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A Treatise on Madness, William Battie, 1758 AD

"Battie's Treatise was a turning point in the medical approach to mental illness. His division of madness into `original' and `consequential' illnesses are forerunners to the `organic' and `functional' terms used to this day, and his promotion of therapeutic optimism through engagement with the patient, rather than restraint and other physical affronts, prefigured the `moral therapy' of the Tukes at the York Retreat later in the 18th century." (William Battie's Treatise on Madness (1758) and John Monro's Remarks on Dr Battie's Treatise (1758) - 250 years ago, Andrew Morris, British Journal of Psychiatry, 2008)

"William Battie (1703-76) A Treatise on Madness (1758), A: pp. 41-44, B: pp. 68-77, C: pp. 93-99. Battie's work was the most important influence on the treatment of madness in the eighteenth century before the founding of the York Retreat in 1792. He trained at Cambridge, became a governor of Bethlem Hospital in 1742, and in 1750-51 was a leading figure in the founding of St Luke's Hospital for Lunaticks, serving as its first physician until his retirement in 1764. Battie's achievement stands out clearly in his short, pointed, and controversial Treatise on Madness. He was among the first to try to dispense with the multiplication of labels for madness- melancholy, spleen, vapours, and so on-and preferred two simple categories: 'Original Madness', where there was some physical defect from birth, and which was generally incurable, and 'Consequential Madness', which followed upon some injury or external cause, and which would usually respond to treatment. This distinction, together with his insistence on the root cause of madness as 'deluded imagination', which allowed the patient to judge right on wrongly perceived evidence, had profound implications. Madness could now be seen as individual: it was brought about by something specific in the individual's life or personality, and its form and progress derived from the nature of the individual imagination. Battie therefore demanded confinement as a prerequisite for cure. The patient was to be removed entirely from the context wherein he or she had become mad, including family, friends and external pressures. Only in such a state of asylum could treatment have a chance of success. Moreover, Battie dismissed a wide range of conventional treatments, as in extract C below, asserting that management, by which he meant a temperate and ordered mode of living within the regimen of the asylum, would do more than medicine, and that any application of medicine should be judged according to the needs and constitution of the patient. He also took in pupils, including Sir George Baker, who became physician to George III, thereby stimulating the development of a professional line of psychiatric practice which Bethlem, with its father-to-son tradition, had always deliberately eschewed. The example of St Luke's itself instigated the asylum movement throughout the provinces, with hospitals opening in the north east in 1765, in Manchester in 1766, York in 1777 and Liverpool in 1790. Ironically, Battie published no case histories and included no examples in his Treatise, yet did more to make attitudes towards the mad more open and less prejudiced than any other physician of the period." (Patterns of Madness in the Eighteenth Century, A Reader, Allan Ingram, 1998 AD, p112)

A Treatise on Madness William Battie, 1758 AD

Scanned text from the original book:

proofreaders Note: In the 18th century, an "f" was used in place of an "s". "fs" was used in place of "ss".

Copyright 1969 by Brunner/Mazel, Inc.

80 East 11th Street, New York, N.Y. 10003

Library of Congress Catalog Card Number 68-56287

Manufactured in the United States of America

INTRODUCTION

The delight of medical historians is to unearth "firsts" the first time a hypodermic needle was used, the first case of arthritis reported, and so on. Sometimes a first is not discovered until the one to whom the honor belongs is dead. Such is the case with pr. William A. Battie, who lived in England from 1704 to 1776. He, his medical accomplish-ments, and this book form a remarkable series of firsts.

To begin with, Battle was the first teacher of psychiatry in Eng-land; some authorities go so far as to say "in the world." Moreover he was more than a rebel who differed with and defied accepted mid-18th century psychiatric thinking-especially as pontificated by John Monro, the director of Bethlehem. He was a pioneer in mental dynamics, in hospital care of the insane, and in the writing of the first extensive book on psychiatry in England. He abhorred the un-wholesome conditions at Bethlehem and this led him to be one of the founders of St. Lukes' Hospital for Lunaticks in London where he was superintendent until he left to head a large private asylum.

Battie's Treatise on Madness is an especially important work in medical history because it is "the first by a psychiatrist who could draw on his experiences with a large number of patients . . ." (Hunter and MacAlpine, 300 Years of Psychiatry).

As the first psychiatrist to teach his specialty, Battie invites- nay, implores-physicians to read his book, to study psychiatry, to visit his institution (the first private one, incidentally, devoted exclu-sively to the care and treatment of the insane), to accompany him on rounds, and to make their own observations. This was the more novel because the students were not bound by the centuries-old tradi-tion which prevailed in Bethlehem and which was gospel for the profession.

Besides being a psychiatric first, A Treatise on Madness contains some revolutionary (for that time) ideas, many of which are valid by today's criteria. At least Battie sponsored "change"; to throw off the yoke of antiquated and unproven isms and give thought to new concepts even if they turn out to be wrong when given a clinical try-out. Today we call this research. When one reads this book and appreciates how "modern" Battie's medical reasoning is, it is understandable that he would be a minority of one among his contemporary collectgues who, a dozen years after Battie's death, advocated drastic purging, blistering of the skull, bleeding, induction of vomiting, and other similar measures for George III in his first attack of insanity in 1788. Certainly he treated his patients, both at St. Luke's and at his own private hospital, more humanely than did Monro at Bethlehem.

Among his tenets, many of them "firsts," are his (correct) antipathy [opposition] for violent purging as treatment of the insane. He separates each psychiatric symptom, and maintains that a definition must say what madness is and is not. (Ask any contemporary psychiatrist to define "psychosis" and watch his embarrassment!) . He points out that defective sensation is not necessarily psychopathological, differentiates between altered sensation in the normal, the somatically sick, and the insane (to whom he correctly lends the word "delusion" to the perversion or other change in sensation). He envisions sensory pathways and fibers dividing and re-dividing "beyond human vision." Considering his era, Dr. Battie reveals an astounding knowledge of neuro-anatomy. He wipes out the then current misconception that the brain is a gland whose secretion makes sensation possible. He recognizes exogenous and endogenous sources of sensation. Amazingly, he preceded Freud by claiming that all sensation is, at first, crudely received and inter-preted by the brain as either painful or pleasurable; this is a faculty necessary "to preserve life." He points out that if an animal holds its breath, anxiety (pain) compels him to exhale. "Uneasy sensation leads to sickness"-certainly a clear description of what we know as psychosomaticism.

He says that madness begins with "too active sensation" and ends with "too languid sensation." Again, in madness, sensation is often dis-proportional to the external stimulus (today's "over-valuation"). An unpleasant "external object" may disrupt "natural sensation"; so may "nerve weakness." (And Freud, W. W. Keen and others are credited as pioneers in neurasthenia!). Precipitating causes of madness are "black November days, unpleasant weather" and the "tempest of love, hate, and other passions." Where protracted disease and pains persist, a reactive depression may lead to suicide. Dr. Battie certainly proved that there is nothing new in psychiatry.

There are many more "firsts" in this superb book. It is extremely interesting and should be a reading reward for all who peruse it.

("A Treatise on Madness", William Battie, Introduction by James Brussel, p v)

JAMES A. BRUSSEL, M.D., F.A.C.P., F.A.P.A.

Assistant Commissioner, N. Y. State Department

of Mental Hygiene

Director, Bureau of Historical Research

New York, November 1968

A Treatise on Madness William Battie 1758 AD

By WILLIAM BATTIE M. D.

Fellow of the College of Physicians in LONDON,

And Physician to St. Luke's Hofpital.

LONDON;

Printed for J. WiuSroN, and B. WHITE, in Fleet-ftreet. M,DCC,LVIII. dal c-JT

[Price Two Shillings and Six-Pence.]

T

THE MOST NOBLE

GEORGE,

Earl of CARDIGAN,

Prefident of ST. LUKE'S HOSPITAL,

THIS

TREATISE ON MADNESS

IS HUMBLY DEDICATED

B Y

HIS LORDSHIP's

DUTIFUL AND OBLIGED SERVANT

W. BATTIE.

ADVERTISEMENT.

Am. N G the many good reasons offered to the Publick, for efta-blifhing another Hofpital for the

reception of Lunatics, one, and that not the leaff considerable, was the introducing

more Gentlemen of the Faculty to the

Study and PraRice of one of the moil

important branches of ribisick.

The attention of those worthy citizens of London, who first planned and pro-moted this charitable work, was carried beyond its more immediate object. Not content with giving relief to a few

indigent persons of their own age or'

country they interefted themselves in the

care of pofterity , and as far as they

were

[vi]

were able made a more ample and effeaual provifion for that help, which all Lunatics of whatever nation or quality must at all times Band molt in need of.

Agreeably to this their extenfive be-nevolence, they very soon by an unani-mous vote signified their inclination of admitting young Physicians well recom-mended to vifit with me in .the Hofpital, and freely to observe the treatment of the patients there confined.

A command so conformable to my own fentiments I not only molt readily obeyed ; but, that I might answer their expeIations in this as well as in every other particular to the utmost of my power, I moreover offered to the perufal of the Gentlemen who honoured me with their attendance the reasons of those pre-fcriptions, which were fubmitted to their observation.

The

[ vii

The end proposed in committing my thoughts to writing on this fubject has induced me to publilh. Those, for whole use these papers were originally designed, having encouraged me to hope that the same hints may be of fervice to other Students, who have not the same oppor-tunity of seeing practice.

Lately Publifhed,

By JOHN WHISTON and BENJ. WHITE, in ONE VOLUME

Quarto, Price I2S. Bound,

DE PRINCIPIIS ANIMALIBUS Exercitationes viginti quatuor in Theatro Collegii Medicorum Londinenfium habitat. A GULIELMO BATTIE, M. D.

Collegii ejufdem Socio.

Nunguam aliud Natura aliud Sapientia dicit.

TREATISE

O N

M A D N E S S.

SECT. I.

The Definition of Madness.

MADNESS, though a terrible and at present a very frequent calamity, is perhaps as little underftood as any

that ever afflicted mankind. The names alone usually given to this disorder and its several Species, viz. Lunacy, Spleen, Melancholy, Hurry of the Spirits, ctc. may convince any one of the truth of this assertion, without having recourse to the authors who have professedly treated on this subject.

[ 2 I

Our defel of knowledge in this matter is, I am afraid, in a great meafure owing to a defect of proper communication : and the disficulties attending the care of Lunaticks have been at least perpetuated by their being entrusted to Em-piricks, or at best to a few Idea Physicians, most of whom thought it advifeable to keep the case as well as the patients to themselves. By which means it has unavoidably happened that in this inslance experience, the parent of me-dical science, has prosited little, and every Prac-titioner at his first engaging in the cure of Lu-nacy has had nothing but his own natural sense and fagacity to trust to ; except what he may perchance have heard of Antimonial vomits, strong purges, and Hellebore, as Specifically anti- maniacal : Which traditional knowledge however, if indifcriminately reduced to pradice, a little experience will soon make him with he had been an entire stranger to.

There is therefore reason to hope that an at- tempt to discover the causes, effects, and cure of Madness, will meet with a favourable reception ; lince, whatever may be the event, the intention is is right ; and it is same comfort to think that no-thing of this nature, even though it should fall short of what is aimed at, can in its consequences be entirely useless. For the judicious reader will at least be hereby inclined to turn his thoughts to the same subject, and may even receive instrution from the mifcarriages of such an undertaking.

But the peculiar misfortune just now mention-ed, viz. want of proper communication, though the chief, is not the only hindrance to our know-ledge : for Madness hath moreover (hared the fate common to many other diftempers of not being precisely desined. Inafinuch as not only several symptoms, which frequently and acciden-tally accompany it, have been taken into the ac-count as constant, necessary, and essential ; but also the supposed cause, which perhaps never ex-hted or certainly never acted with such effea, has been implied in the very names usually given to this distemper. No wonder therefore is it, whilst several disorders, really independent of Madness and of one another, are thus blended together in our bewildered imagination, that a treatment, rationally indicated by any of those disorders, should be injudicioufly directed againft Madness itself, whether attended with such fyrnp-toms or not. Much lets can we blame the Phyfician, who being prejudiced by the supposed cause couched in the name of the distemper he has to deal with at every new or full Moon attenuates, evacuates, or alters the peccant hu-mours by medicines peculiarly adapted to the black or fplendid Bile, ctc.

