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A TREATISE 



NATURE, SYMPTOMS, CAUSES, AND TREATMENT 



INSANITY, 



WITH PRACTICAL 



OBSERVATIONS ON LUNATIC ASYLUMS, 



A DESCRIPTION OF THE 

PAUPER LUNATIC ASYLUM FOR THE COUNTY OF MIDDLESEX, 

AT HANWELL, 

WITH A DETAILED ACCOUNT OF ITS MANAGEMENT. 



|V^B^>^ 



SIR W. C. ELLIS, M.D. 

JtT M^^/j^0kMERLY OF THE ASVliUft^^ 1 • ^ * • ' » « 

NOT TO B3 BBMO'V X. 



AT WAKEFIELD. 



}}o ^L ^ ^ 



LONDON : 
SAMUEL HOLDSWORTH, AMEN CORNER, 

PATERNOSTER ROW. 
1838. 



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/■■ 



roNBON : 

R. CLAY, PRINTER, B READ-STH EKT-HTLt. 




TO 

COLONEL CLITHEROW, 

BOSTON HOUSE. 



My dear Sir, 

To whom could I dedicate the following 
attempt to afford relief to the most suffering 
class of my fellow-creatures, with so much 
propriety, as to yourself, whose whole life has 
been employed in promoting every scheme of 
benevolence, and whose personal happiness 
has increased in proportion to the success of 
your endeavours ? 

You have long stood forward as the bene- 
factor, and unflinching protector of the Insane. 
To your influence and unwearied exertions 
is mainly to be attributed this spacious Build- 
ing for their reception : and to your zealous 
and continued attention to their welfare, 
they are indebted for the means of procuring 



IV 

many of the comforts it affords. But with 
this, your philanthropy has not ended : you 
have followed them when restored to reason, 
and have found that they were often home- 
less, friendless and destitute. This was 
sufficient to arouse your sympathy in their 
behalf: you enlisted a Royal Personage in 
their favour ; and, under the gracious patron- 
age of Queen Adelaide, a fund has been 
generously provided for their relief. 

By your having kindly allowed this humble 
effort, for the benefit of those whose con- 
dition you have so much amehorated, to 
be introduced into the world, under your 
auspices, you have added another to the 
many obligations I have already received 
from you, during the years you have honoured 
me with your personal friendship. 

That your useful and valuable life may long 
be preserved a blessing to your fellow-crea- 
tures, is the earnest prayer of. 

My dear Sir, 

Your most sincere 

and obliged Servant, 

W. C. Ellis. 

Lunatic Asylum, llanwell, 
November 1, 1837. 



PREFACE, 



The fearful extent to which Insanity prevails, 
the severe bodily suffering* usually attending its com- 
mencement and the painful change produced by it, 
in the powers and moral condition of man, render 
it a subject of intense interest to the philanthropist 
and the man of science. Recent parliamentary 
returns show, that there are in England 12,668 
Pauper Lunatics and Idiots ; and the Insane alone, 
including the different classes of society, cannot be 
estimated at fewer than 10,000. From the habits 
and mode of education of the upper ranks, particu- 
larly of the females, the brain and nervous system 
are kept in a state of constant over-excitement, 
whilst the frame is debilitated, from the muscles 
being rarely called into proper and regular exercise. 



VI PREFACE. 

Hence arises a high degree of susceptibility of 
disease, with little constitutional stamina, to resist 
the over-anxiety and other effects of the sudden 
changes in circumstances, peculiarly incident to the 
present times. Amongst the poor, different, but no 
less pernicious causes are followed by similar con- 
sequences. Excess, especially in the use of ardent 
spirits, exposure to cold, the want of the common 
necessaries of life, and the other results of ex- 
treme poverty all create in them a liability to 
Insanity. Were men, habitually, to be temperate 
in all things, to take no anxious thought for the 
morrow, and " to set their affections on things 
above, and not on things below," but few, com- 
paratively, would be afflicted with this disease. Un- 
der existing circumstances, however, I am afraid 
that it would be enthusiasm to hope that its preva- 
lence will be greatly diminished. The objects of 
the following pages are to point out the symptoms 
by which an attack of this disease may be foreseen, 
and the means by which it may be warded off ; and 
in those cases where it has already supervened, to 
explain the mode of treatment most likely to restore 
the patient to reason and society ; and where this 
is impossible, to show how the sufferings may be 



PREFACE. Vll 

alleviated, and life rendered, if not a state of 
happiness at least, one of moderate enjoyment. 
Should the attempt, undertaken amidst anxious and 
laborious professional engagements, prove unsuc- 
cessful, an earnest desire to promote the welfare of 
a large and much enduring class of my fellow- 
creatures, who cannot plead their own cause, must 
be my apology for having made it. 

Though my attention, from early life, has been 
particularly directed to Insanity, and a residence in 
the Asylums at Wakefield and Hanwell, during 
nearly twenty years, has placed under my immediate 
care and observation upwards of 2,700 cases, I 
feel that I have still much to learn. Even if the 
general view taken in the present work be correct 
(as I fully believe it to be), patient subsequent inves- 
tigation will be required to make the picture in all 
its parts complete. Should I succeed in exciting an 
interest on the subject at all adequate to its im- 
portance, it will soon be investigated by men of 
more leisure, deeper research, and greater anato- 
mical skill, than myself. If the end be but answered, 
and the Insane benefited, I care not whether it be 
by the adoption of the plan mentioned in the follow- 
ing pages, or by any other means. Most thankfull 



Vni PREFACE. 

shall I avail myself of any additional light that 
can be thrown on the nature of this obscure disease, 
and of any mode of treatment, however opposite 
to my present views, by which it may be palliated 
or removed. 



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ON THE 



NATURE, SYMPTOMS, CAUSES, AND TREATMENT 



INSANITY. 



CHAPTER I. 



INTRODUCTION. 



The more various the forms in which a disease 
exhibits itself, the more difficult it is to come to a 
correct conclusion as to its nature. In scarlet fever, 
small-pox, and many other acute diseases, we find, 
whatever be the constitution, similar general effects, 
only in a more aggravated form in some than in 
others. In these cases we can always identify the 
disease ; and if we cannot immediately discover its 
origin, we can at least find out the mode in which 
it shows itself. In dyspepsia, and some other dis- 
orders, the immediate effects seem to vary with the 
habits and idiosyncrasies of the individual attacked ; 
and there is consequently a difficulty in determining 
to what morbid affection the particular symptoms 
are to be traced. But in no disease do we find the 
same complicated and varying forms as in insanity. 

B 



INTRODUCTION. 



In some, it is attended with the highest degree of 
maniacal excitement, excessive muscular strength, 
and extraordinary vivacity of intellect ; in others, 
the greatest depression is found, not a word is ut- 
tered, and the patient remains like an automaton 
for weeks together. In some, the senses are quick- 
ened, and the sight and hearing are morbidly acute ; 
in others, they are excessively obtuse, and the whole 
nervous system becomes in a great measure insen- 
sible to feeling. Indeed, from our observing, that 
circumstances apparently similar produce results 
diametrically opposite in different individuals, we 
might be led to conclude, that, in this disease nature 
is at variance with herself, and that, although in all 
other cases she is uniform, insanity forms an excep- 
tion to her rule. A further inquiry into its nature 
will show us that, when fully examined, these incon- 
sistencies do not exist ; and that they are to be 
traced to our classing under the name of insanity a 
set of diseases, which really act in totally different 
ways, and most probably affect different parts. It 
will be seen, that an attempt has been made in the 
following pages, in the first place, to investigate 
the nature of insanity. The results of this investi- 
gation are offered with much diffidence. It is felt, 
that the theory is liable to many and plausible ob- 
jections, and that it is incapable of demonstration ; 
and it is also felt that even if the view be correct, 
not more than the first step has been advanced in 
the inquiry. If it be true that insanity is really, 



INTRODUCTION. d 

in all cases, a disease affecting* the brain and nervous 
system, and that it is highly probable that the parts 
of it which suffer vary according- to the cause, and 
that the disease of each part is susceptible of great 
modification, it is obviously a work of patient ana- 
tomical research and careful previous inquiry to 
point out and to classify the different morbid appear- 
ances of the brain, according to the different modes 
in which the disease has exhibited itself. The 
general result is given as that which, in spite of all 
the difficulties, appears the most reasonable and 
satisfactory. 

Having investigated the nature of the disease, its 
causes will form the next subject of inquiry. It will 
be seen that, in many cases, these can be ascertained 
with a reasonable degree of certainty. And when 
it is observed, that so many apparently trifling things, 
affecting either the body or the mind, will produce 
such a diseased action in the brain and nervous 
system as to cause insanity, somewhat of the diffi- 
culty felt on account of the various forms it assumes 
will be diminished. Its perusal will be attended 
with one cheering effect at least : it will be seen 
that, in many instances, the cause is capable of 
removal ; and that, in most, proper caution and 
attention to the natural constitution will enable 
those, who are even predisposed to the disease, to 
avoid an attack. It is hoped, too, that when it 
becomes known that mere disease of the viscera, in 
many cases, produces it, the painful feeling of con- 

b2 



4 INTRODUCTION. 

cealment, which harasses the minds of the friends, 
and operates most prejudicially to the patient, will 
vanish ; and that the disease will not be suffered to 
be confirmed, from a false delicacy preventing the 
timely application of proper remedies. It will be 
observed that it frequently is hereditary ; but there 
is still no reason why, even in these cases, it may 
not be avoided. Of course, an individual knowing 
that he inherits a liability to a particular disease, 
ought most carefully to avoid those circumstances 
which will have a tendency to produce it. In these 
cases, the constitution should be supported by proper 
nutritious diet ; but the constant use of stimulants 
of any kind should, if possible, be avoided. And 
such a situation in life should be selected, as will 
place the individual in certain, though moderate, 
circumstances, and not expose him to any great 
vicissitudes either of good or adverse fortune. With 
these precautions, those who have an hereditary 
predisposition to insanity, may in general pass 
through life without being attacked. And the same 
high degree of nervous sensibility which renders 
this class susceptible of disease, is usually accom- 
panied with that mental energy and activity, which 
make them the most accomplished and valuable 
members of society. 

But little is known of connate idiocy, and dis- 
section has hitherto scarcely thrown any light on 
the subject. In general the brain, especially the 
cerebrum, is very deficient in size ; but in some 



INTRODUCTION. 5 

instances the head is well proportioned, and the 
contents^ on post mortem examinations, exhibit no 
traces of disease. It was not thought right to pass 
over the subject of fatuity, without adding a warn- 
ing against the pernicious habit, which appears to 
be a very frequent cause of it. 

The Chapter on Symptoms will be found to 
embody a somewhat minute account of those mental 
and corporeal changes, which usually precede an 
attack of insanity. If the attention of friends were 
but sufficiently aroused to these premonitory symp- 
toms, the disease could, in many instances, be 
checked in the onset ; and in others it would, in a 
comparatively short time, yield to simple and easy 
remedies. This chapter also contains a description 
of the most usual mental aberrations, and of the 
marks by which the existence of lesion of the brain 
is indicated. The symptoms exhibited by suicidal 
patients are detailed at some length ; as the care of 
this class is obviously one of the most painful and 
anxious duties devolving upon a professional man. 

Great improvements have taken place in the 
general condition and treatment of the insane, since 
the horrible and disgusting disclosures brought to 
light by the parliamentary investigation in the year 
1814. But although they are, in a great measure, 
protected by the present system of inspection from 
gross acts of cruelty, much ignorance still prevails 
on the method of their treatmejit. Nor will this be 
a matter of surprise, when it is considered that the 



O INTRODUCTION. 

subject of insanity forms but an inadequate part of 
medical education. In many instances, when a pro- 
fessional man is called in to attend a patient in a high 
state of mania, the disease is as new to him as it is 
to the friends, and he is as much terrified as any of 
those about him with the violence exhibited. The irri- 
tation of the patient is increased by the excitement 
into which all those around him are thrown ; and by 
the excessive confinement in which he is necessarily 
placed, from the want of proper and convenient 
i^^eans of restraint. Under these circumstances, the 
nfost vigorous means are adopted ; and as the pulse 
for a length of time appears to indicate excessive 
circulation, they are persevered in, until the phy- 
sical powers are exhausted, and the constitution, in 
very many instances, irreparably injured. So many 
cases have fallen imder my own observation, where 
well-meant, but injudicious treatment, the result of 
want of proper instruction, has rendered all attempts 
at subsequent cure hopeless, that some suggestions 
will be found to remedy this evil : it is hoped that 
they will not be considered out of place. 

It will be seen that the medical remedies, on which 
much reliance is to be placed, are but few, and that 
they are principally of use in the early stages of the 
disease. The moral treatment is by far the most 
difficult part of the subject. In this the most essen- 
tial ingredient is constant, never-tiring, watchful 
kindness : there are but few, even amongst the 
insane, who, if a particle of mind be left, are not 



INTRODUCTION. 



to be won by aflPectionate attention. The attempt 
must be made day by day, and for weeks together ; 
and no discouragement must be felt, if even then 
the end is not accomplished. Persevere, and the 
reward will follow. In many cases, there will be 
the delight of witnessing the gradual return to 
reason and happiness ; in all the peace and satis- 
faction arising from a consciousness of having done 
what is right to the uttermost. The various modes 
subsequently pointed out, in which the patients have 
been acted upon by moral means, are not given as 
an enumeration of all which may be used with 
advantage, but merely as specimens, and for the 
purpose of exciting benevolent ingenuity. 

In the Chapter on Asylums, several minutise 
are gone into, which, it is feared, will be uninte- 
resting to the professional reader. It is, however, 
hoped, that it will afford useful practical informa- 
tion to those, under whose direction similar institu- 
tions are about to be built. Indeed, many things, 
which appear trifling to a superficial observer, 
materially affect both the comfort and the cost of 
the patients. It is hoped, too, that, whilst the hints 
it contains will have a tendency to diminish the 
expense of executing such buildings, an enumera- 
tion of the various requisites for lunatic asylums 
will remove the too general impression, that, be- 
cause they are to be occupied by paupers, they ought, 
therefore, with proper economy, to be erected at as 
cheap a rate as poor-houses. 



INTRODUCTION. 



In the account of the mode in which the Asylum 
at Hanwell is managed, the various steps will be 
traced, by which the system of employing the 
patients has gradually increased, until, at the pre- 
sent, 454 out of 610 are regularly at work; and 
many of them at trades, with which they were 
totally unacquainted until they were taught them in 
the institution. When the system was commenced 
by myself and my wife, on the opening of the 
Asylum for the West Riding of Yorkshire, at Wake- 
field, so gi'eat was the prejudice against it, that it 
was seriously proposed, that no patient should be 
allowed to work in the grounds outside the walls 
without being chained to a keeper. Another sug- 
gestion was, that a corner of the garden should be 
allotted for their labour, and that they should dig it 
over and over again all the year round. The kind 
feeling and good sense of the people in the neigh- 
bourhood soon overcame these prejudices ; and not 
only did they witness with pleasure the unfortunate 
patients happily engaged in their works in the 
grounds of the institution, but they were delighted 
to meet them emerging from its bounds, and, by a 
walk in the country, and a little intercourse with 
their fellow-men, preparing to enter again into 
society. They felt too, when bowed before that 
God, in whose sight all men are equal, that no 
spectacle could be more cheering and appropriate 
than to witness the poor lunatic listening with 
them to those offers of mercy, which are peculiarly 



INTRODUCTION. 9 

addressed to the weary and the heavy laden. Most 
sincerely do I hope that similar feelings will soon 
operate in favour of the patients at Hanwell, and 
that an unfounded prejudice will not long- continue 
to confine them entirely within the pales which 
surround the building. 

An account is also given of the measures actu- 
ally adopted for the punctual and orderly arrange- 
ment of the duties necessary to the management of 
so large a family. It is hoped, that those who are 
about to undertake the conduct of similar institu- 
tions may derive from it some assistance in the 
formation of their plans. A copy of the written 
rules given to each of the domestics is added in the 
Appendix. These have been gradually framed as 
experience has pointed out the advantage of the 
various observances which they are intended to 
secure. But, notwithstanding all the rules that can 
be laid down, much of the comfort of the patients, 
and of the probability of their cure, will depend 
upon an unceasing watchfulness, that those, under 
whose care they are placed, constantly treat them 
with the greatest kindness and forbearance. And, 
indeed, unless proper persons be selected, it is im- 
possible to prevent acts of oppression occasionally 
taking place. When the harassing and irksome 
nature of the duties of the attendants on the insane, 
and the importance of those duties being properly 
fulfilled, are considered, it is obvious, that such 
an amount of remuneration should be proposed as 



10 INTRODUCTION. 

should induce persons of character and respectability 
to offer themselves as keepers and nurses. And, in 
estimating- what is a fair reward for their labour, 
it oug-ht to be remembered, that their lives are 
constantly exposed to be attacked by those whose 
insanity has not diminished the influence of their 
evil passions, but who have sense enough to know 
that however violent or fatal the outrage they may 
commit, their disease exempts them from all liabi- 
lity to punishment. 

A conviction that the insane of the middle and 
higher classes do not possess half the advantages 
afforded by public asylums to the poor, has induced 
me to add a short sketch of a system, which, I 
hope, will secure to them every facility of cure, 
with but little risk of improper detention. I know 
that objections may be raised against the system of 
proprietary asylums, by which I hope that these 
important ends may be attained. But I think if 
the medical superintendent is not allowed to have 
any share in the concern, or to derive any pecuniary 
benefit from the patients remaining under his care, 
it will be so obviously important to his professional 
reputation to use every possible means for their 
cure, and to discharge them as soon as they can be 
safely restored to society, that there will be no 
doubt but, under this system, the rich will, at least, 
be put upon an equal footing with the poor. If 
such a refuge were but established, to which the 
friends of the patients could at once entrust them 



INTRODUCTION. 11 

with confidence, the disease would be stripped of 
half its terrors, and the constant succession of 
patients to such an institution would abundantly 
repay the proprietors. 

A few observations are added on epilepsy and 
the diseases of the insane. On the former very 
little is yet known. 

An attempt has been made to draw a distinction 
between moral evil and insanity. A marked dif- 
ference between the two really exists, although this 
difference is often difficult to be determined in in- 
dividual cases. I greatly fear that, in every large 
public asylum, many will be found morally respon- 
sible before God, as rational beings, for that vicious 
conduct, which is by society mercifully attributed 
to insanity. 



CHAPTER 11. 

ON THE NATURE OF INSANITY. 

The first question which naturally suggests itself 
to the mind, on entering on the consideration of 
this subject, is, What is insanity ? Is it a mental, 
or is it a bodily disease ? or are both the mind and 
the body simultaneously affected ? As it is obvi- 
ously of great importance to have a definite notion 
of the nature of insanity, we shall attempt to 
answer these questions in the present chapter. 

Our total ignorance of the nature of the mind 
itself, and the little knowledge of the brain and 
nervous system, by which it acts and is acted 
upon, that has hitherto been derived from the 
minutest anatomical research, and the most patient 
investigation, will easily explain why so many con- 
tradictory opinions on this subject have existed 
amongst mankind. In the earliest periods, the 
insane were supposed to be possessed by demons ; 
and superstition assigned to the priests the task of 
curing them by exorcism. Hippocrates, and other 
ancient writers, treated insanity solely as a bodily 



ON THE NATURE OF INSANITY. 13 

disease, although they differed as to its immediate 
cause ; he attributing it to a mixture of bile with 
the blood ; others, to a too great determination of 
blood to the head. Amongst the moderns it has 
more frequently been considered purely a mental 
disease, and requiring only moral remedies ; though, 
within the last few years, the doctrine of its being 
a bodily disease seems again to prevail. But as a 
mere enumeration of the contradictory opinions of 
the various writers would evidently not tend to 
increase the distinctness of our notions 5 and as the 
proposed limits of the present work will not allow 
us fully to state the modes by which they severally 
arrive at their conclusions ; we will investigate for 
ourselves the nature of this obscure and mysterious 
disease. Before we proceed, it is necessary to 
observe, that, we shall at present confine our atten- 
tion entirely to Insanity. The different manifesta- 
tions of mind arising from Idiocy, Eccentricity, and 
Moral Evil, often confounded with it, will be taken 
into consideration hereafter. 

We have everv reason to believe, that all livingr 
beings, from the smallest insects to the largest 
animals, possess such a portion of mind, or instinct, 
as mind in animals is usually called, as is adapted 
to their several conditions. Some require no more 
than is sufficient to direct them in the choice of 
food, to warn them of danger, and to induce them 
to procreate their species. In these the corporeal 
machinery is exceedingly simple. They are furnished 



14 ON THE NATURE OF INSANITY. 

with g-ang-lia and plexus of nerves, but are without 
brain. When the powers of instinct are more extend- 
ed, we find, in addition to a more elaborate develop- 
ment of the nervous system, a cerebral organization. 
Ascending" in the scale of creation, we arrive at 
man. He possesses a bodily organization and men- 
tal faculties, of a nature similar to those observed in 
animals, although much more perfect in their kind. 
But, in addition to these, he is endowed with higher 
and nobler faculties. He has, and ever has had, 
the capability of knowing, worshipping, and loving 
God, and receiving the influences of the Holy Spirit. 
And this distinction exists wherever man is found : 
at the poles, or at the equator ; in the white-skinned 
European, the sable African, or the American 
savage : and it is a distinction that can never be 
obliterated. What then do we observe in the form- 
ation of man, uniformly distinct from that which 
exists in all other animals? A more elaborate 
cerebral organization, and a great multiplication of 
its parts, many of which are not found in any other 
animals whatever, although there is no other part 
of the human body which is not, more or less, de- 
veloped in one species or another. Now, in each 
class of animals, there appears to be a certain limit 
to the manifestations of mental power ; and it is 
exceedingly probable, that, in the individuals com- 
posing each class, there exists a great difference in 
their capabilities. We know that in various quad- 
rupeds, and the higher class of animals, such a 



ON THE NATURE OF INSANITY. 15 

difference does exist, and in man, more particularly, 
to a very great degree. 

In judging whether, in any species of ani- 
mals, the functions are healthily performed, we na- 
turally look at the previous habits and capabilities 
of the species ; and we do not consider the absence 
of that which is not usually found to exist in such 
a species, as any indication of disordered function ; 
nor should we think the existence of a capability 
much superior to that which is found amongst other 
species, of itself to constitute any evidence of sound- 
ness, because of the difference of their natural 
powers and habits. Is not the same rule applicable 
to different individuals of the same species, and 
particularly in man ? We know, from experience, 
that an immense difference, both in physical and 
mental powers and habits, from some cause or other, 
exists among men. Whether this would, or could 
not have been obviated, by previous education, is 
foreign to our present consideration ; although I 
think there is very little doubt that differences do 
exist, which no external circumstances could re» 
move. We should be unable to form any opinion 
of the soundness of a limb or muscle, merely from 
knowing its absolute power. The arm of a power- 
ful man, though in a state of disease, may be able 
to lift a much greater weight than the perfectly 
healthy arm of a weak and delicate one. Before the 
present absolute power then can be the test, we must 
know the previous capabilities. Ought it not then 



16 ON THE NATURE OF INSANITY. 

to be the first object of our inquiries, in estimating 
the sanitj of an individual, carefully to investigate 
what have been the previous habits and powers of 
his mind ; what has been the state of his senti- 
ments and passions ; and what has been his general 
conduct ? And w^ould it not be irrational to con- 
clude that a man, possessing great mental powers, 
is necessarily sane, because he is capable of per- 
forming with accuracy certain mental operations? 
and equally irrational to conclude that an indi- 
vidual, of weak mental powers, is not sane, merely 
because he is incapable of performing similar ope- 
rations? But should we not, in either case, be 
justified in pronouncing the individual sane, when 
the manifestations of his mind, his sentiments, 
passions, and general conduct, continue in accord- 
ance with the exhibition of his previous powers and 
habits ? These may have been such, that the indi- 
vidual has been incapable of performing the relative 
duties of life, and he may have been idiotic or 
imbecile : but such cases do not come within our 
present consideration. 

We arrive then at the general conclusion, that, 
independently of cases of idiocy, imbecility, eccen- 
tricity, and moral evil, which will be the subject of 
future consideration, man is sane, when, as we have 
stated above, the manifestations of his mind, his 
sentiments, passions, and general conduct, continue 
either to improve or to keep in accordance with the 
exhibitions of his previous powers and habits. And 



ON THE NATURE OF INSANITY. 17 

this too whether the mental powers are great or 
small ; and whatever may have been the degree 
of cultivation ; and however great the difference 
between the individual and others. The object of 
our introducing the analogy between the mental 
powers of animals and their cerebral development, 
will be seen as we proceed. Let us now go on with 
our investigation as to the nature of insanity. 

The first step in ascertaining the nature of any 
disease, is to find out what, if any, are its invariable 
symptoms, distinguishing these from all others which 
only occur under particular circumstances. What 
then do we find constantly attendant upon insanity ? 
That which is first, and invariably noticed, is some 
injurious alteration, either in the intellectual mani- 
festations, or in the conduct, or in both. 

It is quite clear, that if we can show that there 
is an intimate connexion between the action of any 
part of the human body, and the intellectual mani- 
festations and the conduct, which are the subjects of 
the alteration uniformly found to exist in insanity ; 
and can also show, that where this injurious altera- 
tion exists, there is at the same time diseased organi- 
zation, or diseased action, in such parts ; we shall 
have done much to enable us to come to a right 
conclusion on the nature of insanity. Now, can we 
not trace such a connexion between our intellectual 
manifestations and the brain and nervous system ? 
We have seen that in animals, where little mental 
power exists, there is a proportionate absence of 

c 



18 ON THE NATURE OF INSANITY. 

cerebral organization ; and that in man, where such 
mental powers are found in the highest degree, the 
cerebral organization is the most elaborate. Again, 
when in man the whole brain has become torpid, 
either from the effects of chronic inflammation, or 
pressure gradually taking place from the morbid 
secretion of serum, slowly distending the ventricles 
and membranes, an alteration takes place, and he is 
reduced in point of intellect to the level of the lowest 
aniroals : he is capable of taking his food, but all 
other voluntary action is lost, in proportion as the 
pressure and diseased organization increase. Now, 
what is the case when the brain is excited to an 
unusual state of activity ? We find a corresponding 
alteration, that is, an increased activity, in the men- 
tal manifestations. In the ordinary use of fermented 
liquors, until, from their being taken to excess, tor- 
por is superinduced, by a qiiasi apoplexy, the ope- 
ration of the mind, the sentiments, and the passions, 
are quickened in the same ratio in which the stimulus 
increases the action of the brain. In phrenitis, 
where this increased action of the brain amounts 
to acute inflammation, the violence of the mental 
manifestations corresponds with the activity of the 
disease ; and when, by cold applications and proper 
medical treatment, the inflammatory action is re- 
moved, the mind recovers its tone ; but the intel- 
lectual powers and feelings are never completely 
restored, if the inflammatory action has remained 
unsubdued, until the organization of the brain and 



ON THE NATURE OF INSANITY. 19 

its membranes has become permanently injured. 
This is found, on dissection, to be the case in all 
instances where the insanity has been the result of 
phrenitis. Now it is quite clear, that every other 
part of the body may be diseased or even totally de- 
stroyed, and still, if the brain continue to be healthy, 
the mental manifestations will remain unaffected. 

May we not then, from these instances, fairly con- 
clude that there is a necessary connexion between 
the mental manifestations and the state of the brain ; 
and that, at all events, in these extreme cases of 
complete torpor and excited action, the injurious 
alteration which results in the intellectual manifes- 
tations and the conduct, is to be traced to the state 
of the brain ? And as we know that the assistance 
of the brain is necessary to our intellectual mani- 
festations, to our sentiments, and to our passions, 
may we not reasonably infer that the injurious 
alteration which we have previously described as 
the invariable attendant upon insanity, may, in like 
manner, in less extreme cases, be traced to the state 
of the brain ? This inference receives material 
support from the result of anatomical investigation. 
In old cases, diseased organization of the brain is 
almost invariably found ; whilst in the recent cases 
there is rarely diseased organization, but the vessels 
on the whole surface of the brain are surcharged 
with blood, and clearly indicate the existence of 
increased cerebral action. 

In carefully looking over the post mortem reports 
c 2 



20 ON THE NATURE OF INSANITY. 

of those whose cerebral organization I have exa- 
mined, I find that in 154 male patients, 145 had 
disease very strongly marked, either in the brain or 
the membranes. Of the nine remaining, two were 
idiots from birth ; one died of dysentery, another 
of epilepsy; the other five cases had not been insane 
more than a few months, and died of other diseases. 
Of the females, sixty-seven were examined ; and sixty- 
two found with disease in the brain or membranes : 
in the other five, no disease was to be discovered. 
Two of these were idiots from birth, and, with one 
exception, the others recent cases. I would have 
given the particulars of all these cases ; but as the 
object is not unnecessarily to enlarge the work, but 
to convey as briefly as possible the reasons upon 
which our theory and practice are founded, I shall 
only transcribe a few of them. These may be 
taken, as nearly as possible, as a specimen of what 
is generally found in cases where the insanity has 
been of similar duration. I should not have thought 
even this necessary, had not my experience been 
so much at variance with that of Messrs. Esquirol 
and Pinel, whose authority on this subject has been 
much looked up to, especially in France. 

No. 1, at the time of death, was seventy-four 
years of age, and had been insane seventeen years. 
The calvaria were found adhering, with unusual 
firmness, to the dura mater ; the vessels of the 
dura mater were very turgid ; brain firm, and 
ventricles distended with serum. 



ON THE NATURE OF INSANITY. 21 

No. 2, at the time of death, was forty-eight years 
of age, and had been insane two years. On raising 
the scalp, an unusual quantity of venous blood was 
found at the back part ; the cerebrum was remark- 
ably tense and firm ; there were about three ounces 
of fluid in the ventricles. 

No. 3, at the time of death, was fifty years of 
age, and had been insane twelve years. The brain 
was very turgid, with venous blood ; a good deal 
of serum was under the tunica arachnoidea, and a 
considerable quantity in the ventricles. 

No. 4, at the time of death, was forty-nine years 
of age, and had been insane three years and six 
months. The arachnoid was generally opaque and 
milky in its appearance, with serum underneath it, 
and there was an effusion of four ounces in the 
ventricles. 

No. 5, at the time of death, was forty-two years 
of age, and had been insane seven years and a half. 
The arachnoid was opaque, and the brain very firm ; 
there were two ounces of serum in the ventricles ; 
the parietes of which were highly vascular, and 
considerably thickened. 

No. 6, at the time of death, was forty years of 
age, and had been insane upwards of three years. 
On cutting into the scalp, a large quantity of blood 
poured out ; the vessels of the dura mater were 
very turgid ; brain very firm ; arachnoid thickened 
and opaque, with effusion between it and the pia 
mater ; there was one ounce of serum in the third 



22 ON THE NATURE OF INSANITY. 

ventricle ; the lateral ventricles were not at all 
distended. 

No. 7, at the time of death, was thirty-two years 
of age, and had been insane between four and five 
years. The vessels of the pia mater were turgid ; 
brain firm ; ventricles distended, containing six 
ounces of fluid : in the left ventricle there were 
three hydatids. 

No. 8, at the time of death, was thirty years of 
age, and had been insane about five months. Ex- 
cepting a turgid state of the veins, every part of the 
head was natural. 

No. 9, at the time of death, was forty-six 
vears of aoi-e, and had been insane about three 
months. The pia mater was found highly vascular, 
arachnoid slightly opaque. 

No. 10, at the time of death, was thirty-six 
years of age, and had been insane about seven 
months. The cranium and its contents were 
natural. 

In the cases where the quantity of serum has 
been particularly specified, the fluid was drawn by 
a syringe from the ventricles, and emptied into a 
graduated measiu'e. 

Since the foregoing cases were copied, the theory, 
that increased sanguineous action takes place on 
the commencement of insanity, has been strikingly 
confirmed by a post mortem examination, at which 
I was a short time ago present. The deceased 
was thirty -five years of age, and he had only been 



ON THE NATURE OF INSAMTY. 23 

insane a few months at the time of his death. On 
dividing- the scalp, a considerable quantity of blood 
escaped ; on removing the dura mater, the whole 
surface of the brain appeared inflamed, the minutest 
vessels being highly injected with red blood ; the 
tunica arachnoidea was slightly opaque, in small 
patches ; the substance of the brain was firm ; not 
more than the natural quantity of fluid was found 
in the ventricles. It will be observed, that in some 
of those cases no traces of disease in the brain could 
be discovered. We cannot, however, conclude from 
this that DO disease in the brain existed. We know 
that diseased action may continue in various parts 
of the body for a considerable period, and yet not be 
discoverable by any anatomical investigation. The 
most skilful anatomist cannot find out by dissection 
any traces of tic doloureux, cramp, rheumatism, &c. 
In like manner, a man may have had, for many 
successive years, attacks of gout, and may ulti- 
mately die whilst suff'ering acutely from the disease, 
and yet no trace of it having ever existed may be 
discoverable on the minutest dissection, although, 
in most instances, it produces, after a time, chalky 
concretions and distortions of the limbs. Now, we 
know quite as little of the anatomy of the brain as 
of any other part of the human body ; but we do 
know that a very trifling alteration in its state will 
produce the most important results ; as in apo- 
plexy, the sudden extravasation of a small quantity 
of blood causes death. It is, therefore, exceed- 



24 ON THE NATURE OF INSANITY. 

mg]j probable, considering the minuteness and the 
importance of the various nerves and fibres which 
are found in the brain, that, in those instances 
where we could not trace any disease, a more accu- 
rate knowledge would have enabled us to distin- 
guish its presence. 

We have, 1 think, shown, that the alteration 
which we have described as the characteristic of 
insanity, is, in extreme cases, and most probably in 
all instances, accompanied by diseased organization, 
or by diseased action in the brain. It cannot, how- 
ever, be denied, that this alteration may be com- 
bined with every variety of bodily disorder, and be 
more frequently accompanied by some, than by 
others ; nay, even, as we shall have occasion to 
show in the next chapter, may result entirely 
from the brain sympathizing with other diseased 
parts : but this evidently does not affect the argu- 
ment. 

We have purposely avoided the consideration of 
the question, whether the mind itself, under such 
circumstances, participates in the disease. There 
is much difficulty in our considering that which we 
believe to be purely immaterial to be susceptible of 
disease ; and as the moral remedies, which we shall 
hereafter have occasion to mention, are equally 
applicable, whether insanity be considered a merely 
physical disease, or a disease partly mental and 
partly physical, it is not a question of practical im- 
portance. I cannot, however, refrain from noticing 



ON THE NATURE OF INSANITY. 25 

one or two objections to the theory, that insanity 
is purely a disease of the brain. 

It is contended by some, that insanity is not a 
disease of the brain, but of the mind itself; and 
that, in the same way as fever is but an attendant 
on fractures and various bodily diseases, so the 
unhealthy state of the brain, which accompanies 
insanity, is but a consequence of the diseased mind. 
But, if that were the case, in the same way as fever 
would not of itself bring on a fracture, so, in no 
instance, where disease in the other parts of the 
body has by sympathy caused disease in the brain, 
ought insanity to ensue. But we know, and shall 
have occasion to bring forward many cases, in 
which the insanity arose entirely from diseased 
action in the abdominal viscera, affecting the brain 
by sympathy, and in which it was removed as soon 
as the viscera were restored to their healthy state, 
and ceased to irritate the brain. In the conside- 
ration of this part of our subject, however, there is 
one objection which, as it is enforced by the respect- 
able authority of the late Dr. Halloran, will demand 
our attention. 

The substance of the doctor's argument, which 
occupies several pages of his work, is, that there 
are cases in which insanity must be considered 
solely a disease of the mind, because there are in- 
stances in which it has been cured instantaneously 
by the operation of moral causes. As an illus- 
tration of his argument, he relates a case authen- 



26 ON THE NATURE OF INSANITY. 

ticated by the late justly celebrated Dr. Gregory 
of Edinburgh, " of a man who, in a fit of insanity, 
had determined on self-destruction, and who had 
escaped from his house in London with the deter- 
mination of precipitating himself from Westminster 
bridge into the Thames. When about to complete 
his purpose, he was suddenly assaulted by an armed 
footpad, who threatened him with instant death ; 
this not being the mode by which he had purposed 
to part with life, alarm for his safety instantly 
seized him, to the exclusion of the hallucination 
which had been but the moment before predomi- 
nant. Being freed from his unsought danger, he, 
with altered sentiments, returned to his family, 
fully impressed with the criminality of his design, 
as well as relieved from his previous perplexity." 

Now, had we no instances where diseases, uni- 
versally allow^ed to be bodily, were as instantane- 
ously brought on and cured also by the operation 
of moral causes as these which are said to be purely 
mental, the doctor's argument might be perfectly 
valid. That this however does occur, is so univer- 
sally admitted as hardly to need any proof. To 
those who have been in the habit of attendinof 
many patients subject to gout, instances must occur 
where they will recollect an attack having been 
brought on by violent emotions of the mind, par- 
ticularly by the depressing passions, from some 
vuiexpected calamity overtaking them : and two 
cases have fallen under my own immediate obser- 



ON THE NATURE OF INSANITY. 27 

vation, in which a severe fit of the gout was in- 
stantaneously cured in the first instance by terror, 
which exactly corresponds with the case of insanity 
brought forward by Dr. Gregory ; and in the 
second, by anger. I shall record them as a con- 
firmation of my argument. 

A clergyman, between fifty and sixty years of 
age, who load long been subject to attacks of gout, 
was one day sitting in his library; confined to his 
easy chair by a severe fit in one of his feet : one of 
his daughters, a little girl about five years of age, 
ran against a book-case, which had been left by some 
workmen, who had been repairing it, in an unsafe 
position. It was just on the point of falling upon 
her, when the father, forgetting his gout, sprang 
forward, in great terror, to save his child : he suc- 
ceeded in the attempt, and was much surprised to 
find, that he had lost the pain in his foot, and that 
the gouty attack had instantly disappeared. 

The second instance occurred to the same gentle- 
man many years afterwards. He was then labouring 
under so severe an attack as only to be able to be 
wheeled in his chair from the bed to the fire-side. 
He ordered the servant to bring into the room a 
table, which was too large to be got in at the door, 
except when turned in a particular manner ; this 
the servant was unable to find out or to compre- 
hend, though repeatedly told by the gentleman, 
who sat an impatient spectator of his awkwardness. 
At last he forgot his gout, jumped up in a fit of 



28 ON THE NATURE OF INSANITY. 

passion, pulled the table into the room, and was 
instantly cured of his complaint. 

At a fire in the Old Jewry, in March, 1837, a 
gentleman named Saunders, who had been for some 
time confined to his bed by the gout, is reported to 
have been the first person who made his escape 
from the house. In these instances, the disease 
appears to have departed altogether, in the same 
manner as it leaves one extremity and immediately 
transfers itself to another. This is often done with 
inconceivable rapidity. 

A case has lately occurred, which shows that 
gout is not the only bodily disease susceptible of 
sudden cure from moral causes. A gentleman, 
who had long been subject to asthma, and was at 
the time suffering under it, was unexpectedly called 
upon to nominate a member for parliament. The 
sudden excitement had the immediate effect of 
removing the disease, which did not return until a 
change in the atmosphere, produced by a thunder- 
storm, again brought it on. 

The following case is taken from the second 
volume of " Medical Extracts." A gentleman of 
great courage and honour, who had been subject to 
asthma, by long service as an officer in India, was 
attacked with a severe fit of that disorder, during 
their encampments, which usually lasted from ten to 
twelve days. Upon the third or fourth day of his 
illness, when he could only breathe in an erect pos- 
ture, and without motion, imagining that it was net 



ON THE NATURE OF INSANITY. 29 

in his power to move six yards to save his life, the 
alarm guns were fired for the whole line to turn 
out, because a party of the Mahrattas had broken 
into the camp ; and, fearing* certain death if he 
remained in his tent, he sprang* out with an alacrity 
that amazed his attendants, mounted his horse, and 
instantly drew his sword with great ease, which 
before he could not move from its scabbard, though 
he had tried with his utmost efforts. Hoiv mental 
emotions instantaneously bring on acknowledged 
bodily disease, and as instantaneously remove it, I 
do not pretend to know ; but as it is thus proved 
that the susceptibility of immediate cure from moral 
causes is not confined to mental diseases, this fur- 
nishes us no test by which we can determine whether 
insanity be mental or corporeal ; and therefore there 
is not any force in Dr. Halloran's objection. 

