flexed on the abdomen, which was tumid ; sternum prominent ; chin resting on the breast ; cyanosis from birth, not from mal- formation of the heart but from imperfectly expanded lungs. The brain after death was found to weigh 21 oz. S^ dr. avoir- dupois, being, as Dr. Peacock shows, less than half that of the average, and little more than half that of the smallest healthy brain, at eleven years of age. The cerebrum weighed 17 oz. 2\- dr., and the cerebellum (with the pons varolii and medulla oblongata) 4 oz. 1| dr. The lobes of the cerebellum, when in situ, projected considerably beyond the cerebrum. The cerebral convolutions were very small; the sulci shallow; the ventricles greatly dilated with serum ; the right hemisphere more atrophied than the left. The fal.c cerebri was entirely deficient in its anterior portion. Specific gravity of brain 1030 ; that of a healthy boy, aged eleven, was found by Dr. Peacock to be 1039"6. "Without its nerves the spinal cord weighed only 7 drs. An idiotic female who died at the llctreat, above seventy years of age, afforded an example of the third class ; her ideas produced some intellectual operations and consequent will. The almost lady-like propriety which characterised her, was remark- al)le, and Avas, in great measure, due to the excessive pains taken with her when young. Some would call this a case of congenital imbecility rather than idiocy ; but she could never be taught to read or write. She was full of delusions about children ; she imagined almost every day that she Avas in labour ; and was generally actively engaged in chiding the children which, in imagination, she already possessed. She died of ovarian disease. The brain was very small, and only weighing 22] oz. (avoirdupois) ; the cerebrum, 19 V ; and the IDIOCY, CRETINISM, AND IMBECILITY. 07 ccrrbellura (with pons varolii and inedulla oblongata) 3', . The wcif^ht of the brain, in the new-born infant, is stated by Tiedemann to be from 10 to 13| oz. ; the smallest brain re- corded by Solly weighed 19| (avoirdupois) ; and the next smallest, 22h oz. And if we take the average M^ight of the female brain at 41- oz., and deduct 1 oz. for each decennial period after fifty years of age, we have, in the case at the Retreat, a brain about 20 oz. below the average weight, and 11^ oz. below that of Cuvicr's, which weighed G 1 oz. avoirdupois. In this case, the membranes, Avith the exception of slight opacity of the arachnoid, were healthy, and not adherent ; there was a little fluid upon and beneath the arachnoid ; the vessels generally were empty. The thickness of the grey matter appeared to be fairly proportionate to the white ; the convolutions were small, and the sulci shallow, especially superiorly ; there was an unusually wide and deep division between the posterior and middle lobes ; the corpora striata and optic thalami small, but liealthy ; the ventricles normal, fluid slight in quantity; the pineal gland large and sacculated, like a hollow grape. The commissures and the septum lucidum were entire. The following are the measurements of the head : — Circmiiference ... ... ... ... 18'87 in. From the root of the nose to the spine of the octiput. 11-10 „ Antero-posterior diameter ... ... ... 6-62,, Transverse „ ... .. ... 4*75 „ Total ... ... ... 41-34 „ These contrast very strongly with the same measurements of Etty, the painter, a cast of whose noble head is in our posses- sion : — Circumference ... ... ... ... 24-75 in. From the root of the nose to the spine of the occiput. 16-05 „ Antero-posterior diameter ... ... 8-75 „ Transverse „ ... ... ... 6-37 „ Total ... ... 55-92 „ In the instance of the sheep-like idiot recorded by Pincl, the antero-po.stcrior diameter was 5' 11 inches; and the transverse 3-58 ; the circumference is not given. The measurements of Queuau's head were as follow : — 9S IDIOCY, CKKTINISM, AND I:\1BEC1LITY. Circumference ... ... .-• ... 2007 in. From the root of the nose to the spine of the occiput . 11-33 „ Antero- posterior diameter ... ... ... 6-92 „ Transverse „ ... •■■ ... 563 „ Total ... ... ... 43-9o „ The corresponding measurements of the famous " Aztec " hoj, whom we can only regard as an idiot, were as follow : — Circumference ... ... ... ... 1325 iii. From the root of the nose to the spine of the occiput. 7*75 „ Antero-posterior diameter ... ... ... 4"05 „ Transverse „ ... .. .. 3'75 „ Total ... ... 28-80 „ It must not be concluded, from these examples of micro- cephalous idiots, that a small head is a necessary accompaniment of idiocy. On the contrary, many idiots have large heads, leaving out of the question instances of hydrocephalus. Dr. Parchappe has stated, as the result of very careful inquiiy, that if there exists a general relation between the volume of the brain and the degree of intelligence, " facts are wanting to de- duce rigorously from this relation the different degi'ees of intellectual and moral capacity.'^ Of 100 idiotic heads ex- amined by M. Belhomme, 84 presented more or less decided malformations of the forehead, occiput, and lateral portions. Twenty-five per cent, had a well-marked want of symmetry. On bringing together a hundred well-proportioned heads, he did riot find one true idiot among the niimber. Gallice, after making a large number of observations, came to the conclusion that the more intelligent the idiot is, the larger will be his head ; but that this results from a greater development of the occiput. And this certainly accords with what Leurct had previously recorded, that the occiput in idiots is remarkably small. Des- maisons, in his ' Memoir on the Form of the Head in Idiots,' concludes that idiocy sometimes exists without any malforma- tion ; that it is impossible to fix upon any which is peculiar to idiocy, but that flattening of the posterior portion of the head is as common as that of the forehead. Dr. Zillner, however, has quite recently measured the sutures of the various cranial bones in idiots, aud states that in their skulls the frontal bone is de- cidedly smaller than in those of non-idiotic persons. Gall laid it IDIOCY, CRLTIMSM, AND IMBECILITY. 03 down as an axiom, that idiocy must exist when the head is not more than 13 inches in circumference; and he says that the measurement of heads in those cases which lie between complete idiocy and those admitting of the ordinary exercise of the intel- lectual faculties, is comprehended between the following limits : — the circumference varies from 14 to 17 inches ; and the arc be- tween the root of the nose and the occipital foramen measures not more than 12. These dimensions, he adds, arc accompanied with a greater or less degree of stupidity or fatuity, inability (more or less complete) of fixing the attention on a determinate object, vague sentiments, an irregular train of ideas, speech con- sisting of broken phrases, &c., and blind and irregular instincts. (' Functions of the Brain,' vol. ii, p. 214). When called upon to decide whether a child is idiotic, it is well to have the following among other points of inquiry prominently in view : the general aspect as regards intelligence ; the form of the head, whether large or small, or unsymraetrical; the condition of the fontanelles; the ability to raise or support the head ; the shape of the ears ; the presence of strabismus, and whether the eyes follow an object licld before them, or are affected by light ; whether capable of be- ing amused ; whether the hand can grasp your finger ; whether the limbs generally have the amount of power usual at the age of the child examined; whether (if of sufiicient age) it has begun to walk and talk like other children, and if too young to talk, the character of the vocal sounds should be particularly noticed. After this review of the principal characters of Idiocy, we w ill consider those of Cretinism, with which it is nearly allied, yet from which it difters in some important particulars. In A^hat these consist we shall shortly endeavour to determine. First, what is the derivation of the word ? Some authors, including Fodere, have derived it from Chretien, in consequence of the popular notion that the cretin is especially blessed by Heaven ; others refer the derivation to the word cretina, which signifies stupid, or silly — apparently a more feasible explanation of the word. Esquirol suggested that the term originated in cretine, alluvial soil, believing that an alluvial region was among the causes of the malady. The terms applied to these wretched beings have, of course, varied in diftcrent countries. In Savoy, they are called cretins, or fo-js. In some parts of France, they go by the name of 100 IDIOCY, C1U.TIN1S.M, AND IMBECILITY. cagots. In the Vallais, again, cretins of the lowest class arc called tschengen; those of a higher grade, trissel ; and those of the highest, gauch. In Styria, they are called dotteln. In Italy, scempiaggine. In Piedmont, foulitre, &c. These different tenns indicate, at once, that cretinism is not confined to Switzerland, from which we hear most about it, but that it is endemic in many countries. But, more than this, it is sporadic ; an occasional case being found, presenting all the characters of genuine cretinism, in the cities of various countries, including England. One such case, although in a very modified form, was admitted into the York Hospital, to be treated for bronchocelc. "When asked how he was, his constant reply was, "My belly aches, and my breast is sore;" and it might have been supposed this was the extent of his vocabulan\ A report of this case will be found in the ' Medical Times and Gazette,' September 15, 1855, a portion of which may be cited here : — " He is very short for his age (fourteen), is of rather fair, but pale, and earthy complexion, and of a quiet, apathetic expression of countenance. He is not destitute of intelligence, though very decidedly below par. He lias been sent to school regularly, and has learnt to write fairly ; but can scarcely read at all. He answers questions in a slow, hesitating manner, and can M'ith diffi- culty be got to speak to strangers. . . . The abdomen is large and tumid, but there are no indications of organic disease either in it or the chest. The thyroid gland, although now much reduced in size by treatment, is still enlarged in all its proportions, to a degree quite perceptible to the eye. The arch of the palate is high and narrow, and the teeth have grown very irregularly. The muscles, generally, appear fairly developed, and feel firm to the touch. He can walk and run, but is not active. In regard to his history, it was ascertained that both parents were very short in stature ; and although neither was so deficient in mind as to approach imbecility, yet both were peculiar in temper, and by no means of vigorous intellect. The father is still living ; the mother died of phthisis, with acute intestinal complication, about six years ago. Idiocy is not known to have ever shown itself in the family of either; nor is it certain that any relatives have ever had bronchocelc. Both parents were born in York, and have lived there all their lives ; they m ere in no way related before marriage. All their children, four in uunibor, are delicate IDIOCY, CHKIIMSNi, -AM) .'.>J "^4SM, AND IMBECILITY. The Swiss cretins were spoken of by Felix Plater, so far back as 1500. In later times, numerous writers have given descriptions of this unfortunate class ; the first systematic treatise was by Fodere, in the year 1792. He was followed by Michaelis, Autenrieth, the "Wenzels, and others. Dr. Guggcnbuhl, in 1841, established a hospital upon the Abendberg, in the canton of Berne, for the purpose of caring for, and endeavouring to educate, cretins. In 1850 appeared the Report of a Commission appointed by Charles Albert, the then King of Sardinia, to investigate the causes and nature of cretinism, and to suggest means for the relief of so terrible a malady. From the particulars collected and presented by this Commis- sion in their Report, we are able to obtain much valuable infor- mation in regard to cretinism."^ !Much discrepancy exists in the statements of authors, as to whether cretinism can be recognised at birth. The true state of the case, according to the article already referred to, appears to be this : — that there is no pathognomonic sign by which it can be then diagnosed, but that a certain combination of symptoms may allow us to prognosticate, in childhood, the future develop- ment of cretinism. In well-marked cases, it is stated that, after the fifth or sixth month, the child presents the following symp- toms : — the development of the body proceeds very slowly ; the child, though weak, is remarkably stout, and appears SAvollen ; the colour of the skin is sometimes dusky, sometimes yellow, sometimes natural ; the head is large ; the fontanelles widely separated, and sometimes all the sutures disjointed ;t the ex- pression is stupid ; the appetite is voracious, aiid much time is passed in sleep. The belly is swollen; the extremities are * Vide article in the ' Annales Medico-Psvchologiques,' April, 1850, by Brierre de Boismont. t The 'Contributions to Midwifery and Diseases of Women and Children,' &c., by Drs.Noeggerath and A. Jacobi, contain an essay by the latter physician in which he endeavours to show the great importance of premature closure of the fontanelles and sutures of the infantile cranium, as a cause of cretinism and idiocy. This is quite consistent with the same mcntiil condition being associated in other cases with non-closure of the cranial bones at the normal period, which he decides to be at about thirteen months of age. Virchow's views will be shortly referred to. IDIOCY, URKTIM^^M, AM) IMUKCIl.lTK 103 generally attenuated ; the neck is thick, witliout, however, being always goitrous; teething is not completed for many years, and is aecompanied by an oftcnsive salivation, and frequently by convulsions. Usually, the child cannot stand before its sixth or seventh year, and it is then that it begins to articulate certain sounds, if not deaf from birth. The voice is hoarse and shrill, and words are spoken with difficulty. The development of cretinism, strictly speaking, occurs about seven ; but it is clear that all its main features were present long before. Dr. Morel calls from seven to eight the critical age for cretinism. It is asserted, that no instance is known of a child becoming a cretin after the seventh year, under the influence of local circumstances alone. Of 4888 cases in Avhich the age at which the first symp- toms appeared was ascertained, 4440 were between the time of birth and two years; 187 between two and five; 202 between five and twelve ; 31 between twelve and twenty ; 28 from twenty and upwards. Although speaking of the differences of opinion as to whether or not cretinism can be diagnosed at birth, we did not mean it to be inferred, that there are no cases really congenital. On the contrary, the classification of Dr. Guggenbuhl recognises a con- genital class. His second division includes those affected with rachitis ; the third, those specially characterised by general atrophy; and the foiu'th, those cases complicated with hydro- cephalus. Three classes of cretins are generally spoken of by authors, according to the degree of defective development. 1st. Cretins; manifesting only vegetative functions, and de- prived entirely of reproductive and intellectual faculties, inclu- ding the power of speech. 2nd. Semi-cretins ; possessing the power of reproduction, and some faculty of speech : intellectual faculties limited to corporeal wants. 3rd. Cretinous ; having intellectual faculties superior to the former, and able, in some degree, to apply to trade and other employments. Of G107 cases of cretinism, classified by the Commission, 21G5 belonged to the first, 3518 to the second, and only 424 to the third class. Those of the second and thii-d class have been called megalo- 104 IDIOCY, CllETIMS.M, AND IMBECILITY. cephales by M. Cerise, who measured their crania iu 105 in- stauces, and found them more capacious than those of the first class. There appears to be in a large number of cases a fronto- occipital contraction of the skulls of cretins (brachycephalic), while the sides of the head are prominent. Thus, in a hundred instances, it was found by Dr. Trombotto that the distance from the root of the nose to the occipital spine was less than over the head from ear to ear by four centimetres.'^ The heads of some cretins are in the form of a cone, the apex being at the junction of the sagittal and lambdoidal sutures. The character of the face appears to remain almost unchanged from puberty to old age — that is to say, cretins are ohl men and women at fourteen. The eyes, in addition to their want of expression, are generally affected with strabismus, the zygomatic arch is very large, the mouth of remarkable size, and the lips thick, the lower one hanging down. The superior maxilla is prominent. The inferior maxilla is small, retreating, and its angle very obtuse, as may be seen in the plates in Carus's atlas ; where the reader may also observe the contrast between the " three cranial vertebrae" of cretins and others. In regard to the stature of cretins, there are many in Savoy only about three feet. They rarely exceed four feet eleven inches, and are mostly under four feet, though they may attain even six. The symptoms of cretinism may be thus recapitulated, almost in the words of Brierre de Boismont : — Peculiarity in the form of the head ; a disproportion between all or certain parts of the body, in consequence of defective development ; imperfect nutrition, to a greater or less extent ; generally, absolute power- lessncss of reproduction, or, at any rate, great torpidity in this respect ; little muscular energy ; voluntary movements unde- cided ; inability to stand beyond a short time ; total want, or a marked imperfection, of language; imbecility more or less decidedly exhibited in the countenance, as well as in the character. " The co-existence of all the preceding conditions," ob- * The English inch ^ 2*5399 conti^n^tl•es. Dr. Zillner's more recent measure- ments of the antero-posterior and transverse diameters of cretin crania do not show the same ahsolute difTerence, but, wlien compared with the normal skull, indicate a similar disproportion. IDlOfV, ( lliiTlMSM, AM) I MUKCI Lll V. 103 serves the above writer, " constitutes absolute eretiuisui ; the absence of any one of them and tlie diminution of their intensity, constitutes semi-cretinism. Between these two extremes the gradations arc infinite/^ After this review of the symptoms manifested by cretins, we recur to the inquiry. In what does a cretin differ from an idiot ? In the first pLace, an idiot is horn with his deficient develop- ment ; the malady is congenital and organic. The cretin, on the contrary may for some time appear free from disease, and, if placed under fovourable circumstances, might escape, although it is obvious that he must have a greater predisposition to this peculiar condition than a neighbour who does not become a cretin; this predisposition is clearly hereditary, and Fodcrc ob- served, that if a male affected with goitre, the son of a goitrous semi-cretin, married a semi-cretin, their offspring was a complete cretin. If, on the contrary, a male cretin of the second class married a healthy mountaineer, the ofispring would be a cretin of the best (the third) class. But, if the races did not continue to cross, then the offspring of such an union resembled the grandfather and not the father. As, with the highest autho- rities, we have decided to restrict the term idiocy to a congenital condition, we must distinguish it from cretinism, which may be acquired at various periods of life. Secondly — cretinism is endemic ; idiocy is not so, but appears in our omti country, without any particular regard to locality. At the same time, were cretinism and idiocy alike in other respects, this point of difference could not be maintained, for we should have to regard the former, in that case, as endemic idiocy ; there would be no dift'crence in their nature. Thirdly — the brown or yellow colour of the skin, the remark- ably high and arched palate, the considerable proportion of cases in which the thyroid gland is enlarged,* present points of con- trast to idiocy. Fourthly — cretinism is more curable than idiocy. ]Morel observes with truth, that the idea that cretinism is merely the lowest stage of idiocy has been fraught with mischief, by ren- dering the prospect of cure almost hopeless ; instead of pointing • Of 5923 cretins, 3912 were poitrous, 2011 not. This does not, however, include cases in which the neck was short and thick— a numerous chii«s. 106 IDIOCY, CRRTINISM, AND IMBECILITY. out the existence of some cause — some poison — external to the cretin (althougla it may act upon him even in fcetal life), the removal of which is the first step to take towards benefiting him. But, fifthly and lastly, the most marked distinction exists in the greater degree in which, in cretinism, both systems, the nervous and muscular, are aflfected. In idiocy there may be great deficiency of the mental functions, without anything like the same amount of loss of muscular power and co-ordination. " L'idiot,'' says M. Baillarger, " est un etre dont Tarret de deve- loppement porte sur Fencephale, tandis que chez le cretin, il y a un arret general, tant du developpement du cerveau que de Fen- semble de Forganisme." M. Xiepce also says, " L'idiot est un etre bien conforme, tandis que le cretin presente la degradation des organes.^' The size of the feet is quite disproportionate to that of the trunk, w^hile the prominent abdomen resting upon lank attenuated legs, and the head, which is sometimes eum- brously large, drooping over an ill-developed thorax, exhibit humanity in its most distorted form. To the causes of cretinism we shall now briefly refer; the conclusion at which the Sardinian Commission arrived, was that, notwithstanding many exceptions, the most general and constant cause is a humid or vitiated atmosphere, whether in conse- quence of the character and situation of the country (as in the narrow valleys between the mountains), the position and aspect of the dwellings^ and the badly constructed, ill- ventilated, and dirty houses; or the want of sunlight ; to which must be added the bad quality of the water, and the excess or deficiency of some of its constituents, the bad quality of the food, and its insufficiency for the wants of life. The conclusion at which Dr. Behrend, a German writer, arrived, after a careful examination of the etiology of cretinism, was essentially the same.* Sir John Forbes, to whose graphic sketch of what he saw and heard of cretinism during his ' Holiday ' Ave would refer the reader, observes : — " My present impression is, that its cause is some ■» * In reference to the defective vision of many cretins, it may be stated that Dr. Liehreich, of Berlin, has recently examined with the oi)hthalmo=cope the eyes of a considerable number of idiots, and thinks that in some instances at least (those connected with marriages of- consangiiiiMty), it is the result of "retinitis pigmentosa." — Medical Timp.i a,id Gazette, April fi. 1861 . IDIOCY, tRliTINlJS.M, AND 1 M liil I I.ITY. 107 tbrni of that unknown local influence or tliiufi;, conunonly i-ecognised under the name of miasma or ma/aria, and which operates on the animal system as a poison, producing special modifications of function, and special changes of structure according to certain special conditions, which, however, are, like itself, unknown. As the unknown thing which we term malaria or miasma of marshes, under certain circumstances gives rise, at one time, to simple ague ; at another, to a fatal remittent fever, &c., and produces, at times, a morbid enlarge- ment of the spleen ; at others, diseases of the liver, &c. ; so I can imagine, that some other malaria or unknown thing or in- fluence, of local origin, may be the cause of ordinary bronchocele, of the aggravated bronchocele or goitre of the Alps, and also of cretinism/' Dr. Granger has endeavoured to show that there exists an important relation between the excess of salts of mag- nesia in the drinking water, when accompanied by the absence of iodine, and the development of goitre and cretinism. But, more extensive researches appear to be required, before this can be admitted as the main, though it may constitute one, cause of the disease. Dr. Morel, whose investigations are of recent date, has arrived at the conclusion that the extent of cretinism depends, primarily, upon the geological constitution of the soil. In the Departcment de la Meurthe, he attributes cretinism to a locality abounding in variegated marl, with gypsum and salt (marne irisee de gypse et sel gemme). In Savoy it is almost exclusively upon clayey and gypsum soil that the disease occurs, while wherever compact limestone (calcaire compacte) prevails, it is rarely seen. Again, magncsian limestone would appear to exert a very prejudicial influence upon the development of goitre and cretinism. From all which he concludes, that " we are autho- rised in deducing from the geological constitution of the soil the existence of a poisonous principle, which acts upon the nervous system in the manner of a deleterious miasma." Nor does he think this conclusion ought to be set aside by our meeting with cretins in situations high above the level of the sea, as well as in dark, naiTow valleys. Here he considers that some peculiar configuration of the country takes the place of the consti- tution of the soil. ('Traite des Degenercscences,' &c). Sir John Forbes states that, among similar instances men- 108 IDIOCY, CRETINISM, AND IMBECILITY. tioned to him, a surgeon at Bonneville, in Savoy, pointed out to him a village near that town, in a gorge of the mountain - range that bounds the Arve on the south, as the only place where cretinism prevailed in that district ; and that he knew a family who had had several healthy children while residing in a more elevated spot, and who, on coming to reside in this village, gave birth to several cretins. Some (including llosch) regard cretinism as the most com- plete development of scrofula ; others (with Ackcrmann) main- tain it is an extreme degree of rachitis; while Fodere and others consider that the proximate cause of the malady is hard- ness of the brain, and a defect in its structure. Dr. Behrend defines cretinism to be " a scrofulous, rachitic dyscrasia, accom- panied by chlorosis and imperfection of the intelligence and senses.^' Dr. Brierre de Boismont, with more candour, acknowledges that we possess no definite knowledge on the subject. At the same time, Ave cannot doubt that the imme- diate cause of the symptoms we witness, both in idiocy and in cretinism, is a defect in the quantity, or, when this is not tlie case, in the quality of the nervous matter of the encephalon. Further observations on the chemical constituents of the brain in idiots, such as have been made in regard to the deficiency of phosphorus, &c., may advance our knowledge. Meckel ob- serves, that in idiots the cerebral substance is drier, lighter, and more friable than in healthy brains. ]\Ialacarne declares, that the lamellffi of the cerebellum are less numerous in those de- prived of intelligence. The convolutions of the cerebrum are not, remarks Solly, exactly alike on both sides in healthy brains ; while, " cm'iously enough, we find them almost in exact correspondence in the brain of the monkey and the idiot, and even in some of the lowest of the negroes. '^ ('The Human Brain.') Virchow has made a number of highly interesting observations on the ossification of the various bones of the skull in connexion with cretinism and idiocy. We think, with awriter in the 'Medico- Chirurgical Review ' (July, 1861), that the narrow upper jaw and high palate, are, in part at least, influenced by the arrest of growth of the spheno-occipital (or tribasilar) bone. Yirchow's views respecting the whole subject of ossification of the sutures will be found clearly stated in the above article. " The suture-. IDIOCY, CUKTINISM, AND IMBECILITY. 109 substance itself furnishes the material of ossification, the stroma for a deposition of the lime salts, so that, under ordinary circum- stances, a skull-bone can only increase equally in all directions when this bone-originatino: suture-substance lies on all its sides. If, then, adjoining skull-bones be soldered together by a pre- mature and complete ossification of the interlying suture (by synostosis), a limit is set to further growth in that direction. If this happens to many sutures at the same time, a micro-ccphalous skull results. If it only happens to one suture, or to a part of a suture, an abnormally asymmetrical or deformed shape follows." The antero-posterior contraction of the skull already described is accounted for by ossification of the coronal, and lambdoidal sutures. When, on the contrary, the cretin head assunies a dolicho-cephalic form, there has been, it is presumed, synostosis of the sagittal suture. Having now described the plienomena of Idiocy and Cretin- ism, it is necessary to say a few words in regard to the meaning attached to the term ImbecUity. Some writers have restricted its use to the loss of mental power supervening in infancy, others have applied it indifferently to a congenital and infantile con- dition, and all agree in employing the term to denote a minor degree of mental deficiency than idiocy. Probably, the best way to define the difference between idiocy and imbecility is this : — idiocy always is, imbecility is not necessarily, congenital ; idiocy implies a less amount of intellectual power than imbecility. At the same time, it is obvious that it is possible to have so low a degree of intellectual power in a child congenitally of sound mind, that, in regard to the mental condition, it is rather idiotic than imbecile, and yet, in regard to the period of the invasion of the malady, it is not idiotic, in the sense applied to the word in the previous definition, and as laid down by Esquirol. And again, there may be a weakness of mind from birth, which docs not merit the designation of idiocy. It is clear, therefore, that these dis- tinctions are for the most part arbitrary. When imbecility is present from birth, the sensitive and intel- lectual faculties are somewhat developed ; sensations, ideas, and memory, as well as the aft'eetions, passions, and even inclinations, exist, but only in a slight degree ; such think, feel, and speak, and are capable of acquiring a certain amount of education. (Esquirol.) 110 IDIOCY, CUKTINISM, AND IMBECILITY. Georget speaks of imbeciles as those wlio " are conscious of sensations, have memory, can judge of the simple acts of life, can work at rough occupations which require little discernment ; they employ, in order to express themselves, a language composed of those expressions which are most essential to their ordinary wants/^ Imbecility, like idiocy, is manifested in various degrees. In the lower forms, " imbeciles produce nothing ; and all their movements, both intellectual and moral, are aroused only by impulses from without. They do not think or act, except through others ; their will is without energy. They will and do not. They cannot follow a conversation, still less a discussion. They regard as serious, things the most gay ; and laugh at those that are most sad. Does something interest them, their eyes are fixed, but they do not see; they hear, but do not comprehend; although they affect to have both seen and understood. They reply correctly, but you must not ask them too many questions, nor require fi-om them responses which demand reflection or are contrary to their habits.^^ (Esquirol, Hunt's edit., p. 452.) Some imbeciles know those who are about them, are affec- tionate to their friends, but are often passionate, and are very likely to have a strong tendency to theft. They are equal to the performance of many of the ordinary duties of life, and are able to take care of themselves. Others display considerable shrewdness, and are constantly indulging in jokes ; they pass for half-witted people, whose droll behaviour and ready repartees create amusement. From this class, the court-fools of antiquity and medireval times were de- rived. Unfortunately, there are not a few imbeciles who are dangerous to society : they are sometimes prone to incendiary, and still more frequently to homicidal acts. This is the case even with true idiots ; proving, in both cases, how completely distinct must be the structures which subserve the intellectual and the affective faculties ; there being in the same person, and at the same time, an absence or depression of the former, and an excess or exaltation of the latter. AVe think Gall and his followers are quite justified in urging these facts in favour of a plurality of cerebral organs. He relates the case of an imbecile, who, after killing two of his brother's children, went to the father with an expression of delight, and told him what he had done. IDIOCY, CUETINISM, AND IMBECILITY. Ill Again, instances are given by Esquirol and others, of the presence of considei'ablc moral sensibility, in association -with intellectual deficiency. lUish speaks of a man without a spark of intelligence who devoted his life to works of benevolence. This, however, is of much rarer occurrence than the absence of intellectual power coincidently with the excessive action of animal propensities. Hofl'bauer has divided mental weakness into various classes, according to the extent to which ihe mental faculties are im- paired. Three of these, as having special reference to imbecility, may be referred to. In the first, the individual is incapable of forming a judgment on a new subject, however simple it may be. He can judge very well, however, regarding subjects which are familiar to him ; his memory is, of course, very weak, although he observes a certain routine of occupation with scru- pulous exactness. He is not accustomed to talk much to him- self. He is liable to sudden paroxysms of anger. The subject of the second degree is even less able to judge and act, in regard to his accustomed occupations. He is ex- ceedingly confused, in regard to the place in which he is, and the person with whom he converses, and is very generally at fault in regard to his ideas of time. In the third degree of imbecility, there is more reason to apprehend danger from the individual affected with it ; for he has delusions of the evil intentions of others, and is not only passionate, but suspicious and misanthropic. He frequently talks to himself.''^ Dr. Prichard inclines to the use of similar divisions, and of others still more refined, to assist the judicial questions which arise in connexion with imbecility. We think, however, that a more detailed division than that to which we have referred, would only confuse the reader by its minute distinctions. Herr Sa^gert, of Berlin, is the most sanguine instructor of idiots we have met with, in regard to the recovery of mental power in even the low" forms of idiocy. He assured us, when we visited his school, in 1853, that he had had indubitable cases of idiocy in which the head was small and malformed, yet in which the results of education were so triumphant, that they were ultimately able to mix with the world, without being • This circuu. stance must never, alone, be taken as a proof of mental discuso. Many sane pcrtions arc in the habit of talking aloud to themselves. 112 IDIOCY, CRETINISM, AND IMBECILITY. recognised as idiots. In one instance, a young man underwent confirmation without the priest suspecting that he had been delivered from idiocy. Herr Saegert has representations of the heads of idiots when entering, as well as when leaving his school, and the increase of cerebral development is most striking. Dr. ^Maxwell has obligingly furnished us with the following general result of the care bestowed on the idiots under his charge. He says, "As to the cases we have in the asylum (Earlswood), I think I may say that they all have improved more or less. Kind treatment, good diet, and attention, will improve the most hopeless cases. " Many that come in dirty, irritable, &c., not only become cleanly, but get to speak intelligently, to dress themselves properly, and make themselves useful. Other cases will do a great deal in the school ; for instance, we have a case which came in spiteful, obstinate, and unable to read and write. Now he reads well, writes well, also writes from dictation, draws very nicely, can sing several songs, plays on tlie harmo- iiicum, and can drill, which has made him walk upright. He has latterly been in the mat-making shop, and can make the best part of a mat. Another boy has improved in all the above, and is learning mat-making. He possesses, perhaps, the most intellect of any of the boys ; but I cannot say that I think he will ever be like an ordinary person. The cases most favourable are those between seven and twelve, M^hich are healthy, can speak, and are free from fits and paralysis.'^ In a pamphlet entitled ' Teaching the Idiot,' it is stated that the father and mother of an idiot called at Essex Hall to visit him, and were showTi into the room where he was engaged in company M'ith several others of the same class. " They both said he was not there, after what they regarded as a sufficient scrutiny ; and, when they discovered him, the father could only utter, in a voice choked with emotion : ' jSIy heart is full, I cannot tell you what I feci !' He saw his son rescued from the dreadful slough of brutishness, made tidy, decent, industrious, and happy ; and no wonder he was thus affected by the spectacle." In addition to the already mentioned causes of idiocy and imbecility, the following may ])e enmnerated : — hereditary trans- mission, drunkenness of parents, licreditary syphilis (?), marriages DEMENTIA. 113 of consanguinity, shock, &c., to mother during pregnancy ; inflammation of brain or membranes during foetal life ; pro- tracted labour ; any morbid action causing atrophy of one or both cerebral hemispheres ; and, Avhen imbecility is not con- genital, drugging with opium or spirits, in infancy ; blows on the head ; the exanthemata, or hooping cough. In such cases the causes are of so external a nature that the condition which results ought rather to be called infantile dementia. The proportion which idiots and imbeciles bore to luna- tics, among the pauper population of England and "Wales, was, on the 1st of January, 1859, 29*3 (idiots), to 70-7 (lunatics), per 100 insane paupers. Section II. — Of Dementia. Having disposed of Idiocy, Cretinism, and Imbecility, we M ill now pass on to the consideration of Dementia. Syn. Demence (Fr.) ; Narrheit (Ger.) ; Stupiditd (Ital.) ; Incoherence (Prichard) ; Fatuity. " Dementia," observes Esquirol, " must not be confounded with imbecility or idiocy. In imbecility, neither the under- standing nor sensibility has been sufficiently developed. He who is in a state of dementia, has lost these faculties to a very considerable degree. The former can neither look backward nor into the future ; the latter has recollections and reminis- cences. Imbeciles are remarkable by their conversation and acts, which greatly resemble infancy. The conversation and manners of the insensate, bear the impress of their former state. There exists, therefore, a form of mental alienation which is very distinct — in which the disorder of the ideas, affections, and determinations, is characterised by feebleness, and by the abolition, more or less marked, of all the sensitive, intellectual, and voluntary faculties. This is dementia." In regarding a number of patients in a state of dementia, we have found it convenient to group them in the following way. 1st. Those who, whether previously well or insane, are gradually passing into a decidedly demented condition. Some 8 IH' DEMENTIA. confusion of thoughtj a perplexed ratlier than a stupid expres- sioHj and a failing memory, are the most obvious symptoms. Such patients are not incoherent, or are only occasionally so. They are sometimes conscious of their condition, and carefully avoid committing themselves. They can read and write; hut in regard to the latter, it will be found that after composing a few sentences correctly, they express themselves confusedly, and spell iucorrectly. We have seen a letter written by a patient in the first stage of primary dementia, pretty well composed, but full of mistakes in the spelling. This condition is that of partial or incipient dementia. 2nd. Those who are so far advanced that they cannot tell their names. Many of this class are dirty in their habits. Their time is mostly spent in listlessness, or muttering to themselves, twirling their fingers about in all directions, now catching up something from the ground with -which they play until some fresh fancy seizes them ; or scraping together bits of paper, sticks, string, stones, &c., without the constructive power of the child, but purposeless; or if otherwise, only with the mis- chievous propensity of the magpie. We then have complete or confirmed dementia. 3rd. Those cases which are intermediate between incipient and confirmed dementia. In a considerable number of cases, dementia is complicated with its frequent cause — General Paralysis. A large number of demented patients, of each class, are sub- ject to fits of maniacal excitement, on the slightest occasion ; on the other hand, patients in acute mania are, in consequence of the rapid flow or succession of ideas, perfectly incoherent ; and a stranger to the history of the case might be unable to decide whether the patient were demented or excited, or maniacal and temporarily incoherent. '' We have found om'selves often em- barrassed," says Brierre de Boismont, ''in arriving at a con- clusion as to the nature of such cases ; we have, in conse- quence, been obliged to submit the patient to a more prolonged examination before giving an opinion. It is a good plan to attempt to make them v.rite ; if they do, we then see that they (the former) have forgotten their words r.nd letters. '' Guislain, in speaking of the o/?;>r^.«.*f;'c»» rather than extinction of mental power which i? prcs-cnt in the incoherence of acute mania, well DEMKNTIA. 115 compares it to a veil uliich temporarily covers the intelligence. Dr. Pricliard has divided the disease into fonr stages, which, nearly in his own woi'ds, may he described as follows : — The first may he termed that of forgetfulness, or loss of memory. Its chief characteristic is a failure of memory, es- pecially as to recent events. The power of reasoning, within the sphere of distinct recollection, is not remarkably impaired, and the faculty of judgment is exercised in a sound manner, when the attention can be sufficiently aroused. The second stage brings M'ith it a total abolition of the power of reasoning, depending on a loss of voluntary control over the thoughts. It may be termed the stage of irrationaUty or loss of reasonhiy. In the third stage the individual afteeted is incapable of com- prehending the meaning of anything that may be said to him. It may be styled the stage of incomprehension. It is the con- firmed stage of incoherence ; that epithet applying to it, in a still more striking manner, than to any other degree of the disease. It raiglit also be termed the instinctive stage. Reason being entirely lost, and the instinctive or mechanical principles of action, as they are termed, still remaining in vigour, the latter display themselves more remarkably. The last stage is characterised by the loss of even the animal instincts. The miserable victim of disease, when reduced to this state, has merely organic or physical existence ; he appears scarcely conscious of life, has neither desires nor aversions, and is unable to obey the calls of nature. This is the stage of inappetency or loss of instinct and volition. A considerable proportion of the patients in asylums for the insane afford illustrations of dementia in its various stages, from the most incipient form to that in which the patient has no longer any just perception of the subjects around him ; can no longer exercise his reason; has completely lost tlie comparing faculty ; and has left to him little more than the functions of vegetable and animal life. In contemplating a group of demented persons, it is instructive to. reflect on the various courses by which they have arrived at the same deplo- rable condition. AVerc we to retrace their mental history, we should find that some, a few years ago, afforded examples of melancholia, and were perfpctly conscious of all that passed 110 DEMENTIA. around them. By slow gradations the mental faculties became dulled, confused, and finally obliterated. Some were maniacs, the very intensity of whose mental operations appears to have exhausted their supply of cerebral power; and a too rapid succession of images, which ought to have been spread over a life-time, has been compressed within the narrow limits of a few months. The verj^ brilliancy of the flame has caused its premature extinction ; the oil which should have sustained the lustre of an entire life, has been lavishly consumed in the production of one splendid but useless confla- gration. The ashes in the socket alone remain. Others, again, without any previous stage of mental disease, have suddenly, and it may be by some overpowering shock to the nervous system, become subjects of dementia. Some, lastly, have lost their faculties by reason of old age, and are illustrations of senile dementia — "that last infirmity of noble minds." To many, a group of demented patients appears as unin- teresting a subject of psychological study as can be found in an asylum. This, however, is far from being the case, and we would strongly recommend the student to banish such an im- pression from his mind. For when he remembers that all have once enjoyed mental health, he can have few more interesting inquiries than to ascertain the causes of their present condition. And after having traced their pre^^ous history, he will still find a wider field for study than he may expect, in determining their present actual state of mind, the way in which they pass their time, &c. It is always a help to have some definite points of inquiry in view in such an investigation. How many can dress themselves ? AVhat proportion can read or sew ? How many are unable to attend to the calls of nature ? How many are subject to attacks of excitement, or are labouring under General Paralysis? We will take a few actual cases from a group of demented women now before us (1858), and in the briefest manner touch upon a few of the leading features of their history and present condition. The first is a woman so agile and playful that you are sur- prised to find that she is now fifty-seven. For thirty -three years she has been insane. The disorder succeeded suppression of the ratamenia, which at first only produced symptoms of hysteria. di:mi:ntia. 117 The return of the discliarge, after it had beeu found necessary to place her in an asyhim, was not followed by any improve- ment ; and gradually the condition of mind supervened -which is now so apparent — that of complete dementia. "When you ask her her name she gives no rational answer, or responds only by an unmeaning laugh ; then runs away, and perhaps slams the door in your face. "When you ask the attendant about her habits, you find they are dirty. As to the way in which she employs herself, she can sew a little, but does nothing consecutively. She will sit by the fire, one minute playing some trick with it, another gazing at it Avith some apparent object, then as the fit takes her, looking out of the window or running out of the room. In regard to prognosis you have no hesitation in telling her friends that her case is incurable, but that she may live in her spoiled house to a fair old age. The next case is that of a woman a little more than fifty years of age, and, like the foregoing, became insane when a young woman. She was only nineteen. T\'hen placed under asylum care, three years afterwards, she refused to take her food, grounding her refusal upon conscientious objections. Her attack of insanity was attributed to fever. In the course of years the above condition of religious melancholia passed away, but the mind became more and more weakened, and ultimately lapsed into a state of incoherence, accompanied by exceedingly dirty habits. She is not so excitable as the last patient, is generally placid, and her vacancy is never relieved by even a momentary gleam of intelligence, or playful mischief. She usually, when you address her or ask her her name, replies by an unmeaning interrogatory, expressed in the same words every time. She is stout, eats and sleeps well, and may live many years. The third example of dementia presents much more intelli- gence. It is that of a lady some years older than either of the preceding, who, thirty years ago, became insane in consequence of domestic troubles. She first suffered from chorea (not an un- frequent antecedent of insanity), and was subject to attacks of great mental excitement — recurrent mania. Dementia ulti- mately ensued. She differs from both the preceding cases in giving her name correctly, though deliberately, when asked. Her sentences are sometimes coherent, at other times she ram- 118 UEMENTIA. l)les^ and would never carry on, consecutively, a conversation of any length. Her memory of the past is confused, and in regard to many events quite obliterated. Her habits are clean. In this case, as in some others, dementia proceeds up to a certain point, short of entire incoherence and irrationality, and then becomes stationary for years, perhaps to the end of life. The study of the different degrees of fatuity at which the malady stands still, and exhibits little tendency to advance, is a very interesting one. In our experience the degree of acquired fatuity has not borne any relation to the patient^s original type of mindi This should be remembered, in order that when the question arises as to the probable course of a case after the first exhibition of mental degeneration, too much importance may not be attached to the patient's having a constitutionally feeble mind. The most powerful minds often sink into the lowest forms of dementia, while, as in the present instance, the down- ward course is arrested at a comparatively early stage, although the original mental calibre of the patient was below the average. The fourth case is one of considerable interest, and further illustrates the observation we have just made, the patient having been an intellectual and highly accomplished lady, but now sunk into a state of profound and hopeless dementia. The mother of several children and a widow, she became insane at the turn of life. Several causes operated, however, inde- pendently of this critical period, to produce the attack of mental derangement. These were pecuniary losses, and certain family troubles. A strong suicidal tendency manifested itself, accompanied by symptoms of active cerebral congestion, for which leeches were applied. For fourteen weeks the stomach pump was employed, on account of her persistent refusal to take food. The suicidal symptoms gave way, but were followed by loss of mental power, and at last confirmed dementia. She is quite unable to tell her name, her language is foul and without any coherence, and she never attends to the calls of nature. She almost always sits in one position, and talks incessantly to herself, or rather declaims against supposed enemies in very un- ladylike terms. The fifth case is that of a female sixty years of age, the ■subject of mental disease since she was thirty-two ; the cau.?e DEMKNTIA, 11<) of her insanity not known. Her natural dispositiuu was dila- tory ; she was always averse to vere immediately injured. He became shortly afterwai'ds almost frantic, and after being out of his mind for about two years, he -was brought to the Retreat in- curably demented. In speaking of primary dementia, we have spoken of several cases produced by sudden grief. "We would here add the following remarkable illustration from Pinel : — " An engineer proposed to the Committee of Public Safety, in the second year of the Republic, a project for a newly-invented cannon. A day was fixed for the experiment, and Robespierre wrote to the inventor so flattering a letter, that, upon perusing it, he was transfixed motionless to the spot. He was shortly after sent to the Bicetre, in a state of complete dementia. About the same time, two young conscripts who had recently joined the army, were called into action. In the heat of the engage- ment, 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 afterwards, he was sent, in a state of complete dementia, to his father's house. His arrival produced a similar impression upon a third son of the same family. My sympathy," adds Pinel, "has been frequently arrested by the sad wreck of humanity presented in the appear- ance of these degraded beings ; but it was a scene truly heart- rending, to see the wretched father come to weep over these miserable remains of his once enviable family." Senile dementia may be regarded as another variety, although when established it differs little in its symptoms from the chronic form. Among celebrated men at an advanced period of life who have succumbed to this form of mental disease, one of England's most distinguished writers and poets may serve as an illustration of the various incipient symptoms and ultimate steady progress of senile decay of cerebral power. When sixty- five years of age there was, we are told in the ' Life of Sou they' (vol. vi, p. 38G), evidence of defective memory on some points, less acuteness of the perceptive faculties, an unaccustomed irritability, confusion of time, and of place, as indicated by his losing his way in well-known places. The vigour of his faculties in general w.is observed by his friends to be weakened, — a fleam or two iin'.v and then of liis former genius, but at other 128 DEMENTIA. times a paiuful absence of his usual animation, perspicuity, and elasticity of mind. His appearance is characteristically described as one of placid languor, sometimes torpor, but generally cheer- ful — all fire and strength gone from his face. We have spoken of the painful consciousness which sometimes marks the first stage of primary dementia. So with the poet. He Avould lose himself for an instant, and, being fully conscious of it, " an expression passed over his countenance which was exceedingly touching, an expression of pain and also of resignation." Then there was the altered step, and the eye fixed, now on space, now wandering anywhere ; now turned to his books as he walked round his library, " taking them down mechanically." Recent events, as is usual, were the first to be forgotten, the memory thrown clearly on the far past, and going back further and further, as the mind approached nearer and nearer to its second childhood. When he could not recall a name he would some- times (his son states) "press his hand upon his brow and sadly exclaim — ' jNIcmory ! memory ! where art thou gone ?^ " The final stage was marked by a dream-like state of existence, which extended over the last — the sixty-eighth — year of the poet's life. In regard to the causes of senile dementia, " it is," observes Prichard, " a condition to which old age may be said to have a tendency, and to which, in the last stage of bodily decay, some approximations are readily to be perceived. The change which time alone will, perhaps, sooner or later, bring on in those who long survive the allotted duration of man's days, may be acce- lerated by a variety of circumstances. Among these, is a life of too much activity and excitement, of mental exertion beyond what the constitutional strength of the individual is capable of supporting ndthout constant effort ; excessive anxiety and eager- ness in the pursuit of business, or intense and unremitted appli- cation to studies of whatever kind. A second cause is the too liberal use of vinous or other alcoholic liquors. The same aflfec- tion has been observed frequently to make its appearance in men long engaged in active pursuits, soon after they have relinquished their business or professions, and have laid them- selves by to enjoy ease and leisure for the remainder of their days. The disease often appears in a more marked and sudden manner in elderly persons, Avho have sustained a slight attack of DELUSIONAL INSANITY. 129 apoplexy or paralysis, which has, perhaps, been speedily reco- vered, and might be expected to have left but slight traces of disease. That expectation is verified, so far as the sensitive and motive powers are concerned, but the seat of intellect is found to have been shaken to its very centre." In the instance of Southey, a severe domestic calamity, with forty years' unin- ternipted brain-work, combined to induce the condition of mind just described. Chemical analysis of the Ijruin, in old age, shows that it ap- proaches nearer to the composition of that of the idiot, in regard to three most important constituents — namely, phosphorus, fat, and albumen ; all of which exist in less quantities in the old and in idiots, than they do in the healthy adult. Section III. — Of Delusional Insanity. From dementia, which, with idiocy, cretinism, and imbecility, belong to deficient conditions of our intellectiial constitution, we pass to DELUSIONAL INSANITY, wliicli, for the most part, exemp- lifies undue intensity of the conceptive and perceptive faculties. The term "monomania" was employed by Prichard in this sense. We may here make a few remarks on the use of the word, though anticipating, to some extent, the next Section. '' Monomania, or partial insanity, is characterised by some particular illusion or erroneous conviction impressed upon the understanding, and giving rise to a partial aberration of judg- ment : the individual affected is rendered incapable of thinking correctly on subjects connected with the particular illusion ; while in other respects he betrays no palpable disorder of the mind." (Prichard.) This definition sufficiently describes intellectual monomania, with which, alone, we are now concerned. There is, however, also an affective monomania ; and a mania without delirium [i. e. without disorder of the intellect), or instinctive monomania; these will demand our attention subsequently. Dr. Falret has been represented as denying the existence of monomania; but, although he objects to the term, and inclines 9 130 DELUSIONAL INSANITY. to the idea of the mutual dependence, or soUdarite of the mental faculties, he appears virtually to admit the condition of mind indicated by it, under the head of " partial expansive in- sanity." ^Nloreau ignores monomania altogether ; and observes, that we are mad or we are not mad ; we cannot be half deranged, or three quarters ; full face or profile. Baillarger, in attempting to show that this writer confounds two distinct things — our mental faculties, and the power which governs them, — makes the following observation : — " If we should discover, for instance, that hysteria and epilepsy only arise after some disorders identical in their dynamic nature, must we, on that account, confound the two diseases? Assuredly not; for the symp- tomatic manifestations are so different, that there are evidently other conditions more than sufficient to maintain the distinction between the two. We have seen how decided are the differ- ences between mania, monomania, and melancholy ; and even if all should originate in a state of brain perfectly identical, it would constitute an analogy among them, but would by no means obliterate the essential differences in character which separate them. In conclusion, I believe that the differences among us are chiefly verbal, and that essentially, and in matters of fact, we are very nearly agreed.'' There is much force in these remarks. The term was first employed by Esquirol. Previously, the word melancholia was made use of ; the employment of which was objected to by that writer, on the ground that partial insanity is not necessarily melancholic. Dr. Prichard makes au objection, to the effect, that had the classic sense of the word " melancholia " not been lost, its adoption to signify pleasurable as well as gloomy, partial insanity, would not have appeared paradoxical, for ancient writers attached no idea of despondency, but only madness to the terra. This, however, is scarcely cor- rect ; for although, no doubt, the Greeks employed the word somewhat loosely, they did certainly attach the idea of gloom to it, when strictly defining it. Hippocrates, in one of his apho- risms, says, " If fear or distress contiime for a long time, this is a symptom of melancholy,"'^ And, in other places, he distin- guishes melancholy from mania, by tlic absence of violence. *► Hi' ipojioQ ij CVT9i MELANCHOLIA. l.J9 melancholia attonita of some writers. If this condition be .still further aggravated — if there be a complete torpor of the mental functions — we then have the condition termed by some foreign writers stupidite, which has already been referred to in a pre- vious section. The melancolie avec stupeur of Baillarger com- prises both these varieties of melancholy. A. B., a young lady, sustained a disappointment of the affections. Dyspepsia and obstinate costiveness followed. Symptoms of mental depression then appeared^ succeeded by refusal to take food, and an attempt at self-destruction. The case then assumed the character of melancolie avec stupeur, profound melancholy accompanied with a state of semi-stupor. The prolonged warm bath, continued for several months, restored this patient to health. The unfavom-able symptoms were always disposed to return on omitting the bath. After her recovery, which was complete, she distinctly remembered the condition in which she had been. The subsequent course of melancholia varies mainly, accord- ing to the constitution of the patient, his age, the degree iu which the disorder is simple or complicated, and the presence of hereditary predisposition to mental disease. It has some tendency to pass into that " tomb of human reason — dementia.'^ '* On looking over our general register at Hanwell,'' observes Conolly, ''this circumstance is continually illustrated, a great number of the patients now surviving, and who Avere marked iu the register, on admission, as affected with melancholy, being now in that state of entire prostration of the intellectual faculties to which we give the name dementia." The statistics of the Retreat show that this tendency is much less marked than iu mania. Thus, out of forty-nine patients who died there, and who had been admitted iu a state of mania, sixteen were examples of dementia ; while of forty-eight who died, and who were admitted labouring under niclancholia, Q\\\y four died in a state of dementia. Esquirol states, as the result of his experience, that in melan- cholia the mortality is one in twelve, while in mania it is only one in tMcuty-five. He regarded it, likewise, as less curable than mania. The prognosis is much more favourable in simple melancliolia, than wlicn complicated with disorder of the intellect. Thus, Guislain ICO MELANCHOLIA. has found tliat he cures nine out of every ten of the former class — nearly the Avhole — but only seven out of the same number of both classes combined. He adds to this statement, " the cure in an ordinary case may require from one to three months ; after that period, all medicine, if the patient is not restored, becomes useless, and even mischievous. The patient's cure, if it take place after this, is due to the effect of nature."'^ Haslam observes, " Patients -who are in a furious state re- cover in a larger proportion than those who are melancholic. A hundred violent, and the same number of melancholic cases, were selected ; of the former, sixty-two were discharged well ; of the latter, only twenty-seven. Subsequent experience has confirmed tliis fact.'' There can be little doubt that these cases of melancholia had not been of the simple form, but had been associated with more or less decided lesion of the intellectual functions. The experience of Haslam has not been confirmed by that of the Retreat ; for at this institution, during forty-four years, the mean proportion of recoveries per cent, of the admis- sions was 53'43 in mania, and 5 i'88 in melancholia. Esquirol states that " a greater proportion of cases of mania is cured than of apy other variety of. madness." In his statistics, how- ever, he did not distinguish melancholia from the other forms of monomania. But even, as Dr. Thurnam observes, " when these two groups are united, the proportion of recoveries from monomania, in this more extended sense, would at the Retreat still amount to 42 per cent. ; a proportion much nearer to that of recoveries from mania than is generally supposed to occur." He suggests that this apparent discrepancy is to be referred to the circumstance of a larger number of the slighter cases of melancholia having been admitted into the Retreat, than under Esquirol at Chareuton. Physical Symptoms. — Among the earliest of these are, loss of sleep and disturbed dreams. We have known cases in which the dread of falling asleep was intensely agonizing, from the anticipation of dreaming, and awaking with horrible sensations. The digestive organs are frequently deranged ; the tongue being imnaturally red or loaded, and the substratum firm, while there is a marked fulness at the epigastrium, and the alvine evacua- * ' IvP^ons Orjilos.' vol. iii, p. 79. MELANCHOLIA. lOl tions are deficient in bile. The tongue may in other cases be flabby, pale, and indented at the edges ; a fixed dull pain, or an ill-defined sense of oppression in the head, is also often com- plained of. Tlie pulse is not usually accelerated, but slow and compressible. The urine is often pale ; sometimes high- coloured, and depositing lithates. The skin varies ; usually harsh, but not unfrcquently moist and clammy. In women, the uterine functions are more or less disordered, and are suspended in the large majority of cases. In men, the reproductive instinct is usually in abeyance. The description given by Esquirol of the patient's physical condition is as follows, but applies to only a certain luimber of cases : — " In person, the melaneholiac is lean and slender ; his hair is black, and the hue of his countenance pale and sallow ; the surface over the cheek-bones is sometimes fluslied, and the skin brown, blackish, dry, and scaly ; whilst the nose is of a deep red colour. The physiognomy is fixed and changeless ; but the muscles of the face are in a state of con- vulsive tension, and expi'css sadness, fear, and terror; the eyes are motionless, and directed either towards the earth or some distant point ; and the look is askance, uneasy, and suspicious.^' Sometimes melancholy induces a passive attitude ; the arms hang loose at the side, the hands are open, and the muscular system is relaxed altogether; at other times, grief intensifies the action of the muscles ; the patient's arms are rigidly flexed ; the hands clasped and pi'cssed against his chest, or he wrings them in all the bitterness of despair. Melancholiacs '' complain," observes Dr. Conolly, " when any distinct complaint is made, of uneasy sensations in the epigastrium, in the left hypochondrium, or other parts of the abdomen ; of a feeling of fluttering, drawing, gnawing, or tearing. They even refer a sense of terror to the epigastrium, accompanying a feeling of having done wrong, without knowing what. These sensations sometimes alternate with uneasiness referred to the forehead and occiput, or to the portion of the head corresponding with the superior and lateral boundaries of the occipital bone." In regard to the comparative frequency of melancholia, it comes next in order to mania. At the Retreat, 45 per cent, of the admissions, during 44 years, were examples of mania ; and 11 162 MELANCHOLIA. 35 per cent, of melancholia. Among the former, however, are included cases in which the two forms alternated, but hi which mania predominated. At Ghent, of 100 admissions during a series of years, 35 were maniacs ; while 25, or one quarter, were the subjects of melancholy. Dr. Parchappe found at his asylum, at Rouen, that 42 per cent, of the admissions Avere maniacs; while 25, the same proportion as at Ghent, were melancholiacs. We may, therefore, calculate that about a quarter, probably rather more, of the admissions into asylums for the insane afford examples of melancholia. Melancholia may be simple; complicated; acute; chronic; remittent ; or intermittent. I. Simple form. There is here no disorder of the intellect, strictly speaking; no delusion or hallucination. It is the melancolie sans delire of Etmuller and Guislain ; the lypemanie raisonnante * of Esquirol ; and the melancholia simplex of Heinroth. As there is not unfrequently a misapprehension of what Dr. Prichard intended to comprise under the term ''moral insanity,^^ we are especially anxious to state, in this place, the relation which simple melancholia bears to this form of meutal alienation. It appears to be very generally supposed that, by this term, only those disorders are to be understood in which the animal propensities are under the influence of morbid ac- tion, without any aberration of the intellectual faculties. This is not only wrong in theory, but it occasions much practical mischief. If moral insanity be only spoken of and recognised when vicious acts are threatened or committed, it is natural that the doctrine of moral insanity shoidd be brought into dis- repute, or altogether disregarded ; and that a very erroneous idea should be attached to its area and limits. But if it can be shown that the disorder at present uiulcr consideration may co-exist wdth a sound condition of the purely intellectual * Strictly sjjeaking, however, Esquirol did not emjiloy this term except when the patient is conscious of liis malady. He speaks of such being " sans cesse ramenes par la passion qui les domine aux mcmes idees .... au mcme delire " (vol. i, 420), not sans delire. Some of the most difficult cases of cure, in our experience, are among those who arc conscious of their state ; whereiis melancholia without disorder of the iutcUccL has proved a favourable form of the disorder. I MELAiNCliOLlA. 163 part of our meutal coustitutiou, the proposition of the existence of what Prichard termed (somewhat unhappily) moral insanity will not stand out in such prominent relief in its relation to vice, nor run so perilous a risk of being regarded as the mere apology for crime. Dr. Prichard himself expressly tiays, "The term which I have adopted as designating this disease (moral insanity), must not be limited in its use to cases which are characterised merely by preternatural excitement of the temper and spirits. There are many other disordered states of the mind, which come mider the same general division. In fact, the varieties of moral insanity arc, perhaps, as numerous as the modifications of feeling or passions in the human mind. The most frequent forms, however, of the disease are those which are characterised either by the kind of excitement already described, or by the opposite state of melancholy dejection." And, again, the same writer observes, " A considerable proportion among the most striking instances of moral insanity are those in ■which a tendency to gloom or sorrow is the predominant feature. "When this habi- tude of mind is natural to the individual, and comparatively slight, it does not constitute madness. But there is a degree of this affection which certainly constitutes disease of mind, and that disease exists without any illusion impressed upon the understanding. The faculty of reason is not manifestly im- paired, but a constant feeling of gloom and sadness clouds all the prospects of life. The individual, though surrounded by all the comforts of existence, and even (exclusively of his disease) suffering under no internal source of disquiet, — at peace with himself, Avith his own conscience, with his God, yet becomes sorrowful and desponding. All things, present and future, are, to his view, involved in dreary and hopeless gloom." (' Treatise on Insanity,' p. 18.) "I meet every day,'' observes Guislain, " with melancholiaes who do not exhibit any disorder in their ideas, or lesion of the judgment." " Melancholia is exclusively an exaggeration of the affective sentiments; it is, in all the force of its signification, a gemilthskraakheit, in the sense in which the word is employed by German psychologists. It is a pathological emotion, u sad- ness, a chagrin, a (ear or dread, and nothing more. It is not a 164 MKI-ANCHOLIA. condition -vrhich sensibly weakens the conceptive faculties." {' Lc9ons Oralcs/ vol. i, p. 112.) Simple mclanclioly, tlien^ as is so emphatically laid do-^n by these writers, may exist in association with normal action of the intellectual functions, and is, therefore, fairly illustrative of what Priehard called moral insanity. Here, hoAvever, the doctrine is not fraught with consequences so important to society, nor does it interfere with the prejudices of mankind to a like extent, as when applied to the diseased workings of the propensities common to us and to the lower animals. And yet if it be ad- mitted (and every writer of authority does admit) that a profound melancholy, for which the patient is irresponsible, is not incon- sistent Avith the normal operations of the intellect, we are called upon to admit no new doctrine in mental pathologv', Avhen asked to believe that a like condition of the intelligence may co-exist with a homicidal propensity, in however small a proportion of cases this may actually occur. There is occasionally a very marked physical disturbance im- mediately preceding attacks of mental depression. We have a patient who describes the sequence of her sensations with singular minuteness : the first in the series being a sense of intense oppression at the heart, which appears to her to extend gradually upwards, and is followed by extreme dejection of mind. It is to such cases that the Professor of Ghent refers when he says, " There is a melancholy which I call anxious or pneumo-melancolie , on account of the disturbance of the tho- racic organs. The distress which the patient suffers sometimes resembles attacks of suffocation. Occasionally this condition is associated Avith hysterical symptoms, but generally this is not the case. It is sometimes preceded by a painful feeling, which the patient refers to the region of the heart. This state may last two or three months before decided mental disorder is mani- fest. The patient loses his sleep ; he is harassed with gloomy ideas ; his features become altered ; anguish, accompanied with vague forebodings, aimounces the debut of the malady." He adds, "This variety of melancholy scarcely passes, in some cases, beyond the character of moral insanity. It is then free from all disturbance of the intellectual powers; so that the patient unceasingly complains to those who enjoy his confi- Mi:i-\Nriioi,i.\. in." deuce, tliat he is afraid he will lose his mind. I have known patients who have lived two or three years iu tliis condition, without haWng ever suffered the least derangement of the un- precursor of an attack of epilepsy ; it constitutes the prodromic stage of suicidal insanity. It is not uncommon in females at the climacteric period.'' It is the precordial angst of Dr. Flemming. Nostalgia {votrrog, return; aXyog, sadness), home-siekucss, may sometimes be a variety of simple melancholia. Array surgeons see the most of it. In six years, 1820-6, no fewer than ninety-seven soldiers in the French army fell a sacrifice to this disease. Young men and those from the country are more liable to be thus attacked than older men, and those accustomed to city life. The inhabitants of mountain districts — the Highlander and the Swiss — are observed readily to droop and become nostalgic when abroad. Gavin, however, quotes from Dunlop, the fact that the only two examples of nostalgia which occurred to him were, in a recruit, a country lad, from the fens of Lincolnshire, who died of the disease; and in a London pickpocket, whom he saw in 1824, in the hulks at Sheerness. In a case we recently met with, the patient was a Si)aniard, and died very unexpectedly with cerebral symptoms. His pre- vious mental condition was characterised by apathy and a desire to return home, \Wthout any very definite indications of physical disease. Probably, no one had greater opportunities of observing this disease than the celebrated Larrey. He Mas decidedly of opinion, from the observation of a large number of cases, that the mental faculties in nostalgic patients ai'c the first to undergo a change. Unquestionable aberration of mind was present in the cases which he has recorded. This was evidenced by the great exaltation of the imaginative faculty. The prospect of their native home presented itself to their mind's eye, like the fata morgana to travellers in the desert, depicted in the most extravagant and delusive hues which a morbid fancy could suggest. All this is often in the most violent contrast to the rude, uncivilized, and poverty-stricken home which their better reason might suggest as the sober reality. This state of cerebral ir.O Mr.LANCHOLTA. excitement is accompanied, at the coramencemeiit of the dis- order, by corresponding physical symptoms. Tlie heat of the liead is increased — the pulse accelerated ; there is redness of the conjunctiva; : and unusual movements of the patient may fre- quently be observed — pei'haps occasioned by the uncertain pains in various parts of the body, of "which he usually complains. The bowels are constipated ; there is a general feeling of oppres- sion and weariness, indicated bj^thc patient frequently stretching himself and sighing. There is an inability to fix the attention, and the conversation is, in consequence, somewhat unconnected. The symptoms which succeed are a sense of weight, and pain in all the viscera. The deficiency of nervous power produces a torpid and partially paralysed condition of the stomach and dia- phragm. The symptoms of gastritis, or gastro-enteritis, which immediately supervene, jNI. Larrey considers as but sequela*. The phenomena next presented, as the febrile symptoms in- crease, are those which we ordinarily observe when there is great derangement of the digestive functions, accompanied by fever. The prostration of strength which marks what may be called the third period of the disease is very great. The mental de- pression keeps pace with the decline of bodily strength, and is often manifested by Aveeping, sighing, or groaning. A symptom resembling that of hydrophobia is sometimes present, — namely, great aversion to the sight of clear liquids, as water, together with the nsual disgust of food. A propensity to suicide is not unfi'equently manifested when the debility becomes extreme; paralysis is also common ; but, generally, death is the result of a gradual exhaustion of the vital powers. M. Larrey witnessed, during the retreat from INIoscow, a large number of his comrades perish in a similar condition of mind and body, from the effects of intense cold. It has been frequently remarked, that the inhabitants of cold and moist, or of mountainous countries, are the most liable to the moral impressions which are the origin of nostalgia. The Dutch are a notable example among the inhabitants of a cold and moist, and the Swiss among those of a mountainous climate. Larrey found, that tlie troops enlisted from these two nations were precisely those which, during the disastrous campaign of Moscow, and the cruel vicissitudes experienced, afllbrded the MFJ.ANCIfOLIA. 107 greatest number of victims to tliat morbid cerebral condition, so similar in its symptoms to nostalgia. It was observed, on the other hand, that the army of Napoleon, which served in Egypt, did not produce a single case exhibiting the least symp- tom of nostalgia. On the contrary, the soldiers became exceed- ingly attached to the climate, so as almost to consider it a second home, and, like the Israelites of old, there was not one among them who did not sincerely regret leaving the land of Egypt. The hospital, especially during the year 1820, received many patients from among the Swiss Royal Guard, which were sent thither for undefined complaints, which, however, speedily merged into decided nostalgia ; and this disorder seemed most extensively prevalent during the extreme height of the baro- meter. Larrey cites the case of a soldier in the first Swiss regiment. His state did not appear alarming to Dr. Comae, his physician, when he first entered the fever wards. One day, however, when Larrey visited him, he was informed that the unfortunate man had committed suicide, and, hastening to his assistance, found him weltering in his blood, and at the point of death, from a large wound in the region of the heart, inflicted with a knife. At tlie^os^ mortem examination, on sawing open the skull, M. Larrey was surprised to find a layer of lymph and purulent matter between the dura mater and the pia mater, which covered the entire circumference of the brain, and involved also the arachnoid membrane. On the cortical substance of the brain, especially towards the anterior lobes, and at the superior edges of the hemispheres, many points of suppuration were ob- served. The sinuses of the dura mater, as well as all the vessels of the head, were gorged with black blood ; the ventricles con- tained a rather large ([uantity of serum ; the base of the cere- brum and cerebellum alone remained sound. From the facts of this case, we may, with Larrey, draw the conclusion, that a deep moi'al sentiment, the desire to revisit his native country, was the cause which gradually developed the cerebral disorder preceding the act of suicide in this Swiss, — an act which may be regarded as independent of the patient's volition. In a similar case, opening the skull and the vertebral canal exposed to view a layer of lymph, which covered the 168 MEI.ANCHOJ^IA. hemispheres of the brain ; it was formed beneath the dura mater; yellowish points of suppuration penetrated^ ver}' deeply, into the anterior lobes of this organ; and a considerable quantity of reddish serum filled the lateral ventricles. The encephalon itself was hardened, and the membranes of the spinal cord inflamed. In another patient, who died of the same disease, similar morbid appearances were discovered. There are misanthropical and love -sick forms of melancholy, which may here be enumerated, but do not require any special description. The latter rarely attains to a sufficient degree of intensity to render necessary the restraint of an asylum. Guis- lain estimates its frequency at one in four hundred admissions at the institution at Ghent. Misanthropical melancholy rarely presents itself to our notice in an uncomplicated form, so severe as to constitute mental disease; but, as has been justly ob- served, an aversion to human society, a desire for solitude, and a repugnance to the pleasures of the world, constitute the very essence of all melancholy. {' Lemons Orales,^ vol. i, p. 125.) Hypochondriacal melancholy is by Guislain classed under the head of melancholy without disorder of the intellect, that is, simple melancholia. It is, however, so very generally accom- panied by decided delusions, that it will be more convenient to consider it under the complex form. II. Complicated melancholia, or melancholy with decided disturbance of the intellectual faculties. {Mi'lancolie avec de- lire, la melancoUe deUrante of French writers.) This we believe to be more common than the simple form. Guislain, however, states that in his experience they are of equal frequency. About 13 per cent, of the admissions into his asylum at Ghent were examples of each form. Hypochondriacal melancholy . — INIuch confusion exists in regard to the boundary line between what is populai'ly called hypochon- driasis and genuine mental disease ; and, in truth, this confusion arises, in great measure, from the inexact limit which separates the one from the other in nature. In a particular case, it is often impossi])le to determine the precise period of the super- vention of cerebro-mental disease. Guislain (op. cit., vol. i, p. 119) goes further than most writers, in including hypochon- driacal symptoms under insanity. " Hypochondriasis," he MKL.VNCllOl.I \. ]<■)<.) observes, " is a disorder of the affective faculties — most cer- tainly an alienation. This is proved by the affection being transformed into other mental diseases/^ He divides it into two classes — bodily and mental. Patients afflicted with the former " believe themselves invalids and in suffering : they believe they have every infirmity and every complaint. They experience all the diseases Mhich they hear mentioned. They apply to doctors, to charlatans, to druggists, to quacks, in order to have the disease explained to them, and to obtain remedies, which they generally take with avidity." He estimates that two patients out of every hundred are admitted at Ghent, in consequence of this condition — of course, in an advanced stage. In a common case of this description under the Mritcr's care, the patient, a married woman, was constantly wishing him to prescribe for some fresh symptoms of an alarming cha- racter. Among his notes of this case he finds the following : — " Subject for seven years to attacks of pain in different parts of the body, especially the abdomen ; palpitation, vertigo, &c. Is now fifty-eight. No family. Has the most absurd apprehensions. Is always worst in the morning ; not when she wakes, but at about seven. Improves as the day advances. On one occasion she seemed like a pci'son under the influence of strychnia ; was relieved by calomel and opium. Is constantly dwelling on her state. Great dread of death. Is frequently in bed for a day or two, apparently at death^s door, but without a single morbid physical symptom of real importance; not materially relieved by valerianate of zinc." Such cases, more or less marked, abound in the experience of every physician. "When occurring in the female, they generally assume a more decidedly hysterical form. In another case, that of a gentle- man, the patient was firmly convinced that the testicles had wasted away, and brooded over the supposed loss of repro- ductive power. This is not an uncommon notion with hypo- chondriacal men. To comprehend clearly what relation hypochondriasis bears to melancholy, and the distinction which is to be drawn between the former as employed in its loose, popular signification, and those closely allied forms of indisputable mental disease now under consideration, it will be convenient to consider the symp- iro :\rFi,A\f'ii()LiA. toms of liypoclioiulriasis, and the sense in which the word has been employed. Authors have divided hypochondriasis into three stages; the following are^ for the most part^ adopted by M. Dubois, in his work specially devoted to the investigation of this dis- order. 1. Concentration of all the patient^s attention upon his own maladies. Mental disturbance, excited by the most trifling sensations. Curable. 2. Anxiety of mind increased ; and constant fear of death harasses the patient. If the digestive organs are more particu- larly the seat of complaint, he suff'ers from gastralgia, constipa- tion, dysphagia, &c.; if the organs of circulation, palpitation, dyspncea, throbbings of the arteries ; if the sensations arc general, inertia, languor, sweats, and flying pains. Often, also, the pa- tient has special delusions and illusions respecting his physical condition. Recovery possible. 3. Aggravation of all the symptoms, chronic inflammations of various viscera, and structural changes, especially of the digestive system. {Sapissime cum viscerum abdominalium disorffan- isationibus conjunctum. Richter.) Next, in frequency, are afl'ections of the thoracic organs. Symptoms sufficiently decided to make it certain that there are serious organic lesions. Reco- very almost hopeless. [Tunc prof/nosis quemadmodum in morbo fere semper material} orf/anico, scepissimc infausta. Jahn 196. Ilaase 293. ' Histoire Philosophique,' p. 291.) The division into the preceding stages is somewhat arbi- trary ; the first and second may, however, be conveniently dis- tinguished from the third, for it is important that the student should remember, that hypochondriasis may be associated with actual and fatal diseases, however much the sensations may be exaggerated by the patient. On clearly distinguishing between these stages of the disorder — that in which there is, and that in which there is not, organic disease — his success in prognosis will dcj)end. Hypochondriasis is thus grajjliically dcscril)ed by Sydenham: — " Nor arc the unhappy suflerers from this disease aficcted and shaken in body only — shaken so, as like a ruined building to ajipear upon the eve of falling — but their mind is sickened more tliau the body. An incura))lc despair is so thoro;;irhly the nature .AfKT.ANrilOl.l A. 171 of the disease, that the very slightest word of hope creates anj^er. The patients believe that they have to suffer all the evils that can befall humanity ; all the troubles that the world can supply. They have melancholy forebodings. They brood over trifles, cherishing them in their anxious and unquiet bosoms. Fear, anger, jealousy, suspicion, and the worst passions of the mind, arise Mithout cause. Joy, hope, and cheerfulness, if they find place at all in their spirits, find it at intervals, ' few and far between,' and then take leave quickly. In these, as in the painful feelings, there is no moderation. All is caprice. They love, Avithout measure, those whom they will soon hate without reason. Now they will do this — now that; ever receding from their purpose. All that they see in their dreams are funerals and shadows of departed friends. Thus, they are racked both in mind and body, even as if life Mere a purgatory, wherein they expiated and paid the penalty of crimes committed in a previous state. In all this, it is neither the maniac nor the madman that we write about, — saving and excepting the hallucinations afore- said ; those who thus suffer, are persons of pnulcut judgment, — persons who, in the profundity of their meditations and the wisdom of their speech, far surpass those whose minds have never been excited by such stimuli." ('Epistle Dedicatory,' section 75.) A reference to these descriptions of hypochondriasis will show liow closely the symptoms essential to the disease border on insanity ; and how some of those enumerated by authors, as of frequent occurrence, are inseparable from imsoundness of mind. Thus, we have '' often special delusions and illusions regarding the patient's physical condition," " an incurable despair," &c., &c. Hence it is evident that authors have described, under the same name, a disease which, according as it assumes a mild or a severe form, may present very diflerent aspects when viewed from a medico-legal standpoint ; and which, in its former phase, may be regarded as simple hypo- chondriasis ; but Avhich, in the latter, may properly be termed hypochondriacal melancholy, or melancholy, the prominent symptoms of which are of a hypochondriacal nature. To ascer- tain, in jartieular cases, when the one begins and the other ends is doubtless often a problem, the .solution of which will tax all the acutencss of the psychologist; but th.e difficulty is 172 MELANCHOLIA. not perhaps greater than that of deciding, in some cases, where what is popularly understood as nichmcholy ends, and the genuine melancholia of psychologists begins."