In order therefore to avoid this mifchievous confusion of sentiment as well as language, and that we may fix a clear and determinate mean-ing to the Word Madnefr ; we must for some time at least quit the schools of Philofophy, and content ourselves with a vulgar apprehenfion of things ; we must reject not only every supposed cause of Madness, but also every symptom which does not necessarily belong to it, and retain no one phcenomenon but what is essential, that is without which the word Madness becomes nuga-tory and conveys no idea whatever : or, in other words, no desinition of Madness can be safe, which does not, with regard at least to some particular symptoms, determine what it is not, as well as what it is.

[ 5 ]

First then, though too great and too lively a perception of objets that really exist creates an uneasiness not felt by the generality of men, and therefore discovers a prmternatural state in the instruments of Sensation, and tho' such uneasiness frequently accompanies Madness, and is therefore fore sometimes mistaken for it; nevertheless Anxiety is no more essentially annexed to Madness, so as to make part of our complex idea, than Fever, Head-ach, Gout, or Leprosy. Witness the many instances of happy Mad-men, who are perfectly easy under what is esteemed by every one but themselves the greatct misfortune hu-man nature is liable to.

Secondly, though too little and too languid a perception of things that really exist and are ob-truded with force sufficient to excite sensation in the generality of men, discovers as prxternatural a state or disorder in the instruments of Sensation as uncommon Anxiety, and tho' it sometimes at-tends Madness, and is likewise mistaken for it, eSpecially by the French who call Mad-men and Fools by the same name; nevertheless such defect of Sensation is no more essentially annexed to Madness than the former symptom of Anxiety, which that very frequent symptom of Madness sufficiently proves.

[ 6 ]

But-quiSpecies alias veris caplet, commotus babe- bitur --- And this by all mankind as well as the Physician : no one ever doubting whether the perception of objects not really existing or not really corresponding to the senses be a certain sign of Madness. Therefore deluded imagination, which is not only an indisputable but an essential character of Madness, (that is without which, all accidental symptoms being removed from our thoughts, we have no idea whatever remaining annexed to that found) precisely discriminates this from all other animal disorders: or that man and that man alone is properly mad, who is fully and unalterably perfuaded of the Existence or of the appearance of any thing, which either does not exit} or does not actually appear to him, and who behaves according to such erroneous per-fuafion.

Madness, or false perception, being then a preternatural state or disorder of Sensation; before we attempt to discover its causes effects and cure, it will be necessary for us to inveiligate the seat the causes and the effects of natural Sensation. For the consideration of the abuse or fault of any thing necessarily brings that very thing into comparifon with what it was when found and perfect ; and 'tis impofsible for us rationally to amend or restore what never was the object of our thoughts.

Be it therefore our first endeavour to contem-plate natural Sensation : if haply this moll guishing property of animal life may supply us with actual and pofitive knowledge of some mat-

ters

X71

ters that relate to the present subject ; or at least may point out to us what it is that herein fur-passes our impedect understandings. A science negative indeed, and by no means so satisfactory to the pride and speculative curiofity of man as the former, but very often as useful and as con-ducive to the attaining practical truth.

[8]

SECT. II.

the Seat of natural Sensation.

WHoever is confcious that he hears, fees, or feels, and beholds all animals he is converfant with acting just in the same manner as he does when he hears, fees, or feels, must acknowledge that his own and every other animal body is as really endued with Sensation as that it exists.

Whoever attentively contemplates in what manner he and every other animal is affeted by external impulse, must acknowledge that some parts of the same body, however animated, are quite insensible, some endued with a less degree of Sensation than others.

Whoever is moreover sufficiently verified in Anatomical researches, and has learnt to separate those parts of an animal body, which, however contiguous or closely conneted, are nevertheless really distinct from each other, very readily discovers several soft fibres, each of which is actually divisible into many smaller of the same kind, as far as his eye can trace ; and he by analogy justly concludes that each of those smaller fibres is as capable of being still farther and farther divided beyond the reach of vision, and even of human imagination.

[9j

These soft fibres are all connected with the contents of the cranium, and in different parts of the body they are collected into fasciculi ; every one of which is enveloped by a continuation of those very membranes which within the cranium contain the substance of the brain and its medullary appendages.

Every such fafciculus as well as the several fibres it is refolveable into is called a Nerve : a name borrowed indeed from the ancients, but used by them in a very different signification. For by veL7po and nervus neither the Greeks nor La-tins meant any thing soft and medullary, but on the contrary the hard and elastic subslance of a tendon or ligament ; as the word fill retained by the moderns to signify the fafcia or membrane expanded over and conneting the muscular fibres, sufficiently shews.

[ 10 ]

Every nerve, which is within the reach of our observation, is extended between the medulla oblongata (base of brain) or its appendage the medulla spinalis (spinal cord) and the place of such nerve's destination. But every such nerve is thus extended in a manner very different from the disposition of the blood-vessels, and indeed of all other portions of the same body which are called familiar. For in its passage it neither is split into ramifications, nor is it at all connected with any contiguous parts of the body, except with some substances equally nervous called ganglions chiefly observable in the mefentery.

If a nerve in a living body be distracted by external force, there immediately arises an exquisite sensation called pain. Which sensation is always in a direct proportion to the quantity of such distrading force ; and which never ceafes either untill the distrading force is removed or is become unadive, or untill the material par-ticles which constitute the laid nerve are by this diftraction irrecoverably difunited.

If to a nerve in a living body be applied any acrimonious objects, that is such portions of matter whole surfaces are full of angles, and which when affisted with proper impulse are therefore capable of distracting the particles that constitute the nervous substance, there immediately arises the same painful sensation : which is always in a direct proportion to the quantity and acuteness of such acrimonious angles, and to the impulse with which they are impacted, and which continues as long as in the former case of vifible diftraction occasioned by external force. Those parts of an animal body, in which the greatest quantity of nervous fibres is manifesily contained, and in which such nervou,; sibres lie the most exposed and undefended by any other matter that constitutes the same body, are the soonest and the most affeted whenever any ex-ternal objects are applied with force sufficient to excite sensation.

Those membranes, which not only within the cranium surround the brain, but which also serve as sheaths to the several appendages of the brain, collecting them into nervous fafciculi all over the body as far as the eye can trace, are indeed every where contiguous to and seem intimately connected with the medullary fubflance they contain: nevertheless upon the application of any external objects they all discover no extraordinary signs of sensibility, any more than several other membranes in the same body, which are equally vascular and elastic. Witness the many well attested case of erosions and other accidents of the dura mater unattended with any degree of pain.

[ 12

All which constant and uncontroverted observations prove, I. That the nervous or medullary substance derived from or rather communicating with the brain is the seat or instrument of natural Sensation : 2. That no other matter whatever, whether animated or not, is such seat or instrument,

SECT.

[ 13 i

SECT. HI.

the supposed Causes of natural Sensation.

TH A T the medullary or nervous fub-fiance continued from or rather con- nested with the brain is the seat of Senfation, is a point now so univerfally agreed upon, that perhaps it might have been sufficient barely to have alerted it without any formal proof. Happy should we be, if the causes of Sedation were as clearly and incontestably fettled.

But I am afraid before any right or satisfactory notion can be formed concerning this matter, we must get rid of some opinions, which how-ever absurd have of late passed upon many fox real knowledge.

The reason of this difference, which at pre- fent subsists between the discovery of the seat, and the discovery of the causes of Sensation, is not in the things themselves that have been en- quired after, but in the manner of enquiry. Because in fixing the seat of Sensation we have been content with facts that are apparent to all men, and which if any one should controvert, he must difclaim the evidence of his own senses:

But in assigning the causes of Sensation several things have been assumed as matters of fact, which have never been discovered, and which may at least with equal probability be denied as admitted.

For here the Hypothetical Genius, forgetful that he hath Nature's works for his contemplation, and defpifing that poor pittance of know-ledge which the real appearance of things flip- plies every one with as well as himself, hath dared without any warrant to coin new ideas; hath made free with air, water, ?ether, nay even electrical fire ; and imagining that to he pro-bable which is barely possible, and then heighten-ing this assumed probability up to matter of fact, he takes one large stride more and roundly af-ferts that the brain is a gland; that its cortical portion is a convolution of secretory vessels deigned to separate from the blood one or other of thole ele-mentary .1a:fiances, which he bath by wars un-known introduced into the carotid arteries for this Lis pretext purpose; that the medullary portion of the brain and nerves is nothing else but a colleElion of excretory dugs ferving to convey this elemen-tary matter to all the fenlible parts of the body : which matter either by undulation or retrograde. motion imparts to the Sell°. rium commune all thole impulses it receives from such external objeRs affeat the extremities of the nervous filaments.

C 15

This excrement therefore of the brain tho' invisible is the necessary cause of sight, tho' impalpable the sufficient cause of feeling, and tho' an animal Spirit the material cause of animal Sensation.

Now, as the secretion of such a nervous fluid and consequently its very existence depends entirely upon the analogy that is supposed to lie between the brain and every glandular substance, in case the brain is very unlike a gland in any material circumstance, this whole machinery is immediately destroyed.

Admitting therefore, what has never yet been proved, that the cortical portion of the brain resembles the secretory organ of a gland, yet the medullary or nervous fubifance is different from all excretory ducts whatever : inasmuch as no excretory duct is ever found but what is immediately detached from the gland whence it issues ; whereas on the contrary the supposed glandular or secretory substance of the brain is continued to every part supplied with nerves, and these nerves the supposed excretory duds, after that they have left the cranium and their glandular origin the brain, wherever they are capable of being examined, remain as closely connected not

c16]

only with the cortical or secretory portion of the brain, but even with the productions of the dura and pia mater, as the medullary substance itself whilst contained within the cranium.

This observation alone would be sufficient to destroy the very foundation of a nervous fluid, if any Hypothesis whatever could deserve a serious consideration. But it may be feared that a solemn confutation of chimaeras [mythical creatures] will appear equally ridiculous as an attempt to establish them ; and he may perhaps incur the suspicion of insanity which these theorists have deserved, who shall fight in earnst with shadows, and mispend his time in offering reasons, why the solid constituent parts of the medullary fubilance con-tained in every nerve bid fairer for supplying us with the material cause of Sensation, than a fluid never yet discovered, and which its very authors confess was once foreign to the body, and even extracted from dead and putrefcent matter spirited up, we know not how, into animality.

Let us therefore quit this enchanted ground to those, if such there be, who are fill inclined to dispute upon it ; and in order to clear our way a little more to the real causes of Sensation, let us divert our attention to a very common phrase, viz. weakness of nerves, which tho' not professedly systematical, like the former scheme of animal spirits, is nevertheless extremely delusive ; inasmuch as it seems indiretIy to offer another solution of the phenomenon in question, and to ascertain the cause of Sensation.

17

For since the word weakness, when joined with material substances, can convey no idea but a lax cohesion of such particles as constitute those substances ; therefore the phrase weakness of nerves, which denotes a morbid excels of Sensation, seems to imply that Sensation itself is owing to the loose cohesion of those material particles which constitute the nervous substance, inasmuch as the quantity of every effect must be proportional to its cause.

By this inaccurate manner of talking, the most distinguishing property of animal nature is in danger of being blended with inanimate matter. For, if the case really were what these words seem to import, all bodies whose particles do not cohere with too great a degree of proximity would be nervous, that is endued with Sensation. But, since no portion of matter, however loosely compacted, is nervous except it is part of an animal body, therefore the medullary substance of a nerve is endued with Sensation not because its constituent particles are loosely united [ie weakness of nerves] and every nervous filament, tho' it consists of parts extended and not too closely cohering, is confessedly as distinct from every other material substance consisting of parts extended and equally cohering, as a man from a carcass, or an horse from an equestrian statue.

[ 18 ]

S E T..

[ 19 ]

S E C T. IV.

the real Causes of natural Sensation.

SE N S AT ION, however perplexed it may seem to those who too curioufly enquire into its nature, is to the model+ observer

as clear in idea and as fully to be accounted for, at leaf} to all useful intents and purposes, as any phcenomenon whatever.