The same mode of reasoning evidently answers 
the argument, which is urged against insanity being 
a bodily disease, from its suddenly being produced 
by joy, grief, or any other powerful emotion of the 
mind : as we know that each of these will not only 
instantaneously produce bodily disease, as sudden 
terror the gout, but we have numerous cases on 
record where death itself has been the immediate 
result. 

We will only notice one more objection, which at 
the first seems plausible. It is urged that insanity 
is not a disease of the brain ; because disease of the 
brain, to a great extent, may exist without it. The 



30 ON THE NATURE OF INSANITY. 

objection may thus be answered. It is from our 
ignorance of the quantum of disease which mvist 
exist, according- to the particular constitution, before 
certain consequences are produced. We know, 
from 2J0sf mortem examination, that a disease of the 
lung's has existed to such an extent, as would have 
been attended with the most painful consequences to 
some individuals, and yet so far from the usual 
signs (not stethoscopic) of consumption being exhi- 
bited, no disease of the lungs whatever was sus- 
pected. Yet no one would argue that consumption 
is not a disease of the lungs. By a parity of reason- 
ing, therefore, w^e ought not to contend that insanity 
is not a disease of the brain ; because diseased brain 
does not always produce diseased manifestations of 
the mind. Having then seen, that in insanity there 
is always some injurious alteration, either in the 
intellectual manifestations, or in the conduct, or in 
both ; and having shown that such alteration is, in 
cases of insanity, accompanied with diseased action, 
if not with diseased organization of the brain ; we 
arrive at the conclusion, that insanity is a disease 
of the brain, causing, or at least co-existing with, 
an injurious alteration in the intellectual manifes- 
tations, or in the conduct, or in both. 

Let us next proceed to examine to what extent 
this alteration must exist, before we can pronounce 
an individual to be insane, according to the general 
acceptation of the term. 

Strictly speaking, every individual who exhibits 



ON THE NATURE OF INSANITY. Ol 

an involuntary alteration in his mental manifesta- 
tions, denoting the most trifling disorder, is not at 
the moment in a state of perfect sanity or health, 
that is, he is insane. But as, according to the 
general opinion respecting insanity, every insane 
person is totally unfit to manage his affairs, and 
dangerous to society ; we will next endeavour to 
show, that there are as many degrees of insanity, as 
there are of other diseases ; and that in the same 
way as some bodily diseases are too trifling to inter- 
rupt the ordinary course of a man's pursuit, so 
there are states of insanity which neither require 
restraint, nor incapacitate a man for the various 
duties of life. The measure of insanity, that must 
exist before an individual ought to be precluded 
from all the comforts of social life, virtually con- 
signed to a civil death, and exempted from the 
punishment attendant on the commission of the 
most heinous crimes, will be the object of our most 
serious inquiry. 

But before we proceed, I would again urge the 
necessity and importance of remembering, that, to 
constitute insanity there must be an alteration. For 
a man of a weak intellect, but perfectly capable of 
managing his affairs, may be taken by interested 
relatives to a medical man ; who, from having fixed 
in his mind some vague or arbitrary standard of 
sanity, to which the person examined does not 
come up, will, without any inquiry as to his 
previous state, or upon a hasty examination, give, 



32 ON THE NATURE OF INSANITY. 

uninfluenced by improper motives, but simply from 
ignorance or carelessness, a certificate of his insanity. 
Ag-ain, a perfectly sane man, of ordinary, or even 
more than ordinary, powers of mind, may, from 
some unaccountable eccentricities, which not unfre- 
quently accompany genius, be put into confinement 
solely from the medical person not having inquired 
into his previous habits. Another reason will natu- 
rally suggest itself to us, no less powerful than those 
we have just brought forward, in showing the 
necessity of attending to this distinction ; viz. that, 
from neglecting it, those, who have been really 
insane and dangerous, have been merely considered 
eccentric, and have not been put under proper 
restraint, until some melancholy catastrophe has 
been the result. This we find to be the case in all 
ranks of society. The history of the last few years 
will unfortunately bring to our recollection too 
many fatal incidents, which have arisen from indi- 
viduals, of the most exalted rank, not having been 
properly confined, solely because, in their insanity, 
they have exhibited intellectual powers greater than 
those which are usually found amongst mankind : 
although if their previous habits and capacities had 
been attended to, such an alteration would have 
been seen as would have proved the necessity for 
confinement. And every medical practitioner will 
recollect cases, which have fallen under his own 
observation, in the humbler walks of life, where 
families have been thrown into the deepest affliction, 



ON THE NATURE OF INSANITY. 33^ 

from a father, a mother, or a child having become 
the victim of unrestrained insanity. 

Let us now return to the consideration of the 
extent of the alteration, which must exist before it 
becomes requisite to treat the patient as insane. 
It is quite evident that this alteration may exhibit 
itself in various modes, both as it regards the intel- 
lectual manifestations, the sentiments, and the pas- 
sions. The powers of perception alone may be 
affected. An individual may erroneously think that 
he sees various forms and substances, which do 
not exist except in his own imagination ; but as 
long as his reason is sufficient to correct these false 
impressions, and he is himself conscious that they 
have no real existence, he is not a fit subject for 
confinement. Nay more ; even if his reason be not 
sufficient to correct these false impressions, if they 
be of such a nature as not to interrupt his ordinary 
pursuits, or to render him obnoxious to society ; as, 
for instance, if he imagines that he sees and con- 
verses with spirits, but is not influenced by them, 
it would be unjust to lock him up in a madhouse : 
though it is almost unnecessary to say, that it is of 
the highest importance that^ in both instances, proper 
steps should be immediately resorted to, before these 
erroneous impressions have been too much con- 
firmed by time to be incapable of removal. For 
although in the first instance these effects may be 
harmless, yet, viewing them but as the symptoms 
and result of diseased action of the brain and 



34 ON THE NATURE OF INSANITY. 

nervous system, which may, if allowed to continue, 
cause organic disease ; it is evidently desirable to 
use the most expeditious means to restore a healthy 
state of action in these organs. But if the diseased 
perceptions be of such a kind as to render him inca- 
pable of the management of his affairs, or to make 
his conduct injurious either to himself or to others, 
confinement ought immediately to be resorted to. 
One or two instances will make this distinction 
more obvious. 

O. M., a shoemaker, 48 years of age, had been 
subject to fits of mania, about once in three or four 
months, for many years. During the attacks he 
was extremely violent, and required personal re- 
straint. In the absence of the paroxysms he was 
perfectly harmless, and he now works at his trade, 
being trusted with the knives and tools necessary to 
carry it on ; but he at all times imagines that he 
has specks floating before his eyes. His vision is 
not defective, and his eyes have a natural appear- 
ance, but he invariably complains of these specks 
annoying him. He is gratified by having his eyes 
examined, and will then proceed with his work as 
usual. Now, had this man not been subject to 
periodical attacks of mania, it is obvious that he 
ought not to be confined merely on account of his 
labouring under this delusion. 

A. B., a joiner, 35 years of age, became insane 
in consequence of loss of property. He was very 
maniacal in the early stage of the disease : being 



ON THE NATURE OF INSANITY. 35 

a powerful man, he was kept under constant per- 
sonal restraint for a longer time than he otherwise 
would have been. At the end of twelve months, 
he was removed from the Hospital in which he was 
confined, to the Asylum at Hanwell, where he had 
an opportunity of employing himself in his former 
occupation. He rapidly recovered his general 
health, which had been somewhat impaired by con- 
finement ; and the only delusion which remained 
was, his thinking voices were always speaking to 
him. This had been the case for a long time ; and 
it had been judged a sufficient mark of insanity to 
keep him in confinement. Finding, after some 
months' trial, that the man was perfectly capable 
of pursuing his avocation, and that however much 
this particular delusion might still «xist, it had no 
bad influence on his conduct, he was discharged ; 
and he has continued to be well, and to provide for 
his family for several years. From his own account, 
as he got into his usual habits, the sensation gradu- 
ally wore away, and at last totally left him. Might 
not the appearance of specks before the eyes have 
arisen from some trifling disease of the optic nerve, 
or in the thalami nervorum opticorum ? In the 
latter, it is not improbable that there was some 
disorder in the auditory nerve, and that as this gra- 
dually recc. its tone, the sensation passed away. 
In this mode of considering the subject, it is 
obvious, that in determining whether or not an 
individual be a proper subject for confinement, it 

D 2 



36 ON THE NATURE OF INSANITY. 

is quite unimportant to find out whether his per- 
ceptions are erroneous, solely as regards one class 
of things, or are generally incorrect : as in the 
instance we have mentioned. We need not ask 
whether the patient supposes he sees specks on his 
own eyes,- or on the eyes, nose, face, or hody of 
every one else. If the illusion does not prevent 
him from fulfilling his relative duties in society, 
he ought not to be confined ; if it does, he ought. 

We must precisely in the same manner apply our 
former test, when the judgment, or the reasoning 
faculties, are so affected as to render the individual 
incapable of arriving at accurate conclusions on one 
or more subjects ; though it might at first be sup- 
posed, that a case of this kind could not occur 
without restraint being necessary. 

A man whose diseased brain leads him to imagine 
that he possesses a peculiar talent for oratory, 
music, poetry, or any thing else, of which he is, in 
reality, ignorant and incapable, certainly, as far as 
regards these subjects, cannot be said to be sane : 
but still his notions may not be such as to make it 
necessary to deprive him of his personal liberty. 
The decision in the case of Davies proves clearly, 
that the circumstance of a man erroneously sup- 
posing himself a great orator, was not considered 
by a jury sufficient to justify his 'nuation in 

confinement as a lunatic. And why? because, at 
the time of his examination, he was found to be 
capable of pursuing his accustomed avocations 



ON THE NATURE OF INSANITY. 37 

with his usual ability ; and, though eccentric in his 
thoughts and habits, perfectly harmless, and not 
unfit for society. The only reasons, in cases of this 
kind, which can justify the resorting to compulsory 
measures, are, that the symptoms indicate the exist- 
ence of a diseased action in the brain and nervous 
system, requiring remedies to which the patient 
himself will not voluntarily submit : although, in 
this instance, his conduct may fairly be considered 
to be injurious to himself, and thus, strictly speak- 
ing, he is included in our definition. This is a case 
unfortunately of too frequent occurrence ; for the 
very irritation of the brain and nervous system, 
which makes quiet and abstraction from all business 
absolutely necessary for the cure, at the same time 
creates in the patient an increased disposition to ac- 
tive exertion. The necessity, nevertheless, of employ- 
ing most decisive measures under these circumstances 
is evident, in whatever mode insanity shows itself. 

There are, however, cases in which an error of 
judgment, even on one point alone, makes the most 
forcible restraint immediately necessary ; — as, for 
instance, when a man considers that it is his duty, 
and that he shall benefit society by taking the life of 
another, by burning down a church, or when he 
imagines himself entitled to another's property, to 
which, in his sane moments, he would have known 
he had not the slightest claim, and forcibly proceeds 
to take possession. 

J. F., a butcher, about thirty-five years of age, a 



38 ON THE NATURE OF INSANITY. 

clever industrious man, showed symptoms of in- 
sanity by imagining- himself entitled to certain 
property. At first he only spoke of it to his family 
and friends ; but after a time, when the notion 
became more fixed in his mind, he went forcibly to 
take possession, and turn the owner out of his pre- 
mises. No disease being suspected, he was taken 
up, and sent to prison for the assault, instead of 
having proper remedies immediately applied to re- 
duce the diseased action of the brain. It is scarcely 
necessary to say, that as soon as the time of his 
imprisonment was over, on the first opportunity he 
made an attack again. It was not however until 
after some years, when the disease was too much 
fixed to be removed, that he was sent to the asylum 
at Wakefield. Upon all other subjects this man 
was rational. He was of an irritable temper, but 
very manageable by kind treatment ; was fond of 
gardening, and was trusted to kill the pigs, &c. used 
in the establishment. 

We might pursue the same train of reasoning in 
regard to those cases, where the insanity affects the 
sentiments or the passions, and bring forward many 
instances by way of illustration : — but it will be 
evident from what has been previously said, that in 
these, as in the other cases of insanity, in order to 
justify confinement, there must be diseased action 
sufficient either to render the individual incapable 
of managing his affairs, or to make his conduct 
injurious either to himself 6r to society. 



ON THE NATURE OF INSANITY. 39 

The instances, indeed, in which an individual can 
with safety be allowed to g^o at large, when his sen- 
timents or his feelings are affected, will not be so 
numerous as when the disease attacks the intel- 
lectual faculties only. For it is much more easy to 
fulfil the relative duties of life with diminished 
powers of perception or reflection, than to act 
correctly when under the influence of deranged and 
excited passions. 

In our consideration of this subject, we have 
hitherto had in view only those cases where there 
has been diseased action of the brain or nervous 
system, causing continued alteration in the notions 
and actions. Before we conclude this chapter, it 
will be necessary for us to observe, that there are 
cases when the symptoms so correspond with what 
we have stated as the marks of insanity, that, but for 
their cause, and the shortness of their duration, the 
individual might properly be considered insane. 
Intoxication is an instance of this kind : — in the 
acts of a drunken man we discover not only great 
alteration in his views, but conduct most injurious 
to himself and to society, and this arising entirely 
from the stimulus over-exciting the brain. — But 
though this alteration is merely temporary, ceasing 
when the effect of the stimulus, which he has 
voluntarily taken, has gone off; to exempt him 
from punishment for any crime which he commits 
under its influence, is most reasonably considered 
by the law unjust. 



40 ON THE NATURE OF INSANITY. 

By attending to the following distinction we 
shall, I think, be relieved from all difficulty on this 
part of our subject. If the paroxysms, however 
violent, result from causes within the immediate 
control of the individual, he ought to be amenable 
to the laws for his actions : if, on the contrary, they 
have their origin from sources entirely, or remotely, 
out of his reach, justice as well as humanity would 
attribute the act to madness, and forbid his punish- 
ment. 

Having then, in the present chapter, endeavoured 
to show what insanity is, we shall next proceed 
to investigate its causes, and the modes of their 
operation. 



CHAPTER III. 

ON THE CAUSES OF INSANITY. 

If our theory be correct, that Insanity, in all its 
various forms and modifications, is in reality a dis- 
ease of the brain and nervous system, the imme- 
diate causes of it may evidently be reduced into 
two classes : — the first class consisting of those 
which act primarily on the brain and nervous sys- 
tem; the second, of those which cause disease in 
them merely by sympathy. 

But before we proceed with this part of our sub- 
ject, it will be necessary to make some observations 
on the hereditary predisposition to insanity, which 
exists in different individuals. 

That there are certain constitutions in which 
there is an evident predisposition to particular dis- 
eases, is too well known to admit of the slightest 
doubt. The natural conformation points out some 
persons as particularly susceptible of apoplexy and 
phthisis ; others, again, from birth are liable to 
bilious diseases: analogy, therefore, independent of 
experience, would lead us to infer, that it is most 



42 ON THE CAUSES OF INSANITY. 

probable that the same tendency to morbid action 
which exists in other parts of the body should also 
be found in the brain. Again ; as we find that 
children resemble their parents in conformation of 
the body, in feature and complexion, and even in 
the colour of the eyes and the hair, it is but reason- 
able to conclude that there should be a like resem- 
blance in the structure of the brain and nervous 
system ; and that as other diseases, for instance 
gout, scrofula, phthisis, &c., are propagated for 
generations, so also should diseases of the brain. 
There cannot indeed be any doubt that insanity 
is an hereditary disease. 

Out of 1380 patients, there have been 214 whose 
parents or relatives we have ascertained to have 
been previously insane. In 125 of these cases no 
other cause could be assigned for the disease coming 
on than that of its being hereditary. In sixty-five 
there were various moral causes, in conjunction with 
this hereditary tendency ; and in twenty-four there 
had been blows on the head preceding the attack. 
If we had more complete information, I have no 
doubt but that the insanity would be found to have 
been hereditary in a much greater number. 

It does not however follow, that the offspring of 
parents who have been insane should themselves 
necessarily become so ; particularly if the insanity 
has existed only on one side. For instance, if it has 
taken place on the paternal side, the child may have 
inherited the constitution of its mother, or vice 



ON THE CAUSES OF INSANITY. 43 

versa. Again ; the brain of the parent who has 
been insane may not have been more than ordi- 
narily susceptible of disease, and yet, from either 
physical or moral causes, of a very exciting nature, 
insanity may have been brought on. Now though 
the same structure and constitution be inherited by 
the child, still, if not exposed to similar exciting 
causes, it may escape disease. But even if the 
brain of the parent who has been insane has had a 
very high degree of morbid susceptibility, which has 
descended to the child, yet, by carefully avoiding 
every exciting cause, it may pass through life with- 
out suffering from this direful calamity. It is very 
possible that, had not the sixty-five patients in 
whom the disease is said to have been brought on 
by moral causes, and the twenty-four, where it was 
preceded by blows on the head, been exposed to 
circumstances tending to produce the disease, they 
might have escaped ; but the hereditary predispo- 
sition existing, insanity was the result. 

On making inquiries of the friends and relatives, 
we find, that there are a great many patients, in 
whom no hereditary tendency could be traced, and 
who have become insane entirely from moral causes. 
Indeed, we are all probably more indebted for our 
sanity to circumstances and to education than we 
should at first be willing to acknowledge. When in 
early life the inclinations have never been thwarted, 
and the passions have been allowed to remain 
unsubdued, the disappointments and reverses of 



44 ON THE CAUSES OF INSANITY. 

fortune, which almost invariably attend every human 
being in his passage through this world, frequently 
cause such over anxiety in the mind, before unac- 
customed to restraint, that it is no longer capable 
of abstracting itself from the consideration of the 
painful events ; and its organ, the brain, from over 
exertion, becomes diseased as the consequence. 
When we find, then, that distressing circumstances, 
combined with the want of proper education, are 
very frequently sufficient to produce insanity in 
those who have no hereditary predisposition to it, 
how manifestly important is it for those who have 
the care of children, whose parents or ancestors 
have been deranged, to teach them from their 
earliest infancy, habits of self-government ; and 
afterwards to place them in situations of life where 
they may have the prospect of moderate and certain 
success, rather than the doubtful hope of aggran- 
dizement, with the possibility of failure ! 

There is at the present period a laudable anxiety 
to instruct children at a very early age. As far as 
this tends to their moral education, it is most advan- 
tageous : but I am afraid that the systems which 
exist in some infant-schools, will tend rather to 
weaken than to strengthen the brain, by too early 
calling forth the powers of the mind. In fact, the 
soft structure of the brain in infancy seems to 
indicate the impropriety of exercising it too much 
in its immature state : and how rarely do we meet 
with instances of those who have exhibited very 



ON THE CAUSES OF INSANITY. 45 

precocious talents, fulfilling the anticipations of their 
friends in after life ! But I am afraid that the 
intellectual powers not being eventually so strong 
as they otherwise would have been, is not the only 
mischief. The constant undue excitement of the 
brain, before the constitution has attained sufficient 
strength, will make the rising generation peculiarly 
liable to disease of that organ, and of the nervous 
system in general. 

There are some cases in which the hereditary 
predisposition to insanity seems to be so strong, 
that no mode of education whatever will apparently 
prevent its taking place, even in circumstances the 
most favourable. In many cases, upon questioning 
the overseers and the friends of the patients, who 
have been intimately acquainted with them for years, 
as to what brought on the attack, their answer 
has been, '' Their relations have been so before them, 
and we know no other reason." And upon the 
most careful investigation, we have not been able 
to discover any other cause, either physical or 
moral. But it is possible, that if we knew every 
circumstance connected with the case, some bodily 
complaint, too slight to have attracted the notice of 
any but a medical man, would have been found to 
have existed. Where the disease has assumed any 
particular form, this is also very frequently inherited, 
especially in cases of suicide. 

Sarah T., aged forty-two, the widow of a labour- 
ing man, had been insane eighteen months previous 



46 OM THE CAUSES OF INSANITY. 

to her admission. She was reported to have a strong 
tendency to suicide. Her mother and two of her 
sisters hung* themselves : she had made several 
attempts on her own life. In a short time she im- 
proved in bodily health, and she appeared not to be 
so much depressed : she continued sometimes better, 
and sometimes very desponding, for eight months. 
She was watched with the greatest care, and not 
permitted to be alone ; but notwithstanding every 
effort, she unfortunately contrived to secrete herself 
in a bedroom, and hung herself to the iron window- 
frame, and was not discovered until life was extinct. 

I cannot omit to mention in this place, that 
relatives by blood, intermarrying with each other, 
have a progeny prone to insanity. Why it is so, 
I do not presume to give an opinion; but of the 
fact I have no doubt, not only from what has 
come within my own knowledge, but from its 
having been particularly noticed by Dr. Spurzheim, 
and others, who have paid great attention to the 
subject: it cannot be too generally known and 
guarded against. 

We will now enumerate those causes which fall 
under our first division. 

One of the most obvious of these is a blow on 
the head ; it injures the brain, in the first instance, 
either by compression or concussion. W^hen the 
skull is fractured, so that the bone presses upon 
the brain, stupefaction is generally the immediate 
result ; this continues until the pressure is removed. 



ON THE CAUSES OF INSANITY. 47 

Very frequently, when no fracture has taken place, 
and stupefaction is the consequence of concussion 
only, the patient has recovered from it, but yet has 
subsequently died or become insane, in consequence 
of inflammation or irritation of the brain or its 
membranes, occasioned by the blow. It does not 
fall within the design of the present work to take 
into consideration those cases, where death has 
ensued from injuries of the head ; but a history of 
one or two instances w^here insanity has been the 
consequence, will tend to illustrate this part of our 
subject. 

Benj. K., a clever, sprightly lad, was employed 
as a farmer's servant, until he was 18 or 20 years 
of age. At this time, he received a blow on the 
head from a kick of a horse, which fractured 
the right parietal bone. The particulars attending 
the accident are not known ; but it appears that, 
after the trepan had been applied, he recovered 
from the stupefying effects of the blow ; but he ever 
afterwards exhibited a deficiency of intellect, and 
became subject to paroxysms of mania, particularly 
after taking an extra quantity of beer. Previously 
to being placed under my care, he had been for 
many years in the workhouse ; and, to prevent his 
running away and begging liquor, he had been 
chained to a log of wood, which weighed upwards 
of forty pounds — the iron ring to which this log 
was fastened being changed from one leg to the 
other, when the skin was worn off by its friction. 



48 ON THE CAUSES OF INSANITY. 

He was a most miserable spectacle when admitted : 
on the removal of the chain his legs quickly healed, 
and with the good diet of the house, his general 
health was soon restored ; but no improvement 
ever took place in his intellectual faculties. He 
was occasionally subject to pain in the head, espe- 
cially on getting rather fuller diet than usual. He 
afterwards became very stupid and somewhat inco- 
herent ; he was, however, soon relieved by the 
application of leeches, and a little purgative medi- 
cine. He continued in this state for four years, 
when he had a paralytic attack : he afterwards 
became fatuous, and died in about fourteen months, 
after having all the medical applications usual in 
such cases. 

George T., aged 55, was admitted, after having 
been insane two years ; but it seems he has never 
been perfectly well since he got a blow upon the 
head, by a piece of timber falling upon it ; how long 
before is not stated. He has been a very temperate 
man : attempted to cut his throat prior to admis- 
sion : was in a very feeble and emaciated state when 
admitted, and died in three weeks. 

Inspection, — Arachnoid membrane remarkably 
thickened, and opaque nearly throughout : here and 
there depressions, the size of a horse-bean, in the 
cortical substance of the cerebrum, where the opa- 
city was interrupted. Much serum was found under 
this membrane, making, together with what was 
in the ventricles, about eight ounces. Plexus 



ON THE CAUSES OF INSANITY. 49 

choroides very pale, with large and numerous vesi- 
cles : thorax natural : large intestines, full of foeces 
to a great extent. 

It not unfrequently happens that, after the 
patient recovers from insanity produced by a blow 
on the head, the brain and nerves are left in such 
a state of irritability, that a very trifling exciting 
cause is sufficient to bring on a recurrence of the 
disease. 

Matthew L., aged forty-five. In consequence of a 
disappointment in love, he enlisted as a soldier 
when seventeen : went first to the Cape of Good 
Hope, where he was five years, and was afterwards 
ten years in India. In storming a fort, he received 
a blow on the head, and fell from the wall : he was 
found after three days, and taken to the hospital, 
where he remained for some time in a state of 
blindness and stupefaction, and then became ma- 
niacal. After being fourteen months in that state, 
he was discharged, and sent home to England : 
during the voyage, he gradually recovered both his 
sight and mental powers ; and, on his arrival at 
home in 1821, nothing but weakness remained of 
his former complaints. Ever since, he has been 
liable to short paroxysms of violent passion ; and on 
drinking a small quantity of beer or spirits, such as 
before the accident he could take with impunity, 
he becomes restless, has sleepless nights, and, if he 
continues drinking for a few days, becomes insane. 
His temper has always been extremely firm, or 

E 



50 ON THE CAUSES OF INSANITY. 

rather obstinate : on his father offering to buy him 
a commission in the army, after he found he had 
enlisted, he refused it, unless he might marry the 
young woman to whom he was attached. He had 
had several attacks of insanity previously to his being 
placed under my care ; and he soon recovered. 
He has always been remarkably fond of travelling, 
and even now does not like to live long in one 
place. 

As we find insanity to be the result of com- 
pression from a blow on the head, may we not trace 
to a similar cause some cases which are attended 
with nearly equal stupefaction, and which cease as 
instantaneously as those do which have arisen from 
pressure of part of the skull upon the brain, on its 
removal ? As, in apoplexy, a very small quantity 
of blood suddenly effused, is sufficient to produce 
death, may not some part of the brain be internally 
pressed upon in these cases, by the sudden accumu- 
lation of a very little excess of fluid, yet still suffi- 
cient to cause the stupefaction ? Is it unreasonable 
to suppose, that this pressure may be taken off by 
some internal operation, as instantaneously as that 
of the bone by the trepan ? 

The following case will illustrate what is here 
meant : — T. J., a sailor, thirty years of age, was, 
when placed under my care, reported to have been 
insane only ten days ; but he was said to have had 
a slight attack a few weeks previously, for which no 
cause could be assigned. His temper was naturally 



ON THE CAUSES OF INSANITY. 51 

sullen, his habits sober : he was veiy taciturn, and 
refused his food. The pulse was natural, tongue 
white and tumid, and bowels costive. He took 
some brisk purgatives, after which his appetite im- 
proved ; but he continued restless, taciturn, and 
obstinate : the extremities were cold, with a pulse 
small and frequent. Continuing in this state, 
leeches were applied to the temples, and the purga- 
tives repeated : he seemed a little relieved bj these 
remedies, but continued silent, heavy, and stupid : 
the eyes were not red, and the pupils but little 
sensible to light, and there was not any flushing in 
the face. Purgatives were repeated, blisters applied 
to the back of the neck, and sinapisms to the feet. 
He continued much in the same state, and perfectly 
mute for about a month, when he had a very severe 
attack of dysentery. He recovered in about a fort- 
night, a good deal weakened by the disease, for 
which the usual remedies were applied ; but without 
the slightest change in his mental affection. Dur- 
ing the two following months, the warm bath was 
ordered ; and the latter half of the time, a perpe- 
tual blister was applied at the back of the neck, 
without producing any improvement. He was then 
seized with convulsions. The vessels of the tunica 
conjunctiva being much loaded with blood, leeches 
were applied to the temples, and his bowels kept 
open, and his usual bodily health soon returned ; 
but his mental disorder remained unaltered, and no 
impression could be made upon him by any moral 

e2 



52 ON THE CAUSES OF INSANITY. 

means. His wife and relatives came to see him^ 
and brought with them his child ; but he took no 
notice whatever of any one of them, and remained 
perfectly mute. He continued in this state for three 
months, until one morning when the keeper, on 
going into his room, was astonished to hear him 
inquire where he was. The patient told him, that 
when he awoke in the morning he found all his 
senses and powers of mind restored to him. He 
had no recollection of any event that had occurred 
for seven months. He continued perfectly well for 
some weeks, when he was discharged. During the 
time he was convalescent, all his old habits were 
resumed ; he enjoyed his pipe and tobacco, and the 
gait so peculiar to sailors returned, and he paced 
the galleries exactly as he would have done the 
deck of his ship. 

Coup de soleil is another instance of primary 
injury of the brain causing insanity. W. S., age 
thirty-five, married, and has six children ; has been 
employed in a warehouse, and has occasionally tra- 
velled for the house. During his journey in a very 
hot day, he felt himself extremely oppressed with 
the heat, and was seized with a violent pain in the 
head. His father thinks he has never been per- 
fectly well since ; for though no aberration of 
intellect took place until about seven weeks after- 
wards, yet his friends perceived a little unsteadiness 
in his gait, and a trifling stammering in his speech. 
The first symptoms of derangement which were 



01^ THE CAUSES OF INSANITY. 53 

observed were involuntary fits of laughter, great 
and unusual rapidity of expression, and general 
good-tempered excitability. Temper naturally 
mild, habits very temperate, bowels open ; he is 
reported to have been cupped, blistered, purged, 
&c., but at what period after the attack came on 
does not appear. He took nitre, squills, and digi- 
talis for about ten davs ; he afterwards continued 
the diuretics, with inf. gentian for about six weeks, 
occasionally taking jalap and calomel to keep his 
bowels open. He improved very much in his 
general health under this plan of treatment, but 
very little alteration took place in his mental mani- 
festations. He imagined that he possessed the 
power of instantly transporting himself from one 
country to another. After remaining about six 
months in this state he was removed home by the 
desire of his friends ; and I afterwards learnt that he 
gradually became fatuous, and died in about twelve 
months afterwards. 

G. B., age thirty-seven, single ; is reported to 
have been insane ten weeks. He says, that in one 
of the hot days in August, being too late for a 
coach by which he intended to go, he ran a consi- 
derable distance without his hat, and was imme- 
diately seized with a violent pain in the head, and 
had never been quite well afterwards. Bowels 
regular, temper mild, habits sober, pulse ninety- 
two, tongue furred ; imagines that he labours under 
syphilis, but has no symptom of that disease — is 



54 ON THE CAUSES OF INSANITY. 

much depressed. His bowels were kept open by 
small doses of rhubarb, he used the warm bath 
three times a week, and took tonic medicines. He 
gradually recovered, and was discharged, cured, in 
three months ; he continued perfectly well when the 
last accounts were received of him. 

Amongst the primary causes of insanity we must 
not forget to mention old age. It seldom happens 
that the decay of the body is so general and uniform 
that some one part of it does not show symptoms 
of disease, while the other parts remain unaffected. 
In many cases the limbs give way, and lameness is 
the first symptom of decreasing vigour ; in others, 
weak vision, loss of hearing, or disordered functions 
of the stomach or liver, announce a fast approaching 
dissolution. Now the brain in the same way becomes 
weakened and worn out ; we find in the loss of 
memory, defective judgment, diminished reasoning 
powers and altered views, symptoms of its disease. 
The most amiable of mankind, under this afflictive 
dispensation, so lose the power of restraining their 
feelings as to render themselves unfit for the society 
of their relatives and friends, and to make restraint 
and confinement absolutely necessary. It is, how- 
ever, consoling to reflect, that these painful changes 
are not the result of any alteration in the moral 
character, but solely of a disease of the brain. In 
all cases where we have examined the brains of 
those who had previously had senile insanity, 
considerable disease has been found. 



ON THE CAUSES OF INSANITY. 55 

Wm. D., aged seventy-five, has been insane two 
years ; it appears from the overseer, that he has 
for some time been m an imbecile state ; but, being 
harmless, very little notice was taken of him. He 
has lately been restless in the night, has wandered 
about for days together, and destroys his clothes. 
Temper sullen, habits sober. He was attacked with 
pulmonary disease, and died in about three weeks 
after admission. 

On examination, the dura mater was found 
adhering to the cranium. Arachnoid opaque to a 
great extent, with here and there white patches of 
organized lymph, and a good deal of serum under 
it. Pia mater very much thickened, its arteries 
minutely injected, and its veins enormously dis- 
tended ; the membrane being so tough and firm as 
to allow of its being pulled out entire from the 
whole of the cerebrum. The brain itself very 
flaccid, shrunk, and exsanguineous ; lateral ven- 
tricles contained about four ounces of serum ; the 
plexus choroides had hydatids attached to both 
sides ; septum lucidum open, cerebellum also flaccid. 
Some flakes of coagulated lymph were found on the 
surface of the right lung, and adhesion had taken 
place in several parts of the left lung ; contents of 
the abdomen nearly natural. 

Joshua L., aged eighty-eight, had been labouring 
under senile insanity between three and four years 
before his death. He was totally blind in the left 
eye, and the vision of the other was nearly gone. 



56 ON THE CAUSES OF INSANITY. 

On dissection the dura mater was found firmly 
adhering- to the cranium, the latter very thick ; 
brain soft, six ounces of serum in the ventricles ; 
optic nerves very flat and collapsed, with great vas- 
cularity in the brain just behind them ; basillary and 
other arteries much ossified, as well as the aorta 
and the iliacs. Left lobe of the lungs contained a 
good deal of pus. 

T. B., aged seventy-eight ; had been labouring 
under senile insanity for four years before his death. 
Arachnoid very opaque, firm, and nearly as thick as 
the dura mater ; between one and two ounces of 
serum between the membranes, and three ounces in 
the ventricles. Substance of the brain soft. 

Joseph I., aged seventy-five, had been insane 
some years before his death, the faculties having 
gradually declined. Arachnoid generally opaque, 
with serum underneath ; pia mater much thickened 
and consolidated. About two ounces of serum were 
found in the ventricles. 

C. H., aged seventy ; reported to have been 
insane only six weeks ; but his appearance and 
manner indicated senile insanity of much longer 
standing. There was a general diminution of the 
powers of the mind, with considerable feebleness of 
body, which daily increased. He died of chronic 
diarrhoea, about six months after admission. 

Post-mortem Examination. — Head— cranium thin. 
Arachnoid opaque, and much thickened in some 
parts 5 eight ounces of serum \vere found in the 



ON THE CAUSES OF INSANITY. 57 

ventricles : olfactory nerves softened ; brain gene- 
rally soft, and full of bloody points. Thorax — 
four ounces of serum in the left side ; great adhe- 
sions and venous congestion in the lungs, some parts 
of them hepatized. Abdomen — spleen and liver 
small and pale j pancreas tubercular. 

Apoplexy and Epilepsy will be the subject of 
future consideration, although I am aware that they 
are, by many writers, classed amongst the causes of 
insanity. But as both are always attended by a 
morbid state of the brain or its vessels, I think 
them rather the consequence of the same diseased 
action in the encephalon, (which, in some constitu- 
tions, would have produced insanity,) than the direct 
causes of it. In fact, as we know that there exists 
in certain individuals a liability to be attacked by 
some diseases, and a great indisposition to be 
affected by others, we ought not to be astonished 
at the different results which take place from 
similar causes acting upon the brains of different 
persons. 

By far the most general primary cause of diseased 
action of the brain, and therefore of insanity, is 
over-exertion. When the brain has been for too 
long a time intensely employed upon any subject, 
it is thrown into such a state of excitement that its 
operations are no longer under the control of the 
will : the incipient stage of insanity then com- 
mences, a superabundant flow of blood is propelled 



58 ON THE CAUSES OF INSANITY. 

to the head, irritation and want of sleep are the 
immediate consequences, and, if proper treatment 
be not applied, inflammation is the ultimate result. 
This diseased action, if unchecked, produces dis- 
eased organization, or that chronic state of insanity 
which is attended by congestion of the vessels, 
the opacity of the membranes, and serous effusion 
under them and in the ventricles, so generally 
found in the heads of those who have been insane 
for any length of time. 

To this over-exertion we must attribute an im- 
mense number of the cases arising from moral 
causes ; for, as the brain is the organ of the mind, 
not only will an undue exertion of the sentiments 
and the passions cause this irritation, but too conti- 
nued thought on subjects difficult to be compre- 
hended, or even on those which are within the grasp 
of our understanding, when they interest us too 
deeply, is quite sufficient to produce such over- 
excitement. 

Among the class of patients admitted into pau- 
per lunatic asylums, intense study is not a usual 
cause of disease. We select the following cases : — 

G. C, a very respectable young man, twenty-six 
years of age, was entirely dependent upon his bro- 
ther, a clergyman, who had himself but a small 
income and a large family. He was reading for 
orders ; and his anxiety to pass a good examination 
before the bishop, induced him to apply with such 
intensity as to bring on derangement. He had 



ON THE CAUSES OF INSANITY. 59 

been twelve months confined in a private asylum 
previously to his coming under my care : he is said 
to have been much depressed in mind ; he appeared 
in a weak, feeble state. He was put on a nutritious 
diet, and had half a pint of porter daily ; he took inf. 
gentian, and small doses of rhubarb occasionally, to 
keep his bowels open. An improvement was very 
soon evident both in the powers of his mind and body. 
This continued for about a month, after which no 
improvement took place mentally for five months, 
when he gradually began to recover his mental 
powers, and was discharged, cured, after having 
been nine months in the asylum. He was enabled 
soon after to pursue his studies, and obtained ordi- 
nation. When I last heard of him he was perform- 
ing his duties as a Christian minister, much to the 
satisfaction of his parishioners. 

The following case is a remarkable instance of a 
multiplicity of objects, not of themselves indivi- 
dually calculated to excite the mind, overworking 
the brain from their too rapid succession, and 
producing insanity. 

M. P., age twenty-one, a single woman ; had been 
insane about three months. The attack came on, in 
a slight degree, when she was in London, where she 
was on a visit. The novelty and great variety of 
the objects presented to her view^ brought on con- 
fusion of ideas, which she was unable to overcome. 
On her return to the country this confusion con- 
tinued, and she became insane. She has been very 



60 ON THE CAUSES OF INSANITY. 

much depressed ever since the disease came on, and 
attempted to hang* herself. She recovered perfectly 
in four months. 

Another female from the country, about twenty- 
five years of age, was in London for a short time, 
and was affected precisely in the same way ; except- 
ing that, instead of its producing the distressing- 
feelings with which the former patient was afflicted, 
she was very cheerful, was making- speeches, and 
acting as if she was constantly surrounded by com- 
pany ; and talked of nothing but the parks, theatres, 
squares, streets, &c. &c. The disease coming on 
gradually, but little notice was taken of the altera- 
tion in her manner and conduct : no remedies were 
applied for a long time, and the disease was found 
to be incurable. 

As the asylums at Wakefield and Hanwell are 
established solely for the reception of the poor, it 
will not be a matter of surprise that a greater num- 
ber of its inmates, both male and female, are sent 
thither through distressed circumstances, than from 
any other moral cause. These cases generally occur 
amongst married persons. Parents, in addition to 
their own personal sufferings from want of the com- 
mon necessaries of life, are continually enduring the 
most painful anxiety, from seeing their children, who 
look up to them for support, undergoing the same 
privations, without their being enabled to afford them 
any relief. It is a lamentable fact, that the most 
frequent instances of insanity, from this cause, are 



ON THE CAUSES OF INSANITY. 61 

amongst the honest and industrious. A poor man 
who has been in the habit of maintaining his family 
in respectability, has been, from depression in trade 
or some untoward circumstances, thrown out of 
employment, or not able with his utmost exertions 
to earn what has been sufficient for the bare suste- 
nance of his wife and children. He has been 
unwilling to apply to the parish for assistance ; or, 
when driven there by absolute necessity, has received 
such a scanty pittance from a harsh and unfeeling 
overseer, as barely to enable him to drag on a miser- 
able existence, with a body emaciated from want. 
The brain participating in this general weakness, is 
no longer able to endure the high state of action 
into which it is thrown by anxiety, without having 
its functions injured. 

J. P. had been a surveyor, and had a wife and 
large family. He was in tolerably good circum- 
stances, until he became bondsman for a person who 
failed, and he was called upon to pay the money. 
This involved him in difficulties which he could not 
overcome: he gradually became so reduced, as to 
be at last without the common necessaries of life. 
The daily scene of misery created an anxiety which 
in a short time rendered him insane. He was in a 
very feeble state when admitted into the asylum, 
apparently from insufficiency of nourishment. In- 
deed, he informed me, after his recovery, that 
frequently not having adequate food for his family, 
he left his house at dinner-time, to save them the pain 



62 ON THE CAUSES OF INSANITY. 

of seeing him fast, while they shared in a scanty meal. 
After a few months, proper diet, with active em- 
ployment, restored him. His mind was relieved 
by the promise of business on his discharge. He 
returned home, obtained employment, and conti- 
nued well. 