^ Hypochondriasis may certainly exist with the latter, and of course melancholia may be present without hypochondriasis ; but the two are frequently combined; and for this combined morbid condition we do not know that there is any better phrase than hypochondriacal melancholy. In simple hypochondi-iasis, the patient fears, without any sufficient reason, that he will soon die in consequence of his supposed complaints; but when insanity more decidedly supervenes, he may fear that he w411 be poisoned, or have his life terminated by other violent means. Again, in simple hypochondriasis, the patient exaggerates the importance of a trifling, but probably an actual, ailment. AYhen, however, there is well-marked cerebro-mental disease, he will invent the most absurd and impossible maladies that can be conceived, and become possessed with delusions which will leave no doubt as to his insanity. Thus a patient, to whose case we shall shortly refer, gravely attributed the eructations from which he suffered to the three frogs mentioned in the Revelation of St. John. AVhile, however, as in this instance, the character and gross- ness of the patient's conviction will lead us to decide upon his insanity ; in others, this opinion may be formed from collateral circumstances. Thus, it may happen that, in two cases, the error under which the patient labours will be precisely the same, and yet we may be justified in arriving at the conclusion that, in the one, the false conviction is, and in the other it is not, the result of cerebral disease ; this opinion being formed indepen- dently of the character of the delusion, from a consideration of various facts, proving the existence of ccrcbro-mental dis- order. The case of Buranelli, who was executed for murder in 1855, was a remarkable illustration of the ill-defined boundary line which often separates these affections, and of the difficulty Mhich exists when this occurs, and when the case involves the question of criminal responsibility, of deciding upon the existence of cerebro-mental disease. The medical evidence given at this * The subject is more fully treated of l)y the author in the ' Asylum Journal of Mental Science,' January, 1857. MELANCHOLIA. 173 trial may, in connection with this subject, be advantagcoiisly read in the 'Journal of Psychological Medicine,' July, \H')~). !M. ^lichea, ■svho has Mritten a treatise on hypochondriasis, concludes that this affection must be regarded as without the pale of insanity, so long as the depression of mind is not the consequence of a delusion {idee fioee), so long as it has not for its exclusive object an extreme fear of death, and so long as it yields promptly to consolations offered, and to reason. ^lany of the observations now made in regard to the relation which hypochondriasis, in a simple form, bears to hypochondri- asis complicated with decided ccrebro-mental disease, apply to hysteria when regarded from the same point of \'\c\\. Hysteria is not insanity. But there is a form of mental disease in which aggravated hysteria constitutes a prominent symptom ; and which, except in degree, can with difficulty be distinguished, in some cases, from simple hysteria. It may here be observed, that hypochondriasis and hysteria have been regarded as identical diseases by Piso, Hygmore, Sylvius, Sydenham, Boerhaave, A'au-Swieten, Lorry, Tissot, and other medical writers. ( Vide Dubois, op. cit., p. 330.) They have been distinguished, however, by Celsus, Paulus ^'Egineta, Stahl, CuUen, Pinel, Mllermay, Georget, and others ; and there are, undoubtedly, many distinguishing signs. Thus, while hypochondriasis affects both sexes, but principally the male, hysteria affects the female sex almost exclusively ; while the mode of invasion of the one is slow and gradual, that of the other is characterised by sudden attacks ; while the former is marked by the symptoms already described, there is usually present in the latter, the globus hystericus, a facial expression better known than described, and attacks of partial or complete unconsciousness, convulsions, spasms, and even lock-jaw. Some remarkable instances are on record, in which intense mental emotion has appeared to be followed by changes in par- ticular structures, in relation to which the emotion was excited ; and which would seem to suggest the probable course w hich some cases, at least, of hysteria and hypochondriasis may have taken. As some of these may seem too rcmarkal)lc to be easily credited, we will refer to a case well known to ourselves, — that of a highly respectable and most intelligent lady, in which this phenomenon was exhibited. This lady was one day walking 174 MEl.ANCllOLlA. pus;t a public iustitutioUj uiul observed a childj in ^vliom she was particularly interested, comiug out through an irou gate. She saw that he let go the gate after opening it, and that it seemed likely to close upon him, and concluded that it would do so with such force as to crush his ankle ; however, this did not happen. " It was impossible," she says, '' by word or act, to be quick enough to meet the supposed emergency ; and, in fact, 1 found I could not move, for such intense pain came on in the ankle corresjjonding to the one which I thought the boy would have injured, that I could only put my hand on it to lessen its ex- treme painfulness. I am sure 1 did not move so as to strain or sprain it. The walk home — a distance of about a quarter of a mile — was very laborious, and, on taking off my stocking, I found a circle round the ankle, as if it had been painted with red-currant juice, with a large spot of the same on the outer part. By morning, the whole foot was inflamed, and I was a prisoner to my bed for many days." Now, if, as in this instance, a powerful emotiou, directed into a certain channel, can result in such marked physical changes, without the agency of any local cause, is it not highly probable that, in some instances, the firm conviction of an individual (it may, or may not be, the consequence of cerebral disease), that he has, or is about to have, some particular disorder, and the constantly dwelling upon and dreading it, may produce, by some mysterious power, the very disorder upon which his apprehen- sions are concentrated ? Melancholy may be complicated with many other delusions, besides those we have considered in connexion with hypochon- driasis. Some of these have unavoidably attracted our attention when speaking of delusional insanity. jNIany insane persons have liallucinations, and very definite delusions of a gloomy character, in regard to what is going to happen to them. Doubtless, in the large majority of cases, the delusion derives its tone entirely from the disorder of the affective faculties. Be this, however, as it may, the patient no longer suffers from simple melancholia ; the disease is compound ; the integrity of the understanding is impaired. Religious melancholy [nieluncoUe reliiji(juse, monomaiiic religleuse of French writers) may, or may not, be associated with disturbance of the intellectual faculties. As it not uufre- MhLANCHOLlA. 175 queutly is so, it may properly be considered in this place. Init, it may be well to observe, that Dr. Prichard draus from theuce some of liis illustrations of " moral insanity. '^ ;Many patients become victims to the most gloomy fancies, and the conscience becomes so morbidly acute, that " Nij^lit-riding incubi Troubling the fantasy. All dire illusions Causing confusions; Figments heretical. Scruples fantastical, Doubts diabolical," — are incessantly presented to the mind, and life is rendered into- lerable by perpetual misgivings as to the propriety of the most trifling circumstance ; or, the patient may be unceasingly en- gaged in devotional exercises. An Irish priest in the Bicetre kneeled so constantly, that his knees were almost completely anchyloscd, the skin also becoming as tongh as leather. Plutarch has given a graphic sketch of the condition of those labouring under religious melancholia in his day, or the super- stitious {EiKTi^alfioviai), as he terms them. It would be difficult to employ more appropriate language for the present purpose. " To such a man, every little evil is magnified by the scaring spectres of his anxiety. He looks on himself as a man whom the gods hate and pursue with their anger. A far worse lot is before hira ; he dares not employ any means of averting or of remedying the evil, lest he be found fighting against the gods. The physician, the consoling friend, are driven away. ' Leave me,' says the wretched man, — ' me, the impious, the accursed, hated of the gods, to suffer ray punishment.' He sits out of doors, wrapped in sackcloth or in filthy rags. Ever and anon he rolls himself, naked, in the dirt, confessing aloud this and that siu. He has eaten or drunk something wrong; he has gone some way or other which the Divhie Being did not ap- prove of. The festivals in honour of the gods give no plcasui-c to him, but fill him ratlier with fear and affright. He proves, in his own case, the saying of Pythagoras to be false that wc are happiest when we approach the gods, for it is just then that he is most wretched. Temples and altars arc places of refuge for the persecuted ; but where all others find deliverance 176 MliLANCHOLlA. from their fears^ there this -wretched man most fears and trem- bles. Asleep or awake, he is haunted alike by the spectres of his anxiety. Awake, he makes no use of his reason ; and asleep, he enjoys no respite from his alarms. His reason always slum- bers; his fears are always awake. Nowhere can he find an escape from his imaginary terrors.^' A case possessing some points of interest fell under the writer's notice several years ago, — one of religious melancholia (with, as it afterwards proved, an absorbing delusion), accompanied by symptoms of a trance-like or cataleptic character. A female servant, under twenty, had only been in service two days ; had not been considered out of health ; catamenia regular. She, how- ever, herself observed that her tongue was very much furred, and pointed it out to some one in the house. In the evening her master rang the bell several times w'ithout being attended to. On going into the kitchen in consequence, he found the servant standing motionless Avith her eyes and hands raised in the atti- tude of prayer, " as if in a trance." She did not reply to his questions, nor cry, nor laugh. For three days slic remained in this statue-like condition, totally unconcerned about what was passing around her, but occasionally saying " yes," when asked a question ; wdthovit, however, any regard to the sense. When seen by the Avritcr on the fom-th day, she was in the above con- dition ; frequently, but not always, placing herself in the attitude of prayer, and apparently absorbed in devotional exercises. When the arms were raised, a heavy weight was attached to one of them by a cord. When this was suddenly cut, the arm re- bounded very slightly, showing that it was not retained in that position by the mere exercise of the will. On being addressed, she stared with a vacant expression, and would sometimes whisper " yes." The tongue was covered with a thick brown fur; the pulse about 88, soft; the bowels constipated. (It appears that her paternal grandmother was confined in an asylum.) A purgative was administered; motions and urine passed in bed. She M'as with great difficulty induced to take food. On the fifth day she began to talk more freely and to look better. On the sixth she relapsed, was quite silent, and passed her evacuations in bed. Tongue much cleaner. A shower bath was given, which was violently opposed. In a day or two she improved again ; wine and ammonia were given, but she again fell into her former Ml'.LANCUOLIA. 177 state. From this she suddenly emerj^ed, without any apparent causCj four weeks after lier first attack. She appeared then quite well in mind, and told the writer that she had all the time be- lieved she was about to be burnt upon a fire or in oil, and that the reason she would not eat was because she believed she should be burnt the moiiient she did so. She had experienced frightful dreams, which added to her apprehension of some impending calamity. She also fancied that it was " the last day of the world.'' She stated she was now perfectly convinced that these impressions were delusions, but that even now, especially at night, they presented themselves very strongly to her. "With regard to her state at the time she became ill, she said she had felt sick and out of order for several days before going to her situation. We may illustrate this form of insanity by an interesting case, in which the religious depression, and the delusions springing out of it, were intimately blended together. The patient, a gentleman of highly cultivated mind, (with hereditary predispo- sition, and the father of three sons more or less deranged,) be- lieved himself doomed, by an irrevocable decree, to eternal flames. He imagined that an entire change had taken place in the state of mankind ; that all, except himself, had entered upon a state of bliss, but that he was reserved for everlasting torments, as an atonement for the sins of the whole world. He stated, that he had heretofore entertained the same views as others in regard to the character of Jesus Christ — namely, that His sufferings had obtained a general atonement ; but that he had now found that Christ was a triumphant, he a suffering Sa- viour. He now perceived that the Scriptui'cs, and many other books, were full of predictions respecting himself; that the ac- counts of Cain, Esau, &c., although historically true, had a relation to him; that he was the son of perdition, the scape-goat, the man of sin, spoken of in the Bible ; that, in fact, both the Old and New Testament were full of predictions respecting him. AVhcn dissent from such views was expressed, the patient would respond, " Oh, I know you will deny it ; you are bound to deceive me. I do not mean voluntarily, but from the fictitious state of your own existence. You are only the corpse, the remains of your- self. It is, to be sure, idle to talk of my state to you ; but the heart that is full seeks, though in vain, to vent itself." When the individual thus addressed assured him, that he had as firm 12 178 MELANCHOLIA. a conviction of his existence in the same state of body that he had always been in, as he could possibly have respecting the mysterious change -whicli he supposed we had all undergone ; and that, as he (tlie patient) was quite singular in his opinion, he must allow, that there was the strongest possible evidence against the correctness of his views : '' I would admit it," replied he, '' if there were another human being in the world but my- self; but, alas ! all the appearances of existence in persons and things around me are fictitious ; all are enjoying felicity but myself. I only am reserved to endless torment. Everything has changed its aspect. Objects around me are no longer seen in perspective, but appear flat, and raised one above another, like a Chinese drawing. Spring will no more return." When a confident belief Avas expressed that spring would rctiu-n, and a hope that it would remove his apprehensions, " They are not apprehensions," he replied, with earnestness ; " they are con- victions ; but if spring does return, and resume its usual appearance (I don't mean a few crocuses and snowdrops), I will acknowledge myself in error." At the close of an interview Avith this patient, who was not then in an asylum, "It may seem strange," he said, " to ask you to visit me again, but I shall be glad to see you ; for even the shadows, the resemblances, of those we know, are pleasant amongst strangers." The power of self-control was singularly illustrated by a cir- cumstance which occurred in the course of this case. At the very time when he could not restrain the expression of his gloomy feelings before his wife, and coidd not attend in the least to his family aff'airs, he paid a \isit to the poet Southey. Subsequently, the poet, who was cognizant of his guest's mental infirmities, expressed to the patient's wife the satisfaction he experienced in seeing him so well ; and added, he never kneWj- him reason more clearly. On the wife repeating this to her husband, he exclaimed, " Why, you know, I could not think of showing my weakness before him." The unintentional con- fession of his weakness is also an interesting feature in this reply. C. D — was another case of a very painful character, in which melancholia alternated with mania. The patient, also a gentle- man, imagined (although he had led a regular and religious life) that he had entirely neglected his duties, and that he would MELANCHOLIA. 179 therefore be burnt alive as a sacritice to an oftended Deity. Three months after he was placed in confinement, he became maniacal, vociferating and swearing constantly. These symp- toms passed away, and the former state of despondency returned, accompanied by a suicidal tendency. During four months these opposite conditions frequently alternated — a phase of insanity popularly known as " high and low.'^ At last, while in his low mood, he suddenly became cheerful, and spoke ration- ally. Undisturbed sleep, to which for long he had been a stranger, followed, and he recovered perfectly. He subse- quently married. The inquiry into the connexion between religion in its various forms, regarded as a cause* and the occurrence of religious melancholy, is one of great interest, and opens a wide field for observation. It is hardly necessary to say that Christianity undistorted, and preached in its just proportions, is calculated to prevent, not cause, insanity. The exciting cause of religious melancholia is sometimes to be traced to the fiery denunciations of a well-meaning but inju- dicious preacher. It is remarkable that, even in pagan times, Marcus Aurelius made a law condemning to banishment those " who do anything by which men' s excitable minds are alarmed by a superstitious fear of the Deity." If the modern authors of such fearful results are not themselves to suflfer banishment, it is heartily to be wished that the practice were entirely banished from the pulpit. In the following case the mental disorder was closely con- nected with, if not caused by, unwisely prolonged religious exercise. E, F — , aged sixteen, was apprenticed to a whitesmith, and bore an excellent character. One Sunday evening he went to a ^Methodist chapel, and from thence, with some of his ac- quaintance to a private house, where a party met for the purpose of prayer and exhortation (or, as it proved, excitation). Tlic boy • At an early period of liis observation — before the npread of intidel principles in France — Pinel calculated that about one fourth of the cases of insanity with the causes of which he was acquainted were due to excessive religious enthu- siaaui ; whili-, at a later period, Esquirol found that, in upwards of GOO lunatics iu the Salpetri^re, tliis was the cause in only eight cases, and, in 337 admitted into his private asylum, this was supposed to be the cause in only one instance. In the place of religious, iwliticul excitement became a fruitful cause of insanity. 180 MELANCHOLIA. returned home at half-past ten o'clock. The Bible, which his father had been reading, lay on the table, so he read several chapters in it, and tlien prayed himself in a somewhat excited manner. They slept in the same room, and his father observed that he lay awake some hours, frequently sighing, but was not " irrational." On returning home from his work in the evening, he found his son had been unable to work during the day, had eaten nothing, and was in a state of great depression, accom- panied by a tendency to stupor. On the next day, when a gentleman called at the house, he clasped his hand in his, burst into tears, and talked incoherently. He evidently could not collect his thoughts, and was labouring under a sense of unde- finable alarm. He was reluctant to walk or to sit down when desired to do so, but did not exhibit any aversion to his friends. For several days he continued in much the same state, and was mostly silent. The warm bath and purgatives were followed by complete recovery, and at the end of a fortnight he returned to his work. We may add that he subsequently married, settled respectably in life, and made an efficient workman. He had no relapse. " Revivals " are not unfrequently the ex- citing cause of religious depression. To this subject we shall again refer, when speaking of religious exaltation. Melancholia, as has previously been stated, may be acute or chronic ; and this, of course, may be the case, whether it be simple or complex. The term acute, as applied to dementia, has reference in general rather to its duration than to its clia- racter ; just as we often speak of acute rheumatism (the symptoms of which may be mild), to distinguish it from the chronic form. When applied to melancholia, however, the terra conveys, in most instances, a correct impression of its character ; and, when exhibited in this active phase, it is truly distressing to witness. The writer has now in mind a case very illustrative of this condition ; and he mentions it here, not as in any way remark- able, but simply as a type of the class. The patient, possessed of good general ability, and a skilful artist, would sit crouched for hours, covering his face with his hands, bitterly bemoaning his lot; at other times silent, with the exception of groans and sighs. His suffering appeared to be most acute. His expres- sion was intensely sad ; the facial muscles fixed, as if by spasm, MKI.ANCHOLIA. l«l ami altogether expnssive of concentrated grief. But, while exquisitely sensitive to his condition, he never wept ; a reference to the causes of his dejection never caused a tear, but only an obstinate rejection of all proffered consolation. This complete absorption in grief tyrannized over, rather than extinguished, his purely intellectual faculties. His power of recollection was as acute as ever, but he recalled the sorrows, and not the plea- sures, of memory. The comparing faculty was in action, but only engaged itself upon contrasting his former happy with his present miserable condition. His judgment was still good, except when he judged himself to have more"* cause for grief than any one else in the world ; and as to his reasoning powers in general, it was a case in which, to a very great extent, the patient reasoned correctly enough, only from false premises. His perceptive faculties were sufficiently quick, but he perceived only the dark side of his case. His imagination was but too active in painting all the sufferings which awaited him. In short, he was full of fears, devoid of hope, and seemed as if he " would not if he could be gay." This patient died of phthisis, and, till within a few moments of his death, manifested the same acute symptoms of melancholia. Chronic melancholia is but too frequently the sequence ofthe acute condition. It often alternates with mania, and its ten- dency to pass into dementia has already been noticed. The dis- order may also be decidedly intermittent. All the varieties of melancholy are disposed to be remittent ; and it is generally observed, that the remission takes place in the latter part of the day, the patient suflering the most acutely early in the morning, and for some hours subsequently. This circumstance affords a useful practical hint, in those cases in M-hich a suicidal tendency exists. Esquirol investigated and ascertained the causes of melancho- lia in 482 cases. Now, if we except hereditary predisposition (110 in 482), we find that there were 207 produced by direct moral causes, and only 165 by physical. The former were : — domestic troubles, 60; reverses of fortune and consequent misery, 48; disappointed affection, 42; fright, 19; anger, 18; wounded self-love, 12 ; jealousy, 8 ; total — 207. Inasmuch as the causes of melancholia are predisposing or remote, proximate or exciting, these distinctions cannot be 182 MELANCHOLIA. applied witli precision (and the above writer fully asserts it) to this or that cause ; for it often happens, that those causes which we call predisposing are exciting, and vice versa. " The exciting causes alone seem to have been sufficient to provoke the malady ; iisually, however, there is a concurrence of the two orders of causes ; a first event predisposes to the dis- ease, a second causes it to break forth." The physical causes, in the above 1G5 cases, were distributed as follows : — critical period of life, 40 ; libertinism, &c., 36 ; con- sequences of parturition, 35 ; suppression of the catamenia, 25 ; intemperance,* 9 ; fall upon the head, 10. Total, 165. These statistics must, however, be cautiously received, and not valued at more than they ai-e worth. For example, "libertinism," although classed under physical causes, cannot be separated fully from the thousand moral influences which a course of dis- sipation involves. Nor, again, can " the reverses of fortune, and consequent misery," referred to the moral causes, be entirely separated from the bad diet or starvation, which, of themselves, interfere with the nutrition and vigorous action of the cerebral organs. Dr. Conolly observes, that it is difficult to avoid con- cluding, as cases of melancholia are so frequently met with abt)ut the period of the cessation of the catamenia, that the cerebral disturbance is generally connected with some morbid state of the uterus. Melancholia will also occur " after several hffimorrhagic attacks, in which there is a constant sense of weight in the situation of the colon, with pain apparently in the sigmoid flexure, and occasional hoemorrhage from the bowels. There is, in such cases, severe mental despondency, and inability to decide upon anything, and a loss of all hope and joy, and religious confidence. Spasms of the lower extremities, and hys- terical lameness, sometimes become complicated with this state." His conclusion is, that, " remembering the same invasion of despondency, lasting for a year or two, is not at all uncommon in men as well as women, when between forty and fifty years of age, this state would seem more probably to depend upon some general alteration in the circulation, or some climacteric change in the brain itself, at that time of life when both physical and mental commotion, in some shape or otlier, seem peculiarly incidental to the huinan constitution." It was found, at the Salpetriere, that melancholy was PARTIAL EXALTATION. 183 frequent between the a^nes of twenty-five and tliirty-five ; that after this period it diminished in frequency, and rarely appeared after the age of fifty-five. The same result was sliown by statistics drawn from the wealthier classes. This result, how- ever, is partly accounted for by the greater number of persons living in the general population at the above decade. In regard to the influence of the seasons, it was observed at the same institution, that the admissions of melancholiacs were greatest during the months of May, June, Jidy, and August. Section Y. — Of Partial Exaltation, or Amenomania. From melancholia, we may turn to the consideration of the opposite or exalted condition — that, namely, to which the terms Amenomania [amvemis, agreeable) and Cli(eromaniu {^aipio, to rejoice) have been applied ; the former by Rush, the latter by French writers. It is the gay, partial insanity, or monomania proper of Esquirol. There is, very generally, so intimate a connexion between those examples of delusional insanity, in which the delusion is of a gay and elevated character, and those exalted states of the feeling which we proceed to consider, that the two are rarely separated. They may be so, however; and it therefore happens, of necessity, that in the description of the various forms of mental disorder, we shall come upon the same phenomena, when engaged on very different forms of insanity. Thus, when our attention was specially directed to delusions, it was im- possible to avoid a reference to those cases in wliich the patient believes himself a king or the Deity, — " Delusional in- sanity of an exalted character ;" and, in the consideration of the present division, we necessarily meet with cases in which the exalted state of the emotions led to these delusions. The student cannot be too often reminded of the close relation which thus subsists between false conceptions and a morlnd condition of the sentiments; of which latter, the former may only be symptomatic. lie must consider, in each particular case, which is primary, and which is secondary, in the order of morbid mental phenomena. For it is needful that he should i^l PARTIAL EXALTATION. never forget, that convenient and necessary as are classifica- tions and divisions, for the purpose of facilitating the compre- hension of the multiform phases of insanity, which, -without them, would present a more rude and undigested heap than is at present the case, nature herself cannot be so precisely limited ; and that, in her book, as opened to him in the wards of an asylum, he must be prepared to find a combination, a blending, if not a confusion, of the elementary fonns which it has been our endeavour to illustrate. But, while this is true, it may be doubted whether he will be more perplexed and disappointed in this discovery ; that when, after mastering the typical forms of disease in general, as pre- sented to him in his medical text-book, he goes to the bedside of a patient, and in looking for the presence of every symptom as detailed under the appropriate head, he discovers that the disease is provokingly diflferent from (indeed not half so good as) its description. But a more enlarged experience will teach him to apportion to his teachers a juster and a higher meed of praise. lie will then employ their writings as a help, an index rerum, but not as a substitute for individual observation of disease, as it is actually to be seen in nature. This individual labour, no description or classification of diseases ever did, ever will, or ever ought to supersede. Rhases, ten centuries ago, averred that " he who does not form in his mind a clear conception of the nature of diseases before he enters the chambers of the sick, will find that, from ignorance and misapprehension, he will confound one complaint with another — for this obvious reason, that he has come to his task unprepared and unin- structed.^^ When Esquirol restricted the term, melancholia, to its present popular signification, he applied that of monomania,* at least the affective class of monomanias, to examples of exaltation of the sentiments. Thus he observes, " The melancholiac fastens upon himself all his thoughts, all his afi'ections ; is egotistical, and lives within himself. In monomania, on the contrary, the sensibility is agreeably excited. The gay and expansive passions react upon the understanding and the will. The monomaniac lives vnthout himself, and diftuscs among others the excess of * For the various senses in which Esquirol employed this term, see p. 131 of this work. PARTIAL KXALTATIOX. 185 his emotions. The physiognomy of the monomaniac is ani- mated, changeful, pk-asant; the eyes arc lively and brilliant. The monomaniac is gay, petulant, rash, and audacious. The melancholiac is sorrowful, calm, diffident, and fearful. The former takes a great deal of exercise ; is talkative, blustering, pertinacious, and easily irritated ; nothing appears to oppose the free exercise of all his functions. The latter opposes every movement; dissembles, excuses or accuses himself; the func- tions are accomplished painfully and slowly. . . . Such arc the essential differences between melancholia and monomania, so clearly pointed out that we need not confound these two patho- logical conditions, nor impose upon them the same name, if we desire precision in medical language." It is customary to speak of a monomania of pride, of vanity, &c. ; and French authors have la monomanie vaniteuse, or Narcisse ; and la monomanie ambitieuse, or oryueilleuse, or des riches, or des grandeurs. The former is described by Guislain in the following terms : — " It ordinarily manifests itself under the form of a tranquil mania, which exhibits the patient infatuated with his beauty, his grace, his mind, his dress, his talents, titles, and birth. These lunatics love to see themselves in the glass, and to deck themselves out ; sometimes they display an astonishing art in varying their attire, although their wardrobe may be very scanty ; they invent new fashions ; they arrange their hair tastefully ; and they study to set themselves off to advantage, by attention to their toilet, person, and figure." We are acquainted with such a case at present; a patient who has no very decided delusion, but who is influenced by the most exalted notions respecting himself : his every gesture, and expression, and con- versation, display his diseased self-love, his " monomanie vani- teuse," associated, however, with great intelligence, and an extent of knowledge of which many who are sane might be justly proud. He constantly boasts of his " descent from one of the best families in the United Kingdom," " a family of note," and that his family have in their possession '^ three different coats of arms, finely emblazoned on parchment." His " ma- ternal blood is equally good." He is intensely sensitive to every- thing which can, by any possibility, be construed into a slight of himself; and the omission of any of the most trivial accus- 18G PAHTTAT, KXALTATIOX. tomcd marks of respect is tortured into intentional incivility. The studiously arranged dress, the self-satisfied attitude, and the buoyant step of this patient, are all in keeping with the sentiments which are present in such morbid excess. The following case is an illustration of morbid vanity in a lady, althotigh not developed to an extent which raises the question of confinement. G. II — , a maiden lady, aged seventy, her face bearing the furrows of many years, walks erect not- withstanding, and is decked out in the most antiquated foppery. All the colours of the rainbow may be seen upon her person, and while the eye is dazzled with gilt and tinsel, it is difficult to suppress a smile at the expense of this caricature of human vanitv and weakness. As she walks along the streets, children flock around her, bowing and curtseying, and soliciting sweet- meats and halfpence, with which she is always provided, and which she gives with an air of most gracious condescension, quite characteristic of her class. This conduct does not arise from benevolence, but is the fruit of vanity in another form — the attempt to obtain homage from the only class willing to give it. Her eccentricities do not interfere with the peace and good order of society, and she converses with entire rationality. She has one brother equally eccentric, and another is confined in an asylum for the insane. Not unfrequently, these several forms are confounded with general mania, when from their partial character, and from the small degree in which the succession of ideas is confused, they may properly be distinguished from ordinary mania. Esquirol complained of this confusion. "Writers have not observed the difference between monomania and mania ; be- cause of the excitement, susceptibility^ and fury of some mono- maniacs.'^ " Amongst monomaniacs, the passions are gay and expansive ; enjoying a sense of perfect health, of augmented muscular power, and of a general well-being, this class of patients seize upon the cheerful side of everything; satisfied with themselves, they are content with others. They are happy, joyous, and communicative. They sing, laugh, and dance ; con- trolled by vanity and self-love, they delight in their own vain- glorious convictions — in their thoughts of grandeur, power, and wealth. They are active, petulant, inexhaustible in their lo(|uacity, and speaking constantly of their felicity. They are I PARTIAL EXALTATION. IHT susceptible and irrita1)le ; their impressions arc vivid, tlieir all( c- tions energetic, tlieir determinations violent ; disliking opposition and restraint, they easily become angry, and even fnrions." But, while thus distinguishing monomania from melancholia, on the one hand, and mania on the other, a caution may be entered against falling into the error of supposing that a strictly speaking monomaniacal state is of frequent occurrence ; on the contrary, it is exceedingly rare. Foville has stated, that his ex- perience only afforded two or three examples of it. We think that Esquirol's employment of the term monomania in a gay or exalted condition of the sentiments, was unfortunate ; and that his own description of the mental condition so affected is in opposition to any legitimate use that can be made of the Avord. The man who is " gay, petulant, rash, and audacious," can scarcely be called, with any propriety of language, a mono- maniac. Of his three varieties of monomania — intellectual, affective, and instinctive — we think that the first and third can alone lay claim to anything like accuracy of definition. The term must not, however, in even these eases, be used in an exclusive sense ; all that need be implied, as Baillarger has remarked, is, that a marked predominance of certain feelings or ideas exists, in the magic circle of which the individual is unmis- takably mad, while without it he is as rational as most people. If more than this be looked for, the student will often justly think he has discovered polymania, when he has been told that the patient offers an example of monomania. Guislain estimates the frequency of the monomania of pride at one in 300 admissions, exclusive of cases of general paralysis, with which extravagant ideas respecting wealth are so frequently associated. Religious Exaltation or Excitement is less common than the opposite condition — that of religious melancholy or depression which not unfrequently succeeds it. It has been estimated that only one per cent, of cases of excitement assumes this form. It includes the ttieomania of Esquirol. In the boy whose case we mentioned when speaking of re- ligious melancholy, religious excitement was the first phase of the attack, depression the second. In asylums, patients are not so commonly admitted in the early stage of excitement as afterwards, when signs of depression are present. 188 PARTIAL EXALTATION. The observations made, when speaking of melancholia in regard to the relation it bears to the " moral insanity '^ of Dr. Prichard, apply ccjually here; and we find this writer giving the following excellent description of religious excitement, as illustrative of disoi-der of the moral faculties without lesion of the intelligence : — " A person/^ says he, " who has long suffered under a sense of condemnation and abandonment, when all the springs of hope and comfort have appeared to be dried up, and nothing has been, for a long time, felt to mitigate the gloom and sorrow of the present time, and the dark and fearful anticipa- tions of futurity, has passed all at once from one extreme to the other ; his feelings have become, of a sudden, entirely changed ; he has a sense of lively joy in contemplating the designs of Pro- cadence towards him, amounting sometimes to rapture and ecstasy. Such a change has been hailed by the relations of the individual thus affected, when they have happened to be pious and devout persons, as a happy transition from a state of re- ligious destitution to one of acceptance and mental peace ; but the strain of excitement is too high, the expressions of happiness too ecstatic, to be long mistaken : signs of pride and haughtiness are betrayed, and of a violent and boisterous deportment, which are quite unlike the effects of a religious influence, and soon unfold the real nature of the case ; or it is clearly displayed by the selfishness, the want of natural affection, the variableness of spirits, the irregular mental habits of the individual. In the cases to which I have now referred, there has been no erroneous fact impressed upon the understanding — no illusion or belief of a particular message or sentence of condemnation or acceptance specifically revealed ; a disorder so characterised would not fall under the head of moral insanity." ('Treatise,' p. 20.) Most authors, and especially Heinroth, have referred to this form of mental disorder those pei*sonagcs of antiquity who professed to foretell future events, as the Pythia at Delphi, Cassandra, &c. This subject we have already considered, in the first chapter of this work. Some of the founders of religious sects may, with more proba- bility, be regarded as the subjects of religious insanity ; and have, in some instances, been themselves the dupes, when cen- sured for having duped their credulous followers. Irving, in modern times, is a familiar illustration of the class. To what PAKTIAI, F.N.ALTATION. ]H[) extent Mahomet was also au example, oflers an inquiry of {rreat interest, but cannot, in this place, be discussed. We may, there- fore, refer to a work entitled, ' Mahomet considere eomme alic'ue * par le docteur Beaux, in a report to the lloyal Medical Academy, by Dr. Renaudin. A patient at the Retreat believed it was his religious duty to have " two wives and a concubine.'' It is easy to see that under favourable circumstances, and among the igno- rant, such a delusion might lay the foundation of a new sect — Mormonism for instance. The founder of the sect might be deluded, but sincere. " Religious revivals," whatever opinion may be entertained in regard to their general or ultimate influence for good or for evil, are doubtless the occasion for the outburst of some mcU- marked examples of intense religious excitement, in which ex- cessive devotional feeling overrides the reason. In some cases a feaiful state of prostration, either of mind or body, or mainly the former occurs ; but in others the condition is one of religious ecstasy or exaltation, complicated in many instances with hys- teria. Some fall into a trance, others see visions. " Some of the convicted see in their visions," we are told, " a black horse, others see a black man ; others see Jesus Christ on the one side, and the devil on the other, and they cry, ' O, Jesus Christ save me from the devil.' " An eye-witness of the Irish revival speaks of ' theomania.' " Insanity," says the Rev. W. Mcllwaine, of Belfast, " generally in one of its worst forms, theomania, (and not unfrequently in other forms of insanity equally to be dreaded, such as acute mania,) has been developed to a fearful extent. Speaking guardedly, I may assert that, from unquestionable sources, I have come to the knowledge of at least fifty such cases within the last six months in this im- mediate neighbourhood." Some of the disciples of Irving appear to have been in a very remarkable state of religious exaltation. And, in passing, it may be observed as a curious circumstance, that some of his congregation uttered a peculiar cry or sound, which Archdeacon Stopford, who heard it, instantly recognised thirty years afterwards as identical with what he heard in Belfast. " That moment it flashed upon my memory ; it was, with some slight modification, but in its character essentially the same, the unmistakable cry of Irving's pro- phetess — a sound that while I live I never again can mistake or 190 EMOTIONAL INSANITY. misinterpret." Religious exaltation assumes a variety of epidemic forms. Assisted by the infectious influence of sym- pathy, it was exhibited in some phases of the " dancing mania ;" among the " Convulsionnaires ;" and among the American Shakers, who profess to have originated in the Camisards or French prophets. In the chapter on Classification we observed that erotomania might be regarded as one of the forms of partial exaltation. It is more convenient, however, to describe it among those varieties of mental disorder, with which it has this in common, that it involves the lower propensities, and raises the question of criminal responsibility. Section VI. — Of Emotional Insanity (proper).^ In the tabular statement of the forms of mental disease, given at page 89, we have included under the division of Emotional Insanity a variety " of a melancholy character " (melancholia without delusion). In our description, wc have found it most convenient to describe this variety when treating of melancholia in general. Among the examples of partial exaltation are also to be found some which may justly be regarded as illustrative of purely emotional insanity. Emotional insanity, indeed, as Dr. Prichard observes of his moral insanity, embraces in theory as many forms of mental disease as there are distinct afiective faculties. Practically, however, the class of cases which demand most consideration and discrimination are those to which we are now about to direct our attention, which are mainly of a destructive character, and may be distinguished from emotional disorders of a melan- choly and exalted character, by the term " emotional insanity proper." Syn. Gemuthskrunkheit (Ger.) ; Manie raissonnantc (Pinel) ; Reasoning (also affective) monomania (Esquirol) ; Folic d'action (Brierre de Boismont) ; Moral Insanity [proper] (Prichard) . * Sue p. 88-'J ol" this work. tMOTlUxNAL INSANITY. I'Jl That intellectual power and the perception of moral truths do not necessarily exist in the same degree in the same person, that they do not always develop themselves pari passu, arc profjo- sitions which, as the result of common observation, obtain general acceptance. But that there should be anything like., congenital defect of the moral sense {anomia of Dr. Rush), in conjunction with intellectual powers not strikingly deficient, is a proposition not so generally recognised, nor so easily estab- lished. It is obviously one which must be carefully considered in the description of mental diseases. AVith its medico-legal bearings we are not now concerned. Many analogies subsist between the moral and intellectual faculties, and, in many respects, they may be observed to be under the influence of the same laws. The sentiments, no less than the intellect, are indicated by, or associated with, certain temperaments and physical signs ; thus, good nature usually co-exists with a sleek and fat habit of body. Virtuous and ^dcious tendencies would often appear to be hereditary ; or, as congenital, are displayed from the earliest infancy in childi-en subjected to the same educational influences. The moral facul- ties may be either excited or depressed by disease. " Who has not seen," asks Dr. Rush, " instances of patients in acute diseases discovering degrees of benevolence and integrity that were not natural to them in the ordinary course of their lives?'^ Dreams afiect the moral faculties as well as the intellect; under their influence, we are benevolent, devotional, passionate, and affectionate, as well as imaginative and talkative. Ray, in his ' Jurisprudence of Insanity' (p. 163), after treat- ing of mania as it aflects the intellectual powers, proceeds to ob- serve, that a more serious error can scarcely be committed than that of limiting its influence to them. " It will not be denied," he adds, " that the propensities and sentiments are also integral portions of our mental constitution ; and no enlightened phy- siologist can doubt that their manifestations are dependent on the cerebral organism. Here, then, we have the only essential con- dition of insanity — a material structure connected with mental manifestations; and, until it is satisfactorily proved that this structure enjoys a perfect immunity from morbid action, we are bound to believe that it is liable to disease, and consequently, that the affective as well as the intellectual faculties arc subject 19.2 EMOTIONAL INSANITY. to derangement." This writer cites from HofFbauer the fol- lowing unqualified assertion to the same effect : — " It is clear," he says, " that mania may exist uncomplicated with mental delusion. It is, in fact, only a kind of moral exaltation [toUheit), a state in which the reason has lost its empire over the passions and the actions by which they are manifested, to such a degree, that the individual can neither repress the former nor abstain from the latter. It does not follow that he may not be in possession of his senses, and even of his usual intelligence, since, in order to resist the impulse of passions, it is not sufficient that the reason should impart its counsels ; he must have the power to obey them." One of the most striking features of insanity in general, and the strongest proof of the presence of any of its forms, is the change which takes place in the individual's character and habits. To cases of congenital deficiency of the intellect, however, whether altogether idiotic or only partially imbecile, it is at once manifest that this test does not, and cannot, apply. In such instances the natural character is itself in an abnormal condition, and ceases to be the standard of health. This observation applies with equal force to the matter now under consideration. If there ever be, congenitally, a condition of the moral sense analogous to imbecility, it is impossible to apply, in such instances, the test referred to — a test which is alone applicable to mental disease when acquired. We have seen several well-marked examples of lunatics, who, on arriving at manhood, were placed under restraint, because age brought with it a certain legal responsibility, the absence of which, in early life, rendered the patients' friends willing to content themselves witli their own surveillance. In such cases, parents assert that the child, the boy, and the young man, alike presented the symptoms of an inert moral nature, and of an activity of the animal propensities, over which threats, i*ewards, or punishments exercised a very trifling control. There was formerly a patient at the Richmond Lunatic Asylum, Dublin, whose case illustrates this class. We are informed, that " he exhibited a total want of moral feeling and principle, yet possessed considerable intelli- gence, ingenuity, and plausibility." " He has never," says Dr. Crawford, "been different from what lie now is; he has never evinced the slightest mental incoherence on any one point, nor KMUIIONAL INSANITY. ] O.T any kind of luillucination. He appears, however, so totally callous with regard to every moral principle and feeling, so tho- roughly unconscious of ever having done anytliing wrong, so eompletely destitute of all sense of shame or remorse when reproved for liis vices or crimes, and has proved himself so utterly incorrigible throughout life, that it is almost certain, that any jury before whom he might be brought, would satisfy their doubts !)y returning him insane." There Mas admitted into the New York State Asylum, a patient, who is described as l)eing the "exact counterpart " of the preceding case. " He has ))een," says Dr. Benedict, in his 'Annual Report' for 1850, "a scourge to his family from childhood ; was sent to the army to get rid of him, from which he was turned out as an incorrigible villain — always fighting and getting drunk, for which he was repeatedly flogged. By seclusion, he becomes so savage as to render the task of entering his room and supplying his wants by no means enviable ; and, when at large, lie often assaults those around him. His chief employments are eating and fighting; and, although he is constantly cndeavoiiring to get out of "these barracks," he seems to liave no particular ol)jcct in view but the more free indulgence of these propensities. In all but this one case, moral treatment alone has accomplished our ol)ject, but on him little moral influence can be exerted. By the aid of nauseat- ing remedies, frequently administered, we are enabled, in some degree, to control him. Blisters, and setons to the back of his neck, are now being tried." Dr. Benedict speaks of the above patient as possessed of intel- ligence. A very remarkable (and, in some respects, analogous) case is reported in the 'American Journal of Insanity,' (Oct. 181G,) of a girl eighteen years of age, guilty of arson, and who is repre- sented to have been destitute of the moral feelings. " She pos- sessed quick perceptions, good reflective capacity, and a large share of ideality, &c., but no human kindness had she ; nothing human, iudccd, but her form." She is stated to have resembled a serpent in her movements. Her skin was cold — circulation very slow ; her skin was also " spotted like a common species of snake." Dr. Prichard, in his smaller volume, ' On the Different Forms of Insanity," (2nd edit., p. 157,) speaks of a youth, " an incorri- 13 194 EMOTIONAL INSANITY. gible thief, and addicted to falsehood and deception in every way, and apparently devoid of all perception of right or wrong. The mother of this hoy was addicted to mania, or raving mad- ness." And Dr. Pri chard, although he mainly had in view cases in Avhich the moral character underwent ii change, has not en- tirely overlooked the class now referred to :— "It seems not im- probable, that many persons, wrong-headed and perverse throvgh life, and singularly capricious and depraved, would afford in reality, if the matter could be ascertained, examples of moral insanity, native or conyenitaJ." Other examples of moral mad- ness in early life will be found in Ray's ' Medical Jurisprudence of Insanity,' p. 99, and in Esquirol's ' ^Maladies ]Mcntalcs,' tome ii., p. 115. It must, of com'se, be admitted, that ordinary idiots are idiotic morally, as well as intellectually ; but we have not yet seen sufficient evidence to prove that a condition deserving the name of moral idiocy exists, in connection with an average development of the intellectual faculties, notwithstanding the statements of some observers, whose opportunities of observation, both in regard to the insane and idiots, have been very large. Dr. AVood- ward, formerly physician to the State Lunatic Asylum in ]Massa- chusetts, held that, " besides a disease of the moral powers, there seems to be, in some cases, something like moral idiocy, or such an imbecile state of the moral faculties from birth, as to make the individual irresponsible for his moral actions. The persons to whom I refer have rarely much vigour of mind, although they are by no means idiots in understanding." Dr. Davey has ex- pressed himself very decidedly in favour of the same view, in an interesting paper in the ' Association Medical Journal ' (Sept. 13, 1856) ; and, although we hesitate to admit moral idiocy apart from lesion of the intellect, wc fully grant that there may occasionally be good intellectual abilities, in association with con- genitally feeble moral powers and volition. For ob\dous reasons, we are i)revcnted publishing the details of many cases of this description falling under our own observa- tion. We may mention, however, the case of a patient admitted into an asylum at the age of seventeen, labouring under moral insanity and epilepsy. He possessed remarkable intellectual vigour, united with an exceedingly ol)tuse perception of moral responsibility. His father stated, that his character had been EMOTIONAL INSANITY. 195 tlie same " from the cradle." At nine years of nge^ he en- dangered the life of a little boy — his playfellow ; subsequently at school^ he was charaeterised by similar mental qualities, learning more quickly than other boys, yet committing many acts of violence. He was, consequently, obliged to leave several schools. Still, the term ''moral idiocy " is scarcely ap- propriate.* We know of another well-marked case of peculiarity in the temper and moral disposition, which was manifested from the earliest infancy, but in which the intellectual faculties are not only equal to, but above, the average. The disease, or defect, was hereditary. He has been in an asylum for years. " We have seen," says Marc, (vol. i, p. 329,) " homicidal mania manifest itself dui-ing the first years of life. Thus age, considered by itself, cannot be any true guide in regard to mental disorders." Dr. Hulnie Williams remarks., that " as in the mental, so in the moral constitution, the most marked difierences are per- ceptible. It requires but slight research to satisfy the inquirer, that many instances of crime are on record, and that many ex- amples could be adduced to prove, that such an original deficiency or natural perversion of the moral faculty appertained to some individuals, as argued brutality rather than depravity of their dispositions." We presume Dr. Williams uses the term " brutality " in the sense employed by Dr. Mayo. The same writer classifies moral insanity under four heads, one of which is, " Cases in which the development of the moral feel- ings or affections appears originally deficient." Now, if this be a form of moral insanity, it appears inconsistent to say, as this able writer says further on, of the persons who are examples of it, " their disease is vice.'' That all forms of insanity involve disease of the brain, whether functional or organic, whether primary or only secondary to, and symptomatic of, disease in some other viscus, is a truth it has been our endeavour continually to insist Tipon, as their distinctive characteristic. But let us clearly understand * Since this was written the patient has died of disease of the spinal cord, which caused paraplegia and disease of the pelvic viscera. This result is one of many illusti-ations of the close relationship subsisting between disorders of the' moral faculties and the Nervous System, J9(» l.MOnONAI. lN>VMi'V. what Mc imply by the term disease. " Health," observes Dr. C. J. B. Williams, " consists in a natural and proper condition and proportion in the functions and structures of the several parts of Avhieh the body is composed. From physioloj>;y we learn that these functions and structures have to each other, and to external agents, certain relations, which are most conducive to their wellbcinof and permauency; these constitute the con- dition of health. But the same knowledge also implies that function and structure may be in states not conducive to their permanency and well-being; states which disturb the due balance between the several properties or parts of the animal frame ; and these states are those of disease." — ' Principles of Medicine,^ p. .2. To apply these principles to our present subject, we may say that disease signifies, in any cerebro-mental affection, that such a condition is present other than health, as to cause a particular mental state, or act, of an individual. It must comprise conge- nital deficiency ; all arrests of development occurriug in infantile life ; and the various diseased psycho-cerebral conditions of adult life. In some persons, there is rather a congenital proclivity to disease than actual disease itself; and in these a circumstance, which in persons vnthout that proclivity Avould produce no result, will call into action abnormal, that is to say truly dis- eased, mental manifestations, although they may be only func- tional, and subside Avhen the exciting cause is removed. It is to analogous cases that the above writer alludes, when he observes that " disorder may arise from au undue proportion or predo- minance of a function," Should it be said that disease involves a " cham/ed condition or proportion of function or structure in one or more parts of the body," it is to be observed that this change may have taken place at a period w^hen it woiUd escape notice, or even during foetal life. During the latter period, diminished nutrition of the body, or diminished nutrition of one part and increased nutri- tion of another, may have occurred : and thus resulted in the production of an undue proportion or predominance of a func- tion — "hypertrophy of some textures frequently coexisting," as the eminent writer last cited observes, "with atrophy of others, perverted nutrition being often combined with excessive or de- fective, and several of these different changes often occurring in L-MOTlU.NAl, liSSAMll. 107 succession, in consequence of the operation of tlie same causes." There is, indeed, durinj^ fojtal life (and we may practically widen this period, and say, during- that which elapses before the character is or can be observed), abundant opportunity for the influence of perverted nutrition ; whether it be in the formation of cell-germs^ their passage into cells, or the subsequent pro- cesses connected Avith the growtli and organisation of the tissues ; or again, whether the elements of the circulating blood be in an abnormal proportion ; or lastly, whether it be the mys- terious but well-recognised principle, in virtue of which there is an hereditary predisposition to disease, which rules over and perverts the nutritive processes. Thus, in a case of what woidd probably be regarded as congenital moral imbecility, the mother of the patient was the subject of malignant disease of the uterus, during gestation. Now it is possible that this con- dition of the mother interfered with the proper nutrition of the cerebral tissue of the fa'tus, and w as oHj, among other causes, which contributed to the final result. Persons born with talipes, or strabismus, owe their defect to some disease of embryo life. In like manner, during the same period of existence, the brain may undergo pathological changes which induce defective moral power. Dismissing the consideration of congenital cases of disease of the moral faculties, Ave may pass on to those in Avhich this con- dition of mind comes on or is first exhibited in adult life : and here the test already spoken of, may be most properly applied. The standard of mental health may then justly be sought for in the natural and habitual character of the patient. This it is Avhich is now altered, and the symptoms by Avhich it is rendered manifest may next be considered. Usually the change in the feelings and conduct of the patient is gradual. Frequently he is more absorbed and reserved, and on any provocation, however slight, is unreasonably irritated. He becomes suspicious, liable to attribute false motives to his friends and others, and to cast u\igeiierous reflections upon his nearest relatives. The husband suspects the fidelity of the wife, the wife that of the husband, Avithout the slightest foundation. The patient is observed by strangers to be morose; aiid, as the cloud gathei-s, his acquaint- ance become conscious, Aipposinenty years of age, liowever, lie suffered from melancholia, followed by alternate attacks of excitement and depression, but was not placed in confinement. Ultimately, it was necessary to place him in an asylum, when he afforded a marked example of moral insanity. A case rocordcd in Pr. "Wiijan's -work. "^ On flio Pnnlit\- of the EMOl'IONAL INSANITY. 201 Mind/ is generally known, anil well illnstratcs the influence of injury to the cerebral substance upon the moral character. A blow ujjon the head^ given by a teacher with a ruler, w;i^ followed by an entire alteration in the moral feelings. Mi-. Clinc trephined, there being a ^ery slight depression of the bone, and a bony spiculum was found pressing upon the brain. Pei-fect recovery of mind followed. Sauvages and others attempted to distinguish in their classi- fications, between huUuc'iuationes and nwrhi pathet'ui, hui Pinel drew from his practical experience, much more decided conclusions, and recognised a form of mental disorder to which he gave the name of munle sans de'/ire, or "madness without delirium," that is to say, without lesion of the intellect. To the question placed at the head of his chapter, " Can mania exist without lesion of the understanding?" (' Traite Medico Philo- sophiquc sur 1' Alienation Mentale, 2nd edit., p. 155,) he replies, '• We may entertain a just regard for the writings of Locke, and yet think that his notions about mania are very incomplete, Avhen he regards it as inseparable from delirium. Like this author, I thought so myself, when I resumed at the Bicetre my researches on this disease, and I was not a little surprised to sci- many madmen, Avho at no time liad manifested any lesion of the undci'stauding, and who were under the dominion of a sort of instinctive fury, as if the afl'ective faculties alone had been diseased." This description, howcver,only includes one class of cases, those, namely, in which there is simi)le instinctive fury or excitement, — an ungovernable passion, excited upon the least provocation {emportement mamaque). Pinel's first example of mania without delirium is of this order. (Op. eit., p. 15G.) AV'e know of a ease in which a man was an example of strict integrity and honour, but exhibited such extreme violence of passion and irritability of mind, that it was almost impossible to associate with him. He Mas extremely suspicious, and looked on the dark side of every circumstance and character, and when once he luid formed an opinion, it became a prejudice which nothing could surmounf. lie was not in an asylum, and liad he committed a homicidal act, it is very doubtful whether the law would have lield liini irresponsible. His father and mother li\ed in a cottage on the edge of a moor, and were both «ubj(>et to att:ieks of unmistakable 202 EMOTIONAL INSANITY. insanity. At these times tliey would leave their home and wander among the furzc^ where they were frequently found laid on the ground by hunting parties. The right understanding of the conditions to which Pinel applied the terms " reasoning madness/' and " mania Avithout delirium/' as also the moral insanity of Prichard, is much assisted by the adoption of EsquiroFs division into affective and instinctive monomania. We have^ in a former section^ objected to this -writer's " affective monomania/' as applied to cases of exaltation. Here, however^ the use of the term is much more legitimate. In the first diAision^ '^monomaniacs are not deprived of the use of their reason ; but their affections and dispositions are perverted. By plausible motives^ by very reasonable explana- tions^ they gratify the actual condition of their scntimentSj and excuse the strangeness and inconsistency of their conduct." This condition we spoke of in the first edition of this work as ''Mania, with general extravagance of conduct." It might per- haps be described as one of general moral obliquity — dependent of course upon cerebro-mental disease. In the second, "the patient is drawn away from his accustomed course, to the commission of acts to Avhich neither reason nor sentiment determines, whicli conscience rebukes, and which the will has no longer power to restrain. The actions are involuntary, instinctive, irresistible." Dr. Prichard's observations on moral insanity apply more espe- cially, but by no means exclusively, to the first diA'ision, {Manic raisonnante of Piuel ; Folic cV action of Brierre dc Boismont.) Esquirol observed that Dr. Prichard had confounded the in- stinctive madness of Piuel, with his moral insanity ; and Dr. Prichard, in a subsequent publication, admitted that the terms have reference to two distinct classes of cases, "We have already taken occasion to point out the wide area of morbid mental phenomena which this writer's term embraces ; and a reference to his own definition may tend to a clearer apprehension of a disorder, Avhich, more than any other, has puzzled the psycholo- gist, perplexed the advocate, and disconcerted the divine. He defined it to be " a morbid perversion of the natural feelings, affections, inclinations, tempers, habits, moral dispositions, and natural impidscs, without any remarkable disorder or defect of EMOTIONAL INSANITY. 203 the iutellectj or kuowint^ and reasoning facultici, and particu- larly without any insane illusion or hallucination." " The signs of reasoning monomania,"^ observes Esquirol, "consist in the change and perversion of the habits, dispo- sitions, and affections. . . . The understanding is not essentially disturbed, since it assists in the acts of the insane person, and the patient is always ready to justify his sentiments and con- duct. Reasoning monomania has an acute and chronic course. We distinguish three periods in it. In the first, the disposition and habits are changed. In the second, the affections arc per- verted; and, at length, in the thii'd, a maniacal excitement appears; or else a weakening of the faculties, more or less rapid, leads the monomaniac to dementia.-"^ " It is necessary to admit,^' observes Marc, " since facts de- maud it, that there are two sorts of monomania, one of which is instinctive, the other reasoning. The first bears the mono- maniac on, by the effort of his ^nll, primarily diseased, to instinctive and automatic acts, which are not preceded by rea- soning ; the other determines acts, which are the consequence of a certain association of ideas.'^t (Vol. i, p. .24i.) The same writer observes, in regard to the lesion of the will, that it may be primary or secondary; " in i\\e former, the lesion is exclusively manifested in the faculty of the will itself, of which we shall give examples under instinctive monomania, which will leave no doubt as to the reality of this singular and inexplicable moral affection. In the latter, the lesion of the Mill results from the general imperfection of the intellect, or from delusions — the tenacity and the vividness of which, exercise such a tyranny over the will, that they subjugate it, and render it their slave. It is, if I may be allowed the comparison, the depraved legislative power which usurps the legal independence of the executive power, and renders it its blind instrument." (Vol. ii, p. 187.) Thus, then, it is highly important to remember, that all ex- amples of what are called moral insanity are not necessarily instinctive, impulsive, irresistible. For although (in a loose use of the M ord) the man morally mad may be said to be irresistibly * Synonymous with the siune writer's affective iinniuinaiiia. t By u-iU must bo mulcrstootl, not the desire, l>ut the jwwer to execute the desire. riOi EMOTIONAL INSANITY. so — that is, his condition of mind is not voluntary, — the ex- amples of irresistible impulse belong to quite a difterent class. Ignorance of this distinction has often led to the most deplor- able confusion. A case of sudden and irresistible impulse may, and generally does, aftbrd an illustration of moral insanity ; but many cases of moral insanity do not fall under the division of instinctive madness. !Modcrn physiology teaches that there is a rtjlex action of tlie cerebrum, as well as of the spinal cord; and thus satis- factorily explains the existence of automatic or instinctive acts.* To such cases Dr. Cai^penter alludes, (' Human Phy- siology,' fourth edition p. 840,) when he says, " So far as the directing influence of the will over the current oi thought is suspended, the individual becomes a thinking automaton, destitute of the power to Avithdraw his attention from any idea or feeling by Avhich his mind may be possessed, and is as irresistibly impelled, therefore, to act in accordance A\ith this, as the lower animals are to act iu accordance witli their instincts. '^ In treating of classitication we remarked on the duplex cha- racter of our affective faculties — the " moraF' and " animal." It is more especially when actions are " involuntary, instinctive, irresistible," when, in short, true instinctive monomania occurs, that we witness the faculties common to man and the brute, no longer governed and regulated by the higher poAvers peculiar to man. What is health in the brute is disease in man. What is noble and grand in the lion is base and sickening in him to whom dominion over the beast of the field Avas giveu. This reference to the propensities connnon to man and the lower animals does not, however, derive nuich illustration from several of the Avell-marked examples of instiuctivc mania, as suicidal and dipso-mania, in both of Avhich there may be a blind irresistible impulse, accompanied by an acute sense of the nature of tlic acts committed. A\ e do not Avitness in these cases the merely unrestrained action of instincts characteristic of animals beloAV nuin ; but rather, in the one case, the perver- .sioii of an instinct common to both (self-preservation, or the * On tlic f;L'iifi"il .-ubjtcl i_>t" oiTi'lmil rellox iu-tion, sec I'rofesNor LayfOslimatpcakiiig of some cases of suicide in children, referred to their frequcntlv trivial causes or motives. In the ' Express ' of June 20, 18()1, Ave observe mention made of suicide in a boy aged eleven, of Kusel (Germany), who hung himself because his parents did not allov him to buy a squirrel \a Inch he had taken a fancy to possess ! Wc may refer also to the case of a woman, aged twenty-three (' Jixpress,' June 12, 1861), who attempted to commit suicide, and was with difficulty rescued from the llegent^s Canal, the reason assigned by herself when brought before the police court being, *' I wanted to see Blondin at the Crystal Palace, and my husband would not take me ! " It must not, however, be for- gotten that in some of these cases^ did not we know all the cir- cumstances, a trivial cause might prove to be one among others of greater magnitude. Of the 3.j98 suicides tabulated in a former page, 977 were referred to insanity as a cause (doubtless greatly underrated), ]-.■> 1 w ere the result of family troubles of various kinds, 203 of embarrassed circumstances, 313 of the desire to escape physical suftcring, 208 of habitual drunkenness, 179 of want and the fear of want, IGG of the disgust of life, and 1 12 of bad conduct and debauchery. The desire to be talked about, the love of notoriety — is a very frequent motive among suicides of the uneducated, though 224 KLEPTOMANIA. iicNvspaper-readiug, classes. It is also well kuoAvu that many cases of suicide have been prompted by imitation. Epidemics of suicidal mania, and of self-mutilation short of suicide, are among tlic many strange examples of epidemic insanity. Suicide so often succeeds the homicidal act as to indicate a very close relationship between them, due allowance being made for the mere desire to escape punishment or disgrace. It has been calculated that in 60 per cent, of cases of murder, suicide is attempted. In the preceding observations avc have, of course, been speak- ing of suicide in general, not those cases only in which mental disease was certainly present. Section IX. — Of Kleptomania. Kleptomania, — Theft may be committed by the insane, either in consequence of certain delusions, or of some motive, as revenge, or as the result of what appears to be an instinctive impulse ; lastly, the mind may be so perverted b}"^ disease, that under circumstances of powerful temptation, theft may be committed, Avhich icould nut have been the case, had the indi- vidual been free from any mental affection. The fact of external motive does not, therefore, remove the possibility of insanity, although, doubtless, those cases which are motiveless are niucli more easily credited. " This condition,'^ as Marc observes, " is, doubtless, very sin- gular and inexplicable, as are so many other of the intellectual and physical phenomena of life ; but it is not the less real on that account, as is proved by numerous examples. ]5csidcs, the existence of facts of this description is now generally admitted by medical men, and even by laAvycrs, wlio have devoted any attention to mental diseases." (Vol. ii, p. 302.) This affection is sometimes strikingly hereditary. The follow- ing is a highly interesting example, apparently the result of dis- ease, and in Avhich tlie propensity descended both to son aud grandson. We give it on the authority of Dr. Julius Steinau, the author of an excellent little book on hereditary diseases : — " When I was a boy, there lived in my native town an old man. KLEPTOMANIA. 223 named P , who was such au inveterate thief, that he went in the whole place by that name. People, speaking of him, used no other appellation but that of ' the thief* and everybody knew then who was meant. Children and common people were accus- tomed to call him by that name, even in his presence, as if they knew no other name belonging to him ; and he bore it, to a certain degree, with a sort of good-naturedness. It was even customary for the tradesmen and dealers, who frequented the annual fairs in this place (which are there of a more mercantile character than in other countries), to enter into a formal treaty with him — that is, they gave him a trifling sum of money, for which he engaged not only not to touch their property himself, but even to guard it against other thieves. " A son of this P , named Charles, afterwards lived in B during my residence there. He was respectably married, and carried on a profitable trade, which supported him hand- somely. Still, he could not help committing many robberies, quite without any necessity, and merely from an irresistible inclination. He was several times arrested and punished. The consequence Mas, that he lost his credit and reputation, by which he was at last actually ruined. He died, while still a young man, in the House of Correction in Sp , where he had been confined as a punishment for his last robbery. " A son of this Charles, and grandson of the above-mentioned notorious P , in my native town, lived in the same house where I resided. In his early youth, before he was able to dis- tinguish between good and evil, the disposition to stealing, and the ingenuity of an expert thief, began already to develop them- selves in him. When about three years old, he stole all kinds of eatables within his reach ; although he always had plenty to eat, and only needed to ask for whatever he wished. He, there- fore, Mas unable to eat all he had taken ; nevertheless, he took it, and distributed it among his playfellows. When playing with them, some of their playthings often disappeared in a moment, and he contrived to conceal them for days, and often for weeks, Mith a slyness and sagacity remarkable for his age. When about five years old, he began to steal copper coins ; at the .age of six years, when he began to know something of the value of money, he looked out for silver pieces, and, in his eighth year, he only contented himself with larger coins, and, 15 226 KLEPTOMANIA. proved himself to be, on public promenades, an expert pickpocket. He was early apprenticed to learn a trade ; but his master being constantly robbed by him, soon dismissed him. This was the case with several other tradesmen, till at last, in his fourteenth year, he was committed to the House of Correction. "Whether that institution was fortunate enough to correct this ill-fated youth, the writer of this essay is unable to state." An analysis of the cases reported by Marc and some others, as illustrative of kleptomania, is here given under two divisions ; the first, in which disorder of the intellect was not present (cases of Emotional Insanity), — the second, in which such disorder was manifest. First division : 1. M. X. Theft of small value, in a person of ample means, in whom it was difficult to establish anything beyond eccentri- city. The law decided that he had acted involuntarily. (Marc, vol. ii, p. 249.) 2. A young lady of rank was addicted to stealing handker- chiefs, gloves, &c., and mourned over her propensity with tears. No lesion of the intellectual faculties. (Marc, vol. ii, p. 25 i.) 3. Case of a soldier in Saxony, who laboured imder an almost constant propensity to steal. There does not appear to have been any other symptom of mental aberration. He was occa- sionally seized with the impulse in the middle of the night. C^ Magasin de Psychol. Experiment, de Moritz,' tom. ii ; Miiller, 'Med. Legal.,' tom. ii, p. 151 ; Marc, vol. ii, p. 255.) 4. Case of a lady subject to periodical attacks of insanity, generally in the spring, and followed, in one instance, by an irresistible desire to steal, for the gratification of which she was brought to trial, but was acquitted on the plea of insanity. The plea of insanity was urged Math great talent by Esquirol and Marc. When asked what passed through her mind when she committed these thefts, she replied, " I cannot tell ; but I have such a mad longing to possess myself of everything I see, that, were I at church, I should steal from the altar, without being able to resist it.'' (Marc, vol. ii, pp. 275, 303.) 5. Case of a gentleman very wealthy, who stole from time to time, and stated that he could not help it. He restored to their owners the stolen articles a few days afterwards. (' Mag. de Psychol, dc Moritz,' tom. ii.) KLEPTOMANIA. 227 6. Case of a medical man, whose kleptomania was manifested by stealing table-cloths and nothing else. (Marc, vol. ii, p. 355.) 7. Lavater mentions the case of a doctor, who could not leave his patients' rooms without taking something away with him unobserved ; and his wife ransacked his pockets, and duly returned the knives, thimbles, scissors, &c., to their respective owners. (Marc, vol. ii, p. 255.) 8. The wife of the celebrated Gaubius appears to have been similarly affected as No. 2. 9. Acrel mentions the case of a young man who, after receiving a severe wound on the temple, for which he was trepanned, manifested an invincible propensity to steal, which Avas quite contrary to his natural disposition. After committing several larcenies, he was imprisoned, and would have been punished according to law, had not Acrel declared him insane, and attributed his unfortunate propensity to a disorder of the brain. (Gall on the ' Functions of the Brain,' vol. vi, p. 140.) 10. "An ex-commissary of police at Toulouse, Beau-Conseil, has just been condemned to eight years' confinement and hard labour, and to the pillory, for having, while in office, stolen some pieces of plate from an inn. The accused persisted, to the last, in an odd kind of defence : he did not deny the crime, but attri- buted it to mental derangement, produced by wounds he had received at Marseilles in 1815." ('Journal de Paris,' March 29, 1816.) 11. Dr. Rush mentions " a woman who Avas exemplary in her obedience to every command in the moral law, except one — she could not refrain from stealing. What made this vice more remarkable was, that she was in easy circumstances, and not addicted to extravagance in anything. Such was the propensity to this vice, ^hat when she could lay her hands on nothing more valuable, she would often, at the table of a friend, fill her pockets secretly with bread. As a proof that her judgment was not aflfected by this defect in her moral faculty, she both confessed and lamented her crime." (' Medical Inquiries and Observa- tions,' vol. i, p. 101.) 12. Case illustrative of the effect of utero-gcstation in exciting this monomania. (Marc, vol. ii, p. 262.) 228 KLEriOMANlA. 13. Another highly interesting example of the same. (' Jour- nal de Medecine de Levoux et Corvisart/ April, 1815, p. 308; Marc, vol. ii, p. 2G4.) 14. A government employe at Vienna had the singular habit of stealing only household utensils, which he stored up in a room rented for the purpose, but neither sold nor made use of them. No more particulars of this case are furnished ; it is, therefore, impossible to ascertain whether there were other symptoms of mental disorder or not. (Marc, vol. ii, p. 254.) 15. Victor Amadeus, King of Sardinia, was in the habit of stealing objects of little value ; but no further particulars in regard to his mental condition are furnished. (Marc, vol. ii, p. 25 1.) Second division : In cases of general paralysis, it is not uncommon for this propensity to develop itself, in consequence of the delusion that everything belongs to the patient. 1. Dr. Prichard mentions a case in which paralysis and soft- ening of the brain existed, and in which >a lady, the wife of a man of large fortune, was so habitually accustomed to pilfering whilst shopping, that her husband was obliged to remove from a town to a country residence, in order to curtail his wife's sphere of pilfering. But this case, probably, differed little from those preceding, it not being ascertained that any delusion was mixed up with the propensity. 2. Case of Renaud, aged forty-four. His ideas appear to have been very limited, indicating a degree of imbccilit}'. The medi- cal commission, Denis and ]\Iarc, arrived at the conclusion : — 1st. That his moral faculties were so feeble as to constitute a state of imbecility, which, however, did not preclude a certain degree of cunning, when he delivered himself up to his pro- pensity, or when he endeavoured to deny the acts which arose from it. 2nd. That it is exceedingly probable that Renaud ex- perienced, at times, maniacal excitement ; and it was especially in this exalted state that he twice attempted the theft. 3rd. That, in any case, the mental condition of this individual did not appear to allow of the supposition that he had that degree of discernment and moral libcrt}' which forms a necessary con- dition of criminality. (Marc, vol. i, p. 170.) 3. Case of a woman who abstracted articles of value, in con- EROTOMANIA. 229 sequence of labouring under the delusion that she was the legitimate proprietor of them, (Marc, vol. i, p. 308.) Some cases of kleptomania will be found reported by M. Renaudin, in the 'Annales Medico-Psychologiques/ April, 1855. This is not the place to enter into the subject of the medico- legal bearings of kleptomania ; but a description of the disease would be incomplete without a brief reference, in conclusion, to the characters by which it may be recognised. The existence of hereditary disease ; evidence of mental derangement prior to the development of the propensity ; the occiii'reuce of any phy- sical disorder, as brain fever, the suppression of any discharge, or an injury to the head; the absence (in most cases) of any inducement to steal ; the presence of physical symptoms in close connexion with the act, as cephalalgia, cerebral congestion, &c. ; and what is very important, if a female, her pregnancy ; the general conduct of the individual during and after the act, especially the confession of the crime after its commission, and the voluntary restoration of stolen goods — all these are circum- stances of great importance, in attempting to decide upon the existence of kleptomania. Section X. — Of Erotomania. According to Esquirol, ^larc, and others, this term should be restricted to those cases which are characterised by excessive love for an object, whether real or imaginary. " In this dis- order," the former observes, " the imagination alone is affected ; it is an error of the understanding ; it is a mental affection in which amatory delusions rule, just as religious delusions rule in thcomania or in religious melancholy. It diflers essentially from nymphomania {vvfKptj, nyntplue) and satyriasis [auOi], penis.) In the latter, the evil originates in the organs of reproduction, the irritation of which reacts upon the brain. In erotomania, the sentiment which characterises it is in the head. The nymphomaniac, as well as the victim of satyriasis, is the subject of a physical disorder. The erotomaniac is, on the contrary, the sport of the imagination. Erotomania 230 EROTOMANIA. is to nymphomauia and satyriasis^ what the ardent aflfec- tions of the heart, when chaste and honorable, are in comparison with frightful libertinism ; while proposals the most obscene, and actions the most shameful and humiliating, betray both nymphomania and satyriasis,'^ '' The subjects of erotomania," the same writer observes, " never pass the limits of propriety ; they remain chaste." And ]\Iarc also observes, that " in erotomania, the disease has the cerebral functions for its point de depart ; while in nymphomania and satjTiasis, the source of the disease lies in the reproductive organs." (Vol. ii, p. 183.) It is by no means easy, however, to draw these distinctions in practice. The two may exist together. Patients may com- pletely exceed the limits of propriety, without our having any evidence that the primary disease is in the reproductive organs. It is difficult, in not a few instances, to determine whether the origiji of the malady is there or in the head. Nor do EsquiroFs examples of erotomania sufficiently sustain the definition with which he sets out. It may, perhaps, therefore, be better to employ the term in a more comprehensive sense, so far as to consider Esquirol's description of erotomania as but one of its forms — the sentimental — or as erotomania proper ; and nymphomania or uteromania (haNdng reference to females), and satyriasis (having reference to males), as additional forms. These latter are comprised under the term aidoiomania {alSola, pudenda, and fxavia) introduced by IVIarc ; and the fureur genitale of Buisson. In erotomania there is sometimes great depression of the vital forces ; and in these cases, if the remedies employed do not soon take effect, the patient becomes more and more de- pressed in mind and body, emaciated, and rapidly sinks ; an example of the erotic fever {fievre erotique) of Lorry. In some cases there is, doubtless, an erotic condition, which interferes but very slightly Avith the accustomed exercise of the intellectual faculties, but which entirely overmasters the patient's controlling power (Emotional Insanity). To these Prichard has referred, in connexion with moral insanity, and gives the following in illustration : — " A young man, previously of most respectable character, became subject to severe epileptic fits, which were the prelude to attacks of violent mania, lasting, as I EROTOMANIA. 