A treatise on Insanity:
in which are contained the Principles Of A New And More Practical Nosology Of Maniacal Disorders
(Doctor at Bicetre Asylum in France)
Philippe Pinel would rise up today and oppose the chemical psychiatrists who believe insanity is a chemical imbalance of the brain, that insanity is incurable. He would object to labeling the insane as biological misfits for life because it unnecessarily robs the soul of all hope.
"Pinel's liberation of the mental patient should thus be viewed as social reform rather than as innovation in medical treatment." (The Myth of Mental Illness, Thomas Szasz, 1961 AD, p23)
See also: History of Psychiatry homepage
In 1806 AD, Philippe Pinel, doctor for the Bicetre Asylum in France, gets our gold star of achievement of all the major mad house doctors. Pinel correctly understanding that insanity was a spiritual problem, not an organic/physical problem with the brain. Instead of drugs, he cured insanity by "moral treatments". "My faith in pharmaceutic preparations was gradually lessened, and my scepticism went at length so far, as to induce me never to have recourse to them, until moral remedies had completely failed" His views were in fact what church preachers had understood since before the 1500's. Pinel describes the treatments practiced at Bedlam as a, "depleting system of treatment to a state of extreme debility or absolute idiotism", his views were remarkable correct and chemical psychiatrists of today should learn at his feet. D. D. Davis, stated in the introduction that "The inestimable importance of moral management is the great key note sounded by the present author almost in every subdivision of his treatise ... for subduing the extravagances and arresting the hallucinations of the insane" Pinel's moral treatments cured people in: "chaos and confusion ... gloomy and desponding melancholy ... furious ... perpetual delirium ... violent sallies of maniacal fury ... stupid ideotism and imbecility." He rejects the etiology that brain legions caused insanity and identifies this error as the reason doctors of his time also viewed the insane as incurable. This is exactly what we see today when chemical psychiatrists view insanity as a chemical imbalance in the brain and you labeled for life as a mental biologic misfit. He reveals his "great and invaluable secret in the management of well regulated hospitals" is understanding that insanity is not an incurable organic disease, but a curable condition caused by the human spirit "nervous excitement" which he said affects both body and the way people think: "affects not the system physically by increasing muscular power and action only, but likewise the mind". He describes his "moral treatment" as such: "we trace the happy effects of intimidation, without severity; of oppression, without violence; and of triumph, without outrage. How different from the system of treatment, which is yet adopted in too many hospitals, where the. domestics and keepers are permitted to use any violence that the most wanton caprice, or the most sanguinary cruelty may dictate."... "I saw a great number of maniacs assembled together, and submitted to a regular system of discipline. ... I then discovered, that insanity was curable in many instances, by mildness of treatment and attention to the state of the mind exclusively, and when coercion was indispensible, that it might be very effectually applied without corporal indignity. As a Frenchman, he gives the credit for the "experimental" concept of "moral treatment" to the English: "I Have given a sufficient number of examples to illustrate the importance which I attach to the moral treatment of insanity. The credit of this system of practice has been hitherto almost exclusively awarded to England." Penel was a humoral doctor and did believe a bit of quacky stuff. He rejected phrenology in all cases of insanity "the heads of maniacs are not characterised by any peculiarity of conformation", although he inconclusively wondered if physiognomy might explain "idiots" with diminished brain capacity: "double the ordinary density. From the extraordinary thickness of this skull, it would be easy to calculate how much the internal capacity of the cranium was diminished". Finally, Echoing the fact that even today there are no medical tests that can detect insanity, Pinel notes that there is no real test for insanity back in his day either: "It may be thought astonishing, that in an object of so much importance as that of ascertaining the actual existence of mental derangement, there is yet no definite rule to guide us in so delicate an examination. In fact, there appears no other method than what is adopted in other departments of natural history: that of ascertaining whether the facts which are observed belong to any one of the established varieties of mental derangement, or to any of its complications with other disorders." Philippe Pinel would rise up today and oppose the chemical psychiatrists who believe insanity is a chemical imbalance of the brain, that insanity is incurable. He would object to labeling the insane as biological misfits for life because it unnecessarily robs the soul of all hope. (A Treatise on Insanity, Philippe Pinel, 1806 AD)
The Trans-Allegheny Lunatic Asylum reasons for Admission 1864-1998 AD
The vast majority of schizophrenia patients in 18th century mental asylums had known etiologies that anyone would could diagnose. Nothing has changed today except psychiatrists and drug companies want to confuse everyone by suggesting a "medical only" etiology of insanity.
A treatise on Insanity, Philippe Pinel, 1806 AD
A treatise on insanity: in which are contained the Principles Of A New And More Practical Nosology Of Maniacal Disorders, Philippe Pinel, 1806 AD
Than Has Yet Been Offered To The
Exemplified by Numerous And Accurate Historical Relations Of Cases
Trom The Author's Public And Private Practice: With
Plates Illustrative .Of The Craniology Of Maniacs
By Ph. Pin El,
Professor Of The School Of Medicine At Paris,
Senior Physician to the Female
Rational Asylum la ^alpetiiere, late Physician
to the Asylum de Bicetre, and Member of many leaned Societies.
Introduction of the translator: "But this volume is chiefly valuable for the great attention to, the principles of the moral treatment of insanity which it recommends. Works of practical value, usually leave some one strong and permanent impression on the mind. The inestimable importance of moral management is the great key note sounded by the present author almost in every subdivision of his treatise. This part of the subject is examined in all its bearings, and accompanied by examples of the methods, for subduing the extravagances and arresting the hallucinations of the insane, which were adopted in the lunatic establishments over which Dr. Pinel so ably presided. To enter into a more particular detail of what the author has accomplished in this volume, and of what he has left for others or deferred to another opportunity, would be to anticipate the judgement of the reader. The subject is so abstruse and extensive, that the expectation of any thing like a perfect treatise upon it, in the present state of our knowledge, could be formed, only to be disappointed." (Introduction by translator: D.D. Davis, p lv)
GENERAL PLAN OF THE WORK.
NOTHING has more contributed to the rapid improvement of modern natural history, than the spirit of minute and accurate observation which has distinguished its votaries. The habit of analytical investigation, thus adopted, has induced an accuracy of expression and a propriety of classification, which have themselves, in no small degree, contributed to the advancement of natural knowledge. Convinced of the essential importance of the same means in the illustration of a subject so new and so difficult as that of the present work, it will be seen that I have availed myself of their application, in ail or, most of the instances of this most calamitous disease, which occured in my practice at the Asylum de Bicetre. On my entrance upon the duties of that hospital, every thing presented to me the appearance of chaos and confusion. Some of my unfortunate patients laboured under the horrors of a most gloomy and desponding melancholy. Others were furious, and subject to the influence of a perpetual delirium. Some appeared to possess a correct judgement upon most subjects, but were occasionally agitated by violent sallies of maniacal fury ; while those of another class were sunk into a state of stupid ideotism and imbecility. Symptoms so different, and all comprehended under the general title of insanity, required, on my part, much study and discrimination; and to secure order in the establishment and success to the practice, I determined upon adopting such a variety of measures, both as to discipline and treatment, as my patients required, and my limited opportunity permitted. From systems of nosology, I had little assistance to expect; since the arbitrary distributions of Sauvages and Cullen were better calculated to impress the conviction of their insufficiency than to simplify my labour. I, therefore, resolved to adopt that method of investigation which has invariably succeeded in all the departments of natural history, viz. to notice successively every fact, without any other object than that of collecting materials for future use; and to endeavour, as far as possible, to divest myself of the influence, both of my own prepossessions and the authority of others.
With this view, I first of all took a general statement of the symptoms of my patients. To ascertain their characteristic peculiarities, the above survey was followed by cautious and repeated examinations into the condition of individuals. All our new cases were entered at great length upon the journals of the house. Due attention was paid to the changes of the seasons and the weather, and their respective influences upon the patients were minutely noticed. Having a peculiar attachment for the more general method of descriptive history, I did not confine myself to any exclusive mode of arranging my observations, nor to any one system of nosography. The facts which I have thus collected are now submitted to the consideration of the public, in the form of a regular treatise.