For is not what we feel a plain matter of fact, of which we are not only certain and confcious ourselves, but which we are likewise capable of communicating to others by words or ligns ? And are we not perfectly well acquainted with many things, which when impelled with force sufficient will make us feel ; and which it is frequently in our power to apply, remove, or avoid, as best fuits our interct ?

It is the heedless or rather the wilful neglect of precisely feparating these many evident and external causes of Sensation as well from their unknown and internal operations as from their in-termediate and equally unknown effects, that has created such difficulties in contemplating this phcenomenon.

D 2 For

C20

For the mutual colnefion of material particles, as essential to our idea of an animal body as sense itself, but not better accounted for, hath however been looked upon as a thing much less my steriou s.

Which seeming diversity can be owing to no-thing else, but because the generality of man-kind have contented themselves with the useful and the attainable knowledge of such external objects, as will harden or soften those bodies they are applied to, without enquiring too nice-ly why the conslituent particles of those bodies, are more or less united upon such application, or indeed why they are united at all : whereas the philofopher in his contemplation of sensible matter is not content with knowing certainly like other men what objects externally applied to a nerve will create, increafe, or deaden sensation, but moreover conjectures why ; and attempts by any means whatever to afsign the manner in which these external objects act upon, and the changes they produce in the nervous substance previous to sensation their last effect ; which ef-fect, for reasons bell known to himself, seems to demand a more explicit solution than the co-INefion of material particles.

r 21

In endeavouring therefore to afsign the causes of Sensation, be it one of our chiefest cares to distinguish them from one another as effectually in our mind, as they are really different in their nature, and to separate what we actually and usefully know from what we are, and perhaps shall always be without any great damage, en-tirely ignorant of.

For which purpose, it may not be amifs to premife a few considerations on causes in gene-ral ; which will illustrate the fubject of our present enquiry and at the same time be confirmed thereby.

First then, by observing that any one phenomenon frequently follows another, we conclude that the second is owing to the first ; and hence we get the ideas of cause and effect.

Secondly, by observing that any one phenomenon never fails to follow another, we conclude that the first is not only a cause but alto a sufficient cause of the second.

Thirdly, by observing that the second phenomenon never occurs but in consequence of the first, we further conclude that the first is not only a cause but a necessary cause of the second, which is therefore called the carfa fine qua non.

Fourthly, by observing that the second phenomenon follows the first without either the evident or the demonstrated intervention of any other phenomenon as necessary or at least accessory to its existence, we conclude that the first phenomenon is moreover the immediate cause of the second.

Fifthly, by observing either that the first phenomenon is not always succeeded by the second, or that the second is not always preceded by the first, we conclude that the first phenomenon is either not a sufficient or not a necessary, but merely an accidental cause of the second.

Sixthly, by observing or by admitting as undeniable that any one or more phenomenon intervene between the first and the last in question, we plainly discover that the first is remote, and that the several other intervening phenomenon in their order approach nearer and nearer to the immediate cause.

Seventhly, a very little reflection upon causes and effects as thus stated will make us conclude that the remote and accidental causes of any effect may be many, but that the sufficient and necessary as well as the immediate cause can be but one. Since either of two causes supposed sufficient will render the other unnecessary ; and either cause supposed necessary will render the other insufficient. Which unavoidable conclusion, by the way, might be extended beyond secondary agents or instruments, improperly cal-led causes, and would give an additional proof, if any was wanting, to the unity of the first, the necessary, the sufficient, and indeed stri6tly speaking the sole cause of all things.

Thus, to inftance in our present fubjea ; fight, hearing, taste, fmell, Fee.. which frequently succeed the application of external objects, are look-ed upon by us as the effects of finch external ob-jects ; and we in common difcourse refer our ideas back to thole objects as to their causes, as when we fay we fee the fun, we hear the drum, ctc.

But, forafmuch as the external objects of sense, however forcible their application may be, do not always and in all animal bodies create fight, ctc. And moreover, as the very same perceptions do sometimes, at least in disordered subjects, arise without any external object that really affects them ; it is impofsible but every filch external object must be meerly accidental, and by no means

E24

means the sufficient or the necessary cause of filch its nervous effect. : Which sufficient and ne-cessary cause is therefore internal, that is it in-haeres in the very frame and constitution of the nervous substance itself; whereby alone such substance is rendered capable of being asfeted by any external object so as to create Sensation ; and without which internal cause no thing what-ever would actually become an objea of our senses

For the same reason all such external causes are not only accidental but likewise remote. Since the necesfary and sufficient cause at leas} must intervene ; and betides, before an external objea can create any sensation whatever, it must produce several intermediate effects, viz. motion, impulse, and pressure : all which pre-cede not only fight, eec. thereby excited, but also precede that particular internal asfection of the nerve itself, whatever it is, which is the im-mediate, the necessary, and the sufficient cause of such perception.

The accidental and remote causes of Senfa- tion, as also their intermediate effects, provided such effects are external to the nervous fub- stance, very readily discover themselves, and are clearly comprehended. For indeed they are all bodies

1 25 I

bodies that lye within our observation (many of which are within our reach) and the motion and impulse of those bodies, or of particles emit-ted therefrom, upon the organs of sense : which every one not only has a clear idea of, but is moreover certain of their existence, motion, and impulse.

Now, as no body whatever can be capable of creating Sensation in consequence of its motion and impulse, without pressing upon the nerve af-fected by such impulse ; therefore pressure of the medullary substance contained in the nervous filaments approaches nearer in order to the im-mediate cause of Sensation, than the motion and impulse of any external objet.

Pressure of the medullary fubilance contained in the nervous filaments cannot indeed be ima-gined without some alteration in the former ar-rangement of thole material particles which con-ftitute that fulltance. But we have no idea whatever, either vifible or intelle±ual, how and in what manner those particles are by such pressure differently juxtapofited, previously to Sensation thereby excited.

Whence it undeniably follows that pressure upon the medullary fubilance contained in the

[ 26 ]

nervous filaments is the last in order of all thole causes of Sensation, which we have any idea of. Thus far and no farther our knowledge in these matters reaches, limited by the outfide of the seat of Sensation ; what passes within being meer conjecture. For if a new pofition of medullary particles, which is an immediate and unavoidable effect of external pressure, does not discover it-self any more than their confitutional arrange-ment ; what account can we with any the leaf degree of modefy pretend to give of all the alterations in the nervous substance fill fubfe-quent to such pressure and to change of place thereby occasioned ; a regular feries of which may, for any thing we know to the contrary, precede the immediate cause of sensation.

SECT.

SECT. V.

The salutary Effects of natural Sensation.

SENSAT ION is always accompanied with some degree of pleasure or uneasiness ; no animal being indifferent to what he sees, hears, or feels. These additional and in some degree infeparable assections demonstrate the di-rect tendency of Sensation to the prefervation of life; inasmuch as every one fpontaneoufly flies from those objects which hurt and are at enmity with him, and covets such as create satisfation and are fuitable to his interef.

But, tho' no one at first fight would doubt whether the perception of pleasure is agreeable to his nature, and conducive to its prefervation ; it may with great reason be doubted by those who reflect a little whether such perception, however convenient it may seem to animal life, is alone instrumentai in its prefervation, and without the intervention of the contrary affection ever conduces to health.

For uneasiness is so interwoven in the very frame of mortals, that even the greatest present

C28

satisfaction implies the removing or flifling the greaten uneasiness which before difquieted. And a sense of future pleasure, as it excites desire, in that very defire implies a present uneasiness adequate to the supposed enjoyment of the pleasure in expectation. By which present uneasiness, according to Mr. Locke's just observation, the will is determined.

However paradoxical therefore it may seem, nothing is more true than that Anxiety, a real evil, is nevertheless productive of real good ; and, tho' seemingly disagreeable to Nature, is absolutely necessary to our preservation, in such a man-ner, that without its fevere but useful admoni-tions the several Species of animals would fpeedily destroyed. For sirli, are not hunger and thirft very falu-tary Anxieties ? By which the nerves of the mouth cefophagus and stomach excite all ani-mals from the first moment of their birth to feize on such objects, as are capable of relieving those natural and healthy but agonizing sensations.

Now the real good produced by the gratifica-tion of these appetites is by no means to be pla-ced in their present gratification alone. What-ever he may imagine, who being ignorant of the animal

f29J

animal eaconomy looks no farther than the actual pleasure which accompanies the stiffing such sensations. For the end herein proposed by the Author of Nature is undoubtedly the refection of that very body which hungers and thirsts ; whole constituent particles by the inevitable effects of vital action are in a continual flux and decay ; whereas the efficient or coercive causes of eating and drinking are those sensations alone, which torment every animal to a very good purpose. Who perhaps would not otherwise give himself the trouble of opening his mouth, much less by hard labour earn food wherewith to sill it ; even tho' he should be assured that the loss of meat and drink today, tho' not at all inconvenient to him at present, will be sensibly felt to-morrow by his distempered body, and that his idleness and fasting will be soon attended by fatal consequences.

Secondly, the introducing fresh air into the lungs being as necessary for the immediate con-tinuance of life, as it is for other purposes of the animal ceconomy which are more remote, and at present unknown ; therefore every ani-mal provided with organs of respiration, whether awake or sleeping, draws into his breast and ex-pels a quantity of external air sufficient to dif-tend them from the firsi moment of his birth

[ 30 ]

till the last period of life. Which alternate anion, if he either carelessly or obstinately omits it, he is very soon compelled to perform by that inexpressible Anxiety which attends a long de-tention of air once admitted as well as the re-fufing admiflion to any air at all.

Thirdly, forafinuch as voluntary exercise of the body is no less requisite to the due circula-tion and secretions of the animal fluids, and the salutary consequences thereon depending, than the propulfive action of the heart and the refi-lition of the arterial tubes ; which the ill effects of a fedentary life sufficiently prove ; therefore the uneasy sensation that is always occasioned by fatiety and the wearisome condition of idleness determine all animals, to whom aUivity is thus necesfary, frequently to alter their place of resi-dence, and to remove from those objects they have long been converfant with, however plea-fing and eagerly fought for they might once have been.

Fourthly, all the afore-mentioned instances of uneasy sensation, however nearly allied to and often ending in sickness, are nevertheless the natural effects of perfect health. But be- fides these there occur several other anxieties, which are the unavoidable effects of real sickness

and

[ 31

and moreover frequently determine the will of the patient to such things as are capable either of relieving the present disorder or of prevent-ing its mifchievous consequences. Thus, to in- ,fiance in one particular, feaverish heat threatens putrid obstructions, and at the same time occasions intenfe thirst and an almost infatiable crav-ing for acidulated water. Which defire, if not contradicted- by the osficious and ill-tim'd care of the by-handers, procures a remedy that is both diluting and antifeptic.

Lahly, tho' the nervous energy be neither absolutely necesfary nor alone sufficient to excite muscular action, yet such is the connection be-tween the nervous and muscular sibres, however really distina from each other, that animal sensation often instantaneously precedes animal ac-tion, so as to have confounded these two qua-lities, or at leas} to have made the one appear the immediate and only cause of the other. And, what chiefly deserves our notice whilst we are considering the salutary effects of Sensation, Convulsion itself, a distempered excess of animal motion, which is a frequent effect of uneasy Sensation, sometimes becomes its sudden and ef-ficacious remedy, by removing the material cause of such uneasy Sensation, and that without

any

[ 32

any determination or interpofition of the will whatever.

All which nervous appetites as well as milieu-lar motions, that either preserve or restore health, and are seemingly excited by somewhat rational-ly forecasting their salutary ends, have given rife, I suppose, to some modern metaphorical expressions, viz. Nature, and the Anima invented by Willis and deifyed by Stahl. Which figurative words, tho' not quite philosophical, are innocent and even useful, in case they are applied only to avoid periphrases in relating medical matters of fait. But young Practitioners, who are often told that they are to imitate and aslist Nature, must take great care not to be misguided by the literal sense of words, or fancy any thing like personal consciousness and intellectual agency in the animal ceconomy. For in such case of misapprehension these and the like expressions become as absurd as all the exploded Faculties of the Ancients, and, what is much worse, may be as mischievous as an instrument of death in the hands of a Madman.

SECT.

( 33 I

SECT. VI.

The Causes and Effects of Anxiety and Insensibility, two species of Sensation disordered tho' not delusive.