231 it generally happens in this form of the disease, but a few days, and recurring at uncertain intervals. These complaints, after a time, disappeared in a great measure; but they left the individual excessively irritable in temper, irascible, and impe- tuous, liable to sudden bursts of anger and rage, during which he became dangerous to persons who Avere near to him. Of symptoms of this description, a state approximating to the satyriasis of medical writers is no unusual accompaniment ; but, in the present instance, the diseased propensities of the individual were displayed in such a manner as to render con- finement in a lunatic asylum the only preservative against criminal accusations." ('Treatise on Insanity,' p. 25.) Examples of the various forms of erotomania will be found in Esquii'ol (' Malad. iMent.,' vol. ii, pp. 32, 49). A remarkable example of erotic monomania, in which there was no marked disorder of the intellect, is reported by Ferrus, Esquirol, and ^larc. (' Annales Hygiene Publique et de Mede- cine Legale,' tom. iii, p. 198 ; Marc, vol. i, p. 30.) An interesting ca.se is reported by Marc (vol. i, pp. 14-8-9). Erotic conduct appeared to be the result of the delusion that a lady was not married to her husband. The patient had, in consequence, to be placed under restraint. The same writer (vol. i, p. 209) cites from Gall the case of an idiot, seven years of age, who afforded a remai'kable example of satyriasis. Numerous examples of erotomania proper are given by the same writer in his work, vol. ii, pp. 182, 193 ; and of aidoio- mania. Idem, pp. 193, 291. See also 'Diet, des Sc. Med.,' Art. " Nymphomanic," by Yillermay ; and Art. " Satyriasis," by M. Rony ; and M. Bayard's 'Treatise on Utcromania,' Paris, 1836. Erotomania, in its extended signification, not unfrcquently follows upon religious melancholy ; a case lately iu the Ketreat was an illustration of it. It is not uncommon in the old, and, it may be, in persons who have been patterns of chastity during life. We have seen it among the first indications of senile dementia. It is more frequent among women than men ; and, as Guislain observes, among the unmarried and widows than the married. It may often, in females, be traced to disordered menstruation ; sometimes, as in a patient now in the Retreat, to 232 PYROMANIA. ovarian disease. Nympliomania and satyriasis may be excited also by irritating siibstanccs in the bowels, by ascarides, by hremorrhoids, by cutaneous eruptions,, pruritus, &c. It may attack any age ; but the sentimental form — erotomania proper — more especially affects the young, and those of an ai'dent, susceptible temperament. Idiots are frequently examples of the physical form (aidoiomania) . Erotomania is often compli- cated with hysteria, and sometimes with hypochondriasis. Section XI. — Of Priromania. In a systematic work it is necessary to make some allusion to the condition of mind to which this term (from -rrvp, fire) has been attached, and to which reference is so frequently made in psychological literature. At the same time, we think that it would have been better, had psychologists included pyromania under desti'uctive mania in general, instead of constituting it a distinct form of mental disorder. We are well acquainted with the particulars of a case in which the act of burning was clearly connected with an impulse to destroy everything that came within reach. INIr. had had a paralytic attack about eight years previously, but had very much recovered from its effects, with the exception of uncomfortable sensations in the head, accompanied by slight confusion of mind. He was married, and was very kind both to his wife and children. Soon after retiring to bed, not having been worse than usual the previous day, and equally affectionate to his family (kissing his children before they went to bed, &c.), he shot his wife, attempted to shoot a servant, set fire to his house in at least six different places, and then committed suicide ! The house was burnt to the ground. An examination of the recorded cases of pyromania will result in the rejection of a large number of them from the category of instinctive or impulsive forms of insanity. In a considerable number, there appears to have been a feeling of revenge present, which a perverted moral nature, sometimes independent of, but, in other cases, probably the result of disease, led on to the 1 was aged 8 . -ears 1 „ 10 2 ., 12 „ 2 ., 13 „ 1 „ 14 „ 1 ,. In „ PY ROMANIA. 233 commission of incendiary acts. Of twenty cases recorded l)y Klein and Platner, sixteen appeared to originate in a motive, although, in many cases, of a trivial character. It is remark- able, however^ that, even in such cases, as well as in those of an impulsive character, the age of the parties was under or about the period of puberty, and that a larger number of girls than boys have been the subjects of this disorder. Thus, of 124 persons accused of the crime of arson between 1825 and 1832, reported in the ' Gazette des Tribunaux ' — 7 were aged 16 years. 1 ,. 17 „ 4 ,. 18 „ 3 „ 19 „ 3 „ 20 ,. And Marc concludes, that the period at which pyromania is manifested in young persons, in consequence of the abnormal development of the sexual functions, corresponds nearly with the age between twelve and twenty ; that, if there exist any general symptoms indicative of irregular development, or of critical changes by which the attempt is being made to perfect the evolution of the reproductive system, the probability is, that an incendiary act has been the result of disease. Hence, atten- tion should be paid to such signs as a too rapid growth, or one that is retarded, as well as an arrest in the development of the sexual organs; also, unusual lassitude, glandular swellings, cutaneous eruptions, &c. Further, it is very important to ascertain whether signs were present, before the incendiary act, of approaching menstruation or of its disorder or suppression. Again, this Avriter points out the necessity of ascertaining whether there are any symptoms of disorder of the circulation, as an irregular pulse, deter- mination of blood to the head, vertigo, headache, &c.; or of the nervous system, as involuntary muscular movements, trembling, spasms, and convulsions of any kind, epilepsy and catalepsy. In connexion with all these symptoms, there will generally be found some change in the character, such as a tendency to sadness, irascibility, and other like symptoms of disordered cerebral functions. In some eases on record, there existed, 234 PYROMANIA. from infancy, a condition of mind bordering on imbecility. Dr. Morel, in his recent treatise (I860), lays great stress upon its presence, as an instinctive form of insanity, in some children with hereditary predisposition. In analysing some of the most remarkable cases illustrative of the disorder which are on record, we have classified them under the following heads : — I. Cases in which there was no marked disorder of the intellect. (Emotional Insanity.) II. Those in which such disorder existed. Under the former head, it may be convenient to divide those («) in which there was no premeditation or design, from those {b) in which this was present. Again, under the second head, it may aid the investi- gation of the subject, to separate those cases (a) in which there was a deficiency of the intellect, as imbecility, idiocy, &c. ; from those (b) in Avhich there Avere delusions, hallucinations, &c. ; these generally constituted the motive. I. Without marked disorder of the intellect. (a) Without premeditation or design : 1 . A boy, sixteen years of age, set fire to the house of the father of a person to whom he was much attached. He strug- gled against the impulse for a year. (Marc, vol. ii, p. 291.) 2. Case of ISIaria Franc. She could give no other reason, nor show any other motive for setting houses on fire, than a blind impulse, originating in witnessing a fire. Notwithstanding, says Gall, who reports the case, the fear, the terror, and the re- pentance which she felt in every instance, she went and did it afresh. (Gall, vol. iv, p. 104.) 3. Case of Eve Schembomska, aged twenty-two, who ap- pears to have laboured under a powerful impulse ; to use her own words, '' an inward agitation that tormented her.'' (Klein's * Annales Judiciaires/ xvi, 311 ; Ray's ' Medical Jurisprudence of Insanity,' p. 191.) 4. Case of a peasant girl, Kalinovska, aged seventeen, who was suddenly seized with a desire to burn after returning from a dance where she got heated. After struggling for three days against the impulse, she yielded to it, and declared that on seeing the flames, she experienced a joy such as she had never felt before. (Klein's * Annales Judiciaires,' xii, 53 ; Ray op. cit., p. 191.) 5. Case of a servant girl, named Weber, aged twenty-two P VUG MANIA. 235 who committed three incendiary acts. Her mistress liad ob- served that she was sad, that she would frequently seem as if buried in thous^ht, and woidd cry out in her sleep. It appeared that she had had, two years before, violent pains in the head, disordered circulation, insensibility, and epileptic fits ; since which, the catamcnia had been absent. (Klein, op. cit., xiii, p. 131 ; Ray, loc. cit.) (b) With premeditation and design : 1. Case of a servant girl in a German village, who, in 1830, twice set fire to the premises of her master. The physician who examined her concluded that she was not responsible for her acts, and that they proceeded from an incendiary impulse, which was a consequence of interrupted physical evolution. She was released, and, under appropriate medical treatment, she had no return of this morbid tendency. (' Neues Archiv. dcs Criminal- rcchts,' x^-i, 393 ; Ray, op. cit., p. 193.) 2. Case of Jane Wells, aged thirteen, servant in Mr. Stone's family, near London. Dr. Southwood Smith certified, that she had been suffering from brain-fever some time before ; that her convalescence had been protracted, and that her mind might have been injured. The chief motive in this case appears to have been the pleasure of seeing a blaze. (Marc, vol. ii, p. 369.) II. With disorder of the intellect : (a) Depressed condition of the intellect, imbecility, &c. 1. Case of a servant girl, aged seventeen, in whom the motive was trivial. (Platner's ' Quajst. Med. Forensis,' 1821; Ray, op. cit., p. 193.) 2. Case of a boy, K — , aged eleven years and six months. The conclusion arrived at by the expert who examined him was, that, owing to a defective education, he was still infantile, and that the first incendiary act of which he was guilty was a childish trick — the second, the result of secret ill-will ; but that, independently of this, there was disease — congenital or acquired — which exercised a certain influence upon his conduct. (Dr. Meyer, of Pinnebcrg, ' Annalcs de Henke;' Marc, vol. ii, p. 330.) 3. The celebrated ease of Delepine reported by Georget. He was sixteen years of age. Marc characterises it as a case of feebleness of mind, or dcmi-idiocy. (Georget, ' Discu.ssion 236 DIPSOMANIA. Medico-Legale/ Paris, 1826, p. 139; Marc, vol. i, p. 392.) 4. Case of slight imbecility, and of pyromania, in a lad aged seventeen. No motive appeared beyond the love of mischief. It is, however, a highly interesting and instructive case. (]Marc, vol. i, p. 406. (b) Exalted condition of the intellect, hallucinations, &c. : 1. Case of a girl aged seventeen years, in which an inward voice was heard commanding her to burn. This was the only sign of aberration of the intellect. {' Questiones ]\Iedicinre Forensis,' 1821 ; Ray, op. cit., p. 193.) 2. Case of a girl aged fifteen, named Graborkwa. Here the only disorder of the intellect was a hallucination that an appa- rition was constantly before her, impelling her to acts of incen- diarism. (Klein, ' Annalen/ xii, p. 136 ; Ray, loc. cit.) 3. Case of a young man, M. B — , a patient in an asylum in Paris, whose propensity it was to set fire to everything. It is to be inferred that it was associated with mania. (Marc, vol. ii, p. 309.)* Section XII.— 0/ Dip so man w. Dipsomania {h\pog, thirst). Mania crapidosa vel ehriosa, Oinomania, Monomanie d'ivresse (Esquirol), &c. — This is a foi'm of mental disorder which, in an especial manner, requires to be discriminated from what may be termed a merely physiological condition, in which the human animal chooses to indulge in alcoholic beverages to excess. On the one hand, the admission of this disease into the department of mental pathology does not need to make us conclude that there is no such thing as intemperance without disease ; and, on the other, the fact that the abuse of alcoholic drinks lias, oftentimes, no disease to plead in its excuse, must not lead us to the opposite extreme of denying that a truly diseased cerebral condition may exist, the result of which is inebriety. How, then, shall we distinguish the two * Dr. Jessen has recently published an inij)ortnnt work on this siihject, 'Die Brandstiftungen in Aflectcn und (Jeistesstorunfjcn.' Kiel, 1860. Dll'SU.MAMA. 2o7 conditions, when tlie result — intemperance — is the same in both ? First, by observing; whetlicr there are any symptoms present which can be referred to primary disorder of the nervous sys- tem, tliat is to say, other symptoms than those which, as in ordinary drunkenness, can readily be accounted for by the pro- longed indulgence in alcohol. The family psychological history, again, is of great importance. Cases in which an insane parent lias a drunken son point strongly, of course, to disease. The development of the appetite for stimulants, in early life, is another indication in the same direction. But, to come more closely to the circumstances attending the habit itself, the pro- minent feature of this propensity is its irresistib'iUly ; the thirst for drink is the tyrant which overbears all the higher emotions, and blindly leads the oinomaniac to a course against which his reason and his conscience alike rebel. Dr. Ilutcheson was among the first to draw especial attention to this disease. After observing that there are individuals who, at the festive board, invaria])ly become excited, if not intoxicated, but are otherwise habitually sober, and, in the course of the year, drink much less than others who never appear to be under the influence of stimulants, and that others indulge in their potations in a regu- lar manner, and daily consume a larger quantity of liquor than is consistent with good health and sobriety, he proceeds : " All these, however, possess self-control, and can, at any time, refrain from stimulants ; but those afflicted with the disease cannot do so, however convinced they maybe of the impropriety of yielding to their propensity, or however desirous they may be to subdue it. *' The disease appears in three forms — the acute, the pei'iodic, and the chronic. " The aatte is the rarest of the three. We have seen it occur from hsemorrhage in the puerperal state, in recovery from fevers, from excessive venereal indulgence, and in some forms of dys- pepsia. "The y;<'//olioukl In; Ik'Ucvc that he is about to ivi'orni tlic state of society (the proniiucnt symptom of Dr. Arnold's " scheminii: insanity"), he()vcrflo\\s uith benevolent plans, projects, and intentions, all devised i\ v the certain amelioration of mankind. If Ave cannot listcii to these until the description is concluded, or if he should be thuarted in his endeavour to cany into execution these imprac- ticable schemes, a violent explosion of passion, accompanied by imprecations and perhaps a display of his pugilistic powers, will probably be the termination, for the moment, of his ex- j)ausivc philanthropy ; and the seclusion room becomes the receptacle of the reformer of the world. He is bent on de- stroying- whatever lies within his reach ; his clothes, if not sulHcieutly strou-;-. are sacrificed to his rage ; and the scraps of paper on m liich he has so ingeniously designed the means by which his ideas may be realized, the letters to the Queen and Prime !Min- istcr in which he has so conclusively set forth the remedies for the relief of every human ill, are now, it is not unlikely, torn into a thousand pieces. If to this condition be added dirty habits, or ihc dirt-eating propensity, a truly deplorable picture is presented of what the " lord of the creation " may become when atilicted with mental disease. Dangerous violence, destructivcuess in regard to senseless objects, a total disregard of cleanliness and decency, vociferous denunciations, loud and threatening lan- guage, rapid and impetuous utterance, harsh voice, imprecations and stamping Avith the feet, now mark the climax of the paroxysm the madman labours under in this marvellous dis- turbance of the emotions, involving, as it does, the overthrow of the moral, and the perversion of the intellectual portions of our mental constitution. The face, and the Avhole external man would tell, were the patient silent, of the commotion which Avas raging within. The tension of the muscles, the contracted brow, the Hushed features, tlic brilliance and congestion of the eyes, the head thrown back in audacious contempt, or iixcd in a menacing attitude, the dis- ordered or even bristled hair, the putting of the neck, and con- gested veins, — all indicate the mcntid tempest by which he i > agitated. The emotions thus aroused and cxt-ited. in the woids of Shakespeare, — 246 MANIA. ■• .Stirten thf sinews, siimuion up the Ijlouil, Lend tierce and dreadful aspect to the eye, Set the teeth close, and stretch the nostril wide, Hold hard the breath, aiid'l)ind up every spirit To it3 full height "' But it must not be inferred, from these descriptions, that everv case of acute mania presents either such well-pronouneed symp- toms, or even precisely the same passions of the sonl in diseased activity. Fortunately, raving madness is, at the present day, to be found (thanks to tlie altered system of treatment, and perhaps also to an altered — that is to say — more asthenic phase of disease in general) much better described in Ijooks than observed in our asylums for the insane. The statement made by Arnold in regard to a patient labouring under " plu-enitic insanity,' ' tbat '' he raves incessantly, or with short and those rarely lucid intervals, either about one or various objects ; and laughs, sings, whistles, weeps, laments, prays, shouts, threatens, attempts to commit violence either on himself or others, or does whatever else the nature of his delirium prompts him to," is not applicable to nearly so large a proportion of cases of insanity as it was when iVrnold wrote. The student in quest of a graphic picture of mania may read Chiaruggi's description (cited by Prichard, ' Treatise,' p. 76), since he may have some time to wait before he can witness its counterpart in the realities ol" asylum life. Perhaps the most remarkable fact, in regard to tlic connexion between the mental symptoms developed in mania, and the [)hy- sical health, is the slight degree in Mhich the latter is cnidangercd, or even (it may be) materially disturbed. Careful notes taken of the state of the tongue, pulse, the renal secretion, and the alvino evacuations in a condition of great excitement, and compared M'ith notes taken of the same patients when convalescent, will sometimes fail to show that chang(^ which would appear to be commensurate with the altered physical condition of the patient. This statement must, of course, be so far qualified, that the muscular exertion and rapid locomotion connected with the period of actual violence, necessarily induces some temporary changes in the physical state, sucli as heat of the skin and acceleration of the pulse, which, however, cannot be regarded as ollirf tlian the natural effect of certain actions; Avhich ert'ect MAMA. 2-17 would take pliiee in individuals pcrt'orniin}'- ihcm, aithuuf^li iu perfect licaltli. And it is furtlier sometimes observed, ^vhcn pliysieal disorder has been marked^ tliat, in the change from excitement to tranquillity^ there is a persistence of morbid phy- sical plienomena ; that is to say, some morbid physical symptoms were not wanting in the maniacal stagc^ but they did not pass away immediately on the subsidence of the excitement ; — a fact whichj to some extent, is explained by supposing that the phy- sical symptoms induced by the cerebral irritation, had not had time to subside, although their immediate cause had disappeared. Dr. Couolly, after stating that he has attempted to convey an idea of the symptoms of acute mania, observes, " that even acute mania is not always accompanied by the ordinary external signs of excitement. It would seem as if wc had yet to learn the real symptoms of cerebral irritation. Certainly, in recent cases of mania, — cases which had not lasted more than six weeks, and in young persons in whom I have since seen the maniacal attack pass into dementia, — I have known the most acute paroxysms of mania exist, rapid and violent talking, con- tinual motion, inability to recognise surrounding persons and objects, a disposition to tear and destroy clothes and bedding, without any heat of the scalp or of the surface, -without either flushing or paleness of the face, with a clean and natural appear- ance of the tongue, and a pulse no more than 80 or 85/' This is, however, exceptional ; and we believe that, in a very early stage (often prior to admission into an asylum), well-marked physical symptoms are rarely wanting ; aftenvards, the system begins, as it were, to tolerate the excitement to which it is sub- jected. A case lately seen at the house of the patient, illustrates the foregoing, Avell; and it illustrates another fact, which is, that in the onset of the attack, the symptoms may be those chiefly of irritation, while, in the course of a few days, they become much more decidedly febrile in character. The patient — a young man — complained, in the first instance, of feeling generally ill, and was unusually nervous, fearing to sleep alone, &c. His pupils were dilated, the conjunctiva pale, the water copious and light in colour, and the pulse about 80. In a day or two, the mind became more attected, and the symptoms of acute mania set in. With these psychical symptoms, the conjunctiva became intensely injected, the urine scanty and high eolouvtul, the pulse more f re- 21S MAMA. queJit, ;uid the liL-atl very hot. The tongue, -whieh was foul before, became iiicreasiugly so, aud red. For several days, the patient was aeutely maniacal ; after which, the excitement abated, and, coincidently with this abatement, the tongue became cleaner, the pulse slouei-, the conjunctiva paler, and the urine more copious. What, then, are usually the evidences atibrded by the physical symptoms of the patient, of his maniacal condition? Drs. Leuret and .Mitivie have made some very careful observations on the pulse in mania, and have arrived at tlie conclusion, that the mean number of pulsations in a minute is 90, being about 15 above tlie average of the healthy adult. "^ According to Dr. Conolly, the pulse is frequently quick and feeble, seldom below 96, often as higb as 120, variable, and readily increased in rapidity. It is difficult, however, to know, as has before been intimated, how much of this increased frequency is due to mus- cular exercise and other accidental circumstances, and how much to the disease itself. Jaeobi tliinks, that the condition of the pulse in mania does not so much indicate the state of tlie pa- tient's mind, as the physical disorder existing with, and probably the cause of it. He regards the observations of Leui'ct and jNIitivie as defective, and appears himself to have arrived at negative, rather than positive results. Dr. Foville has made observations on the frequency of the pulse in the insane gene- rally. He took sixty-two patients (male and female) promiscu- ously, chronic and acute cases, and found the average pulsations to be 81 in a minute. Guislain thinks, that cerebral excite- ment is generally proportioned to the quickness of the pulse. " Occasionally," he adds, " it is slow, as in some cases of mchuieholy and ecstasy, but then there is a peculiar rhythm ; each pulsation, even when the contraction of the heart does not indicate disease, presents a certain energy, hi some degree, con- vuIsIn e. Occasionally, the pulse is slow, from a diminution of cerebral excitement. Scarcely ever is there eitlicr hardness or fulness of the pulse.'' The .slchi is sometimes moist, aud olt'ensive to the sense of *■ Di'. Guy made observations on the jniKe iu til'iy i)ei'soiis free from mental or bodily disease; and, when eomj)tired witli the results of Leuret and Mitivie, it would appear, that " it in only between 80 and UO pulsations that there is any ifrent excess on tin' side of the iiisjuic." Furihsir jifiifh/itr, y. 270. MAMA. '4VJ siuell, sometimes thy aiul liavsh. The Ibnuer condition is^, occa- bionallvj tlie cause ot" as diagnostic an odour as the nevcr-to-be- Ibrgotten elHuvium attendant upon a varioltMis patient ; and is then immediately obsoiAcd on entering a room where the maniac hao been for some hours, and especially during the night. The room smells like a mouse-trap. Ur. Jacobi, however, inclines to doubt whether there is anything special in it. The bouxls are sometimes relaxed for a considerable period in mania, but constipation is more usual ; whether loose or con- fined, there is very frequently decided evidence of gastric and hepatic derangement. The dirty habits of maniacs are referred, by (,'almeil, to two causes — forgetfulness and design, but not to any paralysis of the sphincter ani. Dr. Jacobi foinul, out of titty cases, the bowels inactive in twenty instances, regular and of normal form in seventeen ; while, in thirteen, the stools were decidedly ludiealthy, and, in nine of these, irregularly relaxed and contined. The urine is frequently sutliciont in ([uantiLy, without being high coloured ; at the same time, during an accession of violence, il is often more scanty, aud deeper in colour. Some years ago. Drs. Sutherland and lligby examined the urine of a large num- ber of patients at St. Luke's, and found that, in 100 cases of mania, it was of "dark colour" in 5.2, and deposited a sediment in 87 instances. Incontinence of urine is common, aud may, in most instances, be explained, on Calmeil's supposition iu regard to the fieepl evacuations. Dr. Sutherland, in conjunction with Dr. IJealc, has recently made a series of experiments on the urine of nn.niacal patients, and has amved at the following conclusions : "1. A plus quantity of phosphates exists in the urine, m the paroxysms of acute mania. " :l. A minus quantity exists in the stage of exhaustion iii jnania, in acute dementia, and in the third stage of paralysis of the insane. '• 3. The plus and minus ([uantities of pliospiiaies in the urine correspond with the quantitative analysis of the brain and of the l)luod ; for a plus quantity of phosphorus is tbund in the brain, and a slight excess of albumen in the blood of maniacal patients ; and a minus quantity of phosphorus and albumen is found in the brain of idiots; and a minus quantity of albumen in the 1)1<)()(1, in ]);iralysis of the ins.'U,'. 250 MANIA. " 4. The plus quautity of phosphates iu the uriue of cases of acute mania, denotes the expenditure of nervous force, and is not a proof of the existence of acute inflammation in this dis- ease.'^ Contrary to the conclusion at -which Erlenmayer arrived, namely, that the urine is generally alkaline in recent cases of mania, Dr. Sutlierland concludes that it is generally acid. " I find that in 125 cases of recent mania, admitted during two years under my care, into St. Luke^s Hospital, the urine was acid in 111 cases, neutral in 1, alkaline in 13 ; being in the proportion of 884- per cent, acid, lOi alkaline, and, omitting fractions, 1 neutral ; whereas in 100 cases of chronic mania and dementia under my care at the same time, the urine was acid in 61, neutral in 6, alkaline in 33 ; and in 25 cases of paralysis of the insane, the reaction of the urine -was acid in 12, neutral in 1, alkaline iu 12." The tongue is usually redder than it should be, its muscular tissue firmer, and its papilla) unduly prominent. Of 50 cases of acute mania examined in this respect by Jacobi, the tongue was in 17 instances very foul, white or tawny, grey or yellowish grey, but in no case actually dry, although it was frequently but little moist; in 16 cases the tongue was slightly furred, and in the remaining 17 it was quite clean. In the same number of cases, the breath Avas in 20 sweet, in 15 somewhat offensive, and in the same number decidedly so, iu some of these being " ex- ceedingly sour." In regard to the saliva, the same observer found out of 50 cases, that it was excessive in quantity in 21 instances (in 2 of which it was only so during the paroxysm), and slightly increased in 4. As a rule, the appetite of maniacal patients is great, and often excessive ; sometimes more so at the onset, and during a paroxysm, than when the patient is calmer. A maniac may refuse food altogether, but he rarely persists so long as to occa- sion any danger. Referring to Dr. Jacobi's 50 cases, we find that in 23 the appetite was normal, in 13 it was voracious ; iu 7 it was at first poor, and subsequently excessive ; in 3 it varied, iu 2 the appetite was increased duriug the exacerbations, and in the remaining 2 it was very bad. Thirst was a prominent symptom in 7 cases, in there was less than usual, and the romaiuiug 31 did not vary from a state of health in this respect. MAMA. 251 In tlic majority of ca.scis of" acute iiuuiia oi-cm-ring: in wonion the catamenia arc suppressed. The patient |;enerally ficts thinner; the same remark ob- viously applies here that was made in regard to the pulse, that this may residt entirely from circumstances which ai-c associated with, but are not essential to, the disease. In some cases, there is marked emaciation. In 21 of Jacobi's 50 cases, there was very decided evidence of defective nutrition, and in 15 this was in some degree the case ; in 15 eases there was more or less evi- dence of dyscrasia, and in 14 the complexion was sallow or earthy, with a dark areola under the eyes. Extreme, and sometimes sudden, exhaustion, is a symptom always to be feared, and carefully to be watched, in the progress of mania — Avhile the gradual loss of flesh, so often obsei'Aed, is not, even Mhen veiy considerable, a circumstance which need occasion alarm, either as to the recovery of mind or body. Dr. Conolly records seven cases in which it proved fatal, one of which is so instructive, that we shall cite it in illustration here. " .V male patient, aged thirty-six, a coachman, lost his situation and became maniacal in consequence, threatening the life of his wife, trying to get out of the window, and saying that the devil was in his room. When admitted, about a fortnight after his attack, he Avas thin, i)ale, restless ; always talking incoherently, (H* singing ; his tongue was white, but it soon became dry and coated, and then in a few days moist. At first he refused food, then took it freely; the bowels were costive, his voice was hoarse, the pulse at first 96, soon afterwards 120, and always \ cry feeble ; he could give no distinct answers. Here was a ease of recent mania from a moral cause. Leeches were applied to the head, he had warm baths; eroton oil was given when food was refused ; the tincture of henbane at night, and, after a trial of thi.s medicine, porter; but he sank rapidly, became quiet and sleepy, and died ten days after admission." ('Lancet,' IK 15.) Pinel informs us that an Austrian prisoner Mas brought tu the JJicetre, who was, for two months, in a state of violent and perpetual agitation, unceasingly singing or crying, and breaking to pieces everything that came in his way. " His api)etite was so voracious that lie ate I lbs. of bread daily. On the night of October 25th, the third year of the republic, the pai'oxysm subsidi-d. In the morning he was observed to be in lull possession of liis rcasou^ but in u state of extreme e\- liaustion. After breakfast, lie Avalked for a short time in the court; on returning to his apartment, in the evening, he coni- l)lained of a sense of chilliness, -which v,e endeavoured to remedy by increasing- his bed-clothing. The keeper, on going his round some hours afterwards, found the unfortunate man dead in his l)ed, in tlie position in which lie had left him." The case is ad- duced by Pinel, rather in illustration of the effect of severe cold, than of simple exhaustion. Dr. Bell, of America, has specially called the attention of the profession to a form of mania in Avliicli the disease runs a rapid course, and is attended by extreme exhaustion after excite- ment. In " Bell's disease," (as it has been called,) the attack is sudden ; and loss of sleep, delirium, and loathing of food, are prominent symptoms. Ray regards such cases as identical with what Abercrombic descril)es as '' a dangerous modification of meningitis," which is liable to be mistaken for mania.''" Dr. Benedict considers that the cases which he has reported under the term " exhaustive mania," are examples of Bell's disease ; but Dr. Hay thinks their identity improbable, since Benedict's cases recovered, and Bell's died. Dr. A. V. AVilliams refers to the same category, what he calls '' typhomania," from the typhoid character of the symptoms. This, also. Dr. Ray regards as distinct from Bell's disease. The diversity of symptoms in mania may, to a certain extent, be explained by the McU-known fact, that an equal amount of excitement may result from two distinct and opposite conditions of the system ; excessive nervous action often co-existing with deficient nervous power. This it is most important ever to bear in mind. One patient may be mad from an excess, another from a deficiency, of vital force. The one may recjuire the lancet, the other stimulants. I'herc may be a surplus nervous energy and excitement, and there may be a stati> of nei'vous debility and consequent irritation, precisely ojjposite in its nature. A^'^• may very properly speak, therefore, oislJienir and asthenic mania, both being still acute or active. To the former, the description ah'cady given of the physical indications, more especially applies. In the latter, the pulse is often very feeble, although frequent ; • Dr. \\';i!s()ii snjfivmes that Aliercro'.iibie whs nnur is (Ucidcdly pale, thin, flat, llal)by, and j)io])al)ly in- dented at the edties; the lips pale; the eoujimctiva watery, and cither pale, or if vaseular, not presenting the same bright red injection Avliich is generally present in acnte sthenic mania; the pupil is not so much contracted, and it may be dilated. In books, a dilated pupil is sometimes mentioned as characteristic of mania, but this is by no means the case ; and, when it is present, it will usually be found in mania of the asthenic variety .■^•" The scalp may, or may not^ be hotter than usual ; and in regard to this, and every other symptom, it may be observed, that no just inference can be drawn from any one of them alone; they must be judged of in their entirety. In regard to the course Avhich acute mania takes after it is established, it may either yield rapidly to treatment ; may, as we h.T\ e seen, end in death by exhaustion ; may become chronic ; or may terminate in melancholia, or dementia. When, in women, it does not yield to treatment, although suj)- l)rcssed catamcnia return, there is great danger of an incura])ly chronic form of dementia. Esqnirol was of opinion that the ma- jority are cured at the termination of the second or fourth month of treatment. Guislain's experience is to the effect, that while an iicute attack of mania may terminate in three or four days, it most frequently does so at the end of three months ; frequently, also, at the end of six or nine. After two years' continuance, he has rarely seen mania cured. Esquirol has seen cures after two or three years' continuance ; Brierre de Boismont after twelve ; and Pinel after twenty-five years. Persons generally estimate the danger of mania by its intensity ; but, in general, the proba- bility of cure is rather in proportion as the excitement involves the whole mind, and not any single faculty. A noisy, general excitement is usually recovered from. At the asylum at (ihent, 7 out of 10 eases of mania recover, some of these sooner or later relapse, returning to the asylum after an absence of one, two, four, seven, and ten years. Guislain thinks there is a good deal • Dr. Pliny Earle, liowevcr, in .nn oxpcllcnt paper in the 'Amcritan Journal of Insanity ' (April, ISoH, observes : — "In ninny ca.«es of the most furious nianiu, anil that too, not unfrequently, in rohu^it or plethoric persons, X\w jiupll remains of its natur.il size. So.netiuies, it is even diliiteil. Tiie oases in whidi it is {generally most contracted are those of slender, nervoiis, perhaps (hhilitated jicr- sons, in whom there are variotis evidences of high excitability, niid who not only tolerate, hut require a tonic, sometimes a stimulant treatment." 254 MANIA. of periodicity in rcg-ard to tlic return of the attacks. The par- oxysm has been observed to return at various periods, occasionally regular, as after an interval of a month or a v^-eek ; and some- times, it assumes a quotidian, tertian, or quartan type. Occasion- ally, as in the ease of a female known to us, a maniacal pa- roxysm comes on every year. In some cases, Guislain has ob- served mania to return every four, in others every three mouths, and in others every month. This is more especially the ease when complicated with epilepsy; in regard to which complication it may be stated, that out of four hundred patients at the Salpetrierc, fifty were maniacs. The connexion between lunar influence and the return of maniacal paroxysms is not yet sufficiently well estaljlished. The remissions in mania arc not, generally speaking, the same, in regard to the period of the day, as in melancholia, in which the exacerbations usually take place towards morning. The night may be marked by great excitement, and tlic day begin with comparative calmness. However much the patient may have had the aspect of health during the early period of the attack, it almost invariably happens that, when it becomes chronic, he has an ill look, a haggard ex- pression, makes little red blood, is cachectic; and although, in some instances, among a group of patients, the subject of chronic mania does not attract any special attention as being out of health, and has not any prominent morbid symptom, he would, were he placed by the side of a man enjoying robust health, present a sufficiently striking contrast. He Avould look etiolated. Melancholia often succeeds to mania, and a simple depres- sion of spirits, weeping, &c., are frequent attendants on recovery. But mania and melancholia frc(]uently alternate. These cases arc far from favoTirable. Mania exhibits a constant tendency to pass into dementia. Of 49 cases of mania admitted into the lletrcat, and which ulti- mately proved fatal, the following was the state of mind of the patients at the period of death. In 30, the form of disorder was unchanged, 8 of whom had decidedly improved, and 2.2 were no better. In 19, the form of mental disorder had changed ; 16 into dementia, and only three into melancholia. Again, of 91 patients in the Retreat in 1810, 88 had been admitted in a MANIA. 255 state of mania, of whom 11 had passed into dementia, and 27 •were still examples of mania. ('Statistics of Insanity/ Tab. 33, 15.) It fares, indeed, with the patient after an attack of mania, as with a city or garrison after the horrors of an assault. The milder but more permanent supremacy of the enemy may succeed ; or the whole may present but a heap of smoulderinji; rains ; or the reaction of native streno:th having repelled the foe, there may be more or less of obvious dilapidation to mark the fierceness of the conflict. The mortality at the Retreat of those admitted during a state of mania, during forty-four years, was 3'99 per cent., while, in melancholia, it was nearly double this, — namely, 090. In regard to its frequency, it may be stated, that at the same institution, and during the same period of time, 015 cases were admitted, of whom 277, or about 15 per cent., were examples of mania, offering a contrast to melancholia, of which there were 35 per cent. The two sexes appeared to be equally the subjects of mania. Esquirol considered the male sex the most liable, crania may attack the very young, though rarely. It is chiefly observed between the ages of twenty and thirty-five or forty. It is a disease of manhood and middle life. An interesting case of mania, occurring in a little girl only six years old, was admitted into Bethlem Hospital in 184'2. ''When admitted, her conduct was violent and mischievous, — striking those about her, tearing her clothes, and destroying everything within her reach. . . . Sixteen days after her admission, she was attacked with diarrhoea of a mild character, from which she recovered at the end of a few days. Soon afterwards, a con- siderable impi'ovemcnt took place in lier general behaviour, and she began to pay attention to the directions of one of the con- valescent patients. . . . She still continued decidedly insane. She could not be induced to employ herself in any way, and was subject to violent and unaccountable outbursts of passion, in which she tore lier clothes, and bit and scratched all who attempted to restrain her. After she had remained about six months in the hospital, she became much more docile, and began to employ herself in sewing, &c. From this time, also, a marked improvement took place in her manner and conduct, until she was reported well, after having bcLMi al)out twenty months under treatment." :2~i() rUEKl'KKAL INSANITY. General paralysis may supervene upon mania; exaggerated and absurd notions in regard to property M'ill always excite suspicion. Hemiplegia is rare, and apoplexy seldom occurs in the acute stage. Abdominal and pulmonary affec- tions are the more common physical complications. AVe have seen a case of acute mania terminate fatally in a fit of epilepsy. The patient was not subject to epilepsy before the maniacal attack. In regard to the causes of mania, among those termed moral may be enumerated anxiety, disappointed affections, jealous}', excessive joy from i)rosperity, &c., any intense mental emotion or strain on the intellectual powers, fright, ambition ungratified, ^^■ounded vanit}' or self-esteem. Among physical causes, here- ditary predisposition, intemperance, injuries of the head, fever, disappearance of a cutaneous eruption, erysipelas, retrocession of gout, suppression of the catamenia, parturition, lactation, abuse of mercury, &e. Section XTV. — Of Puerperal Initomiy. I\ speaking of the causes of mania, parturition and lacta- tion were mentioned among others. The excitement resulting from the puerperal state is so important, that it merits our special attention. It is a disorder which invades the sick- chamber at a time when it is most acutely felt ; nor is it of very rare occurrence. Thus, during five years, one eighth of the females admitted into Bethlem, were the subjects of ))uerpcral insanity (not mania only). At the Salpetriere, a twelfth, and — during some years — a tenth of the female admis- sions were of the same nature ; and, in private practice, Esquirol met with a still higher proportion. It is a remarkable fact, however, as has been pointed out by Dr. Reid, that, in lying-in hospitals, the nimiber of patients who are so attacked is very small. He states, that at the General Lying-in Hospital, West- minster, in which patients remain for three weeks after labour, out of 3500 who were delivered there, only nine were affected with insanity. The experience of several other large institu- PUKRPKRAL INSANITY. 257 tions was to the same effect. \Vc do not observe that Dr. Reid offers an explanation. It might, perhaps, be most satisfactorily accounted for, in connexion with the very favourable circum- stances (such as quiet, good nursing, and sufficient nourishment) which surround the hospital patient, as compared with those of a patient of the same destitute class at her own home. Nor must it be overlooked, that the absolute number of cases of puerperal insanity may be large, while, as compared with the enormous number of cases of labour, it may appear small. Al- though it may seem extraordinary that, in Esquirol's experience, patients of the higher class, among whom quiet, good nursing, and sufficient food would not be wanting, suffered more from this malady ; it is not to be forgotten, that here these favour- able circumstances may have been counterbalanced by others of an unfavourable description, more or less connected with luxu- rious living. The experience of the Salpetriere and of ISethlcm Hospital is, we think, considerably above that of other asylums; in most of which, we believe, it will be found, that the number of cases of insanity arising from pregnancy, parturition, and lactation, are from about one fourteenth to one twentieth of the females admitted. In those cases in which insanity occurs during pregnancy, it is usually recovered from when the patient is delivered. Oc- casionally, symptoms of mental derangement appear immediately after conception. It must not be supposed that mania is the only form of in- sanity which results from this condition of the system in women. On the contrary, melancholia, delusional forms of insanity, and even dementia, may ensue. ^lania, however, is undoubtedly the most frequent form of mental alienation. Of 57 cases under Dr. Burrows's care, 33 Mere maniacs ; in 8, mania and melan- choly alternated ; and in 16, melancholia was the form of the disorder. E.squirol found that, out of *J2 cases, 49 were maniacs, 35 were monomaniacs (including melancholiacs) , and 8 afforded examples of dementia. Of 19 cases in the Grove House Asylum, reported l^y Dr. Palmer, 15 were examples of mania, and only 4 of melancholia. This term, puerperal madness, is by different writers cm- ployed in a more or less comprehensive sense. It is frequently made to comprise — (1) Cases occurring during utero-gcstation ; 17 258 PUERPERAL INSANITY. (2) those occurring within a short period (a fortnight or four weeks) of parturition ; and (3) those arising during the period of lactation. But it is more especially intended to imply, by this term, those cases referred to in the second class ; and among these, a larger proportion of examples of mania exist than when insanity develops itself in connexion with lactation ; then melancholia is more generally manifested. Of 92 cases collected by Esquirol — IG became 21 17 19 19 msanc from the 1st to tbe 4th day after labour. 5th „ 15th „ 15th „ 60th „ 60th day to 1 year. „ immediately after forced or voluntary weanin*. From which it will be seen, that upwards of 40 per cent, of the cases occurred during the first fortnight after lalx)ur. Dr. Burrows thought the third and fourth day after confinement the most obnoxious to the invasion of this disease. Of 66 cases reported by Dr. Macdonald, formerly physician to the Bloomingdale Asylum, 29 became deranged within the first week after labour, and 15 during the next three weeks ; that is, 44 cases during the first month. In the course of the second month, 5 cases occurred ; and the general conclusion arrived at by this writer is, that " the proportion increases from day to day, as we approach the day of parturition, and diminishes as we depart from it." Puerperal insanity more frequently attacks females in their first than in subsequent labours. The character of the mental disturbance in puerperal mania diflFers somewhat, but not in any very essential particulars, from that of mania arising from other causes. We think it is Dr. Gooch Avho makes the remark, that were any one conversant with mental maladies to be introduced to a patient suflcring from puerperal insanity, he would not be able to tell, without inquiry, that the case was of puerperal origin. As Dr. Macdonald, however, observes, " in the acute form of the mania which succeeds parturition, avc observe an intensity of mental excitement, an excessive incoherence, a degree of fever, and, above all, a disposition to mingle obscene words with the broken sentences ; things which arc rarely noted under rUKKl'EllAL INSANITY. 259 other circumstances. It is true that, in mania, modest -woincu use words wliich in licalth arc never permitted to issue from their lips : but in puerperal insanity, this is so common an oc- cuiTcncc, and is done in so gross a manner, that it early struck me as being characteristic.^' Before the mental symptoms are fully developed, the patient becomes uncomfortable, peevish and restless, and cannot sleep ; the head aches, and there is an altered expression of countenance. The milk and lochia are often either diminished or suppressed ; the tongue is white, the bowels loaded, the urine generally scanty, and, Professor Simpson has pointed out, frequently containing albumen; the abdomen, in most cases, tolerant of pressure; the pulse accelerated, and usually irritable in character, rather than febrile. There is, however, a class of cases in which the pulse and other symptoms indicate an in- flammatory condition of the sjstem, and such cases arc of a much more serious character. Dr. Burrows noticed them chiefly in connexion with the first secretion of milk (on the fourth or fifth day). Some of these are examples of phrenitis, and not properly of mania."^ Frequency of pulse is a symptom of primary importance. As the patient attacked by puerperal madness becomes more decidedly insane, " the talking is almost incessant, and generally on one particular subject, such as imaginary wrongs done to her by her dearest friends ; a total negligence of, and often very strong aversion to, her child and husband are evinced ; ex- plosions of anger occur, with vociferations and violent gesticula- tions; and, although the patient may have been remarkable previously for her correct, modest demeanour, and attention to her religious duties, most awful oaths and imprecations are now uttered, and language used which astonishes her friends; the eye is wandering and unsteady, and the hearing most acute. . . . The suicidal tendency is not uncommon, especially in the cases of melancholia; and it is important to recollect the fact in the treatment of such patients. In 111 cases of puer- peral insanity at Bcthlcm Hospital, 32 were afteeted by it." (Dr. Reid, in 'Psychological Journal,' No. 1, p. 135.) A brief note or two of a case under the writer's care will • Of 16,-14-4 cases dolivercd at the Dublin Lyinjj-in Hospital, three only arc rciwrtcil by Dr. Collins to have ilietl of phrenitis. — (Ileiil.) 260 PUEIIFEIIAL IiNSAMTV. serve to illustrate one form of puerperal insanity. ]Mrs. C — m as confined with her seventh child (a girl) ; labour perfectly natural. She had miscarried eighteen months previously, and liad never menstruated afterwards. After the labour, the pulse was 80 and soft, the tongue clean, and the lu'ine was passed the same evening. On the following day there was a fair lochial discharge, the pulse was only 80, and the skin was warm and moist, but she considered the supply of milk less than usual. On the tliird day the secretion of milk increased; the bowels had been opened in the morning by medicine. The pulse rose to 100. Fourth day : had a restless night, and was feverish during the day. Pulse 120, soft and compressible. The tongue, however, was clean. Fifth day : less fever, and thought herself going on well. Pulse less frequent, 108, very compressible ; tongue quite clean and moist. There was a good supply of milk, and the lochia were not unnatural in their character or quantity. No pain or ten- derness in abdomen. The only thing she complained of was ■\-ertigo ; evidently required support. Sixth day : same. Seventh day : the writer was called to see her at six, a.m. The change of expression was very marked. She was in a sluggish state, and replied very incoherently to questions. It appeared that during the night she had been excited, talking nonsense, &c. The pulse was 120, full, but not hard. Tongue covered with a white fur, inclining to be dry ; skin hot, but moist. The secretion of milk was now decidedly checked. The head was hot, and had been very painful in the night ; but the conjunctiva was not injected, and the pupils were dilated. Towards even- ing the tongue became drier, with a brown fur down the dor- sum ; total inability to sleep ; increased confusion of mind, &c. The case was clearly one of exhaustion, and was treated accord- ingly. In two or three days the unfavourable mental symptoms passed away, and the patient made a good recovery. We may also refer to the case of a young woman, only eighteen, in whom this disease assumed the form of hysterical mania. When in service she became enceinte, and about a month after conception had " a fit," which appeared to have ])een mainly hysterical in character. At nearly the full time of of her pregnancy she was frightened by a thunder-storm, Avhich caused her to be ill for several days, with pain in the head and vertigo. Eight days afterwards she suddenly fell down uncon- Prr.RPKRAL INSANITY. '201 scions, burnt her hand with the fire, bit her tongue, and foamed at the mouth. She Mas bled by the surgeon mIio attended her; and on the following day a dead child was born. There were frequent attacks of convulsions dni-ing the labour. From this time till a fortnight afterwards, when we first saw her, she was excited and incoherent. The milk had soon been dispersed, and the lochia had ceased the sixth day. She was very pale ; pupils dilated ; pulse 100, and weak ; tongue flat, furred pos- teriorly ; bowels confined ; urine light coloured ; got very little sleep, and was always worse during the evening and night. During the following week she made decided progress, though frequently "roaming and outrageous:" then she had an hys- terical attack, which lasted about eight hours ; apparently un- conscious, but no con^^llsions. These attacks recuiTed several times, but she steadily recovered from her maniacal condition. The catamenia appeared two months after her confinement. It should be added to the foregoing, that an aunt of her father was the subject of suicidal melancholy, and that she had an uncle who was a desperate drunkard. Her mother attributed her daughter's insanity to having herself " fretted very much on account of her husband's illness and death," when pregnant. In the case of a poor woman who gave birth to an illegitimate child, this circumstance and poverty conspired to upset her mind. The attack did not come on until two months after her confinement. It was characterised by crying, laughing, and a total indifference to the baby. She was insane for about six weeks, recovering under morphia and iron. The child was weaned ; but the catamenia did not appear until five and a half months after recovery. The child had hereditary syphilis. The mother subsequently married. We had at one time a very troublesome case under care, one of melancholia succeeding abortion, in which there had been an alarming loss of blood. She was very anaimie, and for long the symptoms appeared to be little influenced by the phar- maceutic remedies employed; but she gradually improved. In another case, a woman, aged 37, had a child, and recovered well from her confinement. In about five months she became melancholic, aljsent, and was troubled with strange notions for which she was unable to account — scruples, suggestions, &c. She could not sleep ; she was pale ; tongue flabby and in- 202 rUERPKUAL INSANITY. dented at the edges ; pulse frequent and feeble ; skin relaxed ; bowels confined ; urine sometimes thick, sometimes clear ; no appetite; head cool; conjuctiva pale. In about four months she recovered under obviously indicated remedies, but was subject to hysterical attacks for some time after. In the case of a woman under care at the same time, melan- cholia was solely due to prolonged lactation, and was recovered from when the mother was obliged to wean the child. The mortality from puerperal insanity is not, on the whole, large. Out of the 92 cases already referred to, only 6 died, and none within a period of less than six months after child- birth. Perfect recovery of the mental faculties follows in a large proportion of instances. If the lochia or the milk have been suppressed, their return will generally be the first sign of improvement. After a later period, the re-appearance of the catamenia is equally important. In some cases there is for a time much weakness of mind, but this proves transient. Dr. Webster states, as the result of his statistics, that "three in every five cases of puerperal insanity may be confidently ex- pected to recover within the year." Two thirds of Esqviirol's cases were cured within the first six months after the com- mencement of the attack. Of Dr. Palmer's 19 cases, 14' had recovered after four months' treatment, and 2 were convalescent. Haslam reports, that 50 out of 85 were cured at Betlilcm, but Dr. Burrows's success was not at the same rate ; he cured 35 out of 57, of whom 28, or six sevenths, recovered within six months. At Bethlem the largest number were cured during the fourth month. Eighty per cent, of Dr. ]\Iacdonald's cases recovered ; out of 53 recoveries, 3-1 took place within the first six months of the attack. Brierre de Boismont asserts that cases of puerperal insanity (exclusive of melancholia) have recovered under his care, on an average, in about a week. He has always found refusal to take food a bad sign. To the fore- going statistics of Burrows, Haslam, and Esquirol, it should be added, what Dr. Gooch and Dr. Prichard have observed, that they do not lead to a prognosis even sufficiently favourable, inasmuch as cases are not usually admitted into asylums in a recent and therefore the most curable stage of the disease. " Of the patients about whom," says Gooch, " I have been con- sulted, I know only two who are now, after many years, dis- PUERPERAL INSANITY. 2G3 ordered in mind, and of tlicm, one had already been so^jeforc her marriage." Among the canscs of puerperal insanity may be enumerated — hereditary predisposition ; flooding ; puerj)eral convulsions ; mental shocks of any kind; distress of mind, especially fi'om being unmarried when pregnant or confined ; a suffering labour ; cold; sudden weauing; exhaustion from prolonged lactation, CHAPTER VIII. THE STATISTICS OF INSANITY. Section I. — Of the Causes of Insanity. The Causes of Insanity may be either predisposing or ex- citing. For example, a man may be in an exceedingly feeble condition of health, in which the death of a friend, or other domestic trial, may induce an attack of insanity, from whicli he would not have suffered, had he been in the enjoyment of sound health at the time of the event. In such a case, the predis- posing cause of the patient's insanity was ill health ; the exciting cause, domestic grief. Among the most important predisposing influences are — hereditary predisposition, delicate mental organi- zation, &c. Among the exciting arc — blows on the head, intemperance, disappointed affections, &c. In different persons the same circumstance (intemperance, for instance) may have acted in the one as a predisposing, in the other as an exciting cause. The causes of insanity may come into operation at the period of conception. We should expect this a priori, and experience appears to prove it. We allude more especially to the case of a parent begetting insane children when drunk. It is obvious that, on the one hand, the mental and physical condition of either parent at the moment of conception, must exercise an important influence upon the future being, quoad his insanity ; while on the other hand, it is equally obvious that there are but few instances in which the connexion between the transient mental states of the parents and the character and diseases of offspring, can be satisfactorily traced in the way of cause and effect. At the moment of conception may also be transmitted, so far as the father's influence is concerned, any hereditary predispo- sition which may exist. That other diseases of the parent be- sides insanity may predispose the child to mental disease, can CAUSES OF INSANITY. 205 scarcely be doubted ; and among such diseases may be included, not those alone which belong to the nervous system, as epilepsy, but probably others,, such as phthisis. Wheu the ovum is impregnated, it is subjected to the in- fluence of the mother's diseases or predisposition to disease. It is also liable to receive unfavourable impressions from tran- sient conditions of the mother, mental shocks of any kind, &c. The embryo may have also idiopathic disease of the brain. "We may speak of a child's mental disease being cognate or innate, as distinguished from hereditary, when it is derived from in- fluences operating during intra-uterine existence. There can be no question as to the origin of a considerable number of eases of insanity from causes referable to this division. Then follow the risks of birth — injurious compression of the cranial bones and brain from a contracted passage or a protracted labour. Many crania are misshapen from this circumstance, without idiocy or insanity resulting ; but a distorted or asymme- trical skull must be regarded as a predisposing cause. The child who is free from predisposition to mental disease, who has safely escaped the perils of conception, foetal life, and birth, is still exposed to a variety of agents, some external, others internal. Among the former, is the milk of a nurse strongly predisposed to insanity, or (as with cretins) unwhole- some water, food, &c. Among the latter is the first dentition, convulsions caused by which (however common they may be com- pared with cases of insanity) exert no inconsiderable influence in arresting the development of previously healthy children. If, safely escaped from the risks attendant upon the first and second dentition, the child grows up, he is exposed to others at the period of puberty. At this stage of development the danger is no doubt greatest in the female. After puberty, both sexes, but especially the male, are exposed to unfavourable intluenccs, which may be comprised under the terms intellectual and emotional excitement. Man's capacities for enjoyment and misery are alike increased ; if wiser, he is also sadder. Then follow, with women, the dangers connected with pregnancy, parturition, lactation, and lastly, the critical period of life. These are the trial-epochs of life which test the mental strength and integrity of individuals. In our own experience, when at the periods of puberty and the critical age, changes take place in ::d66 CAUSES OF insanity. the moral character, they must he regarded in a very un- favourahle light. Old age, finally, plays an important part among the causes of insanity. From this rapid sketch of the circumstances eapahle of generating mental disease to which man is exposed from the moment of conception to the time of his death, we proceed to consider the causes of insanity in detail. Predisposing Causes. Hereditary Predisposition. — Hereditary predisposition is a term often made to comprise very different degrees of consan- guinity. It is sometimes used to signify direct ancestors only. Evidence of insanity in a direct line is clearly of far the greatest value. It may also mean the existence of insanity in the uncles and aunts of any prior generation — a circumstance affording a strong presumption of hereditary predisposition. Again, it is an important evidence of family predisposition , if the brother of the patient has been insane ; for he has pre- cisely the same blood in his veins. At the same time, it is clear that it would be a misnomer to speak of a patient's in- sanity being derived by hereditary transmission from a brother, or, indeed, from an uncle. It is, however, evidence of the ex- istence of family predisposition, when the brother or sister and an uncle or aunt of the patient have been insane ; indeed this is almost as strong as wlien a lineal ancestor has been deranged. Lastly, it is obvious that the fact of hereditary predisposition cannot be inferred from the insanity of cousins, owing to the presence of fresh blood from which the taint may liave been derived. When we employ the term " direct," wc mean lineal an- cestors only; and by "collateral," that the existence of in- sanity has been traced to an uncle, an aunt, or a brother or sister, cousins not being included. It should be added, that the occurrence of insanity in a parent after the birth of the person affected, cannot be regarded as certain proof of hereditary predisposition ; at the same time, such predisposition remains highly probable : its value must be judged of by the history and character of the attack under which the prrent laboured ; CAUSES OF INSANITY. XiG7 whether, in short, it appears to liavc been accidental ratlier tlian constitutional. Esquirol observes, that, of all diseases, insanity is the most hereditary. '' Althouf^h observed 337 times among 1375 lunatics, I am persuaded that tliis predisposing cause is still more frequent." This is nearly one fourth of the cases in which the cause was ascertained, and 21 per cent, of the admissions. He appears to use the term in an extended sense, but does not define it. Guislain estimates hereditary pi'cdisposition at one fourth of the admissions (5G out of 224? patients) . He thinks it probable that it was actually 30 per cent. He includes the insanity of direct ancestors, uncles, aunts, brothers, sisters, and cousins. As we have already observed, insanity in these relations may, Avith the exception of cousins, be fairly taken as evidence of predisposition. The same writer states, that Hoist traced it in 323 out of 467 cases, or 69 per cent. ; and that Jcsscn dis- covered it in 360 out of 522 eases, or 65 per cent. These writers, doubtless, include a wide area of relationship. Dr. Parchappe traced hereditary predisposition ("direct and collateral") in only about 15 per cent, of the admissions. M. Michea believes, that at least one half, if not three fourths, of the insane have had, or still have, some members insane in their family. Dr. Damerow traced, in 773 patients admitted at Halle, hereditary predisposition in 187, or about one fourth. Dr. Webster, in a paper on the statistics of Bethlera Hospital, states, that 32 per cent, of the patients had hereditary predisposition. The experience of the Retreat, from 1796 to 18 10, was as follows: Male. Female. Total. Hereditary on the paternal side 19 20 39 Do. maternal side ... 17 23 10 Do. on both paternal and maternal sides ... . 3 3 Do. wliether on paternal or maternal side not known 32 30 GR Known to be hereditary Not known or stated to be hereditary 71 82 153 152 161. 316 223 216 4G9» * We take this opportunity of acknowledging our obligation to Dr. Thumam's ' Statistics of Insanity ' — a work unrivalled in this department, for original and laborious research. 208 CAUSES OF INSANITY. From this it appears that^ in 153, or nearly one third of the total number admitted, direct hereditary predisposition was traeed. Dr. Thurnam observes, that those eases have not been considered of an hereditary character, the history of -which was only characterised by the existence of insanity in collateral blood relatives. He adds, that had these (including cousins) been added, the proportions would have been raised to about one half, or fifty- one per cent. It must not, however, be overlooked, that a certain number of insane persons will necessarily have insane ancestors, without there being a necessary connexion, in the way of transmission, be- tween the ancestor and the insane descendant.'^ In connexion with this subject, there are three very inter- esting inquu-ies ; — first, whether the insanity of the mother is more frequently hereditary than that of the father ? secondly, in cases of hereditary transmission, is the disease of the mother transmitted to a greater number of the offspring than that of the * A mathematical friend would correct this source of fallacy approximately as follows : — Assuming that there is no peculiar predisposition — no peculiar likeli- hood — that the descendants of persons insane will themselves be so, there is, nevertheless, a certainty that, in the nature of things, such will, in some instances, be the case. What is the probability, in any given instances, of this ? — a probability which must be deducted from tliat actually found to exist as tabulated, in order to ascertain the amoimt of influence possessed hy the fieritable character of the disease. Now, in order to ascertain this probability, we must first define what are the limits of the terms descendant and ancestor. If simply parent and child be the relation considered, the question is very simple. If 1 person in n throughout the world, or the districts whence the statistics are derived, be insane, the probability that of three individuals — A, B, C — selected at random, two at least shall be insane, and that A shall be one of those two, will be 2 given by . Now, if A be an insane person, and B and C his parents, we have here the probability that one or other of his parents (possibly both) would be insane. Now if we increase the number of persons included in the list of ancestors, say to m persons (A), B, C, D, E, F . . . the probability that one at least of these m will be insane when A is so, will be __. And it is obvious that by in- creasing m sufficiently we can include not merely ancestors, but collateral relatives. For example, assuming the proportion of insane persons in the district examined to be 1 in 500, and taking into account direct ancestors only for 6 generations back (126 in number), the probability that one at least, possibly more, of these 126 will have been insane when the individual himself is so, will be tzsVAtt. or ■000501, or -0504 per cent. In order, therefore, to make this source of fidlacy important — on an assumption like ^ J77, we must take our line of ancestors back nuu'h further than six generations, or else include collateral relationships. CAUSES OF INSANITY. 2G9 father ? and, lastly, is insanity more frequently transmitted from the mother to the daughters, and from the father to the sons ? To the determination of these questions, M. Baillarger has directed his attention, and the following are the results at whieh he has arrived : "1. The insanity of the mother, as regards transmission, is more serious than that of the father ; not only because the mother's disorder is more frequently hereditary, but also because she transmits it to a greater number of children. "2. The transmission of the mother's insanity is more to be feared with respect to the girls than the boys; that of the father, on the contrary, is more dangerous as regards the boys than the girls. "3. The transmission of the mother's insanity is scarcely more to be feared, as regards the boys, than that of the father ; it is, on the contrary, t^^'ice as dangerous to the daughters." (' Annales ^Mcdico-Psyehol.,' 1814, p. 333.) The reader may also consult an article in the ' Allgemeine Zeitschrift fur Psychiatric,' 1848, p. 540. The number of cases of hereditary insanity from which these conclusions are deduced amounted to 600, of which 410 were hereditary in the direct line by the father or mother, 13 had at the same time both collateral relations and brothers or sisters insane, 147 had only collateral relations insane. The fact of hereditary predisposition is assumed in the second as well as the first class (making a total of 453) ; but cases of the third class are rejected as being uncertain. Baillarger appears to include " cousins " in the term collateral. We find from statistics given by the late Dr. Brigham (Report, 1847), that the first and second of Dr. Baillarger's conclusions are confirmed by his experience. Dr. Leubuscher, of Berlin, has written an interesting article on hereditary insanity, which will be found in the ' Journal of Psycliologieal Medicine,' April, 1848. In this article, he points out, among other important facts connected with hereditary transmission, that the lower forms of mental disease, as imbe- cility or silliness, and various forms of depression, appear, in a remarkable degree, to be of an hereditary nature ; and also, that the outbreak of an hereditary disposition to insanity is especially connected Mith the process of development, as the occurrence of puberty, childbirth, and the climacteric period. We may here refer briefly to the important question of ^/U CAUSES OF INSANITY. tlic influence of marriages of consanguinity npon the gene- ration of insanity. It is a very complex one, and in oiu* judgment it is far from being thoroughly worked out. On the one hand, those who deny the ill effects of these unions point to such facts as the following, (see, especially, Steinau's Essay, referred to at p. 221): — Among animals, certain valued varieties are propagated within narrow limits, without their de- terioration ; certain breeds of cattle, and Arabian horses, are noted for beauty and health while crossing has been studiously avoided. When deterioration occurs in animals among the offspring of parent and child, it is explained by the age of the former. Among men, there are certain people, as the Indians of North America, among whom very little insanity or idiocy exists, and yet marriages Avithin very near degrees of relation- ship are common ; some chiefs, also, in the South Sea Islands are remarkable for strength and vigour, but are descended from a stock carefully limited in its alliances. The custom of the patriarchs is further adduced — the marriage of Abraham to his half-sister, of Isaac to his first cousin once removed, and of Jacob to his first cousin, without any known injurious results. These are the main circumstances brought forward in support of the inuocuousness of the marriage of near relations, and they have a certain amount of weight ; but they are not sufficient, the writer thinks, to set aside other facts on the opposite side of the question; at any rate, they do not justify us in encouraging the marriage of near cousins. Dr. Morel believes that experience shows the injurious influence of such unions sooner or later " in a peremptory manner," and refers to the aristocracies of France. Dr. Bcmiss has published some important facts bearing upon this question, which we extract from the ' JNIedico-Chirur- gical Review ^ for July, 18G0 : — "Of 31 children born of brother and sister, or parent and child, 29 were defective in one way or another; ID were idiotic, 1 epileptic, 5 scrofulous, and 11 deformed. Of 53 children born of uncle and niece, or aunt and nephew, AO were defective ; 1 deaf and dumb, 3 blind, 3 idiotic, 1 insane, 1 epileptic, 12 scrofulous, and 14 deformed. Of 231 children born of cousins, themselves, the offspring of kindred parents, 12G were defective; 10 deaf and dumb, 12 blind, 30 idiotic, 3 insane, 4 epileptic, 44 scrofulous, and 9 deformed. Of 154 children born of double cousins, 42 were defective; 2 deaf and dumb, 2 bliud^ 1 idiotic, G insane, 2 epileptic, 10 scro- .CAUSES Of INSANITY. 271 fulous, and 2 deformed. Of 2778 children born of first cousins, 793 were defective; 117 deaf and dumb, 63 blind, 231 idiotic, 24 insane, 44 epileptic, 189 scrofulous, and 53 deformed. Of 513 children born of second cousins, 67 were defective; 9 deaf and dumb, 5 blind, 17 idiotic, 1 insane, 6 epileptic, 15 scro- fulous, and 9 deformed. Of 59 children bom of tliird cousins, 16 were defective ; 3 deaf and dumb, 1 idiotic, 1 insane, 2 epi- leptic, and 10 scrofulous." These facts are important, but they must not be taken as necessarily proving that intermarriage caused all these diseases. In many of these cases it cannot be doubted that the intemper- ance and immorality of the parents had a large share in pro- ducing insane and idiotic offspring. There arc various circumstances which constitute predisposing causes of insanity, both physical and moral, and which are separated by very delicate lines from the original disease on the one hand, and from exciting causes on the other. There is a certain congenital weakness of mind, falling far short of imbecility, which may be regarded as predisposing an individual to mental derangement ; that is to say, he might escape, without injury, many of the trials of life but for this limited mental calibre. Among the predisposing causes of insanity at the Retreat, Dr. Thurnam attributed the attack to this predisposing cause in 20 per cent, of cases admitted there for the first time. It is very difficult, however, to decide how far the condition of mind, in such instances, should be regarded as itself a part of the mental disease, Avhich has merely assumed larger proportions or a more active form. On the other hand, it may be urged with reason that such congenital feebleness of mind ought to be comprised under the same category as hereditary predisposition, inasmuch as we must suppose both to be associated with a peculiar physical structure. To the same category may be referred such a temperament (e. g. the melancholic) as consti- tutes a predisposition to a certain form of mental disorder. Old age may, in a considerable nimiber of cases, be regarded as a predisposing physical cause of insanity. Other physical causes are, in some persons, the predisposing, and in others the ex- citing, cause of the attack ; such are fever, disordered uterine functions, intemperance, &c. Among moral predisposing causes, a misdirected education plays an important part, but is very 272 CAUSLS or insanity. difficult to estimate in individual instances. Using the term in its widest sense, education may greatly help to steel the mind against the invasion of insanity, or may render it very liable to give way in the presence of any exciting cause. There arc certain circumstances which cannot be appreciated by statistical tables, but Avhich are of importance in their relation to insanity ; such are sex, age, marriage, &c. They are best considered in connexion with the predisposing causes of mental diseases. Relative Liability of the Sexes to Insanity. — The conclusion at which Caelius Aurelianus arrived, that women are less subject to insanity than men, has been opposed by Esquirol, Copland, Brown, and others. Dr. Haslam likewise stated, that, "in our own climate, women are more frequently afflicted with insanity than men." Sufficient care, however, does not appear to have been taken to ascertain the relative numbers of males and females in the general population ; a point obviously neces- sary to determine, before any just conclusion can be drawn as to the relative liability of the sexes to insanity. These writers found the existing number of female lunatics greater than that of the males, and hence arrived at the conclusion that the female sex is more subject to insanity than the male. Moreover, the preponderance of women over men at those periods of life during which insanity most frequently occurs was not recognised ])y Esquirol. Dr. Thurnam, however, has clearly pointed out this source of fallacy, as well as that which arises from the fact that the mortality of insane men exceeds that of insane women by 50 per cent. Hence it is obvious that Esquirol erred in comparing the existing instead of the occurring cases of insanity, in the male and female sexes. If, in our asylums, women live longer than men, they Avill of course proportionately accumulate. The preponderance of females over males in England and Wales at the recent Census (1861) was 514,021. This excess at all ages does not, however, prevent the proportion of insane appearing greater among women than men, viz. 1 to 483 of the former, and 1 to 547 of the latter. (See page 33.) The num- bers living at different periods of life in 1861 are not yet pub- lished; but in 1851, the number of females living above the age of fifteen, exceeded that of the males at the same period of life by 8 per cent., which is double the excess existing at all ages. CAUSES OF INSANITY. 273 Thisj of course, i;* the period of life wliicli, owing to the compara- tive infrequcney of insanity before the age of fifteen, is very im- portant in the present inquiry. Dr. Thurnam, taking the Census of \^\\, found the excess to be " still greater" between the ages of twenty and fifty. But we do not find this liolds good in 1851, for the excess at this period was somewhat less, viz. 69 per cent. "VVe cannot, therefore, take this time of life for the pur- pose of explaining the apparently larger amount of insanity among women than men. But we may still refer to the decade between twenty and thirty, the importance of Avhich period Avill be seen when we speak of " age/' and here we find tlie excess of females (in 1851) at a maximum, viz. 98 per cent. Between thirty and forty the excess is still considerable, 5*5 per cent. " In order that the comparison of the occurring eases be a strictly accurate one," observes Dr. Thurnam, " the proportions of the two sexes, at the several ages, attacked with insanity for the first time, should be compared with the proportions in which the two sexes, at the same ages^ e.rist in the community in which such cases occur. The nearest approximation to this method which we have the means of employing is, to assume that the proportions of men and women admitted into public institutions, dui-ing extensive periods, represent the relative proportion of cases which occur for the first time." (Op. eit., p. 149.) From an examination of a table prepared by this writer, we ascertain that, in twenty-four of the thirty-two asylums which it com- prises, there has been a decided excess of men in the numbers admitted. " In many British asylums, the excess amounts to 25, 30, and even 40 per cent.; and, in the whole number of thirty-two asylums, there is an average excess on the side of the male sex of 13*7 per cent. In the nine English county asylura.s contained in the table, the excess amounts to 12 per cent." From the same table, it appears that, in the asylums of the metropolis, the propoi'tion of females admitted is much greater than in the provinces. This appears to be in part accounted for by there being a considerable excess per cent. (13 per cent, at all ages, and 19 per cent, at all ages above 20) of women over men in the metropolis. Hence, the experience of Beth- lem and St. Luke's led Dr. Webster to the conclusion that no doubt can exist regarding the greater frequency of mental alienation among females than males. Dr. Thurnam appears 18 274 CAUSES or insanity. to regard it as probable, that the statistics of insanity in France resemble, in this particular, those of the metropolis,'^ although, us has been pointed out, the method of inquiry adopted by Esquirol was vicious. Dr. Jarvis, of Dorchester, Mass., has wiitten an able treatise on the subject now under discussion ; and after examining the statistics of asylums in Great Britain, Ireland, Trance, Belgium, and America, has arrived at the conclusion that " males arc somewhat more liable to insanity than females." He very properly shows, however, that the causes of insanity which act upon males are more extensive than those which act upon females, and adds, that the above statement, in regard to the liability of the sexes, " must vary with different nations, differ- ent periods of the world, and different habits of the people." {' Ou the Comparative Liability of ]\Iales and Females to Insanity,' 1850.) On the whole, while it is clearly proved that, in general, fewer women, as was taught by Cselius Aurelianus, become in- sane than men, it is difficult to establish that the female sex is intrinsically less susceptible to the causes of insanity than the male, since the former is less exposed to those causes than the latter. At leasts to establish the greater intrinsic liability of females, it must be shown that they arc exposed to the pre- disposing and exciting causes of insanity to as great an extent as males. This, however, does not alter the fact that Esquirol's conclusion is reversed, when w^e take into account the great ex- cess of females in the population between the ages of twenty and forty (the age specially subject to attacks of insanity), the accu- mulation of females in asylums by reason of their low mortality, the fallacy of drawing conclusions from existing instead of occur- ring cases, and finally the fact that the admissions of men into the asylums of Britain (and, according to a table prepared by Dr. Jarvis, into those of America, Belgium, France, and CJcrmany, taken together), are greater than those of women. Aye. — Without reference to cases of idiocy and imbecility it may be observed that uo age is exempt from attacks of Insanity. Such attacks, it is true, are comparatively infrequent under fourteen or fifteen years of age. Scattered through this work, however, will be found a considerable number of refer- * Kven in the luctropolis, however, iu the asj'luins of the middle and upper classes of society, 38 per cent, more males than females were admitted. (Op. cit.) 40-50 50-60 60-70 70-80 80-90 years. 15-9 10-6 6-03 •97 •21 '= ino CAUSES or INSANITY. 275 euces to cases of insanity imdcr puberty, and they might have l)cen considerably increased. They are met with in private practice much more frequently than in asyhims, the statistics of which therefore give too favourable an impression as to the frequency of attacks of insanity in children. Between fifteen and twenty they increase ; while between twenty and fifty they are the most frequent. Whether they preponderate between twenty and thirty, or thirty and forty, may admit of question. During tlie forty-four years between 1796 and 1840, of those admitted at the Eetreat, the greater number, one third of the whole, were atfackerf l^etween twenty and thirty years of age. Each subsequent decennial period is marked by a gradually decreasing proportion. Thus — Of every hundred cases, at the origin of the disorder, there were, at successive decennial periods of life, as follow (' Statis- tics of Insanity,' p. 71) : 0-10 10-20 20-30 30-40 ■96 1277 3253 20- Now, it is obvious that, to render these statistics of any value, they must be compared with the numbers living in the same particular community at the same periods of life. This means of comparison (not available when Dr. Thurnam wrote) we afford in the following table : Of every hundred individuals, there were living, in 18t7, at [successive decennial periods of life, as follow : 0-10 10-20 20-30 30-10 40-50 50-60 60-70 70-80 80-90 years. 16-7 18-0 15-4 12-4 11^9 lOS 7^8 l-9 1-2 '= 100 From which it is evident, that the large proportion of persons rho became insane (of those admitted at the Kctrcat) between twenty and thirty years of age, cannot be explained by the rcater proportion of the numljcr living at tiiat period. When [;he whole of this series is worked out, the order of frequency of ittack, in decennial periods, was as follows : — 20-30 (maximum) ; -40; -10-50; 50-GO; 00-70; 10-20; 70-80; 80-90; 0-10 [minimum). It will be seen from this that, not reckoning Attacks prior to man's majority, the decades follow in their 276 CAUSES OF INSANITY. natural order, ^^'itll regard to the decade 20-30, the experi- ence of the American asylums,, and some others, including; that at Turin (Bertolini's tables), accords with the above result. If the experience of these institutions can be taken as fairly representing asylums generally, we should infer the increased liability of man to insanity between the ages of 20 and 30, or that during this period he is brought into contact with an increased number of the causes of insanity ; probably both. The admissions into many other asylums do not, however, exhibit a similar preponderance between 20 and 30, but between 30 and 40. It must be remembered that odtnissions do not necessarily agree with the periods of attack, and that therefore such preponderance in the latter decade might be true of admissions, and not of attacks ; but it would seem, from a table prepared by Dr. Thurnam, exhibiting, from various asylums in Britain, the period of attack, that the larger number of cases of insanity occur between 30 and 40 ; not, as at the Retreat, Turin, and the asylums of America, between 20 and 30. Also, in these asylums more persons become insane between 40 and 50 than between 20 and 30. But it is probable that, while this may be true of pauper lunatics, there would, among the upper classes, be a larger proportion of attacks between 20 and 30 than 40 and 50. Be this, however, as it may, insanity is more frequent in manhood and in middle life than subsequently — from 50 and upwards. The order of frequency in decennial periods is, according to the above statistics, as follows : — 30-40 (maxi- mum); 40-50; :20-30; 50-60; 60-70; 10-20; 70-80; 80-90 (minimum). In the Report of the Poor Law Board for 1859-60 an attempt is made to determine the age at the time of attack of 13,672 lunatics chargeable to the Poor Rates Jan. 1, 1859. "Wo have compared these returns with the numbers living at the same ages in the general population, and, Avith this correction, find the succession of decades to be as follows : 30-40 (maxi- mum) ; 40-50; 50-60; 20-30; 60-70; 70-80; 80-90; 10-20. We should suppose that, in a large proportion of cases, the age when the disorder first manifested itself was not accurately ascertained. Although, however, an imperfect return of this kind must have the effect of post-dating the age specially liable to attacks of insanity, there is considerable agreement between U-15 15-20 20-30 30- iO 40-50 50-GO 1-16 511 20-87 24-80 31-32 11-il CALsKS or INSAMTV. 277 ii :iucl tiic lust given cleccimial series, and wlieu iuak'.s uiily arc taken the agreement is almost complete.'-" The fallacy of taking merely admissions (and re-admissioniri) may be shown from the last Report of the Commissioners in Lunacy (1861), in which a return is given of admissions, during five years, into all the asylums in England and Wales, in decennial periods, amounting to 30,190 cases. We can calculate from these returns that, of every hundred cases admitted or re-admitted at successive deccnniuras, there were — GO-70 70 iiml iipsvai-ils. 8-17 3-58 = 100 At the same periods of life there were living, at the Census of 1851— 0.15 15-20 20-30 30-40 10-50 50-GO 00-70 70 ami upuaril!:. 