Few subjects in medicine are so intimately connected with the history and philosophy of the human mind as insanity. There are still fewer, where there are so many errors to rectify, and so many prejudices to remove. Derangement of the understanding is generally considered as an effect of an organic lesion of the brain, consequently as incurable; a supposition that is, in a great number of instances, contrary to anatomical fact. Public asylums for maniacs have been regarded as places of confinement for such of its members as are become dangerous to the peace of society. The managers of those institutions, who are frequently men of little knowledge and less humanity, (a) have been permitted to exercise towards their innocent prisoners a most arbitrary system of cruelty and violence; while experience affords ample and daily proofs of the happier effects of a mild, conciliating treatment, rendered effective by steady and dispassionate firmness. Availing themselves of this consideration, many empirics have erected establishments for the reception of lunatics, and have practiced this very delicate branch of the healing heart with singular reputation. A great number of cures have undoubtedly been effected by those base born children of the profession; but, as might be expected, they have not in any degree contributed to the advancement of science by any valuable writings. It is on the other hand to be lamented, that regular physicians have indulged in a blind routine of inefficient treatment, and have allowed Themselves to be confined within the fairy circle of antiphlogisticism, and by that means to be diverted from the more important management of the mind. Thus, too generally, has the philosophy of this disease, by which I mean the history of its symptoms, of its progress, of its varieties, and of its treatment in and out of hospitals, been most strangely neglected.
(a) The English legislature has taken some cognizance of the crying evils which formerly existed in this country, as they now do in France, from the indiscriminate toleration of empyrical lunatic establishments. More however might and ought to be done.
Intermittent or periodical insanity is the most common form of the disease. The symptoms which mark its accessions, correspond with those of continued mania. Its paroxysms are of a determined duration, and it is not difficult to observe their progress, their highest developement, and their termination, The present essay will, therefore, not improperly commence with an historical exposition of periodical insanity. The leading principles of our moral treatment will then be developed. Attention to these principles alone will, frequently, not only lay the foundation of, but complete a cure: while neglect of them may exasperate each succeeding paroxysm, till, at length, the disease becomes established, continued in its form, and incurable. The successful application of moral regimen exclusively, gives great weight to the supposition, that, in a majority of instances, .there is no organic lesion of the brain nor of the cranium. In order however to ascertain the species, and to establish a nosology of insanity, so far as it depends upon physical derangement, I have omitted no opportunities of examination after death. 'I, therefore, flatter myself, that my treatment of this part of the subject will not discredit my cautious and frequently repeated observations. By these and otter means, which will be developed in the sequel, I have been enabled to introduce a degree of method into the services of the hospital, and to class my patients in a great measure according to the varieties and inveteracy of their complaints An account of our system of interior police, will finish this part of the enquiry. The last section will comprehend the principles of our medical treatment.
In the present enlightened age, it is to be hoped, that something more effectual may be done towards the improvement of the healing art, than to indulge with the splenetic Montaigne, in contemptuous and ridiculous sarcasms upon the vanity of its pretensions. I flatter myself, that the perusal of the following work will not excite the sentiment of that celebrated censor of human extravagance and folly, when he said, "that of whatever of good and salutary fortune or nature, or any other foreign, cause may have bestowed upon the human frame, it is the priviledge of medicine to arrogate to itself the merit."
CIRCUMSTANCES FAVOURABLE TO THE AUTHORS RESEARCHES UPON THE SUBJECT OF INSANITY.
2. The Asylum de Bicetre, which was confided to my care during the second and third years of the republic, widened to a vast extent the field of enquiry into this subject, which I had entered upon at Paris, several years previous to my appointment. The storms of the revolution, stirred up corresponding tempests in the passions of men, and overwhelmed not a few in a total ruin of their distinguished birthright as rational beings. The local disadvantages of the hospital, perpetual changes in the administration, of public affairs, and the difficulty of obtaining a variety of means that might have conduced to its prosperity, were circumstances that frequently perplexed but were never allowed to dishearten me. For these serious inconveniences, I found ample amends in the zeal, the humanity, and intelligence of the keeper; a man of great experience in the management of the insane, and every way calculated to maintain order in the hospital. The advantages, which I have derived from this circumstance, will stamp a greater value upon my observations in the present treatise, than any attempts to discover or establish new remedies.
For, in diseases of the mind, as well as in all other ailments, it is an art of no little importance to administer medicines properly: but, it is an art of much greater and more difficult acquisition to know when to suspend or altogether to omit them.
PERIODS OF ACCESSION OF INTERMITTENT INSANITY,
13. It is curious to trace the effects of solar influence upon the return and progress of maniacal paroxysms. They generally begin immediately after the summer solstice, are continued with more or less violence during the heat of summer and commonly terminate towards the decline of autumn. Their duration is limited within the space of three, four or five months, according to differences of individual sensibility, and according as the season happens to be earlier, later, or unsettled as to its temperature. Maniacs of all descriptions are subject to a kind of effervescence or tumultuous agitation, upon the approach either of stormy or very warm weather. They then walk with a firm but precipitate step; they declaim without order or connection ; their anger is roused by trivial or imaginary causes, and they express their feelings by clamorous and intemperate vociferation. We must not, however, extend this law of solar influence beyond its natural boundary, nor conclude that the return of maniacal paroxysms is universally dependent upon a high temperature of the atmosphere. I have seen three cases in which the paroxysms returned upon the approach of winter, i. e. when the cold weather of December and January set in; and their remission and exacerbation corresponded with the changes of the temperature of the atmosphere from mildness to severe cold.
It will not be improper to mention in this place two instances of insanity, the return of whose paroxysms occurred at very distant and unusual periods of time;—that of the first, after an interval of three years; and that of the second, after an interval of four years. For several years they recurred in the summer season; but the last attack in each instance, did not take place till towards the decline of autumn and the commencement of the cold weather.—Upon what then depends this nervous disposition of the system to be deranged at stated periods; a disposition that appears to be governed but imperfectly by general laws ? What becomes of Dr. Brown's principles of medicine in relation to the action of cold and heat upon the human body, and of the character of a sthenic diathesis which he ascribes to insanity ?
PERIODICAL INSANITY INDEPENDENT OF THE INFLUENCE OF THE SEASONS.
4. I Now proceed to describe the general progress of periodical insanity,. Among its various causes; exclusive of changes in the state of the atmosphere, my experience leads me to enumerate as the most frequent; undue indulgence of the angry passions; any circumstances calculated to suggest the recollection of the original exciting cause of the disease; intemperance in drinking, inanition, &c. There are some instances of periodical insanity, which, in the present state of our knowledge, we are not authorized to ascribe to the vicissitudes of the seasons, nor to any of the causes which have been just mentioned; but which appear to depend upon a peculiar idiosyncracy, the existence even of which, we can infer only from its constant and regular effects. This form of the disease is much more difficult of cure than the other; but, fortunately, much Jess frequent. From a general examination of the patients, at the Asylum de Bicetre, in the second year of the republic, which was undertaken for the purpose of ascertaining the relative number of each variety pf the disease; it appeared, that, out of two hundred maniacs, there were fifty-two of the class subject to paroxysms of insanity at irregular periods; and only six, whose periods of accession observed a regular intermission. Among the latter class, there was one, whose paroxysms returned regularly every year, lasted for three montbs, and ended towards the middle of summer. A second, was subject to extreme fury during fifteen days in the year, and was perfectly calm and in possession of his reason for the remaining eleven months and a half. A third case, having one day of complete intermission, appeared to observe the type of a tertion fever. I shall be excused, if I mention three more cases, whose paroxysms invariably returned after an interval of eighteen months, and lasted precisely six months. The peculiar character of those unfortunate cases consisted in a few but well marked circumstances. Their ideas were clear and connected ;—they indulged in no extravagances of fancy;—they answered with great pertinence and precision to the questions that were proposed to them: but they were under the dominion of a most ungovernable fury, and of a thirst equally ungovernable for deeds of blood. In the mean time, they were fully aware of their horrid propensity, but absolutely incapable, without coercive assistance, of suppressing the atrocious impulse. How are we to reconcile these facts to the opinion which Locke and ; Condillac entertained with regard to the nature of insanity, which they made to consist exclusively in ; a disposition to associate ideas naturally incompatible, and to mistake ideas thus associated for real truths?