HAVING contemplated the seat causes and effects of natural and true Sensation ;- before we proceed to consider delusive Sensation, the only subject of this enquiry, it may be not improper to take some notice of those two other disorders of the same quality, which were excluded from our definition of Madness, viz. preternatural Anxiety or Sensation too greatly excited by real objects, and its contrary Insensibility or Sensation not sufficiently excited by real objects, tho' acing with their usual force and tho' capable of engaging the attention of all other healthy animals of the same Species.

For, although Madness in its proper sense be clearly distinct from the too lively or the too lan-guid perception of things really existing, it how-ever very often is preceded by or accompanied with the first and as often terminates in the fe-cund of these two disorders. Befides the being too much affected by external impulse, tho' it

F does

34

does by no means imply Sensation materially delusive, inasmuch as the ideas excited by filch im-pulfe are referred to true and correfponding ob-jeds ; yet the quantity of concomitant affection not being proportionate and therefore not in all reSpects correfponding to the natural quantity of its real cause hath apparently some deviation from absolute truth, and from the natural and usual circumstances of this animal function. And Sensation not proportionate to real impulse, tho' it is not strictly speaking delusive, hath however as great a deviation from absolute truth as excessive Sensation itself.

Now Sensation, which in its most natural and perfect state is sooner or later attended with some degree of uneasiness, may with very little addition be heightened into Anxiety either by the too great or too long continued force of external ob-jects, or by the illconditioned Rate of the nerve itlelf, whereby it is rendered liable to be too much affeded with the usual action of such ex-ternal objects.

This illconditioned Rate of the nerve may be inhaerent in the internal proper and unknown constitution of the medullary substance, or it may be external to that substance, and arise from the loss or defed of thole membranes which en- velope

[35]

and sheathe the seat of Sensation, and are designed to protect it from such rude attacks and impreflions as might otherwife endanger the dif-solution of so loft a matter.

For, whenever those integuments are quite re-moved from a nerve which is endued with no more than a common share of fensibility, An-xiety must enfue the application of any external objects that are capable of exciting natural Sensation. And in fad we find that the laying bare any sensible part and exposing it to the common air, which usually refreshes the body whilst cloathed with 'kin, immediately distrads us with intolerable torment.

For the same reason Anxiety, which follows an entire removal of the nervous sheaths, will in some degree arise whenever those sheaths are not strong and sufficiently compacted so as to answer the purpose of defence. That is the sensation of the nervous or medullary fibres, tho' they con-tinue the same, will be in a reverse proportion to the cohesion of those minute particles which constitute the solid and elastic fibres. And in fact we find that Anxiety is almost always the consequence of morbid laxity, except where the intervention of fat, lymph, or vifcid congestions

F 2 owing

[ 36 I

owing to such laxity subsiitute an occasional de-fence.

No wonder is it then that the straining or loosening the solid parts of human bodies should frequently render those bodies liable to be violently affected by such objects as are scarce felt or attended to by other men, who enjoy a natural or artificial strength and compactness of fibres.

And from hence we are enabled to annex a true and intelligible meaning to that expression before taken notice of, viz. weakness of nerves. Which word weakness would not have been so improper, if it had been joined in idea not to that substance which is strictly nervous, but to its integuments and contiguous membranes; and if laxity, an accidental and remote cause of excessive and therefore uneasy Sensation, had not been thereby made liable to be mistaken for its immediate necessary and sufficient cause.

Whatever may be the cause of Anxiety, it chiefly discovers itself by that agonizing impatience observable in some men of black November days, of easterly winds, of heat, cold, damps, etc. Which real misery of theirs is sometimes derided by duller mortals as whimsical affectation.

And

[37]

And of the same nature are the perpetual tempests of love, hatred, and other turbulent passions provoked by nothing or at most by very trifles. In which state of habitual diseases many drag on their wretched lives ; whilst others, unequal to evils of which they see no remedy but death, rashly resolve to end them at any rate. Which very frequent case of suicide, though generally ascribed to Lunacy by the verdict of a good-natured Jury, except where the deceased hath not left assets, are no more entitled to the benefit of passing for pardonable acts of madness, than he who deliberately has killed the man he hated deserves to be acquitted as not knowing what he did.

Among the morbid effects of Anxiety or the praeternatural excess of Sensation one, which frequently attends upon it and more particularly demands our attention, is Spasm or the praeternatural excels of muscular adion. Which state of morbid motion, tho' sometimes salutary as has been before observed, is often occasioned by this nervous disorder to no good purpose whatever ; and, when very violent or of long continuance, is necessarily productive of numberless evils and of acute and chronical distempers, which if not relieved in time almost always end in death.

[38]

Another area of Anxiety or of the preternatural excess of Sensation is the nervous disorder directly contrary to it, viz. Insensibility, that is a prxternatural defect or total loss of Sensation.

Whether this entire change from one extreme to the other is owing to the material instruments of Sensation having been strained by Anxiety or rather by some of its causes, cannot perhaps, be determined with any degree Of certainty. But thus much is clear in reason that any distraction, which is sufficient to disunite or break in pieces the medullary substance, must be sufficient to make it unfit for its function ; and it is as undeniable in fact that Anxiety is frequently either attended with such spasmodic disorders or occasioned by such external injuries as must necessarily distract the nerves thereby affected.

Not that Insensibility is owing to no other cause except Anxiety. For it is at least as often occasioned by the internal and unknown con-stitution of the nervous or medullary fulastance itself, which was either formed impellect at first or bath since degenerated.

[39]

And, besides the internal and unknown defect in the seat of Sensation, Insensibility may as often be ascribed to another cause external to the nerve and sufficiently understood. For, since the nervous integuments or neighbouring membranes do sheathe the medullary subslance, and thereby prevent the morbid excess of its energy ; whenever the fibres that compote those integuments or membranes are preternaturally compacted and of too close a texture, instead of moderating they undoubtedly mutt deaden or destroy Sensation. And for the same reason those nerves that are pillowed with fat, foaked in lymph, or Rifled by obstructed vessels, cannot and in fad do not receive a proper that is a fen-fible impulse from external objects, altho' such objects are rightly and forcibly applied, and al-though the nervous substance itself is perfectly found, and in its internal constitution sitted for the efficacious reception of such external impulse.

But, whatever may be the cause of Infenfibility, its ill effects are many and as obvious as they are unavoidable, and need not be here enumerated. For they are all those disorders in the animal economy, which Sensation in its natural vigour was designed to prevent. The

[40)

defect therefore or loss of this salutary and vital quality must either hurry on or fuller the sickly body to approach nearer and nearer to the laD period of animal life.

VII The Causes of Madness

Whoever is satisfied with our account of the seat and causes of natural and true Sensation, will acknowledge that the one immediate necessary and sufficient cause of the preternatural and false perception of objects, which either do not exist, or which do not in this instance excite such sensation, must be some disorder of that substance which is medullary and strictly nervous. And moreover, as he cannot discover the natural and internal constitution of this medullary substance, which renders it fit for the proper perception of real and external impulse or rather of the ideas thereby excited; he must for the same reason own that he is unable to discover wherein consists that preternatural [above or beyond the normal course of nature] and internal state of the same nervous matter, which disposes it to be without any such impulse affected by those very ideas, that would have been presented to the imagination, if the same nervous matter had been acted upon by something external. Or, to speak more technically, forasmuch as the one immediate necessary and sufficient cause of the perception of real objects is unknown, we must likewise remain entirely ignorant of the one immediate necessary and sufficient cause of the perception of Chimaeras, which exist no where except in the brain of a Madman.

But, altho' the immediate and internal cause of delusive as well as of true Sensation is absolutely hid, many remoter and external causes thereof frequently discover themselves to the by-stander, notwithstanding that the idea thus excited is not by the patient himself referred to any one of those true causes, but to something else, which may or may not exist, and which certainly does not in this particular case act upon the affected organ.

Thus, to instance in a very common accident, the eye that is violently struck immediately sees flames flash before it; which idea of fire presented to the imagination plainly shews that those material particles which constitute the medullary substance of the optic nerve are affected by such blow exactly in the same manner, as they are when real fire acts upon the eye of a man awake and in his senses with force sufficient to provoke his attention. Thus variety of sounds disturb the ear that is shocked by the pulsation of vessels, by the inflammation or other obstruction of those membranes which line the meatus auditorius, by the intrusion of water, and in short by any material force external to the medullary portion of the seventh pair of nerves; which force hath no connection with any sonorous body, that by its elastic vibration communicates an undulatory motion to the intermediate air.

Now suppose that any one perfectly awake without the accident of such a blow sees fire, or without the pulsation of vessels, inflammation, or any obstruction in the meatus auditorius, ctc. hears sounds; or suppose that the idea of flame really excited by a blow is by him referred to an house on fire, or the idea of sound excited by the pulsation of vessels, ctc. is referred to a musical instrument, which is not near enough to be heard, or is not really played upon; the man who is so mistaken, and who cannot be set right either upon his own recollection or the information of those about him, is in the apprehension of all sober persons a Lunatic.

From whence we may collect that Madness with respect to its cause is distinguishable into two species. The first is solely owing to an internal disorder of the nervous substance: the second is likewise owing to the same nervous substance being indeed in like manner disordered, but disordered ab extra [from outside]; and therefore is chiefly to be attributed to some remote and accidental cause. The first species, until a better name can be found, may be called Original, the second may be called Consequential Madness.

The internal disorder of the medullary substance, or the cause of Original Madness, for the same reason as the immediate necessary and sufficient cause of true Sensation, can be but one : but the external and accidental causes of Confequential Madness, as well as of true Sensation, may be many.

Now no external cause whatever can be supposed capable of exciting delusive any more than true perception, except such cause aas materially upon the nerve thereby disordered, and that with force sufficient to alter the former arrange-ment of its medullary particles. Which force necessarily implies impulse and pressure in cielu-five Sensation, in the same manner and order as it does in the perception of objects really corref-ponding thereto.

Pressure therefore amongst all the external and discoverable causes of false as well as of true perception is in our apprehension the nearest to such its apparent effect. As to the intermediate alterations

145

of the medullary substance, that may really precede delusive Sensation, they are all as much unknown as are the nervous effects which intervene between the pressure made by any external objet and the true and adequate idea of that very object.

But, altho' Consequential Madness cannot be supposed without some sort and degree of pressure upon the nerves, nevertheless every sort and degree of pressure does not always and unavoidably produce Consequential Madness. For the nerves may suffer external impulse, and yet the pressure thereby occasioned either may not have force sufficient to excite any idea at all ; or it may act with too great a force and in so shocking a manner as to dissolve or greatly difunite the medullary matter ; in which case Sensation, which can never exist but whilll that matter does properly cohere, instead of being perverted will be abolished, or at least fuspended untill the con= stituent particles are reunited.

What this particular fort and degree of pref- fure is, which is capable of creating delusive Sen- fation, we are not able to afcertain ; because the different circumstances of the unknown fubject aced upon will make-the nervous effects variable and oftentimes contrary, notvvithsianding the ac- tion

[46]

of the known cause considered per fi is in all refpe1s the same.

But, altho' we cannot exaaly defcribe the particular flrength of that external impulse which excites, any more than we can discover why it excites delusive ideas ; thus much we may reasonably conclude in general that all material ob-jects, which by their action or refinance occasion a sufficient but not too great a pressure upon the medullary substance contained in the nerves, may be the remoter causes of Consequential Madness.

Which conclufion is not only agreeable to reason, but is moreover confirmed by matter of fact and almost every day's experience. Witness the internal exostofes of the cranium, the indu-rations of the finus's and processes of the Dura Mater, which have frequently been found in those who died mad ; witness the intrapression of the skull or concusfion of the head, which if not apciplectic is almost always attended with a delirium. And indeed every one, who contem-plates several case of Consequential Madness and those accidents which precede the same, will find that pressure of the medullary substance somewhere or other collected intervenes between such accidents and these their delirious effects.

[47]

One case of Consequential Madness that proves the intervention of such pressure is an etrect of Infolation or what the French call coup du soleil. An instance of which I lately met with in a Sailor, who became raving mad in a moment while the Sun beams darted perpendicularly upon his head. Which maniacal effect of heat could be attributed to no assignable cause, except either to the violent impression of the Sun's rays, upon the medullary substance of the brain, which the cranium in this case was not able to defend, or to the intermediate rarefaction of blood contained in the vessels of the Dura or Pia Mater, which vessels being suddenly distended compressed the same medullary substance. Of the same nature and owing to the same rarefaction of fluids in the brain are those delirious fevers called Calentures ; one of which was, I suppose, mistaken for the plague by the Author [Dr. Dover] of the Physicians laft Le-gacy, and treated with bleeding ufque ad aniini deliquium, which indeed is its only cure.