35- II- 'J-96 17-15 13-36 9-98 6\)(i I'lO 2-75 = 100 From working these figures together, it will be found that the admissions were, as regards age, in the following order of frequency : — iO-50 (maximum) ; 50-60; 00-70; 30-40; 70 and upwards; 20 and 30; 15 and 20; under 15 (minimum). It will be seen that the order of decades dijGfers considerably from that ab-eady given, when the actual age at attack formed the basis of calculation. It is clear that, when re -admissions are not excluded, the periods of life specially subject to insanity will be thrown later than is really the fact. The Roman ages of man, according to the division of ^^arro, were five in number, ending with 15, 30, 15, 00, 75 and upwards. The first may be made to comprise the risks to which the embryo, the suckling, the tooth-cutting child, and the youth ai-rived at puberty, arc exposed ; it is the age of idiocy and imbecility, but none of the foregoing statistics exhibit congenital disease ; avc Iuia c no account of the number * These returns illustrate the luct tliat insanity attacks the female later in life tlian the male sex. Thus the order of fretiuency for men was — 30-40 ; 40-50 ; 20-30; 50-60; 60-70; 70-80; 80-90; 10-20. For women, 10-50; 30-40; 50-60; 20-30; 60-70; 70-80; 80-90; 10-20. 378 CAUSES UF lIsSAMTY. of idiots auuually born to compare -with the total number of births. This fact myst be borne iu mind in regard to attacks of insanity ^^ under 15/^ The second age develops the passions of manhood, and adds marriage, external excitement, and the struggles of early manhood ; the liability to insanity is greatly increased, and, according to the statistics of some institutions, attains its maximum. The third epoch Avitnesses the termina- tion of the reproductive age of woman ; with man it is the period of hopes and disappointments, of greater strain and anxiety, but also of greatly augmented capacity and knowledge, — shall we say it is man's age of civilization? — it is, at any rate, that which statistics at present point to as the one during Avhich, in Britain, a majority of persons appear to become insane. The fourth epoch, if in some respects one of still greater consolidation and matured wisdom, does not close with- out some indications of declining power; the tendency to insanity is less. The fifth age brings man to his grand climac- teric ; the liability to acute attacks of mental disease is still smaller ; but, ere it terminates, man becomes subject to mental decay or second childhood ; the pitcher is broken at the foun- tain, and the wheel at the cistern. Influence of the Seasons. — M. Parchappe has supplied us Avith some carefully prepared statistics on this subject. (' Notice Statisque,' p. 2G.) Thus, he found that out of ."2000 admissions, the period of the year Avas as folloAVS : Diu-iug the Six Summer Months. (March— Aug:ust.) Diu-ing the Six Winter Moiitlis. (Sept.— Feb.) Xo. Prop, in 100. Ko. Prop, iu 101 1. Men Women 779 668 560 52-3 612 610 4-1-0 47-7 Both Sexes 1447 54-2 1222 45-8 This result — the greater frequency of insanity in the summer months — accords Avith the experience of Esquirol. Guislain observes that there is a relation between the Avarmth of the atmosphere and mental disturbance. Periodical insanity is especially manifested in the spring. Atmospheric Avarmth CAUSES or INSANiTV. :^79 induces agitation in the insane ; a fall of temperature often calms them. MM. Aubauel aud Thore observe, as the* result of their investi- gations, that the month of June appears to have the most influence in producing insanity ; then July and August ; next, May and April ; January having the least influence. The question of the influence of climate -n'ould seem inti- mately connected -with that of the seasons ; but, as Guislain observes, '' we do not, as might have been expected, find more insanity in hot climates than in cold. He regards this as a proof that it requires the predisposition to insanity before the injurious effects of heat can be experienced.^' For information respect- ing the influence of season on suicide, see p. 2.22, and in regard to the extent of insanity in various climates, see p. -15 of this work. Toum and Country Life. — Dr. Prichard states, that " a most remarkable difference is found in the proportional number of lunatics in agricultural and in manufacturing districts. Pre- vious to inquiry, wc should conjecture that the causes of insanity would have more influence, and the disease be more prevalent, in a manufacturing than in an agricultural population ; but the contrary is the fact." "We have already entered fully into the question of this apparent excess of pauper lunatics in the agricultural counties of England. (See p. 39.) Dr. Parchappe has arrived at the conclusion that, so far as re- gards the population of the Lower Seine, the country -people arc more aftiieted with insanity than the towns-people ; in support of which he gives the following tabular analysis : 7-79 li; f o tliese figures Dr. Parchappe adds : *' It is proper lo note that, for many years, the hospital of Havre has provided a .Vdnu.:.ul,i I'r..]. Piipulnlioii ut St. Yoii ,HT KM rown o fUoucn... 0G,OO2" 9G.-5-] 1005 Havre... 27,2ol ^ l.jl ■.n:> loG ^1,203 3-90 L Dieppe lt;,lj:jf 79 1-80 f ' - Ell.uuf . ll.GlUj 53, .3GI. ArriMul of Iloueii 107,573) 78,692 1 l.-,G 2-11 .^ Havre So 1-OS „ Yvetot , 124,208 ) . 91,951/ , 78,151^ 180,881 l.jG 081 1-25 1 Dieppe 102 110 Neufchfit . 82 1-t daiiglitcr died. The eldest, upon whom the mIioIc of the jjroperty now devolved, continued insane for some time, then recovered, and subsequently married. Her husband lost all her money, and left her reduced as low as, if not lower than, she was before the accession of riches which caused the overthrow of her reason. ^Might not a recurrence of the attack have been expected y On the contrary, however, she bore her losses patiently, and she remained quite healthy in mind. An inter- esting example of the eft'ect of excitement in causing insanity is gi\ en l)y Dr. \Valker, in his ' Report of the Boston Asylum (U. S.) ' for 1851 : an Irish boy, thirteen years of age, after arriving at that city in an emigrant vessel, became raving mad in two days, apparently from no other cause than the strangeness and novelty of what he sa\\ . 1 founded FeeVhiys is a term comprising '' wonndcd self-love or respect,'' " being reproved," ''injured reputation," and similar circumstances mentioned in Asylum Reports as inducing the attack fin- which the patient was admitted. On the Continent, the returns under this head are much more frequent than in England, where they appear to cause but a fraction per cent, of the admissions. The various proportions of the cxcithiy causes which we have now passed in review, account for about GO per cent, of cases of insanity. No cause was ascertained in about .20 per cent. Probably we shall not be far wTong in diWding these among intemperance, dissolute habits, and anxiety, chiefly connected with pecuniary difficulties. There remain 20 per cent, of cases in which jin'd'ispos'niff causes alone, could be referred to as causing the condition of mind the patient laboured under when admitted. Of these, hereditary predisposition would be the only cause in some instances ; congenital malformation in a consider- able number; and lastly, "old age," which, in sonic tables is placed, not without reason, among the exciting causes, and which precedes about 5 per cent, of the admissions into our asylums. Rrhtive i/ijluence of moral and physical causes. — Pinel and ICs(piirol arrived at the conclusion that moral causes are much more productive of insanity than are physieal. (iuislain esti- mates, that of 100 admissions, (56 arise from the former, approaching very nearly the result arrived at by Dr. Parchappe, 19 2U0 CAUaiE^i ur l.NSAMTl'. viz., 67*1 per ceut.; iiud that of Hare, to whom Guislaiu refers, viz., 66 per cent. Dr. Hood, in his ' Statistics of Bethlem Hospital,' states that the moral causes of the attacks of those admitted greatly exceed those of a physical nature. At the Retreat the proportions have been reversed, the physical being in excess of the moral by 25 per cent, of the whole, when tlie predisposing and exciting causes, exclusive of hereditary predisposition, are added together ; or stated differ- ently, for 100 moral there were 165 physical causes. As the prcdisposhig causes of insanity are mostly physical, the result we arrive at, as to the relative influence of moral and physical causes, will obviously be aff'ected by their addition, or otherwise, to our figures. Taking our own collected cases, we find that, having regard exclusively to the exciting causes, arranged in accordance with the distinction already adopted, of 30,087 cases in which the exciting cause was ascertained, 16,986 were due to physical and 13,101 to moral causes, being at the rate of 120 physical for 100 moral causes. How are we to account for results so different from those arrived at by Pinel, Esquirol, and others ? The circumstance arises in part from the inlierent difficulty of the subject, and partly — as in everything else a])out which men differ — fi'om the different definition of the terms adopted. In illustration of the former it is only necessary to mention the extremely doubtful nature of vicious indulgence in this point of view. It is of mixed character in most instances, ai}d yet we generally refer it solely to the division of physical cau.ses. In a less degree, a patient w^ho has become insane after leading an intemperate life, may have became so partly in consequence of domestic troubles. Dr. Parchappe might enter the case under the latter head, by which it would increase his division of moral causes; anotlier might enter it under intemper- ance, and so add to the list of physical causes. It is, we suspect, mainly in this Avay, that although we have ari-angcd Dr. Parchappe's table in accordance with our own classification of exciting causes, tlie moral preponderate over the physical causes. It is quite possible (although, without knoM'ing each case, impossible to decide) that his mode of tracing and appropriating the cause has been the correct one. It is im- possible to avoid altogether this element of uncertainty. \Vc also believe that among our li^ely French neighbours, moral agcuts do I'xcit ii ^rciitfr inliiiciice tluiii with citlar the Euglish or tlie Americans. " Auiour-proprc l^lcsse/' and other items under " AVotindcd Feelings/' figure to a nmch greater extent in their reports of causes than in ours. As an example of the second source of discrepancy ^ve may refer to the different Avays in whicli epilepsy is regarded. Some add it, like ourselves, to the column of physical causes ; others omit it altogether, in eonset|uence of regarding it as simply one stage of the disease. If we deduct from our own cases those in which epilepsy was the alleged cause, the physical causes Avould be materially reduced, and still further by the exclusion of jipoplexy and paralysis., all of which are omitted by Dr. Par- chappe. Again, it is certain that one explaiuition of the ap- parent discrepancy between statistical m riteis on insanity is to be found in some adding constitutional feebleness of mind to the list of (predisposing) causes ; while others, regarding it as a part of the disease, take no account of it. This will partly explain the different balance of figures given by Dr. Parchappc and by Dr. Thurnam. When, in regard to the Retreat, we only take the excit'nif/ causes (in Avhich this element of discrepancy does not appear), Ave find the moral exceeding the physical causes, although not to the same extent as with the former writer. On the whole, then, while the statistics we have collected together, indicate a preponderance of physical over moral causes-, we arc not prepared to say that they are sufficient, without further evidence, to negative the conclusion to which we think a priori considerations would conduct us, namely, the superior force in civilized countries of moral agencies in the generation of mental disease. A larger number of cr.ses, and especially the means of tracing each to its real eau^e, would probably materially modify these figures. AVe now refer solely to the txcitiny causes of insanity, for we can have little doubt that if hereditary jjredisposition (when the only cause), congenital feebleness of mind, old age, and some other predisposing circum- stances are added, the catalogue of physical agents will actually, as well as appaiently, exceed those of a moral charaeter. lii'lutice jrequoinj of tiic vurlous Jurms oJ[ uwiitid disorder. — AYc have given some statistics on this subject in the descriptive phapter. A difficulty arises from the various senses in which the same terms are emijloyttl. AVe have ascertained the form 2\)2 rROPORTION or KECOVJiKlES AM) RELAPSES. on admission from a considerable number of Asylum Reports, and believe that the difference which exists between them is chiefly occasioned by the different ^dews entertained in regard to '^ monomania/^ AVhen it constitutes a separate and im- portant division, under which are included monomania of pride and vanity, &c., and the several forms of moral insanity, the pro- portions per cent, (exclusive of idiocy) appear to be usually as follows: — ]\Iania (acute and chronic), 50; melancholia, 30; dementia, 11; monomania, 8 or 9. AVhen, however, fcAV or no cases are referred by the reporter to '^ monomania," the admissions under the head of " mania " are proportionately in- creased. A very different proportion would appear if we cal- culated the relative frequency of the various forms when the patients die, the largest number at the time of death being examples of dementia (frequently complicated with general paralysis). The next form of insanity in order of frequency at the time of death is mania (usually chronic) ; then melancholia ; and lastly, monomania. Proportion of insane and idiotic to the (/eneral population. — See pp. 32 and 113 of this Avork. Section II. — Proportion of Recoveries and Relapses. The method of calculating the proportion of Recoveries has been the subject of some difference of opinion, and has involved a slight diversity of practice. Very generally, however, and, in our opinion, correctly, the recoveries have been calculated on the admissions. Dr. Farr, on the contrary, has, in some instances, calculated the recoveries upon the discharges. The superiority of the former method has, we think, been con- clusively shown by Dr. Thurnam. From the elaborate statistical tables of the latter it would appear, that during a term of years the recoveries in a large numlicr of British, American, and Continental asylums varied, at the period at which he wrote, from about 25 to 50 per cent. An examination of the later Reports of Asylums for the insane will show that the difference between the niaxiniuni and minimum continues to be very similar ; of course in asylums where only curable patients are admitted, the per-centage of cures may be much higher — GO per cent., for example, as has happened at St. Luke's during a term of ten years. It is quite as true as when the ^ Statistics of Insanity ' was published, that, " as regards PROPORTION OF RF.COVKRIES AND HKI.APSES. 293 tlie recoveries in asylums wliich have been established during any considerable period,— say twenty years, — a proportion of much less than 10 per cent, of the admissions is, under ordinary circumstances, to be regarded as a low proportion, and one mucli exceediag: 45 per cent, as a higli proportion." (p. 136.) On examining the Keports of eleven Dutcli asylums for pauper and private patients, mc find that the recoveries, during a certain number of years, amount to 3.2*4. In the last ' Report of the Lunacy Commissioners' (1861), the recoveries in the Lunatic Asylums, Hospitals, and Licensed Houses in England and Wales during three years (1857 — 1859) are given. From this statement it appears that of 7708 patients admitted during the year 1857, 2740, or 35-5 per cent, were discharged cured during the above years. No doubt, out of the patients re- maining, a certain number Avould subsequently recover, and raise this per-centage. It is of great practical importance to remember, that the chances of cure are very much greater in recent, tlian in chronic cases. This is clearly shown by the experience of tlie Retreat, in tlie following table : Table. — Shovnny the Average Proportion of the Recoveries, in Cases of Recent and Longer Dnration, when admitted, 1796 to 1861. Duration of Disorder when lulmitteil. Proportion of Recoveries per cent, of Admissions. MALE. FKMAI.E. ME.\>. First Class— First attack, and within 3 months Second Class— First attack, above 3, and within 12 months Third Class— Not first attack, and within 12 months Fourth Class— First or not first attack, and more than 12 months 70-51 43-94 59-21 13-17 7013 43-48 66-50 25-51 71-61 43-70 63-07 17-08 Average 42-24 47-78 45-22 From the above it will be seen that when the disease was taken in time — treated Mitliin three months — above 70 per cent, of the patients admitted into the Rrtreat up to the present year, have been cured. By some physicians the proportion is stated to have been higher, but this will often happen 291 IMIOJOIITION OF r.i'.COVJilUES AND RELAPSES. •NTitliiu a short and not a longer term of years. Thus, at the Retreat, the proportion of recoveries in the same recent chiss of cases, -was, up to 1810, about 80 per cent. Further, if very unpromising cases (those, for instance, -which are complicated with epilepsy or paralysis) are excluded by those who make report, the fact of still more favourable returns is easily explained. lu the table of the Lunacy Report already referred to, it appears that of 2209 patients admitted in 1857 the dura- tion of whose disorder was under one month, 1125, or 50-9 per cent., and of those insane under three months, 48 per cent., wore discharged cured in the three years 1857 — 1859. Of those admitted who had been insane six years and iipwards, only 5 per cent, recovered. This, although an interesting, is, it will be seen, only a partial picture of results. To be of real value, a long term of years, as in the above Retreat table, must be taken. There are various other circumstances, besides the duration of the disorder, which affect the prospect of recovery. Among these may be enumerated the form of the disorder, physical complications, the cause of the attack, age, sex, the civil condi- tion, and hereditary predisposition. The influence of the form of the mental disorder upon re- covery has been referred to in our description. We may here add the experience of the Pennsylvanian Hospital for the Insane, from its opening in 1841 to 1857, during which period 1 125 patients were discharged cured. The proportion of the cures ori the admissions for mania Avere, Dr. Kirkbride states, 59 per cent. ; for melancholia they amounted to 51 per cent. ; for monomania to 42 per cent. ; and, lastly, for dementia^ to 11 per cent. — ^most of whicli, it is scarcely necessary to observe, were of tlie acute form, described at page 123 of this work. Among physical complications, the presence of epilepsy, Avhile it does not necessarily prevent partial recovery, renders a permanent cure higlily improbable. Apoplexy or paralysis is so grave a com}jlication that some Avriters speak of the accompany- ing mental disease as hopelessly incurable; but while this is the general rule, we have known several exceptions, l^aralysis may remain and the mind recover. \\c do not include in these re- marks the general paralysis of the insane, recovery from which it has not been the writer's good fortune to witness. The blood- tumour of the ear_, first described by Ferrus {' Gazette des H6pi- taux/ 1838), adds, when present, to the serious nature of the case. PROl'OKTION or KECOVKimvS AM) KKLAl'SKS. 20.") ^Vith regard to the relation of the cause of attaek to rceovcry, it may be observed, that so far as the experience of the Retreat goes, pliysical causes liavc appeared most to interfere with the prospect of recovery among tlic female patients; while among the males, those cases which were due to moral causes have re- covered least favourably. Those arising fi-om intemperance often rapidly recover, and remain well while under asylum supervision, to relapse when again exposed to the original occa- sion of the attack. The generally favourable termination of puerperal cases has been already remarked upon (p. 2C)2). In- sanity occurring after fever is often permanent, but is also not unfi'cquently recovered from in the most satisfactory manner. Too much importance must not, therefore, be attaclied to con- tinued fever as a cause, unless its form has been such as to involve primarily the cerebral functions. The result of those cases of insanity which follow traumatic affections of the head is unfavourable, thougli we hav(> knoAvn remarkable exceptions to this general rule. In referring to age, it maybe stated that at Bethlem, oftliosc admitted luider twenty-five, about three fifths have recovered; between thirty and sixty-five, about one half were cured ; and of admissions after the last- mentioned age, about one seventh re- covered. Insanity in the very yoimg cannot be regarded hopefully. First attacks of insanity after fifty are very unfa'sourable. It is needless to add, that when loss of mental poMer is caused by advanced age, recovery is hopeless, although there may be transient gleams of intelligence. The writer knows a case, that of an elderly lady, who, after being the subject of senile dementia for years, spoke rationally for a short time within twenty-four hours of her death. It is a popular belief that this brightening before death is frequent Avitli the insane generally. In the writer's experience, however, it is extremely rare. As regards sex, in relation to recovery, it has been found at Bethlem, that there is not so much diftereuce with the female sex, as some other statistics have indicated. During ten years, "j^'l per cent, recovered among the females, and 5.3*8 among the males. (Op. cit. p. 27.) At the Iletreat (irOfi-lRGl), the difference in favour of the women has been as great as 1.3 per cent. At St. Yon (Rouen) the excc.-^s was only per cent. (Parchappc's ' Notice Statisticpie,' p. Ik) There was only a slight difference observable at Bethlem, in .'290 PROPORTION OF RECOVERIES AND RELAPSES. the recoveries of the married and unmarried, namely, morrie/I 5 1.-9, vnmarr'H'd 53"H, and wUloiced 50 per cent. Hereditary prcdispositio}i is unfavourable to permanent re- covery ; that is to say, although it may not materially affect tlic prol)ability of cure^ it renders relapses much more probable. The followinj^ circumstances happening during an attack of insanity may act favourably upon the disease : — Discharges of any kind, after l)eing suppressed ; dysentery, fever, parturition, cutaneous eraptious, sudden moral shocks, accidents. "We know of a case iu which a very severe fall on the head had the happy effect of cansing recovery ! The season of the year Avhich has a beneficial influence upon recovery is one neither of ex- treme heat nor cold. At St. Yon, the autumn quarter has proved the most faAourable, the winter quarter the reverse. Thus, 518 cures were distributed as follows: — Winter quarter (December, January, February), 9.2 ; Spring (]Marcli, April, May), 123; Summer (June, July, August), 1 4.5 ; Autumn (September, October, November), 158. With regard to the usual period of time those who recover are under treatment, it may be observed that, in the experience of the Retreat, more than one third have been discharged within six months after admission. The average duration of residence, from 1796 to 1840, was about a year and four months. In descrilnng the various forms of insanity, we have referred to cases of recovery after the lapse of many years. Bi'hipscs. — But the preceding estimate of recoveries would l)e obviously imperfect, withoiit a consideration of the question, what proportion of those who recover, subsequently relapse ? I'^squirol, and others, by taking re-admissions as equivalent to relapses, have presented an imperfect view of this question. The former calculated, that, out of 100 recoveries, about 10 relapsed. This estimate has, however, been shown to be far l)clow what is actually the ease. Dr. ConoUy reckons tlie relapses at IlanwcU at 50 per cent. In 1851, Dr. Max. Jacobi traced the after-history of GO! ])atients who had been admitted into the Siegburg Asylum during 20 years (1825-1845). Of these, 322 had not relapsed; 127 had relapsed once and recovered again; Gi had relapsed and appeared incurable; 11 remained under care; 137 had died, of whom G8 had not relapsed ; o7 died insane, while there were 12 respecting whom no information could be procui'ed. PROPORTION OF RECOVERIES ANT) RELAPSES. 297 In the coui-se of years no doubt more would relapse. Dr. Thurnam succeeded in tracing out the subsequent history of every patient who had been under care at the Retreat, during forty-foiu* years, in whom death had occurred. As the history of each case was therefore completed, the table Mhicli follows is of greater value than that prepared by Jacobi. Died Insane during the first .Vttack. Kecovered from first Attack. C:tfe9 followed tlirouali LilV. Total. Recovery permanent. l)ied Sane. Had subsequent .\ttack. Died Sane. Died Insane. Total. .Males ... 113 Females ... 131 55 58 58 73 21 2t 6 31 35 37 19 Total ... 21-t 113 131 45 . 66 86 From this it appears that, of 131 cases discharged cured (after the first attack) only 45 had no return of the disorder. But of the 8G who had a return of the disease, 20 died sane. Hence, altogether, 65 or 26-6 per cent, of those who recovered died in a state of sanity. " In round numbers, then, often persons attacked by insanity, five recover, and five die sooner or later during the attack. Of the five who recover, not more than two remain well during the rest of their lives ; the other three sustain subsequent attacks, during which, at least two of them die. But, although the picture is thus an unfavourable one, it is very far from justifying the popular prejudice, that, insanity is, virtually, an incurable disease; and the view which it presents is much modified, by the long intervals which frequently occur between the attacks ; during which intervals of mental health (in many cases of from ten to twenty years' duration) the individual has lived in all the enjoyments of social life." (Op. cit. p. 123.) There is an interesting table in the Report of the Pennsylvania Hospital for the Insane (1857), showing the number of attacks on admission in 2018 cases. The facts are as follows : — First attack, 2,099 ; second, 191 ; third, IGG; fourth, 08; fifth, 27; sixth, 21 ; seventh, 11 ; eighth, 1; (in the periodical cases) ninth paroxysm, 2 ; tenth, !• ; eleventh, 3 ; scventeentii, 1 ; eighteenth, 3 ; nineteenth, 1 ; twentieth, 2 ; twenty-first, 2 ; twenty-second 298 MoiiTALiTV or Tin-: insane. to twenty-sixth, cacli 1 ; tweuty-seventlij 2 ; twenty-ninth, 1 ; thirtieth to thirty-third, each 1. Sectiox III. — Mortality of the Insane. Much diversity of practice has obtained in regard to the mode of calculating the deaths occurring in asylums for the insane — some having calculated them on the admissions or on the dis- charges ; Avhile the correct method is that of taking for the l)asis of calculation, the mean number of patients resident in an asy- lum — in other words, its average population. From the Lunacy Ileportof the present year (18G1), we learn the annual rate of mortality during live years ending December .'^1,1858. The deaths (calculated on the mean numbers resi- dent, viz., 20,225) amounted to 10"97 per cent., being for males ]3'25, and for females only 8-96 — corroborating the remarks made in a former Section, on the greater mortality of male luna- tics. The mortality (for both sexes) during the above period, was only 8*73 in the lunatic "hospitals." In provincial licensed houses it was 9-16, coimty asylums 11'17, and in the metropoli- tan licensed houses 12*51 per cent. In the last Report of the Scotch Commissioncr.s, the mortality during the three years which have elapsed since the appointment of the Board, was 9*05 for males, and 7'()7 for females. At the lletreat, from its open- ing to the present year, the annual mortality has been 5-29 — being G'03 among the male, and 4.77 among tlie female patients. The above statistics range (for both sexes) between 5 and 1 1 per cent. — a mortality beyond which, for a mixed class of patients, must be regarded as excessive, while one of fi or 7 per cent, is very satisfactory. The period of the year exerts, as might be expected, an influ- ence on the mortality of the insane. Thus, out of 1557 deaths at the Bicetre, during eight years, the numbers, in regard to the seasons, were as follows : — Spring (March, April, JNIay), 419 ; Winter (Dcceml)er, January, February), 411; Autumn (Sep- tember, October, November), 382 ; Summer (June, July, Au- gust), 315. The same proportions obtain, according to MAI. Aubanel and Thore, as regards the deaths of the inhabitants of Paris itself. In both oases Alarcli is the deadliest month, owing to the sudden variations of temperature. In the table of deaths prepared by Esquirol, the maximum mortality was in AYinter. MOllTAJ.lTV or THK INSANE. 299 We may coiicliulc that Spring and Winter arc the most fatal periods of the year ; then Autumn, and lastly Summer. At Bethlem Hospital, the deaths during the Winter months appear to have only very slightly exceeded those Avhich occurred during the Summer months. (Hood's ' Statistics/ p. 81.) A most important question remains to be answered. Is the mortality greater among the insane than the sane ? Undoubt- edly it is. The Registrar (icncral's lieport for 18.j4, gives the mortality of England and Wales for the preceding 17 years, at 2'2 1 per cent, for all ages. Now, in every asylum for the in- sane, whether at home or abroad, statistics of which arc pub- lished, the rate of mortality is very much higher. We have already giA'en the mortality in the asylums of our own country ; the lowest mortality being more than double the above, namely, .■j'29. In eleven Dutch asylums, we find the average to be 14-5. At St. Yon (Rouen) during seventeen years, it was 7'6 percent. The average age, at the origin of the disorder, of the patients who died at the Retreat, from 179(5-1810, was about 39 years, at which period the expectation of life is at least 28 years. Instead, however, of the average age, at death, of these patients being 67 (39 + 28), it was only 5G. (' Statistics of Insanity,' p. 101.) The high mortality of the insane at various ages will be seen from the followinsr : — Table. — Shoimny the Mean Annual Mortality jyer cent, at different ayes in the County and Borough Asylums, Hospitals, and Licensed Houses of England and JVales during the five years enaing Uec. cSl, l«o»; compare 'rt lOlth t he Mort nitty at l lie same ages in the general 2Jopidation of England and Jl 'ales. Insane in Asyliuns. General Popnl.ition. MHles. Females. Males. Fenmlcs. 15 — 25 8-26 7-87 •805 , -833 25 — 35 10-36 7-17 •958 ! 1009 35 — 45 ... 14-35 7-66 1^249 1-242 45 — 55 ... 14-44 7-36 1-77G 1-518 55 — 65 ... 13-70 1 10-35 3^141 2-782 G5 — 70 ... 70 — 75 ... \ 6-613 5-885 70 and upwards 31-lG 25-7(5 75 — 85 11-391 13-201 85 — 95 29-frlG 27-553 300 MORTALITY OF THE INSANE. As the above is a high mortality, and extends over a short period, it may give a juster impression to add the lower deatli- rate of the York Lunatic Asylum (1814 — 1840), and the Retreat (179G — 1840), which we have thrown together from table 26, and table E of the ' Statistics of Insanity.' "We are unable to give precisely the same decennial periods. For both sexes : 20-30, 418; 30-40, 4-80; 40-50, G-35 ; 50-60, 5-43; 60-70, 6-61; 70-80, 1033; 80-90, 26-49; all ages, 6-02. Mortality of the sane during the corresponding periods: — '98; 1*16; 1-43; 2-14; 4-05: 8-74; 1908; all ages, 2 24. Dr. Farr has strongly insisted on the greater rate of mortal- ity among the insane than the sane. {' Stat. Journal,' April, 1841 , p. 24.) It does not, however, necessarily follow, from the fore- going, that insanity itself shortens life, inasmuch as the circum- stances which have induced the disease (as intemperance, vice, and bodily disorders) may be the real causes of injm-ing the con- stitution, and curtailing the life of the patient, independently of mental disease. But there can be no question that a part of the high mortality of the insane is directly due to acute attacks of the disease itself proving fatal. It would appear that, Avhatever influence insanity may have in shortening the duration of life when the disease is in its acute stage, there is not the same tendency when it has assumed a chronic form. Some statistics have shown even a greater dura- tion of life among the incurably insane than among those in good health ; but as these figures comprise only a small number of cases, we suspend our judgment until more extensive data are procurable. CHAPTER VIII. DIAGNOSIS OF INSANITY No class of diseases with which man is afflicted are so various in tlieir manifestations as those known under tlie general term of insanity. No diseases present such an infinite variety of light and shade belonging to their own nature^ or to their intermix- ture M-ith other maladies, or to the influence of temperament, of individual peculiarities of habit, or of social position ; and, therefore, the diagnosis of no other class of diseases taxes nearly so much the ingenuity and the patience of the physician. The diagnosis of almost all other diseases depends principally upon weighing the evidence afforded by physical signs and symptoms, ui)on evidence addressed to the senses ; but in mental disease, it is, for the most part, dependent upon evidence which is cog- nizable by the intellect alone, and upon data which the senses furnish to us only at second hand. The physician is compelled to l)ring to this investigation, not only a knowledge of those functions which are subservient to the vegetative and animal life of the individual, but also a clear and analytical conception of those which collectively constitute mind. He must not only be a physician, but a metaphysician ; not, indeed, in the almost opprobrious sense of this term, but in that better sense which designates a lover of truth, seeking to ascertain, not the essence of mind or any other unattainable abstraction, but the laws of mind, which arc as regular as any other natural laws, and to at- tain the knowledge of which ofl'ers an useful and legitimate ob- ject of philosophic research. Wc adopt in this chapter the well-known clas.sitieation of in- sanity, into ^lania. Monomania, Melancholia, Dementia, and Idiocy J not because we think this classification unexception- 302 DlAtiNUSlS UF INSAMTV. able, but because it seems to Ije a convenient urn-, lounded upon the most prominent plienonicna of the disease, to be provision . ally used, until a more scientific classification, founded upon the pathological causes and real nature of insanity, can be esta- blished. The Diagnosis of Insanity presents itself to the physician cither in a purely medical, or in a medico-legal point of view. "When the question is of the former character, upon the answer given will depend not only the kind of medical treatment, as in other diseases, but the enjoyment or the loss of the patient's liberty ; inasmuch as the fact of insanity having been once established, in the great majority of instances the patient is not merely placed under treatment, as in an ordinary disease, but " detained under care and treatment," Avith loss of personal freedom, and, unfortunately, also, with a certain amount of unjust opproln'ium attaching to himself and his relations. The question, as a medico-legal one, may occur either in civil suits and proceedings, or in criminal trials. In the former case, the distribution of property to a vast amount, the validity of wills, of purchases, and of other social and commercial acts, often depend upon the decision of the physician ; and in crimi- nal trials the issue of the ([uestion is the awful one, Avhether a human life shall l)e sacrificed with violence and ignominy, or saved by establishing the plea of insanity. "Whether the question be purely medical, or medico-legal, in its bearings and apparent consequences, the grounds of the diagnosis must be the same. For, although, in criminal trials, the nature of the crime itself, and the manner in which it has been efiected, must often be allowed to have no inconsiderable weight in the formation of the judgment, yet, these circum- stances arc essentially no other than a part of the coiuluct of the patient ; and the conduct nmst be carefully estimated, even when the question is most purely medical. But, while it is necessary clearly to understand that the principles of dia- gnosis arc the same, Avhate\cr nuiy be the object for which the diagnosis is required, it will be found practically convenient to consider its difficulties separately, as they occur under thcdiller- ent circumstances above alluded to. \Ve shall, therefore, in the first place, treat the question as it presents itself to a medical man called to see a patient DIAUNOSIS Ul' INSAMTl. 3UI5 lubouring under syniptoius which liuvc caused aUirni uud anxiety to his friends, wlio are desirous to ensure his and their own safety, to provide without delay the treatment Avliieh aflbrds the best promise of reeovery, and, al)Ove all things, to have the momentous question deeided for them, of confinement in an asylum, or of treatment at home. In the second place, ^\c shall endeavour to lay down rules for distinguishing the diflerent forms of insanity from each other, and from those neuroses i'ov which it is possible they may be mistaken. And, in the third place, we shall treat of the diagnosis of sound and unsound mind, in relation to civil capacity, and responsibility for criminal actions, and to feigned and concealed insanity. Difficulties of Inquiry. — When a medical man is called to seca patient whose conduct has excited suspicions of insanity, before he proceeds to personal interrogation and examination he will act wisely in making himself as thoroughly acquainted as he possibly can be with the antecedents and the history of the patient. He will naturally expect to be instructed on these subjects, with fulness and candour, by the near relations of the patient ; but in this expectation he will repeatedly meet with disappointment. The systematic manner in which members of families, often deeply tainted with insanity, attempt to deceive both themselves and everyone else, throws no small difficulty in the way of the medical man. The dread of insanity in many families of this kind is so great, as to constitute in itself a morbid feeling sufficiently strong to mislead the observation, to warp the judgment, and to occasion sins of concealment and luitruthfulness towards those who have a right to expect and to demand the fullest and most explicit contidcnce. The great pertinacity with which memljcrs of insane families will often deny the slightest hereditary taint of insanity, even to a medical man, called in to treat a patient lal)Ouring under the disease, would scarcely be credited, weic it not a matter of no infrequent experience. Much of this may, no doubt, be attributed to the sense of the shame and disgrace which has most unrighteously been connected with the idea of mental disease. But a great proportion of it must also be attributed to the unhappy fact, that all the members of such families, even while they retain the full [jossession of their mental sanity, aie not unfrequently peculiar, Strang.*, eccentric, unaccountable, and by no means to 304' DIAGNOSIS Ul' INSAMTY. l)c depended upon in aftairs requiring the exereise of sound sense, good temper, and self-denial. In sueli a family, the medical man, whose professional assistance has been solicited on account of marked and obvious mental symptoms of one member of it, -will often find himself surrounded by relatives of the patient from uhom he can derive little information Avliich is unbiassed and trustworthy. He will often find the household divided against itself, one portion of it extenuating and palliating the conduct of the patient, the other exaggerating and attributing it to the worst motives. Under such circumstances, the medical man had better take things as he finds them, and listen to all parties with patience. He will be able to arrive at conclusions the more readily if he avoids cross-examination, and all appear- ance of participation in the family feud. If he cannot obtain information upon which he can rely from the immediate rela- tives of the patient, he will do well to make inquiries, with prudence and caution, of friends and neighbours, whose evidence will often be the more truthful, as it is less subject to the bias of feeling. In this manner, the physician will be able to satisfy himself as to the existence or not of hereditary predisposition, and of previous attacks, two points of the utmost diagnostic importance; perhaps not less so than that of haemoptysis in the diagnosis of consumption. DiaynosfAc Value of Hereditary Tendency. — The degree of hereditary taint may, to a certain extent, be ascertained and estimated. Thus, the insanity of one parent would indicate a less degree of predisposition than that of a parent and an uncle, and still less than that of a parent and of a grand-parent, or of two parents. The insanity of a parent and a grand-parent, with an uncle or aunt in the same line, may be held to indicate even stronger predisposition than the insanity of both parents. The influence of the insanity of parents in creating a predisposition, will depend, to a great extent, upon whether it has taken place before or after the state of parentage commenced. The insanity of a parent, occurring after the birth of a child, if it arose from a cause adequate to excite it, without previous predisposition, would of course be held as of no value in the formation of here- ditary tendency. The insanity of brothers or sisters may be of much or of little value, as evidence of predisposition, according to the circumstances under which it has shown itself. If several DIAfJXOSIS or INSANITY. 305 of them, both oklcr and youiificr tlian the patient, have Ijecome insane, tlie fact tells strongly in favonr of predisposition, although neitlicr parent nor grand-parent may have been lunatic ; since it is Avell known, that otlier conditions in the parent, besides that of actual insanity, may create this predis- position ; for instance, violent and habitual passion, the debility of old age, and, most of all, habits of intemperance at the time of procreation. The insanity of cousins cannot be said to be worth anything, as evidence of predisposition, except in cor- roboration of nearer and Mcightier facts. It "will thus be seen that the evidence of hereditary predispo- sition may be of such a character as to render the insanity of the patient an event in the highest degree probable ; or, on the other hand, it may be so weak as to add a scarcely appreciable amount of probability to the character of the disease. Of Previous Attacks. — The value which ought to be attached to evidence of previous attacks of insanity is considerable, since few diseases more frequently reciu* than those which affect the mental functions of the brain. A slight and transient attack, hoMe\ei", respecting the real nature of which there may have l)een some differences of opinion, will be of very different import to a prolonged attack of decided character. Moreover, the greater the length of time which has elapsed since any previous attack has been recovered from, the less will be the value of it as an indication of the nature of the existing disorder. Of Change of Habits and Disposition. — Besides these two important points of hereditary predisposition and of previous attack, the physician must inform himself respecting the habits, the character, and the disposition of the patient. In doing so, lie must bear in mind that they will influence his judgment in three ways. In the first place they will enable him to form an opinion as to the kind of man which the patient has been when in health, and as to the greater probability of his having become the subject of mental disease or of some other disorder, as, for instance, a chronic attack of drunkenness, or if a woman, of hysteria. The disposition and character when in health, would be of considerable value as evidence, if the physician could know it from personal observation ; but descriptions can scarcely be given w ith suflieient lucidity to render any opinion formed upon them of equal importance. An alienist physician of judg- 20 306 DIAGNOSIS OF INSANITY. ment and experience might be able to point out, in the circle of society with M'hich he is acquainted, nearly all the men who are very likely to become insane ; but were he imprudent enough to make known this invidious prescience, it would be found that his judgment differed widely from the opinions on this subject Avhich arc current in the world. It would be found, for instance, that his prophecy would not often rest upon those men who are called eccentric. Eccentricity more frequently depends upon a disregard of public opinion^ in trifling and non-essential matters, than upon any tAvist or perversion in the mind of the individual. The eccentric man is often a large-hearted and a courageous man, and as such, one of the last to become insane. The ominous forethought of the physician would rather rest upon the man over-susceptible concerning the good opinion which others may entertain of him ; the suspicious and timorous man, who hears scandal before it is spoken, and apprehends the com- mencement of every possible mischief; the man Avho has not at the bottem of his heart a sincere liking for his felloAV-ereatures, but who is querulous and contentious, and Avho perpetually finds himself in disaccord Avitli the world. This is the type of man whom predisposing and exciting causes are most likely to plunge into insanity. In the second place, these inquiries Avill enable the physician to compare the present behaviour and habits of his patient Avith those Avhicli Avere his Avhen in a state of health ; to contrast him, as it Avere, Avith his former self, a proceeding Avhich often affords a most satisfactory evidence of morbid change. It must be l)ornc in mind, that in insanity the natural character of the patient is either changed or exaggerated. When simple exaggeration has taken place — Avhen a man Avho has all his life been intemperate, or passionate, or gloomy, has merely become more intemperate, outrageous, or desponding, the change Avill have been, in all probability, miobserved for a much longer period than when an actual alteration of character lias taken place ; and even Avhen observed, this exaggeration of natural character is less readily attributed by friends and relatives to the effects of insanity, than in the other case. The physician, therefore, finds it more difficult to obtain satisfactory evidence of the infiuence of mental disease, Avhen it onlji, exaggerates the natural character, than Avhon it changes it. And Avhen he is able to obtain such evi- DIAGNOSIS OF INSANITY. 307 dence, he will very frequently find that the disease has already been of long standing ; an unhappy circumstanee^ attributable to the insidious manner in whieh it progresses when it takes this form. "When, on the other hand, the natural character of the patient undergoes a change, the event is generally too remarkable to escape early observation. When, for instance, the man of sober and steady habits becomes intemperate and dissipated ; -when the prudent and careful man suddenly becomes rash, speculative, and extravagant ; -when the moral and religious man enters into coiu'ses of dissolute and shameless impropriety; ■when the carefully nurtured and modest female demeans herself in a bold, froward, and indecent manner, the contrast is so great, that it arrests the attention at an early period, and seldom fails to satisfy the friends of the patient that it is occa- sioned by disease. At first sight, the two modes in which insanity announces itself by its influence on the character appear to be essentially diflerent. On a nearer new, however, it will perhaps be found that the difterence is more apparent than real, and that in those cases where the gi'catest alteration of character seems to take place, the real effect of the disease has not been to develop that which did not exist before, but merely to remove the cheeks and restraints which have kept it in subjection. A passionate or dissipated man merely becomes more passionate or dissipated under the excitement of incipient mania; just as he would become so, for a time, under the excitement of intoxication ; liis natural character has never been under control; and, there- fore, morbid excitement removes no previous restraint. But it is otherwise with persons mIiosc natural propensities are re- strained by moral and religious principles. There is a latent devil in the heart of the best of men ; and when the restraints of religious feeling, of prudence and self-esteem, are weakened or removed by the operation of mental disease, the fiend breaks loose, and the Avhole character of the man seems to undergo a sudden and complete transformation. Every medical man has observed the extraordinary amount of obscenity, in tliought and language, which breaks forth from the most modest and well- nurtured woman under the influence of puerperal mania ; and although he may be courteous and politic enough to join in the wonder of those around, that such impurities co\dd have entered 308 DIAGNOSIS OT INSANITY. such a mind, and even for liimsclf repudiating Pope's slander, that " every -woman is at heart a rake/' he -will nevertheless aeknowledgc that religious and moral principles alone are effi- cient in suppressing the sensuous tendencies of the female constitution ; and that, when these are Aveakcned or removed by disease, the suhterranean fires hecomc active, and the crater gives forth smoke and flame. In estimating exaggerations or alterations of character, the physician must be careful to make allowance for those which take place naturally, and in healthy minds. It by no means follows, because a person has becoine "a changed man," that he must therefore be an insane man. The nature of the change must be estimated with careful reference to its apparent cause and character. For instance, if, in the midst of prosperity and domestic happiness, a man underwent a change from a joyous and lively disposition to one of gloom and wretchedness, without any other apparent cause than the influence of predisposition to insanity, the change would justly be held to be one of the most serious and ominous import. But if predisposition did not exist, and if heavy losses or domestic afflictions afforded a reasonable cause, such a change might take place withoiit exciting the slightest alarm on the score of impending insanity. Great changes often do take place in the character of individuals, and in their habits of life, without the slightest suspicion of insanity. For instance, when a dissipated and reckless young man is brought under the influence of strong religious convictions, the external manifestations of his character undergo a complete change. On the other hand, a youth who has been brought up in the strict observance of a rigid religious discipline without appreciating the principles upon Avhich it is founded, when the repressive in- fhience of parental or other authority is removed, may inidergo an unfavourable change of character, and become thoroughly dissipated, without affording any indication of mental disorder. In the exaggeration of character, also, the natural influence of circumstance must be allowed to have its due weight. Tims, particular callings and professions have a strong tendency to develop particular characteristics. If, for instance, a clergyman acquired arbitrary and dictatorial habits, or a physician became particularly intemperate and jovial, such developments of cha- racter would liave a very different significance to that which DIAGNOSIS Ol" INSANITY. 300 would attach to tlicni, if the first had occurred iu a sca-captaiu, and the hist in a Boniface. One caution is necessary iu estimating sudden and remark- able changes of character, namely, to be on guard against the vagaries of liysteria. The hysteric temperament, in cither sex, often produces the most extraordinary changes in apparent character ; but they are changes in appearance only, and the versatile subject of them, who is "everything by starts, and nothing long," remains essentially the same fickle, superficial, deceptive being, under all phases of character. In the third place, a careful inquiry into the habits of the patient "will often enable the physician to discover an adequate cause for the production of insanity. It will often, for instance, make him aAvare of habits of intemperance, which are an amply sufficient cause ; or of habits of strong mental excitement, such as those afforded by gambling, whether it be of the unlawful sort or the legal gambling of rash speculation ; or it will indicate to him religious and social habits and practices testifying to the existence of that fanatical temper, and those peculiar views, Avhich statistics prove to be most influential in the production of mental disease. Such a preliminary inquiry will also make the physician aware of family feuds and dissentions, and it w ill instruct him on many other matters of the like kind, which it is absolutely essen- tial that he should know, before he can weigh all the evidence of his patient's insanity, with that nice discrimination which tlie delieate and difficult nature of the inquiry frequently demands. Although we have not yet introduced the physician to his patient, we have, nevertheless, engaged his attention in matters which will greatly assist his judgment. Thus, if he is informed on crcdil)le testimony, that the parents or grand-parents have been insane, that tiie patient has beforetime undergone attacks of insanity, that his character has recently become changed in a notable and strange maimer, and that, moreover, he has been intemperate, or subjected to some other influence capable of exciting mental disease; if all, or part of these circum- stances, have been ascertained, the pliysician will find the further examination, and the formation of his ultimate judgment, infinitely more easy than if he had entered upon the former without such previous instruction. ^10 DIAUNOSIS or INSANITY. Maunet' of Examination. — In the personal examination of the patient, the greatest tact and discretion are required. A physician called to treat any bodily disease, at once commences with direct and pertinent questions ; but, in all difficult cases of mental diagnosis, such a proceeding would surely defeat its ends. Tlie physician, often indeed, finds some difficulty in contriving to be introduced to the patient, and in commencing a conversa- tion without bringing about the eclaircissement which, above all things, is to be avoided. If the patient is strongly prc-oceupied Avith a delusive idea, or by maniacal excitement, of course no difficulty will exist j and sometimes, in cases of melancholia, the patient will himself be most anxious to consult the physician on his mental state. But, when the disease is in the incipient stage, and when the patient is suspicious and hostile, the matter of introduction and the opening of conversation require much tact, and sometimes a little contrivance. In cases of bodily disease, it would not be unusual or improper for the physician to commence with, '^ I am sorry to hear from your good lady, that you have lately been troubled with shortness of breath, and pain in the chest, &c.^^ But if the alienist physician were to open the campaign after this fashion, with, " Sir, your wife in- forms me that you have lately been subject to fits of ungovern- able passion, alternating with despondency, &c.," the patient w^ould probably turn the flank of the maladroit physician, or, al least, beat a hasty retreat. We cannot go so far as to assert, that small deceptions must never be practised; such, for in- stance, as apparently calling in the physician to see another member of the family, affected with a convenient illness ; but of this wc are convinced, that the discovery of even the slightest deception, will have a prejudicial influence on the future treat- ment. In almost all cases, the physician may readily enough engage the attention and the goodwill of the patient, if he com- mences with sympathising inquiries respecting any bodily symptoms and ailments, or respecting any matters in Avhich he can ascertain that the patient takes a lively interest. The physician will rarely act Avith wisdom, if he at once assail the citadel of the disease. lie must first endeavour to occupy the outworks. His efforts must be directed to placing himself on good terms Avith his patient. For this, only general directions can be given. He must employ that tact derived from good DIAGNOSIS Ul' i.\.SA.MT\. 311 sense and knowledge of mankind, uithout which lie Aviil iiiul liimself lame and impotent in this fiekl of medical practice. 13y the time that a good understanding has been established be- tween the physician and the patient, the former will have obtained, from tlie various sources which we have specified, information of the utmost importance for the guidance of his interrogations. If he is so unfortunate as to have absolutely no history of his patient, he will have observed in him one of four things, either — firstly, a vacant and meaningless expression, and a childish absurdity of action, the signs of dementia, of im- becility, or those of general paralysis ; or, secondly, a facial expression of deep and concentrated sorroAv ; or, thirdly, indica- tions in physiognomy, or demeanour, of strangeness and irregu- larity ; or, fourthly, no outward indication of mental disease. In each of these four main divisions of mental disease, a some- what different method of interrogation must be pursued. In melancholia, the patient is often only too ready to converse on liis mental symptoms. In imbecility, and early dementia, liis apprehension is not sufficiently alert to place him on his guiu'd ; and, in mania, he either suffers from head-symptoms, respecting Avhich he will readily converse with a medical man, or his mind is actively engaged on some project or object, which will afford tlic physician appropriate materials for conversation. The most difficult cases are those in which diftcrences of opi- nion and of interest exist among the members of the patient's family, and the patient has quietly been told that it is wished to prove him insane, and to place him under confinement, and that the doctor is coming to examine him for that purpose. Under such cii-cumstances, m liicli arc by no means uncommon, the physician must do the best he can ; and, if this is but indiffer- ently well, he must content himself with the reflection that the fault is not his. Peculiarities of Residence and Dress. — Immediately that the physician tinds himself in the presence of his patient, " the facts observed by himself," upon which alone the law very properly insists that the diagnosis of insanity shall really be made, will require the keenest exercise of his perceptive and analytic powers. Of course, tlierc are a great number of cases iu w hich the existence of insanity is so evident, that, strictly speaking, diagnosis becomes quite unnecessary. When insanity lias 312 DIAGNOSIS Oi' INSANITI. assumed so marked a form, that, as Mrs. Page saitli, — " any madness I ever yet beheld seemed but tameuess, civility, and patience, to this distemper he is now in," — the question of dia- gnosis gives way to that of treatment. But, in slight cases, and in early stages of the malady, the symptoms are by no means invariably conclusive, or even satisfactory. The physician will, therefore, do right to avail himself of every circumstance which can assist him in forming a correct judgment ; even as, in the diagnosis of phthisis, the evidence afforded by auscultation and [)crcussion does not justify him, where any doubts exist, in neglecting to examine the state of the hair, the finger ends, the gums, or any other part of the body capable of aflPording corro- borative testimony. On entering a house in which the head of the family is supposed to be insane, the physician wiU not un frecpiently find his attention attracted to many little circum- stances, testifying to a want of order and direction in the house- hold affairs. In the room principally occupied by the j)atient, things are especially found to be out of place ; bizarreries often ])rcscnt themselves in the decoration of the walls and the arrange- ment of the furniture. A short time since, on visiting the house of a gentleman on whose mental condition we had been called upon to report, we remarked, among other things, a uilmber of trumpery clocks. There were seven or eight of them iu the hall, diligently at work to show the hour of tlie day, but all of them, like Charles the Fifth's timepieces, entertaining individual and very difl'erent opinions on that important point. In fact, the variations of time indicated by them extended to full three quarters of an hour. In reply to a remark, the owner of this array of pendulums told us, that it was a great point with him to know the precise time, and that he bought all the clocks, at auctions and clseAvhere, which he could obtain under a certain sum; he had so many clocks because, if one did not go accurately, another might. When told, that a really good timepiece pur- chased with the collective price of his trumpery horologes, would give him much more reliable information than all of them put together ; since, if any one of them did by chance go accurately, he could not tell which it was; he was evidently convinced against his will, and retained his own opinion still. A love of order is rarely seen among the insaiu^, except iu some chronic cases where it has been acquired under asylum discipline. DIAGNOSIS Ol' INSANITY. 313 The residence and the room of the patient often, therefore, bear traces of disorder; articles of ch)thing are scattered aronnd, everything is disarranged, and the dress and person of the patient often bear evident marks of want of care and cleanliness. In fact, the description given by llosalind of a lover, would have been much more true to nature if applied to an insane person — namely, "a lean cheek, a sunken eye, an unquestionable spirit;'^ " then your hose should be ungartered, your bonnet unhanded, your sleeve unbuttoned, your shoe untied, and everything about you demonstrating a careless desolation." This description was, very likely, taken from the negligent dress of the insane, since the fair speaker, immediately afterwards, expresses her opinion, " that love is merely a madness, and deserves as well a dark house and a whip as madmen do.'^ AVhen Hamlet's mind was first shaken, lie went, •' With his douhlet all unbraced. No hat upon his head, his stockings loose, Ungarter'd and down-gyved to his ankle." In erotic madness, the dress is not as fair Rosalind would have it, careless and disordered, but generally the contrary, and oftoi fantastic, arranged with care and with the evident desire to attract admiration. The patient's dress not unfrequcntly presents characteristic traits indicating the direction of insane delusion ; for instance, in ambitious insanity it is made to ape the military or the regal cut, if the patient thinks himself a great general or a king. But these indications belong to a later period of the disease; and it may be taken as a general rule, that in the earlier stages of mental disorder the dress and personal condition of the patient are neglected. Sometimes tliere is great intolerance of dress, the patient seeming to suffer irritation from the customary articles of clothing. The propensity to remain wholly or partially naked is frequent, and owes its origin to various causes. A young lady nniy desire to live in the primitive sim])licity of paradise ; or she may think her body invisible, and wish to remove the gross en- velopes which would render this corporeal translucency of no avail ; or, clothing may be thrown off and destroyed out of mere mischief and dcstruetiveness ; or, the sensibility of the skin may be greatly enhanced, and the warmth and friction of clothing may cause much annovance. 314 DIAGxNOSlS 01' INSANITV. The physician's observation of the negligences, inconsistencies, vanities, and various peculiarities of the patient's cbess will pro- ceed concurrently with the more important observation of his appearance, demeanour, and conduct. The appearance of the patient will depend upon the expression of his physiognomy, the traits of temperament, the bodily conformation and condition, and the habitual postures and gestures. The whole of the above may be classed under the terms, appearances and demeanour. That which the patient says and does we may distinguish as his conduct. Peculiarities of Bodily Condition. — The bodily condition of the patient, in regard to plumpness or emaciation, the state of the skin, the pulse, and the tongue, rarely affords informa- tion of any practical value in the question of diagnosis. The instances are so numerous in which the mental functions of the cerebral hemispheres may be greatly disordered, while the func- tions of all the other bodily organs remain healthy, that the deviations of the latter from the normal state cannot be relied upon as trustworthy data in the formation of an opinion as to the existence of mental disease. It may be laid down as a general rule, to which, however, there are numerous exceptions, that the insane do not possess robust bodily health. The early stages of insanity arc very frequently marked by emaciation, occasioned by loss of rest, wasting of the tissues from increased activity of the mental and bodily functions, and derangement of the ali- mentative processes. This emaciation is one cause of the alteration and sharpening of the features which so constantly take place. AVhen, however, the process of mental disease is gradual and insidious, especially if it arises from a strong predisposition, and witliout the inter- vention of disease in any of the organs subservient to the vege- tative life, there may be little or no emaciation at any period. During the later stages of those forms of mental disease which are characterised by diminution or loss of power, it is well known that the body is inclined to obesity. Little reliance can be placed upon the indications either of the pulse or of the tongue, although in the early stages of in- sanity the former is generally quicker than in health, and the latter is not uufrcqucntly coated with a white central list. The skin is very generally harsh and Iry, and not unfrequently DIAGNOSIS or INSANITY. 315 affected with eruptive disorders. It is exceedingly rare to .see a person in the early periods of insanity, with a thoroughly clear healthy complexion. The point of real importance to he attended to in the exami- nation of the patient's bodily condition, is to ascertain whether any diseased condition of any of the organs exists, which may liave been the remote cause of the malady. Disordered states of the abdominal viscera arc of such frequent occurrence, that the veteran Jacobi, and some other physicians of eminence, have believed that they altogether account for the causation of mental disease. "We arc far from being able to concur in this narrow view of the etiology of insanity ; but no physician of much experience in this department of medical science Avill be likely to deny, that disordered states of the stomach, the intestine.?, and the liver, do frequently constitute the remote causes of cere- bral disease. The indications, therefore, of gastric and hepatic disorder observable in the tongue, the skin, and the nutrition of the body, are signs of the existence of this cause. It is as yet very uncertain whether diseases of the heart and of the lungs often operate as remote causes of insanity. In our opinion, the probability is against this supposition, notwithstanding the numerous instances in which these organs arc found to be di.'i- eased in ])crsons dying insane. But there cau be no doubt that uterine disorders constitute one of the most frequent remote causes of insanity Avith which we are acquainted. If, therefore, the pliysician can ascertain that his patient has suffered, or is suffering from gastric, hepatic, intestinal, or uterine disordei*, he will have discovered a well-known and frequent cause, the existence of which must be allowed to exercise its due influence in the diagnosis. Peculiarities of Gesture. — The features and gestures of the patient are oftentimes strongly expressive of mental disease. The muscular system is the bond of connexion between the mental functions of the cerebrum and the external world. It is the muscular system which, obeying the behests of the meta- physical Eyo, executes its commands, and interprets its desires and its passions. Strictly speaking, changes in the physiognomy and in the vocal articulation must also be referred to this source ; but it is convenient to consider them apart, and at the present time to direct attention to those grosser muscular actions which 316 DIAGNOSIS Oi' INSANITY. arc commonly understood as the postures and gestures of the body. These are generally more pronounced and more expressive in insanity than in health. In artificial states of society, the sign-language so commonly employed by the savage or the man of nature to express his feelings and his wants, is discontinued ; speech is perfected, and articulate or Avritten language becomes the sole juedium of intercommunication. Gesticulation, as a means of communicating thought, has been foimd to be too demonstrative, too simple, and perhaps also too true to be con- venient for the use of man in that state in which it has even been said by one of the ablest men of the age, that " the use of language is to conceal thought.^^ But children, savages, and especially the deaf and dumb, converse by the sign- language of gesture ; and the insane man, removed from the restraints imposed upon him by so-called civilization, returns to the state of the child or of the savage, and expresses his desires and his feelings by the sign-language of nature. The panto- mime of the insane is often perfect. It cannot be called acting, since it is real ; and hence arises the most frequent cause of failure in attempts to simulate insanity. The counterfeit mad- man, acting the part which he assumes with grotesque clumsi- ness, leaves a M'ide and easily detected interval between himself and the real lunatic. In order to describe all the postures and gestures of the in- sane, it would be necessary to dilate upon all the resources of pantomimic expression. It is, however, unnecessary to enlarge upon this subject, since every member of the human society is compelled to study both the language of gesticulation and that of facial expression, from earliest infancy ; and there are few men who do not become adepts in interpreting the signification both of look and gesture. A man Avho can appreciate the differ- ent numtal conditions designated by the terms sadness, melan- choly, despondency, despair, will find no difficulty in the inter- pretation of the sign-language by which they are outAvardly expressed. Sadness he will expect to see manifested by simple repose and quietude of manner ; melancholy, by quietude deep- ening into immobility, with clasped hands, bowed head, and heavy step, and the desire of solitude ; in despondency he will see an exaggeration of all these characteristics, the posture often crouching and bent togethei', like that of a person suftering DIAfiXOSIS OF INSANITY. 317 from cold ; wliilc in despair, the extremity of mental agony acts as an excitement, and the sufferer is stimulated into action, or he is held rigid in the cramp of intense fear. A Avide difference intervenes between the commencement of melancholia, in which it may be said of the patient, " There was a listeninsc fear in her regard, As if calamity had but begun," and the extreme of mental agony, which produces reaction, either in the form of the most painful and dangerous excite- ment, or of concentrated suicidal purpose — " the resolution of despair." It will be needless to detail the various modes in which emo- tion depicts itself, in motion and attitude, in partial insanity. This is not different to what occurs when the same emotions are excited in a healthy brain, or the difference exists only in degree. Pride, anger, fear, sadness, jealousy, and all other passions, find that appropriate and distinctive expression, which the language of poetry can alone describe with adequate force and truth. The fixed and intense expression of any one emotion may be taken as a presumptive symbol of partial insanity. AVhen the attitude is restless, the motions quick and viva- cious, and expressive of various and changeful emotions, a state of mania or general insanity is indicated. ]\Ielaneholia is, on the contrary, known in some of its phases by fixed attitudes and slow gestures ; in others, by gestures of earnest supplication and intense dread ; or by the reckless wildness, or intense reso- lution, of despair. Imbecility and dementia are marked by slovenly postures, and by undecided and aimless movements, indicating that both the action and the repose of the miiscles are under feeble and iueflicient direction. All these details it would be wearisome and useless to dwell upon ; but the alienist physician must have his eye open to seize upon their minutest shades, and his mind apt and prepared to appreciate them. In the early stages of insanity, it is often the collective evidence of things, indindually unimportant, upon Mhich the judgment must be based. The P/iysiof/nonnj of Insatiihj. — The extreme distortion of face produced by acute mania,or melancholia in its higher degree, is easily recognised. It may, however, be needful to distinguish 318 DIAGNOSIS OF INSANITY. it from the expression of cerebral inflammation, or of fever. The distinguishing characteristics of cerebral inflammation attended by maniacal s3mptoms are, a greater snfl'usion of countenance ; a firm knitting of the brows expressive of intense pain, and a fierce, prominent, and bloodshot eye. It is in meningitis, rather than in mania, that it may be truly said — "And each strained ball of sight seemed bursting from his head.'^ The patient suffering from cerebral inflammation has a motiveless ferocity of aspect, rarely met with in pure mania. The stage of effiision in meningitis, and all the stages of some forms of deep-seated cerebral inflammation, in which the meninges are not aff^ected, require to be distinguished from dementia^ rather than from mania. The history of the case, however, and the aflection of the muscular system in phrenitis, will generally render the diagnosis easy. The aspect of countenance in the delirium of fever is suffi- ciently diff'crent from that of mania, to aff'ord valuable aid in the discrimination of these two conditions. In fever, whatever may be the degree of excitement and the amount of delirium, the countenance indicates low emotional force. In the delirium of mania, on the contrary, the expression of emotional force is highly exaggerated. This difference is very marked in the ex- pression of the eyes and the mouth. Whatever may be the character of febrile delirium, the expression of the eyes is com- paratively devoid of meaning ; the muscles of the mouth, although relaxed, are devoid of mobility. The muscles of the face, like those of the body in general, arc greatly deficient in power and tone ; and the features, which are controlled by the facial muscles, are relaxed and without expression. If there is any mobility of the facial muscles, it is tremulous and feeble, indicating want of power ; whereas, in mania, the play of these muscles is full of expression and purpose. It is vigorous and tense, and plainly marks a concentration of nervous force. The deepening wrinkles on the face of a patient suff'ering from the delirium of fever, are the result of emaciation ; those which furrow the face of a maniac, result from the tense contraction of the muscles of expression. Lavater recommends the student of physiognomy to commence Avith tbe insane, because they will aff'ord to his art extreme and crucial instances. DIAGNOSIS OF INSANITY. 819 We tliiiik that, in this instance, the acute founder of pliysio- gnomical science has not displayed his usual clcar-si'ji:hted per- ception of the correct order of ohservation. To commence the study of physiognomy in a lunatic asylum, would be not less impracticable than to study physiology in the first instance by means of pathology. It would have been as irrational to expect that the functions of the lungs could be discovered by the in- spection of a piece of hepatized pulmonary tissue, as that the signs of natural expression could be determined solely by the observation of that which is strange and \mnatural. It Avoidd seem, that, in all departments of investigation, it is right to commence with the study of that which is most common, simple, and regular ; and from thence to proceed to inquiries respecting that which is unusual, and irregular. Notwithstanding Lavater's recommendation to his followers, we much doubt whether he ever himself pursued his pliysiognomical researches in the wards of a lunatic asylum. His nearest approach to it appears to have been a careful study of the insane productions of the painter Fnseli. lie speaks of madness as an entity, the presence of which may possibly be discovered by some single mark or token in the lineaments. Actual researches in a lunatic asylum would have speedily undeceived him on this point. It may positively be asserted, that any one totally ignorant of the right meaning to be attached to the different expressions of the human face, would find himself more perplexed in the wards of a lunatic asylum, than in any other place in the world, because he would find every variety of expression in every degree of intensity, Mithout the existence of circumstances corresponding to, and explaining the physiognomical signs. Our own advice, there- fore, to the student of physiognomy, would be the con\erse of that given by Lavater; and we arc prepared to afhrm, that no one can become proficient in the recognition of the various forms of insanity, who has not acquired a considerable amount of physiognomical tact by his intercourse with the sane ])ortion of mankind. If we may trust the description transmitted to us by dra- matists, poets, and painters, the facial expression of insanity was much more intense in the olden times, than at the present day ; and the idea entertained of a madman by the public, is more frequently taken from such descriptions than from per- 320 DfAGNOSIS or INSANITY. sonal observations. Wc lla^•c seldom been more amused by the disappointment of a friend, that we were by that of an accom- plished gentleman, who has now, for some years, made it his business and his delight to read Shakspeare to the English public. After patiently examining the numerous inmates of the Devon Asylum, he pronounced his opinion that they were all '' stale, fiat, and unprofitable." Doubtless they were so in iiis point of view, for he said, " "Where is the poetry of madness ? I see none of it— no flashing eyes, no foam on the mouth. "Why your people are as sober and respectable as a vestry meeting ! " It was a great artistic disappointment ; but rather flattered than abashed, we admitted that, since the insane had been treated on rational and humane principles, they had ceased to off'er the best and most constant examples of exaggerated pas- sion. But even did it continue to exist, the mere expression of intense and uncontrolled emotion Avould not, in itself, be a symptom of insanity ; since emotion is often both intense and uncontrolled in those who are undoubtedly sane. Since, how- ever, insanity is, by common consent, acknowledged to betray itself by the facial expression, it becomes necessary to inquire what are its true physiognomical symptoms. It Avould be tedious and unprofitable to dilate at length upon this subject. Its importance, indeed, cannot be easily over- rated; but the art of physiognomy cannot be taught in dissertations or treatises. Like the art of judging of the weather, acquired by the mariner and the sportsman, its only school is the wide field of observation. A few principles may, indeed, be laid down, by which observation may be rendered more easy. They are, however, but few, and the exceptions to their applica- tion arc frequent. The expression of the physiognomy in a sane person is com- pounded of intellectual, emotional, and propcnsive expression. Intellectual expression may be divided into that which is sensa- tional, or perceptive, and that which is reflective. The first is marked by the obvious activity of the organs of sense, especially by that of the eye, and by a certain fixedness of the features, indicating concentrated attention. The reflective expression, on the other hand, is marked by the more or less complete inacti- vity of the organs of sense, accomj)anied, however, by the same fixedness of feature, which, in this instance^ betokens concen I DIAGNOSIS OF INSANITY. 821 t ration of attention upon an internal object. It would seera, tliat a purely intellectual expression, of either kind, must be unalloyed by traces of emotion. But, on the other hand, a physiognomy indicating the presence of strong emotion, may, nevertheless, be highly intellectual. An ample brow, a clear and steadfast eye, a firm and well-proportioned mouth, so con- stantly accompany a high degree of intelligence, that they are almost instinctively recognised as the signs of its presence, even although the features may be deeply marked by tokens which indicate the existence of one or more of the passions. The emotional expression of the physiognomy is not capable of so simple a description and classification as the intellectual. The distinct emotional expressions are as numerous as the emotions themselves. They may, however, be conveniently classified into those which are expansive, and those which are contracted. To the former usually belong the feelings which arc generous and honourable ; to the latter, those which are selfisji and mean. The former arc generally accompanied by feelings of well-being, or happiness ; the latter, by those of suftcring. Numerous exceptions, however, exist. Pity, for instance, is a generous but painful emotion. The expressional impress of strong animal propensities, or the absence of such expression, is a point of the highest im- portance. The sensual expression of physiognomy is not much modified by any one prevailing instinct ; it is, however, greatly modified according to the presence or absence of intellectual power. Without the latter, the facial indications of powerful and unrestrained instincts often profoundly degrade and bru- talise the human face. When, however, they are conjoined with intellectual power, strong propensities often appear to lend force and energy to the character ; and by the miion of the two, the facial expression is wholly redeemed. The student of the physiognomy of the insane must, above all things, endeavour to separate and to distinguish the three elements of expression above named, and to estimate the degree in which they severally exist. Having done this, he must bend all his powers of perception and discrimination to the character which prevailing emotion has stamped upon. the physiognomy. In persons of placid temperament, and especially in the earlier years of life, the facial traces of emotion may be so slight as to 21 3.23 DIAGNOSIS OF INSANITY. defy the keenest scrutiny. But after the middle period of life, the habitual emotions become stamped in legible characters upon the features of almost all men ; and in the rare instances where this is not the case, this fact in itself becomes a key to the character, pointing to an extraordinary absence of passions and desires, or a still more extraordinary control over their external manifestation. Insanity anticipates the effect of years, and prematurely impresses upon the human face the strong character- istics of habitual emotion. In the youthful insane, the facial lines of anger and pride, sorrow and fear, are more deeply cut than in sane persons of advanced years ; and in a mature or aged lunatic, they are often displayed in an exaggerated degree rarely observed in persons of sound mind. It will be foreign to the object of this work, to descant upon the minutire of phy- siognomical expression ; for these, the student must consult works devoted to the subject, and especially those of Lavater, the astute and laborious founder of the science. It will be sufficient, in this place, briefly to refer to the most obvious physiognomical signs. When the plicae of the forehead are longitudinal, regular, and broad, they indicate a calm and reflective character; when tortuous and abrupt, they indicate the prevalence of angry emotion. The scowl of anger must be distinguished from the heavy brow of melancholy ; in the former, the eyebrows are forcibly approximated ; in the latter, they simply droop. The various expressions of the mouth and nostrils must be duly esti- mated. The dilated nostril of pride and scorn must be distin- guished from that of fear, llic compression and mobility of the lips ami corners of the mouth, indicate resolution or obstinacy, disgust and aversion; or on the other hand, satisfaction and the amialjlc feelings. The vivid and changeful expressions of the eye are so subtle, that they will scarcely submit themselves to verbal description ; but the steadfast gaze of pride, the languish- ing look of desire, the tlnvart glance of distrust, the glare of rage, characteristically express themselves in a manner which it is impossible to misapprehend. In judging of the insane by their facial expression, the phy- siognomical characteristics are, in many instances, exactly similar to those observable in the sane; the intensity of ex- pression l>eing frequently exaggerated. DIAGNOSIS OF INSANITY. 323 111 a great number of cases, however, a remarkable peculiarity is observable in the physiognomy of the insane ; this exists in a want of accord in the expression of the different features. This is often remarkable and characteristic, and reminds one of those chiUlren's toys, in which the upper and lower halves of painted figiu'es arc separable, and capable of being joined in fantastic rc-union. Thus, the lower face of an alderman may be added to tlie ui)pcr face of a handsome woman ; and upon the simpering month of the latter may l)e snperadded the stern brows of a soldier. The effects produced by this amusing toy arc only exaggerations of what may be observed in the insane. The expression of mouth often gives the lie to that of the eye and the brow ; and while the whole features are full of expres- sion, it is often impossible to designate truly that Avhich is expressed. This is, perhaps, the most characteristic peculiarity of the insane physiognomy, since it is only observed among the insane. It is, however, frequently absent in them ; and the patients in whom this pccidiarity is strongly marked, are probably less numerous than those in whom it is absent. Its presence, therefore, as a symptom of insanity, is of considerable value; while but little weight can be attached to its absence. Another pecidiarity in the physiognomical expression of the insane, is the apparently causeless and motiveless play of feature which is frequently remarked in them. This is only obsened in chronic mania, and in the earlier stages of acute mania; and conjoined with the last-mentioned conditions, it occasions that state of facial expression upon which the popular idea of a mad- man's looks is founded. These changes, although apparently causeless and motiveless, are not so in reality ; they are, indeed, a reflection of those rapid changes in the emotional state, which often exist in mania. The physiognomical expression of the insane must be studied with reference to the form of disease. Thus, in melancholia, the facial expression is emotional ; while in mania, it is emo- tional and intellectual, and is marked by the characteristics of changeablcness and inconsistency above described, ^n dementia, on the other hand, all expression has disappeared, the vacant stare and the meaningless lineaments indicating the lo.ss of thought and of desire. It is only necessary, in this place, ))riefly to advert to the great pecidiaritics observable in the face of general 324 DIAGNOSrS OF INSANITY. paralytics, — tlic trembling lips, the drooping broAvs, the features expressive of a mixed state of imbecility and excitement, the eyes with pupils of unequal size, together afford to the ex- perienced alienist, unquestionable testimony of the existence of this most hopeless of maladies. The physician Avho is a good physiognomist (and no physician can practise his art satisfactorily and successfully unless he is so), when introduced to a patient suspected to be insane, must diligently study the features in conformity with the above prin- ciples. He will very frequently find his opinion strongly biased by the impression which the looks of the patient make upon his experienced judgment ; and upon this ground alone he will, in numerous instances, be able to pronounce with accuracy, not only that the patient is insane, but the general form of the insanity under which he labours ; at least this will be the case in numerous instances of incipient mania, in dementia, and paralysis. The cases in which the looks of the patient will often defy the scrutiny of the physician, arc those of monomania or partial insanity, and of melancholia. In cases of partial insanity, where the delusion or delusions are not of a kind strongly to implicate the feelings, the mental disease frequently leaves no trace Avhatever on the physiognomy, and the looks of the patient are exactly those of a sane man. In the earlier and middle stages of melancholia, also, the physiognomical expression of sadness is often not to be distinguished from that of natural and healthy grief. The extreme anxiety and wistfulncss of acute melancholia, and the dark shadows of the severer forms of chronic melan- cholia, are, however, not to ])e mistaken. "With the above-named exceptions, the physician will derive invaluable aid from the physiognomical study of his patient. The information thus derived he must immediately turn to account, in the conduct of his interrogation and conversation. Demeanour toivards the Patient. — In observing the patient's expression, demeanour, attitude, &c., the physician will do Avell to avoid a marked and obvious attention ; and in passing from ocular observation to conversational investigation, the more quietly and naturally he conducts himself, the more likely he is to succeed in disarming the suspicions of the patient, and in dis- covering his real mental state. jNIuch has been written about the manner and mode of address Avhich it is desirable to put on DIAGNOSIS OF INSANITY'. 