M. A. formerly moved in a very respectable 
circle. During many years, by her professional 
exertions in music and drawing, she contributed to 
the support of her aged parents, and obtained a 
sufficiency to purchase a house, besides some trifling 
amount of funded property. Age coming on, she 
was unable to follow her employments ; and, not- 
withstanding the most rigid economy, her little 
capital was soon expended. She was obliged, too, 
to part with her house ; and the purchaser, by 
taking advantage of her necessity, obtained it for 
one-third of its value. The grief and anxiety from 
these accumulated misfortunes, operated so power- 
fully upon her active and sensitive mind, that she 
became insane. 

M. R. formerly resided in London, and traded 
in ready-made baby-linen. By industry and eco- 
nomy she maintained herself comfortably, and, in 
consequence of an increased business, re-fronted the 
shop at her own expense. Soon after this, she 
received notice to quit; though the landlord had 
promised, when she made the alteration, to grant a 
lease for seven years. As he neither listened to 
remonstrance nor allowed any compensation, she 



ON THE CAUSES OF INSANITY. 63 

was obliged to leave the premises, and give up 
business. Having no other means of subsistence, 
the prospect of poverty harassed her mind, her 
anxiety brought on excessive watchfulness, and 
insanity followed. She came into the asylum a 
short time after the attack commenced. She was 
in a very maniacal state ; but this having been 
overcome, her attention was soon attracted to some 
work in progress in the bazaar established in the 
asylum, of a similar kind to that in which she had 
previously been occupied. She voluntarily offered 
to cut out some children's caps and other baby- 
linen ; from this time she began to recover rapidly, 
and was shortly afterwards discharged cured. 

J. C, about fifty years of age, once occupied a 
small farm, and had the management of another 
around the mansion of his landlord. He was highly 
respectable, and much esteemed by his master. 
During the depressed state of the agricultural and 
commercial interests, after the great panic in 1825, 
he began to lose money, and the utmost diligence 
and labour could not prevent his rent being in 
arrear. He was an affectionate father, and the 
prospect of a large family being reduced to poverty 
haunted him ; he became sleepless, restless, melan- 
choly, and unable to pursue his occupations, though 
convinced that great exertion was requisite to avert 
impending ruin. His family were unwilling to send 
him from home, and his landlord behaved kindly. 
As nothing could allay his irritable feelings, he 



64 ON THE CAUSES OF INSANITY. 

was, after a long unavailing struggle, sent to the 
Wakefield asylum. His head was hot, his extre- 
mities cold ; the stomach and bowels were disor- 
dered, and he had sleepless nights. Application of 
cold to the head, and warmth to the extremities, 
with proper remedies to restore a healthy action of 
the chylopoietic viscera, together with his being 
absent from his family and all those scenes which 
recalled his former painful feelings, soon restored 
him, and he returned to his occupation. 

This state of poverty, too, is not only a source 
from which the disease first originates, but it very 
frequently is the cause of relapses. Removal from 
the scenes of misery which have been so painfully 
felt, and occupying the mind with other objects, 
aided by the influence of good diet, have often pro- 
duced very salutary effects in a short time, and 
ultimately restored the patients to sanity. A return 
to the poverty which they had left, has, however, in 
many instances brought on fresh attacks almost 
immediately. This is a fact that cannot be too 
forcibly impressed on the minds of those whose 
duty it is to watch over the poor. A few pounds 
judiciously applied in such circumstances would 
often not only rescue a fellow-creature from the 
sufferings attendant on this disease, but, in addi- 
tion, save the parish the expense of maintaining the 
man himself, probably for life, and his family until 
they can provide for themselves. 

Within the last few years, by the miniificent 



ON THE CAUSES OF INSANITY. 65 

bequest of a thousand pounds from the late John 
Harrison, Esq., of London, to the Asylum at Wake- 
field, the visiting- magistrates of that institution have 
been enabled to bestow a donation of a few pounds 
on patients who have been discharged cured, when 
their circumstances have required such assistance. 
The cheering influence upon the mind from the 
possession of such a little independence, upon which 
they could rely without applying again to the 
overseers for assistance, until they could obtain 
employment, has, I have no hesitation in saying, in 
many instances, preserved them from the immediate 
recurrence of the disease. 

The following is a very striking case of the good 
effects arising from timely assistance being afforded 
when intense anxiety, arising from poverty, is the 
cause of insanity : — 

G. W., aged fifty-three, a weaver, of very sober, 
industrious habits, but with a large family, fell 
into very distressed circumstances from his wages 
being low, and having much sickness amongst 
his children. These combined brought on a fit of 
insanity. He was admitted into the Asylum at 
Wakefield, and after remaining eight months, per- 
fectly recovered. During his confinement, his 
eldest daughter, with most exemplary kindness and 
good feeling, had contrived, by great labour and 
the strictest economy, to support both herself and 
the younger children, without any assistance from 
the parish. But a year's rent of five pounds 



66 ON THE CAUSES OF INSANITY. 

becoming due, they were totally unable to provide for 
it. The landlord threatened to distrain ; and their 
loom, the only source of their maintenance, was 
about to be taken from them. The poor girl came 
over to relate the painful circumstance to her father, 
who was then convalescent ; but such was the shock 
produced by this intelligence, that in all probability 
he would have relapsed, had not the money for the 
rent been provided. This was done, and he went 
home with a thankful and joyful heart. 

I cannot forbear making an extract from a re- 
port of my intelligent successor at Wakefield, Dr. 
Corsellis. It will shew, in a very forcible manner, 
the great advantage derived from the fund. 

" A poor woman, the mother of a large family, 
was admitted from the township of Leeds, labouring 
under the most distressing melancholy, having 
several times attempted self-destruction. It was 
ascertained that debts to the amount of twenty 
pounds, a sum she had no prospect of ever being 
able to pay, were the originating cause of her dis- 
order. On investigation of the circumstances, the 
parish authorities of Leeds, with that humanity so 
peculiar to them, unhesitatingly agreed to allow 
the same sum towards liquidating the debt, as 
that awarded from Harrison's fund. The cre- 
ditors readily accepted ten shillings in the pound, 
and ten pounds discharged the whole debt. The 
relief of mind was soon apparent in the cheer- 
fulness of this honest creature ; she rapidly recovered. 



ON THE CAUSES OF INSANITY. 67 

and in a few months after was discharged perfectly- 
cured." 

Too intense thought upon religious subjects is 
the moral cause, which, next to distressed circum- 
stances and grief, has produced, as far as we have 
been able to ascertain, the greatest number of cases 
in the institution at Wakefield. Very few of the 
patients in the asylums on the Continent are said to 
have become insane from this cause. This great 
disproportion might at fii'st be matter of surprise ; 
but when we see that religious discussion is in some 
countries forbidden, from political reasons, and that 
in others it never takes place, from the general 
prevalence of infidelity amongst the higher orders, 
and ignorance and blind superstitious obedience to 
the dictum of the priests amongst the lower classes, 
the mystery is easily solved. As there are more 
sectarians of all kinds in England than in any other 
part of the world, except America, religion is more 
immediately brought home to the poor as a subject 
of thought and examination. Wherever a variety 
of opinion exists, and freedom of discussion is 
allowed, the attention is naturally roused, and the 
feelings become excited. And when the immor- 
tality of the soul, and the awful realities of eternity, 
are first impressed upon the mind of an individual, 
who has never before given the subject any serious 
thought, he is led to consider those objects which 
he formerly pursued with avidity as altogether vain 
and delusive, and to devote the whole of his time 

f2 



68 



ON THE CAUSES OF INSANITY. 



and every mental energy, exclusively to the inves- 
tigation of this now all-absorbing subject. When 
he finds that his conduct has been diametrically 
opposite to the pure morality of the gospel, and 
unhappil}^ applies to himself the awful denunciations 
of Scripture, without receiving the consolations of 
its promises ; the anticipation of that eternal misery, 
which he fancies to be his inevitable doom, conti- 
nually fills his mind with gloomy apprehensions, and 
eventually sinks him into the most suffering state of 
insanity, from the over action of the brain in think- 
ing on this subject. 

W. A., a cheesemonger, about thirty-six years of 
age, is married, and has a family. About ten years 
ago he became much alarmed by the denunciations 
in the Bible against wilful sin ; and the effect was 
so powerful, that he could not sleep at all for a 
fortnight. He then, being distracted, was sent to 
the workhouse, and from thence speedily removed 
to a private madhouse. Not finding any religious 
consolation, he determined upon making some 
sacrifice to obtain it. For this purpose, taking the 
words of Scripture in a literal sense, he attempted 
to pluck out his right eye. Self-injury was pre- 
vented, but he continued in agony, and generally on 
his knees, refusing every encoiiiragement or conso- 
lation. After enduring this state four years, he 
was conveyed to the Asylum at Hanwell, where he 
became by degrees more composed, and he was, 
after some time, persuaded to attempt shoemaking. 



ON THE CAUSES OF INSANITY. 69 

This had a happy effect ; he gradually recovered, 
and was discharged. He remained at home, and 
provided for his family one year and five months. 
Another attack then coming on, he was sent back 
to Hanwell, and remains there alternately sane 
and insane. 

M. D., aged forty-two, has been insane some 
years. Erroneous views on religion are said to be 
the cause of the disease. 

It appears, that some years ago she was living 
with a married cousin and her husband. She was 
in the habit of repeating to the husband the con- 
versations which passed between her cousin and 
herself, especially when he had been the subject of 
them, and had been spoken of with opprobrium. 
In consequence of these communications, quarrel 
took place between the husband and wife, and they 
eventually separated. She became extremely sorry 
for her conduct when it was too late. She con- 
sidered that she had been guilty of a great crime, 
and that no pardon from God would ever be shown 
to her for it ; and to this hour she entertains the dis- 
tressing and erroneous idea, that she has sinned the 
unpardonable sin against the Holy Ghost, and that 
eternal misery is her inevitable doom. She is 
generally in delicate health, and is kept as much 
employed as possible, to divert her mind from the 
gloomy thoughts which continually obtrude them- 
selves upon her. 

T. A., thirty years of age, had been insane one 



70 ON THE CAUSES OF INSANITY. 

year before admission. The disease came on gra- 
dually, from intense thought and anxiety on religious 
subjects. He was married, but had led rather a 
dissolute life, and, though not a drunkard, was in 
the habit of spending his time, and the money which 
ought to have supported his family, at the public- 
house. He became awakened to the true state in 
which he stood as a sinner before God ; and over- 
looking all the promises of pardon contained in the 
gospel to those who truly repent, or imagining they 
could not apply to him, he became miserable. He 
saw nothing but condemnation before him, without 
one ray of hope. His sleep was gone, — the brain, 
overworked, lapsed into a state of great irritability, 
and insanity followed. In his hallucination he 
imagined that he w^as different from all other men, 
not only in the operations of his mind, but in the 
formation of his body ; that he was without blood. 
Having requested, in vain, that he might be bled to 
prove it, he one day took an opportunity of seizing 
a knife, and with one blow he nearly severed the 
fore finger of the left hand. Though the operation 
convinced him of this error, others remained equally 
as absurd. His mind was always in such a state of 
perturbation that he could not for a long time com- 
pose himself sufficiently to settle to any employment. 
By degrees light at length dawned upon him ; he 
began to perceive that though the threatenings of 
the Scriptures are most alarming to the impenitent, 
yet the hopes and consolations they contain to the 



ON THE CAUSES OF INSANITY. 71 

repenting sinner are equally powerful ; and with 
this confiding- view he was enabled to lay aside all 
his unnecessary anxieties. The overwrought action 
of the brain had happily not produced diseased 
organization ; he perfectly recovered, and returned 
to his family, a better and a happier man than he 
had ever been before. 

The next primary moral cause which we shall 
notice is Grief. Females form by far the largest 
proportion of this class. The greater part of them 
have become deranged from loss of their children. 
After what Ave have already said, it will be unne- 
cessary to point out the steps by which insanity, 
from this cause, may also be traced to over-action 
of the brain. As in the preceding cases, irritation, 
want of sleep, and subsequent inflammation, are the 
general symptoms and consequences. 

R. W., a female about forty-five years of age, has 
been insane some time. She lost two or three 
children very suddenly, either from fever or small- 
pox. She was a most affectionate mother, and 
became inconsolable for her loss. At the time of 
her admission, all the violence of her grief had 
abated. She seemed to have forgotten the parti- 
cular circumstances of their death, and appeared 
only conscious of their absence, without being able 
to account for it. She used constantly to walk 
about the gallery and bed-rooms, looking behind 
every door and into every corner, expecting to find 
them ; and, if she could wander into the garden, or 



72 ON THE CAUSES OF INSANITY. 

about the premises in any direction, her only busi- 
ness was to seek for her children, and then return 
lamenting" her disappointment. By degrees, she 
was induced to employ herself. She recovered 
her health, and ultimately got quite well, and was 
discharged about eighteen months after her ad- 
mission. 

S. T. had been insane two years when admitted. 
She was sitting with her husband at breakfast, and 
remarked to him, that she thought he appeared 
unwell ; but he said, *' No, he was much as usual." 
In a short time she left him, and went up stairs. 
She had scarcely gone out of the room, when she 
heard a sudden noise, as if something had fallen 
down ; she immediately ran down stairs, and found 
that her husband had fallen out of his chair on the 
ground, and was unable to rise. He spoke to her, 
and she ran to the next door, to send some one for 
medical assistance ; but when she returned, he was 
a corpse. In consequence of this sudden bereave- 
ment, she was left with four children entirely des- 
titute. A subscription was raised on her behalf: 
but the effect of this sudden shock on the nervous 
system produced a depression of spirits so over- 
whelming, that she was incapable of attending to 
any thing : she could obtain no sleep, and was 
accustomed to walk her room, in an agony of grief, 
all the night long. Notwithstanding every kind- 
ness that could be shown to her, she became worse, 
and was ultimately removed to a public hospital. 



ON THE CAUSES OF INSANITY. 73 

from which she was discharged as incurable. She 
at length died from pure exhaustion. 

H. G., aged thirty-six, had only been insane 
three weeks when admitted. She was in a most 
distressing state of misery, arising from poverty and 
remorse. It appears that, some time ago, she was 
reduced to the most abject beggary, and unable to 
obtain food for herself and her little boy, who was 
about four or five years old. Under this pressure, 
she was induced to sell her child to a chimney- 
sweeper for a guinea. She had scarcely done the 
deed before she repented of it ; and she set out 
to find the man, return the money, and reclaim her 
child. She soon became much excited, she wan- 
dered about all night in every direction, but could 
not hear any tidings of him. In addition to the 
painful feelings thus naturally produced, she had 
the mortification either of losing, or of being 
robbed of, the very guinea for which she sold him : 
this she considered a just punishment for the crime 
of which she had been guilty. She continued 
wandering about from place to place, going to 
all the chimney-sweepers she could hear of, and 
making every inquiry, but all in vain. Her child 
was never found again. The health of the body 
and powers of the mind, as might be supposed, at 
length sunk under the united effects of want and 
anxiety. She was picked up as a lunatic vagrant, 
and sent to the Asylum at Wakefield, where I left 
her unimproved, two years after her admission. — 



74 ON THE CAUSES OF INSANITY. 

In this instance, remorse was, probably, as much 
the cause of the insanity as grief. 

The violence done to the natural affections, as 
recorded in the above cases, is not however the only 
mode in which grief brings on the disease. The 
following is a striking instance of its occurring from 
a purely moral feeling. 

J. F. had been a porter eighteen years in one 
warehouse, and he possessed the confidence of his 
employer. There was a general order for all the 
inmates to return to the house by ten o'clock at 
night ; this he disobeyed ; and displeasing his master, 
a misunderstanding took place between them, 
which terminated in separation. The loss of his 
situation and of his master's confidence overwhelmed 
him with anguish ; and though he entered into 
business with most favourable prospects, he was 
unable to attend to it, and did not succeed. This aug- 
mented his grief, and sleep was banished by constant 
watchfulness, accompanied with pain in the head. 
These symptoms increasing, he became insane, and 
was removed to an asylum. He has partially re- 
covered, but has been subject to relapses ever since. 

There are, however, one or two moral causes, 
the powerful effects of which upon the system are 
universally acknowledged, but by no means easy of 
explanation. How are we to account for the mode 
in which sudden joy or terror sometimes instanta- 
neously destroys life, and sometimes as instantane- 
ously brings on idiocy or insanity ? 



ON THE CAUSES OF INSANITY. 75 

Several instances of death, produced by the sud- 
den effects of Joy, are mentioned by Dr. Mason 
Good ; and he also gives the particulars of a case 
which occurred to himself, in the person of a clergy- 
man with whom he was intimate, but whose death 
was not so immediate. 

This gentleman, who had consented to be nomi- 
nated one of the executors of the will of an elderly 
person of considerable property, with whom he was 
acquainted, received a few years afterwards, and at 
a time when his own income was but limited, the 
unexpected news that the testator was dead, and 
had left him sole executor, together with the whole 
of his property, amounting to three thousand pounds 
a-year in landed estates. He arrived in London in 
great agitation, and on entering his own door 
dropped down in a fit of apoplexy, from which he 
never entirely recovered ; for though he gained 
his mental and much of his corporeal faculties, 
his mind was shaken and rendered timid ; and 
hemiplegia had so weakened his right side, that 
he was incapable of walking further than a few 
steps. 

A melancholy instance of the sudden effect of 
terror happened a few years ago in the north of 
England. A lady had gone out to pay an evening 
visit, at which she was expected to stay late. The 
servants took advantage of the absence of the family 
to have a party at the house. The nurse-maid, in 
order to have enjoyment without being disturbed 



76 ON THE CAUSES OF INSANITY. 

by a little girl who was entrusted to her care, and 
who would not remain in bed by herself, determined 
upon frightening- her into being quiet. For this 
purpose she dressed up a figure, and placed it at 
the foot of the bed, and told the child if she moved 
or cried it would get her. In the course of the 
evening the mother's mind became so forcibly im- 
pressed that something was wrong at home, that 
she could not remain without going to ascertain if 
any thing extraordinary had occurred. She found 
all the servants dancing and in great glee ; and on 
inquiring for her child, was told that she was in bed. 
She ran up stairs and found the figure at the foot 
of the bed, where it was placed by the servant, and 
her child with its eyes intently fixed upon it, but, 
to her inexpressible horror, quite dead. 

A case occurred within my own observation, 
where insanity was the immediate consequence of 
fright. A woman was walking through the market 
of a town in Yorkshire with her husband, and seeing 
a crowd, she went to learn the occasion of it, when 
a large dancing bear, which a man was showing the 
public, suddenly turned round and fixed his fore 
paws upon her shoulders. She became dreadfully 
alarmed. She was got home as soon as possible ; 
but the excitement was so great, that she could not 
sleep, nor could any thing persuade her but that the 
bear was every moment going to devour her. At 
the time I first saw her, which was some months 
after the occurrence, she was in the most pitiable 



ON THE CAUSES OF INSANITY. 77 

state of distress, obstinately refusing all food, which 
she thought was only given to her to fatten her for 
the bear. She got no sleep, and was in great terror 
from hearing the noise of the steam engine^ which 
was near the ward in which she was placed. She 
was removed into another, out of the sound, as she 
imagined, of the grumbling of the bear ; and she 
afterwards slept better. She was kept alive for nine 
months by food being forced into the stomach, but 
never without having to overcome all the resistance 
she could possibly make. In the end she became 
consumptive, and died. 

In these, and similar cases, the immediate effect 
of the sudden shock upon the nervous system is to 
diminish the action of the heart ; and where death 
is the result, this action ceases entirely. When the 
shock is not so violent as to cause an entire stop- 
page, the heart gradually resumes its functions ; 
but the circumstances which caused the shock con- 
tinue vividly impressed upon the mind, and produce 
excessive action in the brain ; and we find in these 
cases, after the first effect has subsided, the same 
watchfulness and excessive sanguiferous action in the 
brain, which accompany insanity when it arises from 
any other moral cause. The manner in which 
idiocy is brought on, is of more difficult explanation. 
It is probable that in these cases the brain sustains, 
from the sudden retreat of the blood, some physical 
injury, which is never afterwards recovered ; but 
after all our surmises, we must acknowledge our 



78 ON THE CAUSES OF INSANITY. 

ignorance of the precise mode in which the senses 
act, so as to produce such powerful effects. 

Mortified pride, disappointed love, jealousy, and, 
in fact, any other feelings which excite the brain to 
undue action, produce insanity as effectually as any 
of the moral causes of it which we have previously 
enumerated. The following are some of the cases 
which have come under my own observation, where 
it has originated from these feelings : — 

J. W. had been insane twelve months. He was 
a young man about twenty-three years of age, whose 
connexions could not be considered as paupers, nor 
would he have become one had he not been ren- 
dered incapable of any employment by an attack of 
insanity. He had been an apprentice to a retail 
shopkeeper in the country. He had a fine person 
and pleasing manners, with a large share of self- 
esteem, combined also with much love of approba- 
tion. He was altogether a very romantic person ; 
and having fallen in love with a young lady, he felt 
no doubt in his own mind that, as soon as his inten- 
tions were made known, he should be accepted. 
He was very pedantic in his manner ; and being 
anxious that all his proceedings should be conducted 
in the most correct manner, he proceeded very 
formally to make his proposals. To his utter 
astonishment, they were not only rejected, but he 
was dismissed, to use his own expression, ^' with 
the most contemptuous scorn." This was more 
than his offended pride could bear. It was not the 



ON THE CAUSES OF mSANITY. 79 

loss of the lad J that affected him so much as the 
mode in which his offer had been received. It 
totally overcame him ; he could g-et no rest night 
or day, and incurable insanity followed. At the time 
of his admission he had lost all the painful feelings 
which annoyed him on the first coming on of the 
disease, and he amused himself by imagining that he 
was some great man. He was very obliging, and 
for a long time assisted as a clerk in the office. He 
died of consumption about eleven years after his 
admission. 

E. C, a female about thirty years of age : how 
long she has been insane is not exactly known. 
This case, like the preceding, was the consequence 
of offended pride. She was a fine young woman, 
but of ambitious views. She too, had become 
attached to a person in a more elevated situation 
of life than herself; and the mortification of being 
rejected, on account of the difference of rank, was 
a wound to her pride which she could not brook : 
she became incurably insane. Many years of men- 
tal suffering have not in the least tended to abate 
her self-esteem ; and though she acts as a servant, 
in which capacity she lived before the attack, when 
unemployed in actual domestic duties, she never 
fails to display her pride, by assuming a very digni- 
fied carriage, and acting with the greatest hauteur 
towards all around her, especially if she has an 
opportunity of doing so befoj-e strangers. She is 
extremely fond of dress; but, in order to excite 



80 ON THE CAUSES OF INSANITY. 

attention, will adorn herself even grotesquely, 
rather than not be thoug"ht singular. The grati- 
fication of these harmless passions appears to afford 
her much pleasure. She is in general very happy, 
but there is no hope of the disease ever being 
cured. 

M. T., aged thirty, has been insane four months. 
Cause of the attack, disappointment in love. She 
formed an engagement with a young man, about six 
years ago ; and he left her, after promising mar- 
riage. She says, that she has never been com- 
fortable in her mind since, though she has worked 
regularly until within a few weeks. But she has 
shown evident symptoms of derangement : she 
neglected her business, and returned to her friends, 
saying, her state of mind would not permit her to 
work. About a week before her admission, she 
passed a whole night in the street, and she has 
since meditated self-destruction. Was discharged, 
cured, in eleven months. 

E. S., aged thirty-seven, is married, and has been 
insane five years from jealousy of her husband. 
She has been a laundry-woman, was twelve months 
at St. Luke's, and afterwards went to visit her 
friends in Dorsetshire. She has a most violent 
antipathy to her husband, and no kindness or con- 
ciliation on his part at all softens it. He is very 
attentive, and brings her tea, and other little luxu- 
ries not provided in the house ; but all are ungra- 
ciously received, and sometimes she adds blows to 



ON THE CAUSES OF INSANITY. 81 

her words. When she is employed, which, happily 
for herself as well as others, is generally the case, 
she is tranquil ; but the slightest allusion to her 
husband is sufficient at once to throw her into a 
paroxysm of rage. 

M. D., thirty years of age, had been insane only 
a few weeks. She had been brought up as a dress- 
maker, but unhappily had been seduced by an 
officer, to whom she was very much attached ; 
after living with him for some time, he deserted 
her for another. Grief, mortified pride, and jea- 
lousy, all combined, produced a state of excitement 
which ultimately ended in insanity. She had sleep- 
less nights, the natural secretions were disordered, 
and violent mania was the consequence. It hap- 
pened unfortunately that my wife had so strong a 
resemblance to her rival, that nothing could per- 
suade her but that she was the identical person. 
In consequence of this similarity, whenever she 
went into her presence her rage knew no bounds. 
This irritation was avoided as much as possible by the 
patient being usually shut up in her own room before 
the former passed through the wards ; but on one 
or two occasions, unfortunately, this precaution had 
been neglected, and the patient flew upon her with 
the savageness of a tiger, and literally pulled nearly 
all the clothes from her person before the nurses 
could rescue her from her grasp. On a subsequent 
occasion she accidentally found herself alone with 
her in an upper gallery, used only as a dormitory ; 

G 



82 ON THE CAUSES OF INSANITY. 

she disappeared on a sudden, when my wife instantly 
ran to the door, and had just time to get through 
it before she came up. When out of sight she had 
gone into one of the rooms to get a large leaden 
pot, with which she said she had intended to murder 
her. She was not violent against any one else, and 
would sometimes even beg of her, as she had got 
her lover from her, that she would be kind to him. 
She died of consumption in about two years. 

Having considered those causes which act prima- 
rily upon the brain, whether physical or moral, let 
us now proceed to investigate those, which affect it 
by sympathy. It will be scarcely necessary to enter 
into any argument to prove, that the brain and 
nervous system sympathize with every other part of 
the body. Upon what other supposition could we 
account for the fact, that the irritation of teething, 
worms in the intestines, punctures in different parts 
of the body, will give rise to convulsions, which are 
universally allowed to be the consequences of dis- 
ordered brain ? The morbid action of the part pri- 
marily diseased, spreads itself along the whole chain 
of nerves, until it reaches the sensorium ; irritation 
is caused there, and hence arise the convulsions. 
This irritation, however, when once produced, will 
not always cease on the discontinuance of the cause ; 
and thus the convulsions frequently remain for some 
time after the primary cause of them has been 
removed. It is precisely in the same manner that 
diseases of the stomach, liver, lungs, intestines, &c. 



ON THE CAUSES OF INSANITY. 83 

SO operate upon the brain as to produce insanity. 
A large class of patients from sympathetic causes, 
and by far the most easily cured, are those who 
have become insane from disorder of the chylopoietic 
viscera. A train of hypochondriacal symptoms 
usually exists in them for a length of time before 
they can be pronounced decidedly insane. 

F. G., aged forty-one, has had repeated attacks of 
insanity. No cause for the disease coming on can be 
assigned but the disordered action of the chylopoietic 
viscera. He is an honest, sober, and hard-working 
man, an affectionate husband, and a kind father, except 
when suffering from this distressing malady. The 
attacks are usually preceded by his tongue becoming 
white and furred, his breath foetid, digestion bad, with 
pain in the epigastric region, and bowels costive ; he 
begins to be restless, complaining of some pain in 
the head ; the eyes become red, and he imagines 
invisible spirits come to tell him of his wife's infi- 
delity. It often requires very active purgatives to 
procure evacuation, and it is necessary to relieve 
the head by local bleeding and cold applications. 
As soon as these objects are accomplished, the 
symptoms gradually abate ; and as no real moral 
cause exists to keep up the disordered action, it sub- 
sides altogether ; but it is necessary to be extremely 
attentive to the state of the digestive organs, not 
only when he is recovering, but when he is in his 
best health ; for if he allows the digestive organs to 
become disordered, an attack of insanity is as sure 

G 2 



84 ON THE CAUSES OF INSANITY. 

to follow, as quinsey does in those liable to that 
disease, when they have been exposed to severe cold. 

It is often very difficult to determine whether the 
disease of the chylopoietic viscera has not in reality 
arisen from, instead of produced, diseased action of 
the brain ; as the stomach, intestines, &c. sympathize 
quite as much with the brain as the brain does with 
them. When, however, we are unable to find out 
any other cause for the mental alienation, and per- 
ceive that it ceases as soon as the secretions are 
restored to a healthy action, we have a right to con- 
clude that the origin of the disease has been in the 
chylopoietic viscera. 

We have many cases of insanity where the brain 
has apparently become affected by sympathy with 
diseased lungs. But as in the early stages of it, 
disease is rarely found to exist simultaneously in 
both the lungs and the brain, but rather appears to 
alternate from one to the other, our ignorance of 
the previous history of the patients, and the impos- 
sibility of finding out how long a disease of the lungs 
may have existed undiscovered, makes it most diffi- 
cult for us to determine which of the two has first 
been attacked. In many cases this form of insanity 
seems to be combined with hereditary predisposition. 

Many years ago I had a very interesting young 
woman under my care, a Moravian, who had been 
labouring under cerebral excitement for some little 
time, but by no means violent. No cause was 
assigned for the disease coming on. She had been 



ON THE CAUSES OF INSANITY. 85 

educated, as persons of that sect generally are, 
with the strictest attention to all the moral virtues ; 
and her whole conduct and demeanour, notwithstand- 
ing her insanity, were so engaging as to interest 
every one around her. She was not long before 
she began to improve mentally ; but as the mind 
improved, it was evident some disease was going on 
in the chest. She began to have a cough, with a 
slight pain in her side. She had the usual remedies 
applied under such circumstances, which had the 
effect of diminishing the symptoms ; but no sooner 
did these begin to subside, than the excitement again 
commenced in the cerebral organs. After a period 
these again abated ; but as sanity returned, the 
pulmonary disorder came with it ; and thus first one 
affection, and then the other, alternately predomi- 
nated, until nature sank under the successive attacks. 
J. J. had been insane about twelve months before 
his admission. He was a painter and glazier, and 
succeeded his father, who had died a short time 
before, leaving him a good business and some pro- 
perty. He no sooner got into possession of this, 
than he began to launch out into extravagant 
expenses, much beyond his means ; and instead of 
being diligent to increase his income, so as to meet 
his enlarged expenditure, he neglected his business 
altogether, and finally became a bankrupt. This 
alteration in his circumstances, combined with in- 
temperate habits, brought on insanity. A very con- 
siderable improvement took place in him mentally, 



86 ON THE CAUSES OF INSANITY. 

after he had been confined about three months; 
and he employed himself at his business, and 
was about to be discharged, when he was seized 
with hoemoptysis. He recovered from this attack ; 
but as the disease of the chest abated, the cerebral 
excitement was increased to a much greater degree 
than it had ever been before. Ultimately phthisis 
came on, and in the same degree as the diseased 
action of the lungs became violent, there was in 
general an abatement of the maniacal symptoms, 
though from the first attack of the pulmonary 
complaint, he could scarcely ever be said to be 
so sane as he had been immediately prior to its 
coming on. 

Exposure to cold, which in most constitutions 
produces inflammation of the lungs, rheumatism, 
quinsey, &c. is not unfrequently the immediate 
cause of insanity in those who have a great predis- 
position to disease of the brain. 

T. C, a labouring man, thirty-nine years of age, 
is reported to have been very maniacal for ten days. 
He had been washing sheep, and exposed to cold 
and wet, particularly in his lower and upper extre- 
mities, for some days prior to the attack. This 
appears to have been the immediate cause of its 
coming on ; but it is stated that he had an uncle 
insane, and he had himself suffered a disappointment 
in not receiving some money which a relation had 
left him by will. He died exactly three months 
after admission. There was but little disease 



ON THE CAUSES OF INSANITY. O/ 

observable in the brain. Half an ounce of serum 
was found in the ventricles, and the arachnoid was 
opaque. 

W. F., a blacksmith, age twenty-eight, had been 
insane twelve months prior to admission. He is 
reported to have had no symptom of the disease 
until he went into a cold bath about a week before 
he was attacked. At the time of going in he was 
in a state of great perspiration. It appears from his 
wife, that an alteration in his manner was perceived 
almost immediately after : he became low and de- 
sponding, his temper was naturally bad. He re- 
covered in about three months. 

Much of the insanity amongst the agricultural 
labourers is to be traced to their exposure to cold, 
and to the vicissitudes of the weather, combined 
with their poverty and their indifferent diet. 

Not only do we find that exposure to partial cold 
and checked perspiration are causes of insanity, but 
such a sympathy seems to exist between the brain 
and the skin, that in some individuals, when a 
cutaneous eruption has been repelled, a seton or 
an issue dried up, or an old ulcer healed too rapidly, 
the disease has been transferred to that organ, and 
has produced insanity in some cases, paralysis in 
others ; and as the brain suffers from the stoppage 
of an external discharge, so also is the same effect 
produced by the sudden suppression of the natural 
secretions and internal evacuations ; whether they 
be healthy and natural, as the menses and the milk. 



88 ON THE CAUSES OF INSANITY. 

or unhealthy, as in hoemorrhage from the hmgSy 
nose, piles, &c., or in diarrhoea. 

R. H., aged twenty-four, had been for many years 
a nursery maid in a family of distinction. She 
was a young woman of exemplary character, and 
esteemed for her kindness and attention to the 
children. An alteration had been perceived in her 
conduct for eight or nine months before I saw her. 
She had become anxious and melancholy, without 
any apparent cause. Her former activity and 
diligence were succeeded by languor and irksome- 
ness in every act. She complained to me that she 
seemed to have lost all mental feeling ; the children 
on whom she used to doat, and a respectable young 
man, to whom she was shortly to have been married, 
after an engagement of some continuance, were 
now both disregarded by her, and she could not 
account for this ; in fact, all natural affection 
seemed gone. She more especially lamented, that 
religion had lost its usual power to comfort her : 
all was changed. At this time she lived with a 
cottager, whose wife was a laundress, and had a 
family. On inquiry, I found that the catamenia, 
from what cause she was unable to explain, had not 
appeared for some time prior to the presence of 
these symptoms ; the bowels were costive, and 
the liver torpid. After she had taken alteratives 
and emmenagogues, and used the hip bath for 
some time without effect, leeches to the labia 
pudenda relieved her on their first application. 



ON THE CAUSES OF INSANITY. 89 

The secretions afterwards took place in their 
natural course, and she got perfectly well. During" 
the time when she was using the remedies, she was 
actively employed in walking to considerable dis- 
tances, and took an interest in needle-work. She 
returned to her situation, and has since married the 
young man to whom she was engaged before her 
indisposition. 

Women who have any predisposition to insanity, 
seem, both during pregnancy and immediately after 
delivery, more susceptible of its attacks than at any 
other periods. An inflammatory diathesis is, in fact, 
so commonly an attendant upon the state of gesta- 
tion, that during some part of the time, in many 
cases, it is found necessary to abstract a few ounces 
of blood from the system. Now when the brain is 
the part attacked, and the disease is allowed to go 
on unchecked, insanity is very frequently the result. 

M. N., about thirty-four years of age, became 
insane during pregnancy. No other cause could be 
assigned for the appearance of the disease coming on. 
She was in a state of great excitement when admitted, 
and continued so for two months, when she was con- 
fined. Very soon afterwards an alteration for the 
better took place ; the cerebral irritation gradually 
ceased. No untoward circumstances whatever oc- 
curred. She soon became interested in her child, 
and maternal feelings overpowered every other. She 
was discharged perfectly well within three months. 

The following case was accompanied by distressing 



90 ON THE CAUSES OF INSANITY. 

melancholia ; but it disappeared as rapidly as the 
former after child-birth. The patient became insane 
about three months after pregnancy had taken place ; 
but she was not sent to the Asylum until three 
months afterwards. She was then in a state of 
melancholia. She took no notice of any thing- 
around her, and was perfectly mute. She was con- 
fined about two months after her admission. The 
pains of child-birth at once aroused her dormant 
feelings. The child was still-born ; but all the 
secretions coming on in the natural course, she 
quickly recovered. It appeared from her own 
statement that she had long been living in a state of 
concubinage with a man to whom she had borne 
several children ; but so deeply was she now im- 
pressed vrith the sinfulness of her conduct, that, 
though the man repeatedly came to her and urged 
her to return, no solicitation could prevail ; she 
would not even see her children, unless she was 
first married. The man was very fond of her, (and 
they appear to have lived unmarried more from a 
thoughtlessness of the vice, than from any objection 
to marriage on his part,) and he readily consented. 
The banns were properly proclaimed in the parish 
church, the parties were married from the Asylum, 
and she returned with him to her former abode and 
family, cheerful and happy. 

After delivery, insanity more frequently arises 
from the brain sympathizing with the uterus, from 
the stopj)age of the lochia, or from its sympathizing 



ON THE CAUSES OF INSANITY. 91 

with the breasts, from cold, or any other cause 
interrupting- the secretion of the milk. 

J. G., about thirty-five years of ag-e, had been 
insane about six weeks when admitted. The disease 
came on four days after her confinement. She says, 
she awoke with an impression that the nurse had 
overlaid her child. A fever immediately ensued, 
the natural secretions ceased, she became sleepless, 
and insanity followed. She was in a very high state 
of mania when she arrived, — incessantly talking, 
mischievous, and destructive ; tearing in pieces her 
clothes, bedding, and whatever came in her way. 
It was some months before any improvement took 
place. The bowels and other secretions were at 
length brought into their natural order, when she 
began to recover. In the course of a few weeks 
afterwards she was induced to work in the garden. 
From this time her recovery v/as very rapid. Her 
husband and friends came to see her, and she was 
much cheered by it, having only before seen them 
when she was incapable of appreciating the kind- 
ness of their visit. She was perfectly recovered 
and restored to her family in ten months. 

M. A. B., a single woman, about twenty-four 
years of age, had an illegitimate child a few months 
before her admission. She is reported to have 
taken cold soon after her confinement ; this was 
attended with fever, the flow of milk ceased, and 
insanity was the immediate consequence. Very 
little information could be obtained respecting her. 



92 ON THE CAUSES OF INSANITY. 

Her head was hot, and her bowels costive. She 
continued in a low, depressed state, refusing to 
occupy herself in any way for a considerable time. 
The natural secretions were disordered, and difficult 
of correction. It was not until fourteen months 
after her admission that she became interested in 
some new work, the spinning of twine, which had 
just been commenced in the ward where she was. 
This she was persuaded to attempt, and by degrees 
she employed herself in it many hours a day. The 
exercise of w^alking up and down the gallery, one 
hundred and eighty feet long, had a most beneficial 
effect. She soon began to improve in her general 
health, all the secretions became regular and healthy, 
and in a few months she was quite well. 

E. S., aged fifty-seven, has been more or less 
insane twenty-four years. She says, she was first 
attacked after she had been confined about a week ; 
she caught cold, when the milk, and other secretions, 
immediately ceased. She recollects being extremely 
violent, and getting out of bed without any clothes. 
She was sent to one of the public hospitals, and 
remained there some time. She recovered suffi- 
ciently to go into service for a short period, when 
she again became deranged, and has been alter- 
nately better and worse ever since. She has occa- 
sionally a maniacal paroxysm, but it lasts only a 
short time. 

Where puerperal insanity has once occurred, 
whenever pregnancy takes place subsequently, the 



ON THE CAUSES OF INSANITY. 93 

irritation very frequently reproduces the disease. 
We have had several cases of relapse under similar 
circumstances. This, however, may sometimes be 
prevented by carefully watching" all the premonitory 
symptoms, and guarding- against it. 

H. S., aged twenty-five, the wife of a kind-hearted 
labouring man, was brought to bed of her second 
child in June, 1821 : about ten days afterwards she 
became insane. Her husband was unwilling that 
she should be sent to the Asylum, and she was kept 
at home for two months. She was then admitted as 
a patient into the institution at Wakefield ; she 
was in a very emaciated state, with a quick and 
feeble pulse, bowels confined, wild and incoherent 
in her language, and the countenance showed that 
much diseased action was going on in the brain. 
The bowels were kept open by aperients, a blister 
was applied to the back of the neck, and the 
general health supported by nutritious diet. She 
was a little relieved by these means. On the fourth 
of October she had improved in her bodily health, 
and was also more rational. From this time until 
the ninth of November, little alteration took place 
mentally. She had then grown stouter in person, 
but was very little better in mind, and she com- 
plained of pain in the head: the bowels were 
confined. There had been no appearance of 
the catamenia since her confinement. Leeches 
were ordered to be applied to the temples. She 
took emmenagogues, and her bowels were kept 



94 ON THE CAUSES OF INSANITY. 

regularly open. From this time she improved daily ; 
she became quite rational, and was discharged cured 
about four months after her admission. 