:

[ 48

Another case of Consequential Madness is a sudden inflammation arising in those membranes which surround and therefore when thus distended compress the contents of the cranium and its nervous appendages. This Esate of inflammation whilst the patient lives discovers itself by the sudden redness of the eyes external coat, which is a part or rather a production of the Dura Mater : and that membrane after death is frequently upon dissection found turgid and difcoloured with a red bloody suffufion, just in the same manner as if it had been artificially injected.

Another case of Consequential Madness is a gradual congestion of ferum or other fluid mat-ter upon the same membranes which envelop the medullary fubftance ; whereby those membranes, tho' not with equal danger as when they are fud,-7 denly inflamed, yet with the same delirious ef-fects compress their nervous contents. This fe-rous congestion is discoverable by the opaque and cloudy appearance of the cornea, for the same reason as an inflammatory tumor in the Dura Mater is betrayed by the external coat of the eye being tinged with blood.

Pressure of the medullary substance, the nearest in our apprehension to Madness of all its known and remoter causes, most frequently and most effectually produces this its nervous effect, whilst it acts upon the contents of the cranium, as is evident from the case above-mentioned. But, altho' the brain is undoubtedly the principal seat of delusive sensation, nevertheless it is not

c 49

the only one : forafmuch as the same fangui-nary or ferous obflrudions are capable in any other nervous part of the body of exciting false ideas as well as in the brain, at lean to some degree and in proportion to the quantity of medullary matter there collected so as to be sufficiently compressed by such obstructions. Thus the stomach, intestines, and uterus, are frequently the real seats of Madness, occasioned by the contents of these viscera being slopped in such a manner as to compress the many nervous filaments, which here communicate with one another by the mesenteric ganglia, and which enrich the contents of the abdomen with a more exquisite sensation. Thus the glutton who goes to bed upon a full stomach is hagridden [torment] in his sleep. Thus Men prove with child as powerful fancy works: And patients truly hypochondriacal or hysterical refer that load of uneasiness they feel in their bellies to some imaginary object, which if it really existed and ailed upon their senses would excite the very same idea.

p 50

SECT. VIII. The causes of Madness

FOrafmuch as prxternatural pressure upon the nerves is in human apprehension the nearest to delusive sensation thereby excited ; whatever injury creates such pressure must be a remoter cause of Consequential Madness.

Under this head therefore of remoter causes are to be ranked the internal exostoses of the cranium, the induration of the Dura Mater, the fracture and intropression of the skull and concussion of the head, as also, if it were of any service in the cure of madness to enumerate them, the many and various accidents these delirious injuries may be owing to.

To the same number of remoter causes we must add morbid distensions of the vessels contiguous to the medullary fubflance. And, as several case mentioned in the foregoing section are clearly refolvable into such distenfions, whole re-moval or diminution will frequently be sufficient to answer our intention and is almost always ne-cefftry and serviceable in the cure of this distemper; it may be of use to spend a little time in examining into the nature and origin of those vascular distensions which end in Consequential Madness.

Whoever has attended to the accidents that animal bodies are liable to must have observed that several membranes, which in their natural state appear smooth and even, are sometimes suddenly at other times gradually elevated beyond the surface or plane they before helped; to compose. To the first of these two case wri-ters on Surgery have given the name-of Tumors by Fluxion, to the second that of rumors by Congeflion thereby ascribing the quick or slow ap-pearance of these fwellings to the different mo-tion of the fluids themselves, which materially formed them, and which according to the me-dical philofophy then in fashion contained all the refources of life health and sickness.

Now, altho' the discovery of the blood's cir-culation hath demonstrated that the fluids are paffive in every circumstance of animal life whe-ther found or distempered, it will however be very useful in profecuting the present enquiry to take into our account the case themElves as dif-tingislaed from one another by their different manner of appearance which cannot be contro-

H 2 verted,

[ 52 ]

verted, and then endeavour to afsign other reasons for such their appearance, which not only really exist, but which also are sufficient to pro-duce either Species of tumor.

Tumors then by Fluxion ending in Madness are either vessels distended by the rarefaaion of their proper and natural contents, as in the case of Infolation ; or, which is the most frequent ac- cident, they are the same vessels obstructed by the sudden intrufion of improper fluids into finaller canals which were never designed to give either a pasrage or admittance to such contents, as in the case of Inslammation. Now this change of place and forcible propulsion of :fluids from their natural ducts into improper receptacles must apparently be owing to some power external to the fluids so propelled, which power either was not excited or did not effectually act the moment before filch delirious obstructions took place. But the spasmodic constridion of those muscular fi- bres which furround the extremities of arteries and veins, and are at res} till rusfled by some ac,-, cident, is a power occasionally excited, and when ailing with sufficient force is capable of driving the blood out of its natural channels into vessels not originally fitted for its reception. And it is moreover a repeated observation that Madness frequently succeeds or accompanies Fever, Epilepfy, Child-birth, and the like muscular disorders ; and that the tumultuous and visibly spasmodic passions of joy and anger are all at least for a time maniacal. But these passions constringe the muscles of the head and neck, and therefore like a ligature force the blood that was descending in the jugular veins back upon the minutest vessels of the brain. Spasm therefore, when it is productive of tumors by Fluxion or of sudden distensions in the vessels contiguous to the nervous substance,, as also spasmodic passions such as joy and anger are to be reckoned amongst the remoter causes of Madness. Not but that the same muscular constric-tion is often excited by the application of several external objets ; which objects are therefore to be added to the same class. For befides the ma-ny well attested case of poifons or medicines, which as soon as fwallowed convulfe the body and intoxicate the understanding, such as Hem-loc, and the root lately mistaken for Gentian, filch as Opium when administered to some par-ticular patients, eec. The many bottle-companions whole pulses beat high and quick, whose faces are flushed with blood in the same manner as if they were strangled, who are first wild and then stupid, who drink till they fee double, and then drink on till they cannot fee at all, as well as the crowds of wretches that infest our streets and fill our hospitals, evidently prove to the vulgar as well as to the Physician that vinous spirits inflantaneously provoke an irregular action of the muscles succeeded by temporary delirium ; and that, if the same noxious draughts are taken in too large doses or frequently repeated, they be-come a very common tho' remoter cause of continual madness.

If any one rather supposes that such external objects, which produce Madness, act immediately upon the nerves thereby affected, and that spasm, tho' an undoubted effect of the same objects, is the companion and not the intervening cause of their delirious effect : However probable the contrary opinion may fill appear to those, who consider that spasm never fails to precede or to accompany the nervous disorders subsequent to such application, and moreover that spasm is sufficient to produce maniacal symptoms ; nevertheless the nearest known cause of Madness re- mains exactly the same, and these external objects are fill to be reckoned among its remoter causes, which ever opinion is the more probable. Since it is impossible for any one of them to act at all upon the nerves without motion impulse and pressure in the same manner and order, as if they had previously occasioned muscular constriction

[ 55

friction and vascular obstruCtion its most usual effect.

As for Tumors by Congestion ending in Madness, that is to say those loads of fluids which gradually overcharge the vessels contiguous to the nerves, and by compressing a sufficient quantity of medullary matter create delusive sensation as effectually as does inflammation or any sudden distension of the same vessels : such gradual or chronical congestions are frequently, tho' not al-ways, an effect of a very different fort of muscular constriction, easily distinguishable from the former by its manner of invasion and continuance. For this spasmodic action of the muscular fibres is very gentle at first, and so far from alarming either the patient or his friends, that for Tome time it is very little attended to or even discernable. But what it wants in violence is more than made up by its obstinate duration and encreafe : inasmuch as it seldom remits, and is with great difficulty relieved by art. This Species therefore of spasm must likewise be added to the remoter causes of Consequential Madness.

[ 56

To such constant muscular constriction, and to the gradual or chronical congestions in the brain or mefenteric vifcera thereby occasioned, the despairing bigot, incapable in his own apprehension of being pardoned by infinite mercy, or predefined by infinite justice to eternal misery before he had a being, the moping lover, the motionless widow or mother bereft of her children, may at fiat view be afcribed. Who all wear contractae feria frontis, and discover the fixed muscular marks of passions flower indeed in their operation than the turbulent forms of joy or anger, but which in consequence of pref-lure upon the nerves are as much the remoter causes of Madness, and indeed sooner or later are as destructive to every animal power.

The same Tumors by Congestion, capable with intervening pressure of creating Consequen-tial Madness, are indeed oftentimes an eifea of laxity in the overloaded vessels themselves. But even this weakness, if traced to its original, will frequently be found owing to one of the two aforementioned Species of muscular conflridion.

To such vascular laxity arising from muscular spasm may be referred the many instances of Madness occasioned by praemature, excesfive, or unnatural Venery, by Gonorhceas ill cured with loads of Mercury and irritating Salts, by fevers, and other such like convulsive tumults. And from hence we may account for the chimaerical dreams

57 3

dreams of infirm and shattered Philofophers, who after having fpent many days and nights without cloling their eyes in unwearied endea-vours to reconcile metaphysical contradictions, to fquare the circle, to discover the Longitude or grand Secret, have at WI fallen half afleep, and who by excesfive attention of body have strained every animal fibre, and may without a metaphor be faid to have cracked their brains.

But, altho' laxity arising from spasm is most commonly the cause of gradual obstruelions end-ing in delusive Sensation, nevertheless the same delirious tumors by Congeslion, more eSpecially thole that act upon the nervous matter contain-ed in the abdomen, are formed sometimes without laxity or any fpafinodic disorder whatever, either by excess of eating or by defect of voluntary motion : which motion is just as necessary to a due propulsion of the fluids thro' the uterine and hemorrhoidal vessels, and thro' the many and intricate ramisications of the vena porta', as is the action of the heart or the refilition of the vessels themselves. Gluttony therefore and idleness are both to be added to the remoter causes of Consequential Madness. To the first [Gluttony] is owing the meagrim of the Epicure [inclined to pleasure]. To the second [idleness, sloth, laziness], perhaps more than to a spirit of lying, may be ascribed the temptations of St. Anthony and the lazy Monks his followers, the ecstasies of sedentary [slow paced life] and chlorotic [iron-deficiency anemia, primarily of young women, characterized by a greenish-yellow discoloration of the skin. Also called greensickness] Nuns, and their frequent conversations with Angelic ministers of grace. Not to mention what now and then happens to the senior Recluses in our Protestant Monasteries at Oxford and Cambridge.

SECT.

[ 59

SECT. IX.

The Diagnollic Signs of Original and Colfepen- tial Madness ; and the PrognoJlic al-Ong there-from.

AVIN G in the two preceding Sections discovered most of the causes of Madness that deserve our attention, and thereby divided this disorder into two Species, viz. Original and Consequential : It will be ne-cessary to mention some particular circumslances attending either Species, which will enable the Physician not only to diftinguish Original Madness from Consequential, but also the better to fettle his prognostic and method of cure.

First then, there is some reason to fear that Madness is Original, when it neither follows nor accompanies any accident, which may justly be deemed its external and remoter cause.

Secondly, there is more reason to fear that, whenever this disorder is hereditary, it is Ori-ginal. For, altho' even in such case it may now and then be excited by some external and known cause, yet the striking oddities that characterife

[ 6o ]

whole families derived from Lunatic ancestors, and the frequent breaking forth of real Madness in the offspring of such illconcerted alliances, and that from little or no provocation, strongly intimate that the nerves or instruments of Sensation in such persons are not originally formed perfea and like the nerves of other men.