325 in intercourse with the insane ; but many of tlie insane arc themselves aeute observers, quick and ready to see through the mask of an assumed manner. A pliysician, therefore, wlio feels that it is needful for him to assume towards the insane a manner foreign to his natural disposition, will do well to keep out of their way, and to direct his attention to other brauches of pro- fessional practice. A quiet and self-possessed manner is most successful with the insane, but it is only successful when it is natural. Diagnosis of Dementia. — In the mature stages of dementia, when the patient can neither understand nor answ^er a simple question, of course interrogation is both unnecessary and im- practicable ; but in the early stages of primary dementia, the task of ascertaining the extent of mental debility is not unat- tended with difficulty. In this form of disease, there is little in the patient's conduct or demeanour to assist the judgment of the medical man ; the physiognomy, indeed, is silly and expression- less ; the eyes have a meaningless look, and easily and frequently suffuse with tears ; and a vacant smile plays upon the lips. The features, however, are often fixed in meaningless apathy. In this form of disease, the mind suttcring from deprivation and not from aberration of function, it becomes needful only to test the degree in which the functional power has been lost. This must be determined by testing the three fundamental functions of mind — namely, those of attention, memory, and comparison. The inattention of dementia is widely ditt'crent to tliat of mania. "When brought to the test of repeating any statement, madness " gambols " from re-wording the matter. Dementia does not gambol ; it halts, or stands stock still. The fault of attention in mania arises from the " thick crowding fancies," which prevent the mind from dwelling upon any one object in a manner to fix the attention. An object is seen clearly, although but for a moment. In dementia, no object impresses a distinct idea upon the perception, although the attention may have dwelt upon it for some length of time. The test devised by the English law for idiocy, namely, the appreciation of nuniljcr, is a useful one in the early stages of dementia. It is remarkable at how early a period of the malady, patients lose not merely the power of understanding anything like an intricate account, 326 DIAGNOSIS Of INSANITY. but the value of very simple numbers. To this fact is to be attributed many instances of reckless expenditure and apparent prodigality in persons ])ecoming insane. Other instances arise from aberration of the judgment, and loss of power to estimate consequences; and others from a morbidly active state of desire ; but in the early stages of dementia, in the dementia of old age, and in imbecility, the patient becomes an easy prey to designing persons, from the weakened power of attention, and the consequent inability to estimate the value of money. The power of memory depends, in a great degree, upon that of attention. A thing which is well observed is well remembered ; Avliile circumstances to which the attention has not been ener- getically directed, hold in the memory but a feeble and treacher- ous place. It is partly to this that must be attributed the well- known peculiarity in the memory of persons suffering from the dementia of old age. The vivid impressions of early life are easily recalled, while the recent ones of declining age leave no traces in the mind. It must not, however, be supposed that the powers of the memory can only be enfeebled in this secondary manner. The memory is itself a cerebral function, and so purely is it a cerebral function, that some metaphysicians, who strenuously deny this attribute of all other mental powers, con- cede it in regard of the memory, and in this manner endeavour to establish an alliance, or a compromise, between the physiolo- gical and the spiritualist theories of the mind. The memory, then, is without question a function of the brain, and cannot fail to suffer injury from any lesion to which its organ is sub- jected. It is, as we have seen, impaired in a secondary manner, from enfeeblement of the attention. That it is also primarily injured in dementia, is proved by the fact, that when peculii\r circumstances have excited the attention to energetic exercise, and have occasioned passionate emotion, the memory, although in a less degree, is still feeble and treacherous. It is remarkable that, in those forms of cerebral lesion which are characterised by enfeeblement and decay of the mental functions, the highest of these functions, namely, the judgment, suffers to a much less extent than either the attention or the memory. The fact is abundantly verified by experience, that in persons whose general powers of mind are in an advanced stage of decay, the judgment often remains sound, as far as its DIAGNOSIS OF 1NSAN1T\. 327 condition is capable of l)cinI 870 DIAGNOSIS OF INSANITY. down upon his beard. Then said Achish unto his servants, Lo, yc sec the man is mad ; wherefore, then, have ye brought him to me ? Have I need of madmen, that ye have brought this felloiu to play the madman in my presence ? Shall this felloiv come into my house V" From whence it appears, that not only did King Acliish make a bad diagnosis, but that the prejudice against tlie insane is as old as the earliest records. Reverting to profane history, Ave find that Palamedes had more diagnostic acumen than the King of Gath. Ulysses feigned insanity, to escape the Trojan war. He yoked a bull and a horse together, ploughed the sea-shore, and sowed salt instead of corn. Pala- medes detected the deception by placing the infant son of the King of Ithaca in the line of the furrow, and observing the pretended lunatic turn the plough aside — an act of discretion which was considered a sufficient proof that his madness was not real. At the present day, one would scarcely pronounce that a man was feigning madness because he retained enough of intel- ligence to recognise, and avoid the destruction of his own son ; but the signs of madness adopted by Ulysses resembled, in a remarkable manner, the conduct of feigning madmen as they exist, and which, to an experienced alienist, would at once suggest the idea of deception. The feigning madman, in all ages, has been apt to fall into the error of believing that conduct utterly outrageous and absurd is the peculiar characteristic of insanity. The absurd conduct of the real madman does not in- dicate a total subversion of the intelligence ; it is not utterly at variance with the reasoning proeccsos ; but it is consistent either witli certain delusive ideas, or with a certain perverted state of the emotions. In the great majority of cases, feigned insanity is detected by the part being overacted in outragcousiicss and absurdity of conduct, and by the neglect of those changes iu the emotions and propensities, Avhich form the more important part of real iiisanity. Sometimes mania is simulated : the man howl5, raves, distorts his features and his postures, grovels on the ground, or rushes about his room and commits numberless acts of violence and destructivencss. If he has had the opportunity of observing a few cases of real insanity, and if he is a good mimic, he may succeed in inducing a person Avho only watches him for a few minutes, to believe that he is in the presence of a case of acute mania : but if the case is watched for a few hours DIAGNOSIS OF INSANITY. 871 or clays, the deception becomes apparent. No muscular endu- rance, and no tenacity of purpose, will enable a sane man to keep up the resemblance of acute mania ; nature soon becomes exhausted, and the would-be patient rests, and, at length, sleeps. The constant agitation, accompanied by symptoms of febrile disturbance, by rapid pulse, foul tongue, dry and harsh or pallid clammy skin, and the long-continued sleeplessness of acute mania, cannot be successfidly imitated. The state of the skin alone will frequently be enough to unmask the pretender. If this is found to be healthy in feeling, and sweating from the exertion of voluntary excitement and eflbrt, it will afford good grounds for suspicion. If after this the patient is foiuid to sleep soundly and composedly, there will be little doubt that the suspicion is correct. Chronic mania may be imitated ; and if this should be done by an accurate observer of its phenomena, who also happens to be an excellent mimic, it cannot be denied that the imitation may deceive the most skilful alienist. It is remarkable that two of the most perfect pictures of insanity presented to us in the plays of Shakspeare are instances of feigned madness ; namely, the madness of Hamlet, assumed to escape the machi- nations of his uncle, and that of Edgar, in Lear, assumed to escape the persecutions of his brother. In Hamlet the strange complication appears to be presented of madness feigned by a man of unsound mind ; that is, of mania feigned by a melan- choliac. These consummate representations of the phenomena of insanity are so perfect, that in their perusal we are insensibly led to forget they are feigned. In both instances, however, the deception was practised by educated gentlemen; and on the authority of the great dramatic psychologist it may perhaps be accepted, that the phenomena of insanity may be feigned by a skilful actor like Hamlet so perfectly, that no flaw can be detected in the representation. Fortunately for the credit of psychologists, insanity is rarely feigned except by ignorant and •vulgar persons, who are quite unable to construct and to act out a consistent system of disordered mind. It must be remem- bered, that all the features of every case of insanity form a con- sistent whole, which it requires as much intelligence to conceive and to represent, as it does to conceive and to represent any dramatic character. The idea which the vulgar have of mad- 372 DIAGNOSIS OF INSANITY. ness is of quite a different kind. They believe it to be a mon- ster, lialf man, half beast ; the emotions they represent im- cliangcd and Imman, the intellectual functions they exhibit entirely perverted, grovelling, and bestial. They think that madness entirely alters the character of a mau^s perceptions, and utterly destroys his judgment, so that he not only ploughs the shore and sows salt for seed, but that he cannot recognise his own son, or avoid the destruction of his life. In more liomely cases, it will be found, that men feigning insanity pretend that they cannot read or write, or count ten correctly, or tell the day of the week, or how many children they have ; they ansAver every question wrongly, which any real lunatic, who could be made to understand the question and to answer it at all would certainly answer right. In illustration of these facts, we subjoin the following case of simulated insanity, re- ported by Dr. Snell, in the ' Allgemeine Zeitschrift fUr Psychi- atric,' December, 1855. The widow Catherine H. had bought a house, the purchase of which she subse- quently regretted. In order to upset the purchase, her children declared that she was insane, and the Court named three experts to examine into the truth of this allegation. "We found her a woman already advanced in years, and partially blind, in consequence of cataract ; her features were exjiressive of stupid listless- ness ; she looked straight at no one, but fixed her gaze on the ground ; a certain restlessnes was, however, to be observed. I wished her to read and write, but was told that she could do neither ; I then made her count, and she counted thus —1, 2, 4, 6, 7, 8, 10, 11, 13, 18, 19, 21. 1 asked her how many fingers she had on each hand ; she answered, after some hesitation, four fingers. I let her count the fingers on her hand ; she counted them, but skipt over the ring-finger, 1, 2, 4, 6. 1 asked her how many two and two were; slie answered, after some thought, six. The following questions and answers then took place : Q. How many children have you ? A. 1 have, I believe, nine children. (She had really seven.) Q. How long has your husband been dead? A. About ten years — (in reality only five years.) Q. In what manner did he die? (lie was suddenly killed by a Ml from a waggon.) A. He lay sick more than eight days. Q. Do you know this daughter of yours ? (Catherine.) A. Yes. Q. ^^^lat is her name ? A. Babetta. Q. Have you other relations? A. I have a sister ; she is called Barbara, and is married to a man called Prince; send to her, she comes no more to me. (This sister had been long dead.) Q. What is the present year ? A. I do not know. Q. How long has Christmas passed ? A. I do not know. Q. Have yon bought a house? A. No; I know nothing of it. I liave ft DIAGNOSIS C)l INSANITY. 878 holl^e— why sliouUl i buy ii house; there were some people who wished to buy wiy house. Q. Where do they live ? A. I do not know. Q. ANHiat is the Kloster Kherbach now used for ? A. There arc yet monks there. (There had been none there for fifty years.) Q. Have you eaten to-day ? A. I have not. (She had just eaten.) Q. What did you eat last evening ? A. Potatoes. (She had eaten soup.) Q. In what month is hay harvested ? A. I cannot remember. Q. In what month is wine harvested ? A. I believe in September. Q. How has last year's wine turned out ? A. It is right good. (It was very bad.) Q. What is the name of the teacher to whose school you go ? A. He is called Ohler. (In truth he was called Muschka.) Q. Do you know the Ten Commandments ? ^\^^at is the first Conunandment ? A. I am the Lord thy God. Q. What is the second Commandment ? A. 1 am the Lord thy God. Q. What is the third Connnandment ? A. I do not know. Q. The fourth ? A. I do not know. Q. The fifth ? A. Thou sluilt not honour thy father and mother. Decided by this examination, I and my colleagues declared the widow R. to be leigning. The witnesses for the widow were condemned for perjury ; and she herself was sentenced to the House of Correction, for deception and seduction to perjury. I often saw her during the period of her imprisonment, and she had entirely given up her simulation. Auother very similar case is related iu the ' Zeitschrift f iir Psychiatric/ upon which Dr. Siiell remarks^ that "patients suflcriug from real imbecility are avcU enough able to tell the number and the names of those who belong to them, and that they understand and answer questions on such matters in a very different manner to these simulators." " Common people," he observes, '' have not the slightest rational idea of insanity ; they believe that all mental manifestations are completely altered iu it, and that an insane person knows nothing ; he ceases to read, to write, and to reckon ; and that all his relations and conditions are completely reversed. Hence it happens, that all uninformed people find it difficult to acknowledge actual insanity. When they speak of an insane person, they say that he is not mad, that he knows every one al)out him, and tliat he altogether conducts himself like a reasonable man, only, that he shows some peculiarities. Uneducated people have the idea tliat an evil spirit, as it were, takes possession of an insane man, and drives out his being with altogether new and perverted elements. Where they observe memory, reflection, feeling of right and 374- DIAGNOSIS OF INSANITY. wrong, they tliiuk that insanity cannot exist ; and yet among the insane, all these things are seldom altogether ^^ anting, and often exist in a high degree. On this rock simulators generally shipwreck, if they attempt a part at all active. But it is more difficult to form a judgment if the simulator preserves a com- plete passiveuess and an obstinate silence. It is not imposssible that, by these means, insanity may be simulated with success ; yet, in order to do so, the simulator must possesss a rare strength of will, in order, through all observations and tests, to preserve his role." In the following case, the simulator was in his first attempt successful in deceiving ourselves and other medical men. W. Warren Avas a notorious thief, indicted at the Devonshire assizes, 18 — , for felony ; pre^dous conviction having been proved against him, he was sentenced to transportation for fourteen years. Two days after his trial he all at once became apparently insane ; he constantly made howling noises, was filthy in his habits, and destroyed his bedding and clothing ; he Avas, however, suspected of malingering, and was detained in gaol three months. During a part of this time it was found needful to keep him in a strait waistcoat. At length certificates of his insanity were forwarded to the Secretary of State, and he was ordered to be removed to the DcA'ou County Asylum. On admission into this asylum, he was certainly very feeble, and in weak health, lie had an oppressed and stupid expression of face ; he answered no ques- tions, but muttered constantly to himself; he retained the same position for hours, either in a standing or sitting posture ; he was not dirty in his habits ; he appeared to be suft'ering from acute dementia. In three weeks' time he recovered bodily strength, and his mind became gradually clear. This change Avas too rapid not to suggest the idea of deception, but the pre- vious symptoms of dementia had been so true to nature that Ave still thought the insanity might not have been feigned. For a period of eight months he Avas Avell conducted and industrious, and shoAved no symptoms of insanity. At the end of that time he Avas returned to the gaol, to undergo his sentence; and, Avith- in one hour of his readmission Avithin its portals, he Avas appa- rently affected Avith a relapse of his mental disease. From this time, for a period of two years, this indomitable man persisted in simulatmg mental disease. He refused to ansAver all ques- DIAGNOSIS OY INSANITY. 375 tions ; walking to and fro in liis cell, he constantly muttered to himself, and sometimes made howling noises, which disturbed the quiet of the prison. Sometimes he refused his food for days together. He employed his time in walking to and fro in his cell, muttering unintelligibly ; or in beating at the door of his cell ; or in turning his bedclothes over and over, as if looking for something. He had a very stupid expression of face, height- ened by inflammation of the eyes from the lashes growing inwards. He slept soundly. For some months he was very filthy ; this habit was cured by the governor of the prison order- ing him to be put into a hot bath, — hot enough to be painful, but not to scald ; he jumped out of the bath with more energy than he had before shown, and thenceforth did not repeat his filthy practices. We visited him several times in prison, and expressed our positive opinion that his insanity was feigned. With the exception of uncleanly habits, he maintained all the symptoms of insanity which he had adopted for two M'hole years ; his resolution then suddenly gave way, he acknowledged his deception, and requested INIr. Rose, the governor of the prison, to forward him as soon as might be to the government depot for convicts. In this remarkable case, the perseverance of the simulator, his refusal to converse, or to answer questions, and the general truthfulness of his representation, made it most difficult to amve at a decisive opinion. Still, the rapidity of his recovery, in the first instance, and the suddenness of his relapse, in the second, were inconsistent with the course of that form of insanity to which he presented so striking a resemblance. Our opinion, therefore, was formed upon a history of the ease, and not upon any ob\'ious inconsistency in the symptoms. Whether the following case was, or was not one of simulation, cannot yet be known ; the recapture of the convict may perhaps hereafter determine the question. John Jakes was convicted at the Devon Easter Sessions, 1855, of pocket-picking; previous convictions ha\ing been proved, he was sentenced to four years* penal servitude. On hearing the sentence, he fell down in the dock, as if in a fit of apoplexy ; when removed to the gaol he was found to be heraiplegie, and apparently demented. He, however, did some things which did not belong to dementia following apoplexy ; for instance, he wavS designedly filthy, and even ate his own excrements. His insanity was certified 370 DlAGNOSilS OF l.NSAMTV. by the sui-geou of the gaol^ and Ijy a second medical man, and he was removed to the asylum. Notwithstanding the medical certificates of his insanity, the convicting magistrates, who knew his character as a burglar and criminal of great ability, thought that he was feigning. Warned by them, avc examined the man carefully ; he had all the symptoms of hemiplegia ; the toe dragged in walking, the uncertain grasp of tlie hand, a slight drawing of the features, the tongue thrust to the paralysed side, all these symptoms were present in a manner so true to nature, that, if tliey were feigned, the representation was a consummate piece of acting, founded upon accurate observation. In the asylum, the patient was not dirty ; he was tranquil, and appa- rently demented. He had to be fed, to be dressed, to be undressed, and to be led from place to place ; he could not be made to speak; he slept well. On the night of the 17th of August, 1856, he effected his escape from the asylum, in a manner that convinced the magistrates that their opinion of his simulation was just, and that he had succeeded in deceiving some four or five medical men. He converted the handle of a tin cup into a false key, wherewith he unlocked a window guard ; through the window he escaped by night, into the garden ; from thence he clambered over a door, eight feet high, and afterwards over a wall of the same height. He got clear away, probably joined his old associates, and has never been heard of since. It is hard to say which is the least improbable — a representa- tion of hemiplegia and dementia, so perfect as to deceive several medical men, forewarned against deception ; or the escape of a really paralytic patient by the means described. It must be remembered that the patient was an accomplished housebreaker, and that things impossible to other lunatics might have been accomplished by him. The earlier writers on insanity lay down excellent rules for the detection of feigned insanity, although some of them arc of a nature Avhich the humanity of the present age would forbid, and others require to be accepted with precaution. Sometimes the threat of severe modes of treatment, or even of punishment, has proved successful in discovering feigned dis- ease. Zacchias relates that an able physician ordered, in the hearing of a suspected person, that he should be severely DIAGNOSIS OF INSANITY. 377 whippcdj on the grounds that, if really insane, the Avhippinnj would produce au irritation on the external parts -wliich would tend to alleviate the disease ; and if not, he would not be able to stand so severe a test. The threat alone served to cure the pretended malady. Another instance was detected by Fodere, who ordered a red-hot iron to be applied between the shoulders of a woman who was accused of several highway robberies, and who feigned insanity with great skill. The patient at once dis- continued her objectionable habits, and Fodere certified to her sanity. It must not, however, be forgotten that measures which may be either heroic treatment, or torture, might in some instances not be without their eftcct upon the really insane ; but any extra professional or non-therapeutic infliction of pain is, undoubtedly, beyond the province of the physician. The operation of medicines, suitable to the treatment of the insane, is a more justifiable experiment for the detection of feigned insanity, and one likely to be more successful than the infliction of punishment. An instructive example of this kind is given in Beck's ' I\Iedical Jurisprudence,' from the narrative of Prof. Monteggia. A criminal, denounced by his accomplices, became suddenly attacked with insanity ; sometimes it seemed to be melancholy, then exhilarating insanity, and then dementia ; he made no answers to questions except by single words, as book, priest, crown, crucifix. " In his presence the physician stated that there were several peculiarities in the ease, and among these, that he made noise during the night, and was quiet in the day-time; that he never sighed, and that he never fixed his eyes on any object. The drift of this conversa- tion was, that the opposite of all these would induce them to suppose him insane; shortly after, in fact, he ceased making noise at night, and did everything which they had indicated." "When ]\Ionteggia was ordered to visit him, he appeared de- mented ; could not look at a person steadily ; never spoke, Init made a hissing noise at the sight of anything that pleased or displeased him ; he was constantly in motion, and it was the opinion of his attendants that he scarcely ever slept. iSfonteggia ordered six grains of opium to be mixed in his soup, but with- out any effect. Some days after, this dose was repeated ; but seeing, after six hours, no proofs of its operation, it was again repeated ; notwithstanding this, he passed the night and the 378 DIAGNOSIS OF INSANITY. next clay awake. The next niglit he seemed disturbed, raised himself in bed_, sighed profoundly, and exclaimed, " My God, I am dying !'^ His attendant, who had never heard his voice before, was extremely frightened, and sent immediately for Monteggia. The patient was tranquil, and speaking sensibly, without any appearance of insanity ; he said he had no recol- lection of the past, but that he had heard persons say that poisoned soup had been given him. From this time he appeared cured. Monteggia seems to be of opinion that actual dementia had resulted from long feigning. May it not be that the powers of the opium were resisted by mental tension and voluntary eflFort ? The case is certainly as anomalous as it is interesting. There are few cases of feigned mania which need any resort to the pharmacopoeia for the means of detection, the voluntary exertions of the feigning maniac generally resulting in exhaustion, and in sleep both natural and soimd. A dose of opium may, however, sometimes expedite the discovery, if the means of pa- tiently watching the movements of the suspected feigner are not available. In France chloroform has recently been employed, for the purpose of discriminating between real and feigned insanity, it being supposed that, during the intoxication pro- duced by chloroform, a real madman will continue to rave on the subjects of his delusions ; and that a person feigning mad- ness will be overcome by its influence, and allow his imposition to be unveiled. We entertain doubts on both of these points. At least we have verified, by repeated experiments, that a real maniac under the influence of chloroform, administered to a degree short of producing coma, will sometimes, under its tran- sitory influence, become reasonable and tranquil. In the detection of feigned insanity, much stress has been laid by writers upon the suddenness of the attack, which, they say, distinguishes it from real insanity, Avhose invasion is gradual. This point of diagnosis must be accepted, however, with much caution. We have known real cases of mania manifest them- selves with the utmost suddenness ; avc have known patients who went to bed apparently in good health, awake in a state of mania ; we have known patients become suddenly maniacal, under the influence of exciting and denunciatory preaching, and during other conditions of intense temporary excitement. Doubt- less, in all these cases the brain was previously prepared for the DIAGiNOSlS Uf INSANITY. 379 sudden explosion^ but the symptoms of latent disease had not been of a nature to attract any observation ; and, therefore, in a diagnostic point of view, the sudden outburst of real insanity must be accepted as possible. The most important diagnostic point of feigned insanity is the want of coherence in its manifestations, not only with mental disease in general, but with the form or variety of insanity which is feigned, in particular. Thus not only, as before stated, does the feigner overdo the intellectual perversions and absurdities, and the oiitrageous or ii'rational conduct of insanity, to the neglect of emotional disturbance ; but he mixes the various forms of insanity together. Thus, in Monteggia's ease, the patient vacillated between melancholia, exhilarating in- sanity, and complete dementia. In the ease of "William "Warren, the symptoms, when he was first in prison, were those of mania ; at the asylum, they were those of dementia ; and, on his return to prison, they were those of mixed mania and dementia. In Jakes' case, the clever imitation of dementia following ajjoplexy was injured by the introduction of maniacal symptoms, such as the eating of his own ordure. To deceive a skilful alienist, who takes pains patiently and fully to investigate the case, the simulator of insanity must, if he displays any active symptoms, not only have carefully observed the symptoms, but be able himself to represent those symptoms, with powers of imitation which are possessed by few. How hard it is on the stage, and for a few minutes only, for a man to represent the manners of a sailor, a peasant, an old man, or any other characteristic manners, so that the deception shall l)e acknowledged complete ! But the histrionic powers of a feigning maniac or raclancholiac must be kept for days and Mxeks on the stretch, in the representation of manners and modes of thought far more difficult to imitate than those which are usually the subject of histrionic art. Dr. Rush is reported to have dis- criminated feigned from real insanity by tlie relative rapidity of the pulse ; Dr. Knight and other writers have claimed the same power for the sense of smell. At the present day, the deposits in the urine would, we suppose, be appealed to. Much reliance, however, is not to be placed upon any one, or even upon several, of the physical signs of nervous disturbance. They have a scientific, but scarcely a diagnostic value. They may serve to 380 DIAGNOSIS OF INSANITY. direct the inquiries of the physician^ or even to coufirm his opiniou founded upon other data ; but, standing by tliemselves, they arc of little importance in the diagnosis of insanity. The Diagnosis of Concealed Insaniti/ {insania occulta) is to be made on the general principles laid down in the previous pages. Some patients are to be met with, who converse and reason well on all subjects except those connected with some delusive opinion. One of the most remarkable instances on record is that of a man named "Wood, who brought an action against Dr. Munro for false imprisonment, and underwent the most severe examination by the defendant's counsel without exposing his disease. Dr. Battie suggested to the judge (^Nlansficld) to ask him what was become of the princess with whom he corresponded in cherry juice ? and immediately a whole group of delusions became apparent. Wood indicted Dr. ]Munro a second time, for false imprisonment, in the city of London, " and such,'' said Lord ]\Iansfield, " is the extraordinary subtlety and cunning of madmen, that Avhen he Avas cross-examined on the trial in London, as he had successfully been before, in order to expose his madness, all the ingenuity of the bar, and all the authority of the court, could not make him say a single syllable upon that topic which had put an end to the indictment before, although he had still the same indelible impression upon his mind, as he had signified to those Avho were near him ; but, conscious that his delusion had occasioned his defeat at West- minster, he obstinately persisted in holding it back." This and other cases which might be quoted, refute Heinroth's assertion, that although patients can conceal, they never can deny their fixed ideas. Doubtless, in the majority of cases, Hcinroth's opinion is correct ; and people who, when sane, were not remark- able for veracity, who would not indeed scruple to utter any amount of falsehood whenever their interests seem to require it, overlook every advantage, and stand at no absurdity or disgrace, ■\\ hen they have a delusive idea to maintain. The first principle of interrogation, in ranging the mind for a delusive idea, is, to converse freely and naturally with the patient on the subject of all his relations, his relation to God, to his neighbour, including his wife, parents, his children, those in authority over him, and those over whom he may have authority ; his relation to property, his indebteduessj or his DIAGNOSIS OP INSANITY. 3H1 fortune ; his profession, his ambition, his desire of wealth or of rank ; his bodily health, his studies, his amusements, his history. Ileinroth proposes that the physieian should narrate the patient's own history disguised as the history of the physician, in order that tlie patient may suppose a parallel between his own case and that of his examiner, so that the dulce habere aocium malorum may elicit circumstances which he ■would otherwise liave concealed ("Wharton and Stille). This round-about pro- ceeding would, we fear, in most cases, tend rather to excite the suspicions than to elicit the confidence of the patient ; still, if the patient refuses to talk of himself, the physician has no option but to talk of himself, or of third persons, and by the expression of opinions likely to be challenged by the patient, thus to draw him into discussions which may eventually 1)etray the morbid train of thought. If the patient is much below the social rank of the physician, assistance may be often obtained from persons of the patient's own position and modes of thought. A man whose ideas revolve in the narroAV circle of a peasant's uncultivated mind, will often put himself into a mental posture of silent and sullen antagonism to all persons whom he considers above him, while he will expand and communicate freely to his equals and ordinary associates. Frequently it is found that the insane discover the delusions of the insane more rapidly than others can do. If the patient can write, he should always be freely encouraged to do so. Insane patients, it is true, often write letters which bear no impress of their delusions. ]\Ien who constantly con- verse and act irrationally, will write letters on matters of business with good sense and precision. But the converse of this is sometimes observable ; and patients avIio, in conversation, adroitly conceal their delusions, display them with fi*eedom in WTiting. We have, for many years, had a well-educated man under our care, who can never be brought to converse on his delusive ideas. When pressed, he adroitly turns the conversa- tion, or he states his opinions in such a form that they could not be called delusive ; that is, he not only conceals, but, to a certain extent, he denies his fixed ideas. Once a month, how- ever, he presents us with a long and closely-written letter, in which his delusions of persecution, forced marriages, &c., arc sufficiently apparent. 382 DIAGNOSIS OF INSANITY. Another patient of ours^ a barrister, so completely concealed and denied his delusions in conversation, that he succeeded in persuading his relatives, and especially his mother, a woman of rare intelligence and discrimination, into the belief of his perfect recovery from an attack of mania, and of his capacity to resume liis professional labours. During the whole of this time he was writing letters to relatives living at a distance, full of delusion relating to his supposed marriage with a servant, to the distri- bution of a large fortune which he did not possess, and to a yacht voyage to every part of the globe. The conduct of the patient should be observed by night as well as by day. We have, for several years, had under our care a respectable tradesman, whose conduct and conversation, during the day, exhibit scarcely a trace of mental disease. He is indus- trious, sensible, and kind-hearted; and it is strange that his nights of suftering have left no painful impression on his pleasing features. At night he sees spectres of demons and spirits, at which he raves aloud, and prays with energetic fervom*. That it is important to test the memory and the capacity by examinations, repeated at various times, is shown by the case recorded by Sir H. Halford, in his Essays. A gentleman sent for a solicitor, gave instructions for his will, and told the soli- citor that he would make him his heir ; soon after this, lie be- came deranged. After a month's violence, he was composed and comfortable, and manifested great anxiety to make his will. This request was evaded as long as possible, but at last con- sented to. The solicitor received the same instructions as before, the will was drawn, and it Avas signed by the physicians (Sir Henry Halford and Sir George Tuthill) as witnesses. After leaving the room, and conversing on the delicacy of their situation, the physicians returned to the patient's room, and questioned him how he had left his property. He mentioned the legacies cor- rectly ; but when asked to whom the real estate was to go, he said, '' To the heir-at-law, to be sure." CHAPTER IX. PATHOLOGY OF INSANITY. The widely differing opinions which are entertained hy the ablest physicians respecting the pathology of insanity, clearly show that there is some difficulty at the bottom of the question, greater than that which exists in determining the nature of other classes of disease. The soiu'ce of this difficulty is not hard to find. A rational pathology must ever be founded upon the basis of physiology. It is indeed a kind of physiology ; it is an account of the abnormalities of organization and of func- tion, which as much depend on the natural laws of our being as do those of health. Fair weather and foul equally depend upon the laws of meteorology. Health and disease equally depend upon the laws of animal life. The division of their study into the two departments of pathology and physiology is, therefore, perfectly arbitrary, and useful only for purposes of classification. But the knowledge of the laws of aberration cannot precede, or even be contemporaneous with, the knowledge of the normal laws of action. The high-road of health must be well known, before the bye-ways and devious paths which sur- round it can be investigated. Great advances have been made in the knowledge of the physiological laws, on all organs of the body except the brain, and the amount of this knowledge bears a close relation to the obvious adaptation of each organ to the discharge of its function. The adaptation of the heart to the propulsion of the blood, the adaptation of the intestinal canal to the processes of digestion and nutrition, and of the lungs to those of respiration, are so obvious and so simple, that a positive knowledge of tiie laws of their action has been gained, and upon these a rational pathology of their diseases has been founded. 384 PATHOLOGY OF INSANITY. But it is quite otherwise with the uoble organ which lords it over the rest of tlie body. The mass of that which we call iierve-substancCj because nerve-function is found to inhere there- unto, i)ossesscs no adaptation which we can trace to the ends to which the Creator has made it subservient. An agglomcratiou of delicate cells in intimate connexion with minute tubes or fila- ments, which communicate impressions made upon the cells at one end, to those cells which lie at their other extremities ; this is the nervous apparatus. Its modus operandi is, and probably always will be, utterly unknown to us. The knowledge that the different sets of nerve -tubes convey dificrent impressions, is doubtless a fact of much practical importance, but it is far re- moved from any intimate knowledge of the laws of nerve-force. To claim for these minor details of the nerve-office the dignity of satisfactory physiological knowledge would be as absurd, as to claim the knowledge of an engine or machine, because we saAV how the far off wheels acted upon each other, -while of the engine itself we knew not whether its motive force was steam, wind, water-power, galvanism, or any other source of movement. But although the connexion betw^een the nerve-function and nerve-organization is a mystery which remains veiled from our most anxious scrutiny, still we are acquainted with many of the conditions which this connexion requires, and without which it is discontinued. AVe know that if that dominant nerve-mass, the brain, is not supplied with a due amount of plasma from the blood ; or if plasma is supplied to it containing noxious sub- stances, such as urea, or narcotics; or if it is subject to pressure, or if it is over-stimulated and deprived of due repose, its func- tions are interrupted or perverted. In default, therefore, of real knowledge respecting the conditions of nerve -function, we must l)e satisfied with the recognition of the fact, that the great organ of this function is sulijected to the general laws of decay and reparation of animal tissues, and to some other laws havino- special reference to its own degeneration and repair. It is upon this physiological basis only, that, in default of more precise and extensive knowledge of the changes in the nerve-cell and the generation of nerve-force, cerebral pathology can be established. The one physiological principle upon which ive have to build a system of cerebral patholoay is, that mental health is dependent upon the due 7iutrition, stimulation, and npose of the brain ; that PATHOLOGY OF INSAMTY. 385 hj tqjon the conditions of the exhaustion and reparation of its nerve-substance being maintained in a healthy and rei/ular state ; and that mental disease results from the interruption or disturb- ance of these conditions. If we ai'e certain of any one fact iu the physiology of the nervous system, it is, that iiervc-forcc is generated in or by the vesicular neurinc, and that the tubular neurine conducts it. But, \vliat is the nerve -force of the human brain? and uhat is the activity of its vesicular neurine ? Its purpose is, the ability to receive sensations of all kinds ; the power of comparing these sensations, and of storing the results of their comparison ; tlie power of combining these sensations in new arrangements, of imagining, — not, indeed, new sensations, — but new combina- tions of them : the power of feeling emotions and propensities. The activity of the vesicular neurine of the brain is the occa- sion of all these capabilities. The little cells are the agents of all that is called mind, of all our sensations, thoughts, and desires ; and the growth and renovation of these cells are the most ultimate conditions of mind with Mhich we are acquainted. There may be more profound conditions, but they are beyond our ken, and, so far as we know, there is no better sanction for their existence than the fantastic alliance of spurious physiology and visionary metaphysics. How any combination of cells can be attended by processes of thought is to us inconceivable; but it is not more incon- ceivable than that similar combinations should residt in the phenomena of life, or that a combination of atoms should result in the movements of the solar system. All Ave can say is, that the cerebral cell and gravitating atom are creatures of tlie Almighty Creator, acting in obedience to laws impressed upon them l)y His fiat, laws the phenomena of which we can trace, but the ultimate nature of Avhich we cannot miderstand. Recent researches indicate the existence of a remarkable and complex apparatus of cells in the cortex of the cerebrum and cere- bellum, most resem])ling the granular and bacillar layers of the retina, and which Yirchow thinks "very likely stand in some close connexion with the psychical functions." The great pathologist, indeed, entertains little hope that any positive knowledge of the modus operandi of this apparatiH will be acipiircd. We merely see more of the machinerv, without knowing better how it moves. 25 386 PATHOLOGY OF INSANITY. The ultimate condition of mind Avitli which Ave are acquainted being the due nutrition of the brain-cell, it is of the utmost importance to have a clear idea of the manner in which this is eflFectcd. The grcj' substance of the human brain contains millions of vesicles, lying in a semi-fluid granulated substance (stroma), and bound together by a minute net-work of capillary blood-vessels and fine areolar tissue. Now, the fundamental truth of physiology being the activity of the cell, and this activity being accompanied by its decay, and demanding its renovation ; the markworthy points in the relative position of the brain-cell are, — First, its relation to the nerve-tube, from which it receives and to which it conveys impressions, the taking and the giving of which are the causes of its exhaustion: Secondly, its relation to the blood capillary, which exudes a plasma in which the cell is bathed and renovated, and from which new cells are formed to replace those (if such there be) which are finally ex- hausted. With regard to the first of these relations, so far as the indi- vidual cell is concerned, it would appear, that injurious results could only arise from stimulation so excessive as to hasten the progress of decay beyond the powers of reparation. With regard to the second relation, a crowd of circumstances may occur, to interrupt or prevent the growth or reparation of the cell. All states, either physiological or pathological, of the cerebral cell, are occasioned by infiueuces impressed upon it, either by the nerves or the blood-vessels, with which h stands in such inti- mate relation. Whether any changes can be self-originated, is more than doubtful. The la■\^■s of its life, transmitted to the cell from the parent .organism, include, indeed, the conditions of perpetual change, but the cause of change must be sought for in the nerve or the capillary. At one time it was the custom to regard diseases as distinct entities, which were capable of being expelled from the body by the art of the physician. To this period succeeded one, in which every disease was viewed as a single pathological action. Mental diseases were once thought to be occasioned by evil spirits, which could be exorcised ; and by many persons, even at the present time, they are attributed to diseases of the '^ spiritual essence," or to other conditions pertaining to the mysteries of ontology. An error more recent, and which even PATHOLOGY OF INSANITY. 387 now prevails widely,, is to refer insanity to some one or other of the pathological conditions of which the appellations are in the mouths of all men, hut the nature and relations are appreciated by few. Thus, some attribute insanity to irritation, others to exhaustion, others to inflammatory action ; and these absurdly narrow views are even entertained by medical men who would be quite incapable of attributing all diseases of the stomach or the lungs to one sole pathological state. What would be thought of a physician, Avho, at the present day, should deliberately argue, that all diseases to which the lungs are subject are inflammatoiy ; or, that all dyspepsias are the result of irrita- tion or of nervous exhaustion? Yet, the prevailing methods in which mental diseases are treated of by physicians, who are too enlightened to submit their intelligence to the theories of spiritual essences, and other exploded absurdities, are of this kind. One able physician attributes all insanity to nervous ex- haustibility, while another refers it to congestion and the earlier processes of inflammation, and a third to irritation. The broad view of the production of insanity appears to be this : The brain, like every other organ of the body, for the perfect per- formance of its functions requires the perfect condition of its or- f/anization, and its freedom from all patholoyical states ivhatever. Consequently, the existence of any pathological state in the organ rf the mind interrupts the functions of that organ, and produces a greater or less amount of disease of mind — that is, of insanity. Such is the foundation of the pathology of insanity which we maintain, and of which the particulars will be elucidated here- after. At present, some attention must be paid to the definition of terms and to the preliminary explanation of views. And first, when -we speak of the brain as the organ of the mind, mc mean that portion of the cerebral mass which physiological experiment, and observation upon the dead, amply prove to be the seat of mental function. We do not include in the term those portions of the brain lying at its base, which are acknowledged to be but a prolongation and development of the excito-motory and spinal nervous apparatus. Experiment and observation, in oiu* opinion, prove, beyond doul)t, that the scat not only of the intellectual, but also of the instinctive functions of the brain, is in the convolu- tions of the cerebrum proper, and that the cerebellum and the central masses of grey matter arc subservient to motion alone, 388 PATHOLOGY OF INSANITY. excited either by the decrees of the Avill, or by impressions upon the nerves of sensation, or upon tliose of excito-motory action. It is also sufficiently proved that the medullary substance of the brain, forming so large a portion of its mass, is merely a con- ducting medium. Pathological conditions may exist in this Avhite substance, in the cerebellum, the corpora-striata, and thalami, ■without affecting the mental functions. Sensation and motion ■will be affected by them; but judgment, memory, and emotion may be left intact. It is true that diseased conditions Avhich affect the mind, also frequently, nay, commonly, affect the lower functions of the nervous system. The state of the muscular system has even been called " the pulse of insanity ;" but the state of these functions in insanity does not commonly amount to that degree of aberration from the natural functions which v,e should be justified in calling disease, if it existed by itself. The muscular activity is frequently excited or depressed, but only in exceptional cases is it perverted and irregular. ^Moreover, in a great number of instances of chronic insanity, the motorial func- tion is in nowise afleeted. Diseased action, therefore, may be strictly limited to that portion of the brain in which the mental functions are enthroned, and which, by the process of reasoning by exhaustion, is shown to be the grey matter of the convolutions. On the other hand, disease may affect and be limited to those portions of the cerebral mass which either conduct impressions to or from the seat of mind, or which subserve tlie function of muscular activity. In this manner, cerebral paralysis of various kinds may occur without mental disease. Circumscribed effusion of blood in the white substance of the brain often produces loss of mental function when it first takes place, from the pressure which it exerts on the grey matter of the convolu- tions. But when the mischief occasioned by this pressure has been removed by the adaptation of the blood in the cerebral vessels to the contents and capacity of the cranium, the powers of mind return, while those of motion remain injured until the integrity of the torn substance is restored. Lesions, or patho- logical conditions of the conductive or motive parts of the l)rain, frequently propagate themselves to the seat of the mental functions; and active pathological states of the latter seldom exist without implicating, to a greater or less degree, the integrity of the former. They are parts of the same organ. PATHOLOGY 01' INSANITY. 389 essentially different^ indeed, in function, but so intimately con- nected, that pathological conditions readily extend themselves from one to the other, both by continuity and by sympathy. All these points of difficulty being admitted, the important fact remains, that diseased conditions ichich affect the mental func- tions must have their seat in the grey matter of the cerebral con- volutions ; and in speaking of disease of the brain in relation to insanity, we desire, therefore, to be understood as speaking of the cerebral convolutions alone, unless where the contrary'- is expressed. We shall take the present opportunity to state, with distinct- ness, oiu' views of the nature of pathological conditions, not only in the brain, but in all the organs of the body. Diseases have commonly been distinguished into those which are organic, and those which are functional. At first the distinction arose from the fact, that in some instances diseased organs presented obvious and palpable changes of structure, while in other instances they presented no such changes. Diseases which our forefathers called functional, because the rough examinations with which they were content made them acquainted with no changes of structure, liave been made known to us by the aid of the microscope as strictly structural diseases. For example, fatty degeneration of the heart and epithelial desquamation of the uriniferous ducts are structural diseases to us ; a short time ago these conditions were regarded as functional. Facts of this kind woidd of themselves be sufficient to create distrust in the theory of functional disease ; but many accomplished physicians Still maintain that abnormal Aital phenomena may be, and are likely to be, occasioned by dynamic aberrations alone ; and that such phenomena are correctly designated as functional disease. We cannot concur in this opinion ; and we perfectly agree in the justice of the observation made by the great German chemist, that " Everything is specific which we cannot explain ; and dynamic is the explanation of all which we do not understand ; the terms having been invented merely for the purpose of con- cealing ignorance by the application of learned epitliets." — (' Liebig's Chemistry of Agriculture.') What is called force, of every description, is connected with, if not dependent on, changes in the atoms of matter. Force is tlie hypothetic agent which underlies the phenomena of material 390 PATHOLOGY OF INSANITY. change ; and to aflfirm that dynamic modifications of A-ital func- tions may exist Tvitliout alterations of material organization, is to ignore tlie fundamental principles of pliilosophic physiology. All disease, tlicreforc, in our opinion, is organic. Kot only is this so -with diseases which come under the common observation of tlic physician, without leaving traces of organic change — asthma, for instance^ and angina, and epilepsy — hut mental and nervous diseases also, of eveiy kind and form. Not a thrill of sensation can occur, not a flashing thought or a passing feeling can take place^ without changes in the living organism ; much less can diseased sensation, thought, or feeling occm', without such changes ; changes which we are not able to detect, and which Ave may never be able to demonstrate, but which we are, nevertheless, certain of. For whether we adopt the theory that the states and things which we call heat, electricity, vitality, &c., are distinct entities, or what is called imponderable matter; or the far more probable theory, that they are only phenomena belonging to ordinary ponderable matter ; an atom or a cell charged with electricity or heat, or in a state of chemical ac- tivity, is essentially in a different condition to a cell or an atom in chemical or electrical equilibrium with surrounding sub- stances. On the lowest A'iew of organic action, therefore, alterations of what are called dynamic force cannot exist, without . corresponding changes in material condition. If it is possible to suppose that the cells of a living structure, in a state of disease, can only differ from the cells of the same structure in a state of health, by an alteration in their electric states ; this will in itself constitute a material difference, capable of being re-adjusted by appropriate remedies. Although it may hereafter be proved that all forces are not merely correlated but identical, there is as yet small ground for supposing that vital force and electrical force are the same, or that anomalous action of living bodies ever depends upon the mere distribution or activity of such force. The only force capable of explaining any of the phenomena of life, is the chemical one, and this only in a state of constant activity and interminable change. In a state of health, such change takes place within a range the limits of which permit beneficial and restrict injurious action ; in a state of dis- ease, the range of chemical change is widened or contracted, so that mischief results from excess of action, or the well-being of PATIIOLOGV OF INSANITY. 891 the organism is lost by deficient action. In either case^ the chemical composition of the cells cannot fail to be altered from the standard of health ; and alteration of chemical composition is the real gronnd-work of organic disease, since it invariably interrupts the healthy function of the part affected. Those ab- normal states which depend upon an altered condition of the blood, are not less strictly organic than all other diseases ; for not only can no change take place in the composition of the blood, without in some degree afl'ecting all the parts which are nourished thereby, but this fluid is, strictly speaking, itself a living cellular organism, and every change which takes place therein is organic. It may seem superfluous that, after having expressed our opinion that the noblest functions of the healthy nervous sys- tem are invariably accompanied by organic changes therein, we should argue that such changes must exist -when the functions are performed abnormally. It is true that the greater proposi- tion, that function is always accompanied by organic change, includes the lesser proposition, that diseased function is so ac- companied ; but the latter has a difficulty to contend with, from which the former proposition is free, — it has to oppose and sub- vert a long-established erroneous theory. Nosological arrangements and classifications are, to a great extent, natural, but they are influenced by the arbitrary laws of custom and convenience. It is thus that the class of diseases grouped under the general term of insanity, has been framed to exclude the delirium of fever, of cerebritis, and other diseases of an acute form. A strictly natural nosology would, doubtless, include under the term, all diseases of the cerebrum proper accompanied by aberrations in the mental functions ; but inas- much as such aberrations are a frequent concomitant of a large proportion of cerebral diseases to which man is suliject, it be- comes necessary to restrict the term insanity to those forms of disease in which alterations of the mental functions are not only a constant but a prominent symptom. "While, however, the convenience of this restriction is acknowledged, it wovdd, in an investigation of the pathology of insanity, be most unwise to overlook those occasions of mental disturbance which take place in the course of other diseases. AVc often go abroad to gain accurate information and opinions on that wliich is taking place 392 PATHOLOGY OF INSANITY. at home ; and the special student of insanity -will do well to study the causes of delirious thought and perverted feeling, in all classes of bodily disorder AA'herc they are observable. If he studies insanity alone, he will be apt to fall into the common error of attributing its causation to some single pathological state, and his views will be as wrong as they are narrow. But if he studies perverted feeling as occasioned by gouty or hepatic disease, or loss of intellectual power and fatal coma occasioned by suppression of the urine and the delirium of fevers, he will be led to appreciate the full extent of blood change in the pro- duction of purely mental affections. In the delirium of ccrcbritis, he will see a form of insanity undoubtedly produced by inflam- mation ; and in delirium tremens he will see another form of insanity, as undoubtedly produced by nervous exhaustion. He will thus be enabled to reject exclusive theories of insanity, and be prepared to admit the truth of the broad principle — that insanity may Idc occasioned by any and every pathological state which is capable of taking place within the substance of the brain. The pathological changes w^hich are capable of taking place therein, are to be learnt from a study of the symptoms of mental disease, from the effects of remedies, and from the 2iost-mortem appearances. Some preliminary foundation for this study may be provided by a consideration of the influences to which the organ of mind is obnoxious, tending to interrupt or defeat its functions. Sane mind being the result of the normal and physiological action of the brain, unsound mind is the inevitable consequence of its abnormal or pathological action. To what pathological actions, then, is it liable ? As an organ abundantly supplied with blood-vessels, it is obviously liable to all abnormal conditions which irregularities in the quality or quantity of the blood, and the relation thereof to its tissue, can occasion ; it is liable to aniemia and. to hyperemia both passive and active, and to the latter accompanied by organizablc and unorganizable exudates. It is also more readily acted upon by various chemical changes in the blood than any other organ. Excess of carbon or defect of oxygen tells first upon it ; and many substances in the blood which aflect other organs little, or not at all, affect this noblest of the organs with intense force. All diseases, therefore, which depend upon the movement or quantity of the blood, and mauy of those which depend upon its quality, are the PATHOLOGY OF INSANITY. 393 fruitful source of abnormal cerebral conditions. There are, it is true, many blood poisons and diseases which do not affect the brain. Thus, it is strange that although the gout poison affects the temper strongly, and often endangers the intellect, that of rheumatism has no effect thereon. Tuberculosis, more- over, while attacking every other organ of the body, very rarely affects the adult cerebrum. But the brain is liable to a species of disturbance, apparently quite unconnected with the quality, (juantity, or movement of the blood, a species of disturbance to >> hich other organs are liable only in a modified and unimpor- tant degree. We allude to the disturbance caused by sympathy with injuries of, or noxious influences applied to, peripheral portions of the nervous system. ]Moreover, the brain is liable to conditions of exhaustion to a far greater extent than any other organ. Other organs, when over-tasked in the perform- ance of their functions, either refuse to discharge them, or gradually gain such increase of power, that they are at last enabled to accomplish the task imposed. Over-tasking the stomach destroys appetite, and the task is no longer im- posed. Over-working the muscular system does not break down that system itself, but the nervous system, witli which it is so nearly connected; or if the over- work is within the limits of health, the muscles gradually develop by exercise, and eventually overcome the difficulty. The over-tasked lungs throw part of their burden upon the vicarious action of the liver, and the over-tasked liver is relieved by the kidneys. But the over-wrought brain finds no help-mate in the economy of the organism ; it must bear its burden alone, and suffer or succumb according to the disproportion between its task and its energies. Exertion of the brain, if kept within due limits, is followed by a state of repose peculiar to itself; but, carried beyond these limits, the excitement of its functions, while it produces rapid exhaustion of power, also renders the organ incapable of such repose and renovation. Over-work produces exhaustion accom- panied by excitement, which continues the over-work and ac- celerates the exhaustion. Thus the degeneration of tissue goes on in the organ in a ratio of rapid increase, and organic decay is occasioned, — sometimes quickly fatal, but more frequently re- sulting in permanent atrophy of tlie organ, with perversion and degradation of its functions. 394 PATHOLOGY OF INSANITY. Having premised thus mucli upon the generalities of the pathology of insanity, it vriW now be our endeavour to discrimi- nate the particular lesions under -which the brain suffers, as they are made knoAvn to us, either by observations on the dead body, or by a rational estimate of the cause of these conditions. Thus, for instance, the ol)servation of the dead body sufficiently proves that loss of mental function is in most cases dependent upon atrophy of its organ ; but the loss of function which has been consequent upon the ingestion of some deleterious sub- stance, frequently leaves no traces in the organ which are ap- preciable to our senses. Now, to us it is not less an ultimate fact, that certain poisons interrupt the functions of certain organs, than that atrophied organs cannot discharge their functions with vigour ; and, hence, the rational estimate of cir- cumstances which have taken place during life, is not less important in the investigation of pathological lesions than post- mortem observations. The admirable precision which micro- scopic observation and chemical analysis have of late years acquired, has tended greatly to distract the attention of physi- cians from the importance of rational pathology. Now-a-days, all lesions which cannot be calculated in test-tubes, or demon- strated under object glasses, are apt to go for nothing ; but this kind of pathology has hitherto done little towards the elucida- tion of mental disease. The reason of this appears to be as follows : — The pathological conditions of insanity almost always involve the whole of the cerebral hemispheres. It is a matter of the rarest occurrence to observe part only of a hemisphere to be affected with atrophy, that sure indication of pathological change ; and when opportunity is afforded to observe the state of the brain, in the earlier stages of insanity, it is equally rare that partial congestions are observable. Now, a general condi- tion of the cerebral convolutions capable of producing an amount of structural change, distinguishable under the object-glass of the microscope, wouldscarcely be consistent with a continuance of life. Changes in brain substance are frequently such as to be readily detected with the aid of the microscope. Purulent and fibrinous exudates, broken up cell-structure,aud fatty degeneration, are not less readily demonstrable in the brain than in other organs. But if they have existed, in connexion with that amount of chronicity of disease which is essential to insanity, thev must have been of PATHOLOGY OF INSANITY. 395 small extent^ and have affected the functions of the remainder of the brain by contiguous sympathy. Pathological changes of a character demonstrable by the microscope, affecting the Avhole or a large part of the convolutions, are inconsistent with the con- tinuance of life for more than a few days. It is this fact Avhich has raised a nosological barrier between inflammations of the brain and the different forms of insanity ; and it is only by a just ap- preciation of this circumstance that we can console ourselves for the want of that assistance to the sense of vision, Avhich has so much advanced the knowledge of structm-al change in so many other classes of disease. It might, perhaps, be expected, that, if the microscope could not demonstrate the earlier changes of structure in insanity, it might at least make ns acquainted with the chronic results of these changes. The functions of a brain extensively atrophied are scarcely less annihilated by structural change, than those of a cirrhose liver or a fatty kidney. Moreover the obviously wasted and shrunken appearance of the organ itself places Ijcyond doubt the existence of pro- found structm-al change. As yet, neither microscopists nor chemists have been able to demonstrate wherein this change exists. The records of pathological societies abound in micro- scopic observations upon fibrous and cholesteric tumours of the brain, and such like Jocal abnormalities, but they have as yet thrown no ray of light upon the general changes which are as common as they are important. That the disease commonly known as insanity does not result from inflammation of the brain, must be accepted only as a nosological but not as a real truth, since ccrebritis and meningo- cerebritis arc undoubtedly accompanied by great disturbance of the cerebral functions so long as they last. But many autliors have asserted that mental disease, going on from week to week and month to month, is occasioned by inflammatory action of a certain kind in the brain substance. Broussais, who was the great advocate of this theory, was compelled by the absence of inflammatory products in the brains of persons dying insane, to acknowledge that this action M'as of a *«Z»-inflammatory nature. Guislain, however, says, that in some rare cases he has observed the arachnoid to be actively inflamed, presenting the appearance of the inflamed conjunctiva ; and some recent English writers on the same subject, believing that the injected membranes 396 PATHOLOGY OF I^•SA^■ITY. become pale by post-mortem change, have expressed their con- viction that such appearances might be observed if the brain were examined immediately after death. We have never ob- served any appearances, either in the meninges or the convolu- tions of the brain of a person dying insane, "svhich -we could at- tribute to the existence of recent acute inflammation. AVe have, however, in numerous instances, observed unequivocal marks of inflammation not of a recent date. Moreover, the history of the causation of many cases of in- sanity leads to the conviction, that although inflammation may not be the actual condition of insanity, it is not unfrequently its cause. In such instances the course of events is as follows : — A man receives a blow on the head, or some other cause of inflammatory action. In a recent case, which has been under our care, the cause was a stroke of lightning. Immediately after the injury, pain and febrile excitement indicate the ex- istence of inflammatory action. If this inflammation were to extend, the patient's life would be in the utmost danger. But in the instances under consideration, either the slightness of the injury, or rest and a little depletion, localizes the inflammation, and its symptoms soon disappear. After the lapse of a period which varies from ten days to three or four weeks, the patient again becomes sleepless, irritable, suspicious, and fretful, easily excited to anger, always in motion ; and soon delusions appear, and an acute attack of insanity declares itself. Such cases are not unfrequently fatal ; they are accompanied by great violence and long continued insomnolence, and are apt to terminate in an exhaustion of the powers of life, expressed by the sudden or gradual failure of the heart's action. On examination after death, appearances of local inflammation in the meninges and con- volutions are observable. We cannot think that the symptoms of insanity are in such cases occasioned by the inflammation. It is most probable that the inflammation is not the condition of in- sanity, but is the exciting cause of a secondary pathological state upon which the symptoms of insanity immediately depend ; just as the symptoms of abscess in the liver may be caused, but not conditioned, ])y ulcerations in the intestines. AVhat the actual state of an organ is, the functions of which are disturl)ed by the presence of inflammatory action of a small portion thereof, it is not easy to determine. In the loose employment of terms, PATHOLOGY OF INSANITY. 397 which continues to be one of the greatest obstacles to the advancement of exact medical knowledge^ the condition of such an organ would be confidently stated to be one of irritation. But irritation properly defines a cause, and not a state. Irritability is a state of organic structures rendering them liable to be acted upon by irritating causes, that is, by irritation ; and passing, when so acted upon, into a second state, that of excitement. "When the cause of organic excitement is normal, and the organ- ism is sound, the phenomena are regular, and bear a certain definite, or, so to say, symmetrical proportion to each other. Eut when the causes of excitement are abnormal, its phenomena are irregular and disproportioned. The excitement of an irritable nervous system, occasioned by a wound or other lesion, manifests itself in spasmodic action of various kinds ; while healthy ex- citement, occasioned by the natural stimuli, results in a regular activity of the muscular and other organs of the body. Now the presence of a small portion of brain, recently inflamed, acts as an irritant upon the remainder of the organ, producing therein abnormal excitement, which manifests itself in an irre- gular and disproportionate activity of its functions, that is, in symptoms of insanity. Such is our view of the influence of true inflammation in the production of mental disease. We must, however, guard ourselves from being understood to offer the term " irregular excitement of the cerebral functions," as anything more than a verbal formula for the expression of a series of phenomena with several links of which we are little or not at all acquainted. A small ulcer in the mucous membrane of the stomach some- times deranges all the functions of the viseus ; a blow on the head causes vomiting; in either instance we know not liow; but we refer the fact to others of a similar nature, tabulated under the terms of sympathy or irritation ; that is, we provisionally formulate our knowledge. In doing so, we act in accordance with unexceptional methods of philosophising, if we fully and constantly estimate verbal formulas for what they are, and do not permit ourselves to recognise in tliem the undiscovered truths which they provisionally represent. It is probable that the state of brain occasioned by the irritation of an inflamed portion, is that of active, but unequal congestion. This probability arises from the well-known fact observable in 898 PATHOLOGY OF INSANITY. those parts of the body which present themselves to the sight (a hand or an eye for instance), that inflammation of a small portion is accompanied by active congestion of the remainder. The inflamed part distnrbs, in some way or other, the normal balance between the contraction of the capillaries and the pres- sure of the blood. It has been hypothetically assumed that the manner in which this is eft'ected, is by the abstraction of the nerve power of the capillaries ; or, to speak with a less amount of hypothetic guessing, and to omit the influence of unascer- tained power, it will be suflicient to say that every local inflam- mation not only destroys for a time the contractility of the capillaries in the part aftected, but that it also greatly diminishes their contractility in surrounding tissues. And this brings us to the consideration of the influence of congestion of the brain as a cause and condition of insanity; general inflammation being neither — first, because the undoubted appearances of general inflammation are not observed in persons dying in- sane ; and, secondly, because the consequences of general cerebral inflammation are inconsistent with the phenomena of a chronic disease. Such a state, if not speedily removed by active measures, is fatal in a few hours or days. But it is otherwise with general congestion of the cerebral convolutions ; this con- dition is consistent with the phenomena of a cln'onic disease, and it is actually and frequently observable in the bodies of persons dying insane. The consideration, therefore, of its causation, its nature, and phenomena, is of the highest im- portance. We shall not attempt to divide congestion of the meninges from that of the convolutions themselves ; for although the congestion of the former may sometimes be very obvious, while that of the latter is very doubtful, their connexion -svith that membrane which in mental diseases is most worthy of consideration, namely, the pia-niatcr, is of so close and intimate a nature that it is jjlainly impossible for it to be congested mthout a corresponding condition existing in the capillaries of the grey matter of the convolutions. Preliminary to the consideration of cerebral congestion as a state of disease, it will be worth while to review the states of congestion which do not actually partake of that character. Systematic wnters have distinguished various states of the capillaries in which they contain more blood than natural, under PATHOLOGY OF INSANITY. 399 the terms of determinatiou of bloody plethora, active and passive congestiou or hyperoemia, kc. These all appear to be varieties of the same condition, namely, enlargement of the capillaries, with retarded but not obstructed motion of blood tkrough them ; and the slighter degrees of this condition arc consistent with, and, indeed, are dependent upon, the healthy activity of the organs. Dr. Watson says, " Local plethora may be predicated of a part which contains more than its share of blood." The mucous membrane of the stomach contains more than its share of blood, during the process of digestion, and is therefore ple- thoric. If the organ is weak, and if the stimulus of food is applied too frequently to it, the transient condition of healthy plethora passes into that of morbid congestion, and pain, spasm, and morbid symptoms result. The exact counterpart of this takes place in the brain ; the changes which result from the active exercise of its functions attract to its capillaries a greater share of blood, and constitute a transient and healthy state of local plethora. But, if the brain is weakly organized, and if the stimidus of the work is continued beyond due limits, the state of plethora is prolonged and augmented, and the first symptoms of morbid congestion display themselves. There are few stu- dents who are not practically conversant with the slighter symptoms of cerebral congestion. Absorbed in some intellec- tual pursuit, the student's head becomes hot and painful, and his brain even feels too large for his skull. With exhausted powers of thought and attention, he retires at a late hour, as he hopes, to rest, but he finds that he cannot sleep ; or if he does sleep, his repose is unrefreshing, and disturbed by dreams. An hour's freedom from thought, before retiring to bed, would have enabled the partly congested brain to recover itself, and this would have been aided by taking a glass or two of wine, which would have tended to relieve the distended capillaries, by utilising the remainder of the nervous force. It was long ago pointed out by Dr. Billing, that an alcoholic stimulant taken at bed-time Ijy a man with an exhausted and one with an unex- hausted nervous system, will produce contrary eftccts : it helps to relieve the congestion of an exhausted brain ; in the unex- hausted brain, on the other hand, it tends to produce conges- tion, fevcrishncss, and sleeplessness ; just as diluted tincture of capsicimi relieves the congestion of a frog's foot, but applied 400 PATHOLOGY OF INSANITY. to the capillaries in their normal state^ it causes them to congest. The condition of the cerebral capillaries during sleep is un- knoMn to us. They are not^ at least, in that state of active congestion -which is the physiological condition of the capillaries of organs in a state of high functional excitement. AVe have elsewhere propounded and maintained the theory, that the brain- cells derive nutritive renovation from the blood, principally or entirely during sleep. It would seem probable that in the phy- siological state, the brain is liable to determination of blood from two causes, or rather for two purposes ; during waking, for the purposes of functional activity ; and during sleep, for the purposes of nutritive repair. Be this as it may, there are symptoms which indicate the existence of a congestive state of brain after sleep. If its duration has only been sufficiently long to repair the exhausted energies of the organ, and if the indi- vidual be in a state of sound health, the symptoms of congestion on waking are often imperceptible. But in heavy sleepers, and after sleep prolonged beyond the necessities of the body, the period of waking presents some curious phenomena of conges- tion. Daring this state, dreams are common, and the individual is conscious that he is dreaming. Hallucinations ju'csent them- selves to the senses of sight and hearing, which the half dreamer recognises as such. There is, moreover, a sense of weight, ten- sion and throbbing in the head, which is not always got rid of until some time after Avaking is complete. This state has been referred to by the alienists of France, as presenting a very close resemblance to the mental phenomena of insanity. It wants, however, the element of emotional disturbance, for dreams of this kind are mostly sensorial. Doubtless, this and all other states in which the mental faculties are exercised in a partial and irregular manner, have a certain similitude to the pheno- mena of mental disease ; but it seems unwise to push tlic com- parison too far, as the French alienists appear to have done, in declaring the state of dreaming to be identical with that of hallucination from insanity. The phenomena of intoxication present us with another ex- ample of impairment and irregularity of the mental functions, referable to cerebral congestion. This example, however, is liable to the objection that the phenomena result from a poison PAT110],0(JY OF INSANITY. 401 ill the blood, acting upon the brain. This ol)jectioii docs not a])pcar to be well founded, for the following- reasons : — Persons lial)ituated to the use of alcohol can take large quantities of it without experiencing any injurious eftect upon the mental facul- ties. This would not be the case if it acted directly as a poison ujion the brain-substance; for it is observed that substances which do act in such a manner, do not lose their power over the mental faculties by habitual use. The most habituated opium- eater dreams dreams and sees visions under the influence of his drug, even to a greater degree than a beginner. ]\Ioreover, many narcotic substances, which produce very remarkable effects upon the mental faculties, do so without any appearance of cerebral congestion. Stramonium, l)elladonna, and aconite, may especially be mentioned as examples of this fact. These sub- stances, which act without causing congestion, always produce their effects when they are taken ; but the effects of alcohol are most uncertain. A quantity, which in some men will produce little or no alteration of mental activity, will in others occasion the greatest and most irregular excitement of thought and feel- ing. And this ditterence exists not only between men who are habituated to its use and those who are not, but among those of sober and temperate habits, ^loreover, in certain states of the system, as in typhus, the largest quantities of alcohol may be taken without producing one symptom of intoxication. In such states its whole force is expended in sustaining the flagging energies of the nervous system, and if it tends to occasion cere- bral congestion it is pernicious. The phenomena of alcoholic intoxication, therefore, we hold to be in great part due to the cerebral congestion which it occa- sions ; and these phenomena appear to us to present a far closer resemblance to those of insanity than any of the states of dreaming, or of partial and irregular sleep. The phenomena of intoxication are unfortunately familiar to every one ; they vary greatly, however, according to the nervous organization of the drunkard, and according to the form and vehicle in Avhich the alcohol has been imbibed. The sottish, swinish drunkenness of an English ploughman, with his stomach full of sour beer, is quite a diftereut thing to the mad inebriation of an exciteablc Frenchman on fire with eau de vie. In the former, drunken- ness consists more in partial palsy of the muscles and oppression 26 402 PATHOLOGY OF IxVSAJJlTY. of the brain, than iu anything deserving the name of excite- ment. In the latter, exalted and perverted sensation, flighty imagination, blind passion, giving way to maudlin sentiment, a general and violent stimulation of the mental faeulties, are the obvious characteristics of the condition ; and they so closely resemble the phenomena of insanity, that while they last they may be said to be almost identical theremth. If, therefore, alcoholic intoxication is the result of active cere- bral congestion, and if its phenomena so closely resemble those of insanity, that, considered apart from their cause, and the condition of the stomach, they frequently cannot be distin- guished, a strong probability is established, on the principle of referring like phenomena to like cause, that one pathological cause of insanity is that of active cerebral congestion. Such congestion is, doubtless, not uniform throughout the organ. " In the normal, nutritive conditions, a cei'tain uniformity is found to exist ; that is, a uniform distribution of the nutritive material, whence both the central and the peripheral organs are developed. ^^ (Wedl.) But, in abnormal conditions of the circu- lation, this uniformity of distribution no longer exists ; and, in ansemic or hy perse mic conditions, the functions of a compound organ are thrown into a state of unequal excitement or depi-cs- sion. In simple congestion of the organs, " Natural contractility and sensibility are lowered ; but pain, spasm, and morbid sym- pathies are often excited, although in a manner much less distinct and constant than in inflammation or determination of blood. Thus, congestion of the liver is sometimes accompanied by pain or tenderness ; sometimes it is without either. Conges- tion of the stomach sometimes causes gastralgia, nausea, and vomiting, with altered appetite ; but these symptoms are often absent when the amount of disease of the liver, or the heart, and the subsequent occurrence of h?ematemcsis, leave no doubt that the stomach was congested. The same remark is applicable to the kidneys, the uterus, the brain, and other organs." (Wil- liams's ' Principles of Medicine.') Such is the account given by a distinguished and acute pathologist of the irregularity of function produced by congestion ; but the analogy from an organ whose function is simple, to one whose function is so complex as that of the brain, can afford but a slight insight into the effect of similar pathological conditions in the two instances. Of t!ie PATHOLOGY OJr" INSANITY. 408 abdominal and thoracic organs, the stomach is that uhosc func- tions arc the least simple. Its muscular movements are as ingeniously adapted to a purpose as those of the heart ; they are even more complicated and less mechanical. In addition to this, the functions of secretion and absorption discharged by its several sets of glands, add to the complexity of its duties. Con- gestion, as we have seen, causes irregular excitement or depres- sion of all its fiuictions, nervous, muscular, and secretive ; yet, compared Avith the brain, how few and simple are its duties. The functions of the organ of the mind are more numerous than those of all other parts of the body put together; nor less distinct in themselves and inter-distinct in their action. Consequently, any pathological state which destroys their equi- librium, producing irregular depression of some functions, with irregular excitement of others, must cause a wider and more intricate range of anomalies than is observable in a similar state of the more simple organs. The truth of these observations is not alone restricted to states of cerebral con- gestion; they refer equally to all pathological states of the organ dependent upon the condition of the blood-vessels and their contents in relation to the nutritive plasma and the cells. As, in the body at large, it only happens in a state of perfect health that the nutritive fluid is distributed in due and uniform proportion to the several parts, so it is in that microcosm of the body, the brain. In a state of perfect health the nutritive fluid is distributed in due proportion to each of its several parts, producing an uniform and well-balanced excitement of function ; but in abnormal states of the circulation, this propor- tioned excitement of function disappears, and is replaced by irregular excitement, iiome functions become torpid and op- pressed, tvliile others are excited into preternatural activity ; and this state affords the basis of insanity. "We are too little acquainted with the physiology of the several parts of the cerebral convolutions to form an opinion as to the existence of that vicarious action which we observe in abnormal states of the other organs. Probably no such action exists ; probably that part of the brain devoted to the percep- tion of sensation discharges no other function in any state of disease; and the same of those parts devoted to the various functions of intelligence, emotion, and propensity. If this be 40i I'ATIIOLOGI Ul' INSANITY. SO, the whole phenomena of insanity arc the more eapuljle of elucidation from the irregular depression and excitement of the various parts of the brain devoted to the various functions of the mind. The difficulty ^\ hich this theory has to overcome is that of so- called perverted function, in -which a mental state neither ap- pears to be explicable by excitement nor by depression. But with regard to the sensational and intellectual activities, this perversion of function is merely apparent ; and even the pheno- mena of perverted emotion, as we shall endeavour to show in another place, are capable of being explained in a manner con- sistent with the theory, that excitement and depression are the only abnormal states to which the separate functions of mind are liable. It may be objected that the pathological relations existing between the vessels and the cerebral cells, which are imperfectly represented by the terms hypero&mm, anaemia, &c., are not usually, and indeed very rarely, of that partial character which the theory of unequal excitement would seem to require. When opportunities are afforded for the examination of brains in which these conditions are observable, it is found that the convolutions are not in a hyperamic or an anaemic state in parts only, and that in other parts they are in a healthy condition, or in a nor- mal state. It is, on the contrary, found that the pathological appearances afforded in congestion of the pia-mater and Ijraiu, or in a pale and antemie brain, arc general and uniform ; and it may not appear easy to reconcile this uniformity of appearance with the theory of loss of uniformity in function. AVe can however, gain instruction on this point also from analogy. It is found that the pathological conditions affecting the whole body do not occasion uniform excitement or depression. The instance least liable to objection is that of general anaemia arising from loss of blood. In this condition, all the organs are found more or less exsanguine; and it might, a priori, be supposed that the consequence of this state would be a general failure or de- bility of the bodily functions. IBut, in reality, this is found to ])e by no means the case. The greatest irregularity prevails from the excitement of some functions, and the depression of others. It is reasonable to suppose that the same irregularity of function may be occasioned by the same apparent generality PATHOLOGY OF INSANITY. 