Soon after her next confinement, which took 
place in about two years, symptoms similar to those 
which preceded the former attack made their appear- 
ance ; a sudden cessation of the secretions, quick 
pulse, hot and dry skin, with confusion of mind. 
She became much alarmed at these feelings, appre- 
hending another attack. As she lived very near 
me, I had an opportunity of seeing her immediately. 
Similar remedies to those applied two years previ- 
ously were again resorted to, and not only was the 
violence of the attack prevented, but its duration 
was so short, that at the end of the month she was 
quite well. 

Insanity is also the result of fevers, whether they 
be of an inflammatory, or of a low, debilitating 
nature, in the first instance, by the too rapid cir- 
culation of the blood through the brain ; and in the 
second, from the weakness left by the disease in that 
organ, which continues when the other parts of the 
body have recovered their healthy tone. 

The great mischief arising in practice from con- 
founding the delirium of fever with insanity, by 
which it is often succeeded, will make a few obser- 
vations, to enable us to distinguish between the two, 
highly necessary. 

In delirium from fever there is a total derange- 
ment of all the intellectual faculties. The powers 



ON THE CAUSES OF INSANITY. 95 

of perception suffer no less than the reasoning and 
affective faculties ; the language of the patient is 
confused, and generally an unintelligible mass of 
words without any definite meaning. 

Now in insanity it never happens that all the 
intellectual faculties are at the same time disordered, 
except when the patient becomes delirious from 
fever, to which he is of course as liable as those 
who are sane. The insane possess a knowledge of 
the objects around them, and a power of reasoning, 
although incorrectly ; whilst in delirium, volition, 
and even consciousness seem to be suspended. We 
may also be certain, that, when the disordered action 
of the brain has continued some time after the fever 
which caused it has ceased, and the pulse is natural, 
whatever else may be the symptoms, the patient is 
insane, and not delirious. 

B. C, a female, twenty years of age, came over 
from Ireland with a family as a servant. She had 
not been long in England before she was taken ill 
with a fever, which continued for some time. No 
information could be obtained of the treatment ; 
but we learnt that after the other symptoms of fever 
abated, the brain continued very much excited. 
She was in a high state of mania when admitted, 
and she continued very noisy, dirty, and destruc- 
tive, notwithstanding every effort to relieve her, for 
six months ; during the whole of this time her 
appetite was good, and she appeared but little 
affected by the disease, except that she grew thinner. 



96 ON THE CAUSES OF INSANITY. 

A trifling abatement was after this time observed to 
take place ; she began to sleep a little in the night, 
which she had scarcely done previously. She was 
permitted to walk about without personal restraint, 
and became quite well at the end of ten months. 

J. B., a tailor, twenty-six years^ of age, has been 
insane five weeks : the disease was brought on by 
fever. At the time of his admission he was labour- 
ing under great maniacal excitement ; pulse quick, 
and head very hot. He says, he had drunk a con- 
siderable quantity of rum before the fever came on. 
Cooling applications to the head, and the usual 
remedies to restore the secretions to a healthy state, 
soon allayed the disease. He became rational in 
about fifteen days, and at the end of seven weeks 
was discharged cured. 

Vice, in all her forms, tends to weaken the con- 
stitution, and, so far as the brain participates in the 
general debility, to produce insanity. But there is 
a vice, the secret and unsuspected indulgence of 
which seems, in addition to its weakening the 
general powers, to have a specific and direct 
tendency, in many constitutions at least, to operate 
upon the brain and nervous system. Would that I 
could take its melancholy victims with me in my 
daily rounds, and could point out to them the awful 
consequences, which they do but little suspect to be 
the result of its indulgence. I could show them 
those, gifted by nature with high talents, and fitted 
to be an ornament and a benefit to society, sunk into 



ON THE CAUSES OF INSANITY. 97 

such a state of physical and moral degradation as 
wring's the heart to witness ; and still preserving, 
with the last remnant of a mind gradually sinking 
into fatuity, the consciousness that their hopeless 
wretchedness is the just reward of their own mis- 
conduct. This painful subject is more fully dis- 
cussed in a note at the end of the volume. Other 
details, not exactly suited to meet the eye of the 
general reader, will also be omitted in the text, and 
similarly inserted. 

From the reports that we receive with our patients, 
inebriety appears to be a very frequent cause of 
sympathetic insanity. In every case of drunken- 
ness a morbid action exists in the brain ; this gene- 
rally ceases, and the brain recovers its tone in a few 
hours ; but there are some constitutions in which, 
if the stimulus be repeated for a hw days in suc- 
cession, the irritation and excitement of the brain 
continued after the cause has ceased, and the man 
becomes insane. 

T. J. when admitted had been insane some years: 
it was his third attack. He was a butler in a gentle- 
man's family, where he remained for nine successive 
years. His first attack was brought on by exces- 
sive drinking. He went into Wales to visit his 
friends, and whilst there he indulged too freely in the 
use of spirituous liquors, which produced a nervous 
irritability of the brain, disturbed and sleepless 
nights, and for a short period he was quite uncon- 
scious; he was sent to an Asylum, where he 

H 



98 ON THE CAUSES OF INSANITY. 

remained some time, and was discharged. Being' 
out of a situation, and unable to obtain his former 
place, he gave way to despondency and grief, and, 
with a view to relieve his feelings, he again had 
recourse to spirituous liquors, which soon brought 
on another attack. From this he also recovered 5 
but such is now the irritable state of his brain, that 
upon the least excess a return of the disease comes 
on ; at other times he is perfectly rational and 
capable of performing a variety of duties in the 
establishment. He has lately learnt to make sweep- 
ing brushes. 

II . W., eighteen years of age, had been insane 
about three months before admission. He was left 
an orphan when young, and placed under the care 
of a guardian. His father had left him a little pro- 
perty, but not sufficient to live upon without pur- 
suing some business. After leaving school he was 
consequently bound apprentice to a brush-maker. 
He soon began to associate with the dissolute, and 
became intemperate. He was dissatisfied with his 
trade, and conscious of possessing some little pro- 
perty, was impatient of control. He ran away 
from his place. Some time after he thought he 
should like to become a shoemaker ; the guardian 
placed him with one ; but, as might be expected, 
he soon fell into his former vicious habits, and 
again left his employment. He next obtained a 
situation as waiter at a tavern, where he had con- 
stant opportunities of freely indulging his inclina- 



ON THE CAUSES OF INSANITY. 99 

tion to drink. This he did almost without restraint, 
until he brought on a very high state of mania. 
It is not known what remedies were used during 
the first three months of the attack, but he was 
in a state of the most furious mania when ad- 
mitted ; and notwithstanding every effort was made 
to subdue it, he continued in that state for eight 
months before it could be overcome. He after- 
wards got quite well, and has returned to his 
shoemaking. 

But it is not in this immediate and direct way 
only that the intemperate use of fermented liquors 
brings on insanity. The free indulgence in the use 
of them, it is well known, produces venous con- 
gestion of the liver, and a disordered state of the 
chylopoietic viscera in general. In constitutions 
where there is a tendency to this disease, either from 
an hereditary taint, or from any other cause, this 
congestion and disordered viscera often occasion 
functional disorder in the brain, and will, if un- 
checked in such constitutions, engender insanity as 
certainly as it follows from the effects of drunken- 
ness repeated day after day ; and more especially is 
this the case if, whilst labouring under this dis- 
ordered state of the digestive organs, any moral 
cause, even of a slight nature, should arise to pro- 
duce much anxiety of mind. 

Delirium tremens, which is the result of habi- 
tually drinking ardent spirits to excess, is, in many 
cases, the precursor of insanity. 

h2 



100 ON THE CAUSES OF INSANITY. 

The ultimate effects produced upon the nervous 
system from taking opium to excess, are very similar 
to those which arise from spirit drinking ; but as 
this vice is one not generally committed by the 
lower orders, either in Yorkshire or Middlesex, but 
few cases occurring from this source have come 
under my observation. 

It is well known that inanition is a cause of 
insanity. Where men have, from peculiar circum- 
stances, been deprived of food for a long time, as is 
the case with sailors who have remained at sea for 
days or weeks together in an open boat, almost 
entirely without provisions, before death has released 
them from their sufferings, insanity has very fre- 
quently intervened. 

But even where the deprivation of food has not 
been endured to such an extent, yet the gradual 
diminution of it causes such a general ^veakness in 
the constitution, in which the brain participates, that 
insanity is often the consequence. The cases, how- 
ever, of this kind which have come under my obser- 
vation, have been so combined with poverty and other 
distressing circumstances, that they can hardly be 
said to have arisen entirely from inanition ; though 
better diet, aided by moral treatment, without any 
medicine, has very frequently restored them. 

Gout, which has been classed by many authors as 
a cause of insanity, is of such rare occurrence 
amongst the poor, that very few cases from this 
source have fallen under my notice. We have not 



ON THE CAUSES OF INSANITY. 101 

had one instance where, as far as we could ascertain, 
gout has been the cause of insanity ; but I have no 
doubt that if it, or any other disease, be suddenly 
repelled, it will, in some constitutions, fly to the 
brain. 

Dropsy is another disease, which my own expe- 
rience would not lead me to assign as a cause of 
insanity. That dropsical affections have existed to 
a considerable extent amongst the patients, both at 
Wakefield and Hanwell, I cannot deny ; but they 
have usually occurred amongst those who have long 
been previously insane, and have generally been 
the symptoms of a gradual breaking up of the con- 
stitution rather than the cause of the disease. They 
are generally soon after followed by death. 

We have now enumerated most of the usual 
causes of insanity, and referring to our previous 
classification of them, it will be seen that such of 
them as affect the brain primarily, are either phy- 
sical injuries, or an over-exertion of the whole, or of 
some part of it, produced by moral causes ; whilst 
our second class comprises all those cases where the 
disease of the brain has been the result of its sym- 
pathy with some other diseased part of the body. 
But whatever may have been the cause, in a very 
large proportion oi post mortem examinations of per- 
sons, who had been insane for some time previous to 
death, the appearances of the brain clearly indicate 
the existence of long continued inflammatory action, 
that is, of an unhealthy excess of blood ; and omit- 



102 ON THE CAUSES OF INSANITY. 

ting the consideration of cases of compression wliicli 
we have already noticed, may not its progress be 
thus traced ? The brain, or more frequently some 
portion of it only at the commencement of the 
disease, being unduly exercised, or suffering from 
irritation, caused by sympathy with some other 
diseased part of the body, demands and receives an 
accelerated supply of blood ; this accelerated supply, 
unless the cause be removed, continues, the tone of 
the brain gradually becomes weakened, and a mor- 
bid structure eventually takes place, not only in the 
portion of it at first attacked, but by degrees in the 
whole mass, and in the membranes. The effusion 
of serum in the ventricles, and under the mem- 
branes, is the consequence of this diseased accele- 
rated action ; and it increases in quantity as the 
disease advances. The fact that pain is frequently 
not felt in any part of the head is no objection to 
the theory, as on dissection it has been discovered 
that organic disease has existed to a very great 
extent, yet the patients had never complained of any 
pain ; nor does the circumstance that in mania, 
large bleedings have seldom produced much perma- 
nent relief, militate against it. In all those cases 
where insanity has not arisen from direct physical 
injuries, the result of the excessive bleedings from 
the system is to weaken the strength of the patient, 
but not necessarily to remove the cause of the 
diseased action. If that be purely moral, of course 
this will be unaffected by the bleeding, and will still 



ON THE CAUSES OF INSANITY. 103 

continue to produce an over-exertion of the brain, 
or of some part of it ; and although the general 
volume of the blood will be diminished, yet the brain 
will receive an undue share of that which remains 
in the system, and the delusion, which is the result 
of this diseased action, will continue. If the cause 
of the disease be sympathy, the bleeding will be of 
use or not, according as it affects the disease of the 
part with which the brain sympathizes ; but this 
subject will be considered more fully in the chapter 
on Treatment. 



CHAPTER IV. 

ON THE SYMPTOMS OF INSANITY. 

In the first chapter we have entered so fully into 
a description of insanity, that we have, in a great 
measure, anticipated the subject of the present one, 
at least as far as regards its general outline. Its 
various modifications are so numerous, that it would 
be quite impossible, in the limits to which we pro- 
pose to extend this work, to give an account of 
each. 

As utility is the principal object in view, it will 
be only necessary, then, to state those modes which 
are really important, and of the most frequent 
occurrence. 

The misery which would be prevented, were the 
premonitory symptoms of its approach but gene- 
rally known and carefully attended to, will amply jus- 
tify our extending our inquiries to these symptoms. 

When organic lesion of the brain exists, one of 
the first symptoms that is observed, is, that the 
intellectual faculties gradually become confused, the 
senses appear benumbed, there is embarrassment in 



ON THE SYMPTOMS OF INSANITY. 105 

speaking, and a general difficulty of articulation, as 
if the tongue had suffered a slight paralysis. In this 
stage the patient when roused will be able to give 
rational answers to questions of the kind that are 
usually put to him. 

As the organic disease increases, we find a torpor 
in the limbs, and a gradual indisposition to any 
muscular exertion. The circulation becomes lan- 
guid ; there is a great congestion of the vessels of 
the extremities, particularly of the feet and legs, 
which are cold, purple, and often oedematous. A 
gradual emaciation of the system takes place, until 
at last death terminates the automatic existence. 

When insanity arises from slow, spontaneous, 
inflammatory action of the brain, or its membranes, 
it is often, though not always, preceded by severe 
and continued pain in some part of the encephalon, 
which every mental exertion tends to increase ; a 
variety of ideas seem to float across the mind with- 
out making the slightest permanent impression ; 
there exists a consciousness, that the mind is wan- 
dering without a power of controlling its operations. 
Sometimes the senses become extremely acute, that 
of hearing in particular. When this spontaneous 
inflammatory action has proceeded so far as to cause 
insanity, the symptoms are the same as when the 
insanity has arisen from diseased action, produced 
by moral causes, which we shall notice immediately. 

Intense abstraction of mind may be considered as 
the first alteration that is observable in the great 



106 ON THE SYMPTOMS OF INSANITY. 

majority of patients who become insane from moral 
causes. The ordinary duties of life are either alto- 
gether neglected, or only performed upon the press- 
ing solicitation of friends. After this state has 
continued for a short time, it becomes necessary, if 
we wish to arrest the attention of the patient, to speak 
to him loudly and repeatedly ; and when at last he 
seems conscious of what is said, he appears as if just 
aroused from a dream, and relapses into the same 
state of forgetfulness, as soon as the sound of the 
voice has ceased to vibrate in his ears ; his whole 
air and manner evidently indicate that the inner 
man is dwelling upon a subject far different from 
that about which he is being addressed. The 
general desire to please no longer influences the 
character, and the dejected looks, and the forlorn 
dress, sufficiently proclaim that the mind is entirely 
absorbed in its own contemplations. 

This is the period when the alarm of friends 
ought to excite them to the most active measures ; 
this is the time when the advice of a physician is 
truly desirable. There is now an opportunity of 
resorting with success to measures, which will pre- 
vent the coming on of a malady, the treatment of 
which is at all times difficult, and which, if neglected 
at the commencement, is attended with circum- 
stances the most painful to the patients and to their 
friends, and too frequently sinks the unhappy 
sufferers into a state of hopeless wretchedness, from 
which no remedies whatever seem able to release 



ON THE SYMPTOMS OF INSANITY. 107 

them. I cannot refrain from mentioning- a case 
which fell under my own observation, and which 
will' exemplify, in a striking manner, the conse- 
quences of neglect on the one hand, and of timely 
attention on the other. 

Sarah C, aged twenty-eight, married, and has 
several children, was admitted into the Asylum at 
Wakefield in August 1824. She had been insane 
about five months. She had an aunt insane ; but 
neither her father nor mother had been so. The 
attack came on from great anxiety, in consequence 
of one of her children having been lamed. Her 
husband and friends were unwilling to send her away, 
until, in a fit of despondency, she cut her throat very 
severely, and lost a great quantity of blood. After 
her admission, no medical remedies were required, 
except purgatives on the bowels becoming costive, 
and the application of a few leeches to the temples 
in October, in consequence of pain in the head. 
She gradually recovered, and was discharged Decem- 
ber 10th. She continued quite well until July 
1830, when she became abstracted, was seized with 
continued pain in the head, had restless nights, 
and said she felt much as she had done at the com- 
mencement of the former attack. She was greatly 
depressed in spirits, and alarmed at another coming 
on. The digestive organs were much disordered : 
head hot : pulse quick. I ordered twelve leeches 
to be applied to the temples, her head to be shaved, 
and kept constantly cool by thin cloths dipped in 



108 ON THE SYMPTOMS OF INSANITY. 

cold water, and her feet warm by the pediluviuni. 
She took calomel and ext. colocynth as a brisk 
purgative. Her head was soon very much relieved ; 
and after taking- rhubarb, soda, and ginger, in small 
doses three times a day, for about a fortnight, she 
recovered both her health and spirits, and did not 
exhibit the slightest appearance of derangement. 
As no moral cause existed at home to keep up the ex- 
citement, I did not think it necessary to remove her> 
and she continued there during the whole period of 
the attack. This patient's life was nearly falling a 
sacrifice to neglect in the first instance ; in the latter, 
timely attention entirely warded ofi' the attack. 

The silent abstraction most frequently arises from 
depressing causes. The symptoms of insanity pro- 
duced by joy and unexpected success assume a 
different character. Under these circumstances, 
the alteration, wdiich displays itself in the increased 
quickness and vivacity of the demeanour, the con- 
tinued talking, and extravagant expressions of hope, 
is as indicative of an unhealthy action of the brain 
and nervous system, and requires to be as carefully 
watched on its very first appearance, as the depress- 
ing symptom of abstraction which we have just 
described. It must not be supposed that in order 
to make precaution necessary, incoherence must 
exist ; or that the mind when called into action 
should be incapable of displaying its usual powers. 
These are amongst the last and severest conse- 
quences of an unhealthy action in the brain, which 



ON THE SYMPTOMS OF INSANITY. 109 

may exist without producing them for a consider- 
able period ; but as every prudent man, when he 
feels a pain in his chest, and a teasing* cough, 
attended with fever, indicating an inflammatory 
action going on in his lungs, does not wait until the 
expectoration of pus has taken place, to denote that 
the disease has already reached the state of phthisis, 
before he sends for his physician ; so ought we to 
consider the premonitory symptoms we have men- 
tioned, as the evidence of a diseased action of the 
brain having commenced, of which insanity is the 
end. And as we should look upon this even with 
more horror than we should upon consumption, so 
ought we still more carefully to use every possible 
expedient to prevent its approach. I know an 
instance where a man became insane from a sudden 
access of prosperity ; but no notice was taken of his 
altered conduct until he ordered a carriage and 
four to go to London to pay off the national debt. 
His friends then saw the necessity of placing him 
under medical care. It was too late ; the disease 
had been allowed from neglect to gain a hold which 
was never recovered. 

When insanity arises from the brain sympathizing 
with the chylopoietic viscera, the premonitory 
symptoms are dyspepsia combined with hypochon- 
driasis, of which it is unnecessary to give a parti- 
cular account. After the unhealthy action of the 
brain has proceeded to such an extent as to pro- 
duce insanity, its symptoms, from whatever cause it 



110 ON THE SYMPTOMS OF INSANITY. 

may primarily have arisen, depend very much upon 
the natural character of the patient, except in the 
case of organic lesion of the brain, which we have 
mentioned already. One of the most frequent 
modes in which these mental aberrations exhibit 
themselves, is by inducing a constant feeling of sus- 
picion. The patient continually fancies that every 
one is combining against his happiness ; his most 
intimate friends and connexions, probably from 
being more immediately in contact with him, are 
the most frequently suspected, and are the subjects 
of his greatest aversion. In these, as in all other 
instances of mental delusion, every attempt to con- 
vince the patients by reasoning of the extravagance 
of their notions, is worse than useless, 

T. P., about sixty years of age, a short, fat man, 
with a red face, indicative of having been a hard 
drinker, came into the Asylum after having been 
insane only a few weeks. The symptom first 
noticed was his altered manner to his wife, with 
whom he had formerly lived very happily, but 
whom he suspected of having determined to take 
away his life. He was convinced she intended to 
poison him by mixing arsenic with the sugar which 
he put into his tea. Upon no other subject did he 
appear the least irrational ; but this delusion so 
haunted him, that he could settle to no business. 
He was continually moving about from one place to 
another, drinking considerable quantities of brandy 
and water at the same time. It was necessary, at 



ON THE SYMPTOMS OF INSANITY. Ill 

length, to send him to the Asylum. The abstaining 
from spirits, and leading a temperate life, made a 
considerable improvement in him ; but he still 
retains the notion that his wife intends to poison him. 

Religious delusions, as will be readily anticipated 
from what has before been said on the effects of 
over-anxiety on this subject, are another very com- 
mon symptom of insanity. The whole topic of the 
patient's thoughts and conversation, is the eternal 
perdition that he feels assured inevitably awaits 
him. This excessive anxiety about religious sub- 
jects is often found amongst those who have led the 
most virtuous and moral lives. The same cautious 
feeling which produces such distressing fears for 
the future, has, when not over-excited, been pre- 
viously the means of preserving them from falling 
into gross vices. Many patients, particularly fe- 
males, imagine that they are bewitched. 

Mary W., aged forty-three, a remarkably fine 
woman, with very soft and pleasing manners, but of 
abandoned character, had been insane several years 
when admitted. The only symptom of derange- 
ment she ever exhibited, was that of imagining she 
was beset with witches. When at home, and 
occupied with her domestic concerns, she was quiet 
and industrious ; but at other times she would go 
about the house with a lighted candle, threatening 
to burn it down. I have frequently known her get 
lip in the most violent agitation, go into the passage, 
and fight the witches, with whom she was continually 



112 ON THE SYMPTOMS OF INSANITY. 

holding long- conversations ; but her principal inter- 
course with them was in the night. It seldom, 
indeed, happened that she had not a violent com- 
plaint to make in the morning of the ill treatment 
she had been receiving from them. They had 
pinched and bruised her all over, and vvould allow 
her to get no rest. The nurse used to report that 
she often heard her fighting with them the greater 
part of the night. She remained several years in 
the Asylum, and, with the exception of her libidi- 
nous manners, conducted herself remarkably well. 
She was very industrious, good tempered, and 
obliging ; but to the end of her life she retained the 
notion that she was always under the influence of 
witchcraft. 

S. ¥/., about thirty years of age, has been insane 
for four years. This patient has no other symptom 
of the disease but her peculiar notion of witchcraft. 
She considers that she is under the influence of 
three witches, one of blood, one of spirits, and 
another of death, and that each takes possession of 
her in turn. She is sometimes filled with the blood 
of other people, her own being first abstracted. If 
a patient in the ward, or one whom she has known 
in any other part of the house, dies, she imagines 
the spirit witch transposes the body of the dead 
patient into her, and she suff'ers exceedingly from it. 
Nothing can persuade her but the witch of death 
frequently comes to her and stops the action of her 
heart for a season, and then suddenly departs. 



ON THE SYMPTOMS OF INSANITY. 113 

Another imagines that witches have power to 
throw gas upon her, so that she is almost suffocated 
with it. She says, the first feeling she had of the 
kind, "was on one evening when she was looking at 
herself in a glass, she suddenly saw something which 
she could not comprehend, and became dizzy. She 
afterwards found it was high witchcraft, and that, 
besides throwing gas, the witches have the powder of 
putting electricity into every part of her body. She 
says, she is always glad of employment, for that they 
then keep most away from her. The result, which 
her experience has taught her, that the mental 
delusion is the least powerful during the time of 
active employment, is not, as we shall have occasion 
to observe, confined to the cases where witchcraft 
is the subject of it. 

It ought to be mentioned, that very few of the 
cases admitted into public institutions, where the 
disease has arisen from erroneous notions of sus- 
picion or witchcraft, are entirely cured ; and I attri- 
bute it to the following cause : the diseased action 
of the brain comes on so slowly, and the conse- 
quences of it are apparently so little injurious, 
either to the patient himself or to society, that 
it is permitted to go on unattended to, until 
it has existed for a very long period, and be- 
come a habit of the constitution, until, in fact, 
the notions interfere with the regular duties of 
life, and prevent the patient's having any intercourse 
with society. 



114 ON THE SYMPTOMS OF INSANITY. 

Another very curious and frequent effect pro- 
duced in the mind by insanity, is the hypochon- 
driacal supposition of the existence of venereal 
diseases. So strong" is this delusion, that in one 
instance, although there was no possibility of the 
disease having existed, the patient fancied she had 
been infected by it in some unaccountable mode, 
and could not rest satisfied until put under a course 
of what she imagined to be mercurial medicines. 
After having taken these for a time, though nothing 
more than pills made of bread-crumbs, the patient, 
from the expectation that they were to produce 
salivation, spat such a quantity of saliva as to require 
a vessel constantly by her side for that purpose. 
After this had continued for some time, she ima- 
gined that the medicine had produced its effect ; 
she discontinued the bread pills, and the excessive 
action of the salivary glands ceased. 

Another very frequent symptom of insanity is 
the patients' entertaining very high notions of their 
own consequence and ability. It would be an end- 
less and useless task to give the history of all the 
emperors, kings, queens, and nobles that we have 
had in our pauper establishment; even Omnipotence 
itself has not wanted a representative. 

It has been stated in a former part of this work, 
that when there has been an hereditary liability to 
insanity, it is very apt to recur precisely in the same 
manner from one generation to another ; and that 
this particularly happens in the case of suicide ; 



ON THE SYMPTOMS OF INSANITY. 115 

but not only does a tendency to suicide exhibit 
itself where there has been any hereditary predis- 
position to that particular form of the disease, but 
it is unfortunately a very general, and in many cases 
the only symptom of insanity, where there is no 
hereditary tendency to it. 

Some persons are constitutionally so depressed 
and melancholy in their dispositions^, that as the 
mode in which insanity exhibits itself depends very 
much on the natural character, the unhealthy action 
of the brain, occasioned only by some trifling cir- 
cumstance, which to persons of another temperament 
would almost pass unheeded, in them increases the 
feelings of gloom and despondency to such an extent 
as to lead them to the commission of suicide. This 
is only, however, a symptom of insanity, and may 
reasonably be expected to be removed as speedily 
as most other forms of the disease. The conse- 
quences of it are so direful, that the most early and 
unceasing watchfulness is absolutely requisite. 

Patients having this propensity, will have their 
periods of convalescence and of exacerbation pre- 
cisely in the same manner as those, whose insanity 
assumes any other form, have their lucid intervals 
and paroxysms. I have known them remain for 
weeks together without the slightest disposition to 
injure themselves. In fact, in these patients, as well 
as in those who are liable to fits of rage and mis- 
chief, the particular propensity seems entirely to 
disappear for a season, during vyhich personal 

i2 



116 ON THE SYMPTOMS OF INSANITY. 

restraint is unnecessary. By far the greater pro- 
portion of patients of this class, who have been 
admitted into the institutions at Hanwell and Wake- 
field, have been necessarily those in whom the 
determination to destroy themselves has been pre- 
meditated, and not the result of a sudden impulse. 
The greater part of these consist of individuals of a 
melancholy temperament, who have become insane 
solely from hereditary predisposition, without any 
other assignable cause. 

It would be of very little practical utility to 
enumerate those moral causes which, operating upon 
a gloomy disposition, excite this painful propensity. 
It sometimes arises from fear of disgrace or punish- 
ment ; and in this establishment some of the patients, 
with unaccountable inconsistency, have been driven 
to attempt the desperate act, from a conviction that 
they were doomed to the severest everlasting punish- 
ment, the actual suffering of which, to their diseased 
imagination, seemed more tolerable than its mere 
anticipation. 

The retiring from the pursuits of an active and 
busy life has been stated as producing that feeling 
of ennui, which has led to self-destruction ; but in a 
pauper establishment, no patients of this description 
are ever found ; nor do I recollect one case of this 
kind in private practice, where there has not pre- 
viously been such a habit of drinking, as might be 
supposed to lead to organic disease ; and in these 
cases the mode which has usually been adopted for 



ON THE SYMPTOiAIS OF INSANITY. 117 

the destruction of life, has been by taking- a large 
quantity of laudanum. I have not seen any of those 
cases of indirect suicide, or of the destruction 
of others, that the patients themselves might be 
punished with death, — stated by some authors to 
have proceeded from the patients imagining, that 
by the commission of this crime they should instan- 
taneously secure to themselves eternal happiness ; 
although I have no doubt of their existence. 

Many cases of suicide, in those who have a 
natural predisposition to it, arise from the brain 
sympathizing with the liver ; nor can this be a 
matter of surprise to any one, who has felt the 
depression of spirits incident to a disease of that 
organ. So many cases have occurred from this 
cause, that many writers, from not finding, on sub- 
sequent dissection, any organic lesion of the brain, 
have referred it to diseased viscera only. But as 
we find that the insanity ceases when the liver is 
restored to health, there is no reason for suppos- 
ing that the insanity is, in these instances, any 
other than a disease of the brain. 

J. C, about fifty years of age, has been insane 
about two years. He had formerly been in respect- 
able circumstances, and occupied as a writer in an 
office. He is reported to have made several at- 
tempts on his life. Has been in the habit of drink- 
ing spirits very freely, and has a disease of the liver, 
which appears of some standing. At the time of 
his admission he was in a most emaciated state j his 



118 ON THE SYMPTOMS OF INSANITY. 

legs scarcely able to support him. His face and 
body also were covered with an eruption ; tongue 
furred ; his stools very dark : he was much de- 
pressed, and always moaning most piteously ; com- 
plained of heat and numbness in the head, and pain 
in all his limbs. Leeches and cold lotions were 
applied to his head, his bowels opened by calomel 
and colocynth, and he went into the warm bath 
every other day. He was much relieved by these 
means. He still continued, however, to moan as 
before. His tongue remained furred, and stools 
unhealthy. He took pil. hydrargyri gr. v. alter, 
nocte for some time. These were then left off 
awhile ; no improvement taking place, he began the 
pills again, and has continued them now for two 
months with evident advantage. His tongue has 
become clean ; he is less depressed ; he is stronger, 
and gaining flesh ; the biliary secretions are much 
improved. He now is occupied in the office ; and 
every day, as the action of the liver seems to im- 
prove, his mind makes a corresponding advance. 

It has before been observed that phthisis and 
insanity alternate with each other ; and it does not 
unfrequently happen that this peculiar symptom of 
insanity, the tendency to suicide, has come on in 
the very last stage of consumption. Many, who have 
rushed unbidden into the presence of their Maker, 
would, in the ordinary course of the disease, in a few 
days have been released from their sufferings. 

I had a patient in Hull, many years ago, who 



ON THE SYMPTOMS OF INSANITY. 119 

was suffering in the very last stage of phthisis, and 
who could not apparently have lived many days. 
During the absence of his wife, who had left him for 
a short time, he cut his throat ; and on her return 
she found him quite dead, leaning over the back of 
his chair, with a large pool of blood near him. She 
thought it had arisen from the lungs, as he had 
occasionally had hoemoptysis, until she made the 
melancholy discovery, that it was the result of his 
own act. 

A singular expression of countenance, especially 
in the eye, has been noticed by many authors, as an 
unvarying attendant on a disposition to suicide. 
This, as well as the foetor before described, cer- 
tainly exists in a great many cases. Indeed, when 
powerful feelings or passions are in active operation, 
in the insane or in the sane, they draw the muscles 
of the face into particular forms ; and if they con- 
tinue for a length of time to be greatly predominant, 
they impress upon the countenance an appearance 
indicative of the character. This is felt and acted 
upon unconsciously in the common intercourse of 
life. A good countenance is a letter of recom- 
mendation ; and we have, in spite of ourselves, 
an unfavourable feeling towards a stranger, where 
this is absent. Now in the generality of suicidal 
cases, the desponding feelings are in constant and 
active operation ; hence there is usually a melan- 
choly and gloomy expression of countenance. This 
arises from no mysterious cause peculiar to 



120 ON THE SYMPTOMS OF INSANITY. 

insanity, but is perfectly intelligible on common 
physiognomical principles ; but there are numerous 
instances where the most experienced physician 
would be unable to detect, by inspection only, the 
slightest mark of either a disposition to suicide or 
insanity. The absence of this expression must 
not, therefore, induce us to suppose, that this dis- 
position does not exist. 

The mode of self-destruction usually attempted 
by the patients, who have been brought into the 
Asylum at Wakefield and Hanwell, has been by 
hanging. In some cases, so determined have they 
been to destroy themselves, that, even after admis- 
sion, they have made the attempt in situations 
where the only point of suspension has been so low 
as to compel them to sit or kneel down, in order to 
accomplish their purpose ; and had they not been 
discovered by the keepers, in all probability they 
would have succeeded. 

The particular mode by which suicides are desirous 
of accomplishing their purpose, appears to be a matter 
of much thought and consideration ; and after the 
plan is once settled, they seem to neglect all other 
means of self-destruction which may offer themselves, 
imtil they have an opportunity of perpetrating it in 
that particular way. An old man, upwards of seventy 
years of age, who had a market-garden near to the 
Asylum at Wakefield, came to consult me as to the 
best mode of destroying himself, as he had made up 
his mind not to live any longer. He said he had 



ON THE SYMPTOMS OF INSANITY. 121 

thought of hanging himself, if I could not recom- 
mend an easier death. I talked to him for some 
time upon the heinousness of the crime he contem- 
plated, and endeavoured to show him, too, that 
hanging was a most horrible death, from the suffoca- 
tion that must be felt ; but apparently with little 
success. Finding, however, that the chylopoietic 
viscera were a good deal disordered, I prescribed 
for him, and sent to inform his wife that he ought 
never to be left alone. The medicine had the effect 
of restoring the secretions to a healthy action, and 
he got better. I heard no more of him for some 
time, when I was at length informed that he was 
discovered dead in a little shed in his garden, where 
he used to keep his tools. But so fixed was the 
mode in his mind by which he was determined to 
accomplish his death, that, though the place was so 
low he could not even stand upright in it, and he 
had not a rope or even a string with which he could 
suspend himself, he contrived it by getting a willow 
twig and making it into a noose, which he fastened 
to one of the rafters. He stooped to put his head 
through it, and then pushing his feet from under 
him, suspended himself until he died. Now if he 
had not made up his mind to destroy himself in this 
particular way, he might have accomplished it with 
much greater ease by drowning himself in the pond 
in his garden, or by cutting his throat with his 
garden knife, which he always had about him ; but 
neither of these was the mode he previously intended. 



122 ON THE SYMPTOMS OF INSANITY. 

It may be practically useful to all who have the 
immediate care of suicidal patients, to bear this in 
mind ; and if they can find out that any particular 
plan is contemplated, they ought to be especially 
careful to remove the means of accomplishing it out 
of their reach, and to prevent their having an op- 
portunity of carrying their particular plan into 
execution. 

I had a patient some years ago who had attempted 
to hang himself, and was still bent upon doing it 
when he was admitted. He eventually got well. 
He told me that for a considerable time after his 
admission he was constantly seeking for an oppor- 
tunity of doing it, but was so closely watched that 
he could not succeed. At the very same time this 
man was constantly employed as a carpenter with 
edged tools ; but self-destruction by those means he 
had never contemplated. 

We have had an instance where a woman took a 
sheet from the bed, fastened one end of it round 
one of the foot-posts, and afterwards bringing the 
other end over the bed, then made a noose, into 
which she put her head, and sitting down, attempted, 
though ineffectually, to strangle herself. Indeed, 
where the determination to effect their purpose 
is very strong, the arts which the patients resort to 
are scarcely to be credited by any but those who 
have witnessed them. 

A female had made repeated attempts, during 
her residence in the Asylum at Wakefield, to hang 



ON THE SYMPTOMS OF INSANITY. 123 

herself, but had been so watched that* she had not 
succeeded. One evening* the servant, on going to 
remove all her clothes out of her bed-room, which 
is the regular practice, thought she saw something 
bright on the top of her chemise ; upon examination, 
this was found to be a pin. She had contrived, just 
before bed-time, to take off her garter ; and know- 
ing that her pockets as well as her clothes would 
all be removed, she contrived to pin it within her 
chemise, so high up that it would not reach below 
the bottom of it. Very providentially, the bright- 
ness of the metal discovered it, and she was again 
prevented from accomplishing her purpose. By 
degrees the propensity wore off, and after a resi- 
dence of eighteen years in the Asylum, I found her, 
a few months ago, living, though upwards of eighty 
years of age, in a comparatively tranquil state, wait- 
ing her removal in the ordinary course of nature. 

After finding that they are so unceasingly 
watched, and so carefully secured, that they have 
no opportunity of executing their design, they will 
assume a most cheerful manner for days and weeks 
together, in order to lull suspicion ; and when a 
favourable opportunity offers itself, it is never 
neglected. 

A man who had long been in a state of despon- 
dency, and had made many attempts to hang him- 
self, but had always been prevented, very suddenly 
appeared much better. He became apparently 
cheerful, and being desirous of employment, was sent 



124 ON THE SYMPTOMS OF INSANITY. 

out with a large party into the hay-field. He con- 
tinued in this, and other out-door occupations, for 
some time, gradually improving. One evening, on 
returning from the field, when the rest of the party 
went in to tea, (which they were allowed when hay- 
making,) he told the farming man that he did not 
feel thirsty, and as it was very warm, he would 
rather remain at the door. He was left there. A 
short time afterwards his keeper came down to 
inquire for him, and being told where he had been 
left, immediately exclaimed, " Then he has hung 
himself!" It was also singularly impressed upon his 
mind, that it was in one particular out-house that 
he had done it : there he went, and found him sus- 
pended and dead as he expected. 

The principal symptoms to be noted of this fatal 
tendency are general despondency and great ab- 
straction, very frequently arising from the mind 
contemplating how the purpose can be most securely 
accomplished. After a time, if no opportunity has 
offered to make the attempt, an affected cheerfulness 
is sometimes put on in the presence of others ; but 
upon careful watching this will be seen only to exist 
in company, and when alone the same gesticulations 
and desponding expressions are exhibited as before. 

It rarely happens that attempts at suicide are 
made in the presence of others ; but one of the 
female patients who was under my care, would, 
if she was at liberty for a minute, even though 
the nurse was in the room with her, tie either her 



ON THE SYMPTOMS OF INSANITY. 125 

handkerchief or her apron-strings tight about her 
throat, for the purpose of choking herself. 

Suicides appear sometimes to take place from a 
sudden impulse, where no disposition to self-destruc- 
tion has been previously shown or suspected. A 
young woman, about twenty years of age, who 
had been insane but a short time, and appeared 
to be recovering, after having assisted the nurse to 
whitewash and clean the ward, was sitting in the 
evening at tea with, her and several other patients. 
She took the opportunity of the nurse going to a 
cupboard for some sugar, to seize a knife with which 
the nurse had just cut some bread ; and in the pre- 
sence of the whole party, in an instant, before her 
hand could be arrested, cut her throat in so dread- 
ful a manner that she died almost immediately. 

Amongst other symptoms usually noticed by 
writers on the subject, is the change that very often 
is observed to take place both in the passions and 
propensities. It frequently happens in cases of 
insanity, that persons of an amiable and benevolent 
temper become, when insane, highly mischievous 
and violent ; and modest and reserved females give 
utterance to language the most opposite to that 
which might have been expected from their pre- 
vious habits. 

A patient in the Asylum at Wakefield, the wife 
of a labourer, a kind-hearted and clever woman, 
was afflicted with such a propensity to destroy, that 
she was almost constantly obliged to be kept in 



126 ON THE SYMPTOMS OF INSANITY, 

confinement ; and when at liberty, she could not 
resist the pleasure of breaking any thing she met 
with. In one instance she saw some tea-cups on a 
table, and for some time walked backwards and for- 
wards, and checked the inclination ; but eventually 
the temptation proved too strong, and she swept 
them at once on the floor. She afterwards regretted 
the circumstance ; but the impulse was too powerful 
to be resisted. Numbers of similar cases, and of 
instances of change in the conversation and demea- 
nour of virtuous females, might, if necessary, be 
enumerated ; but it will be more to the purpose to 
try to explain the causes on rational principles. 