Thirdly, we may with the greatct degree of probability asfirm that Madness is Original, when it both ceafes and appears afrefh without any af-signable cause. For, although we cannot guess why this difeafe of the nerves is ever relieved without the real assistance of art, or why it at-tacks the patient again without any new provo-cation, any more than we can account for the fpontaneous intermisfion of convulsion, fever, head-ach, and such like spasmodic disorders of the mufcles ; it is however impossible that any one effect whatever can perfecly ceafe, so long as that cause which was capable of producing it continues to act upon the same fubjet and in the same manner. And it is as impofTible that the effect of any action can after a total difcon-tinuance arise again, without its being regenerat-ed by the same or at least by a fimilar aaion. Therefore that disorder, be it muscular or ner-vous, be it convulsion or Madness, which fpon-taneoufly ceafes and as fpontaneoufly invades

again,

[ 61

again, cannot be consequential to any external cause, which always exisis, and whole anion al-ways continueth the same.

Original Madness, whether it hereditary or intermitting, is not removable by any method, which the science of Physick in its present im-perfect Efate is able to suggest.

But, altho' Original Madness is never radically cured by human art, its illconditioned fate is however a little recompenfed sometimes by a per- fect recovery, sometimes by long intervals of fa-nity, without our Alstance and beyond our ex-pectation. Befides Original Madness is in itself very little prejudicial to animal life. For it is. notorious that men really mad live as long as those who are perfecly in their fenle:: ; and, whenever they sicken or die, they like other mortals are most frequently attacked by illnesses, which have no necesiary connection with or de-pendance upon their old complaint of false per-

ception.

Madness, which is consequential to other dif- orders or external causes, altho' it now and then admits of relief by the removal or correCtion of such disorders or causes ; yet in proportion to the force and continued anon of such causes, and according

[ 62

according to the circumstances of the preceding disorders, it is very often complicated with ma-ny other ill effects of those causes and disorders ; and, tho' it may not in itself be prejudicial to bodily health, any more than Original Madness, yet by its companions it becomes fatal or greatly detrimental to animal life.

Madness, tho' it may be Consequential at first, frequently becomes habitual and in ellect the very same as Madness strictly Original. In which case the internal frame and constitution of the nervous substance retains that ill difpofition which was communicated to it ab extra, even after that the cause of such communication is quite re-moved or ceafes to act : And the same subslance, tho' formed originally as perfect as that of other men, yet by the continual and forcible action of such external cause is at last essentially vitiated in the same manner and to as great a degree, as if it had been created impeded and of itself ca-pable of exciting delusive sensation.

When internal exostoses of the cranium, or induration of the Dura Mater are the causes of Consequential Madness, each of these case is apparently incurable by art. Fracture or intro-pression of the cranium, and concuffion of the head, or rather its effects, tho' very dangerous

[ 63 I

and difficult to be managed, have sometimes been relieved.

When Insolation by the intervening rarefaction of the blood contained in the brain produces delirium, this its mischievous effect frequently yields to the lancet, if not too late or too sparingly applied. But if Madness is the more immediate consequence of the Sun's anion upon the nervous substance, and if, however occasioned it is from want of care or from obstinacy of the case pro- tracted after that the piercing darts of heat its remoter cause are quite abated, it is generally of long duration and very often incurable : for-afmuch as the medullary portion of the brain is either (hocked by the continued distenfion of the contiguous vessels, or is disiraded by the fiery impression in such a manner that its constituent particles are quite deranged from that order, which is necessary to the performing their natu-ral functions in a proper manner.

Madness consequential to the inflammation of those membranes that furround the brain is very dangerous : because such obstruction is formed in minute vessels which lie out of our reach, and which cannot be soon enough relieved by the moll plentiful evacuation ; nor can the brain thus overcharged endure any additional (hock of

[ 64

errhines, vomits, or rough purges : Since spasm thereby excited would either endanger a rupture of the distended vessels, or heighten the delirious pressure up to Apoplexy, or convert the inflam-matory matter into mortification.

And indeed this 'late of Madness, called Phrenzy, let the Physician act ever so fkilfully, frequently ends in one or other of the two laft mentioned case. The first of which is plainly threatened by stupidity succeeding to delirium ; and mortification of the brain may be declared coming on, or rather formed, when the mania-cal symptoms ceafe without any apparent reason, and when the patient who was raving be-comes calm and sensible in an infant ; whilft greater debility and a pulfe hardly perceivable, together with coldness in the extremities, foretell that this unexpeected recovery of the understand-ing, however it may flatter, will be fatal.

Madness consequential to a gradual or chroni-cal congestion of fluids frequently admits of re-leif, if applied in time. And such congestion is leis dangerous and more easily removed when-ever the mefenteric nerves alone are thereby af-feected ; inasmuch as every difficulty and danger that attends any injury must be less the fewer those nerves are that fuller the same.

When

[6s3

When spasm is productive of obstructions upon the brain and nerves, and in this case becomes a-nother and a fill remoter cause of Consequential Madness, if such spasm is suddenly excited either by the tumultuous passions of joy and anger, or by intoxicating drugs and vinous spirits, it is indeed very violent and oftentimes fatal by its immediate effects. But in case the patient is ca-pable of bearing the first shock, and has not been weakened by frequent attacks of the same nature ; such sudden and irregular action of the mufcles together with all its phrenetic or mania-cal consequences is much sooner either fpontane-oufly abated or relieved by art, than the gradual and continued muscular constriction, which is occasioned by the more gentle pail-ions of love grief and despair, or by long and uninterrupted attention to any one object however pleafing and agreeable. For Madness consequential to such obstinate muscular constriction must be as obsti-nate as its cause: and befides in this case of con-tinual or increafed congestion, there is great reason to fear leaf the internal frame of the nervous substance itfeif may at last be essentially vitiated ; and Madness which is habitual or of the same nature with that which is Original may succeed, and take the place of what at first was only Consequential.

K Laxity,

[66]

Laxity, whenever it intervenes between spasm and delirious pressure and thereby becomes a remoter cause of Consequential Madness, admits of cure if timely and properly applied ; and very often the weakened membranes spontaneously recover their former elastic tone, provided the spasmodic impulse is abated, before their constituent fibres are distracted beyond that natural tendency to approximation which was originally implanted in them.

Madness consequential to gradual or chronical congestions occasioned by gluttony or idleness easily yields to medical care, if seasonably and properly applied.

Madness consequential to or accompanied with other disorders affords no particular prognostic, but what arises from those disorders when considered as primary distempers distinct and separate from Madness itself.

[67J

nal integuments which were given to the ner-vous substance for its defence, in such case An-xiety however afflicting promifes better success.

Insensibility or Ideotifm, when it arises from an internal and constitutional defect of the or-gans designed to excite sensation, or when it is a symptom or consequence of Original Madness, like Original Madness and for the same reason must be pronounced incurable by art. But, what is very remarkable and much to be lamented, when Insensibility is the effecte of Consequential Madness, or when it may be attributed to the pr2eternatural clofeness and rigidity of the ner-vous integuments, or to obstructions in the con-tiguous vessels ; tho' it may Teem as curable as Consequential Anxiety, yet in fact (whatever is the reason of the difference) it is very seldom re-lieved either by art or Nature.

Anxiety, when it arises from some fault in- ctwing in the internal frame and constitution of the nervous substance, which is thereby rendered too sensible, like Original Madness and for the same reason is not radically curable. But when its only cause is a laxity or defect of those exter-

nal

K2 SECT.

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SECT. X.

B. The Regimen and Cure of Madness.

The Regimen in this is perhaps of more importance than in any distemper. It was the saying of a very eminent practitioner in such cases that management did much more than medicine; and repeated experience has convinced me that confinement alone is oftentimes sufficient, but always so necessary, that without it every method hitherto devised for the cure of Madness would be ineffectual.

Madness then, considered as delusive Sensation unconnected with any other symptom, requires the patient's being removed from all objects that act forcibly upon the nerves, and excite too lively a perception of things, more especially from such objects as are the known causes of his disorder; for the same reason as rest is recommended to bodies fatigued, and the not attempting to walk when the ankles are strained.

The visits therefore of affecting friends as well as enemies, and the impertinent curiosity of those, who think it pastime to converse with Madmen and to play upon their passions, ought strictly to be forbidden.

On the same account the place of confinement should be at some distance from home: and, let him be where he will, none of his own servants should be suffered to wait upon him. For all persons, whom he may think he hath his accustomed right to command, if they disobey his extravagant orders will probably ruffle him to the highest pitch of fury, or if they comply will suffer him to continue in a distracted and irresolute state of mind, and will leave him to the mercy of various passions, any one of which when unrestrained is oftentimes more than sufficient to hurry a sober man out of his senses.

Every unruly appetite must be checked, every fixed imagination must if possible be diverted. The patient's body and place of residence is carefully to be kept clean: the air he breaths should be dry and free from noisom steams: his food easy of digestion and simple, neither spirituous, nor high seasoned and full of poignancy: his amusements not too engaging nor too long continued, but rendered more agreeable by a well timed variety. Lastly his employment should be about such things as are rather indifferent, and which approach the nearest to an intermediate state (if such there be) between pleasure and anxiety.

As to the cure of Madness, this like the cure of any other disease consists, 1. In removing or correcting its causes: 2. In removing or correcting its symptoms: 3. In preventing, removing, or correcting its ill effects.

These three intentions are to be answered either by general and rational science; or, if that is wanting, by particular experience alone collected from plain and similar facts, which the history of practice supplies us with.

Original Madness indeed deserves our first attention, as it is the least complicated with any other disorder. But a very little reflection will serve to convince that all our consideration will never enable us to treat this first species of Madness in a rational manner. For it is impossible by any thing like judgment or previous design to answer the first intention, viz. to remove the immediate necessary and sufficient cause of Madness, which cause lies out of the reach even of our imagination....

And as to the second and third intentions, they in Original Madness are as little to be answered as the first. But that is not because either the symptoms or the ill effects of Original Madness lye out of our reach, or their causes are unknown; but because Original Madness when considered per se is not accompanied with any symptoms or succeeded by any effects, which if not prevented removed or corrected would endanger the life or health of the patient .

Nor does experience, which oftentimes supplies the defer of rational intention in many disorders that are hitherto inexplicable by general science and the common laws of Nature, furnish us with any well attested remedy for Original Madness. For, altho' several Specific Medicines have by the merciful direction of Providence been of late successfully applied in some distempers otherwise incurable by art, such as Mercury in the Venereal infection, Opium in pain and watch-fullness, the Peruvian Bark in mortification intermittent fevers and many other complaints ; and altho' we may have reason to hope that the peculiar antidote of Madness is reserved in Nature's store, and will he brought to light in its appointed time ; yet such is our present misfortune, that either this important secret hath been by its inventors withheld from the rest of man-kind, or, which is more probable, hath never yet been discovered.

[72]

Since therefore the first species of [Original] Madness is incurable by any remedy which reason or experience suggests, let us divert our attention to the second species: And here to our great comfort we shall find that Consequential Madness is frequently manageable by human art.

For, altho' delusive Sensation, by whatever external accident it may be occasioned, when considered as a distempered state of the nerves themselves, admits of no rational or specific relief any more than Madness which is not consequential to any known cause; nevertheless the previous disorders and external causes of delusive Sensation are frequently within our reach. And this, as well as any other morbid effect, may in reason be and in fact often is prevented or abated; provided the known cause is taken care of in time, that is before its continued action hath altered the nervous substance to such a degree as to have rendered it essentially or habitually unsound.

Now, forasmuch as pressure of the nervous or medullary substance amongst all the known and external causes of Consequential Madness appears the nearest to its delirious effect, and indeed so necessary a cause, that without its intervention nothing external can be supposed capable of exciting delusive Sensation, this cause therefore must be the first object of our care.

In the next place our endeavours are to be employed in preventing removing or weakning those other external accidents before enumerated, which by occasioning intermediate pressure are the remoter causes of Consequential Madness.

Delirious pressure of the brain or medullary substance contained in the nerves, which is the nearest of all the known causes of Madness and therefore demands our first attention, is incapable of being effectually relieved, except the compressing matter itself be lessened, diverted, or dislodged from the part affected: or, to speak technically, the chief intentions under this first article are 1. Depletion; 2. Revulsion; 3. Removal; 4. Expulsion.

Not that all these intentions are to be answered in all cases and circumstances of delirious pressure. For when internal exostoses, induration of the Dura Mater [brain matter], fracture intropression and concussion of the head occasion such pressure, Removal (which indeed intropression does now and then admit) is apparently impracticable. Nor can Expulsion in any one of these cases, or indeed in any oppression of the brain that is similar to tumor by Fluxion, be attempted without imminent danger to the patient's life.