405 of pathological condition in the brain. Of the congeries of organs that subserve to animal life, some are more disposed than others, eitlier from congenital or acquired tendencies, to take on diseased action. Of general pathological conditions of various kinds, some arc disposed preferentially to affect one organ, others to affect other organs. Similar laws hold good in that congeries of organs which subserve to mental life; and hence the explanation of the fact that pathological states, which, to all appearance, implicate impartially the whole extent of the cerebral convolutions, result in comparative excitement of some functions, and depression of others. In brains organized with exact similarity, like pathological changes would, doubtless, occasion like effects. Tiic effects would indeed differ from each other, in consequence of the selection which pathological agents invariably exercise in their action upon the organism. For in- stance, urea in the blood would invariably affect the temper; stramonium, or chloroform, would as surely affect sensorial activity ; and other pathological states of the nutrient fluid would exercise a similar preferential choice. The pathological condition being given, the results would always be uniform, if the congeries of mental organs possessed an uniform proportion. But, in fact, this is not so. No one brain is like any other brain. Either by the force of inheritance from parent organisms, or through the influence of education or other modifying cir- cumstances, every mind possesses such a peculiarity and iudi- nduality in the relative susceptibility and strength of its organs, that the same distui'bing influence never produces in two brains exactly the same pathological effects. Thus, that transitory pathological state, occasioned by the introduction of alcohol into the blood, causes in one man excitement of angry feeling, in another that of jovial and benevolent sentiment, in another maudlin self-depreciation, in another intellectual vigour and enjoyment. Thus it is obvious that pathological states, whose symptoms during life, and appearances after death, seem to mark them as states of the whole cerebrum, arc caj)ai)lc of being the cause of the most diverse forms of excitement or depression in the congeries of organs whose union builds the brain, and whose action constitutes the mind. Of late years, the application of a stricter logic to the ap- pearances in the minute blood-vessels, recognised by a diligent 406 PATHOLOGY OF INSANITY. use of the microscope, and to the phenomena of nutrition and decay, liave occasioned great modifications in the scientific meaning of the terms congestion, inflammation, atrophy, S:c. A part is not now acknowledged to be necessarily inflamed in which there is pain, heat, redness, and swelling. One patholo- gist insists that stasis of blood in the capillaries is necessary to the condition ; another, that the true mark of the inflammatory action is the formation of fibrine exudates ; and Yirchow goes so far as to call all disturbances of nutrition, and even all atrophies and degenerations, by the term inflammation. Now, that condition of the small vessels of the brain wliicli has in these pages been designated hyperemia or congestion, doubtless gives rise to occasional stasis, and still more certainly is the occasion of ncAV exudates. That these exudates do not tend to consolidation, or to the formation of fibres or of pus- cells, may perhaps be allowed to distinguish them from those which take place in the so-called inflammations. And our opinion that insanity is frequently conditioned by congestion, and rarely or nevier by cerebral inflammation, may be expressed with greater accuracy in the terms, that insanity is conditioned by disturbances of the cerebral circulation, which produce transparent exudations of serum, and interrupt the normal endosmotic motions, but which do not occasion the fibrinous and purulent exudations which are found in cerebritis. Tlie real importance of disturbances in the circulation depends upon their being the cause of disturbance in the nutrition of organs. The microscope has done much to elucidate the patho- logical changes which take place within the vessels, but next to nothing to inform us of those more important changes which take place in the cells. The changes which take place in the vessels accelerate, impede, or interrupt the nutrient supply of the cells ; and questions relating to the stasis of the blood, to the formation or increase of the white corpuscules, to the dila- tation or contraction of the smaller arteries or veins, the permanent size of the capillaries, the disappearance of Valen- tine's quiescent stratum, and other questions and facts relating to changes in the small blood-vessels in congestion and inflam- mation, derive their real importance from their bearing upon the question of interrupted cell-nutrition. Outside the vascular wall, the microscope has been able to make but few and PATHOLOGY OF INSANITY. 407 inconclusive revelations. Exudates can, indeed, be observed when they have become organized, although they escape observation when they first transude, fluid and clear. But those far more common and important exudates, which remain iiuid and clear until the pathological condition which has occa- sioned them has passed, those productions of congestion which interrupt by their presence and their pressure the endosmie nntrition of the cells and the functions of organic life, are indis- tinguishable by the microscopic pathologist. The cell also, the agent of function and the centre of interest to the rational pathologist, conceals all its earliest and most important changes under the veil of transparency. In the Avords of Wedl, " If we desire to resolve the life of the organism, as it were, into its elements, we must endeavour to acquire a more intimate ac- quaintance with the vital properties of its elementary organs — the cells ; Ave must endeavour to ascertain hoAv the first appear- ance of the cells in the homogeneous blastema, is evidenced — how their multiplication by di^nsion proceeds — what metamor- phoses they undergo — what are the conditions presented in the cells in their further existence — whether they remain stationary in their external habit or not — what stage of development they reach — whether motile phenomena occur in them — or, in other words, we must strive to eomprehend the cells as something liAnng, in their nutrition, propagation, and movement. This vital and physiological survey must also be carried on in a pathologico-histological point of view, so that we must not be content to confine our regard merely to what is presented in the dead subject." It is adverse to our hopes of rapid progress in the knowledge of the ultimate conditions of disease, that those parts of the organism which are endowed with the greatest vital energy con- tain the smallest proportion of solid material adapted to the successful manipulation of optical and mechanical pathologists. Every minute particular in the formation of bone and cartilage appears likely to be known; and a large space in the 'Transac- tions of the Pathological Society' is devoted to papers read by dentists, on the disease and construction of the teeth. But diseases of the nene-eell arc beyond the ken of eighth of inch object-glasses ; and, in all probability, pathologists will long be baffled by the impracticable translucency and minuteness of 408 PATHOLOGY OF INSANITY. those parts in wliicli the ultimate conditions of disease most formidable to life are seated. The conditions of the minute vessels in a state of hypersemia will, however, explain one important fact on which we have commented above — namely, the depression of function in one part of a compound or^an, with the excitement of function in another part, when the whole organ presents the appearance of uniform congestion. It appears, from the experiments of Bidder, that the notion, hitherto common, of the dilatation and contrac- tion of the capillaries is erroneous. The small arteries and veins which are distinguishable from the capillaries by nuclei, and which also possess a layer of muscular fibres which is wanting in the capillaries, contract under the first stimulus of an irritation, and subsequently dilate. When dilated, they sup- ply a larger stream of blood to the capillaries. From hence arises a large quantity of nutritive plasma, and greater func- tional activity. But, in other parts of the same organ, a different state of the small vessels may exist ; the veins and arteries may be dilated and contracted in a varicose manner, and the flow of blood through them be less than in their normal condition. Or it may be interrupted by adherence of blood-corpuscules to the walls, and to those of the capillaries, indicating the commence- ment of stasis. Under such circumstances, the nutritive plasma, exuding for the renovation of the cells, will be greatly diminished, and functional activity will be depressed. This is one reason why functional uniformity in a compound organ suffers from conges- tion. Another cause arises from the nutritive exudations, which take place in excess in one part of the organ, occasioning a species of hypertrophy in that part, and thus giving rise to pressure on other parts of the organ, which pressure prevents transudation, and impedes functional action. But in addition to this explanation of loss of uniformity of function from the inequalities of pathological changes, another cause of equal potency is to be found in the organization of the compound organ itself. The congeries of organs constituting the brain, like the congeries of organs wliich constitutes the body is rarely devoid of one or more organs, which diftcr from the remainder either in their size and power, or in their weak- ness and in their aptitude to incur morbid change. As in the bodies of different men, any disturbing influence operates almost PATHOLOGY OF INSANITY. 109 exclusively upon the pulmonary or the intestinal mucous mem- brane, or upon the heart, or upon the liver — so, in other men, any cause disturbing the physiological conditions of the brain operates almost exclusively upon some one or other of the emo- tions or propensities. This power of selection may, in some instances, be attributed to the mere size and preponderating force of the organ. Thus, a man in whom the exercise of intel- lect and the subjugation of passion have ])cen the result of life- long effort, will, under tlie influence of any excitement, experience exaggeration of the intellectual functions alone ; or a man who has habitually submitted himself to the domination of benevo- lent or malevolent emotion, will, under excitement, have the benevolent or the malevolent emotions exclusively exaggerated. In the natural and healthy state of the organs, the preponderating force of any one of them may be overlooked ; but when any mor- bid excitement occurs, the preponderating force of the dominant organ makes itself unmistakably felt. In De Quincy, the ex- citement of opium pictured before the imagination a gorgeous array of poetic fancies ; in Coleridge it resolved itself into the more intellectual type of metaphysical subtilties ; in the savage ^lalay it produces revolting acts of headlong fury and bloodshed. The stimulus of alcohol is the occasion, among men of high intellectual organization, of "the feast of reason and the flow of soul ;" among the pariahs of civilisation, it is the cause of base passion and brutal excess. These facts give a clue to cir- cumstances which not unfrequently present themselves in the history of mental disease, in which the natural bent of the cliaractcr and disposition is observed, not to be perverted, but only to be exaggerated beyond the boundaries of sane mind, by the action of morbid changes. A lady, whose character has always been distinguished for conscientiousness, and whose reli- gious education has been of a sombre kind, has an attack of small-pox, during which symptoms of acute delirium and cere- bral congestion show themselves. After recovery from this zymotic disease, the natural bent of the mental disposition is found to be greatly exaggerated. The irrital)ility of conscience has become an actual disease, destroying the happiness of the individual, and rendering her incompetent to discharge any of the duties of life. — A distinguished admiral, who has always been remarkable for pride and liability to passionate anger, is 410 PATHOLOGY OF INSANITY. subjected to severe chagrin by a supposed neglect of Government; lie suffers from a distinct crisis of cerebral excitement, -with loss of sleep and general fcverishness ; and, for the remainder of his life, his pride and passion are exaggerated to the dimensions of undoubted insanity. As in one man a cold always flies to the bowels, and in another to the lungs, so the causes of mental disease strike ex- clusively upon one or the other organ of the mind. In the above instances, which we have given from our own observation, this occurred so, because the organ affected was the most liable to excitement, from its predominance in size and vigour. But the vigour of any bodily organ renders it less rather than more ex- posed to morbid influences. The cold, or the fever, or the poison, flies to the weak organ rather than to the strong one. Tlic cause of this difference between the glandular organs of the body and the cerebral organs appears to lie in this, that in the bodily organs healthy excitability has strict limits, and the amount of functional force within the limits of health is also strictly defined. But in the cerebral organ it is not so; not only do size and power increase with action, but excitability also increases ; use and habit render the intelligence, or any of the emotions, not only more vigorous in action, l)ut more ready to act. In this respect some parts of the muscular system bear a close analogy to the cerebral. There is, however, another class of circumstances opposite to the above, in which causes of morbid change affect a particular mental organ, on account of its weakness and not on account of its strength. There appears to be a difference, in this respect, between the organs which subserve the emotional functions and those which subserve the intellectual. In the former, the size and vigour of an organ render it more obnoxious to be affected l)y morbid influences. On the other hand, in that part of the cerebrum devoted to the intellectual activities, it is the weak- ness and imperfection of the organs whicli render them pecu- liarly liable to take on diseased action. That insanity is frequently conditioned by a preternatural fulness of the cerebral vessels, which interferes with the uniform and healthy interchange of nutritive plasma, passing from the vessels to the cells, and of the fluid cell-contents in a state of involution or degenerative metamorphosis, passing from the cells PATHOLOGY OF INSANITY. 411 to the vessels — a fulness iinaccompaniecl by exudation tending to become organized, tliat is, by congestion, and not by intlam- matiou — is proved — First. By the exciting causes of many cases of insanity, wliich causes evidently tend to hyperemia of the brain, and whicli in their more powerful ojjcration frequently give rise to inflamma- tion itself. Injuries to the brain, from blows, falls, or exposure to heat, if of a certain intensity, produce inflammation ; if they be of a less intensity, in predisposed persons, they give rise to insanity. Repeated congestions of the brain from aleoliolic drinks have a like eftcct. And finally, that frequent and un- questionable cause of congestion in all organs of the body, over- work of the organ itself, is a well-recognised and efficient cause of mental disease. Secondly. The symptoms attending many cases of insanity are those of cerebral congestion. The forehead and vertex are hot, the face flushed, the conjunctiva injected, the carotid and temporal arteries beat strongly. Sometimes there is pain in the head ; more commonly there is a sensation of weight and dul- ness. Moreover, the general system suffers from that imperfect and undeveloped state of pyrexia which accompanies active con- gestion of any important organ. Thirdly. Remedies which are efficient in the removal of congestion, are most beneficial in the early stages of many cases of insanity. Cold applied to the scalp by means of the ice-cap, cold lotions, or irrigations of cold water — leeches to the temples, and cupping to the nape of the neck — derivation to the intestinal canal by purgative medicines, or to the skin by warm baths — pro- duce tlie most marked benefit in the early stages of mania, arising from the causes and accompanied by the symptoms above stated. Fourthly. "When opportunities occur to ascertain the post- mortem appearances of such cases before they have become chronic, and have ^ assed into the conditions of atrophic decay, the appearances are those of congestion of the pia-mater, witii deepened colour of the convolutions ; sometimes, ])ut not always, accompanied by punctiform injection, or general pinkiness of the white substance of the cerebrum. "We are fully aware that an objection may be raised to the congestive theory of the pathology of insanity, from the fact, that certain diseases of the heart and lungs, and tumoui*8 pressing 412 PATHOLOGY OF INSANITY. upon the jugular veins^ -nhich appear to be efficient causes of cerebral congestion, may, and frequently do, exist without symptoms of mental disease. The objection must be admitted for what it is worth. It is sufficient to stimulate inquiry into the essential differences of congestions variously caused ; but it does not appear to be sufficient to set aside the arguments above adduced in favour of the theory. The brain of a person not predisposed to insanity may be able to accommodate itself to congestion slowly produced by the operation of these causes. Such congestions are likely to affect the whole of the cerebral organ equally; and may, therefore, be wanting in that loss of uniformity which constitutes so remarkable a feature in mental disease. Doubtless there are many persons who suffer from extreme degrees of emphysema of the lungs, or of disease of the heart, who display no symptoms of mental disorder. But it is not certain that, in all instances, the congestion which em- purples the face extends itself to the organ of mind. And on the other hand, there are cases sufficiently numerous, in which the impeded return of the blood from the head, occa- sioned by thoracic disease, does appear to produce mental disor- der. We have seen several cases in which asthma has appeared to have this eflfect ; and Mr. Ley, of the Oxford Asylum, has observed many cases in which pulmonary emphysema has been the remote cause of insanity. The probable reason of apparent anomalies in this matter would seem to be, that, in some cases, congestion has been slow in its production, and uniform in its extent and influence. In such cases the mental functions are debilitated, but not deranged. We have never seen an instance of extensive pulmonary emphysema, or of any other disease which occasioned marked and persistent congestion of the head and face, in which there was not some debility of mental func- tion. That such debility is not at first apparent, receives a probable explanation from the fact, that congestions arising from obstructions to the return of the venous blood display themselves in the vessels of the areolar tissue and of the skin, in a more marked degree, and at an earlier date, than in the vessels of large glands and other important organs. Thus, obstructions to the blood in the lower parts of the body give rise to cedema of the cellular tissue of the legs and abdominal dependencies, before they interfere greatly with the functions of PATHOLOGY OF INSANITY. 413 tlic liver, the kidneys, or the intestinal eanal ; and tlie same rule appears to hohl «iood in congestion from venous obstruc- tion in the head. The active discharge of fnnction in large vascular and energetic organs resists tlie influence of sucli causes of congestion long after tlie vessels of the cellular tissue, whose functional activity is nnich lower in degree, have been thrown into u pathological condition thereby. The greater the functional activity of a healthy organ, the more energetic its resistance to the causes of disease. Ancpmia. — That numerous instances of insanity are condi- tioned by the state of the cerebral vessels generally but imper- fectly expressed by the term anremia, may be proved by an array of arguments similar to those which we have adduced to prove the influence of congestion : — First. — The etiicient cause of numerous cases of insanity is actual loss of blood, or a deficiency in its nutritive powers, occasioned by insufficiency of food, or by impediments to the conversion of food into healthy blood ; or by the numerous anti- hygienic influences which limit the quantity or Aveaken the nutritive quality of the blood in the cerebral vessels. Anaemia is a vascular condition with which the raicroscopist is far less intimately acquainted than that of congestion. It is not much that he can learn respecting it from the foot of the frog, the wing of the bat, the tail of the tadpole, or the mesentery of a young rabbit. It is a condition on which the inductive reasoning of the general pathologist is of more weiglit than the prying eyesight of optical philosophers. After death the whole mass of the organ is found to be paler than usual, and that is about all w ith which actual observation has hitherto been able to make us acquainted. But even could it with ease be demon- strated upon the field of the microscope, that cerebral vessels in an anamic condition have any distinctive characteristics, it is improbable that such observations would explain more than the simple fact, which we can understand as well without, namely, that a dilute state of the blood is as great a hindrance to func- tional vigour as that congestive commencement of stasis, which deranges endosmie action by an opposite condition of the capillaries. Certain j)hysiological actions being necessary for the nutrition and the healthy functional activity of the brain-cell, any impediment to these actions interrupts this activity. Ileucc 414 PATHOLOGY OF INSANITl'. the markwortliy fact;, that the essential symptoms occasioned by congestion and ausemia greatly resemble each other. The physical symptoms of fainting from loss of blood, and of coma from suflbcation, are sufficiently distinct ; but the psychi- cal symptoms resemble each other very obviously. In both there are the same affections of the senses, the same sparks and flashes before the eyes, the same tinnitus aurium, the same thick-coming fancies, followed by loss of consciousness, the same painful sensations attending recovery. The slighter but more persistent degrees of hypersemia and ansemia are attended by symptoms readily distinguishable from each other, both by physical and psychical symptoms. In hypersemia, with hot head and fulness of the cerebral vessels, the cerebral functions are discharged with slowness and difficulty. In ansemia, with pale face, cool head, and weak pulse, the cerebral organs are in a state of irritable weakness, easily excited to action ; the action, however, being powerless and irregular. In fact, the mental state in anaemia differs from that which is observable in hypersemia, much in the same manner as the muscular system in an exsanguinated person differs from the muscular system in one morbidly plethoric. In the former it is quick, irritable, and tending to convulsive irregularities; in the latter it is less subject to be thrown into violent action or convulsion, and its motions are slow and oppressed. This distinction, however, is by no means constant. The state of ansemia, carried beyond a certain point, destroys the functional excitability and activity of an organ. ^Moreover, when an organ has made decided progress in the march of retrogressive change, it loses its cxcitabilitj'. Thus it happens that anremia of the brain, combined witli atrophic decay, is accompanied by loss of functional activity, and is a frequent cause of dementia ; while, on the other hand, the rapid nutrition of some portions of the brain, occasioned by a moderate degree of active hyperemia, augments functional wusceptibility and power. "We must in this place guard ourselves from a possible misap- prehension which may arise from the stress which we lay upon the quantity and movement of the blood in the cerebral vessels. AVe are so far from regarding these as the ultimate causes of insanity, that we look upon them merely as one link in the series of proximate causes ; and that link at least one remove I'ATUULOGY or INSANITY. -J.15 from the termiuation of the chain. Between the ultimate cou- tlitiou upon which mental function, either normal or abnormal, depends, and the condition of the blood in the cerebral vessels, there must intei'vene the condition of the cell apparatus. To this may perhaps also be added, the condition of the capillary walls. But these conditions in the brain are beyond the sj)here of our present powers of observation. The state of the blood in the capillary vessels is the circumstance lying the nearest to that ultimate molecular change resulting in functional activity, with which our present powers of observation are able in any way to make us acquainted. We must trace the path so long as it is visible, and we must carefully take its bearings at the point of its disappearance. The direction of its last visible trace is often of more value to guide us onward, than the whole length of its previous course. But the importance of any link in the series of causation must not be under-estimated because it is placed at some removes from the end thereof. The aim and end of science is to predict. If our knowledge were complete, we should be able to predict with certainty, from the conditions of any one part in the path of causation, the conditions of all sub- sequent parts and of the end. If our knowledge were complete of the cerebral organization, we should, from any morbid state of the cerebral capillaries and their contents, be able to predict the anomalies of mental function which would result therefrom. To this end, it is true, we should require to possess a knowledge of the state of the cells, upon which morbid conditions of the circulation have to act. And herein lies the great difficulty of pathological science, that these minute but all-important consti- tuents of the organization refuse to yield their secrets. All that we know of them is, the place where they lie in the path of causation, namely, between the network of capillaries and the phenomena of function. llokitansky has expressed his opinion that the conditions of the nerve-mass are independent of those of the nutrient sxijjply, and that the state of the capillaries and their contents is often, if not generally, a phenomenon consecutive to and dependent upon the state of the nerve-cells. At bottom, this (question re- solves itself into the origin of thought and consciousness. If healthy blood supplied to healthy nerve-substance is the sole occasion of healthy nervous function, such function must be 416 PATHOLOGY OF INSANITY. dependent and consecutive nponsuch a supply of healthy blood. But if healthy nerve-substance can set in movement its own activity, by an independent and spontaneous act, which occa- sions those molecular changes of involution and repair, to effect ■which the capillaries and their contents are essential, then Roki- tansky's vieAv of the pre-ordination of cellular change to vascular change may be correct. But even admitting the possibility of this, the comiection between cellular and vascular change is of so intimate a charac- ter, that it is difficult to assent to Rokitansky's proposition, that pathological conditions of the cerebral vessels are to be viewed as secondary phenomena. This question is of far greater import- ance than may at first appear ; since it has been quite the custom, among a certain class of writers, to argue that the path- ological changes discoverable in the brains of insane persons are secondary changes, of little importance to the elucidation of mental disease. Pinel, and after him, Esquirol, unfortunately expressed this opinion. These great alienists, with vast experi- ence of the phenomena of insanity, lived and wrote before path- ological knowledge was developed into a science. They looked for gross and unmistakeable changes of structure. Failing to discover these, they were led to the admission (which few pathologists of the present day would endorse) that functional disturbance may exist Avithout organic change, and that organic change may exist without necessary connection with functional disturbance. Their observations have been quoted, and their opinions repeated and developed by numerous writers, whose prejudices or preconceived beliefs have led them to regard insanity as the condition of a certain metaphysical entity ; and it is to be regretted that so high an authority as the great path- ologist of Vienna should in any way be available for the sup- port of this false and mischievous theory. The opinion that pathogical conditions of the cerebral ves- sels are secondary phenomena is available for this purpose, because in a large number of instances such conditions are the only visible and appreciable changes which present themselves. The theory of the metaphysicians is based : 1st, upon the as- sumption that insanity may exist without cerebral change ; and 2nd, upon the assumption that the visible changes which are most observed (that is, the vascular changes) are not primary PATHOLOCJY 01' INSANITY. 4-17 aud essential phcuomcna, but secondary and unessential. It therefore becomes of the utmost importance that clear ideas should be formed respecting the succession and dependence of patliologieiU phenomena. TJiat functional disease, both of the brain and of other organs, may exist without appreciable change of structure, is a fact which Avill continue to be explained by some persons of a certain mental constitution, by certain verbal formularies respecting vital and spiritual dynamics, aud Avhich "vvill, Ijy other minds, M'ho submit their operations of thought to more stringent rules, be attributed solely to our limited powers of observation. But, the question of the primary or secondary nature of the patholo- gical changes which are found to exist in the brains of persons dying insane is a point on which differences of opinion exist, even among persons who look to structural change alone as the cause of functional disturbance. The opinion on one side may be thus stated : tlie morbid activities of the cerebral cells, being excited by sensational impressions, are the determining cause of morbid conditions of the cerebral capillaries. The adverse opinion may be thus stated : a morbid condition of the cerebral capillaries, occasioned by agencies influencing the circulation, is the sole determining cause of morbid changes in the cerebral cells. An appeal to the etiology of insanity seems to assure us that both views are partially right, and both are partially wrong. Functional disturbance of the brain may, undoubtedly, be occa- sioned by changes provoked in its organism by sensational impressions, and between such impressions and the cerebral vessels, a condition of the cerebral cells must undoubtedly inter- vene. In cases of insanity so produced (that is, in most cases dependent upon moral causes), it may be granted that a patho- logical condition of the cerebral vessels cannot be antecedent to a pathological condition of the cells. But, if subsequent thereto, it nuist be immediately subsequent and necessary. It is supposable that the first cell change is slightly anterior to any modification of the capillaries which supply nutriment to, and remove material from, the morbid cell ; but it is difficult to believe that morbid changes can take place in the cells of an organ, without the capillaries being immediately infiuenccd thereby. Any change so produced in the capillaries nuiy therefore be theoretically called secondarv ; but, if secondary, it is, ncverthe- 27 418 PATHOLOGY OF INSANITY. less, a necessary change, -without Avhich the condition from whence it arises cannot continue to exist. The physiological vascular changes which take place in the lungs are secondary to impressions made upon nerve-cells. It is thus that they are first excited, and continue to be maintained. But they ai-e a necessary consequence of such impressions, and a necessary condition of the continuance of such impressions. Thus, although secondary, they are not the less physiologically necessary. In most instances of insanity arising from physical causes, it is probable that the pathological condition of the cerebral cells is subsequent to, if not dependent upon, the pathological condition of the cerebral capillaries. It is unnecessary to go through the roll-call of the physical causes of mental disease ; suffice it to say, that injuries to the head, fever, suppressed discharges, alcohol, and other noxious ingesta, can only influence the cere- bral cells through the medium of the capillaries. There may be some doubt respecting cases occasioned by nen'ous irritation, propagated from distant parts of the body, or affecting the brain in the manner which we formulate under the term of nervous sympathy. With regard to all other pliysical causes of mental disease, it is scarcely possible to doubt, that a pathological condition of the cerebral vessels is not only an essential condition of the disease, but that it is also one which takes place in order of time antecedent to any pathological con- dition of the cerebral cells. But, whether the cerebral changes observable in the insane are primary or secondary, it cannot be denied that they are the results of the disease ; and even if it could be proved that they were invariably of a secondary character, they would not the less bear testimony to the nature of insanity being that of morbid physical change in the cerebral organs. Undoubtedly, the vast majority of the pathological appearances observed in the cerebrum are of a secondaiy nature, since they are those of atrophy and decay. But the charred beams and blackened walls of a ruined homestead do not speak more eloquently of previous conflagration, than the dilapidated roof and mouldering structure of a decaying building speak of the slower process of oxydization or eremacausis ; and a brain with organized exudations testifies not less strongly to previous deviations from the normal state, than an atroj)hied brain^ PATHOLOGY OF INSANITY. 119 without such accompauimcnts, speaks to the cxistcucc of the slower process of defective nutrition and degenerative meta- morphosis. According to "N'irehow, liowever, the cell is less dependent in its pathological changes upon the condition of the vessels than it has hitherto been believed to be. In illustration of this view, Virehow not only points to the -well-known fact that inflammatory changes take place in parts of the body which arc at a certain distance from vessels, as in the centre of the cornea, in cartilage, and the internal substance of tendons, but he maintains that in other pathological processes the cell has the ability to draw to itself new material, and again to dispose of it, by " a simply nutritive restitutional power." lie believes that what are called exudations do not exist so frequently as is sup- posed ; for he says, " In a tissue which consisted of cells, 1 could, after the exudation, sec nothing but cells, and in tissues composed of cells and intercellular substance — nothing but cells and intercellular substance." The cells, indeed, were larger, fuller, and filled with matter with which they ought not to have been filled ; but in such cases " the absorption of matter into the interior of the cells is unquestionably an act of the cells themselves." Even in cases where what are called exudations do undoubtedly exist, Virehow considers them to be drawn from the vessel by the activity of the cell, rather than exuded by any action of the vessel. "A good deal is, as we have seen, not so much exudation as, if I may so express myself, an educt from the vessels in consequence of the activity of the histological elements themselves." (Yirehow's ' Cellular Pathology,' ti-ans- latcd by Chance.) In fine, the primary activity of the cell is the broad doctrine taught by this great pathologist — an activity which in inflammatory processes he considers always due to irritation. The doctrine, indeed, is not so new as the facts and arguments adduced in its proof. In multiplying and strcngtlien- ing these, we cannot but hope that much light will be thrown upon the obscurities of our special department of pathology', and that throngh this powerful aid we may, before long, be enabled to speak in more positive terms of the changes known to take place in the cell-apparatus of the i)rain. Cerebral Atrophy. — Insanity is a chronic disease, and not frequently fatal in its early stages. It is therefore unusual to 420 TATIIOLOGY OF INSANITY. meet Avitii the simple appearances of congestion, or of anaemia, wliicli have hitherto occupied our attention. The commonest appearance met -with in the brains of insane persons is that of shrinking. The autlior has, in the January number of the 'British and Foreign Medical Review' for 1855, published some investigations made upon this important subject, and has there tabulated the measurements and weights of sixty-four brains, which were examined for this especial purpose. The manner he adopts for estimating the amount of atrophy is as follows : " The brain, including the medulla oblongata, is slowly im- mersed in a vessel of convenient size and shape, which is filled with water up to the level of a capacious spout placed at an acute angle with the sides. Before the brain is so immersed, the contents of the ventricles, and any serum which may be in the sub-arachnoid tissue, are allowed to escape through several long incisions. The organ is not allowed to remain immersed long enough to imbibe water, Avhieh it is capable of doing in large quantity, as proved by the experiments of Nasse. As it descends in the vessel, the water it displaces escapes from the spout, is caught and measured, and affords a criterion of the actual bulk of the brain. (See 18th column of Table.) " The capacity of the cranium is obtained by a somewhat more troublesome process. It is well known that one of the older physiologists employed millet-seeds for this purpose ; Sir W. Hamilton used sand : but neither of these methods would l)e feasible in the recent subject. The plan which the author has adopted is as follows : — The foramina at the base of the brain are carefully plugged with tenacious clay — that used by statuaries for modelling answers best; a small triangular piece of the fron- tal bone is removed with the saw ; the calvarium is re-adjusted to the base, the dura mater being left attached. The space left by the attrition of the saw, in removing the ealvanum, is filled up with clay ; and a narrow bandage, M'ith clay spread upon it, is made to surround the cranium three or four times, covering this space. If this manipulation has been carefully done, the cavity of the cranium will now be found as tight as a bottle. Sixty fluid ounces of water having been measured, a sufficient quantity to fill the cranial cavity is now poured into it, by means of a funnel, through the orifice in the frontal bone, taking l'ATlIOlA)f;Y OV I.NSAMTV. •1-21 care that the stream does not wash away the luting of the fora- mhia. The fluid which remains, after having filled the cra- nial cavity, is measured, and being deducted from the sixty ounces, gives the amount employed. Thus, if nine ounces and two drachms remain, the capacity of the cranium was fifty ounces and six drachms ; and if the amount of the fluid displaced by the brain was forty-five ounces, the amount of atrophy was five ounces and six drachms. To this must be added half an ounce for the space occupied by the luting, giving the actual amount of atrophy as six ounces and two drachms. Of course this examination is made before the chest is opened." For the results of these sixty-four examinations, we must refer the reader to the table at pages 216 and 217 of the above-named journal. The general results were an average amount of atrophy to the extent of five ounces and a quarter, varying from nothing to fifteen ounces, or one third of the whole cerebral mass. In thirteen patients whose ages ex- ceeded sixty-five years, the average amount of atrophy was eight ounces and one sixth, or more than fifty per cent, above that of the whole number. The amount in epileptic cases was gi'eatly below the average of the whole. The general result arrived at was that — '' In cases of chronic mania, of dementia following mania, and of primary dementia, the amount of cerebral atrophy may gene- rally be calculated upon by the enfecblcment of mental power. In all these forms of disease, we have found some amount of atrophy, and have, for the most part, found this amount to cor- respond with the degree of mental decadence estimated with its duration. The first of these conditions, that is the degree, it is impossible to tabulate ; the second, that is duration, it is not easy to show accurately in a tabular form. The sixth column of the table above referred to represents the duration of disease from the period of the first appearance of symptoms, as nearly as it could be ascertained. These symptoms may have been slight for years, and grave for a short time only before death." " It must not be thought that extensive atrojjhy is only found where the mental symptoms are solely those of impairment or loss of function. It is not inconsistent with much men- tal excitement, or with numerous delusions ; but such ex- 422 PATHOLOGY OF INSANITY, citement is powerless, and the delusions are transitory and puerile. Whether measurable atrophy exists in the early stages of acute mania and mclaucholia_, the data we possess do not prove ; although they arc amply sufficient to demonstrate that the cerebral conditions upon which these forms of insanity de- pend tend to pass into an appreciable and measurable shrinking of the brain substance, unless the healthy cerebral action be speedily restored/' " Opinions on the ultimate nature of the nutritive defect which results in cerebral atrophy and insanity must necessarily be speculative, since the ultimate nature of nutrition itself is unknown to us. " Its apparent and exciting causes may be classified as fol- lows : " \. In predisposed persons it may depend upon poverty of blood, since it is producible by deficient food, and by diseases interfering with the alimentative processes ; and since an analo- gous train of symptoms occurs during starvation. "2. It is probable that in other cases it may depend upon some derangement of '^the intimate connexion between the nervous and vascular systems, through which their most important functions are performed,^ since it is sometimes found to be accompanied by extensive disease of the minute cerebral vessels, the coats of which can be shown to be subject to fatty or earthy decay. " 3. A third class of cases would appear to be producible by the molecular change eflected by blows or violent concussions, and followed by atrophy, owing to some process as yet unknown to us. Atrophy of a testicle from a blow, Avithout inflammation, presents an analogous instance. " 4. Another class of cases are those following inflanmiation, and perhaps also following frequent or long-continued conges- tion. The basis of inflammatory action is an abnormal state in the mutual relationship between the blood and the tissues. That this state efiects changes in the tissues, which, if not speedily repaired, must be followed by conditions of degraded nutrition, is proved by the pathology of every organ in the body. The brain certainly oft'crs no exception. The capillai'ics become blocked up, or their coats become spoiled, for the purposes of nutritive regeneration of the tissues. PATHOLOGY OF INSANITY. 423 " It also appears probable that, during inflammatory or con- gestive conditions, albuminous matter or serous fluid may be eflfused by the capillary network into the intimate structure of the brain ; thus separating its vesicles and tubules from the capillaries, and preventing the due nutrition of the elements of nerve-structure. For this form of atrophy, vre have formerly suggested the prefix of relative, as it may exist -where there is no shrinking of the brain ; atrophy with shrinking being termed positive. The two, however, may, and frequently do, co-exist. " 5. The most numerous class, however, is that which depends upon want of rest, during the especial period of nutrition of the brain — namely, sleep. Want of refreshing sleep we believe to be the true origin of insanity, dependent upon moral causes. Very frequently, when strong emotion tends to the production of insanity, it causes, in the first instance, complete loss of sleep. In many cases, however, the power of sleeping is not lost, but the quality, so to say, of the function is perverted, the sleep being so distracted by agonizing dreams, that the patient awakens jaded rather than refreshed. "We have known several instances in which patients becoming convalescent from attacks of acute mania, have distinctly and positively referred to frightful dreams as the cause of their malady ; and it is probable that a certain quality of sleep, in which dreams excite terror and other depressing emotions more forcibly than waking events are likely to do, is not less adverse than complete insomnia to the nutri- tive regeneration of that portion of the brain on whose action those emotions depend. In such a condition, it is highly probable that the very portions of the brain which most need a state of rest are, even during the sleeping quiescence of other portions, more wastefully engaged in the activity of their functions than they could be in the waking state. The main-spring of insanity is emotion of all kinds. This, stimidated by phantasy, and emancipated from the control of judgment, during harassed sleep,, may be more profoundly moved than at any other time. Bichat considered sleep to be a very complex state, in which it was possible for the cerebral functions to be in very different conditions of quiescence or activity : ' Le sommeil general est I'ensemblc dcs sommcils particulicrs / and he considered that dreams represent the active or waking condition of certain of 434 TATIlOLOdY OF INSANITY. these functions during the repose of the others. In this manner^ a patient, some one or other of whose emotions has been pro- foundly affected, may continue to be sleepless, as far as the activity of the particular emotion is concerned, although he may by no means be the subject of general iusomnolcnce ; and this consideration will aflford what seems to be a fair explanation of the exceptional cases to this rule, that the moral causes of insanity act by preventing the due nutrition of the Ijrain, as it occurs during sleep." On these five classes of the causes of ati'ophy, we shall here make some further observations. In tracing the course of cere- bral atrophy, it will be convenient to select that variety whose causation and phenomena are of the most simple and intelligible kind. This would appear to be presented by the atrophy ac- companying old age. The balance between the functions of repair and decay, which in health maintains every organ in a state of size and power, uniform Avithin certain limits, is lost as age advances, and the tissues of the body lose their perfect organization and pristine vigour. The duration of the life of an animal depends upon the period of its existence when this loss of balance occurs; but it is impossible to explain why these slow but fatal changes take place at certain specified periods ; why the tissues of a sheep become worn out at the end of ten years, and those of a man endure seven or eight times as long. It is impossible even to point out any necessity for this degrada- tion of tissue at all. We must accept, as an ultimate fact, or as a law of nature, that such degradation of tissue in the organs of all living beings takes place at a certain fixed period of their existence. To say that this period is fixed by the laws of here- ditary tendency, explains nothing. In man, this change com- mences, as we well know, at the age of sixty years. About that time, the nutritive repair of the organs begins slowly to fall short of the amount of their decay. The muscles gradually become smaller, weaker, and paler, and the brain undergoes the same process of change. In the brain, one cause of this process is, perhaps, more easily traceable than in other organs — namely, to a change in those minute vessels by means of wliicli the pro- cesses of imtrition are carried on. It is true that the cerebi*al capillaries are beyond the reach of satisfactory microscopical ob- servation ; but the cerebral arteries may be observed with facility. PATIIOT.OriY OF INSANITY. 425 The coats of these are found to be thickened and opaque, and occupied by that which is called atheromatous deposit — namely, by a material composed of fatty substances and earthy salts. In the larger arteries, whose difterent coats are distinguishable, this deposit, or rather this degeueratiou, is found to have its seat external to the elastic coat, and internal to the outside cellular envelope. If this degenerative change can be traced in the smallest arteries, whose construction is capable of being submitted to observation, it is in the highest degree prolmble that the change is not limited to them, but that it extends to the capillaries, whose minuteness forbids its demonstration. Tiie plasma of the blood would then permeate the capillary walls from within, outwards ; and the exhausted cell contents would permeate from without inwards, with slowness ever increasing as the capillary walls were injured by deposit. From this slowness would arise lentor of the cerebral functions, displaying itself at the earliest period in those functions whose activity is not kept alive by habitual use ; and to a still greater degree in those fimctions whose activity is dependent upon the stimulation of the senses, the organs of which have also undergone contemporaneous decay. But debility of function, arising from the slow interchange of material between the capillaries and the cells, would not account for atrophy, if the balance of the interchange was still exactly adjusted. Slowness of mental function is often seen in persons of phlegmatic habit from this cause, without the condition of atrophy being present. But in the degenerative changes of old age, the balance of exchange between the capillary and the cell contents is not maintained. The probable explanation of this is afforded by the supposition, that the greatest activity of exos- raosis from the capillaries takes place in that part of the capillary system which is adjacent to the arteries ; while the most active endosmosis of exhausted cell-fluid takes place into that portion of the capillary system which is adjacent to the minute veins. Now, the pathological changes under consider- ation aft'ect the arterial system, if not exclusively, yet to a much greater extent than they affect the venous system. The arterial capillaries have coats more, thickened and degenerated than the veuous ones ; and thus a gi'cater impediment is placed against the outflowing of the materials for nutrition and repair, than against the inflowing of the exhausted cell-fluid, and the fouu- 426 PATHOLOGY OF INSANITY. elation of atrophy is established. Whether any pathological changes corresponding in their natnre to the fatty degeneration of the arterial coats take place in the cell- walls themselves, we are unable to ascertain, or even to gain better grounds for rea- sonable conjecture, than the probable participation of all the tissues in the degenerative changes. The law which limits the duration of organic completeness, which weakens the force of that unknown something which we call vital power, and which permits the ordinary chemical affinities of the constituents of the body to exert themselves with increasing force, this law, doubtless, operates upon all parts of the organism, although with different degrees of intensity, and at different periods of time. The glands which secrete the hair on the vertex vacate their office before those which secrete the hair on the brows, and the latter do so long before the glands which secrete nails. But the law of decay is universal, and doubtless touches the cerebral cells independently of their connexion with the minute vascular network. The views of Virchow on this point are expressed in the fol- lowing passages of his ' Cellular Pathology :' "If we speak of the action of the liver, we can, both in regard to the formation of sugar as well as that of bile, mean nothing but the action of its individual elements (cells) ; an action which consists in their attracting matters from the passing current of the blood, in their effecting within their cavity a transmutation of these substances, and returning them in this transmuted form either to the blood or yielding them up to the bile-ducts in the shape of bile." ''Now, I demand for cellular pathology nothing more than that this view, which must be admitted to be true in the case of the large secreting organs, be extended also to the smaller organs and smaller elements ; and that, for example, an epidermis-cell, a lens-fibre, or a cartilage-cell be, to a certain extent, admitted to possess the power of deriving from the vessels nearest to them (not always, indeed, directly, but often by transmission from a distance), in accordance with their several special requirements, certain quantities of material ; and, again, that after thoy have taken this material up, they be held to be capable of suljjccting it to further changes witliin themselves, and this in such a man- ner that they cither derive therefrom new matter for their own development, or that the substances accumulate in their in- rATUOLOGY OF INSANITY. 427 tcrior, without their reaping any immediate benefit from it ; or, finally, that after this imbibition of material, even decay may arise in their structure, and their dissolution ensue. At all events, it seems necessary to me, that great prominence should be assigned to this specijic action of the elements of tissues, in op- position to the specific action of the vessels, and that in studying local processes we should principally devote ourselves to the in- vestigation of processes of this nature." " If, therefore, it is the muscular elements of the arteries that have the most important influence upon the quantity of blood to be distributed, and the mode of its distribution in the several organs, and the clastic elements that are chiefly concerned in the production of a rapid and equable stream, they, nevertheless, exercise only an indirect influence upon the nutrition of the parts which lie outside the vessels themselves ; and in this matter we arc obliged to betake ourselves, as a last resource, to the simple homogeneous membrane of the capillaries, without which, indeed, not even the constituents of the walls of the larger vessels, pro- vided with ^■asa vasorum, would be a])lc to maintain themselves for any lengthened period. The difliculty which here presents itself has, as you know, during the last ten years been chiefly got over by the assumption of the existence of diffusive currents (en- dosmosis and exosmosis) between the contents of the vessels and the fluid in the tissues ; and by regarding the capillary wall as a more or less indiff'erent membrane, forming merely a partition between tAvo fluids, which enter into a reciprocal relation with one another ; while the nature of this relation would be essen- tially determined by the state of concentration they are in and their chemical composition, so that, according as the internal or the external fluid was the more concentrated, the diflusive stream would run inwardly or outwardly, and, according to the chemical peculiarities of the individual juices, certain modifications would arise in these currents. Generally speaking, however, the chemical side of this question has been but little regarded." " It cannot be denied that there are certain facts which cannot well be explained in any other manner, especially in cases where essential alterations have taken place in the state of concentra- tion of the juices ; for example, in the form of cataract, which Kundc has artificially produced in frogs by the introduction of salt into their intestinal canal or subcutaneous cellular tissue. 428 PATHOLOGY OF INSANITY. But in proportion as, after a physical study of the phenomena of diffusion, the conviction lias been acquired that the menilH'ane which scjjarates the fluids is not an indifferent substance, but that its nature exercises a directly controlling influence upon the permeating powers of the fluids, it becomes impossible that a like influence should be denied the capillary membrane. We must not, however, go so far as to ascribe to this membrane all the peculiai'itics observable in the interchange of material, and so explain how it happens that certain matters which enter into the composition of the blood are not distributed in equal propor- tion to every part, but leave the vessels at some points in greater, at others in less, quantity, and at others not at all. These pecu- liarities depend, manifestly, on the one hand, upon the different degrees of pressure to which the column of blood is subjected in cer- tain parts, and on the other, upon special properties of the tissues ; and we are irresistably compelled, both by the consideration of simply pathological, and particularly by that of pharmaco-dyna- mical phenomena, to admit that there are certain affinities exist- ing between definite tissues and definite substances, which must be referred to peculiarities of chemical constitution, in virtue of which certain parts are enabled in a greater degree than others to attract certain substances from the neighbouring blood." Returning to the consideration of cerebral atrophy, next to that of old age, that proceeding from pathological changes of the vascular system, approximating to the state called inflammation, is the most intelligible. We have above given reasons for the opinion that the chronic class of diseases known under the generic term of insanity are not referable to inflammation of the great nervous organ. In- flammation, however, may, and sometimes does, cause changes in the organ, which are the conditions of insanity. In the brain, the state of inflammation itself either very quickly ceases, or very soon causes death ; but wdien it does cease, it leaves behind it consequences which are frequently the conditions of insanity, and the causes of cerebral atrophy. Inflammation of all soft organs is apt to result in atrophy, after the organizable products which at first increase the bulk of tlie organ have contracted upon the blood-vessels, and cut off, to a greater or less extent, the nutrient supply. The heart, indeed, affords an apparent exception ; but its structure is seldom I PATHOLOGY OF INSANITY. 429 inflamed, and its liypcrtrophy is consequent upon increased exertion necessary to overcome mechanical diflicultics which have arisen from inflammatory injury of its valves or serous covering. That inflammation of the brain is sometimes followed by atrophy, is as certain as that inflammation of Glissou's capsule is followed by atrophy of the liver, AVhether it arises from the same cause is yet unknown. It is now very generally admitted that the organic elements of the brain are bound together by connective tissue ; the neuro- glia or nerve-cement of Mrchow corresponding more or less in its character with the connective tissue of the liver, which, when altered by inflammatory processes, squeezes that organ into a hobnailed callosity. We have as yet no facts upon which to ground the opinion that changes in the neuro-glia are causes of cerebral atrophy. On this point, as on others, we must await the revelations of microscopic observers, who may perhaps be able hereafter to demonstrate a kind of cirrhosis in the brain. In the meanwhile, the newest pathological science is tending to discredit the agency of the blood-vessels, and to locate all force of change in the cells. The truth in this matter will, perhaps, be found to be between the Berlin professor and what he calls the Vienna school; so that the condition of the cells, and that of the nutrient vessels, may both be found of importance in the causation either of disease or of natural decay. Of this, however, there can be little doubt, that the nutrition of the brain depends upon its exercise, and its exercise depends upon the perfection if its organization. Its organization once permanently injured, its uniform and harmonious exercise becomes henceforth impossible; its nutrition is impeded, and atrophy results. It will appear from the above, that wc attribute a large share of mental disease to pathological conditions of the brain, whose most prominent characteristic is defective nutrition of the organ. In a very large proportion of cases, this deficient nutri- tion is manifested after death by an actual shrinking of the brain — a shrinking which is eo-extensive with the duration and the degree of loss of mental power. This loss of power marks all in- stances of cere])ral decay, and is consequently a condition of most chronic cases of insanity. Partial mental exeitemcnt is, it is true, an incident constantly recurring, even in forms of mental disease 430 PATHOLOGY or insanity. ■wliere the general loss of power is most conspicuous^ and where organic atrophy is found to be most considerable. This partial and irregular excitability is common to organs whose nutrition is defective, and the general vigour of whose functions is greatly weakened. Thus, a diseased stomach, quite unable to supply the amount of solvent secretion needful to digest a due supply of food, frequently torments its wearer by excessive and irritating secretions of gastric juice, at times when it can serve no good purpose, and only tends to heartburn and acid vomiting. So, also, the atrophied brain is exceedingly prone to sudden erethism, more or less partial, which manifests itself in strange and irregular excitement of the mental functions. Such excite- ment is usually followed by increased debility of function ; and it is by no means uncommon to observe a regular alternation of mental excitement and debility. The excitement is more or less partial, and affects principally the emotional functions. The intellectual functions are also liable to be so affected ; but, inas- much as the operation of the whole of these functions is neces- sary to the performance of common intelligential acts, and, as in spoilt brains, the whole of them are not usually excited at the same time, the fact of this condition in any one of them often attracts no attention. The emotional and instinctive functions present the most frequent and easily appreciable instances of cerebral excitement. Pathologically they present counterparts of excessive gastric secretion, which takes place in the ill-nourished stomachs of phthisical patients; and there can be little doubt that, if we knew the locality of the different functions of the brain, and were capable of inspecting its organs during life, we should find this temporary and partial excitement characterised by local erethism of the tortuous vessels of the pia-mater. It is one indication of the small share which inflammatory processes have in the production of mental disease, that the partial hypcrjcmia to Avhich the atrophied brain is peculiarly liable never results in true inflammation. Insatiifj/ by Sympathy. — Tliat the organ of the miiul is thrown into diseased action by sympathy with, that is, by suffering with, other diseased or injiired parts, is scarcely less certain, than that the stomach, the heart, or the spinal marrow, arc so affected. The modus operandi of this cause of disease PATHOLOGY OF INSANITY. 431 is by no means clearly intelligible, cither in relation to the brain or to other organs; the explanations usually offered being little more than diversified verbal formularies of the fact. Thus, when we say, that the irritation of the cervix uteri is re- flected upon the stomach, occasioning vomiting and distress in that organ, we come no nearer to an explanation of the mode of action, than when we say, that the stomach sympathises with, or suffers in conjunction with, or in consequence of, irritation of the organ first affected. And, in like manner, when Ave say, that the brain suffers sympathetically with the uterus or stomach, we use a mere verbal formula for the colligation of two facts, with the intimate nature of whose coimexion we are wholly unacquainted. The knowledge which we actually possess on this subject may, in general terms, be thus stated : the most important organs of the body arc liable to be thrown into states of functional disturbance by irritation or injury of otiier, and frequently of distant, parts. The liability to this disturb- ance depends, in the first place, upon what is called constitutional iri'itability, or a state of the system in which slight causes of nervous action produce great effects; and, in the second place, upon the intimate connexion of the organ secondarily affected with the nervous system, and its liability to be thrown into disorder by any alteration or disturbance in the state of that system. Any premature attempts to explain this important pathological fapt, by h3rpotheses respecting nervous currents, or the exliaustion of nervous power, seem at present rather likely to obscure than elucidate the matter. We may, how- ever, come one step nearer to the view of the fact, by considering all sympathetic disturbance as taking place in the nervous system itself; and in viewing the functional dis- turbance of secreting and other organs as merely the expression of abnormal states of the nerves in those organs. Strictly speak- ing, therefore, sympathetic vomiting or palpitation is as purely a nervous phenomenon as loss of consciousness or convulsions ; and the latter as mental excitement or delusion. In early life the cerebro-mental functions are more intimately connected with those of the spinal system than at subsequent periods, and distant irritations are more frequent and efficient causes of mental disturbance in the infant than in tlu^ adult. Delirium aud coma are, iu children, iicquently produced by 432 PATHOLOGY OF INSANITY. intestinal irritation. In the adult, in comparison witli convul- sions, delirium is so rarely a consequence of simple irritation, that it furnishes one strong proof that the brain proper exercises its functions with great independence of the excito-motory or spinal system. The most frequent and unquestionable instances of cerebral distuj-bance from distant irritation or sympathy are aftbrded in epilepsy and hysteria. In both of these diseases, the paroxysm is compounded of disturbance both of the cerebral and spinal functions ; but diu-ing the interval, cerebral disturlmnce alone is frequently present, and in the paroxysm itself it is never wanting. In epilepsy, especially, is this the case ; for loss of consciousness, which is the primary and leading feature of the paroxysm, is the most serious and profound indication of cere- bral disturbance, no less, in fact, than the temporary abnegation of all cerebral function. In hysteria, loss of consciousness is of less certain occurrence, although sometimes it is doubtless com- plete. In the interval of hysteria, however, cerebral disturbance is not less marked than in epilepsy. The emotions are perverted, and even delirium is by no means uncommon. Now both of these diseases are frequently but the expression of sympathy with irri- tation of distant parts of the nervous system. The one is pro- duced by irritation of the nerves of the uterus and its appen- dages, and the other by the irritation of almost any portion of the peripheral nerves, by worms in the intestines, renal calcu- lus, painful injuries and diseases of the limbs, &c. Therefore these diseases present unquestionable instances of mental dis- turbance, occasioned by sympathy of the brain with irritation of the distant nerves ; of the central organ of the system, suf- fering in its noblest functions, in sympathy with some fibres of its peripheral extension. The most probable explanation of these sympathetic disorders is, that injury to one part of the nervous system interferes with the process of secondary nutrition taking place in other parts. The rapidity Mith which they occur may, at first sight, seem adverse to this view ; for instance, in the case related by Dr. Gooeli, " Dr. Denman passed a ligature round a polypus of the fundus of the uterus ; as soon as he tightened it, he produced pain and vomiting. As soon as the ligature was slackened, the pain ceased ; but whenever he attempted to tighten it, the pain and vomiting returned. The ligature was left on, but loose. I'ATIIOLOCY OF INSAMIY. -153 The patient died about six weeks afterwards, and on opening the body, it was found that the uterus M'as inverted, and that the ligature had inehided the inverted portion." Sympathetic disturbance of the functions of the brain are, in some instances, scarcely less rapidly occasioned, or less capable of receiving immediate relief. Thus, the irritation of a cutting tooth, will sometimes produce iu a child, delirium and coma ; and the removal of the irritation, by incision of the inflamed gum, will remove the symptoms almost as speedily as in the example above quoted. But when it is considered that the processes of secondary nutrition are those upon which the functions of all organs immediately depend, and that any interference with these processes must necessarily and immediately disturb the normal course of the functions, the short interval which is fre- quently observed to exist between the production of irritation and its sympathetic consequences, will present no difficulty to the theory which explains the latter in the manner here sug- gested. In our present state of ignorance of the manner in which inliuences arc communicated from one part to other parts of the nervous system, it is impossible to explain how the pro- cesses of secondary nutrition in the nervous structure are inter- fered with in distant parts thereof. But this difficulty scarcely diminishes the probability that the explanation ofiered is the true one; and, indeed, only presents one of those imperfect links in reasoning, which the immaturity of physiological science renders of such constant occurrence in all departments of medi- cal science. The operation of remedies is consistent with this view of sympathetic disturbance, since those narcotic substances which retard the processes of waste and repair in the nervous system, aflbrd the most efficient means of preventing the nerv- ous function from suffering in consequence of peripheral nervous injury. Moreover, this view of pathological sympathy, is con- sistent with the only rational view of physiologicarsympathy. Secretions are the result of secondary nutrition. Many secre- tions are normally excited by the irritation of nerves more or less distant ; that of the mamma, for instance, of the testis, and to some extent, of the gastric glands. Here then, at least, are processes of secondary nutrition energetically influenced by the irritation of distant nerves. It may be doubted whether the application of this argument can be extended to the functions 28 •131 PATHOLOGY OF INSANITY. of the brain. It has, indeed, been affirmed that the organ of alimentativeness or of amativeness is excited to functional activity — that is, a quicker process of secondary nutrition — by irritation of peripheral nerves. But -what central organ is excited to desire the heat of a fire, by the painful impression of cold ? or the luxuiy of repose, by the not less painful sense of fatigue? There is scarcely a separate organ for each of the many wants and desires which nature, or still more imperious habit, has impressed upon us. The desire of alcohol, perhaps, comes under the alimentative head ; but the desire of opium and tobacco is not less urgent in those habituated to their use. The organs of the brain are far less xmder the influence of the peripheral nerves, than are the periodic glands. A man may be as hungry as a famished wolf, without thinking of food. Loud sounds may strike upon the waking ear, or ^'ivid and re- markable objects upon the retina, without exciting attention, if the mind is deeply absorbed in other matters. Nevertheless, the mind may and constantly does act in sympathy with the state of the peripheral nerves ; and the normal waste and repair of the brain is constantly, although not solely, influenced by the impressions made upon the nerves of general, special, and functional sense. This independence of the brain upon those nervous irritations and impressions, — which doubtless impart to it the first stimulus to functional activity, but which subsequently exercise a permissive, rather than an imperatorial influence, — this independence was needful for the preservation of mental health. The brain has its own laws, and is no abject dependent upon the sensations. Had it been otherwise, sanity would scarcely have been possible, and man vould have been the puppet of every mean circumstance, the reasoning automaton of wind and weather. The moral law could for him have had no existendte ; and his thoughts, feelings, and actions, must have followed as the necessary consequence of the latest sensory im- pressions. Sensations are, in the first instance, needful to excite the mental functions into activity. AVithout the stimulus of sense, the infant cerebrum would remain devoid of ideas and emotions, an inert mass like a lung, perfect in structure, but into which air has never been admitted. But once excited to action and supplied with ideas, the brain is no longer dependent PATHOLOGY OF INSANITY. 435 upon the organs of sense. It can act without them or against tlicni, employing its energies iipon the provision of ideas furnished l^y memory, and by its own emotional and instinctive habits. Pathology of Monomania. — Every one conversant M'ith the phenomena of insanity, is aware that there are patients in whom the aberrations from mental soundness are limited in the range of objects to which they apply, and in the range of subjective faculties which they implicate. In many instances of this kind, an enduring perversion of the modes of thought, the foundations of belief, and the Avorkings of emotion on one, or at least a few objects, are the well-reeoguised symptoms of that form of disease which systematic writers treat of under the head of ^Monomania. It would be incorrect to say, that in the purest cases of monomania none of the faculties are weakened ; since the simplest hallucination or delusion proves a want of healthy energy in the perception or the judgment. But as a whole, and outside the morbid subject of opinion and feeling, the mind is not weakened. Moreover, the general health of such patients is excellent; and if they die of any acute intercurrent disease, no pathological appearances are observed in the brain. To account for the perverted opinions and emotions of such patients upon the principles advocated in these pages, is a more difficult task than in the more numerous cases in Avhich existent pathological change can be demonstrated in the cerebral organ itself, or reasonably inferred from the accompanying symptoms. Con- sidering the vigorous and healthy activity of the mental functions most implicated in monomania, on all subjects outside the circle of delusive opinion; considering the unimpaired state of the bodily health, so frequent in these cases ; and lastly, considering the absence of pathological appearances in the brain after death ; it is impossible to attribute the mental phenomena to active pro- cesses of disease existing in the cerebral organs. But, inasmuch as all perverted function is dependent upon abnormal states of the material organ ; inasmuch as many instances of the kind under consideration originate in the ordinary causes of morbid change, and are accompanied during the early part of their course by the onlinary symptoms of cerebral disease, and that they sometimes, though rarely, give way under the influence of time and moral treatment ; it is certain that these functional per- 436 PATHOLOGY OF INSANITY. versions are dependent upon abnormal states of their organ ; but which it is diflBcult to recognise as pathological^ how much soever they may deviate from the standard of structural perfection. The only rational explanation of which these conditions of func- tional perversion with apparent health of the organism appear capable^ is that afforded by the establishment of a habit of cell- growth and nutrition in the mould or type impressed by a previous state of diseased action, A morbid process of some kind or other establishes a certain irregvdarity in the cell development, and impresses upon the in- timate structure of the organ an abnormal habit of nutrition, which endures after the pathological factors have been removed. The physiological habit or constitution of the whole body is frequently altered by an attack of acute zymotic disease, which has, nevertheless, left behind it no legacy of determinate patho- logical change. That which takes place in the body at large, is by no means uncommon iu its most important organs; and an irregular habit of functional activity is a frequent legacy of disease in the stomach, kidneys, and uterus. This habit depends upon a peculiar arrangement of cells, or mode of cell-growth, impressed by diseased processes, and continuing in the same mould or type after these processes have ceased. This explanation of diseased function arising from physio- logical growth, taking place in a pathological mould or type, has been admii-ably elucidated in Mr. Paget's second lecture on ' Surgical Patholog5\' He says : " The last condition which I mention as essential to healthy nutrition, is a healthy state of the part to be nourished." " This is indeed involved in the very idea of assimilation which is accomplished in the formative process, wherein the materials are supposed to be made like to the structures among which they are deposited ; for unless the type be good the anti- type cannot be." " When any part or constituent of the blood has been injured or diseased, its unhealthy state will interfere with its nu- trition, long after the immediate effects of the injury or disease have passed away. Just as in healthy parts, the formative process exactly assimilates the new materials to the old, so does it in diseased parts ; the new formed blood and tissues take tl^e like- PATHOLOGY OF INSANITY. 437 ness of the old ones in all their peculiarities, whether normal or abnormal ; and hence the healthy state of the part to be nourished may be said to be essential to the healthy process of nutrition." "After any injury or disease by which the structure of a part is impaired, we find the altered structure, whether an induration, a cicatrix, or any other, as it were, perpetuated by assimilation. It is not that an unhealthy process continues ; the result is due to the process of exact assimilation, operating in a part of which the structure has been changed ; the same process which once preserved the healthy state maintains now the diseased one." " Yet, though this increase and persistence of the morbid structure be the general and larger rule, another within it is to be remembered ; namely, that, in these structures, there is usually (especially in youth) a tendency towards the healthy state. Hence, cicatrices, after long endurance, and even much increase, may, as it is said, wear out; and thickenings and indu- rations of parts may give way, and all again become pliant and elastic." " I can hardly dou])t that herein is the solution of what has been made a hindrance to the reception of the M-hole truth concerning the connexion of an immaterial mind with the brain. When the brain is said to be essential, as the organ or instrument of the mind in its relation with the external world, not only to the perception of sensations, but to the subsequent intellectual acts, and especially to the memory of things which have been the objects of sense, it is asked, How can the brain be the organ of memory, when you suppose its substance to be ever changing? Or, how is it that your assumed nutritive change of all the particles of the brain, is not as destructive of all memory and knowledge of sensuous things, as the sudden destruction by some great injury is? The answer is, because of the exactness of assimilation accomplished in the formative process. The eflfect once produced by an impression on the brain, whether in perception or intellectual act, is fixed and there retained ; because the part, be it what it may, which has been thereby changed, is exactly represented in the part which, in the course of nutrition, succeeds to it. Thus, in the recollection of sensuous things, the mind refers to a brain, in which are retained the eftccts, or rather the likenesses, of 438 rATHOLOGY OF INSANITY. changes that past impressions and intellectual acts had made. As, in some way passing far our knowledge, the mind perceived, and took cognisance of, the change made by the fii'st impression of an object acting through the sense organs on the brain; so afterwards it perceives and recognises the likeness of that change in the parts inserted in the process of nutrition.^^ INIr. Paget tlius supplies arguments for a strictly cerebral view of mental power, which go deep to the root of the matter. If he repudiates the conclusions to which his reasoning necessa- rily tends, it may be owing to some lack of confidence in his audience. He may think that to teach the identity of mind and of cerebral function, is mental food too strong for the College of Surgeons ; as Mephisto exclaims : " Das Beste das du wissen kannst Darfst dii den Buben doch nicht sagen." But his teaching will strengthen the mental digestion, and after a while stronger diet may be ventured upon. Is physiology never to be freed from the incubus of a supposed tendency to atheistic opinions ? It has, indeed, been unfortunate, that this beautiful science has found some of its most diligent cultivators among men of such opinions, who have perverted its truths to the support of their impious sophisms. But, at the present day, Atheism, and its twin sister, Pantheism, have their strong- hold among the anti-physiological spiritualists, while the great hope of the Christian in a future life, and the basis of his faith in a personal God, are defended, even by the ablest divines, upon physical grounds. (See the Rev. Isaac Taylor's ' Pliysical Theory of a Future State of Existence/) All that Mr. Paget says, respecting the physiological growtli of brain upon the pathological type of disordered sensation, will fully apply to the same growth on the type of disordered emo- tion ; and his views afford an admirable basis for the only rational explanation of partial insanity occurring in persons in whom, during life, there arc no physical phenomena of diseased brain, and in whom, after death, there arc no pathological appearances in the organ of mind. To resume — the theory of partial insanity, without appreciable cliangc of the brain, is as follows: — When the disease first ex- ists, it is attended by pathological states of the cerebral cells and vessels. A morbid condition of the cerebral organization is oc- PATHOLOGY OF INSANITY. 439 casioned, attended l)y the phenomena of insanity. After a sliort time the vessels recover their tone, the hrain is nonrished, and its size maintained as a -whole. But the original balance of its organs is not regained ; their nutrition having been impressed in the type or mould of their diseased state. Perhaps some of the cerebral organs encroach on others by their actual Imlk ; un- doubtedly some of them overbear others by their greater acti- vity. The result is chronic mental disease, of a nature which leaves behind no pathological appearance. Account of Special Pathological Changes. — It has been unfor- tunate for the cause of cerebral pathology, that those writers wlio have devoted much care and attention to the observation of cerebral changes presented in post-mortem examinations, have either lacked the desire or the opportunity to make themselves acquainted with the mental phenomena which had preceded death. The careful and minute detail of appearances observed in the brains of persons supposed to have died insane, disconnected from any account of the symptoms which existed during life, are of comparatively little value, in the present imperfect state of pathological science. A few fossil teeth and bones enable Pro- fessor Owen to reconstruct the probable similitude of an extinct animal ; but the science of pathological anatomy has attained far less certitude than that of comparative anatomy; and thus such descriptions as those of the post-mo7iem examinations made in Bethlem by Dr. Webster, have their practical value diminished from the want of some account of the symptoms which in each case preceded death. The descriptions of the older anatomists, Morgagni, Bonetus, and others, have the same defect ; a defect, indeed, of which Morgagni was fully sensible, and of which he offers an explanation, or rather an excuse, in the fact that the medical men who had observed the cases, during life, frequently did not know whether to call the patients melancholiacs or maniacs. He says, " melancholia is so nearly allied to mania, that the diseases frequently alternate, and pass into one another ; so that you frequently sec physicians in doubt whether they should call a patient a melancholiac or a maniac, tacitur- nity and fear alternating with audacity in the same patient ; on which account, when I have asked under what kind of de- lirium the insane persons have laboured whose heads 1 was about to dissect, I have had the more patience in receiving answers 410 PATHOLOGY OF lNSA?sITY. which were frequently ambiguous, and sometimes antagonistic to each other, yet which were, perhaps, true in the long course of the insanity." — {De Sedibus et Caiisis Morbormn, Epist. A^ii.) Of the thirteen examinations recorded, ^lorgagni himself made eleven ; his pupils made one ; and the other one was made by Valsalva. The appearances noted by them in this small number of dissections, include a large part of the morbid ap- pearances which extended observation, and the advantages derived by later anatomists from the instructions of those pre- ceding them, have been able to distinguish. In one or other of the eases, the dura-mater was found thickened and adherent to the cranium ; the vessels of the meninges distended with dark blood ; serum was found between the meshes of the pia-mater, sometimes in large quantity ; there were also air-bubbles in the vessels of the pia-mater ; the consistence of the brain altered — sometimes soft, sometimes more or less hard ; discoloration of the medullary substance, from distension of its blood-vessels; serum in the ventricles, sometimes clear, sometimes turbid ; the choroid plexus in some cases injected, in others containing cysts; the vessels of the brain sometimes distended with black and fluid blood ; in one instance the coats of the arteries were uiiusually firm (query atheromatous). In one instance a fibrinous clot occupied the whole of the longitudinal sinus. This occurred in a young woman who died with general prostration of the vital powers. It is probably the earliest instance recorded of this appearance, and it is interesting in connexion with Dr. C. B. "Williams's views on the formation of fibrinous clots in the cere- bral sinuses of asthenic subjects. Of the thirteen insane persons dissected by Morgagni, it is remarkable that no less than four came to an untimely end. One threw himself out of a window in the night, and was killed. One was tied by the throat by his keeper, so that he was stran- gled. One was starved to death during severe weather; and one, after recovery from insanity, died from inflammation of the intestines, occasioned by a finishing dose of black hellebore. Morgagni concluded that the cause of insanity existed in many cases, in the morbid changes of the pineal gland, and in many others in an induration of the brain. We are ini'ormcd that, in his examinations, he was in the habit of removing the \ PATHOLOGY OF INSANITY. 