THE CHARACTER OF MANIACAL PAROXYSMS NOT DEPENDING UPON THE NATURE OF THE EXCITING CAUSES, BUT UPON THE CONSTITUTION.
5. To believe that the different species of insanity depend upon the particular nature of its causes, and that it becomes periodical, continued or melancholic, according as it may have originated from unfortunate love, domestic distress, fanaticism, superstition, or interesting revolutions in the state of public affairs, would be, to fall into a very great error. My experience authorizes rife to affirm, that there is no necessary connection between the specific character of insanity, and the nature of its exciting cause. Among the cases of periodical mania, which I have seen and recorded in my journals, I find some which originated in a violent but unfortunate passion; others in an ungovernable ambition for fame, power or glory. Many succeeded to reverses of fortune; others were produced by devotional phrenzy ; and others by an enthusiastic patriotism, unchastened by the sober and steady influence of solid judgement. The violence of maniacal paroxysms appears, likewise, to be independent of the nature of the exciting cause ; or to depend, at least, much more upon the constitution of the individual,—upon the different degrees of his physical and moral sensibility. Men of robust constitutions, of mature years, with black hair, and susceptible of strong and violent passions, appear to retain the same character when visited by this most distressing of human misfortunes. Their ordinary energy is enhanced into outrageous fury. Violence, on the other hand, is seldom characteristic of the paroxysms of individuals of more moderate passions, with brown or auburn hair. Nothing is more common than to see men, with light coloured hair, sink into soothing and pleasurable reveries; whereas it seldom or never happens that they become furious or unmanageable. Their pleasing dreams, however, are at length overtaken by and lost amid the gloom of ah incurable fatuity. It has been already observed, that people of great warmth of imagination, acuteness of sensibility and violence of passions, are the most predisposed to insanity. A melancholy reflection !—but it is not less true than it is calculated to interest our best and tenderest sympathies.
I cannot here avoid giving my most decided suffrage in favour of the moral qualities of maniacs. I have no Where met, excepting in romances, with fonder husbands, more affectionate parents, more impassioned lovers, more pure and exalted patriots, than in the lunatic asylum, during their intervals of calmness and reason. A man of sensibility may go there every day of his life, and witness scenes of indescribable tenderness associated to a most estimable virtue.
SPASMACAL PAROXYSMS CHARACTERISED BY A HIGH DEGREE OF PHYSICAL AND MENTAL ENERGY.
9. It is to be hoped, that the science of medicine will one day proscribe [condemn] the very vague and inaccurate expressions of "images traced in the brain, the unequal determination of blood into different parts of this viscus, the irregular movements of the animal spirits," &c. expressions which are to be met with in the best writings that have appeared on the human understanding, but which do not accord with the origin, the causes, and the history of insanity. The nervous excitement, which characterises the greatest number of cases, affects not the system physically by increasing muscular power and action only, but likewise the mind, by exciting a consciousness of supreme importance and irresistible strength. Entertaining a high Opinion of his capacity of resistance, a maniac often indulges in the most extravagant flights of fancy and caprice; and, upon attempts being made to repress or coerce him, aims furious blows at his keeper, and wages war against as many of the servants or attendants as he supposes he can well master. If met however, by a force evidently and convincingly superior, he submits without opposition or violence. This is a great and invaluable secret in the management of well regulated hospitals. I have known it prevent many fatal accidents, and contribute greatly towards the cure of insanity. I have, however, seen the nervous excitement in question, in some few instances, become extremely obstinate and incoercible.
A maniac, who had been calm for several months, was suddenly seized by a paroxysm of his unfortunate complaint. His eyes, darting and protuberant, expressed the commotions within;—his face, neck and bosom, assumed a purple hue?—he thought, that he saw the sun at the distance of four paces ;—said, that he felt an indescribable motion in his head, analogous to that of gurgling or boiling. Upon the occurrence of this symptom, it was his custom to warn his friends, of the necessity of a speedy confinement, as he no longer retained the command of his temper nor conduct. He continued throughout his paroxysm to be violently agitated; supposed that he saw the sun by his side ; spoke with extreme volubility, and betrayed every symptom of disorder and confusion in his ideas. It sometimes happens that the reaction of the epigastric region upon the functions of the understanding, is so far from oppressing or obscuring them, that it appears even to augment their vivacity and strength. The imagination is exalted to the highest pitch of developement and fecundity. Thoughts the most brilliant and ingenious, comparisons the most apt and luminous, give to the maniac an air of supernatural enthusiasm and inspiration. The recollection of the past appears to unroll with great rapidity, and what had long been not thought of and forgotten, is then presented to the mind in glowing and animated colours.
I have frequently stopt at the chamber door of a literary gentleman, who, during his paroxysms, appeared to soar above the mediocrity of intellect which was habitual to him, solely to admire his newly acquired powers of eloquence. He declaimed upon the events of the revolution with all the force, the dignity, and the purity of language that the very. interesting subject could admit of. At other times, he was a man of very ordinary abilities, (e) The elevation of mind, produced by the nervous excitement now under consideration, while it is as-' satiated with the chimerical' consciousness of possessing supreme power or attributes of divinity, it eapires the patient with the most ecstatic feelings, with a sort of inchantment or intoxication happiness. A madman, who was confined at a pension-house in Paris, whenever his insane fits came on, believed himself to be the prophet Mohammed. He then assumed a commanding attitude and the tone of an ambassador from the most high. His looks were penetrating and expressive, and his gait was that of majesty. One day, when there was a heavy cannonade at Paris, in celebration of some political event, he seemed firmly convinced that it was intended as a tribute of homage to himself. He enjoined silence around him, could not contain his joy, and he resembled the ancient prophets in their pretensions and manners.
(e) A madman, that was cured by the celebrated Dr. Willis, has given us the following account of his own case: "I always expected with impatience the accession of the paroxysms; since I enjoyed during their presence a high degree of pleasure. They lasted ten or twelve hours. Every thing appeared easy to me. No obstacles presented themselves, either in theory or practice. My memory acquired all of a sudden a singular degree of perfection. Long passages of latin authors recurred to my mind. In general I have great difficulty in finding rhythmical terminations ; hut then 1 could write in verse with as much facility as in prose.. I was cunning, malicious, and fertile in all kinds of expedients."
THE ADVANTAGES OF RESTRAINT UPON THE IMAGINATION OF MANIACS ILLUSTRATED.
23. A young religious enthusiast, who was exceedingly affected by the abolition of the catholic religion in France, became insane. After the usual treatment at the Hotel Dieu, he was transferred to the Asylum de Bicetre. His misanthropy was not to be equalled. His thoughts dwelled perpetually upon the torments of the other world; from which he founded his only chance of escaping, upon a conscientious adoption of the abstinences and mortifications of the ancient anchorites. At length, he refused nourishment altogether; and, on the fourth day after that unfortunate resolution was formed, a state of langour succeeded, which excited considerable apprehensions for his life. Kind remonstrances and pressing invitations proved equally ineffectual. He repelled, with rudeness, the services of the attendants, rejected, with the utmost pertinacity, some soup that was placed before him, and demplished his bed (which was of straw) in order that he might lie upon the boards. How was such a perverse train of ideas to be stemmed or counteracted ? The excitement of terror presented itself as the only resourse. For this purpose, Citizen Pussin appeared one night at the door of his chamber, and, with fire darting from his eyes, and thunder in his voice, commanded a group of domestics, who were armed with strong and loudly clanking chains, to do their duty. But the ceremony was artfully suspended;—the soup was placed before the maniac, and strict orders were left him to eat it in the course of the night, on pains of the severest punishment. He was left to his own, reflections. The night was spent (as he afterwards informed me) in a state of the most distressing hesitation, whether to incur the present punishment, or the distant but, still more dreadful torments of the world to come, After an internal struggle of many hours, the idea of the present evil gained the ascendancy, and he determined to take the soup. From that time, he submitted, without difficulty, to a restorative system of regimen. His sleep and strength gradually returned; his reason recovered its empire; and, after the manner above related, he escaped certain death. It was during his convalescence, that he mentioned to me the perplexities and agitations which be endured during the night of the experiment. p 63
INTIMIDATION TOO OFTEN ASSOCIATED WITH VIOLENCE.