But the two first intentions are almost always to be pursued; and delirious pressure of the brain or medullary substance contained in the nerves demand Depletion and Revulsion, let its remoter causes or circumstances be what they will. For, tho' neither of these intentions propose the removal of exostoses or any one accident just now mentioned, yet unloading the vessels contiguous to the brain or nerves, which are thereby aggrieved, will certainly in all cases prevent or lessen the delirious effect. And, if the pressure arises solely from the distension of the vessels themselves, Depletion and Revulsion are apparently the apposite and necessary methods of relief.

When pressure of the brain or nerves is sudden, both these intentions may safely and effectually be answered by the lancet and cupping-glass again and again repeated in proportion to the strength of the patient and the greatness of the pressure; by neutral salts, which gently stimulating the intestines and sensible parts contained in the abdomen provoke stools and urine: of this sort are Nitre, Sal Catharticus amarus, Magnesia alba, Tartar, and all its preparations, more especially the Sal Diureticus deservedly recommended by Dr. Mead in Maniacal cases. And Revulsion in particular may be successfully attempted by the oily and penetrating steams arising from skins and other soft parts of animals newly slain, by tepid fomentations and cataplasms applied to the head legs and feet, by oily and emollient glysters; which are of very great service not only as they empty the belly, but also and indeed chiefly because they serve as a fomentation to the intestinal tube, and by relaxing the branches of the aorta descendens, which are here distributed in great number, make it more capable of receiving the blood; which will therefore according to the known course of fluid matter be diverted from the head.

The same intentions of Depletion and Revulsion seem indeed to recommend sinapisms [ointment made of mustard], caustics [burn the skin to create blister of clear fluid], errhines [induce sneezing], and vesicatories [induce blisters], as also the rougher cathartics [induce diarrhea], emetics [induce vomiting], and volatile diaphoretics [induce sweat by elevating body temperature]. But when we reflect that a spasmodic constriction is by no means the least amongst the remoter causes of Madness, we shall in every case of sudden pressure be fearful of any powerful irritation that endangers constriction, and that cannot answer either intention unless it previously excites an irregular action of the muscles.

And indeed Phrensy or sudden pressure of the brain attended with inflammation of the containing membranes, and intrusion of blood and serum into improper vessels of the head, not only forbid sinapisms and every powerful irritation, but incline us to be suspicious of cathartic salts in too large doses, and even of Nitre itself, tho' it is reckoned specifically antiphlogistic, and tho' it is successfully administered in many other inflammatory tumors before they suppurate.

Delirious Pressure of the nervous substance contained either in the head or abdomen, when gradual or chronical, tho' it is of a very different nature from sudden pressure, and tho' it is similar to tumor by Congestion, yet in robust and plethoric habits alike indicates Depletion and Revulsion. But, if the subject is either naturally infirm or shattered and exhausted by preceding illness, the lancet must be cautiously used or entirely forbidden; and both these intentions can with safety be answered by nothing except the mildest solutives, such as the neutral salts above-mentioned, Cassia, Manna, ctc. and the Gumms quickened with a few grains of Aloes.

But, when delirious pressure of the nervous substance, more particularly that contained in the abdomen, is gradual or chronical, if such gentle evacuants, tho' often and properly repeated, prove unable to lessen or relieve the stagnating matter, and in case the weakness of the patient does not contraindicate, here the third and fourth intentions take place: and it becomes absolutely necessary to shake with violence the head and hypochondria [abdomen] by convulsing the muscular fibres with emetics rougher purges and errhines. For such spasmodic action communicates a vibrating motion to the solid fibres of the whole body; whereby the overloaded membranes and integuments that compress the contiguous medullary substance remove or expell their morbid contents, and the patient delivered from his delirious incumbrances frequently recovers his former sanity of mind as well as body.

C78]

SECT. XI. The Cure of Madness.

Pressure of the medullary matter contained in the brain and nerves, amongst all the known causes of Madness the nearest to such its delirious effect, and therefore the first objet of our attention, has been considered with regard to such methods of cure as are indicated by reason and justified by experience. In the next place therefore we are to turn our thoughts to those other external accidents, which by occasioning intermediate pre ure are the remoter causes of Consequential Madness.

Now the several remoter causes before enumerated, were

Internal exostoses of the cranium [formation of new bone on the surface of the skull]

Induration of the Dura Mater [a deposit of altered blood pigment, stroke]

Fracture or intropression of the skull and concussion of the head ; [blow to the skull]

Insolation; [measure of solar radiation energy received, exposure to sunlight]

One Species of spasm, or muscular constriction, sudden and impetuous but sooner quieted ; which arises either from

Material objets external to the body, viz. poisons, medicines, and vinous spirits, or from [substance abuse]

Tumultuous passions, viz. joy and anger; [it overworks the nerves]

Another Species of spasm or muscular constriction more gradual and gentle in its attack, but frequently increasing, and almost always obstinate in its duration ; which arises from

Unwearied attention of the mind to one object, or from the quieter passions of love, grief, or despair;

Preternatural laxity of the membranes or vessels contiguous to the nerves;

Gluttony;

Idleness [nerves out of shape due to lack of use like building muscles]

Of all which in their order.

Internal [1] exosloses and [2] induration of the Dura Mater cannot be prevented, nor does either case admit of any particular method of relief. [3] Concussion may itself indeed be sometimes prevented, but its ill effects can never be prevented or removed by any intention except that of Depletion and Revulsion recommended under the first article of cure. In fracture or intropreson of the skull the trepan is peculiarly adapted either to give a vent to, or to remove the extravasated and stagnating fluids.

[4] Infolation is quite out of our power ; but its subject we have to deal with is not always so. For, altho' the fiery darts of heat are not capable of being removed or lessened by human means, the patient may be removed; or, when that cannot easily be done, the head may be secure by a proper integument ; for which purpose a cap of thick paper has been successfully recommended.

p 80

[5] Spasm or muscular constriction, as well the sudden and impetuous as the more gradual and gentle, when considered by its self and as abstracted from irritation or any external cause, admits of no method of cure suggested by rational intention : Forasmuch as the immediate necessary and sufficient cause of muscular action, be it natural or distempered, is absolutely unknown. Whenever therefore nothing external to the muscular fibres can be assigned which is capable of provoking their constriction, we have no hope except in Specific remedies, that is in such drugs, whole antispasmodic virtues experience alone has discovered.

Under this head of antispasmodics every one, I suppose, will readily place Valerian, Castor, the Gumms, and Musk ; and, were I at liberty to indulge a suspicion which has for some time occurred, I should be inclined to add Nitre, the Magnesia, the Sal Diureticus, as also all alkaline substances incorporated with acids, all neutral salts, and all alexipharmacs or diaphoretics : whole sudden efficacy in appealing the paroxysms of feverish disorders which are apparently spasmodic can be attributed to no other known power, but such as hath an immediate influence upon the animal fibres endued with motion. Not that any thing more than conjecture is hereby proposed ; which is to be admitted or not, as the conclusions of others arising from their own just reasoning and experience shall determine.

But, whatever class the virtues of Nitre and neutral salts shall hereafter be ranked under, it may at present with great truth be asserted from observations already made that they are the only Specific helps, which can be depended on with any probability of success or even with safety in fits of Madness attended with fury and violent spasmodic motions. And it is as certain that those other anti-spasmodic drugs which are poignant and irritating, viz. Valerian, Castor, and the gumms, are serviceable and indeed harmless only in the second or gradual and gentler Species of muscular constriction.

Which observations by the way not only serve to distinguish what Specific remedies are proper for either case of spasmodic Madness ; but more over suggest a caution to the Physician in the administering even Nitre and other saline febrifuges in spasmodic disorders whether delirious or not because such sharp bodies when over-dosed or when applied to subjects too susceptible of irritation may sometimes aggravate every symptom they are intended to relieve, and may become as mischievous as those other more poinant anti-spasmodics have frequently proved, when prescribed in all convulsive case under the general and improper title of Nervous Medicines.

p 82

[6] The same caution is likewise highly necessary when spasm is occasioned by the sixth class of remoter causes, viz. poisons, medicines, vinous spirits, or any assignable matter which actually excites an irregular motion of the muscles. For it is almost self-evident that in such case all additional irritation must increase every convulsive effect, and that even the most gentle saline remedies will be hazardous or at best inefficacious, until the material cause of spasm if superficial is removed by chirurgical assistance, if it be in the stomach or intestines until it is discharged by the force of vomits or purges, or if such means of expulsion be thought too violent until the offending matter is sufficiently enervated by diluting and absorbing medicines, or in case of extreme necessity until its effect is prevented or Rifled by narcotics. All which different methods of cure in such Consequential Madness must be left to the sagacity of the Physician ; it being impossible to lay down any general direction in a matter attended with so great a variety of unfore-feen accidents.

p 83

But, though the removal of the sixth class of remoter causes, viz. every irritation which produces Madness, is not always feasible or even safe, and though such terrible effect admits of no relief so long as the material cause continues to ad, nevertheless prevention, at least with regard to vinous spirits, is entirely in our power. For which reason it deserves the serious consideration of our governors, how far it is their duty by a total prohibition of the cause to prevent those frequent effects of temporary but real Lunacy, for which many wretches are executed, who in reality are guilty of debauchery alone, which has been rendered familiar by the custom or rather the convenience of their country, and is allowed or commuted for by the laws of the revenue.

[7] As to the seventh class of remoter causes, viz. tumultuous and spasmodic passions, such as joy and anger, in case the patient is not in immediate danger of his life, nothing of any great consequence is to be done at first; in hopes that these passions and their muscular effects will, as they are frequently known to do, subside of themselves. But, whenever anceps remedium is the indication, after sufficient depletion and diminution of maniacal pressure thereby occasioned, we must have recourse to the Specific, that is to the unaccountably narcotic virtues of the Poppy. And, if notwithslanding this temporary relief any one particular passion seems to engross the man or continues beyond its usual period, in such case the discretion of the Physician must determine how far it may be advisable or safe to stifle it by a contrary passion. I say safe, because it is almost impossible by general reasoning to foretell what will be the effect of fear substituted in the room of anger, or of sorrow immediately succeeding to joy.

[8] The eighth remoter cause of Consequential Madness, viz. Muscular Constriction, gradual, gentler and uniform, but more obstinate, may sometimes be relieved or as it were diverted by convulsion that is by an alternate motion of muscular fibres artificially excited in some other part of the body. On which account vesicatories, vomits, rough cathartics, errhines, and the most poinant among the medicines called nervous, may in this particular case of spasm become even antispasmodic. For, ignorant as we are and perhaps shall always be of the reason, experience has shown that, although many parts of the body may be convulsed together, one Species of spasm however occasioned seldom fails to put an end to that other which before subsisted.

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[9] When the ninth dials of remoter causes demands our care, viz. unwearied attention to any one object, as also love, grief, and despair ; any of these affections will sometimes be annihilated by the tumultuous but less dangerous and sooner subsiding passions of anger or joy. But, if such instantaneous alteration from one extreme to the other appears either not feasible or too shocking to be attempted with safety ; bodily pain may be excited to as good a purpose and without any the least danger. It being a known observation, though as much out of the reach of human reason as are most others which occur in the animal economy, that no two different perceptions can subsist at the same time any more than the two different Species of morbid muscular anion, viz. the convulsive and the constrictive. Therefore vesicatories, caustics, vomits, rough cathartics, and errhines, may be and in fact often are as serviceable in this case of fixed nervous Sensation as in obstinate muscular constriction, inasmuch as they all relieve and divert the mind from its delirious attention, or from the bewitching passions of love, grief; and despair.

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[10] The tenth remoter cause of Consequential Madness, viz. Laxity of those vessels or membranes that are contiguous to the nervous substance, apparently indicates such remedies as have the experienced though unaccountable efficacy of contracting the material particles which constitute an animal body. Of this nature is iron, vitriol, and mineral waters impregnated therewith : but above all, when nothing contraindicates, the bathing in cold or rather sea water.