In a state of sanity the various feelings and propen- 
sities are kept under control, partly by their mutual 
inflence upon each other, partly from moral causes, 
and partly from the restraints imposed by society. 
And where careful education and religious feeling 
have rendered their due regulation habitual, strong 
propensities may exist unknown and unsuspected, 
except by the individual. Now insanity does not 
create any new class of feelings or propensities. It 
is, I am aware, a very common opinion, that persons, 
in consequence of their becoming insane, acquire a 
new set of faculties, and especially that they become 
endowed with a great share of cunning. This is 
quite an error. There is no doubt but that this 
faculty may be often found very powerfully and 
actively developed amongst them ; but where this 
is the case, it must have existed in the character 



ON THE SYMPTOMS OF INSANITY. 12? 

previously to the disease coming on. A great num- 
ber of the patients in public asylums, so far from 
being particularly cunning, possess no fraudulent 
dexterity of any kind. The mode in which insanity 
acts, is to cause an alteration in the mental mani- 
festations and in the conduct, by exciting some to 
undue exercise, and not permitting others to have 
their proper influence. Where the passions are thus 
over-excited, and the controlling feelings are not 
in sufficient activity, we have necessarily the results 
previously mentioned ; nor ought they to excite in 
us any surprise, even when observed in the most 
virtuous and amiable. 

Another circumstance of a very painful character 
is frequently attendant upon insanity, and, as far as 
I know, no attempt has yet been made to account 
for it. I am referring to the change which takes 
place in the affections towards those to whom the 
patients have formerly been the most attached. 
This change generally takes place in those cases 
where the patients themselves are quite unconscious 
of the existence of any disease, and where it has 
come on by slow degrees, and is only very partial 
in its eff'ects. This unconsciousness, I should 
observe by the way, is by no means universal in 
insanity ; in many cases the patients themselves are 
perfectly aware that something is wrong. 

When the alteration produced by the insanity 
has by little and little at length become so marked 
that even the most affectionate feelings can no 



128 ON THE SYMPTOMS OF INSANITY. 

longer be blind to the painful reality of its exist- 
ence, those whom the patient has been in the habit 
of controlling, are obliged, for the safety of himself 
and others, to apply not only moral but bodily 
restraint, and to remove him from his home. Not 
being conscious of the necessity of such measures, 
they appear to him harsh and unjust, and he thinks 
that they emanate from a change having gradually 
taken place in the feelings of those about him ; and 
he is ready at once to exclaim, ** You have ceased 
to love me !" As a proof that these feelings of 
estrangement are thus produced, it is to be observed 
that they seldom extend to those individuals of the 
family who have been at a distance, or who are not 
associated in the mind as having been accessory to 
the restraint, first in trifling domestic matters, and 
subsequently in removal from home, and confine- 
ment. I think it may generally be taken for 
granted, that though every other symptom of the 
disease may appear to be removed, yet, so long as 
this feeling of dislike continues towards those for- 
merly loved, and who have really acted in an 
affectionate manner, throughout all the trying scene, 
to the unfortunate patient, that some lingering trace 
of diseased action still continues, and the complaint 
may be expected to return. 

In cases where the patient is suddenly attacked 
with mania, and his immediate removal from home 
is necessary when he is hardly conscious of it, this 
feeling does not exist. 



ON THE SYMPTOMS OF INSANITY. 129 

The bodily symptoms, which occur so frequently 
in insanity as really to deserve to be considered as 
characteristics of the disease, are very few. The 
unhealthy action in the brain and its membranes is 
visible, rather from the alteration in the mental mani- 
festations, than from any uniform corporeal change. 
In the early stages it is usually marked by irregularity 
of the secretions, yet it often happens, even in this 
stage, that, after it has continued for a short time, 
no alteration whatever takes place in the pulse, and 
all the secretions appear to be healthy. This is 
particularly the case where the symptoms denote 
only a small portion of the brain to be diseased, 
and where this disease has come on very gradually, 
the nervous system seeming to accommodate itself 
to the change, without being so irritated as to 
disturb the functions of the other parts of the 
body. And when the derangement has become 
chronic, it is a well-known fact, that many of the 
patients, for years together, enjoy excellent bodily 
health, and exhibit no marks of disease except 
mental delusions. It is probably this circumstance, 
which has led to the erroneous notion that medicine 
is of no use in all cases of insanity. It is singular 
that this uniformly good bodily health is rarely 
found, except in those cases where the hallucinations 
of the patient are confined to one subject. 

Where the unhealthy action of the brain and 
nervous system has been so great as to produce 
deranged manifestation in the faculties generally, 

K 



130 ON THE SYMPTOMS OF INSANITY. 

considerable bodily weakness and disease, of some 
kind or other, uniformly exists. The first thing- 
which we ought to examine is the state of the head : 
it is there that we usually find a marked change. 
With very few exceptions, a considerable increase 
of temperature will be found in it, and it is often 
much hotter than other parts of the body, which 
are even covered with the clothes : when this is 
the case, the pulse is g-enerally found quick, — but this 
increased temperature of the head sometimes exists, 
even to a great degree, without that being the case ; 
and when the heat is not very considerable, no 
variation whatever is usually to be found in the 
pulse : and this rule holds good whether the case be 
recent or of long standing. 

S. M. has been insane and confined for many 
years, — in general very violent ; has been at Han- 
well only eleven months and a half. She had not 
been long in the asylum before she became interested 
with the work that was going on in the garden, and 
requested to be employed. She continued vrorking 
very quietly for six months. She afterwards thought 
she should like to learn brushmaking : this she also 
went on with very steadily for five weeks. She then 
became somewhat unsteady, rambling out of the work- 
shop, and was soon irritated. It was found necessary 
to leave her in the ward, and not to permit her to go 
to work : she was offended and much excited. I 
suspected that some increased action of the brain 
was existing, either primarily from mental irritation,, 



ON THE SYMPTOMS OF JNSANITY. 131 

or from sjmpatlij with the chylopoietic viscera ; 
she was therefore carefully examined ; her tongue 
was found much furred, her head extremely hot, 
and the pulse one hundred, — the usual range of it 
being, as I find from the notes kept of her case, 
about eighty. The stomach and bowels were im- 
mediately attended to, but no alteration having 
taken place, her head was ordered to be shaved, and 
cold applications used. This order occasioned the 
most violent excitement, as indeed did every other 
which was contrary to her own inclinations ; but it 
was accomplished. The following day the head was 
cool, the pulse seventy, and the paroxysm subsided. 

J. L., about thirty years of age, reported to have 
been insane but a short time. The tongue coated 
with a white fur, bowels costive, head hot. Com- 
plains of pain in the upper part of it. Pulse eighty- 
six and full. He took an emetic, and afterwards 
the diuretic drops, every four hours ; the head was 
shaved, and cold applications used ; in three days 
the pulse was reduced to sixty, and he was better in 
every respect. 

W. P., aged twenty-one, has been insane about 
six months. He says it came on in consequence 
of going to a chapel to ridicule the preacher : but 
during the time he was there his conscience became 
so alarmed, that, his mother says, when he returned 
home he was in the greatest agitation, he got no 
sleep, and eventually became insane. On his 
admission, his head was very hot, pulse eighty-six, 

K 2 



132 ON THE SYMPTOMS OF INSANITY. 

tongue dry, bowels costive. Head being shavedy 
cold applications used, and the bowels and secretions 
attended to, he was a little better for three days. 
Without any apparent cause, a more maniacal state 
came on, the pulse rising to one hundred, in which 
state he has continued for two days. 

The two following cases are of long standing. 

P. T. has been insane for several years. She has 
had repeated attacks, and been dismissed and re- 
admitted several times. She had been rational and 
at work for some weeks, when, without any apparent 
cause, except some disorder of the chylopoietic 
viscera, which it is probable existed, though un- 
known, she became excited, talked to herself, and 
was constantly moving about. Considerable increase 
of heat was found in the head, but the pulse exhibited 
no variation ; it was only seventy, and of natural 
strength. She has had sleepless nights* An emetic 
and aperient were given ; the head was shaved, and 
cold lotion applied ; which much relieved her in a 
few days. 

F. G. has been subject to paroxysms of mania for 
several years. Having recovered from one, and 
been sufficiently well to go to work for some weeks, 
the excitement again came on. His head was found 
hot, but the pulse only sixty. Aperients, and 
the cold application to the shaved head, soon 
removed it. 

I could insert a catalogue of cases, in addition to 
those just mentioned, to show that although the 



ON THE SYMPTOMS OF INSANITY. 133 

commencement of insanity and any exacerbation of 
it in the old cases are attended almost invariably 
(indeed I think I should be justified in saying- 
universally) with increased heat in the head : yet 
the alteration in the pulse is by no means without 
exception. In fact, I am fully convinced that from 
the rapidity of the pulse alone we can derive no 
information whatever. In many cases it seems to 
depend entirely upon causes purely nervous. I 
have known it vary in the same patient, during^ a 
single visit, as much as forty strokes, and be reduced 
from one hundred and twenty to eighty. 

This heat in ordinary cases extends over the 
entire surface of the cranium, though in many 
instances particular portions of it are of a higher 
temperature than the other parts.* 

The heat in the head is very generally accompa- 
nied by cold extremities. Want of sleep has been 
already mentioned. A cold clammy perspiration, 
accompanied with a peculiar foetor, often referred to 
by writers on this subject, is certainly found in many 
patients. It gives the skin an appearance of having 
been rubbed over by some greasy substance : it 
varies very much in the same patient; and is most 
perceptible when the individual is labouring under 
a severe paroxysm. It is, however, by no means an 
universal accompaniment of mental derangement. 
A great number of patients, both of those who have 
recovered and those who have died, have never 
* On this subject the medical reader is referred to the Notes, 



134 ON THE SYMPTOMS OF INSANITY. 

exhibited it ; but where it is found it invariably 
denotes the existence of organic disease in the 
brain ; I do not recollect a single instance of a 
patient with this symptom having recovered : and on 
dissection, the ventricles have uniformly been filled 
with a great excess of water. The unpleasantness 
of this foetor may be very much obviated by the 
constant use of the tepid bath. 

A great want of nervous sensibility is another 
very frequent symptom. To such a degree will this 
exist, that diseases of the most painful nature, such 
as inflammation in the abdomen, in which all the 
viscera have, to a certain degree, been affected, have, 
upon post mortem inspections, been most unexpect- 
edly discovered in those patients who neither com- 
plained nor appeared to suffer during their lives 
from this cause. 

This want of sensibility enables them to endure 
that, without shrinking, which in the ordinary state 
of the nervous system would be attended with the 
most acute pain. 

If those cases of insanity which have come on 
suddenly, with much cerebral disturbance, be left to 
themselves, or active measures be not immediately 
applied, before death takes place the result very 
frequently is such a state of diseased organization 
that some of the nerves of the senses, as well as 
those parts of the brain necessary for the mental 
manifestations, lose their specific action. Heat and 
cold cease to produce their usual effects ; the nerves 



ON THE SYMPTOMS OF INSANITY. 135 

of taste are so far injured, that the patient will eat 
his own ordure and drink his own urine, without 
even apparently discovering any thing- offensive. 

The opposite to this want of sensibility in the nerves 
of the five senses, is, however, not unfrequently 
a symptom of insanity. Both the optic and audi- 
tory nerves^ as well as those of sensation, are 
frequently seen to be painfully acute, and give rise 
to many expressions of extravagant feeling, which, 
I believe, are really experienced by the patient, but 
which cannot be understood by those to whom they 
are related. 

In many cases of insanity extreme hunger is 
observed to form a very striking feature. This 
arises from the great mental exertion which is kept 
up, often for days and weeks together, and when it 
is accompanied by much talking, as is frequently 
the case, great thirst is endured as well as hunger. 
But occasionally the reverse of this takes place, and 
the patient appears neither to require food nor 
drink, and sometimes obstinately refuses both for 
days together. This I suppose to arise from the 
secretions being altogether faulty, for the bowels, 
kidneys, &c. seem to be at such times almost in a 
total state of inaction. 

It will be observed that many of the various 
symptoms previously enumerated are mentioned as 
accompanying insanity without any reference to the 
particular cause of the disease. In fact, whatever may 
have been the cause, the immediate effect is an excess 



136 ON THE SYMPTOMS OF INSANITY. 

of blood in some portion, or in the whole of the brain 
and its membranes, except in the cases where it 
has been the result of loss of blood or excessive 
bodily weakness. These cases are of rare occur- 
rence, and easily distinguishable from those, the 
general symptoms of which we have been describing.* 

* The medical reader is referred to the Notes. 



CHAPTER V. 



ON IDIOCY AND FATUITY. 



In treating on this subject, we shall confine the 
use of the term Idiocy to those cases, where the 
deficiency of understanding is congenital. 

I make this distinction, because many patients 
during attacks of insanity exhibit appearances so 
closely resembling idiocy, that they are often con- 
sidered incurable, and allowed to sink without an 
effbrt being made for their recovery. But no case, 
however apparently desperate, unless connate, will 
justify the neglect of the most strenuous exertions. 
Several cases under my care have recovered, where 
the patients have, on their admission, exhibited a 
total deprivation of all the mental faculties ; and 
have befen sent to the asylum only because their 
habits have become so dirty and offensive as to be a 
nuisance to the workhouses, where they had been 
previously confined. 

The following is a striking instance in which, 
from the fatuous appearance of the patient, he 
might have been considered so decidedly incurable 



138 ON IDIOCY AND FATUITY. 

as to be left without any effort being- made or 
thought possible to be of use : but he ultimately 
got well. 

J. P., about twenty-four years of age, had been 
insane about twelve months when admitted. He 
had had an attack some time before, but the par- 
ticular circumstances connected with it are not 
known. At the time of his admission he appeared 
fast sinking into fatuity. He was silent and melan- 
choly, sitting for the whole day in one place and 
position unless roused ; apparently unconscious of 
all surrounding objects, and scarcely any thing could 
induce him either to move or speak. In this state 
he continued for some months, notwithstanding 
every effort was made to engage him in some em- 
ployment. By perseverance, however, he was at 
last induced to assist a little in cleaning the ward : 
no sooner had he began this trifling occupation than 
an improvement took place in his mental faculties ; 
his countenance assumed a more cheerful aspect, his 
spirits were more lively, and manners obliging. 
At the end of seven months, from his beginning to 
work, he was discharged cured, much to the delight 
of his relatives, and the astonishment of every one 
who saw him at his first admission. 

T. T., about fifty years of age, was found wander- 
ing in the street, and sent to the house of 
correction as a vagrant. He was perfectly uncon- 
scious of every thing around him, and appeared 
idiotic. In this state ho was sent to the asylum. 



ON JDIOCY AND FATUITY. 139 

Though grey-headed, and looking much older than 
he really was, he had still the remains of a fine 
person j he was upwards of six feet high, with a 
countenance and form of head presenting a striking 
contrast with his imbecile state of mind. He was 
in good bodily health, and free from all appearance 
of disease, except a small ulcer on the leg. He 
was placed amongst the idiotic patients, and was 
apparently sinking into the last state of fatuity. 
All the information that could be obtained respect- 
ing him was that he had been a soldier. I attempted 
day after day to induce him to enter into conversa- 
tion, but in vain. " I have been a soldier," was the 
most he would say. Many weeks elapsed without 
any improvement taking place, and his case was 
considered quite hopeless. A change for the better 
took place very suddenly. Without any previous 
conversation with any one, he requested the keeper 
to give him a sheet of paper, on which he wrote 
the following letter : — 

" Madam, 

" I feel myself completely at a loss for an 
apology, which would in any way justify the liberty 
I am now taking. Not personally known to you, I 
feel the great awkwardness of addressing you, parti- 
cularly in the character of a petitioner. 

*' I know not indeed whether I can do better than 
state the circumstances which have induced me to 
adopt this measure. 



140 ON IDIOCY AND FATUITY. 

'* Some time ago, driven by the greatest distress, 
I addressed myself to your husband, hoping that in 
consideration of our former intimacy he would have 
afforded me some assistance. I remained a fortnight 
in London without receiving any answer — indeed I 
have no means of knowing whether this letter 
reached him. Since that time I have been a miser- 
able wretched wanderer through the country, with- 
out friends and without shelter. Such were the 
severity of my sufferings that my intellects became 
unhinged, and I am indebted to the charity of this 
establishment for the continuance of my wretched 
existence, and the prospect of being once again 
enabled to mix in society. Whether either the one 
or the other will be beneficial I have my doubts. 
When discharged from this house I have no pro- 
spect but of again becoming a wretched wanderer, 
without resources, and destitute of friends. The 
prospect is truly deplorable, and yet such, in a very 
short time, must be my fate. 

'* These, madam, are the melancholy circum- 
stances which have induced me to endeavour to 
interest you in my fate, a measure I never should 
have adopted if I had not been fearful of a letter to 
your husband sharing the same fate as my last. 

** I will not intrude further on your time than 
merely intreating you to pardon me for the liberty 
1 have taken, assuring yourself that nothing but the 
most extreme distress and despair could have driven 
me to it. Should your humanity be so far interested 



ON IDIOCY AND FATUITY, 141 

as to induce you to afford me any assistance, believe 
me it will be most thankfully and gratefully 
received." 

Not receiving- any answer to the above, the follow- 
ing was sent to a gentleman who very kindly 
assisted him. 

'' My dear Sir, 

" I know not how again to intrude on you 
with a tale of disaster and woe, yet your kind ex- 
pressions, and still kinder manner, when I quitted 
you, are so strongly imprinted on my recollection, 
that I cannot help flattering myself you will not be 
offended with my present application to you. Yet 
it seems unfair, that, because you have once 
befriended me, I should again harass you with my 
misfortunes, again solicit a renewal of kindness, to 
which I feel perfectly conscious I have no claim, 
except what the benevolence of your heart allows 
to those unfortunate beings whom you may once 
have known in better circumstances. 

" The vivid remembrance of the peculiarly heart- 
felt tenderness of your manner to me, when at , 

emboldens me to do what it is impossible to 
apologize for, unless you will admit, as an excuse, 
the truly pitiable situation in which I am at present 

placed. When I left I made several attempts 

in , and afterwards in London and its neigh- 
bourhood, to obtain some employment which would 



142 ON IDIOCY AND FATUITY. 

afford me the means of supporting an existence 
which was daily becoming more and more burthen- 
some. I wull not harass your feelings by the 
melancholy detail of the miseries I endured during 
this fruitless search ; suffice it to say, that after 
several days of misery the most exquisite, without 
shelter and without food, I was taken out of the 

Serpentine River, and conveyed to workhouse. 

There I was discovered by a gentleman, an old 
schoolfellow, who kindly supplied me with some 
clothes and a little money, with which, by his advice, 
I set out for the north of England, with the hope 
that there, amongst those I had formerly known, I 
might obtain some situation that would afford me 

the necessaries of life. At in — • — I was 

taken ill, and so long confined that my small stock 
of money was nearly exhausted ; when somewhat 
recovered, though in a very weak state, I again bent 
my course northward, and have some recollection of 
having been in Newark, Retford, and Doncaster, 
but for many succeeding months my existence is a 
perfect blank, as far as my own recollection is con- 
cerned. I have since learnt that about I was 

found wandering in the streets of , a perfect 

lunatic, and by the magistrates sent to , where 

I have been taken care of ever since with the 
greatest possible kindness ; and am now declared, by 
the physicians, to be perfectly sane. Indeed I feel 
conscious that my mental faculties are completely 
restored, for I am again capable of contemplating 



ON IDIOCY AND FATUITY. 143 

and feeling, with the most acute sensibility, my truly 
forlorn and friendless situation. Something, how- 
ever, must be done ; and it is my intention to go 
down into the north and endeavour to obtain some 
employment, however humble, that will keep me 
from starving : but I am almost destitute of cloth- 
ing and money I Can you ? will you, dear , 

assist me ? I feel the blush of shame burning on 
my cheek whilst I make the request, but the 
most urgent, the most miserable necessity impels 
me. Forgive and pardon your forlorn, unhappy 
friend.'* 

These letters are inserted to show how much 
talent may yet exist when every faculty appears dead, 
and as a stimulus to relax no effort to kindle into a 
blaze the sparks of mind that may yet remain. In 
this instance, under the semblance of hopeless 
fatuity, was hid mental power of the highest 
order. 

It is scarcely necessary to say, that an inquiry was 
immediately made into every particular concerning 
him : when it turned out that he had received a 
liberal education, that he had been brought up 
in expectation of having a very large fortune, but 
his relative on whom he depended had died poor. 
He had a sufficiency to procure him a commission 
in the army, and had been in India. He was an 
elegant scholar, with fascinating manners, but un- 
happily was devoid of those high religious principles 



144 ON IDIOCY AND FATUITY. 

without which the most brilliant talents tend but to 
the destruction both of the possessors and of others. 

He left the asylum quite well, and procured a 
situation which he retained for some years. 

Idiocy arises, either from the brain being defec- 
tive in size and power, where all the mental 
manifestations are found imperfect, and the functions 
of automatic life alone seem to be performed ; or 
from a brain of a natural size having- some organic 
disease or mal-conformation. In these cases, some 
of the faculties are often particularly active, but so 
unduly balanced as to render the individual unfit to 
be at large. 

Idiots are very frequently subject to epilepsy, and 
many of them are highly mischievous, furious, and 
obscene. As far as I have had an opportunity of 
observing, they are not long-lived. 

In such cases, it is needless to say, no medical 
remedies exist. But much may be done by proper 
care and moral treatment, to check the evil pro- 
pensities, and to bring forward the good in 
proportion to the powers : these vary from the mere 
capability of swallowing food to that of behaving 
with propriety in the ordinary scenes of life. 

Fatuity, which is the result of insanity, is, in its 
symptoms and consequences, the same as idiocy, 
the only difference being that in the idiotic the 
faculties were from birth imperfect, and that in the 
fatuous there was a period when the functions were 
performed in a healthy manner. This fatuity some- 



ON IDIOCY AND FATUITY. 145 

tiaies arises from long-continued over-excited 
cerebral action. Another not infrequent cause is 
the weakness arising from excessive general bleed- 
ing-s and evacuations in cases of mania. The 
medical reader is referred to the notes for an 
account of by far the most usual cause. 



CHAPTER VI. 

ON THE TREATMENT OF INSANITY. 

We have now come to the most important part 
of our subject, the previous chapters being only- 
introductory, and intended to throw such a light 
upon insanity as to enable us to ward off an attack, 
or to proceed in the treatment of it on rational 
principles. It is of course impossible to lay down 
any particular plan to be adopted in all cases. In 
those instances where the causes of the disease and 
the circumstances of the patient are the most similar, 
constitutional differences exist, which make varia- 
tions in the treatment absolutely necessary, and 
which require the most watchful care and dis- 
crimination on the part of the physician. It will be 
the object of this chapter to make a classification 
of those cases in which the same system, modified 
according to individual circumstances, ought to be 
adopted ; and to point out the general principles of 
treatment applicable to each class. 

As insanity has been considered, in all cases, to 
be a disease of the brain or nervous system, one of 



ON THE TREATMENT OF INSANrj'Y. 14 



1/ 



the most obvious divisions will be according- to the 
nature of the disease which exists there. We shall 
therefore divide the subject into two classes ; one, 
where diseased action only is going on in the brain, 
and the other, where the continuance of the diseased 
action has produced diseased organization. The 
first class I shall call incipient, and the latter 
chronic insanity. It ought not to be forgotten that 
cure, or much relief, is to be expected only whilst 
the disease is incipient. If lesion of the brain once 
takes place, however the consequence of it may be 
palliated, and the patient rendered moderately com- 
fortable, the mental manifestations can never be 
completely restored. There is a great objection 
to the usual division of insanity into mania and 
melancholia : it is apt to mislead. These are but 
symptoms and results of over-exercise of different 
mental faculties , and they are alike attended with 
excess of sanguineous circulation in the brain. It 
may be of material assistance to our forming correct 
views of the treatment to be adopted, shortly to 
analyze and trace the probable steps of the disease. 
Now, except in the cases of insanity arising from 
loss of blood, want of nutrition, or some other 
debilitating cause, in a very large proportion of post- 
mortem examinations of persons who have died 
insane, whatever may have been the cause of the 
disease, the appearance of the brain clearly indicates 
the previous existence there for a considerable 
period of inflammatory action, that is, of an excess of 

l2 



148 ON THE TREATMENT OF INSANITY. 

blood. May we not then infer, that, with the 
exception of the cases alluded to, insanity, whatever 
may be its primary cause, begins with an excess of 
sanofuiferous circulation in the brain, or in some 
part of it ; and that, from the continuance of this 
accelerated circulation, a morbid change of structure 
takes place, not only in the part of the brain at first 
attacked, but gradually and eventually in the whole 
mass of the brain and its membranes ; and that the 
effusion of serum under the membranes and in the 
ventricles, almost universally found in old cases, is 
the ultimate result of this excessive sanguineous 
circulation. The mere fact, that in cases where the 
disease has been coming on gradually and almost 
imperceptibly for many months or years, no appear- 
ance of inflammatory action has been observed 
during its progress, is no evidence that a measure 
of excessive sanguiferous action, proportionate to 
the gradual change in the conduct and sentiments, 
has not existed. The immediate cause of this ex- 
cess of circulation is either over-exercise of the brain 
or of some part of it, or irritation produced in 
it by its sympathy with some other diseased bodily 
organ. In the former case, an undue quantity of 
blood is required and supplied ; and in the latter, 
the results are the same as in any other cases of 
irritation. 

It may be objected to this theory, that patients 
frequently do not complain of pain in any part of the 
head. Now, in nine cases out of ten, on the com- 



Ox^ THE TREATMiiNT Ol" INSANITY. 149 

mencenient of the disease, they do complain of heavi- 
ness and pain there. This is the fact, with scarcely 
an exception, when the disease comes on suddenly ; 
but after the diseased action has continued for some 
time the parts seem to accommodate themselves to the 
change, and this pain is no longer felt. Indeed, as 
has been previously observed, diseased organization 
may exist to a very great extent without being 
accompanied by any pain. Supposing then this to 
be the mode in which the brain is affected, it 
obviously becomes of the greatest importance to 
ascertain, if possible, what is the cause which 
immediately produces this increased circulation. 
Although bleeding and other medical treatment 
may for a time prevent an excessive volume of blood 
from being sent through the brain, yet if the cause 
remains, and a part of the brain continues to be 
excited to undue exercise, or to be irritated by 
sympathy, it will demand and receive more than its 
due and healthy share of blood from the system. 
Mischievous and fatal results constantly arise in 
practice from want of attention to the cause of this 
increased circulation, particularly in cases of mania. 
Very copious evacuations and profuse bleedings from 
the system are resorted to, and after the animal 
strength of the patient is exhausted, he becomes 
quiet, but the mental delusion still remains. Sup- 
posing the cause of the disease to be a permanent 
one, such as any moral cause, the brain, or a por- 
tion of it, continues to be unduly exercised, and to 



150 ON THE TREATMENT OF INSANITY. 

obtain from the system more than its due share of 
the blood, which the lancet has left. But when the 
loss of blood has been excessive, the vital power, in 
numerous instances, is never recovered, and the 
patient either dies or sinks into a state of fatuity. 
Unfortunately many of the patients received into 
public hospitals, as recent cases, have previously 
undergone this exhausting process. The constitu- 
tion has not energy to rally, and there is, in conse- 
quence of this injudicious treatment, a much greater 
mortality amongst the recent cases than amongst 
the old, in proportion to their numbers and ages. In 
fact, if the cause be permanent, there is a greater 
probability of ultimate cure, when nature is left to 
herself, and the violence of the attack allowed to be 
expended, without any attempt at relief, than where 
her powers have been wasted hy excessive depletions. 
On the first appearance therefore of any of the 
symptoms mentioned in the foregoing chapter, the 
attention ought to be most carefully directed to the 
ascertaining, if possible, and then removing the 
cause. Although the diseased action may not im- 
mediately cease on its removal, yet there can be but 
little hope of cure whilst it continues to operate. 
It has been already shown, that the brain and ner- 
vous system may be affected either primarily or by 
sympathy. Amongst the primary causes of disease, 
blows and other direct physical injuries have been 
enumerated ; but the brain, unlike any other organ 
of the body, is idiophatically liable to diseased 



ON THE TREATMENT OF INSANITY. 151 

action from moral, as well as from physical causes : 
whilst diseased action in the stomach, liver, uterus, 
&c., when induced by moral causes, is only the result 
of sympathy with the disordered brain or nervous 
system. But although similar symptoms of inflam- 
mation and irritation will be observed, whatever 
may have been the cause, it is obvious that diseased 
action in the brain, arising from blows, fevers, 
tumours, or from the pressure of spiculi of bone, 
will require a treatment different from that which 
ought to be adopted where it is the result of over- 
action brought on by jealousy, too great anxiety on 
religious subjects, or any other constantly operating 
moral cause. In the former class of cases, moral 
remedies would be useless, and physical ones must 
be applied ; in the latter, medical treatment is only 
useful to allay irritation, and to counteract the 
physical injury produced by the action of the moral 
cause. The grand object to be attained, with a 
view to ultimate cure, is the removing the cause by 
moral treatment. Again, cases of insanity arising 
from diseased action of the brain, produced by its 
sympathy with some other diseased bodily organ, 
clearly require a peculiar mode of treatment. Some 
of the physical causes of insanity may be only of 
short duration, and may cease almost immediately 
after the diseased action in the brain has been pro- 
duced ; whilst the moral causes of insanity, with 
scarcely any exception, and other of the physical 
causes, may be permanent, and may continue to 



152 ON THE TREATMENT OF INSANITY. 

exert their baneful influence long after the com- 
mencement of the attack. The first step is to ascer- 
tain the cause, and this can only be done by careful 
inquiries of the friends of the patient. There is 
usually not much difficulty in the investigation, 
when insanity has been the result of a blow on the 
head, or of any other direct physical injury, or where 
it has been the consequence of any very marked and 
notorious change of circumstances : but when the 
alteration in the conduct, or mental manifestations, 
has been very gradual, and no hereditary tendency 
to the disease has existed, and there have not been 
any peculiar circumstances likely to produce an 
over-exertion of the brain, or of any part of it, the 
inquiry becomes more difficult. In the latter cases, 
sympathy with some of the disordered viscera will 
very probably be found to be the cause of the 
disease. 

One circumstance frequently exists in the begin- 
ning of this disease, which may accoimt for many 
of the mistakes usually fallen into in its early treat- 
ment : and that is, the perfect state of action in which 
the greater part, if not all but one or two, of the 
organs remain. So that unless these are frequently 
wanted for the performance of the ordinary duties 
of life, diseased action may go on for a long time 
without being discovered. To use a figure, I would 
compare the brain to a piano-forte ; and the feel- 
ings, passions, and various faculties, to the different 
strings. One or two of the notes may be out of 



ON THE TREATMENT OF INSANITY. 153 

tune from over work, or it may happen from being- 
formed of a more delicate material than the rest ; 
but as the note which is out of tune does not pre- 
vent the others from giving their correct sound, the 
instrument may be continued in use for a long time, 
without its being thought absolutely necessary to 
have it repaired : although when the defect is 
observed, no one would expect that it would ever 
regain its proper tone again until properly mended. 
Something similar to this takes place in a very 
large proportion of cases of insanity, with this 
difference, that the piano has no power whatever 
within itself to repair the mischief. Happily for 
man, not only in this, but in most other diseases, 
the constitution possesses a vis medicatrix, which 
works by itself, and often accomplishes its purpose 
in spite of our ignorance and blunders. Many indeed 
are the cases of insanity cured in this way. The 
diseased action spends itself, the brain recovers its 
tone, and the functions are performed as before : 
although in other instances there is not sufficient 
constitutional vigour to restore the healthy action, 
and the disease, being neglected, gradually extends 
to other portions of the brain. This is very con- 
stantly the case where the insanity has first shown 
itself in some slight and gradual alteration in the 
conduct or moral manifestations. As the patients 
are tolerably manageable, no steps are taken to 
cure the disease, and many months constantly 
elapse before they are placed under proper medical 



154 ON THE TREATMENT OF INSANITY. 

care. Now, reasoning* from analogy on the effects 
of disease of any other organ continued for so 
long a period, it must be expected that the disease 
will be difficult of cure, and that, when the brain 
is restored to its healthy action, it will still be 
weak, and will retain a liability to be again attacked 
in the same way ; especially if the same exciting 
cause is applied which first brought on the disease, 
or, indeed, if from any other reason it be over- 
worked. It is well known that some persons are 
liable, whenever ill, to have peculiar parts affected ; 
and that many have periodical attacks of the same 
disease, especially if they have once laboured under 
any severe and long attack. This is precisely the 
case with regard to insanity. It is liable to recur ; 
it frequently comes on periodically ; and in this, 
as well as in other diseases, as the organ becomes 
gradually weakened, so it requires less and less to 
create disturbance in its action. It sometimes 
happens, that, on the very first attack, some part 
has suffered so much as never perfectly to regain 
its functions ; and if this is one, upon the right 
action of which the moral conduct is much influ- 
enced, the patient must necessarily be subject to 
such a degree of restraint as is necessary for his 
own w^ell -being and that of others : but certainly 
to no more. It most frequently however happens, 
that the diseased action is so subdued, that the 
faculties resume their former power, and continue 
in healthy action, either altogether, which is unfor- 



ON THE TREATMENT OF INSANITY. 155 

tunately not often the case, where the disease has 
been suffered for a considerable time to remain 
neglected, or for longer or shorter periods, as the 
excitability of the parts is greater or less. 

Supposing the cause to be ascertained, let us next 
consider the treatment of Incipient Insanity. We 
shall first direct our attention to cases, where the 
disease is attended with an excess of sanguiferous 
circulation in the brain, classifying these, according 
to their causes, into cases, where it is produced by a 
direct physical injury, or by some sudden increase 
of general sanguiferous circulation, arising from a 
merely temporary cause ; secondly, into the cases 
where the brain is primarily affected by the action 
of some moral cavise ; and, thirdly, into the cases 
where the insanity is caused by the brain sympa- 
thizing with some other disordered organ. 

Having considered incipient insanity, attended 
with excess of sanguiferous circulation, the treat- 
ment of it, when it is the result of a want of an 
adequate supply of blood to the brain, will next 
follow ; and under this head will be included the 
cases of insanity arising from the vice previously 
referred to ; as whatever may be the increase of 
circulation in the cerebellum, the cerebrum does 
not in these cases appear to receive its due share. 
Indeed, as they require a peculiar treatment dis- 
tinct from that where the disease arises from any 
other cause, the arrangement is unimportant ; and 
they seem to fall more naturally into this division of 



156 ON THE TREATMENT OF INSANITY. 

the subject than in those previously mentioned. 
The mode of treatment, when the disease is chronic, 
will lastly fall under our notice. Let us commence 
with cases of insanity arising from blows on the 
head, coup-de-soleil, &c. It frequently happens, 
that injuries inflicted upon the head produce at 
the time comparatively little disturbance in the 
constitution ; and consequently little immediate 
attention is paid to them. These, it is well known, 
are often followed by acute inflammation some 
days after the accident, and subsequently by death. 
Sometimes, instead of phrenitis coming on, the 
first symptom of any real injury having been sus- 
tained is shown in some altered manner in the 
conduct or sentiments of the patient. At the same 
time, that there are often wildness of expression, 
irritability of manner, foul tongue, costive bowels, 
a quickened pulse, and sleepless nights. If, in this 
early stage of the disease, these symptoms be con- 
sidered to arise from the accident, and medical advice 
be resorted to, subsequent insanity may be pre- 
vented as easily as high inflammatory action of any 
other organ. At the commencement of an attack 
of this kind, depletion may be used, according to the 
strength of the patient, very freely; and much more 
so than in cases of insanity arising from moral 
causes. Copious bleeding from the temporal artery, 
free purging with calomel and extract of colocynth, 
and cold applications to the shaved head, are the 
means most to be depended upon; the patient taking, 



ON THE TREATMENT OF INSANITY. 157 

at the same time, nitrate of potash in ten-grain 
doses, with small nauseating doses of tartar emetic : 
the extremities being kept warm with bottles of hot 
water, or even stimulated with mustard poultices. 
The apartments should be kept well ventilated, but 
all noise and light should be carefully excluded. 
After such a quantity of blood has been drawn from 
the system as the constitution is thought capable of 
bearing, if the inflammatory action still continues 
violent, local bleeding may follow, either by leeches 
or cupping as may be convenient, and digitalis 
given in conjunction with the nitrate of potash. 
But in the use of digitalis great caution ought to 
be observed as to the dose. I have heard of a 
drachm of the tincture being given at once, and even 
repeated in that quantity. I can only say, that I 
have seen very serious consequences arise from much 
smaller doses ; and I generally find that, independ- 
ently of avoiding the dangerous results of large 
doses, smaller ones, more frequently repeated, pro- 
duce a more lasting and salutary effect. Indeed not 
only in insanity, but in all diseases in which the 
nervous system is much implicated, the operation of 
digitalis is so uncertain, that the greatest watchful- 
ness should be used whilst it is administered. From 
five to ten drops, repeated three or four times a day, 
is as much as we ever begin with. The dose may 
be increased as the necessity of the case and the 
strength of the patient justify : but it should ever 
be remembered, that the debilitating effects arising 



158 ON THE TREATMENT OF INSANITY. 

even from small doses, if they have been taken for 
some time, take place very suddenly; and the most 
extraordinary prostration of strength often follows. 
From this prostration of strength no stimulus seems 
sufficient to recover the patient. If the above 
remedies are commenced in the early stage, and 
carefully followed up, as the strength of the patient 
will bear them, the recovery may take place rapidly; 
and there will be no occasion to remove such 
patient from home, and the immediate care and 
attention of his relations and friends. It not un- 
frequently happens that the stomach becomes so 
weakened by the use of the means requisite to 
reduce inflammatory action, that it cannot digest the 
food required to restore the system to its usual 
strength. Bitters, stimulating tonics, and exercise 
in the open air, are necessary in this stage of the 
disease. Where the patient, notwithstanding the 
application of the remedies above mentioned, does 
not recover, the symptoms and treatment become so 
nearly similar to those where the insanity arises from 
moral causes, that it will be unnecessary to detail 
them here. If any portion of the bone is depressed, 
the pressure must of course be removed before any 
other remedy is attempted. A curious instance of 
the importance of attending to this is mentioned by 
Sir A. Cooper. " A man was pressed on board one 
of his Majesty's ships, early in the late revolu- 
tionary war. While on board this vessel, in the 
Mediterranean, he received a fall from the yard- 



ON THE TREATMENT OF INSANITY. 159 

arm, and when he was picked up he was found to be* 
insensible. The vessel soon after making Gibraltar, 
he was deposited in an hospital in that place, where 
he remained for some months, still insensible ; and 
some time after he was brought from Gibraltar, on 
board the Dolphin frigate, to a depot for sailors at 
Deptford. While he was at Deptford, the surgeon 
under whose care he was, was visited by Mr. Davy. 
The surgeon said to Mr. Davy, * I have a case 
which I think you would like to see ; it is a man 
who has been insensible for many months ; he lies 
on his back, with very few signs of life ; he breathes, 
indeed, has a pulse, and some motion in his fingers ; 
but in all other respects he is apparently deprived 
of all powers of mind, volition or sensation.' Mr. 
Davy, on examining the patient, found that there 
was a slight depression on one part of the head. 
Being informed of the accident, which had occa- 
sioned this depression, he recommended the man to 
be sent to St. Thomas's Hospital. He was placed 
under the care of Mr. Cline, and when he was first 
admitted into this hospital I saw him lying on his 
back, breathing without any great difficulty ; his 
pulse regular, his arms extended, and his fingers 
moving to and fro to the motion of his heart ; so 
that you could count his pulse by this motion of his 
fingers. If he wanted food, he had the power of 
moving his lips and tongue ; and this action of his 
mouth was the signal to his attendants for supplying 
this want. 



160 ON THE TREATMENT OF INSANITY. 

" Mr. Cline, on examining" his head, found an 
obvious depression ; and thirteen months and a few 
days after the accident he was carried into the 
operating" theatre, and there trepanned. The de- 
pressed portion of bone was elevated from the 
skull. While he was lying" on the table the motion 
of his fingers went on, during the operation, but 
no sooner was the portion of the bone raised than 
it ceased. The operation was performed at one 
o'clock in the afternoon ; and, at four o'clock, as I 
was walking through the wards, I went up to the 
man's bedside, and was surprised to see him sitting 
up in his bed. He had raised himself on his pillow : 
I asked him if he felt any pain, and he immediately 
put his hand to his head. This showed that voli- 
tion and sensation were returning. In four days 
from that time the man was able to get out of bed, 
and began to converse ; and in a few days more he 
was able to tell us where he came from. 