24. In the preceding cases of insanity, we trace the happy effects of intimidation, without severity; of oppression, without violence; and of triumph, without outrage. How different from the system of treatment, which is yet adopted in too many hospitals, where the. domestics and keepers are permitted to use any violence that the most wanton caprice, or the most sanguinary cruelty may dictate. In the writings of the ancients, and especially of Celsus, a sort of intermediate and conditional mode of treatment is recommended, founded, in the first instance, upon a system of lenity and forbearance; and when that method failed, upon corporal and physical punishments, such as confinement, chains, flogging, spare diet, &c. (p) Public and private mad-houses, in more modern times, have been conducted on similar principles.
We are informed by Dr. Gregory, that a farmer, in the North of Scotland, a man of Herculean stature, acquired great fame in that district of the British empire, by his success in the cure of insanity. The great secret of his practice consisted in giving full employment to the remaining faculties of the lunatic. With that view, he compelled all his patients to work on his farm. He varied their occupations, divided their labour, and assigned to each, the post which he was best qualified to fill. Some were employed as beasts of draught or burden, and others as servants of various orders and provinces. Fear was the operative principle that gave motion and harmony to this rude system. Disobedience and revolt, whenever they appeared in any of its operations, were instantly and severely punished.
(p) Ubi perperam aliqnid dixit aut fecit, fame, vinculis plagis coercendus est. Cels. Lib. iii. Cap. 18.
A system of management analogous to the above, was adopted in a monastic establishment in the South of France. One of the inspectors visited each chamber at least, once every day. if he found any of the maniacs behaving extravagancy, stirring tip quarrels of tumults, making any objections to his victuals, or refusing to go to bed at night, he was told in a manner, which of itself was calculated to terrify him, that unless he instantly conformed, he would have to receive in the morning ten severe lashes, as a punishment for his disobedience. The threat was invariably executed with the greatest punctuality; while good conduct, on the contrary, was not less equally and punctually rewarded. Those who were disposed to behave orderly, and to observe the rules of the institution, were admitted to dine at the governor's table. But, if any one abused this indulgence, he was immediately reminded of it, by a smart stroke over his fingers with a ferule [like a wooden kitchen spatula], and informed, with an air of great gravity and coolness, that it became him to conduct himself with more propriety and reserve.
It is painful to close this sketch by a reference to an imperfection in the treatment of insanity, by one of the most successful practitioners of any age. I allude to the practice of the celebrated Dr. Willis. In the establishment under his direction in the vicinity of London, it would appear that every lunatic is under the control of a keeper, whose authority over him is unlimited, and whose treatment of him must be supposed, in many instances, to amount to unbridled and dangerous barbarity: —a delegated latitude of power totally inconsistent with the principles of a pure and rigid philanthropy.
A HAPPY EXPEDIENT EMPLOYED IN THE CURE OF A MECHANICIAN.
26.. A Celebrated watchmaker, at Paris, (see page 26,) was infatuated with the chimera of perpetual motion, and to effect this discovery, he set to work with indefatigable ardour. From unremitting attention to the object of his enthusiasm coinciding with the influence of revolutionary disturbances, his imagination was greatly heated, his sleep was interrupted, and, at length, a complete derangement of the understanding took place. His case was marked by a most whimsical illusion of the imagination. He fancied that he had lost his head on the scaffold ; that it had been thrown promiscuously among the heads of many other victims; that the judges, having repented of their cruel sentence, had ordered those heads to be restored to their respective owners, and placed upon their respective shoulders; but that, in consequence of an unfortunate mistake, the gentlemen, who had the management of that business, had placed upon his shoulders the head of one of his unhappy companions. The idea of this whimsical exchange of his head, occupied his thoughts night and day; which determined his relations to send him to the Hotel Dieu. Thence he was transferred to the Asylum de Bicetre. Nothing could equal the extravagant overflowings of his heated brain. He sung, cried, or danced incessantly; and, as there appeared no propensity in him to commit acts of violence or disturbance, he was allowed to go about the hospital without control, in order to expend, by evaporation, the effervescent excess of his spirits. " Look at these teeth," he constantly cried;—" Mine were exceedingly handsome ;—these are rotten and decayed My mouth was sound and healthy : this is foul and diseased. What difference between this hair and that of my own head." To this state of delirious gaiety, however, succeeded that of furious madness He broke to pieces or otherwise destroyed whatever was within the reach or power of his mischievous propensity. Close confinement became indispensible. Towards the approach of winter his violence abated; and, although he continued to be extravagant in his ideas, he was never afterwards dangerous. He was, therefore, permitted, when ever he felt disposed, to go to the inner court. The idea of the perpetual motion frequently recurred to him in the midst of his wanderings ; and he chalked on all the walls and doors as he passed, the various designs by which his wondrous piece of mechanism was to be constructed. The method best calculated to cure so whimsical an illusion, appeared to be that of encouraging his prosecution of it to satiety. His friends were, accordingly, requested to send him his tools, with materials to work upon, and other requisites, such as plates of copper and steel, watch-weels, &c. The governor, permitted him to fix up a work-bench in his apartment. His zeal was now redoubled. His whole attention was rivetted upon his favourite pursuit. He forgot his meals. After about a month's labour, which he sustained with a constancy that deserved better .success, our artist began to think that he had followed a false rout. He broke into a thousand fragments the piece of machinery which he had fabricated at so much expense of time, and thought, and labour; entered on the construction of another, upon a new plan, and laboured with equal pertinacity for another fortnight. The various parts being completed, he brought them together, and fancied that he saw a perfect harmony amongst them. The whole was now finally adjusted:—his anxiety was indescribable:—motion succeeded:—it continued for some time :—and he supposed it capable of continuing for ever. He was elevated to the highest pitch of enjoyment and triumph, and ran as quick as lightening into the interior of the hospital, crying out like another Archimedes, "At length I have solved this famous problem, which has puzzled so many men celebrated for their wisdom and talents." But, grievous to say, he was disconcerted in the midst of his triumph. The wheels stopped ! The perpetual motion ceased ! His intoxication of joy was succeeded by disappointment and confusion. But, to avoid a humiliating and mortifying confession, he declared that he could easily remove the impediment, but tired of that kind of employment, that he was determined for the future to devote his whole time and attention to his business. There still remained another maniacal impression to be counteracted ;—that of the imaginary exchange of his head, which unceasingly recurred to him. A keen and an unanswerable stroke of pleasantry seemed best adapted to correct this fantastic whim. Another convalescent of a gay and facetious humour, instructed in the part he should play in this comedy adroitly turned the conversation to the subject of the famous miracle of Saint Denis. Our mechanician strongly maintained the possibility of the fact, and sought to confirm it by an application of it to his own case. The other set up a loud laugh, and replied with a tone of the keenest ridicule: " Madman as thou art, how could Saint Denis kiss his own head ? Was it with his heels ?" This equally unexpected and unanswerable retort, forcibly struck the maniac. He retired confused amidst the peals of laughter, which were provoked at his expense, and never afterwards mentioned the exchange of his head. Close attention to his trade for some months, completed the restoration of his intellect. He was sent to his family in perfect health; and has, now for more than five years, pursued his business without a return of his complaint.
THE PHYSICAL AND MORAL QUALITIES ESSENTIAL TO THE SUCCESSFUL MANAGEMENT OF LUNATIC ASYLUMS.