[11] As to the eleventh and twelfth remoter causes, viz. Gluttony and Idleness, little is requisite for their particular cure : since, after proper evacuations, temperance is undoubtedly the apposite remedy of the one, and bodily exercise of the other. Both which means of present recovery and of prevention for the future may be effectually prescribed to men of either character, at least whilst they are actually mad and properly confined. For the diet of the glutton in such case is absolutely in the Physician's power. And, although it would be no easy talk to persuade or even to force any person, whether a Lunatic or not, who has long indulged in idleness, to put his body in motion ; nevertheless this state of inactivity may be artificially broke through by vomits, rough cathartics, errhines, or any other irritating medicines : which in this case therefore answer more than one intention, and not only discharge or dislodge the delirious load of stagnating fluids, but also by their convulsive influence upon the muscles of the abdomen and indeed upon every animal fibre of the agitated body crowd as it were a great deal of exercise into a small portion of time, and that without the consent of the patient, or even the trouble of contradicting his lazy inclinations.

Section XII The cure of the symptoms and consequences of Madness. And some observations upon the whole.

IT may be recollected that the cure of Madness, as well as of all other distempers, consists in 1. Removing or correcting its causes: 2. Removing or correcting its symptoms: 3. Preventing, removing, or correcting its ill effects.

A method of answering the first intention has been proposed in the two foregoing Sections: the symptoms and ill effects of Madness should therefore be our next care.

But Original Madness, as hath been before observed, is not necessarily accompanied with any symptoms or succeeded by any effects, that are strictly speaking insalubrious [not conducive to good health].

And indeed, with respect to Consequential Madness, whatever may accompany it as a symptom or follow it as a seeming effect, every such accidental disorder hath in reality no necessary connection with Madness itself: but is either resolvable into other injuries quite foreign to Maniacal affections ; or, if it is owing to any one remoter cause of Madness, it is fill no more than another effect of the same cause ; which effect is just as capable of being thereby generated, whether Madness is or is not produced together with such symptom or before such consequence.

89 ]

For which reason every symptom and every seeming ill effect of Madness, whether Original or Consequential, must be considered either as a primary distemper, or as the effect of some primary distemper, to which a proper method of cure is applicable separate and independent of Madness ; and therefore it is not the subject of our present enquiry.

But, as Anxiety frequently precedes Madness like its cause or accompanies it like its symptom, and as Insensibility sometimes succeeds Madness like its effect ; tho' both these preternatural states of Sensation are as distinguishable and actually separate from delusive sensation, as any other animal distemper is or can well be : the same reasons however, which required a more particular enquiry into the nature and origin of these two nervous affections, will excuse our endeavouring to investigate what method of cure the discovery of their causes may seem to indicate with any the least probability of success.

[ 90]

Anxiety then is either Original or Consequential. For, as hath been before observed, it may arise, I. From some ill-conditioned state of the internal and proper substance of the nerves affected ; 2. From the intolerable impulse of external objects, or from some defect in those integuments and membranes that surround the medullary matter, and when they are perfect defend it even from the natural anion of bodies which would otherwise excite too lively a sensation.

Anxiety, when it is Original, resembles Original Madness, and for the same reason seems as much out of the reach of medical assistance : But in fact its case is more fortunate ; and, tho' Original Anxiety is just as incapable as Original Madness of being relieved by rational intention, it is however frequently palliated by more than one Specific remedy.

For wine, and even vinous spirits which are rightly forbidden to persons in perfect health, when occasionally administered as medicines to animal bodies agonizing with exquisite sensation, beguile the distresses of mortals, and oftentimes procure them tranquillity and happiness, to which they have long been strangers. And, altho' neither wine nor vinous spirits are advisable in the vexatious symptom of watchfulness, which frequently attends upon Anxiety, whether accompanied by Madness or not ; forasmuch as such poignant stimuli must irritate before their narcotic virtues can take effect ; yet I have often prescribed the Extraurn thebaicum [opium] from one to five grains without any ill consequence to such mad patients as were uneasy and raving all the night as well as day. And, where extreme weakness or some approaches to stupor rendered this powerful narcotic not quite so safe, Camphire and Sagapenum have afforded the same anodyne and soporific virtues, tho' not to so great a degree.

Nor ought any one to reject such temporary expedients, as unworthy the attention of a Physician in Original Anxiety, even tho' it should prove incurable by art ; who considers that it is his duty to protract the misery of his fellow creatures, if it be but for a moment ; and that anodynes [a drug that allays pain or soothes] are absolutely necessary in every case of Consequential Anxiety, until either the intolerable impulse of external objects can be entirely removed or weakened by such methods as particular circumstances require, or until the nervous integuments [something that covers] can be restored to their natural firmness by the astringent virtues of the Peruvian Bark, iron, vitriol [a sulfate of any of various metals: copper, iron, or zinc], mineral waters, and cold bathing ; which are the proper and often-times effectual remedies, whenever Anxiety arises from the laxity or defect of those membranes that surround and defend the medullary matter.

93 J

Insensibility, Idiotism, Folly, or whatever name it is usually known by, is, as hath been observed, almost always beyond the power of rational or Specific relief. Nevertheless, that nothing may be left untried, it seems advisable to make general evacuations, and to contrive partial but constant discharges of the fluids from the head and neck by perpetual blisters, setons [thread, gauze, or other material passed through subcutaneous tissue or a cyst to create a sinus or fistula], and issues. It may likewise be of some service, if nothing contraindicates, to shake the whole solid frame by vomits, cathartics, errhines, and all sorts of tolerable irritation. To which may be added, but not without great caution, the subtle and penetrating particles contained in mineral waters drank at the fountain-head, and the concussive force of the cold-bath. or sea, water.

But if Insensibility is constitutional, or owing to the firm and healthy structure of those solid membranes which sheath the nervous matter, such natural defect or impediment is incurable by art. However this slate of stupidity may, at lead by those who are endued with too lively a sensation, be deemed a kind of negative happiness, and rather to be envied than lamented.

And thus ends our inquiry into the causes effects and cure of Madness.

But, before we quit this subject, it may not be improper to subjoin a few remarks, which will readily occur to every one who recollects the premises, and is moreover satisfied of their reasonableness.

We have therefore, as Men, the pleasure to find that Madness is, contrary to the opinion of some unthinking persons, as manageable as many other distempers, which are equally dreadful and obstinate, and yet are not looked upon as incurable: and that such unhappy objects ought by no means to be abandoned, much less shut up in loathsome prisons as criminals or nusances to the society.

We are likewise, as Physicians, taught a very useful lesson, viz. That, altho' Madness is frequently taken for one species of disorder, nevertheless, when thoroughly examined, it discovers as much variety with respect to its causes and circumstances as any distemper whatever. Madness therefore, like most other morbid cases, rejects all general methods, v.g. bleeding, blisters, caustics, rough cathartics, the gumms and faetid antihysterics, opium, mineral waters, cold bathing, and vomits.

p 94

For bleeding, tho' apparently serviceable and necessary in inflammation of the brain, in rarefaction of the fluids, or a plethoric habit of body, is how ever no more the adequate and constant cure of Madness, than it is of fever. Nor is the lancet, when applied to a feeble and convulsed Lunatic, less destructive than a sword.

And, altho' blisters, caustics, and sharp purges quickned with white Hellebore [herb flower: purgative], and indeed all painful applications, not only evacuate and thereby relieve delirious pressure, but also rouse and exercise the body, and seem more peculiarly adapted to Insensibility when it is a symptom or consequence of Madness; nevertheless these and all pungent substances are to be tried with great caution, or rather are not to be tried at all in fits of fury. Nor does even defect of sensation allow their use, whenever such defect is occasioned by the preceding excess of the nervous energy, or when it is accompanied with spasm. As to black Hellebore [Black hellebore, Helleborus officianalis which is drastically cathartic, was formerly regarded as a specific in mental illness. It is native to Greece and Asia Minor, but was especially associated with the town of Anticyra on the Greek coast near Delphi.], it is either not the drug which was recommended by the Ancients and made Anticyra famous, or else it did not really deserve such recommendation.' For after several trials I have not the least reason to think it of any service in Madness.

For the same reason the gumms and all foetid antihysterics, which are undoubtedly serviceable in Madness arising from or complicated with some sorts of spasmodic disorders, are by no means even safe in all prxternatural actions of the muscles: much less can such irritating objects be proper in that particular case of Madness which is attended with feaverish heat, which happens in a plethoric habit of body, or which follows an inflammatory obstruction in the brain.

As to Opium, notwithstanding what hath been before said concerning the great relief obtained by this powerful drug in some particular circumstances, it is no more a specific in Madness than it is in the Small Pox. For no good whatever can be expected but from its narcotic virtue, and much harm may arise therefrom when improperly administered. For it is almost self-evident that in Madness attended with debility and languor, or which approaches towards stupor and insensibility, every thing that deadens sensation must be highly detrimental when given in a sufficient quantity, and may prove fatal when overdosed.

Mineral waters drank at the fountain head and bathing in the sea or cold fresh water have been sometimes chiefly if not solely relied on in the cure of Madness, more especially when attended with Anxiety and known by the name of Melancholy. Nevertheless such methods of relief are all apparently contraindicated, whenever there is sufficient reason to suspect that irresoluble congestions of the fluids clog the membranes contiguous to the nervous substance, or that the solids are strained beyond the possibility of recovering their natural elasticity. For in case of irresoluble congestions every drop of water, whether mineral or not, taken into the circulation will be added to the obstructing matter ; and the contracting force of cold or of sea-water applied externally will make the same matter more incapable, if possible, of being resolved. And, when the solids are irrecoverably strained, they will be in great danger of rupture or at least of a farther disunion of their constituent particles by the expansive force of mineral springs, as well as by the rude shock of cold or of sea-water, which is very sensibly felt even by those bodies, whose solids are strong enough to bear the fame without being hurt thereby.

Lastly with respect to Vomits, tho' it may seem almost heretical to impeach their antimaniacal virtues; yet, when we reflect that the good effects which can be rationally proposed from such shocking operations are all nevertheless the consequences of a morbid convulsion, these active medicines are apparently contraindicated, whenever there is reason to suspect that the vessels of the brain or nervous integuments are so much clogged or strained as to endanger a rupture or further disunion, instead of a deliverance from their oppressive loads. The same objection equally holds good against such muscular irritation, whenever the vessels are contracted with excessive cold, or when their contents are rarefied by heat, as also in constitutions that are lax and feeble or naturally spasmodic, and in several other circumstances which need no particular description ....

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Besides, since the characters that distinguish Original from Consequential Madness are not al-ways so clear and certain as to leave no room for error, and since Original Madness is not cur-able by any method which human reason or experience hath hitherto been able to discover; we should take great care not to do harm where it is not in our power to do any good, and not dwell too long on endeavouring to remove the causes of Madness, which perhaps are only imaginary, more especially if the methods to be made use of are by no means indifferent. For which reason, whenever upon sufficient trial not only of vomits but even of rougher purges, tho' rationally indicated at first, the patient grows worse or at least gains no ground, they are all entirely to be laid aside. For, if in any case the juvantia and laedentia supply us with medical knowledge, they most signally do so in disorders, whose nature we are not thoroughly acquainted with, and where reasoning a priori cannot certainly foretell the success of any one application.

Nor let us immediately despair at being obliged to withhold that assistance which seemed the most effectual, or conclude that, because the patient cannot be relieved by art, he therefore cannot be relieved at all. For Madness, like several other animal distempers, oftentimes ceases spontaneously, that is without our being able to assign a sufficient reason; and many a Lunatic, who by the repetition of vomits and other convulsive stimuli would have been strained into downright Idiotism, has when given over as incurable recovered his understanding.

To which remarks arising as just conclusions from reasoning upon the unavoidable action of vomits and rougher purges, I shall beg leave to add some cautions, which experience has suggested as necessary to be communicated to the young practitioner, even when such active medicines are proper. viz. 1. If the season of the year is in the choice of the Physician, to prefer the Spring or Autumn, as being in neither extreme of cold or heat : 2. Not to persist in their use at any one time for a longer term than six or eight weeks: 3. Even during that term to give a respite every other or at least every third week from all drugs except the gumms, neutral salts, or gentle solutives : 4. As soon as the patient visibly approaches to a state of sanity, entirely to discontinue these and all other violent methods ; that the animal fibres, which have been strained either by the causes of Madness or perhaps by the means of removing them, may be at liberty to recover their natural firmness and just approximation of particles, which a repeated concussion will certainly prevent.

FINIS.

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