411 head from the tnmk, for the sake of convenience, before lie examined the brain. This indicates forcibly the difference be- tween the accuracy and delicacy of the examinations made by the greatest of the old pathologists and those of the present day. An examination conducted after this fashion would be little likely to offer evidence of moderate serous eff'usions, or the less obvious conditions of hypertemia. The pathological records of insanity made by other anatomists of the last century are still less marked by exact observation than those of Morgagni, and are, perhaps, more interesting to the medical antiquary than to the modern pathologist. A brief reference to them may, however, be instructive, as showing that many of the changes which still most readily catch the attention of observers were then noted. Bonetus observed hypertrophy of the brain ; obliteration of the sutures; the dura-mater adherent to the cranium, and turgid with blood ; the pia-mater turgid with blood, and not insinuated between the convolutions ; water in the ventricles and other parts of the brain, in large quantity ; the substance of the brain mai'ked with a black spot, and sometimes with an infinite num- ber of bloody spots, especially on pressing it — in one case, dry, hard, and friable. Boerhaave mentions, that the brain of maniacs has been found dry, hard, and friable, and of a yellow colour. Haller classified the observations made by others upon the brains of insane and phrcnitic persons, and concludes thus : — " From these few observations, for which we are chiefly indebted to Morgagni, but little certainty can be derived; since it not only frequently happens that we can discover no disorder in the bodies of maniacs, or even of such as have been totally insensible ; but where we do, we are as far from being able to perceive an uniform connexion between any one disorder of the mind and some corresponding preternatural state of the con- tents of the skull, that the very same appearances are exlnl)itcd after those most opposite disorders, idiotism and frenzy; which last seeming inconsistency may possibly appear less extraor- dinary if we consider the symptoms of drunkenness and frenzy, in whi(di we may observe that the very same cause produces, at first delirium, and afterwards, as the disorder advances, drowsi- ness and insensible stupor. This, however, seems evident, that 442 PATHOLOGY OF INSANITY. in the disorders of the mind the brain and its connexions are usually affected ; and when, in some rare instances, we can discover no disease of these parts, we may conclude, either that it is seated in their very elementary particles, or has not been sought for ivith sufficient patience and attention." — {' Elements of Physiology/) Greding, in 216 cases, found the skull unusually thick in 167 cases ; the dura-mater adherent to the cranium in 107 cases ; the pia-mater thickened and opaque in 86 out of 100 cases of mania ; and beset with small spongy bodies in 93 out of 100 cases. He observed effusions of serum between the dura and pia-mater in 120 out of 216 cases of insanity, and in 58 out of 100 maniacal cases ; the lateral ventricles were distended in 52 cases. The choroid plexus was found healthy in only 16 out of 216 cases of insanity; and it was thickened and full of hydatids in 96 out of 100 maniacs. These records will convey strongly the impression, that how- ever exact the observations of this pathologist might have been, he did not interpret the morbid appearances as we are accus- tomed to do at the present day. Effusions of serum between the dura-mater and the pia-mater, and diseased conditions of the choroid plexus, are conditions which need some description to be intelligible. Meckel remarked the increased density of the cerebral sub- stance in the bodies of the insane. Soemmering and Arnold confirmed this obsen'ation ; and the latter expressed his conviction that insanity was occasioned by the increased density of the cerebral substance, and of those parts of the brain by means of which the soul is connected with the body. Portal declared that all mental diseases were the effects of morbid alterations in the brain or spinal chord. He enumerated a great number of alterations, but with so much inaccuracy that little reliance can be placed upon his descriptions. He enun- ciated, however, on this subject, the following sound and philosophical doctrine, which, to the present day, may well serve as a text for labourers in this difficult and obscure depart- ment of i)athology : — " ]Morbid alteration in the brain or spinal marrow has been so constantly observed, that I should greatly prefer to doid)t the sufficiency of my senses, if I should not at PATHOLOGY OF INSANITY. 4-13 any time discover any morbid cliangc in the brain, than to believe that mental disease conld exist without any physical disorder in this viscus, or in one or other of its appurtenances." Piuel had no conhdcnee in the revelations of pathological anatomy. In the preface to his excellent work on ' ^Icntal Alienation/ referring to the labours of Greding, he remarks : — " But although one must eulogise his eflbrts to throw new light upon the organic aftectious of the insane, is it possible to estab- lish any relation between the physical appearances manifested after death, and the lesions of intellectual function which have been observed during life ? AVliat analogous varieties does not one find in the skull and In-ain of persons who have never shown any sign of aberration of mind ! And, therefore, how can we succeed in fixing the limits which separate that which is normal from that which must be held to be the result of disease ?'' (p. XX.) In the body of his work (p. 142) he refers the primitive seat of mania '' to the region of the stomach and intestines, from whence, as from a centre, the disorder of the understanding is propagated by a species of irradiation, A feeling of constric- tion, &C.J manifests itself in these parts, soon followed by a disorder and trouble of ideas.^^ Well might Gall exclaim, in reference to these opinions of the great reformer of the treatment of insanity, and to other opinions, scarcely more philosophical, on the same point, of Pinel's eminent pupil and successor, Esquirol : — " It is a sad business that, in writing for men who ought to have the clearest ideas upon mental disease, it should be necessary to commence by establishing the true seat of mania" (tome ii, p. 223) ; and he adds that Fodere actually undertakes to prove that the brain is neither the seat of inclination, instinct or mental power, much less of mania or delirium. Injustice to Pincl it should be remarked, that, however mis- taken his views upon the pathology of insanity may have been, they had at least the merit of referring a bodily disease to a bodily origin. In the preface to the second edition of his work, he thus wisely cxprcs.ses an emphatic condemnation of meta- physical theories on this point : " The most difficult part of natural history is, without doubt, the art of well observing internal diseases, and of distinguishing them by their proper 444 PATHOLOGY OF INSANITY. characters. But mental alienation presents new and diverse difficulties and obstacles to surmount, either in the unusual gestures and tumultuous agitations which it occasions, or in a kind of disordered and incoherent chatter, or in a repulsive or savage exterior. If one desires to account for the phenomena observed, one has to fear another rock — that of intermingling metaphysical discussions and divagations of ideology with a science of facts." Esquirol, the pupil of Pinel, adhered with affectionate perti- nacity to the opinions of his great master. He states, in the ' Dictionnaire des Sciences Medicales,' that the principal changes observed in the brains of insane persons are — " The cranium frequently thick, sometimes eburnated, sometimes with thick- ness of the diploe, very frequently injected, more rarely thin, its thickness variable in different regions ; the dura-mater ad- herent either to the vault or to the base of the cranium, some- times thickened, frequently its vessels developed and injected ; the internal face of the dura-mater clothed with a mcmbraniforra layer, as if the fibrine of effused blood had extended itself in the form of a membrane. Almost always between the arachnoid and the pia-mater serous or albuminous effusions are found, which covei', and almost eflFace the convolutions. Effusions at the base of the brain are common ; they exist almost always in the ventricles." In M. EsquiroPs great work, ' Des Maladies Mentales,' pub- lished so recently as 1838, his opinions on pathology are con- siderably modified. Referring to the case of a recent maniac, who was killed by one of her companions, and in whose body he and his pupils were surprised to find no lesions of the brain or its meninges, he declares, that "pathological anatomy, in spite of the very important labours of MJNI. Foville, Calmeil, Baylc, Guislain, &c., has not been able to make us acquainted Avith the organic cause of mania. Thirty years ago, 1 would willingly have written upon the pathological cause of madness. At the present day I would not attempt a labour so difficult — so much of incertitude and contradiction is there in the results of the necroscopy of the insane made up to this time. But I may add, that modern researches permit us to hope for ideas more positive, more clear, and more satisfactory." j\r. Foville describes in acute cases injection of the pia-mater PATHOl.OCY or INSANITY. 4l5 existing to a greater or less extent, according to tlie degree of intlanimatory action in the cortical substance. In chronic cases, he describes opacity and thickness of tlic membranes, adhesion of the membranes to each other, granulations of the pia-mater, and false membranes. The grey substance, he asserts, is, in acute cases, intensely red on its surface and in its substance. This redness is most vivid in the frontal and vertical region. The redness is not uniform, but mottled and diversified with spots of a violet hue, and with minute extravasations of blood. He describes the consistence of the cortical layer underneath its surface to be diminished, the surface itself licing somewhat indurated. In acute cases, the pia- mater, he says, is not ad- herent to the cortical substance, while in chronic cases it is frequently so ; and in this fact he sees an important distinction, capable of explaining the incurability of chronic mental disease. In chronic cases, the superficial or outer layer of the cortical substance becomes indurated, and capable of being separated from the inner layer, which is softened and mammillated ; the outer layer is harder, the inner layer is softer ; the outer layer browner, and frequently paler, the inner layer redder than natural. Atrophy of the convolutions he also describes as frequent; and this may be confined to the cortical substance, the surface of which is marked with irregular depressions filled with serum. The grey substance is sometimes softened through- out its thickness, and changed to a brownish colour ; the soften- ing of the grey matter is sometimes so great that it may be washed off the white matter (which is sometimes harder than usual) by pouring water upon it. The medullary substance is frequently injected, showing numerous bloody points when divided ; sometimes it is more uniformly discolored, and has a purplish hue ; sometimes it becomes exceedingly white and indurated ; sometimes, however, when indurated, it has a yellowish or grey tinge. Induration of the medullary substance is attributed by M. Foville to the adhesion with cacii other of the several planes of tiie fibres, of which he believes the mass of the white substance to be composed, and whith are united to each other by fine cellular tissue. These observations of M. Foville, made partly at the Salpet- ricre and partly at St. Yon, are highly important and instructive. They agree, in many respects, as we shall hereafter see, with 446 PATHOLOGY OF INSANITY. the precise and admirable rescarclies of M. Parcbappe; and although in some respects it may be difficult to verify their correctness in the post-mortem rooms of institutions where but a few cases are examined^ it is certain that the leading features of the pathological change in the substance of the brain, which were first indicated by M. Foville, are to a greater or less ex- tent recognisable in a great number of bodies, and amply deserve full and patient investigation, in order to establish their nature and their connexion with the various forms of insanity. The researches of Bayle and of Calmeil have reference rather to a particular form of insanity, namely, general paralysis, than to the pathology of mental disease at large. M. Bayle attributes insanity to inflammatory irritation of the membranes of the brain, and paralysis accompanied by loss of mental power, (dementia,) to pressure exerted upon the brain by effusions resulting from this inflammatory state. ]\I, Calmeil attributes insanity in general to a chronic inflam- mation of the brain, and general paralysis in particular, to chronic inflammation, followed by induration, of the fibrous substance. M. Lelut, who published in 1836 his work upon ' The Value of Cerebral Alterations in Acute Delirium and Insanity,' came to conclusions opposed to those of the author last mentioned. He sums up the result of his researches in the following words : '' Istly. Numerous alterations of the brain and its envelopes are met with in delirium and insanity, especially in extreme forms of the latter : but these alterations are neither constant nor exclusive. " 2ndly. Hence it must be allowed that the more or less local and coarse alterations in the skull, the brain, and its membranes, cannot be held to be the proximate causes of insanity. They are, doubtless, capable of existence mth a delirious or insane condition, but they do not constitute this condition ; and frequently they are only the exaggeration, the efl'cct, or the transformation of it. " .3rdly. That which may be given as the nearest approach to the proximate cause of delirium, and to the most acute form of insanity, is inflammatory lesion of the brain and its tunics. But this alteration neither does nor can constitute the state 1'atiioi.o(;y of inisamtv. 447 wliicli is anterior to it, and may even destroy life Avitliout producing it. " 4thly. The conditions of the brain which approach the most closely to the proximate cause of the chronic forms of mental alienation, with or without impairment of motion, are without doubt chronic inflammation of the substance and of the mem- branes of the brain, its atrophy and induration, which may be accompanied by variations in its specific gravity. But yet these alterations are not the proximate cause of these forms of insanity, because they are neither constant nor exclusive, and they do not make themselves apparent except in an advanced period of the disease." The arguments by which M. Lelut arrives at these conclu- sions appear almost as shifting as the organic lesions Mhich are, and are not, according to him, the cause or the condition of insanity. Inflammatory lesions of the brain are, according to him, very near being the cause of acute insanity ; but they are not the cause, because they may destroy life without pro- ducing insanity. Chronic inflammations also approach closely to the cause of chronic insanity, (les conditions du cerveau qui se rapprocheut le plus de leur cause prochaiue); but yet they are not the proximate cause, because they only make themselves obvious after a while. Some years subsequently to the publication of M. Lelut's book, another eminent French physician, ^M. Leuret, published a work on the same subject. The title of this work, ' The Moral Treatment of Insanity,^ would lead us to expect views adverse to the somatic origin of mental disease ; and such, in fact, is the case. Physicians who treat insanity with penal remedies are not likely to regard its cause as a pathological condition of the organism ; and, on the other hand, physicians who refuse to regard insanity as a bodily disease, and who interpret its phenomena as manifestations of a fermentation in the spiritual essence, easily and logically persuade themselves that sharp penal remedies are useful and justifial)le in its treatment. M. Leuret certainly combats the somatic theory, and the pathological facts upon which it rests, with a logical acumen contrasting very strongly with the manner of the author last mentioned, and even of M. Esquirol. AVhile we entirely dissent 418 PATHOLOGY OF INSANITY. from his conclusions, we arc glad to avail ourselves of his assistance to ascertain the weak points of that doctrine which attributes insanity to cerebral change alone ; a doctrine of the truth of M'hich we are convinced, but the proofs of which, it would be vain to deny, require to be multiplied, confirmed, and arranged, with a care and precision which they have not yet received. M. Leuret believes that he has established the follow- ing positions : Istly. That the authors who believe it possible to establish an anatomical change as the cause of insanity differ greatly among themselves ; thus Greding asserted that thickness of the bones of the cranium occurs in 77 out of 100 patients, while Haslam found this condition in 10 only out of 100 patients. Hyperfemia of the brain is recorded by Parchappe in 43 cases out of 100; and by Bertoleni only in 14 out of 100. 2ndly. That some of the cerebral alterations (to which insanity is attributed) are by no means well established. Thus, in the cases which are cited of hypertrophy in the brain, it ought to have been established that this was not owing to fulness of its vessels, or to the presence of a scrosity in its tissue. These observations have not been made. Again, that which is called a dense brain, or a soft brain, expresses nothing distinctly, except in extreme cases. 3rdly. That the value attributed to certain alterations is de- duced from a number of observations by far too small, so that one result frequently invalidates another; thus M. Parchappe has deduced the average normal weight of the healtliy brain from thirteen observations on men, and nine upon women, and upon this average he establishes the rule for atrophy of the brain. This average is evidently too small, and indeed M. Par- chappe gives different averages elsewhere. 4thly. That the pathological alterations referred to insanity arc met with in patients who have never been insane. 5thly. That all autliors confess that there are insane persons in whose brains no pathological changes are found. Gthly. That the lesions which are frequently met with among the insane, to which any value can be attached, are only met with in cases in which insanity has been complicated with paralysis ; and that, in order to decide if any lesion is the cause of insanity, it is at least necessary to find it in a case of simple l'ATlloL(ni\ Ul I.NSAMTV. 41'J mental abcrratiuu, iu which there has been no ati'eetiun of motion or sensibility. That so able an opponent of the somatic theory a.s M. Leiirei undonbtedly is, shonld have been compelled to rest his argnment upon no better foundations than those above nanicd^ appears to afford strong presumptive evidence of the truth of that theory. Wc shall make some brief comments upon cacli of his objec- tions. 1st. That authors should ditfcr so greatly in their estimate of pathological changes, as M. Leurct lias shown tlicm to have done, can prove no more than that authors have been inexact iu their observations, or careless in recording them. The objection may to some extent be valid against the value of statistics in pathological science. It may shew that one author counted slight appearances of change, while another only recorded extreme instances ; but it can in no way detract from the value of the fact, that all authors cited did observe the pathological changes they have recorded, in a certain number of cases. 2ndly. That pathological changes of the brain need to be observed Avith greater exactness than heretofore is undoubtedly true. The}' have, however, ])ecn observed Avith greater exacti- tude than !M. Leuret admits; for instance, in the case he cites, hypertrophy, it is well established that in this rare condition the brain is paler and drier than usual, and that the increase in its volume cannot be attributed either to fulness of the vessels or to serous infiltration. 3rdly. This objection again applies to the statistical metiiod of proof, as it is too frequently used. It applies, however to the abuse of this method in all departments of pathological science. Doubtless, those who count observations without esti- mating them as recommended by Morgagni, misuse the numeri- cal method in their deductions upon all diseases, insanity included. 4thly. If M. Leuret can show that serious pathological change iu the cortical substance of the convolutions has existed in per- sons whose mental functions have never been aft'ectcd, he will go far to upset the somatic theory of the nature of insanity ; but this he has not done, nor, in our opinion, is he likely to do. That some pathological changes which are observed in insane persons but which arc non-essential to insanity, should occur 2[) 450 PATHOLOGY OF INSANITY. also ill persons who have always been sane, is a fact of no value in the present discussion. 5thly. That in the brains of some insane persons no patholo- gical changes are observed, is undeniable ; but would it not, in these cases, be more philosophical to doubt with M. Portal, the sufficiency of our powers of observation, than to use them as an argument against the existence of all pathological change of an organ whose functions are perverted, but Avhosc structure is not obviously injured. Is j\I. Leuret able to point out the patholo- gical changes which cause neuralgia, tetanus, chorea, or hysteria, or those by which life is destroyed by a blow on the epigastrium, or by concussion of the brain V Deficient information should lead us to seek for more light, aud should by no means induce us to veil that which we possess. 6thly. M. Leuret certainly mistakes the fact, when he aflfirins that cerebral lesions are only found in those insane persons who are paralysed. The lesions peculiar to the different forms of ordinary paralysis are by no means "well ascertained, and yet no one doubts that paralysis is always occasioned by lesion of the nervous system ; while the conditions of the brain which arc found in general paralysis are not as yet better understood than those which occur in simple mania or acute delirium. Moreover, whatever doubt may hang over the primary pathological changes which attend the earlier stages of simple mental aberration, there can be no doubt whatever that the secondary conditions v.hich attend the chronic stages of simple insanity, uncompli- cated with paralysis, arc undeniably obvious in degraded nutri- tion and atrophy of the cerebral organ. We have stated M. Leuret^s objections, aud have answered them at some length ; for we must pay him the compliment of considering him the most formidable antagonist of the patlio- logieal view of insanity. He has stated his reasons for the opin- ions he entertains, with precision and candour, and he has thus afforded us an opportunity of answering them, an opportunity which would be sought in vain against the crude opinions upon this point expressed by Pinel, and even by Esquirol and Georgct. j\l. Guislain, the able leader of psychology in Belgium, classes the lesions of the brain found in insanity under nine heads : 1st, a state of sanguineous congestion of the meninges, the brain, or the two together ; 2iidly, a state of serous congestion I PATHOLOGY 01' INSANITY. 451 of tlic above; 3r(Uy, cerebral softening; Itlily, opacity and thick- ness of the ai-achnoid ; othly, adhesions of the membranes to each other, or to the brain ; Gthly, cerebral induration ; 7thly, cereln'al hypertrophy ; Sthly, cerebral atrophy ; 9thly, vices of conformation of tlie brain and of the skull. These conditions are, he thinks, in a practical point of view, capable of being reduced to four fundamental alterations — sanguineous congestion, serous congestion, softening, and indu- ration. It is open to doubt, however, whether the tlu-ee latter of these alterations can be considered fundamental ; and it is certain that the four do not include all the conditions which may be considered fundamental. He does not include those aberrations of nutrition known under the names of inflamma- tory, atrophic, and anremie. That ;M. Guislain admits the existence of such conditions, is abundantly evident from the pages that follow. At page 3G7, "Lemons Orales,'^ tome i, he attributes to the state of congestion, not only ecchymoses of the arachnoid and pia-mater, but false membranes, and a red appearance of the arachnoid, " having the aspect of an inflamed conjunctiva." Such an appearance, and especially the existence of false membranes, cannot be attributed to a state of congestion, and if they occur, should have induced this able physician to have admitted the inflammatory, as one of the fundamental states of the brain in insanity. He estimates that, in one-fourth of the bodies of persons dpng insane, there is a cougestionary state of the encephalic mass ; but he declares his opinion, that this proportion is far from that which obtains among the living insane, and that the majority of those who ai-e cured have never had congestion of the brain in a notable degree. M. Guislain says, " The brain and its membranes may have been congested without the existence of a state which can be called inflammatory. If inflammation were always a condition of congestion, would one see the numerous cures which take place among sanguine and robust maniacs, who offer in the course of their disease those symptoms which one often con- siders to be inflammatory, and which are really only a vascular orgasm, and not a state of phlegmasia. Broussais himself felt this in giving to this condition the name of sub-inflammatory. 452 I'ATIIOLOCV Ol' INSANITY. It is an attlux of blood, wliieh may in a manner be compared to that injection of the cliceks v,hich accompanies shame and modesty ; that injection Avhich makes itself evident in the eyes, over the -\vliole face, the neck, and even over the breast of a man agitated by violent anger/^ It is evident, however, that a mnch more profound and serious change exists in the blood-vessels of the insane brain, than in the transitory blush of modesty or the suffusion of passion. These states are physiological, and leave behind them no ten- dency to destructive change. The state of the congested brain in insanity is pathological, and tends to pass into a state of structural change, respecting the wide deviation of which from a state of health there can be no doubt. If the congestion of insanity Averc of the character Avhich ]\I. Guislain attempts to attribute to it, insanity would be as transient as passion, or passion Avould be as dangerous as insanity. M. Guislain has himself gone further than most writers on this point, in representing by means of woodcuts the microscopic appearances of change in the congcstionary state of mania, in the fatty degeneration following mania, and in congestion with and without softening. "\\'e have been unable to verify the accuracy of these repre- sentations, but we firmly believe that this want of success in recognising the microscopic character of the cerebral changes which result from liypersemic conditions of the brain, has for its sole cause the limits which bound our powers of observation, arising from the want of po^ver in the organs of sense and their mechanical aids. M. Parchiqjpe. The most careful investigations into the path- ological anatomy of insanity, made in France, are, without doubt, those made by M. Parchappe, the present Inspector (ieneral of Asylums in that country. His first work on the diflerent alterations of the brain in insanity was i)ul)lished in 1S:38. ]M. Parchappe commences by admitting fully, "That there is no single pathological alteration Avhich can be pro\ed to exist in all cases of insanity ; but there are three which have been found in the majority of cases. This is a result which might have been expected. The i)athologists Avho have searched ibr one essential characteristic pathological change, might have siived themselves a deception. . . . Tlic point which one I'.VTIIOLOGV OF INSANITY. 453 may reasonably hope to obtain is, to be able tf) (lir.lin^nisli among cases of mental disease those kinds which arc charae- terised both by the constancy of the symptoms, and by that of pathological change." In M. Parchappe's opinion, the uncertain recognition of pathological alterations in insanity, and the occa- sional absence of all appearance of change, disprove, indeed, the theories of those -who attribute insanity to some exclusive patho- logical condition of the brain, — for instance, to chronic menin- gitis, or to induration of the brain, — but they do not prove that these alterations are, as asserted by ]^]squirol, Leuret, and others, mere complications or consequences of the malady. The altera- tions uiiieh exist in simple inflammation of the brain and its membranes, are not those which arc found in insanity. Those which are found in insanity may be distinguished into, — 1st, those which may be considered accidental ; 2nd, those Avhich, existing in other maladies, yet appear to play a part in the production of insanity ; and 3rd, those which are believed to be essential to mental alienation. Among the first may ])e enumerated cerebral hremorrhagcs, partial softening of the white substance, disease of the cerebral arteries ; and, among the second, thickening and opacity of the arachnoid, hyperajmia of the pia-mater and of the brain, serous infdtration of the pia- matcr, dropsy of the arachnoid cavity. In the important last division, this author includes the following changes : sub- arachnoid eeehymosis, and a partial punctiform injection of the cortical surface, with or without softening, extended soft- ening of the middle portion of the cortical substance, ad- herence of the pia-mater to the surface of the brain ; rose, lilac, and violet coloured discolouration of the cortical sub- stance, loss of colour of the cortical substance, atrophy of the convolutions, induration of the brain. M. Parchappe believes, that he is able to establish the following classification of mental disease upon the pathological changes which he has observed. 1st. ^lonomania; in this form of insanity, no patho- logical change is found to exist in the brain, and the probal)le cause is to be sought in the organic predominance of some por- tion of the brain, in consequence of its size or activity. 2nd. Acute ;Mania and Acute ^lelancholia ; in these forms of insanity, the alterations found in the brain to a certain extent resemble those of inflammatory affections of the organ. They are 451 PATHOLOGY Or INSANITY. hypersemia of the pia-mater and of the cortical substance, partial injections of the sub-arachnoid tissue, puuctiform injection, and occasional softening of the cortical substance ; it is rare that the meninges are found extensively thick and opaque. The above alterations are usually more decided in acute melancholia than in acute mania. In sympathetic mania, that is, in mania occa- sioned by the irritation of some part of the distal nervous system, no anatomical changes may be discovered if the exami- nation is made during the early period of the disease ; but after a while, the brain passes from the state of physiological excite- ment into that of pathological change, and then the above alterations may be expected to be found on examination. 3rd. Simple chronic mania ; in this form of insanity, the aspects of the brain are altogether different from those which prevail in the acute paralytic forms of insanity ; they are — atrophy of tlio convolutions, mth loss of colour and induration of the cortical substance, or of the medullary substance, or of both; serous infiltration of the pia-mater, and dropsy of the ventricles, con- nected with, and consequent upon, general atrophy of the brain. 4th. Paralytic insanity (general paralysis). In this the essential alteration consists in softening of the middle layer of the cortical substance ; very frequently, also, the pia-mater is thickened, adherent, and infiltrated; in the acute form, the cortical sul)- stance is hyperjemic and deepened in colour, and the pathological appearances of acute mania are present. In the chronic form, the cortical substance has lost colour and become thin; atropliy of the convolutions, and the appearances of chronic mania are present. 5th. Epileptic insanity. In this the alterations re- semble those of simple chronic mania. In 1841, I\I. Parchappe published his '^ Theoretical and Prac- tical Treatise upon Insanity," a work more fully devoted to necroscopic record than Andral's " Clinique,'' or Lallcmaiid's " Letters." M. Parchappe attempts to establish his deductions by the numerical method ; and in this we think he has fallen into an error ; first, because the number of cases upon which he founds his averages are, under some heads, insufficient to establish a trustworthy average ; and secondly, because he has, in several instances, adopted methods of comparison which arc open to much objection. The manner in which he arrives at an estimate of cerebral atropliy is objectionable, on account of both PATHOLOCa" or INSANITY. }55 of the reasons above given. He founds his estimate upon a comparison between tlic Meight of the brain examined and the average weight of liealthy brains. Now it is evident tliat^ if the diseased brain had originally been heavier than the average, a considerable atrophy miglit fail to be shown by a comparison of this kind. An atrophied brain, of large size, may still be heavier than the average of healthy brains. jNI. Parchappe's average weight of the sane brain may have been deduced from average individuals ; but he could make no selection of this kind for the other side of the comparison. The insane person whose brain has to be examined and com])ared, may have been a well-developed man, Math all the organs above the average size, or with a brain originally large or small in comparison with the rest of his body. So true is the addition which Morgagni made to the dogma of Hoffmann, "Ars med'tca tota in observationibus." Morgagni wrote, " sed perpendenee sunt non numeranda obseriHitiones." In the resume upon thirty-eight autopsies of persons dying in the acute stage of mania and melancholia, j\I, Parchappe (p. 45) affirms the same principles which he has enunciated in his former work, especially the absence of any essential and exclu- sive enceplialic alteration. He affirms, moreover, that these dissections prove the existence of an analogy as strong as possi- ble, if not perfect, between the cerebral alterations found after acute mania and those of acute melancholia ; and therefore he concludes, that the distinction between these two states is not justified upon pathological grounds. The thirty-eight examinations afford the following resume: — In thirty-six the brain was the seat of hypcraemia, either in its peripher}"^, its membranes, or its substance ; in seven instances the hyperemia was simple ; in twenty-nine it assumed the fonn of sub-arachnoid ecchymoses ; in twenty-three instances there were sub-arachnoid ecchymoses, with punctiform injection of the cerebral surface ; and in seventeen of the latter there was als softening of this surface. Sixteen times the cortical sub.stancc was reddened in colour. In one case there was no apparent encephalic alteration whatever; and in several the alterations were inconsiderable. It is needful, therefore, to admit that the pathological condition of acute insanity is of such a nature that it is possible for it to leave no post-mortem appearance. Taken 4o6 PATHOLOfiY Ol' INSANITY. singly, none of the alterations described can he held to express a pathological state of the brain ■which corresponds to the abnormal psychical manifestations ; but examined collectively, these alterations afford an idea of the pathological character which must be attributed to that state — namely, that of hypei-- ;emia. This condition was only absent in two cases out of the whole thirty-eight ; and it is very probable that hyperemia also existed during life, even in the two cases in A\hich there was no trace of it after death. The thickening of the meninges, and the superficial softening of the cortical substance, which arc so frequently found, wonki also indicate that this liyperannia is not that of simple but that of active congestion. •^ A legitimate induction may, therefore, he derived from the facts," says this author, "to the effect that there is usually, during life, an active sanguineous congestion of the brain co- existing with the symptomatic phenomena of acute insanity." "One may even recognise, Tip to a certain point, a relation l)etween the intensitj' of the symptoms daring life, and the extent of the alterations after death." Of chronic insanity, M. Parchappe details the appearances of 122 cases, which may be summed \ip as follows : — In seven instances there were no alterations, or almost none ; in elevcni instances the alterations were simply liypericmic ; in five the substances were softened ; twice there was induration of the true cortical substance alone ; eight times there Avas induration of the white substance alone ; twenty times there was induration of the two substances ; sixty-one times there was atrophy of the cerebral convolutions ; sixty-four times there was hyperaemia, which was simple in forty-six cases, and in eighteen combined with ecchymoses, and in two cases with injection and softening of the cortical substance. This substance was coloured red five times. It Avas deprived of its [normal ?] colour fifty-nine times. It is evident, says M. Parchappe, from these facts, that there is no essential and characteristic pathological appearance in chronic insanity. There may be no trace of pathological change aft; r death, or only the unimportant one of simple hypcra3mia. 15ut the alterations are remarkably difierent from those Avhich be- long to acute iiisanity. In the latter, the predominant alterations ar^: hypcrrcmic conditions, Avith arachnoid ecchymoses, injection and softening of the cortical substance. In chronic insanity, PATIlOr-OGY OF INSANITY. 157 the predominant alterations are atrophy of the eonvohiticMis, and induration of the two substances. "The symptomatic (HliVr- ences in the two forms of insanity correspond j^enerally with tln^ pathok)gical differences in the organ of intelligence.'' In chronic insanity, tiie predominant state is pathologically opposed to the liypcnemic condition of acute insanity ; and the atropliy of the convolutions, especially, expresses a movement of the plastic force opposed to that which represents active hypernemia. " The predominant alterations in chronic insanity express, in general, a state of diminution of the plastic activity ; a state diametri- cally opposed to that expressed by the predominant alteration in acute insanity, which has been shown to be active sanguineous congestion, representing the physiological principle at the highest point of plastic activity. And these conditions of the organism coincide with tlie psychical symptoms peculiar to the two forms of disease which present two opposed dynamical states — the one in which psychical activity is in a plus, and the other in which it is in a minus condition.'' M. Parchappe concludes his valuable treatise Avith a chajiter upon the appearances of the healthy brain. From an early period of liis investigations, he had instituted comparative examinations of sane and insane brains, liaving both before his eyes at the same moment. On this point he says : — " I have thus been able to assure myself how inexact is the assertion frequently made, that between two brains of this kind, it is absolutely impossible to distinguisli that whicli belongs to insanity. The contrary assertion would be much nearer to the truth, especially if one did not make it without some restriction. In regard to pai'alytic insanity, at least, it may be said, that the diflerence strikes the eye, and can only be mistaken })y prejudice or inattention." He sums up the characteristic appearances of tlie sane brain as follows : " Extreme tenuity aiul perfect transparence of the arachnoid, and of the pia-mater. Absence of sub-arachnoid serous infiltration. The membranes may be detaclied from the convolutions without producing decortication. AVhcn the cortical substance is soft, and the membranes begin to become dry, it may happen that, in circumscribed points, they detach with themselves flocculi, and even small plates of the cortical sub- stance. The cortical substance is of a grey colour, of which the 458 PATHOLOGY OF INSANITY. shade varies a little in different individuals, and in the same individual in different parts of the thickness of the substance. To the naked eye the shade of the surface does not appear paler than that of the deeper parts. The internal portion is, perhaps, a little deeper in colour, and between the two we can sometimes distinguish an intermediate shading, paler than cither. The medullary substance is of a pure and striking whiteness. The consistence of both substances is consideral)le when the death has been recent and the temperature moderate. The white substance is rather more firm than the grey. The surface of the ventricular membrane is smooth and brilliant, sometimes offering very fine gi'anulations. The cut surface of the white substance is sometimes dotted Avith a small number of red points. Under the influence of the air, the blood in the vessels becomes more brilliantly red, and the cortical substance takes on a rosy tint, whicli gradually becomes deeper, but which never attains the intensity which characterises pathological alteration of colour of this substance. The influence of time and a high temperature, produces softening and commencing putrefaction, and causes the detachment of flocculi with the membranes, like that produced by the drying of the membranes from contact with air. The convolutions are pressed together, only offering space for imbedding the pia-mater. AVhen the membranes are removed they still touch, and if separated, they return to their apposition on account of their elasticity, and the anfractuosities efface themselves. The thickness of the cortical substance varies in the anterior lobes from two to three milli- meters, and on the convexity, and at the base, from two and a half millimeters to five.'' The eminent author we have here freely quoted, lias done excellent service to the cause of a rational pathology of mental disease. He has excluded all speculative hypothesis upon the nature of mind and its aberrations, and has set a worthy ex- ample to his successors in the careful and laborious manner in which he has observed and recorded the facts upon which alone any trustworthy knowledge in this, as in all other departments of science can be founded. We are far from agreeing in all particulars with M. Parchappc, but to the spint of liis inquii-ics, and to his general results, we give our hearty adherence. These results, however, require to be accepted ^vith some limitations PATHOLOGY OT INSANITY. 159 and exceptions ; and^ as we hope hereafter to prove, some addi- tions to tliem must also be made, to present a correet general idea of mental pathology. It is, however, no small praise to an author to affirm, as may witli truth be done of M. Parchappe, that no candid investigation, even into his errors and defici- encies, can be made, without advancing the science of which he treats. The principal error into which !M. Parchappe appears to have fallen is, that of having made too abrupt a classification of insanity into acute and chronic. The phenomena of the disease by no means justify a distinction of this kind so sharp as to lead to M. Parchappe's assertion, that the two forms of the disease present pathological conditions essentially opposed to each other. Doubt- less the pathological appearances presented in a typical case of each form will sometimes contrast with each other as remark- ably as he insists ; but a large proportion of cases of mania and melancholia are chronic from the first, and a large proportion of cases which are unquestionably chronic in point of duration, present, at intervals, all the symptoms of acute disease, and after death present an intermixture of those pathological condi- tions which ^I. Parchappe has described as opposed to each other from their very nature. Nothing is more common than for an atrophied brain to suffer from temporary hj^erannia. It is a pathological law, that injured and ill-nourished organisms are lialjle to sudden congestions, almost in proportion to the amount of deficiency in their nutrition. Hyperemia is moreover peculiai'ly liable to take place in the atrophied brain in consequence of the loss of external support which the organ has sustained by shrinking away fi'om the cranium. The lengthened, tortuous, and dilated vessels of the pia-mater, in atrophied brains, indi- cate the frequency Mith which they have been in a hypersemic state. The form of mental disease which destroys life in the early period of its course is comparatively rare, and has been thought by many modern writers to be a distinct form. The Frcncli alienists of the present day call it Di'lire aiyu, and distinguish it from recent mania and recent melancholia. In the brains of persons who have died while suftcring from this form of insanity, the strongly marked characteristics of hypera^mia of the sub- stance and the membranes, eve!\ to the sub-arachnoid ccchvmoscs -160 I'ATilOLOGY 01' INSANITY. described by M. Pai-c'aappo, undoubtedly exist. But in the recent cases of mania and melancholia of most frequent occurrence, if death were to occur from some accidental cause or intercurrent disease, wliich did not interfere with the state of the cerebral circulation, it is by no means so certain that strongly marked signs of hyperiemia would be found to exist. In many cases of recent mania, indeed, a condition of the brain the very opposite of hypertemia is known to be the condition of disease, both from the nature of the cause, the effects of the remedies, and the post-mortem appearances, Avhen chance has afforded an oppor- tunity for observation. The fact, that all the symptoms of acute mania frequently arise, and continue throughout the course of an exhausting bodily disease, which leaves every indi- \ddual organ, the brain included, in an ill-nourished and anaemic state, affords irresistible evidence that the phenomena of acute insanity must in many cases co-exist with a state of the cerebral organ, the very reverse of hyper?emie. The rapid formation of ideas is so remarkable a symptom in acute insanity, that -M. Parehappe, in common with ]M. "Falret and others, considers it as a proof that the psychical activity is in a state of exaltation ; and he, logically enough, infers that the plastic activity of the organ of which psychical activity is the function, must also be in a state of exaltation, or, as he expresses it, in a ph/s state. This, however, is not unconditionally true. Doubtless, in some cases, and for a short time, active hypcrtemia of the brain, at- tended by a rapid nutrition and decomposition of its substance, and accompanied by quick-flowing ideas and fancies, may be the condition of acute mania, as it is the condition of cerebral ex- citement in the early stage of intoxication. But it is an error to sujjposc that a rapid flow of ideas is always a sign of that psychical activity M'hich depends upon an exalted state of cere- bral nutrition. There is an idea-forming activity which re- sembles palpitation of the heart from weakness ; and ideas fre- quently flow through a debilitated brain in rapid succession, because the mental impression made by each of them is feeble and transitory. Doubtless they follow a certain train, but this is of the most desultory kind, because the organ answers to the faintest touch. The Germans have a curious term for this im- pressive and remarkable condition of the mind. They call it Mr;{yV/^r; (idea-hunt). It is a hunt in which there is nothing I'ATllUJ.OliV or LNSAMIV. 4-61 hunted ; or, like tlic cliacr of the oeeaii biUous, wlicre the old are ever vauishinj:; and the new arisinji-, without evident luirpose or end : " Ao veluti ventis agitantibiis aniuora, non est .E(iu:ilis rabies fontinunstiue furor. Seil modo subsidunt, intcmiissique sileseunt ; N'iiiKiue putes illos deixjssuisse suuiu." Wv shall now sketch the most frequeut anomalies of appear- ance aud organization ■svliich -vvc have ourselves found in the dissection of the bodies of the insane, On niakiui:: the examination, it is our custom to note the size of the bony frame, measured by the length of the body and its breadth across the shonhlers and hips. This affords a much better standard w ith which to compare the size of the head, and weight of the brain, than tliat afforded by the weight of the body, Avhich has been adopted for this purpose by some pathologists. The weight of the body varies so greatly between the obesity of dementia and the emaciation of mania and melancholia, that the standard it affords is most untrustworthy. Careful observation, however, should be made of the state of emaciation or obesity; also of any bruises, or bruise-like marks ; any bed-sores or deformities. The features, after death, generally lose all expression characteristic of mental disease. The ex- aminer is frequently surprised at the regularity of feature and placidity of expression, in countenances which, to the last hours of life, had been disfigured by the peculiarities of insane physi- ognomy. Even the heavy aud relaxed features of general paralysis are braced up after death, and return to their normal expression. Often have we felt that we have never seen the sane expression of a patient's face until after his death. The dimensions and form of the head should be noted. Although we believe that in the insane the average dimensions of the head are below those of the sane, when the comparison is obtained by the examination of large numbers; still, in a great number of instances, they will be found to be good ; and, in- deed, the head is frequently not only large, but phrenologically well-shaped. We are not aware in what proportion of the sane the shape of ti»c head is peculiar, iince it ir- rare that opportunities occur for making the observation rmotig them ; but among tlie insane 463 PATHOLOGY Oi;' INSANITY. a considerable proportion present decided peculiarities in the shape of the cranium. The most frequent one is a want of symmetry in the two sides. One side is rather flatter or smaller than the other ; or the whole cranium is pushed over a little to one side ; or one side is a little more forward than the other; or the two anomalies co-exist, giving the cranium a sort of twisted appearance. These things will not be seen unless they are looked for, with accurate and careful eyes, upon the shaven scalp. Sometimes the skull is high and dome-like ; more frequently it is as if it had been compressed laterally, and elongated from before backwards — keel-shaped, in fact, like the skulls figured by Dr. Minchin, in the Dublin Medical Journal, in which the centres of ossification of the parietal bones are increased in number. Sometimes the forehead is preternatm-ally flat, nar- row, or receding, or very large and bulging ; or the occipital region is deficient, and the back of the head rises in a straight line with the nape of the neck. Sometimes the skull has a remarkably square configuration. The square and carinated form of skull Ave have most frequently seen in connexion with mania. The dome-like and high vertical skull, and also the unsymmctrical skull, most frequently in melancholia. In mania, the anterior cranium is more frequently of good shape and size than in melancholia. In the latter the forehead is often small and mean, but sometimes it is disproportionately large and globose. The shape of the head as it ought to be according to the rules of phrenologists, can only fairly be expected to coincide with the mental symptoms, in those somewhat rare instances in which insanity is the mere development in excess of natural character ; and in some such instances we have found the shape of the head tally, in its general outline, with the indications of phrenology. Occasionally depressions are found in the outer skull, ^\ liich sometimes do, and sometimes do not, correspond with the bulging of the inner table of the cranium. When they do not so cor- respond, we have found that they indicate a local absorption of the diploe. It is an interesting question how far the shape of the skull alters in insanity. If the forehead expands, even in mature age, under the influence of intellectual development, it is likely that PATHOLOGY Of INSANITY. 468 it will contract under the iutlueuce of intellectual decay. Some writers have asserted that the shrinking of the brain in atrophy is commonly, and to a considerable extent, followed, and tlic cranium filled, by a flattening and shrinking of the cranial bones. (See Paget's "^ Lectures on Pathology.') Rokitansky also affirms that atrophy of the brain frequently gives rise to deposit of bone on the inner table of the skull, especially about the anterior convolutions. We have not satisfied ourselves that the increased thickness of the cranium which is frequently met with in the insane, is in any way connected with atrophy of the brain. Some of tlie thickest and heaviest craniums which we have met with have occurred in instances in which there was little or no cerebral atrophy ; and the condition of the cranium where there is undoubted atropliy of the brain, is not unfrequently one of abnormal tenuity. In pursuing the examination, the state of the ears and of the scalp should not be overlooked. The sanguineous tumour of the ear peculiar to the insane, and the shrinking of this appendage consequent upon such tumour, are noteworthy objects of atten- tion. These tumours, for the most part, occm' in the worst and most hopeless cases; but it is an error to suppose, as some authors have done, that they occur in such cases only. "We have not only seen patients recover after the ear has been shrivelled up by the contraction subsequent to sanguineous tumour, but we have seen several patients labouring under quite recent insanity, in whom a shrivelled ear led to the information that a curable attack had been undergone many years previously, an attack which had been followed by perfect mental sanity of considerable duration. The scalp is sometimes full of blood, sometimes marked with scars and contusions, telling of blows and falls. In old cases of mania it is sometimes remarkably loose upon the cranium. The cranium itself is frequently altered from its nornud con- dition. When thicker and heavier than usual, it is also soft and full of blood. The eburnated cranium, which is at the same time thick, dense, and devoid of blood, is not found in the bodies of those dying insane. In recent eases the only abnormal condition to be expected in the cranium is its discoloration •iGi PATHOLOGY OF INSANITY. from excess) of blood. This is ofteu evident, not only at the nnirgin ^herc it has been separated by the saw, but also over the whole extent of its inner surface, after the dura-mater has l)e^n separated, it presents a mottled, but decided discolora- tion, from sanguineous congestion. In chronic cases the skull-cap is sometimes thicker than usual, congested with blood, and soft in its texture ; sometimes thinner than usual throughout, or partially. In the latter ease the thin l)(n-tion usually occurs in the parietal region, in Avhich the diploe frequently disappears to such an extent that the skull becomes diaphanous. The thin diaphanous skull is met with in all stages, but most frequently in cases of very chronic mania and of dementia, in which the patient has not been subjected to temporary attacks of cerebral hyperajmia. On the other hand, a thick and heavy cranium is mostly met with in cases of chronic insanity, which have been subject to attacks of congestion, or hypersemia e vacuo. The cranium is often strongly marked by indentations produced by the Pacchionian bodies. Not unfre- qupntly, also, the crista galli is elongated and enlarged ; and in epilepsy the protuberances of the sella turcica are enlarged, and the marks of the gyri of the convolutions ai-e more strongly impressed, especially in the middle fossse. Exostoses, or spiculaj of bone, growing either from the vault or the base of the cranium, are exceedingly rare. In 400 examinations of persons dying insane, including a large propor- tion of epileptics, we have only found a cranial exostosis in three instances. The dura-mater is frequently found adherent to the cranium. In old cases, indeed, it is rare to find that this membrane separates from the cranium with its usual facility in adults. The degree of adhesion -which exists in chronic insanity varies, from that which can scarcely be called abnormal, to such a close and intimate union, that on the application of force the membrane splits into layers, rather than part from the bone, IVom which its fibres cannot be separated except by hard scraping. In acute cases, the dura-mater is sometimes dis- coloured by sanguineous congestion. Recent anatomists discard the old view, that the inner polished surface of the dura-mater is a reflection of the arachnoid. It certainly cannot be demonstrated by the scalpel, that any SL-rous membrane lines the dura-mater; and the idea of a parie- rATIIOLOClY OF INSANITY- 465 tal arachnoid appears to liavc been due to the cxi<^cneics of systematic anatomy, rather than to the evidence of demonstra- tion. We adopt the view that there is no parietal arachnoid, and tliat the poHshed surface is actually part of the dura-mater. This polished surface is not unfrequently the seat of exudative processes in the insane ; altlion<;h it is rare to find in this locality exudations of a true fibrinous character, the results of undoubted inflammation, notwithstanding the assertion of llokitansky, that the surface of the brain and the skull, being bound together by a series of successive normal and false membranes, is a " termina- tion of meningitis frequently found in mental disease, especially in cases of secondary imbecility." Notwithstanding this high authority to the contrary, we must assert, that adhesions between the cerebral arachnoid and the dura-mater are ex- tremely rare in the bodies of persons dying insane. On the upper part of the brain we have never met with this state of things referred to by this author. The nearest approach to it that we have met Avith in this region has been the connexion of the dura-mater with the thickened arachnoid and pia-mater, by means of several ligamentous bands, the condensed and organ- ised remains of very moderate fibrinous exudation. In two instances, we have met with adhesion of the substance of the brain and its intervening members to the dura-mater, along the petrous portion of the temporal bone ; and in one instance, along the ridges formed by the alnc of the sphenoid. It is an occur- rence of much greater frequency for the polished surface of the dura-mater to be the source of an exudation not fibrinous, and not tending to contract adhesions. These exudations are very remarkable, and by different authors have hitherto been generally regarded — either, when much coloured with blood-pigment, as in- stances of sanguineous effusion into what was considered the sac of the arachnoid, or as false membranes arising from arachnoidal inflammation. That instances of these latter conditions are not very unfrcquent, renders it the more needful to distinguish the peculiar exudation to which we refer. It resembles a layer of red-currant jelly spread over the surface of the dura-matcr. On examination, there appears to be an extremely fine cellular net- work, containing in its meshes an albuminous semi-fluid sub- stance, coloured with blood-pigment. Sometimes the exuda- tion extends to the temporo-sphenoidal fossae. Sometimes it 30 460 PATHOLOGY Or INSANITY. is confined to this locality. Yircliow has, quite recently, an- nounced its nature to be that of a colloid tumour, flattened into the resemblance of a false membrane by its position. We adhere to the Ijclief that it is an albuminous exudation, con- taining a small proportion of fibrine, and coloured with blood- pigment. Sometimes true haemorrhage is found on the inner surface of the dura-mater. On the appearance of this as a layer, Eokitansky observes, " Those extravasations which have been supposed to be collections of blood between the serous and fibrous layers of the membrane, with the exception of a few cases in Avhich a small efiusion has raised its innermost layer, must have been extravasations into the sac of the arachnoid, •which, after acquiring an adhesion to the diira-mater, have become encysted." (Vol. iii, p. 323, Sydenham Society's Trans- lation.) In many instances of chronic insanity, and of recent insanity in which there had been a previous attack, we have found the dura-materinthe temporo-sphenoidal fossae changed to an orange- yellow colour — not uniformly, but as if freckled. Doubtless this discolouration was due to the blood-pigment of re-absorbed haemorrhages or exudations ; and it points, like the other changes so common in this membrane, to the frequent existence in insanity of one period during which the appendages of the brain are in an hyperaemic state prone to haemorrhages, and to albuminous or albumino-serous exudations, coloured with dis- solved blood-pigment. The coloured exudations above referred to seem to us to bear a close resemblance to the exudations of blood-coloured serum which take place between the cartilages of the ear, and to be owing to the same crasis. Sometimes the structure of the dura-mater is found to have undergone osseous metamorphosis. We have never observed this occurring in the tentorium, where comparative anatomy would lead one most to expect it. We have, however, found it in the falx cerebri. Exostoses of the inner table of the skull probably have their origin in the dura-mater. We have only once found a true tumour of the dura-mater. This was as large as a filbert, pressed upon the pons, and was accompanied by epilepsy. Its structure was fibro-cellular, and it contained an abundant quantity of cholestcrinc in large plates. The Arachnoid. — AVe have never found a state of undoubted rATllOLOGY OF INSANITY. 467 inflammation presenting; the appearance of the inHamcd eonjnnc- tiva, as descrihcd by GuisKain. In a few cases of acntc mania and melancliolia, we have observed the appearances of ramiforni congestion ; but it may be doubted whether this was not due to the underlying vessels of the pia-mater. Doubtless, in some cases, the hypertemia in the capillaries of the arachnoid amounts to actual stasis, otherwise the fibrinous false membranes, and the adhesions which are sometimes observed in it, would scarcely exist. A frequent change of this membrane, found in persons dying insane, is thickening with opacity. "The arachnoid tissue," says Rokitansky, " is opaque, dull like whey or milk, tumid and wliitc, and it has the appearance and density of tendon." Often this change is limited to the arachnoid covering the convolutions of the vertex ; sometimes it is restricted to that part of it which corresponds to the sulci, leaving the part which covers the convolutions thin and transparent. Patches, however, of very decided thickening with opacity are occasionally found on the anterior convolutions of one or other hemisphere. The changes observed in the vertical region are rarely one-sided, or even greater on one side than on the other. "What does thickening with opacity of the arachnoid indicate ? According to the above author, the '' changes frequently discoverable in this membrane can be attributed only to congestion, or to slight and passing attacks of inflammation." " Opacity and thicken- ing of the arachnoid arc very common jjost-mortem appearances. After middle life a moderate degree of them is almost con- stantly found, and their absence is the exception ; for, at that period, every one must have been exposed to repeated conges- tions of the brain and its inner membranes." (Op. cit. p. 329.) The change here referred to as being so common, is, although the same in nature, greatly less in degree than that commonly found in the bodies of persons dying insane. It is merely an opalescence as compared with decided thickening and opacity like a thin slice of the boiled white of egg. The frequently repeated congestions to which Rokitansky refers this ciiangc in the sane, exist in much greater force and frequency in the insane, and give rise to a corresponding intensity of this patho- logical change. It appears not to be the result of inflammation, even of " slight and passing attacks," so much as that of con- gestion. In nature it closely resembles those opaque patches so 4G8 rATlIOLOGY OF INSANITY. frequently found upon tlic visceral pericardium. Its cliaracter is that of albumino-fibrous deposit, wliicli, forming one link in the chain of degenerative change, passes, according to its locality, into atheroma or into fat. In connexion with the arachnoid are the Pacchionian bodies, absurdly called glands. These Rcikitansky regards as granula- tions of the arachnoid, rarely indeed altogether absent, but depending for their development upon the same repeated con- gestions -which render the arachnoid itself thick and opaque. Luschka, however, has recently shewn that these bodies are normal as to their existence, and pathological only as to their hypertrophy. He calls them arachnoidal villi, and refers the genetic cause of their growth to " the disturbances of the circu- lation which attend the natural involution of the organism in old age. In consequence of the impeded motion of the blood, a modified transudation must take place, which (in our ignorance, it must be confessed, of its precise nature) we regard as the principal cause of the increased amount of nutritive material with which the arachnoid is supplied.^^ (Wedl., Sydenham Soc. Trans., p. 352.) Now, in the insane of all ages, the Pacchionian bodies are frequently found to be greatly enlarged, so as not only deeply to indent the dura-mater, but even to perforate it and to form for themselves reception-cavities in the parietal bones alongside the sagittal suture. Before the circulation has become impeded by the advance of age, they are prematurely produced in the insane by the impeded circulation of cerebral congestion, the frequent condition of mental disease. We are not aware whether the minute anatomists of the German school make any distinction between that which they call the ependyma of the lateral ventricles and the arachnoid membrane in this locality. This ependyma, which is the seat of those puzzling bodies, the amylaceous corpuscules, is de- scribed by Virchow as the uppermost layer of the fine connective tissue, the neuro-glia or nerve cement, which binds together the foundation masses of the brain. Be this and the arachnoid of the ventricles identical or not, it is certain that the walls of the lateral ventricles present, in chronic insanity, and especially in general paralysis, a peculiar and frequent change. They appear to be covered with fine sand, or rather to be converted PATHOLOGY OF INSANITY. UYJ into the resemblance of fine shagreen; a change (hio to a nodu- lated deposit of fibro-alhumcn. The arachnoid of the ventricles also becomes more thick, dense, and tough ; a change Mhich is obvious in the septum lucidum, which in the early stages of general paralysis, and in the later ones of chronic mania, becomes a toughish and resis- tant membrane, instead of retaining the exquisite delicacy which renders its demonstration so difficult in health. The Pia-mater — tender mother of the brain and its wondrous offspring of thought and passion — is far more closely and inti- mately related, both in health and disease, Avith the organ to whose more noble parts it supplies nutriment, than either of the other meningeal wrappings. The pia-mater is more than a mere investing membrane ; it is more than a subserous connec- tive tissue of vascularity greater than is common to such parts. It is a vascular plexus, admirably arranged to su])ply the grey matter of the convolutions with an abundant supply of the nutritive fluid, so loose and large in its ramifications as obvi- ously to suggest the idea, that its construction is also subservient to rapid and great changes in the quantity of blood in the part of the organ it supplies. What the submucous vascular layer of the stomach is to the function of digestion, the pia-mater appeai-s to be to the higher functions of the brain ; and it is more than probable, that active thought or intense emotion causes in it hyperemia as sudden, frequent, and transitory as the function of digestion gives rise to in the vascular layer of the stomach. One part of this plexus, or rather an appendage to it, the choroid-fold within the lateral ventricles, has a struc- ture analogous to, if not identical with, ei-ectilc tissue. Upon this rcsemljlance an ingenious writer in the ' Dublin Quarterly Journal of Medicine ' has based his theory, that sleep in the normal state, and epilepsy in the abnormal state, are dependent upon a turgid or erectile condition of this apparatus, by means of which a gentle but general pressure is exercised from within upon the whole substance of the brain. With regard to epilepsy, there are insurmountable objections to this theoiy; but the very existence of such a structure, in connexion with the pia-mater, increases the probability that frequent tur- gescencc of this membrane is a physiological state. " Tliere is no question," says Kokitansky, " that congestion of the pia- 470 PATHOLOGY OF INSANITY. mater is a very frequent occurrence/' " Yet, if we except the post-mortem congestion of the pia-niater covering the posterior lobes of the cerebrum, any considerable degree of congestion is far less commonly met with in the dead subject than is sup- posed ; and there is, perliaps, no respect in which moderation in estimating appearances needs so much to be impressed upon the impractised observer, as in regard to the quantity of blood contained in the vessels of the pia-mater. As a general rule, a very moderate injection of these vessels is erroneously looked upon as congestion/' " The terminations and conse- quences of these congestions vary, according to the frequency and duration of their cause. They consist of thickening and condensation (increase of volume) of the pia-mater and arach- noid, of permanent infiltration of the former, and a varicose condition of its vessels. Such a state of the inner membrane is well marked after the congestions which are produced by continued and forced exertion of the mind, or by repeated intoxication, especially by alcoholic drinks." (Op. cit. pp. 339 and 340.) Thus we learn from this great pathologist the frequency of congestions of the pia-mater; their causation by two of the common causes of insanity, mental overstrain and drunkenness ; and lastly, the difficulty which exists in recognising, after death, the existence of a pathological degree of this frequent conges- tion. The same difficulty exists in the tissue to which we have compared its functions, namely, the submucous vascular layer of the stomach. In both these instances, this difficulty ai post- mortem recognition arises from the same cause. A moderate degree of congestion is in neither instance pathological. Con- gestion only becomes so when its degree or frequency tends to produce structural change. The last moments of life are commonly passed in a state adverse to the continuance of conges- tion, unless they are attended by such difficulty iu the respira- tory movements as to impede the return of the venous blood to the heart, and hence a state of congestion -which may have existed in the pia-mater, even up to a short time before death, may have left no traces discernible after that event. The exudations of the pia-mater iu mental disease, are not of the organizable, fibro- albuminous kind. It is rare even to find them opaque, either from partially coagulated albumen or from PATFIOLOGY OF INSAMTV. 17 \ fat. Even whcMi the araclnioid is tliickencd and npa(|no froui exndations of this kind, those of the pia- mater arc rcmarkahly limpid and scrons. Adherent false membranes are not found once in a hundred cases of persons dying insane ; and even in these rare instances, their occurrence usually is traceable to a pre-existent inflammation, and is not to be considered as a condition proper of insanity. According to Vogel, fibrinous exudations result mainly from the minute capillaries, whilst serous or hydropic effusions derive their source from the small veins. The plexus of vessels which forms the pia-mater is decidedly venous in its anatomical character, and the serous nature of its ordinary exudates may fairly be thus accounted for. Although fibro-albuminous exudates in the pia-mater, and the false membranes and adhesions resulting therefrom, are so uncommon in insanity, there is one form of adhesion of frequent occurrence in this membrane, namely, the slight but important adhesion between it and the grey substance of the convolutions. The plexus of vessels more or less infiltrated with serous effu- sion, is sometimes very readily separable from the grey substance which it invests. But in many instances it is not so. "What are called adhesions more or less intimate and extended are found to have formed, so that sometimes over the whole extent of the convolutions, sometimes only in isolated parts, the convo- lutions cannot l)e divested of their vascular envelope, without small portions of the grey substance remaining adherent to it. In these instances there is no appearance of fibro-albuminous exudation into the pia-mater ; but it is probable that the cells of the grey substance, and their connective tissue, may have received an addition of fibro-alburaen from the minute arteries and arterial capillaries in connexion with the pia- mater ; an addition which may prevent the small vessels from being withdrawn from the soft substance of the grey matter with the same facility as in the normal state. Something, also, may be attributed to an increased toughness in the coats of the minute blood-vessels preventing facile rupture. Congestion of the pia-mater, and consequent serous cfl'usion into its meshes, is the constant result of atrophy of tlie brain. "When an empty space is formed within the skull by a reduc- tion of the volume of the brain, it is filled up by an increase 472 PATIIOLOCIY OF INSANITY. of the volume of the inner membranes of the brain^ and ca- peeially by an extraordinary exhalation of serum into the tissue of the pia-mater, the sac of the arachnoid, and the internal cavities of the brain, more particularly the lateral ventricles. These changes result from the congestion of the vessels ■which the vacuum produces." {' Rokitansky,^ op. cit. antea, p. 364.) Thus arises the Hypercemia e vacuo, the pathological condi- tion of the very frequent cases of spurious apoplexy Avhich occur among old and chronic lunatics — every attack of which renders the vessels of the pia-mater more dilated and tortuous, and more disposed to the recurrence of the congestion. This may, and frequently does, concur with an anaemic as well as Avitli an atrophic condition of the substance of the brain. In the healthy organ, congestion of the pia-mater cannot occur with- out accompanying congestion of, at least, the grey matter of the convolutions ; but, under the pathological conditions which attend atrophy of the organ, a sudden congestion of the loose and water-logged membrane frequently occurs, without affecting the anaemic and atrophic brain otherwise than by adding a temporary impediment to its functions by the sudden pressure. To recapitulate : — The pia-mater, in rare instances, is found to be the seat of fibro-albuminous exudation, and consequent adhesion. It is the very frequent seat of congestion, which may or may not be obvious after death. Frequent congestions en- large and render its vessels more tortuous. They also result in a thin hydropic efiusion — more rarely in a tur])id albuminous one. Not unfrequently the membrane contracts adhesions to the grey matter of the convolutions, but without visible exuda- tion of albumino-fibrine or false membrane. In cases of acute mania and melancholia, thin extravasations of blood, not larger than a finger-nail, occur in its tissue. Diffuse inflammation of the pia-mater, and tuberculous infiltration and deposit, are extremely rare among the insane. Tiie pathological conditions of the choroid plexus arc as obscure as its physiological purpose. It is not found hypcr- trophied in epilepsy, which it should be Avere the theory true Avhich attributes the production of that disease to its turgcscencc. It often contains cysts analogous to those observed in the Mai- PATHOLOGY OF INSANITY. -173 pighian bodies iu Bright's disease ; but wlicthcr tlie frequency of these cysts is greater among the insane than the sane, tlicre are uo data to determine. The Cerebral Substance. — The condition of the cerel)ral mem- branes, and indeed of all other parts, is, of course, in the patho- logy of insanity, secondary and subservient to the state of the substance of the brain itself. The condition of the cerebral substance is the prime question in tlie pathology of mental dis- ease. Frequently this condition can only be judged of by the state of its blood-vessels, or can only be guessed at by that of its membranes, or some still more remote indication. Not uufre- quently, in partial and sympathetic insanity, it appears to be perfectly sound in structure, although the deductions of science assure us that this soundness is in appearance only, and is solely attril)utable to the imperfection of our means of observing and investigating. To the pathologist, the substance of the brain is as yet prac- tically stiiictureless. Although the microscope reveals cells and tubes, up to the present time it has been unable to indicate when they are in a normal or abnormal state ; and although it may prove that in some cases the smaller arteries are diseased — that in a few others there are granule globules, or an increase of fatty particles in the substance itself — it has not yet enabled us to distinguish between the states of the whole organ which must be diametrically opposite; for instance, between the state of hypertrophy and that of atrophy. Practical observation, therefore, must be made upon the bulk, colour, density, and specific gravity of the brain-substance and upon the condition of its blood-vessels. The bulk of the brain varies from a state of atrophy, in which it has been known to lose nearly a third of its volume, to one of hypertrophy, in which, but for the restraining pressure of the unyielding cerebral walls, there is little doubt but that its bulk would be not less augmented. Cerebral atrophy, as the most frequent, is the most important of all changes in chronic con- ditions of mental disease. Wc have already written so fully on this subject, that our limits only permit a few further remarks. A considerable degree of cerebral atrophy is rarely unattended 474 PATHOLOGY OF IXSAMTV. by changes iu the eoloiir and consistence of the brain-substance, sufficiently obvious to the eye of the experienced observer. It is frequently botli anasmic and discoloured ; the grey substance contains less red and more brown ; and its colouration, also, in depth of tint, varies greatly ; sometimes its tint is deeper than is usual in health, but far more frequently it is paler, and occa- sionally it is little more than a darkish buff. On this point Mr. Solly remarks, that having many opportuni- ties of examining the brains of the insane at Hanwell, he made coloured drawings of the cortical substance of all patients indis- criminately; and he adds, " The general result of my observations Avas, that a pale condition of this ganglion was almost invariably found in patients who had sunk into a state of imbecility, and was generally associated with some serous effusion, and thickening of the arachnoid and pia-mater.^^ (Solly ' On the Brain,^ p. 398.) The uniformity of colour of the grey matter, also, is lost. The grey layer of the convohitions consists of six planes, in which white and grey substances alternately preponderate. ]M. Bail- larger, in his memoir on this subject C^ INIem. de FAcad.de ]\Ied.,' tome viii), states that it consists of six of these alternate layers. There can be no doubt that three such layers exist ; but whether these can again be subdivided is a question which we have not been able to determine. In the normal state, this triple division is very obvious to the naked eye in the posterior convolutions of the cerebrum ; but in a state of atrophy it becomes still more obvious throughout all the convolutions whore it was previously not oljservablc. This appearance arises from diminiition in the quantity of the pigment-coloured cells in the Avhole of the cincritious layer. This diminution in the bands where the white matter exists in largest quantity, renders the colour of the latter very apparent. According to the statement of INI. Baillarger, the external layer of the convolutions is white, and not grey. It would, we think, be more correct to say that the external layer contains a less proportion of vesicular neurine to the tubular substance with which it is intermixed, than the layer next but one to the surface, and again, than the layer next but one to that. The consistence of the grey matter of the convo- lutions is very generally lessened when the organ is atrophied. Sometimes the superficial layer is obviously softened, but more frequently the grey layer immediately under it is the seat of the PATIlOLOCiY OF INSANITY. 475 greatest amount of softening. We may hope tliat (Jcrlach's obscnations on what has been called the bacillar layer of the (oi'tcx of the cerebrum, will lead to an important increase of our knowledge of its pathological conditions. The colour and consistence of the tubular neurine are notably altered. Unlike the grey matter, its depth of colour is generally increased. From the clear white of health, almost imperceptibly tinged with pink, it assumes a dirty brownish hue — very faint, indeed, but quite unmistakable. The consistency and density of the white substance vary greatly. In the Atrophia cerebri senium, the consistence of the white matter is generally a little increased. In the Atrophia cerebri prcecox, the consistence is increased whenever the pri- mary condition of disease has been hypera!mia verging on phlogosis, and tending to the addition of albumino-fibrine to the substance of the brain. This is particularly the case in the atrophy which attends the later stages of epilepsy — an atrophy which is preceded by a period of congestive hypertrophy, and meriting the name which has been applied to it, of concentric hypertrophy of the brain, if such a term is not in all instances somewhat absurd. In atrophy not consecutive upon a congestive condition of long standing, but either primary or secondary to a state of general debility or dyscrasia, the consistence of the tubular neurine is diminished — sometimes to the extent of making it appear that the whole brain is infiltrated with serum. Rokitansky asserts that atrophy is accompanied by increased consistence and tenacity, or sclerosis, as it has been called. " The surface of a section of the hemisphere shrinks and be- comes concave ; and here and there certain portions offer more resistance than others, and wrinkle and lie in folds." This, however, is an observation which we have not been able to verify. AVhen induration exists, it is in greatest degree in the neigh- bourhood of the lateral ventricles. The latter are generally en- larged and distended^ with a very limpid effusion ; and thus the bulk of cerebral substance is diminished, both from within and without. Sometimes the lateral ventricles are greatly contracted; sometimes they arc of normal size. Andral states, that nnlcss each lateral ventricle contains more than an ounce of ffuid, it cannot be reckoned abnormally large. •170 PATHOLOGY or INSANITY. It is unnecessai-y to refer, in this plaee, to the shrunken and pinched appearanee of the convolutions, and the widely opened sulci. In not very unfrequent instances, the remarkable appear- anee of circumscribed atrophy affecting three or four convolu- tions, generally about the vertex, is presented. In such instances, the loss of bulk is replaced by a partial oedema of the pia- mater, presenting the appearance under the arachnoid of a gelatinous bag. This partial atrophy of the brain has not hitherto been connected with any peculiar loss of mental function calculated to add an additional proof to the arguments of phrenologists. Atrophy of the brain rarely exists in any considerable degree, Avithout a notable diminution of the breadth of the grey sub- stance of the convolutions. The normal breadth of this substance we have ascertained, by numerous measurements, to be eight hundredths of an inch. In atrophied brains it is reduced to seven, and frequently to six hundredths. It is a remarkable fact, first noticed by Cazauvielh, that atro- phy of the brain is confined to the cerebrum. Even in extreme age, when the cerebrum is much wasted, the cerebellum retains its full size. The usual condition of atrophic brains, with reference to the state of the blood-vessels, is a degree of anaemia ; but some- times, owing to the circumstances of death, this condition is replaced by one of congestion, and the dirty white of the tubu- lar neurine becomes mottled with a faint violet discolouration. This is especially the case when death occurs soon after severe convulsive attacks, or during the course of congestive apoplexy. HypertropMj of the brain is an interesting but rare form of pathological change. But for the pressure exercised by the un- yielding walls of the cranium, the brain would doubtless undergo enlargement with every considerable degree of con- gestion which it suffers. As it is, congestion of the brain con- stitutes one form of hypertrophy, of common occurrence contrasted with the true hypertrophy of the cerebral substance, in M-hich the brain is anaemic, the vessels being emptied by the ever-increasing pressure. In the bodies of persons who have died during the early period of epileptic disease, and of some who have died in the PATHOLOGY OF IXSAMTV. 477 first stages of maiiia^ tlic l)rain appears too large for its case; the convolutions are flattened ; the sulci cease to exist as indenta- tions between the convolutions ; lines only can be perceived in ■which processes of the pia-mater dip. The vessels of the pia- raater itself arc distended with blood ; the grey matter is deepened in colour ; the white matter pinkish, or mottled with pale violet ; and the cut ends of the vessels in it efliise an abundant quantity of puncta sanguinea. This is false or con- gestive hypertrophy. In true hypertrophy, the brain swells up when the cranium is removed, so that the latter cannot be replaced ; the convolutions are flattened, the sulci obliterated ; the arachnoid is transparent, thin, and dry; the pia-mater is exsanguine; the grey substance very pale ; the white substance pure white, -with few traces of blood-vessels, dense and tenacious. As the change progresses, the mental functions, and especially the memory, become more and more feeble ; but dementia, to the extent which follows atrophy of the brain, rarely, if ever, supervenes. Epileptiform con^'lUsions appear towards the close of the case, and usually supply the form of death. In a marked case which came under our own notice, epileptiform convulsions existed at intervals for more than six months before decease. The post-mortem ex- amination displayed all the above appearances, with the addition of the remains of a sanguineous effusion, thin, old, and yellow, surrounding the crista galli of the ethmoid. There have been many difl'erenccs of opinion respecting the j nature of this pathological change. Dr. Ilandfield Jones, in I an excellent paper on " Fibroid and Allied Degenerations," in I the 27th No. of the ' Medico-Chirurgical Review,' maintains I that it is not a true hypertrophy. " It can hardly be thought," he says, " that a true hypertrophy existed, otherwise surely there I would have been some apparent superiority of intellect. The I truth probably was, that there was just the ordinary amount of ! nervous matter, /j/wj? a certain quantity of interstitial exudation." I Doubtless it is not a true hypertrophy in this strict sense of the j term, i. e. the abnormal increase of normal structure ; and I although R()kitansky declares it to be " a genuine hypertrophy," I he explains the meaning he attaches to this term ; so that, ac- ; cording to its acceptance in this country, it would be excluded j from the category. He says, " it consists as such (i. e. as a 478 PATHOLOGY OF INSANITY. genuine hypertrophy), not in an increase in the number of the nerve tubes in the brain, from new ones being formed, nor in an increase in the dimensions of those which ah'cady exist, either as thickening of their sheaths, or as augmentation of their con- tents, by either of which the nerve-tubes would become more bulky. It is an excessive accumulation of the intervening and connecting nucleated substance.^^ He attributes its occurrence to an excessive development of the lymphatic system, although he admits that its immediate cause may be congestion. Dr. Handfield Jones's test of a genuine hypertrophy appears, in this instance, fallacious, inasmuch as an increase of normal tissue may fail to confer increased power of function, if the new tissue is in a condition unfavourable to its actiA'ity, — if, for ex- ample, it is subjected to pressure. Moreover, we have no knowledge leading to the belief that hypertrophy of the organic cells is inconsistent with a pathological condition, tending to interference with their function. An hypertrophied cell may be as much disabled as an atrophied cell. In the absence of microscopic proof, however, it appears to us far more probable that this particular kind of hypertrophy is seated in tlie in- terstitial space, being either hypertrophy of the neuro-gUa, or being due to a slowly formed exudate of an albuminous or fibro- albuminous character, gradually pervading the whole of the cerebral substance. Either of these changes from the normal state, originating in some obscure vice of nutrition, may go on increasing until death from convulsions takes place, and the peculiar characteristics of cerebral hypertrophy are found. More frequently, however, the process undergoes an arrest and an inversion. The hypertrophied tissue, or the exudate pressing upon the normal tissue, and upon the blood-vessels, impedes the nutrition ; this arrests the further progress of the hyper- trophy, and a reverse movement takes place, tending to cerebral atrophy with induration. Such, we believe, to be the true pathology of a large class of epileptic cases — namely, of those in which the nutritive powers are at first in excess, the muscular system highly developed, the functions vigorous, and the health robust, and in which there is an early tendency to maniacal excitement, gradually passing into the opposite one of dementia. The cure of these cases is hopeless, but the relief afforded by PATHOLOGY OF INSAMTV. 