" He recollected the circumstance of his having 
been pressed, and carried down to Plymouth or 
Falmouth ; but from that moment, up to the time 
when the operation was performed, that is, for a 
period of thirteen months and some days, his mind 
had remained in a state of perfect oblivion : — he 
had drunk, as it were, the cup of Lethe ; he had 
suffered a complete death as far as regarded his 
mental, and almost all his bodily powers ; but, 
by removing a small portion of bone with the 
saw, he was at once restored to all the fiuictions 



ON THE TREATMENT OF INSANITY. 10 1 

of his mind, and almost all the powers of his 
body." 

Insanity, arising- from coup-de-soleil, evidently 
proceeds from a physical cause acting- immediately 
on the brain. Such cases are not very common 
in this country. Coup-de-soleil more frequently 
causes frenzy and death than insanity : diseased 
action of the brain is, however, very frequently 
brought on by long'-continued exposure to heat and 
the rays of the sun ; but not in so sudden a manner 
as when it takes place immediately from coup-de- 
soleil. Whenever disease of the brain does occur 
from this cause, no time should be lost in the vigo- 
rous application of the foregoing remedies. We 
have reason to believe that diseased action in the 
brain, arising from this cause, proceeds much more 
rapidly than from most others. As far as my expe- 
rience extends, I have not seen any advantage arise 
from the use of blisters upon the head, especially 
during the paroxysm ; they appear rather to create 
irritation than to allay it ; and they prevent, by 
their application, the use of ice or cold water, 
which has often the most salutary and instantaneous 
effect. It has not unfrequently occurred to us, that 
when the diseased action has existed to such an 
excess, as to have prevented the patient sleeping for 
several days and nights, upon the head being 
shaved and cold applied to it, at the same time that 
warmth has been used to the extremities, he has 
almost instantaneously fallen asleep. If the disease 

M 



162 ON THE TREATMENT OF INSANITY. 

continues, a mode of treatment similar to that which 
will be hereafter prescribed for cases, where the 
insanity has arisen from moral causes, must be 
adopted. 

The only cases of insanity arising from excess of 
general sanguiferous circulation, from a merely 
temporary cause, are, in the instances where it is 
produced by a continuance, for several days, of a 
state of intoxication. When the patient is strong, 
and the system not previously debilitated by a habit 
of spirit-drinking, a treatment similar to the one 
just pointed out may be successfully adopted. Sud- 
den depletion, and to a very considerable extent, 
may have a salutary effect. 

I recollect a case which occurred to me thirty- 
five years ago, of a seaman, who had been living in 
a very intemperate way for some time, until he 
became so maniacal that he could not be kept on 
board his ship. He was sent to the workhouse at 
Hull, where he had only been a few days when he 
leaped out of the window } in consequence, as he 
afterwards related to me, of believing that the devil 
wanted to get possession of him. He thought he 
should escape him if he could but get out of the 
house. He said he felt quite free for some time, 
but he at last heard him beneath the pavement, 
wherever he went in the town. He then thought, 
that, if he could only leap on board a ship, which 
was at some little distance from the wharf, he 
should avoid him ; but he had not been long on 



ON THE TREATMENT OF INSANITY. 163 

board before he felt convinced that he was scratch- 
ing at the bottom of the vessel, and it then occur- 
red to him, that if he got on shore and cut his 
throat, he should be safe. He borrowed a knife 
from a sailor, whom he met, and instantly cut 
his throat from ear to ear. As is very usual in 
these attempts at self-destruction, the pharynx was 
wounded, but the carotids were uninjured ; the 
hemorrhage from the superficial vessels was enor- 
mous. The parts were speedily brought together ; 
the wound healed by the first intention : he was 
never insane one moment after the brain was re- 
lieved by the immediate loss of blood. He related 
to me all the above circumstances ; — he got per- 
fectly well, and went to sea, within a month after 
his unsuccessful attempt at self-destruction. In 
this case we have seen the sudden good effects of a 
very large and copious bleeding, as in other inflam- 
matory diseases requiring such treatment ; and, as 
no exciting cause continued to act upon the organ, 
after the first unintended remedy had been applied, 
the man got well. 

As most of the cases arising from this class of 
causes are attended with mania, and considerable 
violence, it may not be out of place to observe, that 
in all cases where the patient begins to be ungo- 
vernable, the kindest and least afflicting mode of 
proceeding, even to the patient himself, is to pro- 
cure such an overwhelming power to restrain him, 
as to make him feel it useless to resist. Very few 

M 2 



164 ON THE TREATMENT OF INSANITY. 

indeed will contend with three or four determined 
persons; but if only one or two be present, the most 
violent opposition is made. The most simple and 
least objectionable mode of confinement, is that of a 
pair of wide canvass sleeves, connected by a broad 
canvass shoulder-strap, so as to rest easily on the 
shoulders. They ought to come up well on the 
shoulders, and to extend about an inch beyond the 
ends of the fingers : the part covering the hand 
should be made of tolerably stiff leather, to prevent 
the hand grasping any thing. They keep the arms 
hanging easily, and in a natural position, by the 
sides of the body. They are fastened at the back 
by two straps, one going from one sleeve a little 
above the elbow, across the loins to a similar posi- 
tion in the other sleeve ; a second lower down, and 
by three similar straps in the front ; the latter being 
secured by buckles, which, in large establishments, 
where there are many patients to be attended to 
by one keeper, ought to be locked. This mode of 
fastening has many advantages over the straight- 
waistcoat. In the first place, it is less heating, it 
produces no pressure upon the chest, and the arms, 
though secured from mischief, have so much free- 
dom that the blood can circulate freely ; as with 
these sleeves ligatures of every description are 
unnecessary. It is sometimes also requisite to 
secure the feet. For this purpose we find, that a 
couple of leathern straps well lined with wool, 
placed round the ankles, and secured to the bed by 



ON THE TREATMENT OF INSANITY. 165 

staples, is all that is necessary. In hospital practice 
cases will sometimes occur, where it may be ne- 
cessary to secure the bedding* in its place. This 
can be done by having a thick quilt fastened over 
the blankets, by three leathern straps, to the sides 
of the bed. It occasionally happens, that, unless 
this precaution is taken, the patient will toss all the 
clothes off from the bed. In the winter season such 
a circumstance may be attended with bad conse- 
quences, if the patient is not very frequently seen. 
It cannot be too deeply impressed upon the minds 
of all who have any management of the insane, that 
in the application of these, or any other coercive 
measures, the greatest mildness and forbearance 
should be used towards the unhappy sufferers. 
Though it may be necessary, in some cases, to 
assemble such a force that the appearance of the 
persons alone may prevent all opposition, yet it is 
unwise and cruel for the whole party to fly at the 
poor patient, to accomplish that which may be fre- 
quently done under the soothing influence of one 
favoured attendant ; the mind of the patient being 
subdued by the presence of the others, who are 
ready to render further assistance if required. 

Another very convenient and easy mode of con- 
finement, is, by an arm-chair. Each of the arms of 
the chair forms a padded box, which incloses the 
arm of the patient, from a little below the elbow to 
the wrist. The box ought to be sufficiently large 
to contain the arm quite loosely, and without any 



166 ON THE TREATMENT OF INSANITY. 

pressure, and the hand will remain at liberty. A 
board, which forms a very convenient rest, is 
attached by hinges to the inner side of one of the 
arms of the chair, and is fastened to the other arm. 
When the confinement of the arms is unnecessary 
the box may be opened, and the patient may still 
remain fastened in the chair, by means of a loose 
strap passing in the front of the body, through two 
holes at the back of the chair, and there buckled. 
The chair may be fitted with a foot-board, a little 
elevated above the floor, and perforated with holes. 
Under this board a vessel constantly filled with hot 
water, ought to be kept, in cold weather. 

The cases of insanity, which arise from any 
physical cause, not producing organic disease in the 
brain or nervous system, vary in their duration 
from one to six months, in proportion as the disease 
is attended to or neglected, on its first appearance. 

We will next consider the treatment of cases of 
insanity arising from moral causes. In these cases 
the diseased action in the brain is rarely produced 
by any sudden shock, but it generally arises from 
the continued operation of some exciting cause, 
producing excessive vascular action in the brain, or 
in some part of it. Unfortunately, the alteration in 
the sentiments and conduct, in many cases, is so 
gradual, that diseased action in the brain may have 
existed without being suspected, until diseased organi- 
zation has actually taken place. When the insanity is 
discovered, it is rarely in the power of the physician 



ON THE TREATMENT OF INSANITY. 167 

immediately to remove the cause. It is however 
necessary, from time to time, to apply such physical 
remedies as may relieve the system, and prevent the 
diseased action from terminating in diseased organi- 
zation ; and, at the same time, to adopt every moral 
means of placing the patient out of the immediate 
influence of the primary cause of the disease. The 
treatment, therefore, of this class of cases, will 
necessarily be divided into medical and moral. Let 
us consider these divisions separately. First, then, 
as to the medical treatment. In all cases of insa- 
nity arising from moral causes, on the commencement 
of the diseased action of the brain, more or less dis- 
order will be found to exist in some of the other 
bodily functions. After the diseased action in the 
brain has continued for some time and become 
chronic, the other functions, in many cases, gradu- 
ally recover their tone ; and when lesion of the 
brain has taken place, the patients frequently enjoy 
a fair state of health. But until the system has 
become habituated to the diseased action of the 
brain, some other part of the body, varying, accord- 
ing to the different idiosyncrasies of the individual, 
will be affected by sympathy. The functions of the 
stomach, liver, bowels, or kidneys are usually dis- 
ordered ; and it becomes necessary to adopt the 
proper medical means to restore them to right ac- 
tion. These means, with the exception which will 
be shortly noticed, are such . as are usually employed 
when the same diseases have come on from any other 



168 ON THE TREATMENT OF INSANITY. 

cause. At the same time, the excess of sanguineous 
circulation in the brain, which is the immediate 
cause of their derangement, should be diminished. 
We will point out the medical remedies to effect the 
latter object. In the treatment of insanity, arising 
from physical injuries, it has been seen, that very 
large bleedings and copious evacuations are fre- 
quently of great use : but this is not the case in 
insanity from moral causes. In these cases, although 
there exists an excess of blood in the brain, yet, as 
this arises from the brain, or some part of it being 
constantly over excited, and therefore receiving more 
than its due share of blood from the system, the with- 
drawing any portion from the system generally 
will not alter the proportion which the brain will 
appropriate to itself, during the continuance of the 
exciting cause. But, in consequence of this extra ex- 
ertion of the brain, the constitution needs all its vital 
energy for its support. In the treatment, then, of 
insanity arising from moral causes, no greater quan- 
tity of blood ought to be abstracted, than that which 
will be sufficient so to reduce the inflammatory 
action in the brain, as from time to time to relieve 
the vessels, and prevent the coming on of diseased 
organization ; and, of course, the more directly the 
blood is taken from the diseased part, the less it will 
be requisite to abstract. In fact, the constitution 
and system generally require supporting, in conse- 
quence of the excessive exertion ; whilst the part of 
the brain locally affected with inflammatory action, 



ON THE TREATMENT OF INSANITY. 16^ 

requires that the gorged vessels should be relieved 
of their load to prevent lesion. As the first means, 
then, of diminishing the circulation, the head should 
be shaved, and the parts of the scalp, under which it 
is probable the excess of circulation is taking place, 
should be repeatedly bled with leeches, or cupped, 
a small quantity of blood only being abstracted at 
each time of bleeding. In many cases, the parts 
of the scalp to which the leeches or cupping-glasses 
may be applied, so as to produce the greatest local 
benefit, with the least expense to the constitution, 
may be discovered by the presence of additional heat 
or pain ; but in some instances the temperature of 
the scalp is equable, and the patient refuses to give 
any information as to his feelings. In these cases, 
the only means of ascertaining the part of the brain 
which is disordered, is by noting the mode in which 
the altered conduct or sentiment exhibits itself. 
In many cases, where the insanity has been clearly 
confined to particular propensities, I have found 
a greater degree of heat in the scalp covering that 
region of the brain which phrenologists have 
assigned as the organs of such propensities, than in 
other parts of the scalp, and the patient has com- 
plained of such parts being the seat of pain. I say 
region, because I wish it to be particularly noticed, 
that I do not pretend that, in any case, the heat is 
quite circumscribed to the particular convolution of 
the brain affected. Every one knows, that when 
inflammation takes place in any part of the body, 



170 ON THE TREATMENT OF INSANITY. 

it is not confined entirely to the spot which is dis- 
eased. Gout may be fixed in the joint of the great 
toe, but the parts of the foot immediately around it 
will partake of the heat. In other cases, therefore, 
where the patient is silent, if I find from the con- 
duct, that a certain set of feelings and propensities 
is deranged, I apply leeches or cupping-glasses to 
the region pointed out by phrenologists as their 
organs. I am convinced, from experience, that this 
mode of applying leeches has been very generally 
successful. I do not say, that if they had been 
applied to other parts of the head, similar results 
might not have followed ; but, in the absence of any 
other means of finding out the particular seat of the 
disease, when no variation in temperature exists, 
and no particular pain is described, I have adopted 
this method, and with success^ as to the ultimate 
result. 

In numerous chronic cases also, (the treatment of 
which will be noticed hereafter,) where, from the 
imperfect manner in which certain functions are 
performed during the most healthy state of the 
patient, there is every reason to believe that lesion 
exists in some parts of the brain, an application of 
leeches, or cupping-glasses, on a similar principle, 
relieves the periodical exacerbations of the disease 
to which they are liable, and very greatly shortens 
their duration. But in these cases again, I am un- 
able to say, that the application to other parts of the 
head would not be attended with similar results : 



ON THE TREATMENT OF INSANITY. 171 

as I should not think myself justified, for the pur- 
pose of any philosophical experiment, in neglecting 
the means which I really believe to be the best cal- 
culated to diminish the sufferings of the poorest or 
most imbecile patient under my care. Supposing, 
then, the head to have been shaved, and the leeches 
or glasses applied where, according to the judgment 
of the physician, they will most efficaciously relieve 
the vessels of the brain, the head ought to be kept 
cool by ice, or by cold applications. Ice is by far the 
best refrigerant. Every public institution for the 
cure of the insane ought to be provided with an ice- 
house. The ice is most conveniently applied by 
powdering it tolerably small, and then putting it into 
a cap made of water-proof cotton ; as that prevents 
it running down the neck and face when it dissolves. 
When no ice is to be obtained, cold water, or weak 
vinegar and water, may be substituted for it ; but 
cold applications of some kind on the shaven scalp 
ought to be most strenuously persevered in, until 
the head becomes cool. The shower-bath is fre- 
quently used in these cases, but I do not think with 
the same advantage as the continued cold applica- 
tions. The re-action which takes place in some 
measure counterbalances the good which is derived 
from the temporary relief to the brain. The lower 
extremities ought to be kept warm ; and, if other 
means for that purpose be inefficient, mustard poul- 
tices may be applied with advantage to the feet, 
particularly in cases where the Avhole surface of the 



172 ON THE TREATMENT OF INSANITY. 

head is excessively hot. And there are cases in 
which the sanguineous circulation is so excessive, 
as to make it requisite to abstract blood from the 
system by the lancet, as well as from the scalp by 
leeches. As in other diseases, acute topical inflam- 
mation sometimes runs so high, as to make it 
requisite to abstract blood from a patient whose 
general health can ill bear depletion. Now it may 
be taken as a principle, that a person insane from 
moral causes is one who cannot, without injury to 
the constitution, bear depletion : and the lancet must 
be used with great caution even in the plethoric, 
and in those who are apparently the strongest. 
The local bleedings with leeches may be repeated 
as often as it is judged that the vessels require 
relief. Watchfulness forms so prominent a feature 
in almost all recent cases caused by direct action on 
the brain, that it is necessary to dwell rather more 
at large upon it. To allay irritation is evidently 
the great desideratum : but as it is well known that 
there are peculiar idiosyncrasies in almost every 
constitution, so it will be evident that the means 
must be varied as we find them to exist. The 
same medicine which will allay it in one will not in 
another ; but, on the contrary, increase it. This is 
particularly the case with opium, which is rarely 
found admissible in insanity. It more frequently 
creates heat, and general febrile action, than pro- 
cures sleep : if given at all, it should be in conjunc- 
tion with ipecacuanha ; from five to ten grains 



ON THE TREATMENT OF INSANITY. 173 

of which, taken at bed-time, is sometimes found 
useful — most probably from the action usually pro- 
duced on the skin by this remedy. We find the 
application of cold to the shaved head to be the 
most effectual means, in the first stage of the dis- 
ease, to procure sleep ; and, afterwards, useful 
exercise out of doors. I have repeatedly seen 
patients who had been in the most violent state of 
excitement, and entirely without sleep for many 
days and nights, notwithstanding every effort has 
been used to procure it by the administering various 
narcotics, and the use of hop pillows, sink into 
the most comfortable repose on using the pedi- 
luvium, and applying cold to the shaven head. I 
have sometimes thought, that the placing a patient 
on a bed, kept gently rocked by a person not in the 
room with him, might have a tendency to produce 
sleep. This might be easily contrived, but I have 
not tried its effect. In the first stage of the disease 
we ought, if possible, to avoid the use of narcotic 
medicines ; and to endeavour to procure sleep, by 
allaying irritation, in the method above pointed 
out. I wish particularly to press this, because 
much has been said by some authors, on the neces- 
sity of procuring sleep by any means ; and of 
keeping up the strength of the constitution with 
hearty suppers, porter and other stimulants. There 
is no doubt that a full meal very often produces 
sleep ; and, that in the more chronic stage of the 
disease the exhaustion is often very great, and the 



174 ON THE TREATMENT OF INSANITY. 

constitution consequently requires an extra quantity 
of food. If the patient, under these circumstances, 
goes to bed with a stomach nearly empty, he will 
get no sleep ; but hearty suppers are not admissible 
in the incipient stage. The diet should be low, if 
the patient can bear it ; but certainly, in this stage, 
never stimulating. It may in general be confined 
to gruel, milk, and pudding. Balm tea is the most 
refreshing diluent the patient can take to allay the 
thirst, which is usually suffered on the commence- 
ment of the attack. As the violence of the disease 
abates, a more generous diet may be adopted. If 
the application of cold or exercise be not sufficient 
to procure sleep, five grains of Extract, hyosciami, or 
from fifteen to twenty drops of Tinct. digitalis, may 
be taken at bed-time with advantage, during any 
stage of the disease. I have also found the follow- 
ing draught very useful in these cases: — I^. Mistur. 
camphor. 1 oz. Liq. ammon. acet. 2 dr. Tinct. digi- 
talis, 15 minims. Tinct. hyosciam. J dr. Syr. balsam. 
1 dr. — Mix. But we scarcely possess any remedy 
so generally powerful in allaying irritation as the 
warm bath ; there are very few persons, indeed, 
upon whom it has not a salutary effect. It may be 
used with advantage two or three times a week, or 
even every day, if necessary : it is often found very 
salutary to apply cold to the head when the patient 
is in the warm bath. Whilst these remedies are 
administered for the purpose of decreasing the dis- 
eased action of the brain, the requisite means must 



ON THE TREATMENT OF INSANITY. 175 

be used to restore the other functions to their due 
tone. When, from the furred state of the tongue, 
and other symptoms, there is reason to conclude 
that the stomach is foul, I find that the quickest 
mode of obtaining relief is by giving an emetic : 
for, notwithstanding the use of them would appear 
contra-indicated from the act of vomiting propelling 
the blood to the head, I find this temporary incon- 
venience more than counterbalanced by the removal 
from that viscus of any irritating matter which, 
during its continuance, constantly tends to keep up 
the disease. And if, instead of emptying the stomach 
of the irritating matter at once by an emetic, we at- 
tempt to attain the same result by the slower method 
of purgatives and alteratives, we necessarily lose time. 
The diseased action of the brain and nervous sys- 
tem re-acts upon the viscera, and, in many cases, 
renders it a long and tedious process to restore 
these to a healthy state. Some judgment is required 
in determining the proper doses. In many cases, 
whilst the excess of circulation in the brain conti- 
nues, it seems to absorb all the nervous and vital 
energy. The liver ceases to perform its functions 
aright, the patient will not discharge more than 
half a pint of urine in the course of the twenty-four 
hours, and in many cases the bowels are torpid, and 
there is no evacuation for several days. Now it is 
essential that all the functions should be restored to 
a healthy, but not to an excessive action. If very 
large doses of medicine be administered, there is 



176 ON THE TREATMENT OF INSANITY. 

great risk that the viscera will be roused to excessive 
and debilitating" action for a time, and then will sub- 
sequently sink into a corresponding- state of torpor. 
The safest course is to give small, but repeated 
doses ; but, if necessary, these must be increased until 
the end is attained. In many instances, after careful 
perseverance in administering small and gradually 
increased doses of the usual purgatives, it is found 
requisite to have recourse to croton oil, in doses of 
from one to two drops, repeated every four or six 
hours, in order to get the bowels freely opened. 
In other instances very small doses of cathartics are 
sufficient. But purgatives ought not to be admi- 
nistered when the secretions of the bowels are in a 
healthy state, or in greater doses than are required 
to keep them tolerably open. It ought to be 
observed, that in proportion as the diseased action 
of the brain ceases, the bowels and other viscera 
become more easily acted upon. In cases where 
the patients are plethoric, neutral salts generally 
form the best purgatives : where the circulation is 
deficient, or the digestive organs much impaired, 
calomel, combined with the aromatic pill, is to be pre- 
ferred. But the same circumstances which indicate 
the medicine proper to be selected in ordinary cases 
are also the guide in cases of insanity. The medical 
attendant himself ought to inspect the egesta. Very 
little reliance can be placed on servants ; and the 
patients are frequently so unable or unwilling to 
describe their own feelings, that the state of the 



ON THE TREATMENT OF INSANITY. 177 

body is the only guide as to the general health, and 
as to the proper mode of treatment. I have found 
the following prescription very useful in cases where 
the urinary secretions seem deficient ; and also in 
cases where it has been requisite to reduce the 
circulation : — Tinct. digital., Tinct. scillse, aa. ^ oz., 
Vin antim. tart., Sp. sether. nitr. aa. 1 oz.— Mix. 
I usually administer it in doses of thirty drops 
three or four times a day, combined with ten 
grains of nitre. I would add, as a caution, that 
in every stage of insanity, great attention ought 
to be paid to the state of the skin : and when 
it is hot and dry, and the secretions deficient 
in quantity, five-grain doses of nitre, with a quarter 
or an eighth of a grain of tartar emetic, and a 
little sugar, ought to be administered every four 
hours. If the biliary secretions are also deficient, 
doses of two grains of pulv. antimonialis, with 
half a grain of calomel, may be substituted with 
advantage for the nitre and tartar emetic. It will 
be seen, that, in what has b^en said on the treatment 
of insanity, the division into mania and melancholia 
has not been observed. I am aware that they are 
usually considered as distinct diseases, requiring 
totally different modes of medical treatment. In 
the former, profuse bleedings and violent purgings 
are generally used : from this practice it will have 
been seen that I dissent entirely, except in the cases 
where the insanity has arisen from physical causes. 
In the latter, in the very early stage of the disease, 

N 



178 ON THE TREATMENT OF INSANITY. 

stimulants and tonics are generally administered. 
Now, as far as I am capable of judging, mania and 
melancholia both arise from an excess of blood, 
although in different parts of the brain, and con- 
sequently a similar medical treatment is applicable 
to both. I have certainly found cases of melan- 
cholia derive as much relief from cold applications 
and repeated local bleedings, as cases of mania ; and 
I have no hesitation in saying, that a melancholic 
patient will ceteris paribus bear as much depletion, 
without injury to the constitution, as the maniacal 
one. When febrile action exists, nitre, antimony, 
and other febrifuges, must be equally administered 
to both. These observations, with respect to blood- 
letting, must be understood as entirely confined to 
those cases where no phrenitis exists. In cases of 
phrenitis, immediate recourse must be had to very 
copious bleedings from the system, from a large 
orifice, and local bleedings will generally be found 
to be subsequently necessary. In cases of mania, 
we find the violence of the patient and the quick- 
ness of the pulse greatly reduced by doses of sul- 
phate of magnesia, with half a grain of tartar emetic 
every three hours, until copious vomiting and stools 
have been produced. Small nauseating doses of 
tartar emetic may also be applied with advantage 
in the early stages of melancholia ; and even in 
those cases where the stomach appears to be out 
of order, and the patient seems to have lost his 
appetite and relish for food. They diminish the 



ON THE TREATMENT OF INSANITY. 179 

circulation in the brain, and by their temporary 
relief enable it in some measure to recover its tone. 
And certainly whilst the patient is suffering from 
nausea, the most painful circumstances seem to pro- 
duce but little effect on the mind ; the feeling of 
sickness absorbs every other consideration ; and 
any thing which tends to break in upon the habit 
of constantly dwelling upon painful subjects, even if 
it be but for a short time, is most valuable. Cases 
of melancholia are generally acknowledged to be 
more difficult of cure than cases of mania. This, I 
think, arises from the circumstance, that in cases of 
mania, the violence of the patient's conduct attracts 
instant attention, and remedies are applied without 
delay ; whilst in melancholia, on the contrary, par- 
ticularly when the disease arises from moral causes, 
the alteration in the conduct and sentiments is so 
gradual, that no notice is taken of it ; and no 
remedies are applied until the diseased action has 
existed for a considerable period, and probably not 
until diseased organization has actually taken place. 
One of the first symptoms of the diseased action 
of the brain having ceased, and of the secretions 
having become natural, is the return of plumpness. 
A detailed accoimt of the particular medicines and 
treatment, adopted in a number of cases, would 
convey no useful information. If the principles of 
the treatment be rightly understood, the peculiar 
constitution and circumstances of each patient will 
be the best guide ; and if they be not understood, it 

n2 



180 ON THE TREATMENT OF INSANITY. 

would be perfectly in vain to hope that a transcript 
of cases would make them intelligible. In the 
previous parts of the work, the effect of the general 
plan in a variety of instances has been mentioned. 
I have here inserted the short medical history of 
two cases, as a specimen of what may be expected 
as the ordinary result of the practice. I have 
added another, to show the propriety of using small 
doses, especially of digitalis ; and a fourth, to ex- 
emplify the state to which the chylopoietic viscera are 
sometimes reduced, particularly after the disease has 
not been properly attended to on its first appearance. 
A. B., a female, about sixty-five years of age, had 
been insane only a few weeks, and was in a state of 
great agitation when admitted : head hot ; tongue 
foul ; bowels confined ; pulse one hundred and 
tv/enty, and full. Head was shaved, leeches applied, 
an emetic and purgatives administered, and the 
nitrate of potash, with the digitalis, given every four 
hours. The pulse was reduced in frequency, and 
the general secretions improved by these means ; 
but the cerebral irritation and extreme heat in the 
superior part of the head continuing unabated, it 
was necessary twice to repeat the bleeding by 
leeches ; and the cold lotion was continued for some 
time before the heat and irritation were removed. 
The necessary low diet, with these depleting means, 
though the bleeding was only local, relieved her 
very considerably. The mind became gradually 
more composed. No relapse took place after 



ON THE TREATMENT OF INSANITY. I8l 

amendment began, and she recovered her health, 
mental and bodily, in a few weeks, and was dis- 
charged cured. 

J. S., a foreigner, was found in the street in a 
furious state of mania, and sent to the asylum as a 
lunatic vagrant. Head hot, particularly in the 
region of the temples ; extremities cold ; tongue 
furred. The head was ordered to be shaved, and 
kept cool with cold lotion, the extremities kept 
warm, and the bowels opened with calomel and 
ext. colocynth ; cupping-glasses w^ere applied to the 
temples, and a blister to the back of the neck. Ten 
grains of nitre, with thirty drops of the following 
prescription :— Tinct. digital., Tinct. scilla;, aa. 
2 dr., Sp. cether. nitr., Vin antim. tart. aa. ^ oz. — 
Mix,' — given three times a day. The powers of 
his mind and body were gradually restored. 

This plan was continued, but with little improve- 
ment, for fourteen days. Another blister was then 
applied to the back of the neck, and the calomel and 
the colocynth were repeated, but the drops were 
omitted ; as the patient was thinner and much 
reduced in strength, and some small ulcers had 
appeared in the lower extremities indicating general 
debility, and the excessive heat in the head had 
abated. A more nutritious diet was given ; the 
patient took a grain of sulphate of quinine three 
times a day ; and, as he continued to be restless at 
night, five grains of extract of hyoscyamus were 
given at bed-time ; the patient slept better, but was 



182 ON THE TREATMENT OF INSANITY. 

still mischievous, and sometimes dirty. This plan was 
persevered in, and the heat of the head and maniacal 
symptoms gradually abated. It soon became unne- 
cessary to continue the hyoscyamus ; and, by way of 
strengthening the general health and constitution, 
the shower-bath was ordered. The powers of his 
mind and body were gradually restored, and he 
returned quite well to his native country, in four 
months from the commencement of the attack. In 
this case, the only mode of ascertaining the state of 
the patient was from his bodily symptoms ; as he 
could scarcely speak a word of any language except 
Polish. 

T. L., reported to have been insane only a short 
time. Head hot, and complains of pain at the top 
of it ; tongue white, and furred ; pulse eighty-six, 
and full ; bowels costive ; mind much excited and 
wild. Head was ordered to be shaved, and after- 
wards kept cool with the evaporating lotion, and 
the extremities warm ; he took an emetic, and the 
bowels were opened by a solution of sulphate of 
magnesia, which was followed by the mixture, 
containing ten grains of nitre and thirty of the 
foregoing drops, in each dose, three times a day. 
Balm tea when thirsty. The emetic and purgatives 
operated freely. The cold application succeeded 
in rendering the head cool ; and, consequently, 
leeches and cupping-glasses were not applied. The 
following day the feet were warm, the pulse soft, 
but he had passed a restless night : the common 



ON THE TREATMENT OF INSANITY. 183 

evaporating- lotion was omitted, and cloths dipped 
in a solution of half a drachm of extract of hyos- 
cyamus, in about a pint of water, were kept con- 
tinually wrapped about the head, and the other 
remedies were continued. In three days the symp- 
toms abated, the pulse was reduced in frequency 
and fulness, and he slept better. At the end of a 
week, under this treatment, the pulse was brought 
down to sixty ; the tongue clean, bowels open. 
The remedies were discontinued. The mind gradu- 
ally became less excited, and he was allowed a more 
generous diet, and further medicine became unne- 
cessary. At the time of this being w^ritten, not 
more than sixteen days have elapsed since his 
admission ; and he is now walking about the ward, 
rapidly improving in mind and in general health. 
In this case it will be observed, that although only 
five drops of tincture of digitalis, in conjunction 
with the nitre, were given at a dose, and only 
repeated three times in the twenty-four hours, at 
the end of a week the pulse was reduced from 
eighty-six to sixty. The change of the evaporating 
lotion to the solution of hyoscyamus was an experi- 
ment : I can form no opinion, as to whether this 
had, or not, any influence in producing the rapid 
amendment. 

The following case will illustrate the theory, 
that when the brain is in a very great state of 
excitement the nervous energy is so deficient in 
other parts, that the functions are not performed in 



184 ON THE TREATMENT OF INSANITY. 

a healthy manner, and that it is sometimes requisite 
to use very powerful medicine to restore them to 
healthy action ; though the organs themselves have 
undergone no organic change, and are capable of 
resuming their functions, as soon as the irritable 
state of the brain is subdued. 

A. B., fifty-five years of age, of very active and 
diligent habits, and of high moral and religious 
principles, was observed by his family, contrary to 
his usual habit, to become taciturn and gloomy in 
his manner, and to appear dissatisfied and discon- 
tented. His sleep was at first only disturbed, but 
at length he used to lie awake nearly the whole 
night. These circumstances did not create much 
alarm in his family, so long as he continued to 
attend to his business. The diseased action of the 
brain continuing, other organs began at length to 
sympathize with it : he lost his appetite, and 
became generally unwell. His medical attendant 
prescribed some aperient medicine, which he often 
refused to take, and consequently daily got worse : 
he confined himself almost entirely to his house, 
and, as the winter was approaching, to his room. 
He had been in this state for about four months 
when I first saw him. He was very much dejected, 
and was labouring under morbid religious feelings : 
he had become thin, and the bowels were habitually 
very costive ; head hot ; pulse, about ninety. As 
he was very obstinate, and neither his family nor 
medical attendant had any influence over him, I 



ON THE TREATMENT OF INSANITY. 185 

recommended his immediate removal to a distance 
from home ; and prescribed leeches, cold applica- 
tions to the head, calomel and extract of colocynth, 
to purge him. None of these things were admi- 
nistered or attended to : he continued getting worse 
in every respect. Six weeks afterwards I was again 
desired to see him ; the patient, in addition to his 
other sufferings, was then complaining of numbness 
in one of the limbs ; and exhibited other symptoms, 
denoting such a fulness of blood in the head, as to 
create considerable alarm. The patient was then 
removed from home ; — the head was shaved, and, 
all the upper portion of it being very hot, was bled 
with leeches, and the evaporating lotion applied. 
The secretions from the bowels and kidneys were 
very deficient ; calomel and colocynth were given in 
powerful doses without producing any effect ; and it 
was necessary not only to repeat the pills, but to 
give castor oil, sulphate of magnesia, enemas, and, 
lastly, the croton oil in two-drop doses, before 
any evacuation could be obtained. The same diffi- 
culty was found with the kidneys ; not more than 
half a pint of urine was obtained, sometimes, in 
twenty-four hours. Diuretics combined with neutral 
salts, in conjunction with extract taraxaci and pil. 
hydrarg. were had recourse to, and the obstruction 
was overcome. Firm, but kind treatment con- 
quered the self-will of the patient ; and, by degrees, 
not only was he got down stairs daily, but was 
induced to walk in the open air. The tongue, as 



186 ON THE TREATMENT OF INSANITY. 

might be expected, was generally furred ; the pulse 
between ninety and a hundred, and the appetite 
deficient : the head also continued hot ; it was 
necessary to keep it constantly cool with the eva- 
porating lotion, and repeat the local bleeding. But 
it was not until several weeks elapsed, and the 
cerebral excitement had evidently abated, that any 
improvement was observed in the secretions : un- 
usually large doses of purgatives were constantly 
required to keep the bowels open, and the diuretics 
to be continued to keep the urinary organs active. 
Steadily pursuing this plan, the pulse, after some 
weeks, began to abate in frequency ; the tongue 
became cleaner, and the head cooler. In propor- 
tion as the cerebral irritation abated, the nervous 
system in general was restored to its equilibrium, 
the chylopoietic viscera were more easily acted 
upon, until the functions were performed without 
the aid of medicine. The patient, at the end of 
three months, was sufficiently recovered to take a 
journey into the country. 

Although the plan of medical treatment pre- 
viously pointed out is the best with which I am 
acquainted, for relieving the irritability attendant 
upon incipient insanity, and upon the exacerbations 
in old cases, yet there are many instances in which 
its operation, to say the least, is slow and uncertain. 
Local bleedings at the time appear to afford relief; 
but this seems to be rather the result of their 
removing from the brain the injury caused by 



ON THE TREATMENT OF INSANITY. 187 

irritation, than of their directly affecting and dimi- 
nishing this irritation. I have very little doubt 
that there is in nature some medicine, with which 
I am at present unacquainted, that would operate 
as a specific in these cases. What it is, I know not ; 
but it certainly is not to be found in any of the 
vegetable poisons in general use. I have seen them 
tried repeatedly ; but whatever else may have been 
their effect, they do not seem specifically to act upon 
nervous irritability, although, as must have been 
already seen, some of them may be very generally 
used with advantage. 

Let us next proceed to consider the moral treat- 
ment. The first object to be attained is, if possible, 
to remove the exciting cause of the disease. There 
are some cases, in which this may be effected with- 
out much difficulty. When the insanity has arisen 
from the actual presence of some objects, which 
operate too powerfully on the brain, the immediate 
removal to other scenes, with proper medical treat- 
ment, will prevent the increase of the attack, and 
speedily restore the patient. One of the persons, 
who came as a domestic to the institution at Han- 
well, felt his mind so much excited by the presence 
of the patients, that he lost all appetite ; he could 
obtain no refreshing sleep, and, in fact, could not 
close his eyes without having images of the patients 
continually dancing before him. There is no doubt 
that if he had remained in the institution, he would 
have become insane. His removal into other 



188 ON THE TREATMENT OF INSANITY. 

scenes, with proper medical treatment, soon restored 
him to his usual health. But unfortunately, in 
most instances, when the insanity arises from moral 
causes, the mind busies itself about some painful 
reality, which it is not in the power of the physician 
to remove ; or it occupies itself too intensely about 
some subjects of sufficient real importance to engross 
all its attention. In the former instances, although 
the cause is rarely in the power of the physician, or 
even of the friends of the patient, yet, if from any 
circumstances it be removed, an attack may be pre- 
vented, or, if it have already supervened, one grand 
difficulty in the recovery of the patient will be over- 
come. It has been already stated, that pecuniary 
embarrassments are a fertile cause of insanity in 
England. It cannot be a matter of surprise that 
this should be the result in a country where specula- 
tion is carried on to so ruinous an extent, and where 
a delay in expected payments may reduce a man 
from affluence to poverty. One instance has 
occurred within my own observation, where relief 
from extreme embarrassment, with a little medical 
assistance, was sufficient almost immediately to 
restore the patient to health, A merchant, who 
had formerly carried on a very extensive business, 
from a series of losses became much reduced ; he 
bore up against them, and struggled to support 
a wife and a large family, until he was induced 
foolishly to attempt to increase his capital by 
bill-drawing. This, as is usually the case, led to 



ON THE TREATMENT OF INSANITY. 189 

ruin. He was arrested and sent to prison, his little 
property was sold, and no resource but the work- 
house seemed left for him. He was a man of keen 
feelings. His intense anxiety, as might reasonably 
have been expected, brought on watchfulness and the 
usual symptoms of incipient insanity. As soon as 
his principal creditor became acquainted with the 
true state of the case, he had compassion upon him 
and released him from prison ; and one of his sons, 
a most amiable young man, who was in a good 
situation as a clerk, undertook to provide for the 
immediate wants of the family. The result was, 
that the health of the patient was speedily restored, 
and the attack of insanity, which was evidently 
coming on previously to his leaving the prison, was 
averted. But in those cases where the over-action 
of the brain has been brought on by thinking too 
long and too intensely on painful truths, from 
which there is no escape for the patient, it is exceed- 
ingly difficult to divert the attention, and to prevent 
the mind from dwelling upon them so conti- 
nually as to produce disease ; for although patients 
are conscious of the injury they are inflicting upon 
themselves, and of the inutility of their over-anxiety, 
and judge most accurately of their situations, they 
do not appear to possess the power of controlling 
their thoughts. In fact, the habit of severe mental 
discipline is too much neglected. If in ordinary 
circumstances, as a part of self-education, we were 
to accustom ourselves to fix certain limited times, 



190 ON THE TREATMENT OF INSANITY. 

on which to occupy the mind on particular subjects, 
to the exclusion of all others, and during* those 
periods rigidly to confine the attention, and at the 
conclusion of them, carefully to change the current 
of our thoughts, we should obtain an habitual 
power over ourselves, which would be a most useful 
preservative against the over-anxiously dwelling 
upon painful subjects. When the exciting cause can- 
not be removed, the patient should be placed in cir- 
cumstances calculated as much as possible to produce 
a complete interruption to the train of thought ; 
every object at all likely by association to recall to the 
mind the painful circumstances, should be avoided ; 
the patient ought to be surrounded with other 
objects. The usual routine of his habits ought to 
be broken in upon, and the attention attracted by a 
change in the little domestic arrangements ; and, 
however painful, he should be at once withdrawn 
from the society of his friends. If the diseased 
action be but small, and the attack just in its com- 
mencement, I know of no means of accomplishing 
this more effectually than by sending the patient on 
an excursion into a fine country, mountainous if 
possible : the air, the scenery, and the exercise, all 
have a salutary influence ; and the separation is by 
this means effected without causing any pain either 
to him or to his friends ; but he ought, if possible, 
to be accompanied during the journey, by an 
experienced medical attendant; and the physical 
remedies for the relief of the brain ought to be most 



ON THE TREATMENT OF INSANITY. 191 

carefully attended to. Much disappointment fre- 
quently arises from change of scene producing no 
benefit. This is to be traced to the neglect of the 
use of medical remedies at the same time. It would 
not be less unreasonable to expect that inflammatory 
action of the lungs, produced by cold, would be 
cured by the mere removal into a warmer tempe- 
rature, than to hope that the diseased action in 
the brain should be cured merely by withdrawing 
the patient from the immediate influence of the 
cause of it. Much mischief has arisen from this 
mistake, and valuable time has been lost, to the 
irreparable injury of the patient. I know an 
instance of a gentleman, who became insane, and 
whose insanity was principally exhibited in general 
depression of mind, and in erroneous views on 
religious subjects. His conduct was not such as to 
make personal restraint necessary ; and it was 
thought that a journey on the continent would 
divert the attention to other objects, and speedily 
restore the mind. This was tried ; but medical 
remedies being neglected, the result was such as 
might have been feared. The diseased action 
increased, and he will in all probability be insane 
for life. When change of scene is tried, I should 
strongly recommend varied excursions in a fine 
country, and not the mere change of a residence in 
a foreign capital. 