39. I Have given a sufficient number of examples to illustrate the importance which I attach to the moral treatment of insanity. The credit of this system of practice has been hitherto almost exclusively awarded to England. Though it be a department of experimental medicine that is least understood, I trust, that what has been advanced in this section will rescue France from the imputation of neglecting it. For my ability to use, with any degree of propriety, this language of competition, I am indebted to a fortunate concurrence of circumstances. Among these may be first enumerated, the eminent qualities, both of body and mind, of the governor of the Asylum de Bicetre. He possesses the principles of a pure and enlightened philanthropy, His attention to the arduous duties of his office is indefatigable. His knowledge of human life and of the human heart is accurate, extensive, and easily applied to the frequent and urgent demands that are made upon it. His firmness is immovable, his courage cool and unshrinking. As to his physical properties, he is manly and well proportioned. His arm? are exceedingly strong. When he speaks in anger or displeasure, his countenance expresses great decision and intrepidity, and his voice is that of thunder. Acting in concert with a gentleman of such a character, I had great opportunities afforded me of deriving from my situation every possible professional advantage. Of the knowledge to be derived from books on the treatment of insanity, I felt the extreme insufficiency. Desirous of better information, I resolved to examine for myself the facts that were presented to my attention ; and forgetting the empty honours of my titular distinction as a physician, I viewed the scene that was opened to me with the eye of common sense and unprejudiced observation. I saw a great number of maniacs assembled together, and submitted to a regular system of discipline. Their disorders presented an endless variety of character: but their discordant movements were regulated on the part of the governor by the greatest possible skill, and even extravagance and disorder were marshalled into order and harmony. I then discovered, that insanity was curable in many instances, by mildness of treatment and attention to the state of the mind exclusively, and when coercion was indispensible, that it might be very effectually applied without corporal indignity. To give all their value to the facts which I had the opportunity of observing, I made it an object of interest to trace their alliance with the functions of the understanding. To assist me in this enquiry, I attentively perused the best writers upon modern pneumatologv, as well as those authors who have written on the influence of the passions upon the pathology of the human mind. The laws of the human economy considered in reference to insanity as well as to other diseases, impressed me with admiration of their uniformity, and I saw, with wonder, the resources of nature when left to herself, or skilfully assisted in her efforts. My faith in pharmaceutic preparations was gradually lessened, and my scepticism went at length so far, as to induce me never to have recourse to them, until moral remedies had completely failed, The success of this practice gives new support, were it necessary, to the following maxim of Dr. Grant:—" We cannot cure diseases by the resources of art, if not previously acquainted with their terminations, when left to the unassisted efforts of nature,"
VARIETIES IN THE DIMENSIONS OF THE HEAD CONSIDERED.
46. A Perpetual source of error in the anatomical and physiological researches of Greding, has been to consider as causes of insanity, certain varieties of conformation of the cranium, which may, in some instances, co-exist with this malady, but which are also discoverable after death, in persons who have never experienced it. To avoid erronious conclusions of that nature, I have measured and examined a great number of skulls in different museums. I have also taken, by means of a caliber compass, the dimensions of the heads of different persons of both sexes, who had been, or who were at the time in a state of insanity. I generally observed, that the two most striking varieties, the elongated and the spheroidal skulls are found indifferently and bearing, at least, no evident relation to the extent of the intellectual faculties. But I have likewise observed, that there are certain malconformations of the cranium connected with a state of insanity, especially with ideotism or idiopathic fatuity. In order to represent those truths more forcibly and clearly, I have made drawings of certain heads, which, upon comparing their respective configurations, appear to me, to establish the theory of a connection between an imperfect structure of the cranium and an imperfect operation of the intellectual faculties. Of the head of an ideot, who died at the age of forty-nine, the remarkable property was length. With that I contrasted the cranium of a person possessed of a sound understanding, who died when he was twenty years of age, and whose head was equally remarkable for its rotundity. At the end of the same plate is the. representation of an extremely irregular head of a person who died at the age of nineteen in a state of complete ideotism. At the beginning of the second plate I have given a lengthened cranium. It is that of a maniac of forty-two years of age, who was completely cured about seven years ago. To contrast with this, I have given the very round skull of a young man who died at twenty-two, and whom I can affirm to have been endowed with a perfectly sound intellect. I have concluded my sketches with the drawing of the head of a young man two and twenty years of age, a complete idiot, which is remarkable for its extreme want of symmetry and disproportion, of its dimensions. The two heads at the end of the plate will form the principal subject of my anatomical discussion.
THE HEADS OF TWO FEMALE MANIACS, THE CONFIGURATIONS OF WHICH LEAD TO NO EVIDENT INFERENCE.
47. The anatomical examination of the heads of two female maniacs, of whom one died at the age of forty-nine, and the .other at that of fifty-four, would appear to confirm the opinion which I have already advanced, that intense mental affections are the most ordinary causes of insanity, and that the heads of maniacs are not characterised by any peculiarity of conformation that are not to be met with in other heads taken indiscriminately. Of these heads, the form of the one is elongated, of the other, shortened. The flattened forehead of the one, which appears to form an inclined plane, and the perpendicular elevation of the other, are varieties which are often observable, but which admit not of any induction favourable or otherwise, in regard to intellectual capacity. This observation, however, does not apply to the skull represented by figure 5 and 6, plate n, of which I obtained possession at the death of a girl of nineteen, who was an ideot from her birth. The length of this head is the same as that of the two other maniacs; but its height is one centimetre above that of the second, and two centimetres above that of the first; whilst its breadth is less :— a form which gives to this head a disproportionate degree of elevation and lateral depression very common to jdeotism from the birth. I have marked both appearances in two young ideots who are now alive : and they are said to prevail amongst the Cretins of the Pays de Vaud.
MALCONFORMATTON OF THE CRANIUM, THE PROBABLE CAUSL OF IDEOT1SM FROM INFAKCY.
48. I Have considered the above cranium in another point of view. I have contrasted it with another well formed skull, and I have caused a corresponding section to be made of both in the direction of the most projecting part of the frontal bone and the angle of the lambdoidal stature. I have hence obtained means of comparison between the two irregular ellipses which results from those sections. I have observed, that in 'the well formed skull, the two demi-ellipses are disposed symmetrically around the principal axis, so that the conjugate diametres drawn from the anterior left side to the posterior right side, are evidently equal. On the contrary, in the ill constructed skull, the two demi-ellipses are not placed in a symmetrical order on the two fides of the principal axis; but that which is on the right takes a more prominent curve to the anterior side, whilst on the posterior it is flattened, and that on the left side the anterior curve is flattened, and the posterior more projecting. Tin's difference, which is apparent at first view, is still more manifest on measuring the conjugate axes; since that which goes from right to left measures twenty-two centimetres, and that which goes from left to right measures only seventeen. (/) I have found the same peculiarity of structure in the head of a child eighteen months old. The difference of the conjugate axes in this case was even a centimetre and a half. Was this child doomed to live an ideot ? This is a question which the immaturity of its mental faculties rendered it impossible to determine. Another defective structure of the head that I am describing, which must not be omitted, was that of the thickness of the skull. It was every where double the ordinary density. From the extraordinary thickness of this skull, it would be easy to calculate how much the internal capacity of the cranium was diminished, if its figure had been a regular ellipsoid; since it would only be necessary to determine the solid dimensions of a figure formed by a revolving ellipsis whose great and small axes would be known. But the irregularity of form of the cranium precludes the adoption of such a method of measurement.
The malconformations of the cranium of the above ideot:—the depression of the sides, the want of correspondence between the right and left side, and its praeternatural thickness, must evidently diminish the capacity of the receptacle of the brain. But we must beware of drawing inferences hastily. I shall, therefore, confine myself to historical facts, without absolutely deciding that there is an immediate and necessary connection between ideotism and the various structures which I have described. This young woman was in a state of complete fatuity from her infancy. She uttered, at intervals, some inarticulate sounds; but she gave no indications of intelligence nor of moral affections. She ate when food was presented to her mouth, appeared to be "insensible of her existence, and had every appearance of an automaton. She died last year of the scurvy. Upon dissection we found a large collection of blood effused upon the brain, which, together with the disease, had so altered its appearance that we could form no conclusions as to its softness or specific gravity.
(f) For a table of the new French mea;uros, with their relations to the old measures of that country, and the present measures of'-his country, see a work late'y published by the Rev. T. Gabb, entitled. Finis Pyramidis, &c. London. 1H06, page 103. And also a history lately published of (he metropolis of France, entitled, Paris as it was, and Paris as it is. Ad locum. T.