479 early antiphlogistic treatment, moderate and prolonged, !sui)i)ort.s our view of their pathological character. Inflammation, Conyestlon, and Ancem'ia of the Cvrebnil Sub- stance. — Inflammation of the grey suljstancc of the convolutions is, undoubtetlly, an occasional cause of insanity, although it cannot be admitted as one of its conditions. According to the limitations of that most artificial of sciences, nosology, phrenitis is not insanity, and docs not belong to the speciality of the psychologists. The same may be said of cerebral hsemorrhage. The appearances and symptoms which primarily attend these forms of pathological change are, therefore, excluded from the present notice. But a brief reference cannot be avoided to the changes which they frequently undergo, attended by symptoms of undoubted mental disorder. One of the reliquiaj of inflam- mation of the grey substance of the convolutions is a chronic induration of the superficial layer ; another is that adhesion of this layer to the pia-mater, which has been found by M. Par- chappe so frequent in the insane ; others are a softened con- dition of the middle layer of the grey substance ; induration or atrophy of the whole of this substance ; in some rare instances, entire loss of portions of it by ulceration and absorption. When the functions of the grey substance have been deteriorated by these changes, the white substance of the brain wastes from disuse of functions, as the optic nerve wastes in cerebral amaurosis, and thus atrophy of the whole cerebrum finally results. Inflammation of the white substance of the brain is usually far more limited in extent than that of the grey substance. It is also a more chronic affection — destroying life when fatal, by convulsions, low fever, gangrenous sores, and pulmonary con- gestions. Although, during its progress, the mind is always more or less disturbed, and actual delirium is frequent, yet it is a less frequent cause of insanity in any of the acknowledged forms of the latter than inflammation of the grey substance. Parts of the brain which do not participate in the inflammatory action become ocdematous, and others anremic from the pressure of those parts anIiosc bulk is augmented. This disturbance of pressure and of blood-supply conscciucnt thereupon, is neces- sarily accompanied by disturbance of the functions of the organ, often to a greater extent than the post-mortem appearances ex- 480 PATHOLOGY OF INSANITY. plain, since the pressure of the difiercnt parts equalises itself after the process of inflammation has been arrested by death. The relation which Cerebral Hmnorrhaye bears to insanity is of the same nature, but less intimate than that which inHara- mation holds. Numerous instances of cerebral haemorrhage occur without giving rise to any mental disorder ; but on the other hand, the processes of irritation and exudation, set up by a clot in the brain, not unfrequently give rise to mania, rapidly running into dementia. In such cases the brain is found to be atrophied, and to contain clots or cysts, or cicatrices in the various stages of reparative or degenerative change. AYhen cerebral haemorrhage is subsequent to atrophy, a re- markable modification of the usual symptoms of apoplexy may result. An enormous amount of blood may be slowly eflfused around the cerebral hemispheres, not only without the imme- diately fatal result Avhich would occur if the haemorrhage took place in a brain not atrophied, but without giving rise to urgent symptoms of cerebral pressure. Instead of exerting a fatal pressure upon the substance of the brain, the effused blood only displaces an equivalent quantity of serous fluid which finds its way from the cavity of the arachnoid and the meshes of the pia-mater into the spinal bag. In the 29tli vol. of the ' Medico- Chirurgical Review/ we have given the details of a case re- markably illustrating this statement. In this case a demented patient had an attack of apoplexy on the 29th of September, 1853, and he lived until 7th of July, 1854. The post-mortem examination showed the remains of a sanguineous efl'usion, fibrinous and tough, which completely enveloped the cerebrum. It was situated in the cavity of the arachnoid, and over the vertex and sides of the brain was half an inch thick, and was the colour of venous blood. In the petrous fossa it was also thick, but had become yellow. It did not extend over the cerebellum, but the effusion from which it was formed, had found its way into the lateral ventricles, as these contained masses of dark-red fibrine ; a thin layer, also, extended two inches down the spinal canal. Between the visceral arachnoid and the brain there was a large amount of serous effusion. The cranial cavity required 52 V ounces of water to fill it. The brain displaced only 37-5- oz., so that the atrophy of the organ was equivalent to 15 oz., or nearly one third of its normal bulk. Subsequent to the PATHOLOGY Ol' INSAM'l'V. 'J81 occurrence of the apoplexy, the pritieut lived a kind of ve<^etative existence, with the smallest amount of mental and aninnil function we ever saw in a living human being during so long a l^eriod. The small extravasations of blood often found on the surface of the convolutions in many cases of acute mania and melan- cholia, result from congestion of the pia-mater. In some instances a dyscrasial condition of the blood may aid in the production of these eflusions, as it does in the extravasations, which, in the insane, take place under the conjunctiva and between the cartilages of the ear. One of the most important conditions of the brain-substance is Conf/eslion, but of its appearance little can be said. Con- gestion of the grey matter is indicated by various shades of red, brown, and grey, of which the practised eye becomes cognizant. In recent and acute mania a deeper red tinge pre- vails. In cases of longer standing, and where atrophy of the organ also exists, the deeper tinge is of a brown or grey cast. The same distinction is true in congested states of the whole substance. In acute mania and melancholia the whole sur- face of the centrum ovale, in some instances, presents an uniform pinkish hue ; in others this hue is mottled with the normal white. In other instances, not in any Avay dis- tinguishable froni the last by the previous symptoms, the cut surface of the centrum ovale is mottled with a light violet hue. This hue is never uniform, except after death from long-continued epileptic convulsions. In acute mania and melancholia it is mottled either with white or with pinkish white. The above appearances of cerebral congestion are com- monly accompanied by a great abundance of bloody points due to blood issuing from the cut orifices of the small vessels. This appearance is not constant, even in brains obviously discoloured by congestion. Its absence may be due to the loss of contracti- lity in the small vessels, or to the blood they contain not being fluid. Aneeniia of tlie brain-substance, made evident by paleness both of the grey and white matter, and by the small number of blood-vessels whicii are visible, is observed in a few eases of acute mania; sometimes, also, but more rarely, in melancholia. In many chronic cases, with cercljral atroi)hy, aniemia is the ordi- :)1 482 PATHOLOGY OF INSANITI. nary couditiou of the brain substance^, although it frequently alternates with transient states of severe congestion. The state of the pulse, and the aspect of the skin of the face, the conjunc- tiva, and the lips, may indicate whether congestion or ansemia is present in the brain ; but these conditions cannot always be diagnosed from the mental symptoms. Andral has Avell pointed out this common nature of functional disturbance arising from diverse causes : '' It is a law in pathology, that in every organ, the diminution of the quantity of blood Avhicli normally it should contain, produces functional disturbances, as well as the presence of an excessive quantity of blood. We have found, more than once, the brain and its membranes completely bloodless in children Avho died in the midst of convulsions. We have also seen the state of coma, in which many of their diseases termi- nate, coincide with remarkable paleness of the nervous centres. Sometimes, also, in adults, we have been struck with the com- plete absence of colour in the brain, perceptible principally in the grey substance, in cases Avherein during life cerebral pheno- mena had taken place — such as delirium, convulsive movements, coma. Do not animals, also, who are bled to death, exhibit symptoms of this description V " " But when we have referred the symptoms to hypersemia in one case, and to anoemia in another, are we come to the bottom of the subject ? By no means : for this hyper?emia and this anaemia are themselves mere effects which — a thing very remarkable — the same influ- ence can very often produce. Thus, by an emotion of the mind, the skin of the face becomes red in one person, and pale in another.'' — ('Clinique Medicale.') This enlightened view must be applied to explain the uni- formity of symptoms which attend many other deviations from the normal condition of the brain-substance. Thus, induration and softening are both found in atrophic brains, both in chronic mania and dementia. Either of them may be attended by a con- gested or an ansemic condition, anajmia being the usual condi- tion, and hyperccmia a frequent but transient state. With regard to induration of the brain- substance in the bodies of persons dying insane, we have never met with that " leather- like and fibro-cartilaginous hardness and resistance " to which sclerosis of the brain is described to attain. The slighter degrees of induration dependent upon diminution of water in the brain. PATHOLOGY Oi' INSANITY. 183 and perhaps also upon some amount of liypcrtropliy of the ueiiro-glia, or of albuminous exudation, is common in cerebral atro])liy. The slighter degrees of induration may be general, but the higher degrees must be partial, since the organ could not perform its functions Averc it universally changed into a tough substance, like leather or caoutchouc. Callous cicatrices, marking the locality of old apoplectic rents, have oftered the only examples of leather-like induration which we have met with among the insane. (Edema of the brain, a state in which the tissue of the organ is permeated by water or serosity, is a not unfrequent condition with persons who, with atrophy of the brain, have great general debility or cachexia of the body. The brain appears unusually moist, and its cut siirface is of a brilliant white. In extreme instances, this condition is exaggerated until parts of the organ are almost broken down into a pulp, and the appearance of ramollissement is produced. It is not, however, to be considered one form of the latter affection. The two forms of ramollissement are not found frequently in the brains of persons dying insane. The rame may be said of the cellular infiltration described by M. Durand Fardel. In fom* hundred autopsies of the insane, we have only met with it in two instances. In both instances it occurred in aged persons suffering from chronic mania, in whom it gave rise to a series of convulsive attacks, which terminated in death. The brains of the insane appear to be certainly not more liable than those of others to \ arious inci- dental affections. Thus, in four hundi'cd autopsies of the insane, we have only once met with a hydatid, only once with tuber- cular deposit in the substance and meninges, only once with a fibro-cellular tumour, and not once with malignant disease. The ai-teries at the base do not appeal* to be more frequently or extensively affected with atheromatous change, than those of sane persons of the same age. And in the bodies of tlie insane we have never yet met with that cretaceous deposit in the coats of the small arteries, which makes them feel like pieces of fine wire imbedded in the brain-substance. In a large number of brains of the insane we have diligently examined the tissue, with a first-rate microscope. The results appear to us to have afforded no distinction between the sane and 484 PATHOLOGY OF INSANITY. the insane brain. \Vc have sometimes found granule-globules^ or exudation corpuseules^ but only in instances where the existence of inflammatory action uas apparent without the use of the microscope; and therefore this microscopic test of cerebral inflammation proposed by Dr. Hughes Bennett^ appears to be of little value. In inflammatory and softened parts of the brain-substance, we have found fatty degene- ration of the coats of the small arteries : but it remains to be seen whether this change is not as frequent in the brains of the sane. We have not been able to discover fatty dege- neration of the arteries where the pathological changes more peculiar to insanity alone existed. The same may be said of fatty degeneration of the brain-substance^ consisting in the abundant dissemination of amorphous fat particles, which is found in some specimens of cerebral softening. It seemed reasonable to expect that, by the aid of the micro- scope, one would be able to ascertain whether any exudation or addition to the intercellular-substance of the brain, or any change in size, shape, or proportionate number of its cells, takes place ; and in the indurated brain of chronic insanity, whether that finely fibrillated exudate which has been described by some writers actually exists; also, whether, in extreme atrophy of the brain, any part of it exists in the diminution of the size or proportionate number of the cells or tubes. In none of these points of inquiry have Ave been able to attain the slightest success. The atrophied brains of the insane frequently contain a large quantity of those bodies which bear so close a resemblance, both in form and chemical reaction, to starch eorpuseules. We have found them most abundantly immediately under the lining mem- brane or cpendyma of the lateral ventricles, but they are to be met with in all parts of the organ. Small plates of cholcsterine arc not uncommon in degenerated brain-tissue, and we liave fre- quently observed peculiar bodies which we have seen nowhere described. They are in shape like the blade of a lancet pointed at both ends, and about three or four times the Avidth of a ncrvc- tubc. They remind us of the raphides of some plants. Onr present limits do not permit, in this place, any rcfer(>nco sufHciently detailed to be satisfactory, to our investigations ujjon the specific gravity of cerebral snbstance. These we hav(^ already publLslicd ni the 'Lancet' Cor Di.eeniber Jioth, 1852, and rATIIOJ.OGY or INSANITY. 485 the ' Medico-Cliirurgical Review' for January^ 185.'), to which we must refer those of our readers who desire to know more of tliis subjeet. We may state briefly, that in the thirty eases tabulated in the 'Laueet/ tlie average speeifie gravity of the cerebrum was 1010, the range being from 1030 to lOlG; while the average specific gravity of the cerebeUum was 1043, the range being from 1039 to 1046. It was also observed that the specific gravity was higher "when life had terminated in coma or asphyxia, than when it had ended in syncope or asthenia." In our annual report of the Devon .Vsylum, for 18.51, wc published some investigations on the same subject, from which it resulted that the average specific gravity of the cerebrum Avas 1039^, and that of the cerebellum, 10 l.'i. In the sixty-three eases tabulated in the ' Medieo-Chirurgieal Review,' the average of the white substance of the cerebrum was 1039, and that of the grey sub- stance, 1037; that of the cerebellum, grey and white substance conjoined, 1010. The lowest specific gravity of white cerebral substance was 1033, the highest Avas 10-lG ; of the grey sul)- stance the highest was 1018, the lowest 1030 ; of the cerebellum the highest Avas 1010, the lowest 1030. The loAvest specific gravities Avcre generally connected Avith a Avatcry or cedematous condition of the brain, Avhich led us to adopt the term '' relative atrophy," in contradistinction to that of "positiA'C atrophy," Avliere the organ has actually shrunk. The tAvo conditions, hoAv- ever, may co-exist, as Ave remarked in the ' Lancet :' " The additional fluid Avhieh makes the brain light, goes to make up for interstitial atrophy, but it does not Avholly make up for it, and the brain shrinks from its bone ease." "A low specific gravity docs not necessarily indicate a diminution of cohesion, or the commencement of ramollissement, although it points in that direction. A brain may acquire a low specific gravity from an increased quantity of fat globules in its tissue, Avhile retain- ing its normal consistence. "We believe, however, that fat tends to accumulate only in softened brain, so that possibly this source of error may not exist ; but it is, nevertheless, a point of the utmost importance to determine hoAV much of diminished specific gravity in brain-tissue is to be attributed to the eftusion of serum, and how much to the accumulation of fatty matter. This question may be resolved by treating the substance Avitli 486 PATHOLOGY OF INSANITY. ether, and by evaporation. We are convinced tliat in circum- scribed softening of the brain (true ramollissement) the low specific gravity is, to a great extent, owing to the amount of fatty matter deposited. In the last case of the table given, the specific gravity of the cerebrum, generally, was 1011 ; while that of the softened part was 1035 ; and, on examination, this pultaceous substance was found pervaded with an immense quantity of fatty matter.^^ The conditions which favour a high specific gi'avity are congestion and induration — those which favour a low one are oedema and fatty degeneration. A watery or osdematous condition of the brain is frequently met with in dementia and chronic insanity generally, and in such cases the specific graAity is low. It is low in the softened condition of circumscribed portions, which the microscope shows to be one form of fatty degeneration ; and in other cases in which it is low, it is probable that there is much diffused but unrecognisable fat ; finely granular amorphous fat diffused in the stroma, or con- tained in the cells and tubes, it being highly probable that morbid degeneration of brain-substance, like that of muscular tissue, takes place by the running together of the organic elements into forms of hydro-carbon. The pectoral and abdominal viscera present, in the insane, some pathological peculiarities which require notice. Disease of the Heart is very common among the insane. Obstructed valvular disease is often seen in connexion with simple and with hypochondriacal melancholia. Dilatation of the heart, with great irritability of the organ, and attacks of palpi- tation, are frequent in chronic mania; and we have observed, that this condition of the heart appears to impress its character of excessive excitability upon the mental disease, and that those who thus suffer are susceptible, irritable, impiilsive, and subject to gusts of passionate excitement, but that they are neither malevolent nor refractory. In dementia, the heart is liable to undergo fatty degeneration ; and in three instances of chronic mania with dementia we have satisfied ourselves by microscopic examination that the death was occasioned by this change. Disease of the Lungs occurs in the insane in all its varieties. It is frequently latent from the absence of cough, and from the patient's absorption of mind preventing complaint. The absence of cough in sci'ious pulmonary disease is very peculiar. PATHOLOGY OF INSANITY. 487 In dementia it arises partly from torpor of the cxcito-motory system, partly from loss of attention, — from the same cause, in fact, as that which gives rise to the frequent dirty habits of the insane. In mania it arises from the attention being intensely pre- occupied by the vivid ideas and delusions which absorb the mind. "NVc have seen many patients in advanced stages of phthisis, who were never heard to cough so long as they were under the influ- ence of maniacal excitement. When this underwent a temporary diminution, they were greatly troubled Mith cough, which was again arrested by the recurrence of excitement. The continu- ance of colliquative diarrhoea and perspiration, and of emaciation, proved that there was no halt in the progress of the disease, as the absence of cough has led authors erroneously to suppose. The torpor of the nervous system in dementia leads to another peculiarity in the lung and in some other bodily diseases of the insane, namely, the absence of irritative or symptomatic fever j and hence it happens, that in a demented person whose strength is unimpaired, and whose constitution is tolerably good, diseases will obtain a high degree of development, with symptoms so few or obscure as to be incredible to the general physician. It is on this account that the numerous slo\ighing sores to which gene- ral paralytics are liable, produce so little suffering, or constitu- tional irritation. "We have known the stomach disorganised by cancer, without the patient complaining of any pain until a few days before death, when perforation took place. The only case of true carditis we ever saw, occurred in an insane person who complained of no pain, and in whose heart, disease was only sus- pected twenty-four hours before death, in consequence of the failure of the pulse. This peculiarity in the intercurrent diseases of the insane should teach the physician to observe with watch- ful anxiety every physical indication from which he can derive knowledge of the attack of disease, before it is so advanced as to be beyond control. Pulmonary gangi'cne is more common among the insane than the sane ; but not to the same extent here as at Vienna, Avhcre it appears to contribute largely to asylum mortality. Diseases of the Stomach bear to insanity a relation of the highest importance. In acute melancholia, attended by refusal of food, its mucous membrane is frequently found to be inflamed and softened, or ulcerated, and it often requires all the skill of 488 PATHOLOGY or INSANITY. the most experienced pliysiciaii to detcrmiue whether an inflammatory condition of the stomach is the canse or the result of the abstinence. Softening of the coats of the stomach is sometimes an effect or a concomitant of advanced cerebral degeneration. Whether the different forms of stomach-disease classed under the term dyspepsia, are efficient causes in the production of insanity, by impeding the due nutrition of the body in general, and of the brain in particular, there are no re- liable statistical data to determine. The probability is in the affirmative. This, however, is certain, that dyspepsia is com- mon among the insane, and that its removal by therapeutic and dietetic agencies is an important and efficient means of promoting the cure of mental disease. There is nothing remarkable among the insane in the pathology of the small intestines; but the large gut suffers in chronic insanity frequent and extraordinary displacements, which we are quite at a loss to explain. The most common of these displacements is that of the transverse arch of the colon to the lower part of the abdomen, from whence again it ascends to take its proper position as the des- cending portion. But the most extraordinary anomaly we ever met with, was the formation of a eul de sac rising from the middle part of the rectum, and ascending in front of the other intes- tines until it reached the ensiform cartilage, the cul de sac being nearly two feet in length. Its walls were thicker than those of the colon, and it contained all the intestinal coats. The patient in whom it occurred had ascites, and preparations were made for tapping ; but percussion and palpation revealed the exist- ence of something strange, and the operation was not performed. Had it been performed in the usual manner, the trocar would have passed into the rectum. Our friend Dr. Parsey, of the Warwickshire County Asylum, assisted us in this case, and made the j)Ost-moriem examination. The Liver is not more frequently congested, or otherwise diseased, in the bodies of the insane than in others. The old (ireek th'eory, that madness depends upon black l)ile, has no foundation in pathological fact. The only noteworthy pecu- liarity in the liver which we have observed, has been an appa- rent loss of structure, occurring in melancholia and dementia of very long standing, and in which great emaciation and prostra- tion of vital power has long preceded death. In seven instances PATIIOI.Or.Y or INSANITY. 489 of this kind, I liavc found tlic liver shrunk and flal)l)v, and its structure converted into an appearance closely resembling that of the healthy spleen. Dr. Budd describes an analogous change occurring in persons not insane, but uith acute and recognisable symptoms. The Spleen is usually small in chronic insanity. The Kidneijs are remarkably free from disease in all the forms of insanity, and the changes which give rise to albuminous urine arc especially rare in them. We have only met with three instances of decided Bright's disease among the insane; and, upon inquiiy in other asylums, we have found that the experience of others has been of a similar nature. Prior to observation, we should have expected Bright's disease and insanity to have been frequently concomitant, on account of the common influence of intemperance in the production of the two disorders ; or even that the former might be the occasion of insanity, through the influence of its accompanying anaemia, and the toxic action of unsecreted urea upon the brain. Renal and vesical calculi are equally rare in the insane. AVe have not once met with cither, and only once with prostatic calculi. In this case the bladder and kidneys had become diseased from irritation, communicated from the diseased prostate. The Reproductive Organs are frequently the seat of disease, or abnormal function. Among male idiots and imbeciles, in- stances of deficient or excessive development of these organs are common ; and the female ])opulation of every large asylum contains several instances of that masculine development of frame and constitution which indicates an abnormal formation of the sexual organs. There can be little doubt from the num- ber of such instances, that the androgynous character is often accompanied by mental imbecility. Aracnorrhoea is a frequent cause or consequence of, or concur- rent phenomenon with, mental disease ; and its removal leads to recovery of sanity. Extreme congestion of the ovaries and uterus, with false corpora lutea in the former, we have found in two instances of young women who died during the excite- ment of acute nymphomania. Ovarian tumours are not un- common ; and at the present time two insane patients are under our care, sufleriug from ovarian dropsy. One has been tapped several times, to ward off the imminent danger of death from 490 PATHOLOGY OF INSANITY. the upward pressure of the fluid on the stomach and hmgs. The other, an epileptic, with the assistance of Dr. Parsey, Ave, tapped for the same reason, nine years ago, drawing off five gallons of porter-coloured fluid ; and, strange to say, the cyst has only refilled to a slight extent. The Humoral Pathology of Insanity. — The qualitative analysis of the blood of the insane has been made a subject of investigation by some German and French physicians. Although the somewhat difficult manipulations needful to obtain accurate and trustworthy results in an investigation of this kind, may be a severe test of the chemical abilities of alienists, we must admit that the uniformity of the gross result obtained by several independent inquirers, are sufficient to justify the important conclusion, that the condition of the blood of the insane is opposed in character to that which is found to obtain in inflammatory diseases, and that it approximates to that found in non-inflammatory neuroses, and in febrile aff'cctions. Hittorf, of the Siegburg Asylum, analysed the blood of seven patients suff"ering from acute mania; the results he obtained were, that in six out of the seven cases, the fibrine was below 2*5, the per centage of fibrine given by Becquerel and Rodicr as the amount of this substance in healthy blood ; that, in the same number of cases, there Avas a diminution of the globules ; and, in five out of the seven cases, there Avas an increase of water. In Hittorf's analysis of healthy blood, hoAvcver, the amount of fibrine is marked as Ioav as 1"4. This disagreement with the result obtained by physiological chemists of reputation, is sufficient to detract from the value of his conclusions. Erlenmayer has analysed the blood of patients suff'ering from various forms of mental disease. The conclusions he ari'ives at are, that the venous crasis, id est, the increase of globules, is very rare among the insane, and principally occurs in idiocy and dcUrium tremens; and that the l.brinous crasis, id est, increase of fibrine, is equally rare in cases of insanity fi'ce from compli- cations Avhich Avould tend to modify the proportions of this constituent. M. Michea, Avho has investigated the condition of the blood in general paralysis, found that, in the majority of cases, there Avas an increase in the number of globules ; in the majority, also, the quantity of fibrine Avas normal, in some it Avas di- PATHOLOGY OF INSANITY. 491 minished. The inorganic matter of the serum representing the albuminous constituent AAas diminished in little less than one- third of the eases ; from Avhich he infers, that " the spontaneous diminution and the insufficient formation of the albumen of the blood, are the immediate causes of a certain number of the cerebral effusions which occur in the paralytic insane." The analysis which Becquerel and Rodier obtained of blood in acute inflammations (^Path. Chera./ p. 105) shews a proportion of fibrine of 5*8 per cent., the nonnal standard being 2-5 ; a decrease of globules from the normal standard of 135 to 1.23-3; a decrease in the albumen of the serum, and also the alkaline salts ; and an increase of fatty matters. In encephalitis, Pog- geolli and Marchal found the fibrine increased to G"08, and the globules decreased to 10(305, affording a remarkable contrast to the proportion of these constituents found by Hittorf in acute mania ; the highest amount of fibrine found by the latter being 2*03, and the lowest amount of globules being 109*191. The following table shews the proportion of fibrine and of blood -globules in six cases of mania during the period of the accession and that of convalescence, which were reported upon by Dr. Hood, of Bethlem, to the Medical and Chirurgieal Society, jNfay 8th, 18G0. The first three cases were acute, and the last three recurrent mania. The analyses were made by Dr. ]\Iarcet. They all indicate a marked deficiency of fibrine during the period of maniacal excitement, and a correction of this deficiency durinir convalescence. Number. Condition of Fibrine and Blood during uttack. Condition of Blood on recovery from attack. 1. Fibrine, 1-74. Blood-globules, 149-74. Recovered nine montbs after admission. Fibrine, 2-20. Blood-globules, 110-07. 2. Fibrine, 1.55. Blood-globules, 125-48. Fibrine, 275. Blood-globules, 140-61. 3. Fibrine, 1-67. Blood-globules, 104-68. Recovery in nine months. Fibrine, 1-75. Blooscssion of and swalloMcd an ointment which contained 21 grains of opium, and having been cured by the narcotic thus unadvisedly taken, the atten- tion of medical men was particularly directed to the use of this drug in insanity. Valsalva and Morgagni prescribed it, and Pcry cured maniacal patients in whom there was much inso- mania with large doses ; he carried his doses as high as sixty- four grains in the twenty-four hours {' Esquirol,' torn, ii, p. 21 1) — a quantity considerably exceeding the large doses given by Dr. Oliver, by whom tliis method of treatment has recently been recommended in the pages of the ' Lancet.' Although wc have never ventured to use cither morphia or 522 TKEATMKNT OF INSANITY. opium in qiiaiititics at all approaching to those above men- tioned, or to those recommended by Dr. Oliver, we have yet employed thera freely in doses which, compared with those usually prescribed, most medical men would think bold prac- tice. There are, however, many cases in Avhich morphia and opium are only admissible after the operation of, or in con- junction with, other remedies calculated to reduce local cerebral hyperemia, or general plethora. As a rule, opiates are inadmissible in mania so long as cere- bral hyper?emia exists — either alone, or in conjunction with general plethora. When circumstances permit, these should be reduced before opiates are administered ; but frequently this rule cannot be strictly followed. The commonest maniacal condition is that in which the pulse is by no means full or strong; but the head is hot, the eyes arc injected, and the existence of active cerebral congestion cannot be doubted ; the patient is restless and violent, and without sleep for many nights. In such a case, the physician is called upon to determine be- tween two evils. INIorphia or opium, prematurely given, will increase the cerebral congestion, and do mischief Too long delayed, equal, or greater mischief, will result from the want of repose. The violence, restless agitation, and sleeplessness of the patient, will perpetuate a degree of hyper?emia which a judi- ciously administered dose of morphia will often allay. There is great risk in laying down rules, but, as a general rule, after a patient has been without sleep for three nights, a full dose of morphia ought not to be withheld, notwithstanding heat of head, and other symptoms of cerebral congestion. Practically, the physician finds himself in many cases com- pelled to give morphia, and to use remedies to reduce cerebral congestion concurrently with six, ten, or twelve leeches, to the temples, followed by cold lotions to the shaven scalp during the day, with or without an aloetic purgative, according to the state of the tongue, and the strength of the patient. This may be followed the same evening by a warm bath, with the cold still continued to the head, a full dose of black drop or morphia being given the last thing. Such treatment frequently has the most satisfactory results ; the patient gets several hours of sound and refreshing sleep, and a modified repetition of the TRKATMENT OF INSANITY. 523 treatment, continuing tlic antiphlogistic or tlic narcotic reme- dies, according to tlie progress of the symptivvenoit que boh obstination tlans sea I'carts seroit punic le lende- main de diz coups de nerf de Wuf. L'execution de Tarri^t on he made water, and was immediately curctl. Another suppojicd his nose so big, that he should dash it against the wall if hestirre*!; his phy- sician took a great piece of fiesh, and iiolding it in his hand, pinched hint by the nose, making him belecve that fiesh was cut from it. Forestus had a nuianchnly patient, who thought he was dead : lie i)ut a fellow in a chest like a (UmuI man, l)y his bed's side, and made him reare liimself a little, and eat : tlie melancholy man asked the counterfeit, wliether dead men use to eat meat ? he tohl him yea J whereupon he did eat likewise, and was cured. Lemnius hath many oucli instances, and Govianus Potanus, of the \\]ic"—Aiinfomy of Melancholy, vol. i, part ii, see. ii. In another place he says : " Hercules de Saxonia had such a prophet committed to his charge in Venice, that thought he was Kiias, and would fast as he did : he dressed a fellow in angel's attire, that said lie came from heaven to bring him divine food, and by that means staid his fast, and administered his phy»icke: so by the mediation of this forged angel he was cure[ENT Ol" INSANITY. 551) nous nature of the Avork on which such patients arc employed in our public asylums. Occupation which rccpiircs thought is far preferable, in a curative point of view, to that mIucIi re- quires none ; and liencc it occurs that artisan employments for men, and household employments in the kitchen and laundry for women, ai-e far more useful, as curative agencies, than the monotony of spade-husbandry for the former, or needlework fov the latter. AVe entertain considerable doubts as to the curative utility of the promiscuous dances and crowded assemblies which have come into vogue in large asylums. Their influence is too indiscriminate. If they rouse one patient from apathetic dejec- tion, they urge another into mischievous excitement. An hour or two devoted to various kinds of recreation, several days a week, in the diflerent Avards, is a more manageable means of diffusing cheerfulness and diverting thought. In this manner various kinds of amusements are capable of being applied more frequently, and under better management. Surely an hour in the evening, spent in recreation by one's own fireside, in a jovial dance or game, or the enjoyment of music, has a more mIioIc- some influence upon the mind than a weekly or monthly attend- ance at a public ball ; and the parallel appears to hold good in asylum life, not only in theory, but according to our experience in practice. The occupation of the mind by educational processes of a pedagogic kind, has a high value as a means of a moral treat- ment, iu some particular instances. Leurct relates a striking instance (' Des Indications tl suivre dans Ic Traitement Moral,' p. 61) of compelling the patient to learn daily, by rote, a certain number of verses, by which he overcame a peculiar form of insanity, manifesting itself in the constant repetition of fixed ideas, expressed in the same formuhe of Moids. Among edu- cated patients, we have found literary pursuits of the utmost value as a means of moral treatment ; and in a.sylum manage- ment we find school classes, periodical publications, and u lending library, of great importance in aflordiug relief to the monotony of confinement, and in giving topics of conversation and thought. AVith more individualised attention than is afforded in our large asylums, the moral treatment might be de- veloped into something like the powerful means of resistance to insane prc-occupation which M. Leuret has made of it. In the 560 TREATMENT OF INSANITY. Devon Asylum, during eight months of the year, evening-school classes are formed under an experienced schoolmaster, on three evenings in each -week. They arc carried on by the attendants as class-leaders, in several wards at the same time, and consist of reading, writing, and arithmetic classes. Their influence as a source of wholesome mental occupation, has been decidedly i)eneficial. During the snmmer months, the evenings are spent in open air recreation. In works which treat upon the moral treatment of insanity, it has been customary to prescribe rules for the guidance of the demeanour and behaviour towards the insane. From the excess of firmness which is demanded by some, one would think it needful that an alienist physician sihould have " an eye like Mars, to threaten and command,^^ as if his functions were not unlike those of the worthy ^Mr.Yan Amburgh. The universal gentleness and indulgence which others advocate, would lead to an opposite extreme, scarcely less adverse to the true interests of the patients. The truth, as usual, lies between; and the physician who aims at success in the moral treatment of the insane must be ready " to be all things to all men, if by any means he might save some.^^ He must nevertheless have a good back-bone to his character, a strong will of his own, and with all his inflections be able to adhere, with singleness of purpose and tenacious veracity, to the opinions he has on sound and sufficient reasons formed of his patient, and the treatment needed to be pursued towards him. AVith self-reliance for a foundation to his character, it requires widely different manifes- tations, to repress excitement, to stimulate inertia, to check the vicious, to comfort the depressed, to direct the erring, to suj)- port the weak, to supplant every variety of erroneous opinion, to resist every kind of perverted feeling, and to check every form of pernicious conduct. The physician may often, with the best success, take one l)art, and the attendant another, — a good understanding existing between them as to the end in view. " I have often heard my master, the estimable Esquirol, affirm," says Leuret, " that an insane patient ought often to have the services of two medical men who are thoroughly agreed to act in the same direction, but by dittorent means ; the one taking the part of a consoling and officious friend, having only a restricted authority, and sub- TRKATMENT OF INSAMTV. 'Ml mittinj; liinisclf, or at least appearing to sul)niit liinusclt', to a superior authority ; the other exercising the supreme power, knoM-ing everything, judging everytliing, and on oecsusiou si-oUl- ing even his colleague. 1 have found this otlicious friend in M. iMarccl; and one sees with how much tact he has availed him- self of the confidence of the patient. My severity rendered the intervention of a protector needful ; and this protector in ex- change for the support he gave to the patient, acquu-cd the right to his gratitude." The system thus practised by the senior pliysieian and his junior is available, and often successful by the aid of attendunts. The exercise of autliority may be assumed l)y the physician him- self, or by the attendant, according to the temper and p()^ition of the patient, guided also, in some degree, perhaps, by the qualifications of the physician himself, according to which he may best be able to command, or to comfort and soothe. It is essential, however, that every measure should be taken under the immediate direction of the physician, and that there should l)e a perfect understanding l)etween him and his assistants. In the moral treatment of the insane, a divided authority, or a diversity of intention, is fatal to all hope of success. The subject of moral treatment is as wide as that of educa- tion ; nay, wider; for it is education applied to a field of mental phenomena extended Ijcyond the normal size by the breaking down of all the usual limits. Ever}' case has its peculiarities, requiring that its moral treatment should be adapted to them. Moreover, in identical cases, if such can be supposed to exist, the same treatment will not equally succeed in the hands of different medical men. M. Leuret says ("Indications j\ Suivre") — " To combat the same disease two physicians take eaeli a different part ; since, finding in themselves dissimilar faculties and aptitudes, they choose tlic means with the use of which they are best accpiainted. The moral ])harmacoixjL'ia of the physician, if 1 may be permitted the exprosion, is in his jiead and in his heart ; he has in himself that which he gives to his patient. If ingenious, he will give much; if clumsy, although learned, he will do no good. As for precepts and guides, if they exist for you, they are in you; seek them not clsi-where. The moral treatment is not a science, it is an art, — like eloquence, 3G 562 TREATMENT OF INSANITY. paiutinf^j music, poetry. IIoAvcver great a master of tlie art you may be, if you give rules, he alone will submit him- self to them who is your inferior. In matters of physicial seience there are precise rules; in mathematical ones, there are rigorous calculations ; but, in morals, there must be inspiration.^' Mechanical Restraint and Seclusion. — A work on Insanity would certainly be defective if all mention of the topic which, of late, has so much engrossed the attention of alienist physi- cians were omitted. But although we have taken an active part in the warm discussion on the question of the total aboli- tion of all mechanical restraints, we do not feel called upon to revive it in these pages. We have, for sixteen years, conducted a large asylum, whose admissions, during that time, have amounted to 2400 cases, without having had occasion to resort to the employment of mechanical restraint in the treatment of insanity. We entertain precisely the same opinions on the em- ployment of restraint and seclusion as those which, six years ago, we expressed to the Commissioner in Lunacy and which, Avith many others, they have published in their eighth Report. We shall, therefore, be content to quote some passages from that Report, in which we have set forth our opinion and practice in these important questions of treatment. " In the Devon County Asylum, restraint is never employed, except in surgical cases ; in these, of course, the same principles must he adopted for the insane as are necessary for the sane, to ensure that absolute quietude of parts which is essential for the advantageous conduct of the healing process. It is not denied that cases have occasionally arisen in which it was difficult in the extreme to avoid the imposition of restraint ; for instance, those of suicidal patients wIk) have endeavoured to effect their pur^jose, hy thrusting articles of clothing and other suhstances down the throat, hy beating the head against the wall, and other means which are scarcely capable of being obviated by any watchfulness on the part of the attendants. " The occurrence of such cases, however unfrequent they may be, renders it im- possible to deny that the imposition of mechanical restraint may, in rare instances, be rendered necessary for the safety of the patient. " Mechanical restraint in the treatment of the insane is like the actual cautery in the treatment of wounds, a barbarous remedy, which has become obsolete from the introduction of more skilful and humane methods, but which may still be called for in exceptional and desperate cases. It may be said, that as these cases lire so rare — that as large asylums are conducted, for many years, without one of them being met with — that as they do not appear, it may be considered as if ti:e denied that insanity fre- quently displays itself by excitement of the malignant passicms ; and that stmie of the most depraved of mankind terminate their career in asylums. Towards these, seclusion must be occasionally employed in its harsher form, as u coercive means to prevent the welfare of the many from being sacriticee phy- sical functions are regular, and the sleep good. The ferocious expression caught iu the photograph passes into one of ungovernable fury, tiic face be- coming almost purple, the veins of the head and neck turgid and swollen, and the saliva hanging on the lips like foam. In less than half an hour, if spoken to kindly and soothingly, she becomes tranquil. Tonic treatment has been indicated in this case; but, at present, good food and occupation are the only remedies likely to be of use. 568 APPENDIX. Monomania of Phide. E. N., No. 97G. — The central portrait of tlie frontispiece is that of a female aged 38, the dauglitcrof au oCQcer in the Customs. The cause of lier ilhiess is not known, but it appears to have been of long standing. Six years before her admission, she met some soldiers, who, she said, attempted to create a disturb- ance, and who a])pear to have frightened her. For some years before her ad- mission, she was in the habit of coming from D^vonport to Exeter, wlienever the assizes were held at the latter place, in order that she might obtain her rights as Her Majesty's Person. On these occasions, a benevolent magistrate, to whom she liad made herself known, used to send her to her home. "At last, on one of these occasions, she was tiiouglit decidedly unsafe, and was sent to the asylum. Her delusion is, that she is Her Majesty's Person— she is not Her Majesty, but Her Person — a distinction on wliich she lays great stress, but which we have never been able to understand. She is proud, and dignified in her demeanour. Out of the commonest materials of dress she contrives to make a distinguished appearance. She fastens the skirt of her dress low, so as to form a sort of train ; and, with arms folded, the head with its coronal orna- ments thrown proudly back, she would, if permitted, maintain an erect and regal position from morning till night. As she has a dilated and irritable heart it would be dangerous to permit her to indulge tliis fancy; and hence arise some difTereuces of opinion between her and those who have the care of her health. The intense pride expressed in the turn of tlie head and eye, and in the firm compressed lips, cannot be mistaken. It is the physiognomy of one exagger- ated emotion, transmuted into one delusive idea. CONGKNITAL IMBECILITY. S. J., No. 1>71. — The portrait of this youth, the lowest in the frontispiece, represents the vacant, expressionless stare of imbecility. The patient, aged twenty-seven, is the son of a weak-minded father; he has always been of weak- mind, but is said to have become much worse since a blow on the iiead ; this, liowevcr, is doubtful. When first admitted, he was dirty in his habits, restless an 1 mischievous ; a little attention has rendered him cleanly, quiet, and docile. His intellectual power is very low. His head, wiiich has some resemblance to that of a horse, has the macrocephalous shape. The dimensions are as follows : height of i)erson, 5ft. lliu.; circumference of head, 1ft. llin.; from junction of nasal bones with frontal, to the occipital protuberance, 1ft. 3in., to nape of neck, 1ft. 4-2in. ; from ear to ear, over vertex, 1ft. Sin. ; from meatus of car to ear, round chin, 2ft. 3 Jin. The expression of physiognomy is very character- islic of intellectual feebleness ; tlie brow and eye indicate the effort of attention different to the tranquillity of hebetude, which is so characteristically depicted in the portrait of primary dementia. But the effort of attention is not seconded by any power of comprehension ; the expression is that of intense -stupidity. APPENDIX. 5G0 General Taualysis. J. D., No. 1623.— The upper side portrait to the left hand (of the spectator) represents a man, aged forty-eight, the subject of general paralysis. Tiic cause of his insanity was not knowTi. He had been insane three mouths before his admission. He had been destructive of clothing, &c., and had been violent to his wife, attempting to pull her cars off. He said that it was his duty to kill her, and yet that he was always at prayer with her and for her. Allhougli he would kick or scatch any patient who inadvertently touched him, his general condition in the asylum was tranquil, verging gradually to mindlcssncss. He had, only in a modified degree, the delusions of grandeur so common in this form of insanity. He used to say that he had a gold watch, and gold chain, and very fine clothes, but they were in pawn. Ten months after admission, he had two consecutive attacks of that form of convulsions between apoplexy and epilepsy which is common in general paralysis. Soon after emerging from the coma of the second attack, he died in bed in a fainting fit. The body was not examined. The portrait shows the curtain-like face, devoid of all expression, a perfect blank of thought and feeling. The head is well shaped, and the features are handsome ; but the amount of intellectual expression is less even than that displayed in the face of the idiot. The brows droop over the orbits, and the eyelids over the eyes. The muscles of the mouth and lips are relaxed, and were the patient to attempt to speak they would twitch and quiver; but even photo- graphy cannot represent motion, and the blank void of the features in repose is all that can be shown. Acute Suicidal Melancholia. J. B., No. IGSO.— The upper portrait on the right hand side (of the spectator) is that of a man, aged fifty-six, with acute suicidal melancholia. A carpenter of steady habits, insane four mouths before admission; had been dull and depressed, and could not attend to his trade ; refused to take food, because it was too good for him ; was restless by day, and sleepless by night ; said that he must be burnt or scalded to death : he made frequent efforts to get at the hot-water taps, in order that he might scald himself, and to get to a little duck pond, scarcely a foot deep, that he might drown hiinsclf; ran his head once with violence against a wall, to injure or destroy himiclf. Constantly undressed himself, and required to have clothing which fjistened behind with the asylum buckle. He improved under treatment, (opiates at night, and leeches to the temples,) but having been visited by his wife, three months after admission, he became much worse ; said that his wife was a man dressed in woman's clothes, that she had given him poison in a cake ; and from that time to iiis death re- quired to be fed with a feeding s|)oon. Six months after admission, he suf- fered a severe attack of e|)ilep8y, which was repeated three times during the following month. He died from exhaustion immediately after the last attiick. Post-mortem examination, sixteen hours after death. — Calvarium thick, dense, and irregular, in some places tiiinner than usual ; arachnoid opaque and milky ; sub-ai-achuoid fluid considerable ; gray matter of brain paler than usual ; 570 APPENDIX. tlie white subsfance of a brownish-pink hue, most marked in the parts lying over the lateral ventricles ; substance of the brain very firm ; lateral ventricles normal ; soft commissure quite firm ; septum lucidum distinct and firm ; vessels at base slightly atheromatous ; temporal fossa; strongly marked with the im- pressions of the convolutions. Sjjccific gravity :— White matter 1045, gray matter 103G, cerebellum ]OJ:0. Commenis.— Death followed epileptic convulsions, from chronic change in the nutrition of tiie brain. The fear of death and the urgent desire to commit self-destruction, however incompatible with each other they appear to the sane mind, are frequently co-existent in the insane. This patient was intensely restless, a condition which, like the tremors of general paralysis, cannot be re- presented in a portrait. The physiognomical expression is characteristic of anxiety and fear. Pkimary Dementia. S. T., No. 1475.— The lower portrait on the left hand side (of the spectator) represents a case of primary dementia. The patient, now aged forty, had a severe attack of typhus fever when nineteen years of age, after which, her husband says, that "her jaw dropped, and she has never been perfectly right since." This did not prevent her, however, being married to a shoemaker, and bearing five children, the last of whom, six months old, she suckled to the date of her admission, affording an example of one means by which insanity is propagated. She was admitted in a state of extreme filth and personal neglect, in the same mental state in which she still remains, namely, a void of sensation, emotion, and thought. On her blank physiognomy there are no traces of passion telling of former storms of mania, there is not even the slight effort of attention which corrugates the brow of the idiot. She never laughs or weeps, or indicates any want or any annoyance. She knows none of the attendants or patients by name ; says she was never married ; remembers her maiden name, but appears to have forgotten her married name. If she were accidentally liurt, she would feel but little pain ; if she were not fed like an infant, she would die of starvation with little suffering. She is very fat, has a good colour in her cheeks, and her pliysical functions arc performed well. The cata- mcnia are suppressed. She seldom moves, feeling no motive to do so. "When told to move, she progresses with a short, quick trot, like a young child. She eats ravenously, and would choke herself if her food were not carefully minced. She affords a good example of the extent to which physical health may be retained when the activity of the cerebral functions is reduced to its lowest ebb. Secondary Dementia. M. A. Y., No. 1322.— Tiie lower portrait on the right Land side (of the spectator) represents a woman, aged forty-nine, the subject of secondary dementia. She has been insane two years and a half. The cause was attri- buted to religious excitement, and the fear of death from disease of the knee- joint. Tlie form of insanity which first presented itself was that of acute AVPr.NDlX. 571 maniacal excitement, with delusions of a religious type, and suicidal desire. Slie tLouglit that her soul was separated from her body, and that it was for ever lost. She attempted to strangle herself, and also to beat her brains out by running against walls. After admission, this violence subsided, aud she passed into a state of chronic excitement, which, with gradually decreasing mental powers, has continued to the present time. She sleeps badly, and believes that she is visited at niglit by an old lover, towards whom she uses very bad language, and whose supposed attempts to get into bed she resists vigorously. Although quiet cuougii during the day, she is often, in conse- quence of this delusion, very noisy at night. During tiie day, she holds quiet conversations with this lover, and with persons whom she has known in early life. She not only hears but sees these people, and this hallucination has impressed that earncbt inquiring look so faitiifuHy given in the portrait. Her memory of early years is much stronger than tiiat of events which have jubt passed. She cannot tell our name, or the name of the nurses, or of any of her fellow-patients ; but siie can remember the names and residences of the people who lived in the neighbourhood of her home. She takes her food well ; but her attention is so feeble that, without great care, she would lapse into dirty habits. The catamenia are regular. The general expression of the face is that of mindlessness, combined with the deep lines of emotional excitement. From the presence of the Litter her physiognomy presents a great contrast with that of the instance of primary dementia on the opposite side of the plate. The face also presents a striking instance of that want of harmony between the expres- sion of the different features wliieh is often so characteristic a trait of insane physiognomy. The upper part of the face, viewed alone, might be taken to belong to a person in a state of acute mania ; the lower part, viewed alone, might be mistaken for utter fatuity or idiocy. SOME CASES ILLUSTRATING TREATMENT. Mania with violence; disuse of restraint ; recovery. — Some years since we were called upon to attend a lady of fortune, suffering from violent and de- structive mania. Peculiar circumstances rendered it needful that she sliould be treated at home. She had been ill about two months. We found her in the charge of a female attendant from one of the London asylums, who, as usual, had brought a complete set of restraining ai)paratus in iier trunk. The patient was in her drawing-room, which had been denuded of all furniture, except two old chairs and a sofa without covering. On the carpetless floor, dressed in an old wrapper, without shoes (which had been taken away lest she should kick the nurse, or throw them at the window), sat a lady with hand- some, haggard features, volubly abusing her attendant, a fine, high-spirited young woman, who indicated too much sensibility to the unpleasant epithets poured upon her. On examination, wc found our patient to he suffering from what Esquirol called munie raisonnanfe — W\gh mental excitement without delusion, accompanied by violence of conduct more or less under control. L'uder the treatment to which she had been subjected, this violence had not 572 APPENDIX. been controlled. In addition to bad and abusive language, she frequently attacked the nurse and the servants who assisted her, spat upon them, kieked them, bit them, broke windows, destroyed clotliing and bedding, threw her plate and food against the wall and the windows, and was altogether as violent as she well could be. The treatment to which she was subjected was, tlie imposition of the strait-waistcoat whenever her violence and insults exceeded the limits of the nurse's endurance. At night the lady was put into the strait-waistcoat, and tied down to the bed ; the door of her room was locked, and she was left to herself until morning. She complained bitterly of this treatment, and heaped opprobrious epithets upon her nurse. We substituted for her services those of a woman who was probably her inferior in every natural qualification for a good nurse, but who had never seen a strait-waistcoat applied, and would not have known how to put one on. Compelled to rely on other means than those of forcible repression, this woman exercised towards her charge the soothing influences of never-failing kindness. Tor a time slie underwent as much abuse as her predecessor. But " a soft answer turneth away wrath ;" and our mischievous friend soon found it no fun to shoot her arrows of sarcasm and contumely in a direction where they were obviously not felt. The display of violence diminished, pari passu, with the war of words. The patient was made comfortable in the condition of her room and of her dress. The second story of her house was devoted solely to her own use, so that in her restless moods she could walk from chamber to chamber. The windows of her bedroom were fitted with convenient shutters, and a second bed arranged in it ; so that one or two assistant nurses could sleep or watch, according to the state of the patient at night, who sometimes slept well, and at others was very restless — when she would walk about the room for hours, until in weariness she went to her bed, and often slept soundly during the last few hours of the night. In the daytime she took walking exercise in lier grounds, and after a while, walks into the country beyond ; and, in two months from the date of her change of nurses, her state of mind was as good as that which she enjoyed previous to the accession of maniacal symptoms. In this case there was no medical treatment. INIorphia was prescribed for the sleeplessness from which the patient had suffered ; but the first dose having been followed by headache and feverishness, it was discontinued, and no other treatment was adopted. The very marked change for the better which took place in her condition was attributable solely to the change in the moral iu- lluenecs to which she was subjected. When the case approached convalescence, the nurse who had been so successful was replaced by an educated lady, who gave her valuable services as the companion of the patient ; an arrangement which jiroved in every way satisfactory. It may here be remarked, that the person best adapted to conduct a case, during its more demonstrative period, is often by no means well suited to do so during its first or prodromic, and its third or convalescing stages. It is not that persons of educated mind will not submit to the indignities and annoyances incurred during attendance upon cases of active insanity; motives of afl'ection, of benevolence, or of gain, may overcome such repugnance; but it is that the educated and sensitive mind ai'pcars practically ill-adapted to come into useful contact with the turbulent APrENDlX. 573 emotions and indiscriminating perceptions of the acutely insane. But at the period before insanity is developed, and during that before convalescence, when its manifestations become less gross, the finer tact and perceptions of an educated person will frequently prove of the utmost service in the moral guidance of the patient. The above is an example of the tranquillising and curative effect of that demeanour which a nurse is compelled, by tiie non- restraint system, to adopt, and doubtless results from the operation of that law of our nature which may be called emotional imitation. This law, which explains the easily moved enthusiasm of crowds, and the causeless panic of armies, is one of the most powerful agents in the moral treatment of the insane. By the force of this law, a susceptible and ill-trained attendant allows herself to be placed in emotional rapport -with an angry patient; a well-trained and good-humoured attendant, on the contrary, places the patient in emotional rapport with herself. It is a fruitful theme, of which our limits scarcely permit us to state the thesis. Sthenic Mania; recoceri/ under the vse of Tartrate of Antimony. — .\. C"., No. 5Gi. — "Wife of a husl)andman, aged thirty-four. A month before admis- sion, she had a serious quarrel with her husband about the sale of some apples; from that time has been exciteable; has taken knives threatening to injure others and herself; has a delusion that she is a wheelbarrow. Mental state. — Has good-humoured and manageable excitement, but talks bitterly of her husband's ill-usage ; is occasionally irritable and passionate. Bodilj/ condition. — Appearance healthy, head cool, ajipctite good, bowels confined ; pulse firm, not quick; sleep uncertain. Treatment.— k\^cx\tvA?,, Antim. P. Tart. gr.J, ter die. The antimonial produced no nausea ; the patient slept well, and took food heartily; began to employ herself, and generally improved. After a month, and at the time of the catamcnial period, high maniacal excitement came on, with passionate violence; she was always jumping and racing about, pushing and striking everyone she passed ; talking incoherently ; for three nights sleepless, out of bed, and noisy. Liq. Opii Sid. iT\xl, o. n. The ex- citement subsided in about a fortnight ; she gradually im|)roved in temper, and became cheerful and industrious. During the next two months her delusion disappeared ; but she maintained that she had not been out of her mind. In the next month she changed her mind on this point, and was discharged cured six months after admission. Acute Mania subsiding into quiet Melancholia ; recoterj/. — J. N. G., No. 555. — An engineer ; a clever, industrious man, of steady habits. Three months before admission experienced a severe disappointment, in not getting an order for a certain steam-engine which he had calculated upon ; he became excited and irritable in manner, neglected his work, and acute mania gradually came on. Mental state. — Extreme excitement ; believes that he is going to be shot; asks everyone why he is not killed, and begs of them to kill him; shouting all night long; tears his clothes, destroys his bedding, scribbles on the walls and doors; jumps at the gas-pipes, and attempts to pull them down; very destructive and violent; wets and dirties his bed; miscalls persons. 574 APPENDIX. fiincying lie lias seen every one before; uo power of fixing his tilteution. Bodili/ co/idt/ion.—Y.xpression pale, wild, haggard ; skin clammy ; extremities cold, head cool ; losing flesh ; pulse small and quick ; bowels constipated. Treatment. — ^iher. Suljih., Tiuct. Opii, ana 111.xl, ex aqua, 6tis horis ; purga- tives on alternate mornings. Under this treatment he gained sleep, took food, and improved greatly ; still remained occasionally violent, dirty in his habits, quarrelsome and abusive, muttering to himself, and swearing. After five months — has improved considerably ; has been employed in the engine house, but requires careful watching, as he is listless, abstracted, aiid low-spirited, iEthcr and opium now omitted. Under the influence of agreeable occupation this state gradually wore off during the three following months, and he was dis- charged recovered, seven months from the time of his admission. Mania from debility ; recovery under the use of quinine and yood food. — J. B., No. 1731. — A young man, aged twenty, of uo occupation. His mother is insane ; he has had feeble health for many years. Mental state. — Maniacal excitement and restlessness, accompanied by delusions that he has the best breed of black horses in the world, — that he is the strongest man in the world, and can throw the best wrestler in Devon or Cornwall. Violent — attemplinsf to bite and kick, and mischievous. Bodily health. — An exceedingly small, frail, little person, with rachitic curvature of the spine, so great that his back is like the letter D. Body very emaciated and anaemic. Pulse very small and rapid ; head cool, tongue clean ; sleep none for four nights. Treatment. — Morph. Mur. gr. -g-, h. s. omni uoete; Quinsc Disulpb. gr. ii, Vin. Eub. si, ter die. After some days, cod-liver oil was substituted; but the oil produced sickness, and the quinine and wine were again resorted to, and continued, to a week before his discharge. Extra diet, wiih strong beef tea and new milk. Tlie patient gradually gained flesh, and acquired strength, and his mental con- dition improved imri passu. He was discharged recovered, three mouths from admissiou. Mania, with limited delusions; Opiate treatment. — W. C, No. 551. — A master carpenter, in good circumstances, of steady and domestic habits, said to have suffered chagrin from want of children by his marriage. Six months before admission, symptoms of insanity first showed themselves in a sudden fancy he took to join the Odd Fellows' society, about which he constantly talked in an excited manner, saying,, that all who were not Odd Fellows would be ruined ; he took a violent antipathy to his wife, whom he accused of infi- delity, and of attempts to poison him ; has been violent to his wife ; followed his brother on the railway, to warn him -of spirits which he had seen on the platform; refuses food, saying it was poison. Mental state. — Is very morose, obstinate, and dissatisfied ; angry at his confinement, but most angry at his wife, whom he says he hears outside his room at night; obstinately refusing medicine, and at times abusive, passionate, and violent. Bodily condition. — Head over-warm, with frontal pain; tongue white; urine healthy, acid; pulse quick, weak; sleep disturbed. Treatment. — Blister to nape; Til. Ilydrarg., with aperients; occasional shower-baths; Tr. Opii 5j, o. u. After six weeks APPENDIX. 575 01. Tiglii ad caput tonsum ; after tivo moullis Eilicr. S., Tr. 0,.ii, ana 355, ex aqua, ter die ; repeat 01. Tiglii ad caput. The patieut made no progress for two months from admission. After that time tiie opiate treatment then adopted appeared to soothe the irritability of his system, and after the third and fourth months he improved rapidly; he was discharged cured in December, ISiS, and has remained perfectly well ever since. Suicidal Melancholia, changing (0 Mania ; treatment for Cerebral ll;iperasscd ; the air respired passes partly through the wound. He lay quietly, without being able to speak ; did not interfere with the dressings ; took wine eagerly. Wine, brandy and egg, bccf-fra, &c., were administered frequently ; but he gradually sank, and died, after being in the asylum two clear days. Pis(-mor(em. —Crixmnm thick; dura mater fiindy adherent ; Pacchionian bodies Arri-.NDix. 587 large, greatly iudciiling cranium ; venous congestion of pia mater; subarach- noid effusion in small quantity. Substance of brain soft and watery : weight 21b. 11^ oz. Sp. gr. cerebrum 1039 ; cerebellum 1045. Gray matter of con- volutions of a muddy-brown colour, the external layer darker than the internal; the tubular neuriue also of a muddy colour, with numerous blood points. Heart 5^oz. Intestines dark in colour, inflated, covered with old false mem- brane. Cysts in surface of kidneys. Tiie wound in the throat was not interfered with. Mania with changing delusions ; deaih from Chronic Oastritis. — J. B. W. A letter-carrier, aged 48. Ten days before admission he requested his brother to accompany him in his rounds, as people were waylaying him with the intention of destroying him. Had since been very restless, excited, and ungovernable; had suffered much grief from the immoral conduct and death ol' a daughter. No relatives insane. On admission, great anxiety and restlessness ; heard noises of people coming to injure him; head over-warm; tongue furred; pulse quick and weak; sleep fair; muscular movements active and normal. Aperients. Improved greatly during the first mouth; acknowledged his delusions to be such, and said he had been subject to morbid fancies of plots and an impending evil for two years. After a game at cricket, he began to talk of his old delu- sions in a nervous excited manner ; hot head, flushed face, and quick pulse. Autim. P. Tart, gr., J, ex aqua— ter die. This medicine not well borne, and omitted after four days. The delusions of fear gradually changed to others of pride ; said he had £305,000 a year, was a knight of the realm, constantly bowing and kneeling to Her Majesty. Bal. Pluv. o. m. C.C. ad jvj nucUse. After a week. Bain. cal. c. affus. frigid, capiti pr horse dim. o. n. Afterwards head cool, free from pain ; pulse quick, of fair tone ; quiet at night, but wakeful. Warm baths omitted after a week ; morning shower-baths ordered, and omitted after a fortnight. After two mouths, acquired a new leading delusion, that a certain mesmerising surgeon had gained complete power over iiis body and soul, and that he was going to hell ; gloomy and anxious, losing flesh, appetite in- different. Sp. Ammon. Co. Sp., iEtheris C, ana ^ss. Inf. Gent. c. ^, ter die. After two months, wisiicd to be killed, but would not attempt his own life, if Dr. B. would cut off his head when the Queen sent her permission ; often re- fused food, saying it was poisoned, and needed to be fed ; still lost flesh and became emaciated ; tongue thin, with a red tip ; alvine evacuations formed, of a pale clay colour, scanty ; complexion clear ; pulse quick and feeble ; sleep fair; no abdominal pain. 01. Jecoris Aselli; Ilydr. c. Greta, gr. v, o. n. ; Bain. Cal. 9G,° altcrnis noctibus. liggs and new milk diet. Strong ale and wine. For two months longer he gradually declined in health, the delusions remaining the same. Took nourishment better, but enjoyed beer and wine most. Tea months from admission became gradually weaker, lost his voice, did not recog- nise his relatives, became drowsy, and died without a struggle. Post-morlfm. — Body greatly emaciated ; ealvarium thick ; dura mater not adherent ; ar&chuoid transparent, containing jiij of serum in its cavity. Vessels of pia mater on right side much congested and enlarged. Subarachnoid effusion over the whole of the right hemisphere and the anterior convolutions of the left, l^ateral 588 APPENDIX. ventricles normal. The colour of the gray matter of the convolutions not uni. form, the external third of its thickness being darker than the internal. Both the vesicular and tubular neurinc softer than usual ; cerebellum and medulla normal ; pituitary body smaller than usual. Weight of brain 21b. 2oz. Sp. gr. 1-045. Lungs healthy. Heart 7oz., firmly contracted ; aortic valves thickened ; aorta contracted and atheromatous. (Esophagus presenting a jelly- like appearance of the mucous coat. Stomach : the mucous mcmbrauc soft and pultaccous ; decided marks of inflammatory action in cul de sac and along large curvature ; a patch of inflammation the size of a crown-piece near the cardiac orifice. Transverse arch of colon lying in the pelvis ; small intestines con- tracted, and lying in the pelvis ; some enlargement of the mesenteric glands ; spleen contracted. Other organs healthy. Mania from dissipation and intemperance. — S. A. S., No, 1223. — A public prostitute for twenty-five years ; during that time has had seven illegitimate children ; three years since was said to have been married, but this is doubtful. When the person calling himself her husband visited her in the asylum, she cried — " Oh, the brute ! the devil ! why did you allow him to come here ? He is not my husband, and never was ! " Had been maniacal three months ; was extremely filthy in her habits, daubing her person with excrement, &c.; used profane language, and would have been violent if her strength had permitted. Before being brought to the asylum, she was permitted to lie in bed until her legs had become flexed in a fixed position, the knees on the stomach and the heels on the buttocks ; she was extremely emaciated, and altogether an abject specimen of human wretchedness. Wine and quinine, and her favorite liquor gin, were given her, with good soups, &e.; but she gradually sank, and died six weeks after admission. Post-mortem Examination. — Circumference of cranium 1ft. 8in.; weight of brain 21b. 7oz.; capacity of cranial cavity 41^ fl. oz,; dis- placement of water by brain 37 fl. oz. ; cerebral atrophy 4| fl. oz. ; Calvarium very thick and heavy, a quantity of sanguineo-serous fluid escaped on removing it ; dura mater congested ; arachnoid opaque and thick ; the vessels of the pia mater congested, and containing numerous bubbles of air ; gray matter of con- volutions -OG of an inch in thickness, its different layers obvious ; sp. grav. of gray matter of cerebrum 1'035, of white matter 1-041, of cerebellum 1-041 ; substance of brain of normal appearance ; an effusion of coagulated blood into the middle cerebral fossa;, to greatest extent on left side. Lungs healthy, the left pleural cavity containing an abundant sanguineous effusion, forming into laminic attached to the pleura pulmonalis and costalis. Ileart small, flabby, 4 Joz. in weight. General Parafi/sts following Apoplexi/. — J. H., No. 668. — A builder, aged forty, always industrious and well conducted ; the father was insane. About tlirec mouths before his admission into the asylum, a woman to whom he was engaged jilted him, and married another man. For some days after this occur- rrncc he was taciturn and dejected ; he then showed symptoms of excitement in the management of his business, lie then decked himself with garlands of flowers, and pcranibulatod the streets in this masquerade guise, lie visited the gardens Al'PKNDlX. 5Hf, on mental disease, 1, 29,34, II Classification of Insanity, 7« Cieomi'iies, madness of, 14 Climate, influence ol', 250 Cod- liver oil, 543 Committee of House of Commons, ap- pointment of, in 1815, 60 Concealed insanity, 380 case of, 380 Conception and insanity, 257, 264 Condition of insane in modern times, 5J Congestion of brain alter death, 479,481 Consanguinity, marriages of, 44, 270 Convulsionnaires, 190 Copaiva, 544 Cord, spinal, in general paralysis, 497 Corpora amylacea, 468 Corrosive sublimate, 544 Counter-irritation in insanity, 533 Counties, Agricultural and Manufactur- ing, 39 Country life, influence of, 42, 279 Cowper's hallucinations, 145 Cranium, capacity of, how to estimate, 420 in idiots and insane, 97-90, 461 Cretinism, 99 cases of, 100, 101 causes of, 106 characters of, 104 classification of, 89 definition of, 105 divisions of, 103 pathology of, 108 results of the treatment of, 111, 112 Croton oil, 534 Cynanthropia, 139 David feigns insanity, 6, 369 Death, apprehension of, 360 Definition of Insanity, 72 Delire aigu, 459 Delirium-tremens, opium in, 518 diagnosis of, from mania, 335 Delusion, definition of, 132, 134 Delusional Insanity, 129 cases ot, 136, 137, 138, 139, 140, 141, 143, 115, 148, 149, 150, 153. 212, 213, 357, 358, 381-2 classification of, 89 diagnosis of, 380 - suicide from. 217 INDKX. yjb T).'m»';inoiir lownnis the insane, 3:i4 Dementia, na ticiite, 12;J, 402 cases of, 116-19, \22, 1;JJ, 12:.,570, causes of, \-2ti, 128 cbroiiic, 12.) chissilication of, 89 consecutive, 122, 329, 570 ilefinition of, 1 13 diugnosis of, 325 divisions of, 121 frequency of, 292 biillucinations in, \44, 151 pliysiognomy in, 120, 297 primary, 121,328, 570 prognosis in, 125, 29i senile, 127, 327 stages of, 113, lU statistics of, 123, 292 simulateil, 374-5 symptoms of. 120 treatment of, 534, 544 Demonomania, 141 Demons, exorcism of, 12 Dentition, importance of, 'iOO, ..'ti5 Depretion, local, 51 1 , 515 Derivation, use of, 533 Devon Asylum, treatment pursued at, 523, rlanre, 559 Egypt, insanity in, 46 Electra and Orestes, 7 Emotion, ell.tt of, on the Intdy, i7.J on the iniiul, Ati, 2^7 Emotional Insanity, i9o cases of, 192, 19.J, 194,209, 201, 20tJ. 207, 3(jl causes of, 200 classiflcation of, 89 definition of, 190 diagnosis of, 300 st^itlstics of, 29-2 symptoms of, 197 Emotional theory of insanity, 501 Ependyma of lateral ventricles, Wi Epilepsy, 89, 194, 200, 209, 214, 233, 254, 25«, 2tJ5, 285, 291, 294, 3ii8, 43'.'. 4tl0, 470 Erotomania, 229 cases of, 230 classification of, 88 definition of, 229 symptoms of, 230 Eruption, cutaneous, as a cause, 2h7. as a complication, 290 Erysipcliis, repelled, 2H7 Exaltation, General i -ee Mania) Exaltation, Partial, 183 Examination, manner of, 31 Excitement, political, 38, 288 religious, 187, 287, 583 Exercise, muscular, use and abuse of, 511 Exhaustion in mania, 251 Fear and fright causes of in«atii(), 288, 591 Feelingn, wounded, 280 Feigned insanity, 5, 309 cases of, 372, 371, ;n5, 37 7 Fever, erotic, 2.10 as a cause, 2*17 as a complication, 290 Folie circulaire, 119 Freijuency of the Various Forni<« of In. Nanily, 291 r.a«. i.itniis oxid.'. 9 General Paralysis, i:."" ■2;\. -is... 3.iU. 492 Hge III, :(«tn 596 INDEX. General Paralysis (continued) cases of, 569, oS8 delusions of, 366 diagnosis of, 364 electro-galvanism in, 367 epileptiform fits in, 368 hallucinations in, 144 )>iitl)ology of, 493 symptoms of, 364 treatment of, 5 15 Gesture, peculiarities of, in insanity, 315 Gout a cause of insanity, 287 Grey matter, pathological importance o{, 389 Grief, domestic, a cause of insanity, 287,580,581 Haemorrhage, cerebral, 480 Hallucination, 132, 134, 142, 580 causes of, 151 frequency, 1 14 prognosis in, 155 Hanw»rlJ, Dr. Conolly at, 65 Head, injury to the, 286, 295, 296 general form of, in tlie insane, 461 measurement of, in idiots, 97-99 Heart, disease of, as a cause, 287 Heart, disease of, in insane, 486 Hellebore a remedy for madness, 18-19 Hereditary predipposition (see Predispo- sition) llyoscyamus in insanity, 530 llyperjEmia, one cause of insanity, 410 e vucuu, 472 Hypertrojjhy of brain, 476 Ily|)ocliondriasis, 138, 152, 153, 170, 352 Hysteria, 173, 309, 338, 354, 432 Identity, personal, in insanity, 135 Idiocy, 91 oases of, 94, 95, 96, 212 characters of, 92, 99 classification of, 89 definition of, 91 divisions of, 93 moral, 194 prognosis qf. 111 statistics of, 41, 11.3 Miots, erotic. 232 liyromaitiMcs, 235 Idiots, pauper, 41 Ill-health a cause of insanity, 287 Illusion, definition of, 132, 134 Illusions, 152 Imbecility, 109 cases of, 110, 568 classification of, 89 definition of, 109 divisions of, 111 hereditary, 269 moral, 86, 192 India, insanity in, 49 Indian hemp, a cause of insanity, 49 in insanity, 530 Indians, insanity among the, 46 Inflammation of brain, evidence of, in insane after death, 479 Inflammation of brain, as a cause of in- sanity, 396 Injection, subcutaneous, 529 Ino, insanity of, 1 1 Insane, proportion of, to population, 30 Insanity, definition of, 72 apathetic, 123 average duration of, 2W bodily condition in, 314 causes of, 34, 264 classification of, 70 concealed, 380 delusional, 129 diagnosis of, 301 emotional, 190 extent of, 30 feigned, 369 homicidal, 205 how produced, 387 moral, 190 pathology of, 383 treatment of, 498 typlioid, 252, 520 Insanity, Puerperal, 256 cases of. 259, 260, 261, 262 causes of, 263 frequency of, 256-7 hallucinations in, 144 mortality of, 262 prognosis in, 262 stages of, 258 symptoms of, 258 Insensibility to pain, 1.5 Insomnia, 423, 529, .>37 &c. INDKX. ni)7 lii-'pirnlion nnil insanit}', 8 Intemperance, effect of, 43, 285, 688 Intoxicatini^ gas, 9 Intoxication, dia&;no<>i!) of, 334 IphianaMsa, insanity of, 11 Iphinoe, insanity of, 1 1 Irving, 188 Joy a cause of insanity, 288 Kant, insanity of, 36 Kidneys in the insane, 489 Kleptomania, 224 cases of, 224, 22.5, 22tt, 227, 228, 363 diagnosis of, 303 sj mptoms of, 229 without disorder of intellect, 226 with „ 22H Lactation, 256, ','84, 'J86 Legislation for the insane, 68 Lightning a cause of insanity, 217 Lincoln Asylum, Dr. Charlesworth and Mr. Hill at the, 63 Liver in the insane, 488 Lungs, disease of, in the insane, 486 Lycantbropia, 14, 139 Lypemania, 131, 155 reasoning, 157, 162 Lysippe, insanity of, 11 Mahomet, insanity of, 189 Mania, mo acute, 245, 332, 492 asthenic, 252 cases of, 213,214, 247, 567, 571.573, 574,577.578,579, 581, 582, 583, 586, 587, 588, 590 causes of, 256 chronic, '.'54, 336 classification of, 89 diagnosis of, .331, .336, 339 etymology of, 8, 239 frequency of, 292 hallucinations in, 144, '.'li, 3.11 illusions in, 151 in children. 255 inromplete primary, 3.'{7 mortality In, '2.'>.'> periodicHy in, '.'.'>! Mania (conlinued) prognosis in, 2,>3, 2U4 puerperal, 2.")0 simulated, 37U statistics of, 254, 292 sthenic, 252 symptoms of, 243-53 treatment of, 512, 513, 514, 539, 571, &c. with general extravagance of conduct, 202 without delirium, 201, 361 Mania, Homicidal, 205 cases ol, 206, 207, 208, 209, 210, 21 1 , 212, 213,211, 215, 589 diagnosis of, 363 divisions of, 206 symptoms of, 215 with delusions, 2l2 with disorder of intellect, 212 without „ 206 with |iremeditation, 211 without ,, 'J06 Mania, Snicidal, 2I6 cases of, 210, 220, 221, 222,528, 569, 575, 576, 584, 586 condition in regard to age, 219 ., marriage, 2'.'1 sex, 220 divisions of, 217 epidemics of, 222, 224 hallucinations in, 217 heredifarj- transmission of, 221, 359 illusions in, 217 in pueriHjral insanity, 2.>9 minles of death in, 218 motives in, '.'23 seasons, 222 Marriage, influence of, '-'81 Mechanical restraint at the Deton .Vny- lum, .162 at Manwell, 65 at Lincoln, 63 at York Itelreaf. 57 Me5 M.ufe. I HO, a:u\ and .Mama, diagnoim of, i.<6 alloiilta, l.'.O. .'l.iO ruiiiiin, 139 598 INDEX. Melancholia (continued) cases ol, ).3a, 157,1;39, n»), 177, 178, 179, 180, .5'J8, 579,580, 581, 591 causes of, 181 chronic, 181, 336 clui-sificalion of, 88-9 definition of, 130, 155 diagnosis of, 346, 35'2 divisions of, 162 frequency of, 29'.' hallucinations in, 1 14 hjpochunilriacal, 168 misanthropical, 168 mixed, 168 physical symptoms of, 160 prognosis in, 159, 294 religious, 174 simplex, lO'J statistics of, 159, 160, 161, 181, 292 suicidal, 217,571,577 symptoms of, 155 treatment of, 526, 528, 536, 543 Melancolie avec s upeur, 125, 159, 351 uvec delire, 168 pneumo-, 161 sans delire, 162 Menini^itis and Mania, diagnosis of, 318, 335 Menstruation, disordered, 161, 251, 262, 545, 582, &c. Mercurials, use of, 514, 533, 544 Mercury a cause of insanity, 285 Metaphysicians, tlieir theory of insanity, 416 Microscope, results of, in insane brain, 391, 483 Miller, Hugh, 34 Monomania, 183 alVfctive, 202 diagnosis of, 355 frequency of, 292 gay, 173 instinctive, 202 intellectual, 129 of pride (case), 668 of religion (case), 583 of suspicion (case), 138 of vanity (cases), 185, 186 pathology of, 435 prognosis in, 294 reasoning, 203 Moim, influence of, 254 Moral Insanity, i90 classification of, 86, 88 diagnosis of, 360 of a melancholy form, 162 of a religious form, 17.), 188 (See Emotional Insanity.) Moral sense, congenital deficiency of, 192-7 Morphia, use of, in insanity, 528 Mortality of the insane, 298 at various ages, 299 influence of seasons on, 298 „ sex „ 272, 298 Music in insanity, 19, 520 Mjsticism not insanity, 357 Naked, propensity to go, 313 Narcotic fomentations, 20 Nations, uncivilised, insanity among, 45 Negroes, insanity among the, 48 Neuro-glia of Virchow, 429 Non-restraint sjstem, 63, 523 Norris, case of, 61 Nosology, 76, 391 Nostalgia, 86, 165 Nymphomania, 229, 359 case oi", 584 Occupation, influence of, 280 Occupation, its therapeutic importance, 553 fEdema of the brain. 483 Oinomania (see Dipsomania.) Opium, use of, in insanity, 515 a cause of insanity, 49, 285 dangers of, 522 &c. in dementia, 524 in mania, 518 in melancholia, 526 in melancholia with delusions, 527 in typhoid insanity, 520 Order of an asylum, ellect of, 549 Orestes, madness of, 7, 18 Otitis a cause of insanity, 287 Pacchioni glandnlt-e, 468 Paralysis, as a cause, 288 as a complication, 256, 294 Pain, insensibility of the insane to, 15 Pantophobia, 359 INDKX. '>[)\) ParfnritioM, effect of, i3, 2;'.6, Iha I'litlioloiry, ciisess illu!1 Paupers, legislation for, 70 Pauper lumitics, 3'J, 39, 43 Phonomania, 205 Phrenalgia, 155 Physiognomy of insanity, 317 Pin-mater, comlilion of, in insane, 469 Poison, suiciile by, 218 Political commotions, 38 age liable to, ^33 Ciises of, "232 diagnosis of, 36'2 hallucinations in, '238 symptoms of, '233 without disorder of intellect, '234 with ,, 235 Population, proportion of insane to, 30 Possession, demoniacal, 13, 141 Post-mortems, results of, 439, 461 Predisposition, hereditary, 266, 296 diagnostic value of, 304 Pregnancy, as a cause, '257 as a complication, '296 Pride, monomonia of, 185 Prognosis (see under the various Forms and under Recoveries) Prostitution, 'J86 Puerperal Insanity (See Insanity) Pulse, lol, 21H, 209, Arc. Pupil in mania, 253 I'urgation in insanity, 533 Pyromania, '23-2 age liable to, 233 cases of, '23'2 diagnosis of, 30'2 hallucinations in, 236 symptoms of, '233 without disorder of intellect, 231 with ,, 235 Quinine, suli'liate ol, .>.i I, 513 Ramollisement, 483, 486 Recoveries, influence of sex on, '295 influence of age on, lb. ,, phisifiil roniplirntion'< Kecoveiii-^, inflnencc of durntion on, '2»4 ,, cause o( ntlaclc on, '205 ,, m:irri.itce on, '205.(1 ,, hereditary prvdiMponitioii on, '296 , , season of the j ear on, '206 proportion of, 2'.'2 Refusal of food, IIH, 490,56!!. ..K3-5, 591 Regimen, 532, .';41 Ac. Relapses, 292, 296 Religion, as a cause of insanity, 179,28" Reproductive organs in the insane, 488 Requisites of a psychological physician, 548 Residence, peculiarities of, in insanity, 311 Restraint, mechanical, 51, 562 Retreat at York, foundation of, by \\'il- liam Tuke,56 Retinitis pigmentosa, 106 Revivals, religious, 180, 189 Rheumatism, as a cause, '287 Romans, their civilization, 5 Salivation, frequent, in mania, 250 Satyriasis. 230 Savage life, elTect of, 37 Saul, insanity of, 6, 19 Scalp, applications to the, 531 Seasons, influenre of, 278 Seclusion, 562 Self-preservation, desire of, 350 Sensations, false, 142 Sexes, relative liability of, to inaiiit\. 272 Sheet, wet, use of the, 539 Shower-bath, use and duration oi,. .in Skill, state of the, 161, 248 Slwp-drunkeiine.««, 213 Softening of brnin, 483 Sular apoplexy (see Sun-stroke) Solomon and exorciim, 12 South Sea Islanders, insanity of, 49 S|ierific gravity of brnin in the In'Minr, 484 Spine, injury to llie, J'^ti j S)>leeti III Ilie lii.viiii-. ISP Statistics of Insanity, 20 1 I Steal. pro|>on to («■« Kleptomania' Sdmulanta in insanil} , .'IJ GOO St. Luke's Hospital, 54 Stomach, disease of, in insane, 487 Stripes in madness, 51, 502 Stramonium, 530 Study, excess of, 35, 288 Stupidite, 124, 159 Substance, cerebral, conilition of, 472 Suicide (see Mania, Suicidal) S3mpathy, insanity by, 430 Syphilis, us a cause, 287 Syria, insanity in, 48 Teeth, in idiots, 93 Theomania, 187, 189,357 Thirst in mania, 250 Timaeus of Plato, allusions to mad- ness, 9 Tobacco a cause of insanity, 49, 285 Tongue, state of the, IHO, 250,