If the diseased action exists to such an extent as 
to make the change of scene inexpedient, or the 



192 ON THE TREATMENT OF INSANITY. 

circumstances of the patient will not permit such a 
means of recovery to be resorted to, he ought to be 
at once removed from home, and placed under 
medical care. It is painful for friends to intrust 
their dearest relatives to strangers, and to run the 
risk on their recovery of being thought to have 
acted towards them harshly and precipitately ; but 
unless they are willing to have the best interests of 
the sufferers sacrificed to a selfish caution and a 
foolish delicacy, they will not hesitate, however 
trying, to incur the responsibility of placing them, 
on the very commencement of the disease, where 
they will have an opportunity of receiving the best 
medical and moral treatment ; and where they will 
at least be prevented from inflicting upon them- 
selves, or those about them, any bodily injury. 
Many valuable lives have been lost from a foolish 
delay in the adopting this decisive but necessary 
step. In still more numerous instances, persons 
have remained insane for life, who, had promptness 
been used, might speedily have been restored to 
society. County Lunatic Asylums offer to the poor 
the most efficient means of cure ; and no induce- 
ment exists to keep them in confinement there a 
day longer than is desirable for their restoration 
and subsequent continuance in good health. No 
such provision is at present within the reach of 
the wealthy ; but the houses for the reception of 
the rich, and the asylums for the poor, are of so 
much importance, as to deserve more consideration 



ON THE TREATMENT OF INSANITY. 193 

than could be conveniently g'iven to them in 
this place. 

The first step on the part of the medical man, is 
to gain the confidence of the patients by kind treat- 
ment, and a solicitude for their welfare. These are 
soon perceived and properly appreciated. To en- 
gage their attention on some new object, either by 
affording them useful employment or attractive 
recreation, is the next step to be pursued. But 
before any of the faculties of the mind which have 
been in a diseased state are again called into 
action, great care should be taken to ascertain that 
no inflammation, or even irritation of the brain 
remains. For though we well know that nothing 
tends to the restoration of a weakened brain, or of 
a weakened limb, so much as moderate exercise ; 
yet, if that exercise be commenced too soon, much 
mischief is often the result. As this is an error into 
which I have frequently fallen, I think it the more 
necessary to caution others. So long as any symp- 
toms of excessive circulation in the brain remain, 
patients ought not to be permitted to use much exer- 
cise. They should be kept as quiet as possible until 
these symptoms are removed by the medical treat- 
ment previously pointed out. In many cases, particu- 
larly amongst the industrious poor, w^hose previous 
habits have rendered such a system of quiet, and an 
abstinence from muscular labour irksome, a desire 
is frequently expressed to he permitted to work 
before the exercise would be prudent. But with 

o 



194 ON THE TREATMENT OF INSANITY. 

others of this rank, it is a task of no ordinary 
difficulty to rouse the patients to any species of 
exertion, mental or bodily. This is particularly the 
case where the disease has been of long standing ; 
the mind having become habituated to one train of 
thinking, and the body to indolence, the greatest 
repugnance to any exertion is felt. In some con- 
stitutions nothing but the most determined per- 
severance can overcome it. The great means of 
accomplishing this, or indeed, of influencing the 
conduct of the patients in any other respect, is by 
ascertaining what they particularly like and dislike, 
and then granting or withholding the indulgence, 
according to their behaviour. Very few persons 
arrive at the period of life at which insanity comes 
on without having acquired certain tastes and habits. 
It is of the greatest importance that these should be 
ascertained in each individual patient. They are 
the lever, and frequently the only lever, by which 
the moral man can be moved. When the bodily 
health is restored, any little things which the patient 
really enjoys should be withheld, and only granted 
upon his complying with certain conditions, and 
withdrawn on their being broken. The medical 
attendant ought to be ingenious in finding out the 
peculiarities, and to be firm and kind in the treat- 
ment which he founds upon them. He ought fully 
to explain to the patient the reasons for his conduct 
to him ; and endeavour to impress upon the mind, 
that any other mode of treatment would be a breach 



ON THE TREATMENT OF INSANITY. 195 

of duty on his part, and tliat the deprivation is 
painful to him, but essential to the patient. In 
many cases, where the total indifference of a patient 
prevents this mode of treatment being- used, the 
breaking" in upon his habits has a similar effect. 

A female, discharg-ed as incurable from an hos- 
pital near London, was, on her admission into the 
asylum at Hanwell, one of the most distressing 
patients amongst the six hundred. The wringing 
of her hands, and her constant moaning, almost 
night and day, rendered her unfit to be amongst 
the other patients. Liberty and confinement, indul- 
gence and privation were tried without effect j she 
still persevered in the deplorable noise and wringing 
of her hands. As she seemed to dislike the open 
air, she was ordered to be taken out of doors every 
morning, and there kept the whole day. For a 
long time no alteration seemed to take place ; but 
the plan was still continued. In about two months 
her bodily health had greatly improved ; and, 
although she refused to work, her noise was dimi- 
nished, and she expressed her dislike of the going out 
of doors. This was a great point gained. She was 
told, that if she would conduct herself so as not to 
annoy the other patients, and amuse herself with a 
little work, she should remain in the house. On 
the promise of good behaviour, the experiment was 
tried, and it succeeded. She has, for weeks, daily 
occupied herself in sewing. She has little indul- 
gences, the fruits of her labour ; and she rarely 

o 2 



196 ON THE TREATMENT OF INSANITY. 

attempts to wring- her hands or to repeat her moan- 
ing : when she does, a hint that she must be 
removed from her nurse — to vvhom she is much 
attached — and again sent into the garden, is quite 
sufficient to recall her to order. But it is impos- 
sible to point out the various modes of acting, 
according to this principle, on the minds of the 
patients. They are as diversified as the tempera- 
ments, dispositions, and habits of each individual. 
An account of the various species of employment 
adopted at the asylum at Hanwell, and of the 
means practically used to engage the attention of 
the patients in them, will be given in a subsequent 
chapter. Considerable tact is required in adapting 
the particular kind of occupation to the tastes of 
the patients. They are usually more easily induced to 
work at the trades to which they have been brought 
up, than to turn their attention to pursuits entirely 
new. Most men seem to have a natural fondness for 
farming and gardening, and these occupations have 
this great advantage, that there are certain portions 
of the labour in them, in which a violent or suicidal 
patient may be employed, without being entrusted 
with any tools by which he might either injure him- 
self or others. But so important do I consider the 
diverting the mind by employment, that where the 
patient cannot be induced thus to occupy himself, 
or where the occupation is too mechanical to keep 
the mind interested, I do not hesitate, with proper 
precautions, to intrust him with tools, even where 



ON THE TREATMENT OF INSANITY. 197 

an inclination to suicide or to violence exists. And 
altlioug"h I liave adopted this plan in numbers of 
cases, no accident has yet ensued, and it has fre- 
quently been the means of the patient's complete 
recovery. 1 will mention one instance. A car- 
penter was admitted as a patient into the asylum 
at Wakefield. He had previously made several 
attempts at self-destruction, and was then in a very 
desponding- state. After the diseased action had 
subsided, great dejection still remained ; he was, 
however, placed under the care of the gardener, 
who was then constructing a kind of grotto or 
moss-house in the grounds. The contriving the 
building offered a scope for his taste and ingenuity. 
He was consulted on the arrangement of the floor, 
which was formed of pieces of wood of different 
kinds, set in various figures. He was furnished 
with tools, though he was, of course, most carefully 
watched. He took so great an interest in the 
little building, that the current of his thoughts was 
changed. All his miseries were forgotten, and his 
recovery took place at the end of a few months. 
He very justly attributed his restoration to the 
" moss-house." Violent patients may frequently be 
employed with tools, and with safety, by setting 
them to work in a place entirely detached from the 
others, or with one very quiet and harmless patient. 
The great danger arises froni allowing two or more 
violent patients to be near each other. It rarely 
happens that a good-tempered, inoffensive person. 



198 ON THE TREATMENT OF INSANITY. 

who does not attempt to interfere with them, or to 
control them, is injured. 

As might reasonably be expected, from their 
previous habits, a much greater difficulty exists in 
inducing persons of higher rank to employ them- 
selves in bodily labour, than those of the lower 
classes. But there is something so congenial to the 
natural tastes of men in the cultivation of the 
ground, that with a little management and address, 
many who have been solely accustomed to mental 
exertion may easily be persuaded to busy them- 
selves out of doors. This is exceedingly beneficial ; 
for, in addition to the moral advantage derived 
from the mind being diverted, there is an actual 
physical good, by the exercise turning the blood 
and vital energy to the supply of muscular power, 
and preventing excess of circulation in the internal 
organs. Of course, many will be found to whom 
such an employment would be irksome ; but, what- 
ever be the rank of life, or the difference in outward 
circumstance, man is still the same being. He 
feels pain when deprived of the comforts which he 
has been in the habit of enjoying ; — he is to be won 
by kindness, and he is offended at harshness or want 
of courtesy. The being excluded from the society 
of all whose good opinion is valued, begets in the 
insane, as it would tend to do in the sane, a habit 
of giving utterance to momentary feelings, without 
considering their propriety. And with both, where 
the mind has no opportunity of employment on 



ON THE TREATMENT OF INSANITY. 199 

objects of importance, it will either busy itself 
about trifles, or sink into apathy, or allow itself to 
wander unchecked in idle reveries. In Hogarth's 
picture of Bedlam, the straw crown was not the 
mere symbol of madness ; the making* it, however 
valueless, tended to the happiness of the patient, 
and was an act of practical wisdom. It was, in 
fact, the result of the same feeling which induced 
the lonely prisoner to make companions of the 
spiders in his dungeon. Now what would be the 
consequence if we were to take a sane person, who 
had been accustomed to enjoy society, and to have 
** space for his horses, equipage, and hounds/' and 
w^ere to lock him up in a small house, with a keeper 
for his only associate, and no place for exercise but 
a miserable garden ? We should certainly not look 
for any improvement in his moral and intellectual 
condition. Can we then reasonably expect, that a 
treatment which would be injurious to a sane mind, 
should tend to restore a diseased one ? But, unfor- 
tunately, this is the plan too generally adopted with 
the rich, both males and females. 

A young lady possesses great natural abilities, 
high accomplishments, and considerable personal 
attractions. She receives the attention and admi- 
ration of society. She marries early in life, and 
employs her time and talents, as is usual among 
persons of fashion, in giving and receiving pleasure. 
Adverse circumstances, jealousy, or other moral 
causes, bring on insanity. The disease assumes a 



200 ON THE TREATMENT OF INSANITY. 

maniacal form. The usual routine of treatment is 
adopted without any permanent improvement : after 
the lancet, cathartics, and blisters, have been vigo- 
rously used, she is sent to a private house, and placed 
under the care — very possibly — of kind-hearted per- 
sons, who do all in their power to abate the violence 
of the paroxysm. In a shorter or longer time the 
disease begins to wear itself out. From its vio- 
lence having rendered personal restraint necessary, 
one or two stout women are selected to take charge 
of her. In such cases, the patient usually has her 
private apartments, to which no other patients are 
admitted. It is therefore more than probable that 
she has no other society than that of her attendants, 
whose manners are totally at variance with all her 
previous habits. She soon becomes familiarized 
with every object in the house and garden ; and, as 
there is nothing to divert her attention, her mind 
naturally continues to brood over the melancholy 
subject, which has been the cause of her insanity. 
Under these circumstances but little prospect of 
cure exists. The various feelings and faculties of 
the mind, which if recalled to their former activity 
would banish the one absorbing idea, now lie dor- 
mant, from the absence of every object calculated 
to arouse them. Over-action and excess of circula- 
tion continue in a portion of the brain, until at length 
lesion ensues, and she becomes hopelessly and irreco- 
verably insane. This description accurately marks 
the progress of the disease in numerous instances. 



ON THE TREATMENT OF INSANITY. 201 

In a well-regulated institution, every means 
ought to be invented for calling into exercise as 
many of the mental faculties as remain capable of 
employment. We must remember, that the happi- 
ness of man, whatever be his situation in life, 
consists in the proper and harmonious exercise of 
all his powers, moral, mental, and physical. Insa- 
nity, brought on from moral causes, is the result of 
too great and partial exercise of some of the feelings 
or faculties ; the patient, therefore, ought to be 
surrounded with objects calculated to attract atten- 
tion, and to divert the mind from the contemplation 
of its sufferings. In those cases where vicious pur- 
suits have previously occupied the time, the salutary 
restraint from them will render the mind susceptible 
of pleasure from innocent occupation. For persons 
in the higher ranks of society, a mansion should be 
provided, with park, woods, lawns, hot-houses, gar- 
dens, and green-houses. It should be fitted, inter- 
nally, with every convenience and luxury for the 
gratification of the taste. Science and the fine arts 
ought to be pressed into the service of stimulating 
the dormant faculties to healthy exercise. There 
should be, as there is now at Aversa, a music-room, 
which the patients of both sexes should daily have 
the privilege of using ; and one evening in every 
week should be specially devoted to a dress-concert 
or oratorio, to which all, in a fit state to attend, 
should be invited. Such an association of patients, 
of the two sexes, would have a very happy influence 



202 ON THE TREATMENT OF INSANITY. 

on both. And an additional impetus should be 
given, by remunerating for their assistance any 
professional persons, either male or female, residing* 
in the neighbourhood. This would enliven the 
evening's entertainment, and make it more valued. 
It w^ould also tend to lead the feelings to a profit- 
able contemplation of happier days, by showing that 
the capability and the means of enjoyment, in this 
respect at least, were left ; and it might awaken the 
hope, that the avenues to other pleasures, moral 
and intellectual, might soon be opened. In a 
similar manner, scientific amusements should be 
cultivated ; one evening in each week should be 
devoted to them. Lectures on chemistry, with 
suitable apparatus for the performance of the minor 
experiments, would afford much entertainment ; and 
this might easily be provided. An orrery should 
form an appendage. There should be a modelling- 
room, and a studio, where those who have a taste 
for the fine arts should have an opportunity of 
receiving weekly instruction. Botany ought to be 
sedulously cultivated ; the open garden, the green- 
house, and the hot-house, would, according to 
taste, to power of exercise, and to the required 
warmth of constitution, afford important means 
of cure, both moral and medical. The various 
domestic animals and birds, with others of rarer 
species, would contribute to interest and amuse. 
The library should be well furnished ; but, of 
course, care and discrimination would be required 



ON THE TREATMENT OF INSANITY. 203 

in the selection of books, adapted to the par- 
ticular habits, and to the states of mind of the 
patients. An appeal to the moral and benevolent 
feelings will arouse a patient from his morbid 
feeling" to useful action, when a merely intellectual 
inducement is ineffectual. Point out the sufferings 
of the poor, either by a personal visit or by oral 
description, and show that it is in the power of the 
morbid-minded individuals, by their efforts, to 
relieve the wants or to add to the comforts of the 
afflicted ; and many will cheerfully exert themselves, 
whom no other inducements would influence. The 
clothes for the expected baby will be made, and 
the comforts of the mother attended to. By both 
sexes uniting in a work of benevolence, more will 
be done, and with greater cheerfulness and benefit 
to the patients, than could be accomplished by their 
separate efforts. They will mutually stimulate 
each other ; and if a promise be given on the part 
of a gentleman to contribute his share, the lady will 
take care that the good shall not fail from any 
backwardness on her part. The natural feeling of 
interest and kindness, generated in the mind towards 
those whom we have benefited, tends delightfully 
to counteract the morbid feelings existing among 
the insane. Those, who have strictly conscientious 
and religious feelings, afford another ground to 
work upon. Let them be induced to employ them- 
selves in drawing, or in making any little articles, 
from which profit may be derived, and inform them 



204 ON THE TREATMENT OF INSANITY. 

that it will be applied for those religious or benevo- 
lent purposes in which they feel most interested, 
and there will be no lack of industry. The well- 
educated and the wealthy would cheerfully exert 
themselves for the destitute wanderer. There 
would then be an evidently useful object in their em- 
ployment ; and with the insane as well as with the 
sane, labour of every kind requires the stimulus of 
a prospective good. Few minds are so constituted 
as to be able to employ themselves merely from an 
abstract notion, that activity is conducive to happi- 
ness. One great error in dealing with the insane 
is in treating them as if they were differently con- 
stituted from the sane. They are frequently asked 
to work, without knowing for what purpose ; and, 
as might be expected, such occupation becomes 
tedious, and is at length refused. Indeed such 
labour is as wearisome to an attendant as it is 
monotonous and uninteresting to the patient. But 
it is in vain to hope to rouse the intellectual and the 
nobler faculties of patients in the higher ranks, so 
long as they are left to the society of a keeper or a 
nurse. They ought to be the associated companions 
of persons of benevolent dispositions, of refined 
habits, and of cultivated tastes. And if asylums 
were conducted upon liberal and rational principles, 
there would be no lack of eligible competitors for 
the office. The young medical man would find a 
few months spent in such an institution, previous to 
his commencing practice, a most delightful means of 



ON THE TREATMENT OF INSANITY. 205 

general improvement ; and the young lady, whose 
finances might require her to do something for her 
support, would have, in the gently winning back 
the suffering mind to reason and to happiness, full 
scope for her best and noblest faculties. Indeed I 
should not consider that an asylum for the rich had 
attained its highest point of moral management, 
until it had become so happy a place of residence, 
that the patients when restored should regret the 
quitting it, unless drawn from it by ties of family 
and affection. Were such retreats for the insane to 
exist, no more reluctance would be felt in sending 
the insane to an asylum for moral cure, than is 
now experienced in placing children at a school for 
discipline and instruction. 

Many reasons exist which will sufficiently account 
for the fact, that no such a retreat for the insane 
is to be found. In the first place, the capital which 
would be required to supply all the requisites would 
be such^ as no individual would feel himself justified 
in expending, particularly as the prospect of his 
being ultimately repaid would depend almost entirely 
upon the continuance of his life, and of such a 
measure of health as would enable him to fulfil his 
professional duties. But there is a still stronger 
reason ; it is not to the interest of the proprietor 
of a private asylum to cure his patients. In every 
other disease successful treatment raises the repu- 
tation, and tends to increase the practice of a pro- 
fessional man; and a patient when cured feels a 



206 ON THE TREATMENT OF INSANITY. 

pleasure in recommending to others the individual 
from whose assistance he has derived important 
benefit. But with those who have recovered from 
insanity, every circumstance which, in the most 
distant way, alludes to the affliction, is carefully 
avoided; and neither the patient nor the friends 
would be willing" to have its previous existence sus- 
pected. And those whose friends are attacked, 
would think it almost an insult to make any inquiry 
even of the relatives of one who had recovered, 
as to the skill and kindness of the person under 
whose care he had been placed. Indeed they feel 
it a species of disgrace to be connected, although 
remotely, with any one capable of benefiting by 
such information. After the relative has been 
consigned to an asylum, in most instances his 
recovery soon ceases to be expected ; and in many 
it is never desired. There is not, therefore, the 
same inducement to stimulate a professional man to 
careful and active exertion, to find out means of 
cure for this disease, which operates upon him in 
every other. But the evil goes still further. There 
are instances, and these not rare, and occurring too 
amongst the patients from whom the greatest 
emolument is derived, in which it is the direct and 
positive interest of the relative who has placed the 
patient in confinement, that he should never be 
restored to society ; and without imputing improper 
motives either to the relative or to the medical 
man, we know that self-interest tends to bias the 



ON THE TREATMENT OF INSANITY. 207 

judg-ment, and that with great wealth with the one, 
and a permanent income with the other, depending 
upon the patient continuing insane, it is inconsistent 
with human nature to expect that the same anxious 
and unwearied care for his cure will be exhibited, 
as if a personal benefit were to accrue from his 
recovery. Although, under the present system of 
inspection, it would be difficult to retain a sane 
person long in an asylum ; yet it is impossible to 
secure by it the diligent application of every medical 
and moral means of cure, with the careful avoiding 
of every circumstance, however minute, which would 
tend to cause irritation. I do not mean to say 
that there are not many amongst my professional 
brethren, whose high sense of rectitude does not 
overcome the evils resulting from the system. But 
men are unhappily placed, where their duty is 
continually at variance with their interest. It is 
exceedingly difficult to suggest any means of avoid- 
ing this. In fact, when a man becomes insane, he 
is entirely at the mercy of his friends ; and when 
self-interest has banished affection from their bosoms, 
it is impossible to make any provision, which will 
secure to him that watchful attention to his welfare, 
for which he must from necessity be indebted to 
them. I am quite incapable of suggesting any 
means of relief for one, who, in consequence of 
being retained at home, or placed in a house with 
no other insane person, is out of the reach of 
inspection. But still, much would be done if an 



208 ON THE TREATMENT OF INSANITY. 

asylum were provided upon such a plan as would 
furnisli all appliances for cure, and were placed 
under the direction of one, who should derive no 
benefit by the patients remaining* in it, but who 
would feel his professional reputation interested in 
their recovery. It is true, that in some of the 
county asylums, patients of the higher classes are 
admitted, and that in these there is no temptation 
improperly to retain them ; but a great objection is 
felt on the part of the friends to allow their 
relatives to be in an asylum with paupers ; and in 
many of these institutions, the subscribers residing 
in the neighbourhood, both ladies and gentlemen, 
are formed into a numerous and constantly changing 
body of visitors. This is quite sufficient to prevent 
persons of the higher classes sending their relatives 
to such institutions ; indeed nothing can be more 
prejudicial to the patients, than to be exposed to the 
magisterial visits of those with whom they have been 
in the habit of associating : and on their recovery, 
the meeting, in the daily intercourse of society, the 
witnesses of their sufferings and degradation, is most 
painful and humiliating, particularly to persons of 
the higher rank. A man, under these circum- 
stances, feels his self-respect lessened, and he cannot 
meet his fellow-man on equal terms. It is an evil 
to which the poor are not exposed, as the visitors 
are not taken from the class of their companions. 
This system also tends to cramp the energies of the 
superintendent. When his best efforts for the 



ON THE TREATMENT OF INSANITY. 209 

welfare of his patients are liable to be misunder- 
stood, and thwarted by a visitor, whose annual 
subscription has given him, during his monthly rota- 
tion, the power, but not the requisite knowledge, to 
interfere, he gradually ceases to exert himself, and 
is content with kindly performing a dull routine of 
uninteresting duties. 

Another error is of frequent occurrence in the 
management of county asylums. The medical su- 
perintendent and matron, who live on the spot, and 
are nominally at the head of the institution, have 
really very little discretionary power. One or two 
of the physicians residing in the neighbourhood, and 
who are expected to visit the patients once or twice 
a week, have, in many of them, the entire direction ; 
the superintendent and matron having little more to 
do, than to carry their orders into execution. The 
necessary result is, that there is a division of respon- 
sibility. The superintendent, finding himself a mere 
agent, becomes indifferent to the success of the 
institution ; and the physician being incapable, 
during his medical visits, of organizing the details 
(although these materially affect the patient), does 
not feel himself responsible for the domestic or 
moral management. Now it is not possible that an 
asylum can be well conducted, unless those who are 
on the spot are most zealously alive to every little 
thing which can, by possibility, contribute to the 
well-being of the patients. It is by the multiplicity 
of these little things that great effects are produced. 



210 ON THE TREATMENT OF INSANITY. 

The dispositions, habits, and temperaments of the 
individual patients, must be watched from day to 
day; and the moral treatment, and, in a great 
measure, the medical also, must be adapted and 
varied, according to the peculiar and changing cir- 
cumstances of each. Now no person ought to be 
appointed as the resident medical superintendent who 
is not (no matter whether he be physician, surgeon, 
or apothecary,) medically and morally qualified for 
the office : and if he be so qualified he will, from 
being constantly on the spot, have much greater 
opportunities of observing the peculiarities of the 
patients, and of making himself familiar with every 
turn of the disease, and the treatment required for 
it, than a medical man who only pays short and 
occasional visits to the institution ; and he will 
have the still further stimulus for his exertions, of 
knowing that his reputation is at stake in their suc- 
cess. With honourable and high-minded men, (and 
no others ought to be selected,) this will be of more 
avail than a code of regulations, and a regiment of 
visitors to put them in force. It is a foolish eco- 
nomy not to offer a sufficient remuneration, to 
induce men of the first respectability in the pro- 
fession, to be candidates for such situations. Of 
course, cases will occur, in which the most skilful 
man may desire additional assistance. Let him 
have the privilege of calling in, when he finds it 
necessary, the advice of a consulting physician : 
this will suggest to him new remedies, or increase 



ON THE TREATMENT OF INSANITY. 211 

his confidence in the course he is adopting*, without 
lessening- his responsibility. At present, .the county 
asylums are not an adequate provision for the re- 
ception of the higher classes, and very few of the 
higher classes are to be found in them. 

Indeed I am not acquainted with one, at all 
coming up to my notions of what an asylum for 
the rich ought to be ; but I still think, that it is 
perfectly practicable to provide for them an insti- 
tution, possessing every means for cure, and every 
requisite for their comfort and happiness, combined 
with but little risk of their being improperly de- 
tained. I should recommend an asylum on the 
same principle as the Proprietary Schools. Let a 
number of gentlemen subscribe, in shares, a suf- 
ficient capital for the purpose ; — let a committee of 
management be selected ; a proper house, grounds, 
furniture, and apparatus be procured, and the rates 
of admission determined by the committee, who 
would, of course, have the power of refusing any 
applications. A resident medical superintendent 
should be appointed, who should have a fixed 
salary, and should not be allowed to derive the 
slightest pecuniary benefit from the patients re- 
maining in the house. The medical and moral 
treatment should be under his direction, and his 
certificate of a patient's fitness for discharge, 
should be final and decisive. The costs of such 
an establishment would not be so great as might 
at first be supposed. It would be unnecessary to 

p 2 



212 ON THE TREATMENT OF INSANITY. 

erect a building" expressly for the purpose. A 
large mansion, which might be purchased for a 
comparatively small sum, might easily be converted 
into such an establishment. As it is quite obvious, 
that although the disease is the same in the rich 
as in the poor, many of the expensive contrivances 
which are required for paupers would be unneces- 
sary, where each attendant has not under his charge 
more than one or two patients : for instance, airing 
courts, with their walls, which are essential where 
there is only one keeper to twenty or thirty patients, 
would be worse than useless in such an institu- 
tion. The grounds must be the airing courts, and 
the vigilance of the attendants must supply the 
place of walls. The whole establishment should 
resemble, as much as possible, an ordinary habita- 
tion. The usual living rooms should present no 
appearance of confinement, though in these the 
windows may easily be prevented from opening 
beyond a certain height. Apartments must be pro- 
vided, properly secured and fitted up with shutters 
and wire blinds, where the patients may be removed 
during violent paroxysms : but very few of such 
rooms would be requisite. The great expense 
would be in the attendance, and in keeping up the 
gardens and pleasure-grounds, and in the providing 
horses and carriages, and other means, for the 
employment and recreation of the patients. But if 
the institution contained one hundred patients, the 
income would abundantly supply every want, and 



ON THE TREATMENT OF INSANITY. 213 

leave an ample profit to the shareholders. I am 
decidedly of opinion, that it would be g-reatly to 
the benefit of the patients, for the same establish- 
ment to contain both males and females : of course, 
there must be sufficient means not only of separa- 
tion, but of entire exclusion, where it is desirable j 
but I am fully convinced, that the well-regulated 
association of the two sexes would exert a salutary 
moral influence on both. Of course, in such an 
institution wealth would, as elsewhere, procure for 
its possessor additional comforts : but the distinc- 
tion should be there confined to the private accom- 
modation of the patients. The rich man should, if 
his friends thought well, have his three or four 
rooms ; and these might be larger, and more splen- 
didly fitted up, than those of his poorer neighbour. 
But, in the public association of the house, there 
should be no distinction between the man who 
contributed a thousand pounds, and the one who 
contributed a hundred pounds a year. The only rule 
of classification in the different sets of public rooms 
should be, according to the different states of the 
disease, and the various habits and education of the 
patients. I cannot but think that such an insti- 
tution would be a blessing to society : it would 
afford to persons of the highest classes a means of 
cure, combined with the happy and rational exercise 
of their faculties. Instead of being shut up, com- 
panionless, in a small solitary dwelling, they would 
have cheerful association, with space and oppor- 



214 ON THE TREATMENT OF INSANITY. 

tunity for every salutary employment and recre- 
ation. Nor would the middling- classes be without 
their share in its benefit ; although, from the want 
of means, they are at present generally exempt 
from that solitary confinement which is inflicted, as 
the greatest punishment, upon criminals, and ad- 
ministered, from mixed feelings of kindness and 
pride, to the rich insane ; they still have not those 
advantages which this system would secure to them. 
By no other means could they, at the same moderate 
rate, participate in those comforts and elegancies 
which must, in such an establishment, be provided 
for the rich. If such an institution were to be 
formed, and placed under proper care, there would 
be no lack of patients. There ought to be at the 
head of it a medical man, well acquainted with the 
disease, of undoubted integrity, and of high moral 
and religious character ; and, as an essential quali- 
fication, he ought to possess an active and much 
enduring benevolence. He should not be easily 
provoked, and he should have a sufficient genuine 
regard to his patients firmly to deny them any 
thing, however painful to himself, which he would 
know would be prejudicial to them ; and rigidly and 
constantly to enforce, with unwearied watchfulness 
and diligence, every plan for their welfare. There 
should be associated with him, in the honourable 
task of winning back the wandering and perverse 
to reason and to happiness, one, who would be in 
every respect his helpmate for the undertaking. 



ON THE TREATMENT OF INSANITY. 215 

She ought to be wilHiig" to sacrifice, at the shrine 
of humanity, every feeling- of self-indulgence, and 
every prejudice of education and society ; and 
although, from natural endowments and mental 
cultivation, she should excel in gently drawing out 
the sensitive and retiring mind, and in ingeniously 
mingling the cup of consolation, according to the 
peculiar woes of the sufferer ; she should feel 
nothing beneath her notice, that could allay the 
pangs or promote the comfort of the poorest 
imbecile, though incapable of distinguishing his 
benefactress, or of repaying her kindness even with 
a look of gratitude. And she ought to have under 
her training a noble band of young and highly- 
gifted females, actuated by similar motives, and 
willing, from love to God and man, to assist her in 
her anxious efforts. I am far from decrying the 
benefits to be derived from the exertions of my 
own sex, but I know from experience, that these 
are nothing, in comparison to the moral advantages 
to be gained by the benevolence and activity of 
woman. And it would be unjust in me if I did not 
acknowledge, that if I have met with any measure 
of success in my attempts to rouse the dormant 
faculties, to alleviate the sufferings of the insane, 
and to render the patients under my care a happy 
and a united family ; this success is mainly to be 
attributed to the abilities, the courage, the perse- 
verance, the kindness, and. the engaging manners 
of my wife. The female mind possesses a quickness 



216 ON THE TREATMENT OF INSANITY. 

of perception, and a ready tact, which are of much 
more efficacy in winning upon the insane than all 
the slower, and more serious, business-like efforts 
of our sex. Indeed, both amongst the sane and 
the insane, when a new trade has been to be learnt, 
the women have acquired it with twice the facility 
of the men ; and have expressed a pleasure in being 
taught, whilst the men have, generally speaking, 
gone to the work heavily and unwillingly ; and 
have only been induced to persevere from the hope 
of reward, or from being ashamed at the more 
rapid progress of the females. And in commenc- 
ing any new manufacture together, the particular 
portion of the work which has required the greatest 
skill has been uniformly allotted to the women ; 
and, after they have learnt it, the men have slowly 
and tediously been taught their lesson. In an 
asylum conducted upon the Proprietary principle, 
there would be every inducement for the medical 
superintendent to exert himself to the uttermost 
for the recovery of his patient ; and, if he had at 
his disposal the means and the assistance pre- 
viously pointed out, the majority would be speedily 
restored. 

In many cases, the dissipated and vicious would 
learn, in such an institution, the practical happi- 
ness of religion and self-government, and would 
leave it useful and honourable members of society. 
In a large establishment, there would probably be 
some whose minds would be incapable of appre- 



ON* THE TREATMENT OF INSANITY. 217 

ciating the value of a refined association, and whose 
wants could be adequately supplied by a kind and 
judicious nurse or keeper : but none ought to be 
considered to come under this class, until the most 
ingenious and persevering* efforts had been made 
imsuccessfully to rouse every latent spark of mind 
and feeling. Much may be done by kindness and 
a scrupulous attention to the polite etiquette of 
society, even with those whose reason seems almost 
extinct. I know one instance, where, from con- 
tinued confinement day and night for years, the 
limbs had become contracted, the fingers twisted 
over each other, and the patient totally insensible 
to the calls of nature. Two stout, ignorant 
servants, neither of whom could read or write, had 
been the constant attendants. The maniacal vio- 
lence and impatience of restraint, with which the 
commencement of the disease was characterized, 
seemed to have banished from their minds every 
idea of treating the poor sufferer with decency or 
respect : and when the first violence of the attack 
had subsided, no solace was offered to the feelings of 
wounded pride ; but a constant source of irritation 
remained, in the being obliged to submit to the 
domination of such associates. An airing was 
sometimes taken, though the miserable patient, 
tied hand and foot, was fastened in a blanket to the 
bottom of the chaise. No wonder that these 
circumstances should have produced their natural 
results, and that on an occasional visit from the 



218 ON THE TREATMENT OF INSANITY. 

friends, sufficient violence should have been found, 
as apparently to have made such severe confinement 
necessary. Even this case was not beyond the 
reach of amelioration. A removal into different 
society, kind, soothing, and respectful manners, the 
absence of all restraint, except during the actual 
continuance of the paroxysm, have rendered the 
patient cleanly, comparatively happy, and exempt 
from any exacerbation of the disease, for six weeks 
together. Careful friction of the limbs has restored 
the use of the muscles, and the patient now enjoys 
a walk or a ride untrammelled. If such be the 
results where the disease has been of so long con- 
tinuance, and the mental faculties apparently de- 
stroyed, no case ought to be considered sufficiently 
desperate to warrant the intrusting the patient at 
once to the society of the keeper or the nurse, or 
the neglecting any means which may possibly tend 
to cure the disease, or to diminish the sufferings. 
I cannot forbear mentioning another instance, to 
show the importance of proper moral treatment and 
its powerful effects, even in cases of long standing. 
A person of great talents and strong feelings, who 
had been accustomed from early life to elegant and 
refined society, became insane from too anxious 
thought on religious subjects. The melancholy, 
which was the first symptom of the disease, was 
succeeded by great maniacal violence. The patient 
was taken from home, and was for several years 
generally kept under personal restraint ; and during 



ON THE TREATMENT OF INSANITY. 219 

tlie whole of the time the society was either that 
of the immediate attendants, or of other insane 
persons. The passions were entirely without con- 
trol ; the language became abusive and violent, 
although there still remained a capability of giving 
rational answers to most questions. The constant 
confinement had caused paleness and emaciation. 
After this system had been continued for many 
years, the patient was placed where an opportunity 
was offered of the association of a cheerful and 
polite family circle, on the condition of good and 
proper behaviour ; and an assurance was given, that 
personal restraint should not be resorted to, until 
violence of conduct rendered it absolutely necessary. 
A great change for the better could not be expected 
to take place immediately ; but the first trial showed 
that the proper motives had been acted upon. An 
instant banishment to the private apartments, on 
the exhibition of any violation of the decorum of 
society, gradually superinduced a habit of self- 
control. There was not any occasion to use per- 
sonal confinement ; the temporary banishments from 
society became less and less frequent. In fact, the 
feelings seemed to be carefully pent up, until the 
retirement of the private room gave an opportunity 
of giving them vent, without incurring the penalty 
of the forfeiture of the social advantages. The 
patient became conscious when the feelings were 
becoming incapable of control, and voluntarily 
retired into the private apartment. These occasions 



220 ON THE TREATMENT OF INSANITY. 

gradually became less frequent, and, with the excep- 
tion of particular attacks of insanity, when the room 
is still kept, no symptoms of violence, and very few 
even of derangement, are exhibited. Constant exer- 
cise in the open air has quite reinstated the bodily 
health. 

In the moral treatment of cases of insanity, it is 
of great importance to ascertain the ruling passion 
of the patient : an appeal to this will frequently 
divert the attention, and obviate the necessity of 
having recourse to violent measures. A female, of 
great firmness, had for several days refused to take 
her food, and as no persuasion seemed to have any 
influence upon her, preparations were made to 
inject it by the stomach-pump. At this juncture 
my wife discovered that the woman had natu- 
rally a great love of acquiring. She sat down by 
the patient's bedside, and without saying any 
thing on the subject of food, conversed with her on 
her former habits ; and having learnt that she had 
kept cows and poultry, she induced her to give an 
account of the profits she made by them. This 
attracted the attention of the woman : she forgot 
her determination to resist ; and whilst talking of 
the gain of selling the butter, she permitted herself 
to be fed with a basin of bread and milk, apparently 
unconscious that she was submitting to the wishes 
of her attendants. In this instance phrenology was 
of practical use. The existence of the strong 
feeling of love of gain was ascertained solely by 



ON THE TREATMENT OF INSANITY. 221 

the observation of the head at the time. Another 
instance of the power of checking the violent 
operation of one set of feelings by calling another 
into action, also occurred to my wife. A patient, 
who was pruning some trees in the garden, quar- 
relled with another lunatic, during the accidental 
absence of the gardener : he became so irritated 
that he threatened to kill the other. A third 
patient ran into the house to give the alarm. He 
met my wife on the way, and she returned with him 
to the combatants, and desiring to speak with the 
man who had the knife, told him she was surprised 
to find a man, of his talents and understanding, so far 
forgetting himself as to dispute with the other, who, 
as he knew, had been insane for several years. 
This gratified his self-esteem. He said. You are 
right, ma'am ; I shall take no farther notice of him ; 
— and he at once became quiet. It not unfrequently 
happens, that patients, of very irritable tempers, 
are suddenly thrown into violent paroxysms of 
passion from slight causes, and are as often to be 
diverted out of them, by calling other faculties into 
operation, by very simple methods. Many years 
ago, when the workmen were fitting up the asylum 
at Wakefield with gas-pipes, one of them carelessly 
left, in one of the wards, an iron chisel more than 
three feet long. A very powerful and violent 
patient seized it, and threatened to kill any one that 
should go near him. Keepers and patients all got 
out of his way, and he alone was soon in possession 



222 ON THE TREATMENT OF INSANITY. 

of the gallery, no one daring- to go near him. 
After waiting a little time, until he was at the 
further end of it, I went towards him quite alone. 
I opened the door, and balancing the key of the 
ward on the back of my hand, walked very slowly 
towards him, looking intently upon it. His atten- 
tion was immediately attracted ; he came towards 
me, and inquired what I was doing. I told him I 
was trying to balance the key, and said at the same 
time that he could not balance the chisel in the 
same way, on the back of his hand. He immedi- 
ately placed it there ; and extending his hand with 
the chisel upon it, I took it off very quietly, and 
without making any comment. Though he seemed 
a little chagrined at having lost his weapon, he 
made no attempt to regain it, and in a short time 
the irritation passed away. 