THE STUPIDITY AND DEGRADED CONDITION OF AN IDEOT OF WHOSE HEAD I HAVE GIVEN AN ENGRAVING.
49. On a first view of this ideot, figure 5, plate ii, what appears most striking is the extremely disproportionate extent of the face, compared with the diminitive size of the cranium. No traits of animation are visible in his physiognomy. Every line indicates the most absolute stupidity. Between the , height of the head and that of the whole stature, there is a very great disproportion. The cranium is greatly depressed both at the crown and at the temples. His looks are heavy and his mouth wide open. The whole extent of his knowledge is confined to three or four confused ideas, and that of his speech to as many inarticulate sounds. His capacity is so defective, that he can scarcely guide the food to his mouth ; and his insensibility so great, that he is incapable of attending to the common calls of nature. His step is feeble, heavy and tottering. His disinclination to motion is excessive. He is totally insensible to the natural propensity for reproduction ;—a passion so strong even in the Cretin, and which gives him a deep consciousness of his existence. This equivocal being, who seems to have been placed by nature on the very confines of humanity, is the son of a farmer, and was brought to the hospital de Bicetre about two years ago. He appears to have been impressed from his infancy with the above characters of fatuity.
VARIOUS RELATIONS OF THE HEIGHT OF THE HEAD, TO THAT OF THE WHOLE BODY.
50. The extreme disproportion between the height of the head, and that of the whole stature of the above ideot, was strikingly aparent at first view. But to determine its size with more precision it was necessary to take the dimensions of the head with a caliber compass ; to examine its height in relation to that of the whole body; and afterwards to compare this relation, with that of the best proportioned statures. I found that the height of his entire stature was eighteen decimetres, and that of his bead only eighteen centimetres. The proportion, therefore, between the height of the head and that of the entire stature is as one hundred and eighty, to eighteen, i. e. The head is only one tenth of the whole. The maniac on the contrary, of whose head I have given an engraving, figure 1, plate n, and who had been subject only to periodical attacks of insanity, is characterized by much better proportions between his head and entire stature. The dimensions of his whole stature were seventeen decimetres, and of his head twenty-three centimetres, i. e. The proportion of one to the other was as one hundred and seventy to twenty-three, or 7 — to 1. The whole stature is seven and a half times the head, which approaches much nearer to the proportions of the Apollo. How diminutive then is the head of the ideot compared with his whole stature, being only one tenth of its height?—a striking disproportion, and such as I have never observed among a very great number of heads whose dimensions I have taken. Nothing, on the contrary, is more common than to meet with heads which, from their relation to the above standard, would appear too advantageously proportioned, as the stature, to be in just proportion, should be considerably greater. This conformation affords a presumption in favour of the intellectual faculties : but, as we more commonly form our judgement of the man from his conduct and conversation, this indication is neglected.
RELATIVE PROPORTIONS OF DIFFERENT PARTS OF THE HEAD WITH DEVIATIONS FROM THE STANDARD
51. The ancient artists, who were equally remarkable for the delicacy of their touch and their acuteness of observation, could not fail to discover those proportions of the head which are the essential constituents of beauty. They have, consequently, divided those of the Apollo into four parts by horizontal planes at equal distances. One of those parts begins at the roots of the hair on the forehead, and extends to the crown. The form of the head of the maniac, figure 1, platen, varies no more than well proportioned heads in general from this standard, since the whole height of his head isJtwenty-three centimetres, and that of his face seventeen centimetres. Subtracting one from the other, we obtain a remainder of six centimetres, which, compared with the whole height, gives a proportion very nearly approaching that of one to four, as in the head of the Apollo. The height of the head of the ideot, on the contrary, is eighteen centimetres, and his face fifteen. On subtraction we have a difference of three centimetres, which is only one sixth of the height, and which shews how much the vault of the cranium is flattened, and, consequently, its capacity diminished. This diminution is still more strikingly apparent if we examine the human skull in another point of view. In well formed heads, a horizontal section of the cranium made in the direction of thesquammous margin of the temporal bones,gives an irregular ellipsis of such a form, that the double ordinate passing at the anterior portion of those bones,is much shorter than that passing through the posterior part. The head of the maniac, fig. 1 and 2, plate n, approaches in those respects to the proper proportions, for the posterior double ordinate is longer by two centimetres than the anterior. On the contrary, those 1 two lines are about equal in the head of the ideot, as I have ascertained by a caliber compass ; so that the section of this cranium would give a figure very nearly approaching that of a regular ellipsis. Hence it is evident how much the posterior lobes of the brain must be diminished in bulk by this singular conformation. We must not, however, decisively conclude, that this defect of capacity of the cranium is the sole and exclusive cause of the imperfect development of the mental faculties.
INFERENCES FROM THE FOREGOING ANATOMICAL RESEARCHES.
52. The two ideots, the conformation of whose skulls I have described in pages 122and 128, notwithstanding their respective differences present a general resemblance; that of a great diminution of capacity of the cranium, with an almost total obliteration of the affections and intellectual faculties. Has then the physical condition of the head any immediate influence on that of the mind; and may the one be considered as the efficient cause of the other ? I am cautious how I decide; and I confine myself to mark the line which separates truth from probability. The varieties of form ; the exact determination of measures; and the relative proportions of the parts, are the only subjects which I profess 10 discuss. The rest I leave to the wide field of conjecture, which, in other words, is a species of vesania common enough in the world, but which has not yet been recognized 'at the Petites Maisons.(g) The anatomy and pathology of the brain are yet involved in extreme obscurity. Greding, dissected two hundred and sixteen maniacal subjects, and he d< tails all the peculiarities which he observed in the meninges, the substance of the brain, the ventricles, the pineal gland, and the cerebellum. But as those maniacs died by disorders unconnected with their mental ailments, we can form no just conclusions from the morbid apearances which presented themselves. Many varieties of structure might likewise accidentally co-exist with the lesions of the mental functions, without having any immediate connection with them. The same may be said of the experiments of a similar nature, by Haslam in England, and Chiaruggy in Italy. J have attended at thirty-=ix dissections in the hospital de Bicetre; and I can declare, that I have never met with any other appearance within the cavity of the cranium than are observable on opening the bodies of persons who have died of apoplexy, epilepsy, nervous fevers, and convulsions, (h) From such data, what light can be thrown on the subject of insanity? In one of my dissections, indeed, I recollect to have found a steatomatous tumor about the size of a pullets egg in the middle of the right lobe of the brain: but the disease in that instance was not insanity but hemiplegia. What a field would have been opened for hypothesis and comment, had this person been likewise affected with insanity ? But, also, what an additional motive for circumspection and reserve in deciding upon the physical causes of mental alienation ?
The Petites Maispnt at Paris, is au institution similar to our Bedlam
(g) Before I practiced medicine at the hospitals, I fancied that considerable light might be thrown upon insanity, by examining the morbid state of the brain and its membranes: but now I am convinced, that inferences from dissections arc. .»p|l fourdtd only when the maniac has died during a pa'c.xysm of his complaint, a circumstance which rare y occurs. It more frequently happens, that the patient sinks after the termination of a paroxy-m from the state of languor and debility which succeeds. In these cases I have most (Frequently found an effusion of lymph in one or both ».'ntricles. When lunatics, on the contra>y, die of adventitious disorders, it must evidently appear tha' conclusions from the murbir' condition of the parts ate very equiv s.al but I reserve for another occasion the exposition and details of iny anatomical resea che< in regard to insanity, having confined myself in this section to the consideration of the form, and proportions of the head,
IS MANIACAL FURY WITHOUT DELIRIUM SUSCEPTIBLE OF CURE WITHOUT THE USE OF PHARMACEUTIC REMEDIES?
101. In the practice of physic, there are no restrictions upon the employment of superfluous remedies, and there are too many pretenders to the art, who avail themselves of such a system of empyricism in its fullest extent. The methods of treatment too frequently adopted in cases of insanity, of whatever x species, or from whatever cause, consist in the repeated use of bathing and blood-letting, and in the exhibition of antispasmodics in large doses. This blind routine has been followed even where experience has indicated the almost infallible sufficiency of moral and physical regimen. I have found maniacal fury without delirium, which in France is called folie raisonnante, whether continued, periodical, or subject to irregular returns and independent of the influence of the seasons, the variety of the disorder most unyielding to the action of remedies. A madman of this description condemned himself to the most absolute confinement for nearly eight years. During the whole of that time he was exceedingly agitated. He cried, threatened,' and, whenever his arms were at liberty, broke to pieces whatever came in his way, without manifesting any error of the imagination, or any lesion of the faculties of perception, judgement and reasoning. Other madmen, subject to periodical accessions of extreme violence, are frequently sensible of the impending paroxysm, give warning of the necessity of their immediate confinement, announce the decline and termination of their effervescent fury, and retain during their lucid intervals the recollection of their extravagances. An important matter for consideration, and calculated to throw light upon the treatment of this disorder, is that of the different duration of the lucid intervals, which in some are very short, and in others protracted to a considerable length. I have known intervals of calmness of eighteen months' continuance, alternating with paroxysms which lasted for six months. In three different cases, this succession was continued till the death of the patient. A fourth sunk into continued mania from distress of mind. A maniac, who was not delirious, but subject to the influence of blind rage, enjoyed a state of tranquillity for eleven months and a half of the year. During the remaining fortnight, he was under the dominion of ungovernable fury, which was directed against his own person.
Notwithstanding this variableness in the duration of the paroxysms and intervals of periodical mania, a gloominess of disposition and excessive irascibility, are common characteristics of them. Such maniacs are equally artful and malicious; at other times they are actuated by blind and savage ferocity. It is in this variety of the disorder, which has hitherto been considered as incurable, and which has commonly terminated in premature death, that medicine should avail herself of her most powerful resources. Opium, camphre in large doses, sudden emersion in cold water, blisters, the moxa, and copious bleedings, are the remedies to be resorted to. I have not hitherto been able to ascertain the decided effects of opium and castor. I hope, however, soon to have it in my power, from more conclusive experiments, to establish a systematic treatment of this formidable disorder.
Periodical Mania With Delirium And Originating In A Moral Cause, Frequently Cured By Moral And Physical Regimen Exclusively.
105. From the history of several madmen who have been cured for some time, and who have been, since employed in the services of Bicetre, it appears that their disorder, in almost every instance, originated in profound mental affections, such as terror, or distress from domestic calamities. In the greater number its character was that of periodical fury with delirium. The medical treatment which had been employed, appears to have produced little effect; the cure having in general been operated by moral or physical regimen during the paroxysm, or by exercise and laborious occupations during the lucid intervals and convalescence. I observe similar results in nine instances of cures which were performed during the first six months of the year 3. In all of them the occasional causes, species of the complaint, and remedies employed were the same. In this number, there were not any cases of continued mania, of mania without delirium, of mania complicated with epilepsy, of dementia, nor of ideotism. (d) From the necrology of Bicetre, in the second year of the republic, it appears that the most frequent causes of death were accidental diseases unconnected with mania, such as phthisis, dysentery scurvy, inanition from the rejection of food; or else mania complicated with epilepsy, wounds from accidents, extreme debility supervening upon the decline of a paroxysm towards the end of autumn. Out of twenty-seven maniacs, who died in the hospital during the year 2, five were carried off by fits of epilepsy of extreme violence, three by attacks of apoplexy, two by the scurvy, seven sunk in a state of complete exhaustion immediately upon their arrival, three in consumption, two by inanition from the obstinate refusal of food, two by dysentery, and two by accidents, the one from a blow received in a quarrel, the other from bruises and contusions received previous to the date of his admission. The cases which are given in the table and which are vouched for their accuracy, shew, that of the five species of insanity to be met with at hospitals, one only, that of periodical mania, is remarkable for the frequency and facility of its cures. Melancholia, continued mania, dementia and ideotism are more unyielding, and mania complicated with epilepsy is seldom or never cured. Such at least, during a stormy period of the revolution, are the results which I obtained at Bicetre.
(d) I here, except some very rare instances of accidental ideotism, mentioned in a former part of this volume, which were cured by a critical maniacal paroxysm.
THE PRACTICE OF BLEEDING IN MANIACAL DISORDERS AND THE LIMITS BY WHICH IT OUGHT TO BE RESTRAINED.
108. The blood of maniacs is sometimes so lavishly spilled, and with so little discernment, as to render it doubtful whether the patient or his physician has the best claim to the appellation of a madman. This reflection naturally suggests itself upon seeing many a victim of medical presumption, reduced by the depleting system of treatment to a state of extreme debility or absolute idiotism. At the same time, I do not wish to be understood as altogether proscribing the use of the lancet in this formidable disorder. My intention is solely to deprecate its abuse.
CIRCUMSTANCES CALCULATED TO DETERMINE THE USE AND EFFECTS OF EVACUANTS.
109. The use of hellebore in maniacal diseases ; the choice, preparation and administration of that vegetable; the preliminary remedies and precautions adopted to promote its action and to prevent its pernicious effects, formed among the ancients a regular body of doctrine. Experience proved that this drastic sometimes produced violent hypercatharsis, obstinate vomiting, convulsions, inflammation of the intestines and even death. The reader is referred for a detailed account of this subject to the articles Ellebore and Elleborisme in the Encyclopedie Methodique. Whether we consider its empyrical administration or the unfounded theories and superstitious fancies which in some instances sanctioned its employment, the disuse into which this remedy is fallen, ought to cause little regret. The history and distinctions of the disease were neglected through excessive and infatuated attention to the remedy. The science of medicine, enlightened by the acquisitions of chemistry and botany, is now happy in the possession and choice of purgatives and emetics, the effects of which are more determined, and not succeeded by any dangerous consequences. It has been remarked, when speaking of paroxysms of periodical mania, (section i.) that they are generally preceded by costiveness and great sensibility of the intestinal canal. If at an early period of this precursory stage of the disorder, the bowels are set at liberty by a purgative salt, dissolved in a decoction of endive, the unfavourable symptoms are not ' Unfrequently removed, and the threatened explosion of a paroxysm is prevented. This is a fact so well known at the Hospital de Bicetre, and established upon the evidence of so many successful experiments, that a maniac, affected by these intestinal symptoms, is immediately upon his admission put upon the use of an opening medicine, prescribed according to this formula, (see note, p. 44.) Paroxysms of insanity, especially such as have no regular type, and correspond with the changes of the seasons, are by this method not unfrequently prevented. I have also, often remarked, that a spontaneous diarrhea supervening in the course, or towards the decline of a maniacal paroxysm, has had all the characters of a critical evacuation. My experience agrees with the observations of English practitioners on the same subject. "Diarrhea," says Mr. Haslam, " very often proves a natural cure for insanity. The number of cases which might be adduced in confirmation of this observation is considerable; and the speedy convalescence after such evacuation is still more remarkable." Dr. Ferriar likewise mentions a case of insanity which was cured, as it appears, principally by the use of tartar emetic, which operated for some days as a purgative. " A robust woman, about twenty-five years of age, who had been insane a few years before, had now relapsed into a state of furious mania. Her tongue was foul, and her pulse quick. She took emetic tartar, in sufficient doses, to support a constant slight nausea, and had a blister applied about the same time to the crown of her head. In a day or two she appeared more composed, and as she found further relief from the continuance of the medicine, it was given for a week together. At the end of that time she was sensibly calmer, though there was yet no appearance of recovery. I then dropped the medicine, put her on a course of whey and on low diet, and kept her bowels freely open with magnesia. This method was continued for fifteen days. She was then ordered in addition an opiate every night at bed time, and was occasionally purged by black hellebore. Signs of recovery began to appear under this method ; she became dull, and at last tractable and quiet. Her reason returned gradually, and after being completely rational for more than a month, she was discharged cured, at the end of four months from the time of her admission." (i) In another respect, however, my observations do not agree with those of English writers. In England, cathartics are prescribed in small doses. In France, to produce the requisite effect, they must be administrated in much larger quantities. This difference in the effects of medicines may, perhaps, depend upon the nature of the exciting cause of the disorder, which in the former country is commonly intemperance in drinking ; while in the latter, insanity is almost always
111 It has been said, that the bath of surprise has been found a valuable remedy in some cases of insanity which had resisted the effects of the warm bath, the cold shower bath, and other remedies. This superiority of the unexpected application of cold water, has been ascribed to an interruption of the chain of delirious ideas, induced by the suddenness of the shock, and the general agitation of the system experienced from this process. It is well known, that the enthusiast Van Helmont, has made some valuable remarks upon the durable effects of sudden immersion in cold water in some cases of mental derangement. His practice was to detain the patient in the bath for some minutes. It may be proper to observe, that this method, however successful in some instances, might in others be extremely dangerous, and that it can only be resorted to with propriety in cases almost hopeless, and where other remedies are ineffectual; such as in violent paroxysms of regular periodical mania, inveterate continued insanity, or insanity complicated with epilepsy.
FEIGNED MANIA : THE METHOD OF ASCERTAINING IT.
115. Mania, as well as demoniacal possession, epilepsy, catalepsy and other nervous disorders, may be counterfeited, either from views of interest or from worse motives. To distinguish between the dexterous imitations and the real disorder, is a province of medical jurisprudence, equally delicate, difficult and important. I do not here speak of unskilful pretensions and rude artifices calculated to impose only on simple and credulous people, such as Wierus quotes; (/) but of insanity counterfeited on a great scale, and amidst enlightened characters, as in the example quoted by Dehaen [m] of a woman, who, in consequence of attestations given in her favour by certain well informed ecclesiastics, passed for a demoniac, and who after her admission into the hospital of Vienna was convicted of imposture. A guilty prisoner sometimes counterfeits insanity in order to escape the vengeance of the law, preferring confinement in a lunatic hospital to the punishment due to his crime. At other times genuine insanity supervenes in the course of a long and involuntary detention in a place of confinement. Those are cases which it is the important province of the physician to distinguish and to ascertain.
(0 Historia festiva figmeuti fxminap demoniacs Wieri, Op. BJed. p. 344. ('«) Dehaen Meth. Med. Tom. 15.
A man, forty-five years of age, confined in the felon department of Bicetre, on account of his political opinions, was guilty of numerous acts of extravagance, made many absurd speeches, and at length succeeded in obtaining his removal to the lunatic department of the same place. This happened before my appointment. In the course of some months after my entrance upon the functions of my office, I determined to examine carefully into the history and state of his malady, in order to ascertain accurately the class of the disorder to which his case belonged. For this purpose I frequently visited his chambers. At every visit he exhibited some new antic. Sometimes he wrapped up his head in cloths or blankets and refused to reply to my questions. At other times he poured fourth a torrent of unmeaning and incoherent jargon. On other occasions he assumed the tone of an inspired or affected the airs of a great personage. The assumption of so many and opposite characters, convinced me that he was not well read in the history of insanity, and that he had not studied the characters of those whom he endeavoured to counterfeit. The usual changes in the expression of the eyes and other features, characteristic of a nervous maniacal excitement,' were likewise wanting. I sometimes listened at the door of his chamber in the course of the night, when I invariably found him asleep, which agreed with the report of the hospital watchman. He one day escaped from his chamber while it was cleaning and setting in order, took up a stick and applied it, with great effect, to the back of a domestic, in order to impress him and others with the idea of his violence and his fury. All these facts, which I collected and compared in the course of one month, appeared to characterise no decided variety of mania, hut rather a great desire of counterfeiting it. I was no longer the dupe of his artifices; but as he had been sentenced to be confined on account of political matters, I adjourned my report of him, under pretence of wishing to learn some new facts. The 9th of Thermidor (July 28) succeeding put an end to the prosecution which had been commenced against him.
In Vendemaire, (Sep. and Oct.) of the year 3, a young man, of twenty-two years of age, confined in the prisons of Bicetre, was brought to the infirmary of the same establishment. He was exceedingly dejected and silent during my first visit to him. As I found him free from fever, I merely prescribed a light diet, persuaded that his disorder consisted in great depression and distress of mind. On the succeeding days I observed but little change in the state of his symptoms. He still persisted in his silence, even when questions were put to him. He sometimes sighed deeply, and moaned piteously. He had little appetite, no sleep, and, according to the report of the attendants, was subject in the night to nervous agitations of extreme violence. He frequently got out of bed, walked about the ward, and was obliged to be reconducted to his couch, as if out of his mind. Two mouths after his admission into the infirmary, and during one of my visits, he advanced with an air of wildness, and forcibly seized one of the attendants with the intention apparently of throwing him down His looks were wild and fixed. He wished to be informed relative to some particulars connected with a certain female of his acquaintance. He sighed profoundly. Such was the sensibility of his epigastric region, that he could scarcely bear the weight of his bed-clothes. Being desired to ascertain the nature of his disorder, I felt no hesitation in pronouncing his state to be that of decided insanity, consequent either upon disappointed love, or upon the depression of mind occasioned by his confinement, or, perhaps, upon the united influence of those two causes. His conveyance to a lunatic asylum was, at length, decided upon, and all judicial proceedings against him were withdrawn.
It may be thought astonishing, that in an object of so much importance as that of ascertaining the actual existence of mental derangement, there is yet no definite rule to guide us in so delicate an examination. In fact, there appears no other method than what is adopted in other departments of natural history: that of ascertaining whether the facts which are observed belong to any one of the established varieties of mental derangement, or to any of its complications with other disorders. I could here quote several examples of complicated mania illustrative of my position.
I shall confine myself to one, that of a young woman, twenty-eight years of age, with white hair, and little expression in her countenance. Her state of derangement, it is supposed, originally depended upon a fright which her mother received during her pregnancy. She remained like a statue, constantly in the same place. She could not speak, notwithstanding that her organs of speech appeared perfect in their conformation. It was with great difficulty that she was taught to enunciate the vowels e, o. Of affections she appeared not to possess any ; a circumstance that might have disposed a nosologist to refer her case to the species ideotism. But there were two or three acts that she could perform, which appeared to indicate that her ideotism was not complete. She was subject almost every morning to a paroxysm of great fury. If any one attempted to confine her in the strait-waistcoat she was violently enraged, and could use her teeth and nails with great violence and effect: but as soon as she was actually seized, her paroxysm ceased, she submitted without further resistance, and shewed every sign of repentance. Does not this case, at least in its paroxysms, present the character of mania without delirium?
OPINION OF THE AUTHOR'S SUCCESS IN TTHE Treatment Of Mental Derangement
116. Before we conclude, it may not be improper to advert to certain circumstances which ought not to be overlooked, in judging of the success of our labours and researches on the subject of the present treatise. It is necessary to mark the point from which we set out, that at which we have arrived, and the circumstances by which we were guided in our hospital duties. The maniacs of either sex, who were admitted at Bicetre and Saltpetriere, whether as convalescents or incurables, had at other places previously to their admission into those hospitals, undergone the usual system of treatment, by bleeding, bathing and pumping. Among the facts which were most constantly observed, are to be enumerated the permanent recovery of some, the death soon after their arrival of others, and the recurrence of paroxysms which in some instances terminate in complete re-establishment, but most frequently in a state of incurable dementia. Establishment of this kind seldom afford an opportunky of drawing up correct tables of their mortality, of determining accurately the proportion of the cases that are cured, and of fixing with precision the conversions which occur among the different species of insanity. I have therefore, devoted my principal attention to such objects as were within, my power; to the study of the diffident species of insanity, to the examination of the effects of certain "remedies, and to the determination of principles of moral and physical regiment of lunatic asylums To have surmounted many of the prejudices and other obstacles which present themselves in the organization and discipline of hospitals, is a merit which we hope it will be deemed no arrogance to lay some claim to. The fundamental principles advanced in this treatise will enable us, at a future period, to erect a superstructure for the reception and treatment of lunatics, superior to any of the boasted establishments of neighbouring nations. For the accomplishment of these our earnest wishes, we look up to the councils of a firm government, which overlooks not any of the great objects of public utility.
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