The " love of children" is another very powerful 
and general feeling, particularly amongst women. 
Great advantage may be taken of it, in diverting 
the mind from painful reflections. I have fre- 
quently known a patient, who has been for some 
time in a state of great excitement, become quite 
calm on the sight of a child, and amuse herself in 
attending to it for hours together. Indeed, where 
the love of children is strongly marked, conversa- 
tion on the subject, judiciously timed, rarely fails to 
produce soothing and salutary results. It is impos- 
sible to account for the great effect occasionally 
produced in the minds of the insane by circum- 



ON THE TREATMENT OF INSANITY. 223 

stances apparently most trivial. The result is 
beautifully given in the following lines : — 

" Oh, reason ! who shall say what spells renew, 
\^Qien least we think of it, thy broken clew ! 
Through what small vistas o'er the darken'd brain, 
Thy intellectual day -beam burst again ; 
And how, like forts, to which beleaguers win 
Unhoped-for entrance through some friend within, 
One clear idea waken'd in the breast 
By memory's magic, lets in all the rest." 

A practical illustration occurred at Wakefield. 
H. R., a female about forty years of age, had been 
insane for some years when admitted. She was a 
very robust woman, and being usually in a state of 
excitement, was the terror of all the patients in the 
ward, when not in confinement. If at any time a 
softened influence could be produced upon her, and 
more gentle feelings called forth, it was by referring 
to the scenes of early life. One day, when under 
these impressions, a patient began a song, which 
she had learnt when a girl, when turning to my 
wife, who stood near her, she said with great anima- 
tion, " Mistress, when I was young I knew that 
song, and I think I could sing it now." She began, 
and, with the greatest delight, found she remem- 
bered the whole of it. From that hour " a change 
came o'er the spirit of her dream : " her excessive 
violence gave place to the more amiable and kindly 
feelings. Instead of being the dread of all about 
her, she became obliging and industrious. After 
some months of trial she got well and returned 



224 ON TUi: TREATMENT OF INSANITY. 

home. Some years afterwards she came over to 
pay us a visit, and at that period had had no return 
of the disease. The advantage of presence of mind 
and apparent confidence in the patients, when from 
circumstances placed in their power, during a 
paroxysm, was strikingly exemplified in the con- 
duct of my wife towards this patient. In one of 
her most furious ebullitions of passion she contrived 
to seize her, and to twist her hand in her hair at the 
back of her head, and she looked at her with a 
countenance expressive of the utmost rage, and 
told her, that she could "twist her head round;" 
which, from her great strength, was almost literally 
the truth : when my wife answered, with perfect 
calmness, *' Yes, you could; but I know you would 
not hurt a single hair." This confident appeal 
pacified her, and she immediately quitted her hold. 
I hardly know whether it is right to appear to 
acknowledge the reality of the delusion in order to 
use it as a means of cure ; but this may occasionally 
be done, greatly to the advantage of the patient. 
A woman supposed that a witch besprinkled her 
face every night with cantharides : the impression 
was so strong, that for a long time she was gra- 
dually suffering in bodily health from want of sleep, 
as she passed the night in fighting the witches. A 
charm was pretended to be found out which would 
set all the witches at defiance. A little coloured 
milk was applied to the face, with a direction to 
keep the eyes closed, and to remain perfectly silent 



ON THE TREATMENT OF INSANITY. 225 

and quiet, as the whole efficacy of it would be 
broken by a single word being spoken, or the least 
motion being made. She was perfectly quiet 
during the night, and though she considered her- 
self still under the influence of the witches, with 
the continued application of the milk she enjoyed 
undisturbed sleep, and her bodily health greatly 
improved. 

Persons whose nervous temperament is obtuse, 
and who have none of that irritability which is 
so usually seen to exist amongst the insane, can 
scarcely conceive what very slight causes produce 
powerful moral eff'ects upon them. A young wo- 
man, who had been but a short time insane, was 
brought to the asylum at Wakefield one evening, 
when nearly dark. The entrance to it was through 
a very large pair of wooden doors. Before a car- 
riage could be driven into the front court, it was 
awkwardly enough arranged that it must go over 
an iron weighing-bridge : this, with the formidable 
appearance of the building, and the rumbling of 
the carriage upon the bridge, altogether produced 
such an effect upon the young woman, as that, to 
use her own words, '*it turned her heart upside 
down." A great change certainly took place at 
the time, for she never exhibited any symptoms of 
insanity ; and she herself attributed the alteration 
in her feelings to the kind of terror she then expe- 
rienced. 

The principle of fear may often be very succesp- 

Q 



226 ON THE TREATMENT OF INSANITY. 

fully worked upon as a moral means of cure. 
When the patient is naturally timid, a dread of 
consequences will frequently induce self-control. 
The mere abstaining from extravagant conduct, 
and the ceasing to give utterance to violent ex- 
pressions have a great tendency to diminish the 
irritation. This feeling is generally more easily 
worked upon by talking to others of the patients, 
in their presence, than by any direct threats. I 
remember the case of a poor girl whose constant 
moaning, during the night, disturbed the other pa- 
tients. They requested that she might be removed 
from the ward. A representation, in her presence, 
of the exceedingly painful situation in which she 
must be placed, and of the very severe measures 
which must be adopted if she were removed, with a 
hope that the other patients would try her one night 
longer, produced such an effect upon her mind 
that, from fear of the consequences, she refrained 
from making the noise and laid still in bed. In a 
few nights the restraint she imposed upon herself 
produced sleep. She gradually became more and 
more tranquil, and eventually got quite well. But 
there are some cases, in which the mere threat, 
however conveyed, produces no salutary effect. It 
has already been stated that, in insanity, the evil 
dispositions which existed prior to the coming on 
of the disease still remain ; and many of these are 
excited to increased action by the general irrita- 
bility produced by it. It is always, therefore, a 



ON THE TREATMENT OF INSANITY. 227 

matter of great consequence to determine whether 
the conduct is the result of moral evil, naturally in- 
herent in the man, or whether it arises from insanity ; 
that is, from diseased action of any particular part 
of the brain. Much of the moral treatment de- 
pends upon this ; for though it would be most 
cruel to subject the patient to any discipline, either 
moral or physical, for conduct arising from the 
latter, yet, as part of what is objectionable arises 
from the former, no little watchfulness is required 
to keep in check evil passions, frequently long 
indulged without any restraint. Happily the whip 
has for some time, at least in this country, ceased 
to be allowed in any Lunatic Asylum ; and the 
more humane and rational plan of punishment, by 
deprivation and confinement, has been substituted 
in its place. It sometimes however happens, that 
patients are met with who are so obstinate and in- 
corrigibly perverse, that these means alone are not 
sufficient. The shock of the electrifying-machine, 
i^'hich is often found beneficial in cases where the 
powers want rousing, is, in cases of deterrriined ob- 
stinacy and bad conduct, equally useful. The terror 
of the machine will often overcome the vicious incli- 
nation. The same effect is frequently produced by 
the shower-bath, but still more so by the use of the 
circular-swing. These, however, are remedies which 
should never be had recourse to until all other means 
have failed ; and then, never without the most explicit 
orders from the medical superintendent, who ought to 

q2 



228 ON THE TREATMENT OF INSANITY. 

be present whenever the latter is applied. Under these 
restrictions the most beneficial results often ensue ; 
and patients soon learn to put themselves under that 
discipline which will exempt them from such uncom- 
fortable consequences. By patient perseverance in 
kindness, with indulgence as a reward of good con- 
duct, and great firmness in the application of the 
requisite means to overcome obstinacy and perverse- 
ness, many patients who, from faulty education, had 
never been taught to exercise any control over their 
passions, have gradually become quiet and orderly, 
and have been eventually restored to reason. Kind 
and judicious conversation is a powerful moral means 
of cure. In many cases, where it appears to be list- 
ened to with indifference, it is often attended to, and 
subsequently carefully pondered over ; and the mere 
act of thinking upon it diverts the mind, and gives 
a rest to the over-excited feelings. The patient fre- 
quently seems at once to make a great advance 
towards recovery. Sometimes the improvement con- 
tinues, but no further change for the better is 
observed until another step seems suddenly to be 
gained ; and after a time, the patient will as rapidly 
appear to lose ground, until another favourable 
change takes place, and he gradually and slowly re- 
covers. I have no doubt that many of the checks 
might be avoided if what was passing in the mind of 
the patient were better known. The most trifling 
expressions, a word, or even a look may produce 
painful workings of the mind, ill suited to the newly 



ON THE TREATMENT OF INSANITY. 229 

excited action of the weakened brain. The conver- 
sation of the friends of the patients frequently tends 
materially to retard their cure. In public institu- 
tions the natural anxiety of the friends to see the 
patients is one of the greatest difficulties to be con- 
tended with. In numerous instances patients, who 
were apparently recovering- very speedily, have been 
thrown back nearly into the same state as on admis- 
sion, merely from seeing their friends. The sight of 
relatives recalls distressing associations to the mind; 
and, too often, the well-meant but ill-timed informa- 
tion, of their being much wanted at home, begets a 
fretfulness at longer confinement. Probably, the dis- 
tresses and privations of the family are injudiciously 
dwelt upon ; or, some sorrowful tale is told, that 
sets the excited brain into such action, that sleep, 
which had previously been obtained with great dif- 
ficulty, is again banished, and the cure consequently 
very much retarded. Notwithstanding the know 
ledge of these circumstances it is still often very 
difficult to know how to decide. It is sometimes 
impossible to convince an affectionate husband or 
wife, that the sight of one, with whom the patient 
has uninterruptedly enjoyed all the endearments of 
conjugal life, can possibly be injurious ; and, after 
having travelled, perhaps, a distance of thirty or forty 
miles, solely for the purpose of seeing a relative, it 
is a great disappointment to return without an inter- 
view. When interviews are permitted, the friends 
should be earnestly cautioned not to dwell upon 



230 ON THE TREATMENT OF INSANITY. 

painful subjects, but to let the bright side of every 
thing only be shown. In speaking of this part of the 
subject, it ought to be mentioned, that interviews 
with their friends are much less prejudicial when the 
insanity has arisen from a physical than from a moral 
cause. In the first instance, the cause cannot be 
aggravated by it, and if there exists a strong feeling of 
affection in the parties, it will often soothe and do 
good ; whereas in the latter, these very affections, 
improperly indulged, are too often the source of the 
continuation of the disease. It is necessary, there- 
fore, for a much longer time to elapse in these cases 
before an interview can with safety be permitted, 
than in the former. But each case must be regulated 
by its particular circumstances. In many the disease 
has been much aggravated, and much suffering has 
been undergone from the neglect, or total forgetful- 
ness of those, upon whose affection they had every 
claim ; but who, having once got rid of the care and 
charge of them, seem no longer to have retained the 
slightest anxiety for their welfare. It is at all times 
desirable, that the person under whose charge the 
patients are, should hear occasionally from their rela- 
tives ; so that, on any expression of anxiety for them 
on the part of the patient, or on any favourable oppor- 
tunity occurring, to awaken or rouse up a dormant 
feeling of affection, they may be informed that they 
are still held in the most affectionate remembrance, 
and that it is only from prudential motives they have 
not been permitted to see them. 



ON THE TREATMENT OF INSANITY. 231 

In asylums exclusively devoted to paupers, it will 
readily be supposed that many of those admitted are 
in a state of the grossest ignorance ; and that moral 
and religious instruction has been too often totally 
neglected. As the propriety of affording religious 
instruction to the insane has been often disputed, I 
think it right to state, that both at Wakefield and 
at Hanwell the greatest benefit has resulted from 
it ; and from my experience, I venture to say, it is 
only when this great moral remedy is indiscrimi- 
nately and injudiciously applied, that any harm has 
ever arisen. If a man has had the importance of re- 
ligious subjects so forcibly impressed upon his mind, 
that by intense thought upon them he has excited the 
brain to diseased action, it must be evident, that to 
attempt to convince him of any error he is at that 
time labouring under on these subjects, must be in- 
jurious, because the very discussion tends to increase 
the action of those organs, which are already too 
greatly called into exercise. Under these circum- 
stances, neither religious books nor religious con- 
versation should be permitted ; and the greatest 
care will be necessary to mark that no excitement 
on the subject any longer exists, before they are 
resumed. It is from the nature of insanity not being 
properly understood, and from the application of 
even the most useful remedies at improper times, 
that many of these have fallen into disrepute ; and 
this has been the case with religious instruction. 
With few exceptions, the patients, who become 



232 ON THE TliEATMENT OF INSANITY. 

deranged on religious subjects, have been persons 
who have become greatly alarmed on discovering, 
either from hearing sermons, or reading the word 
of God, that thej have broken his laws, and have 
been wicked and guilty creatures. Not immediately 
comprehending the merciful plan of salvation pro- 
vided for sinners, and therefore not immediately 
feeling that assurance of pardon and forgiveness 
which they find is promised in the word of God " to 
all them that truly repent and unfeignedly believe 
his holy Gospel," they become greatly distressed, 
and endeavouring to find out the cause, they fix 
their attention with the most intense anxiety upon 
that, to many perplexing and lamentably mistaken 
passage, *' blasphemy against the Holy Ghost ;" and 
they think, that it is from their having committed 
this siu they do not derive the same comfort and 
consolation from religion which thousands possess 
who believe in the promises of the Gospel. When 
once this idea has taken hold on the mind, and has 
been so dwelt upon as to create disordered action in 
the brain, it is in vain to point out to them, that if 
they had committed that sin, they would no longer 
desire to obtain the favour of God ; and that their 
so desiring it is itself a proof they have not com- 
mitted it ; or to point out to them those consoling 
words of our Saviour, " Him that cometli unto me 
I will in 710 tvise cast out." Neither these nor any 
other words or arguments can be of use ; medical 
means must be resorted to, in order to allay the 



ON THE TREATMENT OF INSANITY. 233 

disordered action of the brain ; and the subject of 
religion, the moral cause of the insanity, must be 
excluded as much as possible from consideration ; 
and if ever mentioned in conversation with the 
patient, of course it should be represented to him 
in its most consoling aspect. A great many con- 
firmed cases of melancholia and suicide take place 
from this cause, and very principally from the 
premonitory symptoms of the disease being so little 
understood. With the best intentions to do good, 
much harm is done by religious conversation and 
praying with persons in this state ; for though 
I by no means intend to say, that if on the coming 
on of those perplexing thoughts, the matter can 
be put in a light so clear as to satisfy them that 
they are not excluded from the favour of God, that 
then the anxiety and overaction of the brain would 
subside ; yet I repeat, that when it has taken place, 
every thing of the kind should be avoided. 

Though it is acknowledged that much mischief 
may arise from injudiciously introducing the subject 
of religion in particular cases, I must not omit to men- 
tion, that many patients have not only been comforted 
by its salutary lessons, whilst they have been in the 
asylum, but have retained the benefit after they have 
been discharged. The lessons of instruction have 
been carried home to their families ; drunkenness 
and licentiousness have been forsaken, and temper- 
ance, decorum, and piety, substituted in their place. 

A. B., a female, about forty-five years of age, a 



234 ON THE TREATMENT OF INSANITY. 

Roman Catholic, was admitted into the asylum at 
Wakefield in a state of furious mania brought on 
from drunkenness. She had lived in one of the 
large manufacturing towns in the neighbourhood, 
and kept a brothel ; her husband at the same time 
being a receiver of stolen goods. In addition to 
this woman's insanity, it was found, after the 
violence of the paroxysm had abated, that she was 
as grossly ignorant of all the vital truths of Chris- 
tianity, as she was depraved and abandoned in her 
conduct. As she began to recover, she was in- 
duced, in the first instance, probably as much from 
curiosity as from any other motive, to attend 
morning and evening family prayers. Light by 
degrees broke in upon her mind ; she saw the 
dreadful consequences that would inevitably result 
from the life she had been leading, and determined, 
by the help of God, to amend it. She remained in 
the asylum until she was perfectly restored to 
sanity, and was so confirmed in the views she had 
imbibed on religious subjects, that on her return 
home, she not only gave up all her vicious courses, 
but had sufficient influence to reform her husband. 
We had the satisfaction of knowing some years 
afterwards, that they were continuing to live in 
respectability, and were members of a Protestant 
Church. 

Neither have the advantages of the religious in- 
struction received in the asylum been confined to 
persons of grossly immoral and vicious character. 



ON THE TREATMENT OF INSANITY. 235 

Many, who, although decent in their outward 
deportment, had, previously to their admission, 
paid little attention to their religious duties, or had 
been content with merely going to a place of 
worship and saying prayers, with the form without 
the power of godliness, have there learnt that all 
are by nature sinners, and that all, however appa- 
rently moral and virtuous, in order to obtain 
reconciliation and peace with God, to enjoy happi- 
ness here in the joyful assurance of happiness 
hereafter, must humble themselves at the foot of the 
cross, and seek pardon and remission of sin through 
the blood of Christ. They have been taught, by 
the operation of the Spirit upon their hearts, to 
know from experience the meaning of our Lord's 
declaration to Nicodemus. Thev have found the 
pearl of great price, and they have so estimated its 
value, that in many instances they have blessed God 
for having afflicted them, and have esteemed the 
suffering, painful as it was, which brought them 
within the sound of the Gospel, and disposed their 
hearts to receive it, as the happiest event of their 
lives. They have taken their religion home with 
them, and have taught it to their children, and they 
have come back to tell us the joyful news, that to 
them also the Gospel of Christ has been " the power 
of God unto salvation." 

Before I conclude the observations on the treat- 
ment of insanity arising from moral causes, I 
would add a caution against permitting a patient to 



238 ON THE TREATMENT OF INSANITY. 

have the uncontrolled manag-ement of himself too 
soon after his recovery. For some time after the 
nervous powers seem to be duly balanced, great 
care and watchfulness will be required to keep 
them in that state, especially when the primary 
cause of the disease is still in existence ; and it 
will frequently be well, after reason seems to be 
restored, to adopt medical remedies, which the 
patient would in all probability neglect, if left 
entirely to himself. It is therefore by far the more 
prudent course, in these cases, not to allow the 
patient to return to his home, or to the scenes con- 
nected with painful associations, until the weakened 
brain has had time not only to have recovered its 
healthy action, but to have acquired vigour and tone. 
This caution is principally applicable to cases where 
the insanity has only continued for a comparatively 
short period. There is a danger of falling into the 
opposite error when the patient recovers after an at- 
tack of some years' continuance. In these instances, 
when the mind is completely restored, and the patient 
able to act and judge rationally, there is frequently 
a very great disinclination to go out again into the 
world ; and, particularly, where much kindness and 
attention have been experienced during the confine- 
ment. The habits become fixed, an attachment is 
formed to those about them, life is spent without care 
and anxiety, and a very reasonable fear exists lest 
the excitement of external objects should induce such 
an over-action of the brain, as to cause a relapse. 



ON THE TREATMENT OF INSANITY. 237 

But in these cases it is only right, if the patient con- 
tinues well for some time, to make the trial, and to 
restore him to society. 

Having- considered the treatment of insanity, aris- 
ing from physical or moral causes, acting primarily 
on the brain, we will next turn our attention to it 
when it is produced by the brain sympathizing with 
some other diseased organ. Many cases of insanity 
have their origin in diseases of some of the chylo- 
poietic viscera. In all these cases the first object is to 
restore the secretions to healthy action by the ordinary 
medical remedies. The same caution, however, which 
has been previously given, with regard to insanity 
arising from moral causes, must also be attended to 
in these cases. The patients will rarely bear exces- 
sive bleedings ; and it is generally prudent, in the 
first instance at least, not to use very violent medi- 
cines, or to give very large doses. With these excep- 
tions the medical treatment will vary very little from 
that which would be required if the patient were 
sane. As the general health is restored the irrita- 
tion of the brain seems gradually to cease ; and, in 
many cases, the patient recovers, without it being 
necessary to apply any means for lessening the cir- 
culation in the brain. Great attention, however, 
must always be paid to the state of the head ; and, 
whenever heat or pain in it is found, cold applica- 
tions and local bleedings should be carefully used. 
Many patients suffer exceedingly from the insanity 
being attributed to moral causes when it really arises 



238 ON THE TREATMENT OF INSANITY. 

from a disease in some of the viscera. Moral reme- 
dies are applied whilst the general health is too much 
neglected. A striking case of this kind fell under 
my observation some years ago. A female, about 
forty-five years of age, who went when quite young 
into a highly respectable family, as a nursery-maid, 
and had continued with them all her life, was ob- 
served to be gradually becoming melancholy ; and, 
from being very active and attentive to her duties, 
scarcely to have energy to move about, and to be 
so lost in thought as to require rousing before she 
could be induced to attend to any thing. The 
family became very uneasy about her, the apothecary 
usually attending was sent for, and finding the cata- 
menia regular, and being informed that her bowels 
were not costive, he considered it a disease of the 
mind. This opinion was strengthened by her having 
some very gloomy religious views, quite contrary to 
her usual disposition. Her affections were appa- 
rently altered, and she no longer felt any attachment 
to a young man to whom she had long been engaged 
to be married. Under these circumstances the atten- 
tion was given entirely to moral remedies, she was 
moved about from place to place, was taken to the 
sea coast, and every thing in short was done for her 
that could be accomplished by these means. At the 
end of five years she was brought, by her kind 
master and his amiable daughter, in his carriage to 
the asylum, where, after much contention of feeling, 
she was left. After making very minute and careful 



ON THE TREATMENT OF INSANITY. 2.39 

examination into all the circumstances, I felt per- 
suaded that the cause had been mistaken, and that 
instead of the brain being- diseased from a cause of 
a moral nature acting primarily upon it, it was 
affected by sympathy with diseased abdominal vis- 
cera. Acting upon this supposition, a course of 
purgatives, alteratives, the warm-bath, and after- 
wards tonics were persevered in for some time. 
The morbid feelings, which from long habit had 
become deeply excited, were diverted as much as 
possible by employment. In a few weeks a striking 
amendment was visible, and before the expiration of 
three months she perfectly recovered, and went back 
to her friends. She afterwards married, and came 
to pay us a visit on her wedding excursion. I do 
not recollect having seen any other case so remark- 
able for the length of time which elapsed before the 
proper remedies were applied, in which the patient 
recovered : but the proportion of the cures from this 
class of patients is by far greater than in those cases 
where the insanity arises from physical or moral 
causes acting primarily on the brain. 

When insanity arises from the suppression of the 
natural evacuations, these must of course be relieved, 
and in many cases, where it is the result of the sud- 
den stoppage of some artificial discharge, it will be 
necessary to re-produce this by medical means. 

Insanity, arising from the intemperate use of fer- 
mented liquors, is the consequence of the brain 
participating in the effects produced on the stomach 



240 ON THE TREATMENT OF INSANITY. 

tlirough the medium of the nerves ; the irritation 
from the stimulus having* been kept up sufficiently 
long" to continue after the absolute stimulus itself 
has ceased to be supplied. These cases also very 
generally recover if the diseased action has not l)een 
so long continued as to produce diseased structure. 
It too frequently however happens, that as the " dog 
returns to his vomit and the sow to her wallowing in 
the mire," so these patients no sooner feel themselves 
at liberty, than they begin their old practices : the 
result is, a speedy return of the insanity ; and, if 
persevered in, paralysis, fatuity, and death. In the 
young and comparatively healthy class of these pa- 
tients, on their first attack, little more is necessary 
than to keep the head cool ; diverting the blood to 
the extremities, and keeping the bowels open, and 
allaying the irritation by effervescent draughts, com- 
bined with small doses of sulphate of magnesia. After 
the incipient stage is gone off some mild tonic should 
be administered. When the practice has been long 
continued, or the patient is in declining years, even if 
it be a first attack, the collapse is often so great that 
the patient would sink at once, if all stimulus was 
immediately to be withheld. A few months ago a 
person was brought to the asylum at Han well, who 
had formerly been a respectable bookseller, but who 
from intemperance had sunk in society, until he had 
become a pauper. He was nearly seventy years of 
age, and he appeared to be fast sinking into fatuity, 
and so reduced in bodily health that there was very 



ON THE TREATMENT OF INSANITY. 241 

little hope of his surviving". He had only been in 
the workhouse a few days, but of course, during- that 
time, had not been allowed any of his long--continued 
potations : his pulse had become intermittent, and 
so feeble, it could scarcely be felt, and his appetite 
was gone. In this case, if we had not had recourse 
to brandy, the patient would in all probability have 
sunk instantly. By the timely application of this sti- 
mulus, however, he rallied ; and, by great care, and 
with accommodating his diet to his weakened diges- 
tive organs, he has got quite well and is discharged. 
Cases of Puerperal Insanity, prior to delivery, are 
not very numerous in public hospitals. Sympathy 
with the uterus and with the morbid action of the 
stomach and bowels is generally the cause. Unless 
there is a strong hereditary tendency to the disease, 
or the patient is of a peculiarly nervous temperament, 
an attack of this kind seldom supervenes, when the 
secretions from all these organs proceed in the natu- 
ral way ; at the same time there is no doubt, but that 
the various circumstances of hope and fear in which 
females are necessarily placed at such times, render 
them more sensitive than usual to the operations of 
a variety of moral impressions. It has been known 
to come on at every period of gestation : it is usually 
accompanied by some inflammatory diathesis, and 
antiphlogistic remedies and bleeding should be ap- 
plied ; great caution should be observed in the use of 
them, particularly of the latter. The cases I have 
seen very generally improved as the time of gestation 



242 ON THE TREATMENT OF INSANITY. 

drew nigh, and all entirely recovered a few weeks 
after delivery. Very few of the cases of puerperal 
insanity, after delivery, are brought to the asylum 
at Han well, until after the lapse of many weeks or 
months. The lacteal and other secretions are gene- 
rally in diseased action, if not entirely suppressed. 
The first thing to be attended to is to restore these 
to a healthy state : the warm-bath, diaphoretics, gentle 
aperients, camphor mixture combined with tincture 
digitalis, or tincture hyoscyami, are often very useful 
in procuring sleep ; but the shaving of the head and 
the persevering in applications of cold are the best 
means of lessening the irritability in this, as in every 
stage of acute insanity. If the treatment be com- 
menced in the early stage of the disease, and there 
is no hereditary predisposition or powerful moral 
cause to keep up diseased action in the brain, it is 
one of the most curable forms of insanity. Puerperal 
insanity sometimes arises from excessive hemor- 
rhage. This may take place at any period of gesta- 
tion after the third or fourth month, but it most 
frequently happens immediately on delivery : the 
brain becomes incapable of performing its functions 
aright, from not receiving a due supply of blood. In 
these cases the powers of the constitution must be 
restored by tonics, and a mild nutritious diet given 
frequently, but in small quantities : moderate exer- 
cise in the open air should be used, the bowels should 
be kept tolerably open, and all excitement, particu- 
larly the presence and conversation of relations and 



ON THE TREATMENT OF INSANITY. 243 

friends, should, as much as possible, be avoided. 
The mental faculties are usually found to improve 
with the general health and strength of the patient. 
During the whole time that puerperal insanity exists, 
and more especially during the first periods of it, 
the strictest watchfulness is requisite to prevent the 
patient from committing suicide ; for there is no 
form of insanity in which attempts at self-destruction 
are more unexpectedly and suddenly made than in 
this. It very usually happens, that the most perfect 
indifference is shown by the mother to her child ; 
indeed it is neither safe nor proper to allow it to come 
to her until some favourable change has taken place : 
but as soon as it can be done with safety, and the 
affections excited by it, a new train of feelings is at 
once called into action, and this has the most bene- 
ficial tendency. 

We will now consider the treatment of cases of 
insanity, where the brain, from any cause, does not 
appear to receive an adequate supply of blood. It 
has been already stated, that in inanition, want of 
an adequate supply of food has been in many cases 
the apparent cause of the disease, although even in 
these instances it may be difficult to exclude, as an 
exciting cause, the operation of anxiety, which 
necessarily accompanies great distress of circum- 
stances. In these cases there is great languor, and 
a feeble pulse ; the bowels are torpid, and the 
patient generally suffers from the long catalogue of 
dyspeptic symptoms. The bodily health must be 

r2 



244 ON THE TREATMENT OF INSANITY. 

restored, and a mild, nutritious, but by no means 
stimulating, diet must be administered. The head 
must be kept cool ; and as the strength will permit, 
if it is exceedingly hot, or there is much pain in it, 
small local bleedings may be used with advantage. 
We have already noticed the mode of treatment 
where the brain is deprived of its due supply of 
blood from hemorrhages attending gestation. Pro- 
fuse hemorrhages, from any other cause, will, in like 
manner, produce insanity, and the treatment of it 
must be similar. 

The only remaining cases of incipient insanity, 
which it will be necessary to notice, are those 
caused by the pernicious practice previously alluded 
to. The medical reader is referred to the note at 
the end of the volume, corresponding to the page. 

We will next proceed to the treatment of cases 
of insanity where the disease has become chronic. 
When we consider the little information generally 
possessed as to the nature of the disease, the neglect 
in making timely application, and the improper 
treatment in the early stages, we shall not be sur- 
prised that a very great number remain for life 
uncured. In large pauper establishments, particu- 
larly on their being first opened, the greater part of 
the patients admitted consists of those who have 
been long under confinement, and who are con- 
signed to them as their permanent abode. Indeed, 
the fact that the lunatics belonging to the counties 
are not placed in circumstances fjivourable for their 



ON THE TREATMENT OF INSANITY. 245 

cure, is the very reason why county asylums are 
built ; and unless they are sufficiently large to hold 
the paupers, insane at the time of their being- opened, 
and also to admit those, who are subsequently at- 
tacked, as soon as the disease makes its appearance, 
they become entirely filled with old cases ; and before 
the recent ones can possibly be taken in, weeks or 
months must elapse, and the opportunity of cure is 
lost. This has been particularly the case with the 
asylum at Hanwell. At the time when it was contem- 
plated, it was known that there were upwards of eight 
hundred lunatics chargeable to the county of Middle- 
sex, and to the different parishes in it, in confine- 
ment. It was originally built to hold three hundred 
patients, but was soon filled almost entirely with old 
cases. As no patients can be discharged except on 
their being cured, or on the undertaking of their 
friends to provide for them, that is, on their ceasing 
to be paupers, the only other vacancies arise from 
deaths ; and as the exercise, the pure air, and whole- 
some diet at Hanwell, greatly tend to prolong life, 
the mortality has been very small : indeed, the 
epileptic and consumptive have formed a great pro- 
portion of the deaths in each year. From these 
circumstances it has, with scarcely any exception, 
been impossible to admit the recent cases on their 
first becoming insane ; and before they can be taken 
in, the most favourable opportunity for the applica- 
tion of medical and moral remedies has passed away. 
Indeed, as the parishes claim the right to send a 



246 ON THE TREATMENT OF INSANITY. 

number of paupers, In proportion to their rental, it 
frequently happens that when application is made 
by a parish for the admission of a recent case, the 
parish has its full number in the asylum ; and that 
when a vacancy does occur, it must be filled up, 
not by the recent case, but by an old and incurable 
patient from another parish, that has a right to the 
vacancy. When alterations were made in the 
asylum, and it was rendered able to contain rather 
more than double the number for which it was 
originally built ; yet as the additional accommo- 
dation was not sufficient to hold one half of those 
who were then confined in the different private 
asylums and workhouses, of course the class of 
patients admitted, still continued to be the old and 
incurable. But much may be done even for these : 
the severity of the exacerbation may be abated, 
and the time of its duration shortened, and the 
patients may enjoy a considerable share of comfort 
and happiness between the attacks. 

We have already stated, that we believe that 
insanity arises in the first instance from diseased 
action of the brain and nervous system, and that if 
this diseased action remains unchecked, diseased 
organization of the brain or its membranes, to a 
greater or less extent, follows. Whenever any 
portion of the brain or its membranes has become 
thus permanently Injured, its functions can never 
again be perfectly performed ; and we have a com- 
plete case of chronic insanity. In some cases the 



ON THE TREATMENT OF INSANITY. 247 

lesion is comparatively trifling, and the derange- 
ment is confined to matters so unimportant in the 
common duties of life, that though it cannot be said 
that no injurious alteration in the character has 
taken place, yet so many faculties are still left 
unimpaired, that the patient is capable of managing 
his affairs ; and unless something occurs to excite 
the diseased part to excessive action, no symptom 
of derangement may be exhibited for weeks or even 
months together. In fact, from the organs of the 
brain being double, a portion of one hemisphere may 
be diseased, and even to a considerable extent ; and 
still, in the absence of excitement, the ordinary ope- 
rations may be performed in such a way as not to call 
forth particular observation. But whenever diseased 
organization really exists, however small its extent, 
there is a great liability to positive attacks of insanity: 
and each succeeding attack tends still further to 
add to the diseased organization, and to weaken the 
mental powers. In some cases these attacks recur at 
regular periods ; in others, the intervals of conva- 
lescence vary, and seem to depend upon the conti- 
nued absence of any exciting cause, physical or 
moral. In many, where the lesion has proceeded to 
a great extent, and the patient at all times exhibits 
decided symptoms of derangement, there is a similar 
liability to exacerbations ; and a very slight exciting 
cause, physical or moral, is often sufficient to bring 
them on. I have known several cases, where they 
have been produced merely from the nervous excite- 



248 ON THE TREATMENT OF INSANITY. 

ment arising from a slight cold, or even from the 
toothache. Many patients, who suffer extremely from 
them, and who are in consequence very much re- 
duced, and made very thin, remain well until they 
attain a certain degree of plumpness : as soon as this 
appears, another attack m.ay be expected. In these 
cases, of course, great care must be used in regulating 
the patients* diet ; as they may, by proper manage- 
ment, frequently escape an attack for many months. 
In the intervals of the attacks, many of the functions 
are performed so well, that although the patient is 
not at any time capable of managing his own affairs, 
he may be usefully and happily employed. The 
symptoms of the attacks, in the chronic cases, are 
very similar to those already mentioned, as prece- 
ding and accompanying incipient insanity : the head 
becomes hot, the secretions are disordered, the pa- 
tient is irritable, and there is an alteration for the 
worse in his general manner and conduct. As soon 
as any of these symptoms are observed, the system 
previously pointed out, as proper to be adopted on 
the commencement of insanity, should be at once 
pursued, but with a still greater caution in the use of 
depleting remedies. By carefully watching the first 
appearance of these symptoms, and at once keeping 
the patient perfectly quiet, and applying the small 
local bleedings and other medical remedies, the at- 
tack, which, if the patient were not properly attended 
to, would/last for many weeks, may be frequently 
stopped in the course of a few days, and with 



ON THE TREATMENT OF INSANITY. 249 

comparatively but little increased diseased organiza- 
tion of the brain. I can speak with some degree 
of confidence, as to the effect of local bleedings in 
chronic cases. Many patients have been under my 
care who afford an opportunity of forming a correct 
estimate of its effect. Under the old system, the 
exacerbations were severe and of long continuance ; 
and, although it is universally acknowledged, that 
the longer the patient remains insane, the more dif- 
ficult and tedious is each succeeding attack to be 
cured, I have no hesitation in saying, that by the 
adoption of the local bleedings, and of the plan pre- 
viously pointed out, the violence of the attacks has 
been diminished, and their duration shortened. In 
fact, where the patient used to suffer for months, 
under the ordinary course of merely attending to the 
secretions, and keeping him as free as possible from 
excitement, he is now frequently restored in a few 
days, by the application of this system, on the very 
first appearance of an approaching attack. In the 
intervals of the attacks, employment, according to 
the various capacities of the patients, combined with 
firm and kind moral treatment, on the plan pre- 
viously mentioned, is the best means of increasing 
their general health, of contributing to their com- 
fort, and of prolonging the period of their convales- 
cence. In many cases, where the disease has been of 
long standing, and the mind has become habituated to 
an erroneous train of thinking, a careful perseverance 
in this plan has gradually prolonged the periods 



250 ON THE TREATiMENT OF INSANITY. 

of comparative convalescence, and diminished the 
length and violence of the exacerbations, until the 
attention has become occupied, and the mind by de- 
grees been weaned from its morbid feelings ; and the 
patient has eventually become sane, and been restored 
to society. Of course, in these cases, a very great 
susceptibility of disease remains ; and any excite- 
ment, particularly immediately on recovery, will 
most probably produce a relapse. Unfortunately, 
when a poor man, who has been for a long time an 
inmate of a lunatic asylum, where his daily wants 
have been supplied without any care or anxiety on 
his part, becomes sane, there is great difficulty in in- 
troducing him again into the world, and making him 
entirely dependent upon his own exertions, without at 
the same time producing a greater feeling of anxiety 
than his enfeebled brain and nervous system are 
capable of bearing. Many of the paupers, on their 
recovery, are entirely without resources ; and they 
are driven of necessity into the workhouses, until 
they can obtain employment : this is more than they 
are able to bear. The benevolence of a gentleman 
of the name of Harrison, has done much to relieve 
cases of this kind, occurring in the West Riding of 
Yorkshire. Her Majesty Queen Adelaide is the 
patroness of a charity, which has for its object the 
supply of the immediate and most pressing necessities 
of the paupers, when discharged cured, from the asy- 
lum at Hanwell. Her Majesty contributed to it one 
hundred pounds, and other sums have already been 



ON THE TREATMENT OF INSANITY. 251 

subscribed, which have raised the amount of Queen 
Adelaide's Fund to the sum of nearly one thousand 
eight hundred pounds : this has been invested in the 
funds ; and the dividends have, in several instances, 
been the means of affording such timely assistance, as 
has, in all probability, prevented a relapse, and enabled 
the convalescent to maintain himself in comfort and 
respectability. But something further is still wanted. 
A comfortable place, where such of the patients as 
might be deemed proper objects, might, for a time, 
find food and shelter, and a home, until they could 
procure employment, would be an invaluable blessing 
to them ; and if such an institution were established, 
even at the cost of the parishes, it would in the end 
prove a saving. Many patients might be tried in such 
an establishment, and eventually restored to society, 
who are now compelled to remain in the asylum as 
lunatics, in consequence of their retaining some erro- 
neous view, on some unimportant matter. Although 
this does not interfere with their capability of judg- 
ing between right and wrong, or prevent them from 
performing their duty, it is an insurmountable bar to 
a medical superintendent signing a certificate of their 
sanity ; and, without this, the visiting justices cannot 
order tiicir discharge. I have no doubt, that in many 
instances, this erroneous impression would be effaced 
by a little mixing in the world, and in the ordinary 
business of life : indeed I have known cases of this 
kind, where the friends have made the trial, and have 
procured the discharges of the patients, on the under- 



252 OxV THE TREATMENT OF INSANITY. 

taking*, that they shall be no longer a burden to the 
parish. The greatest success has been the result : the 
complete change of scene, and the occupation of 
mind have entirely diverted the thoughts from the 
subject, on which the erroneous impression remained; 
and as this ceased to be dwelt upon, the derangement 
gradually wore off, and the patient soon became per- 
fectly sane. The friends of several of the patients 
would gladly venture to make the experiment for 
a few weeks, but they are afraid of undertaking the 
maintenance of them permanently. This difficulty 
might be obviated by providing such a retreat as has 
just been mentioned : but even if this be impracti- 
cable, much might be done by permitting the patients 
when convalescent, at proper times, to go out and 
mix with the world before their discharge. Unfor- 
tunately, so strong a feeling against this plan exists 
in the county of Middlesex, that its adoption at the 
asylum at Hanwell is, for the present at least, quite 
out of the question. In old cases, amongst the afflu- 
ent, where no pressing anxiety exists for the supply 
of the daily wants, 'there can be no doubt but that a 
change of residence, and even a return into the do- 
mestic circle, ought to be much more frequently tried 
than is usually the case. After a time the violence 
of the disease subsides, but the monotony which exists 
in the small situations, in which they are usually con- 
fined, offers nothing to divert the mind. Erroneous 
impressions become rooted, and although these are 
frequently limited to matters of trifling importance, 



ON THE TREATMENT OF INSANITY, 253 

they are sufficient to prevent the patient from being 
certified to be perfectly sane, or, at all events, they jus- 
tify his being- detained. Without some change of scene 
there is but little hope of improvement. In many 
of these cases an introduction again into the world, 
or into the domestic circle, would complete the resto- 
ration, and the trial might be made without risk. 

I cannot conclude this chapter without adding a 
few observations on a subject which materially affects 
the treatment of the insane ; I mean, the medical edu- 
cation of those under whose care they are placed. It 
is perfectly inconsistent with common sense to sup- 
pose that a man shall intuitively know how to treat 
insanity. We have seen, that although in the greater 
number of cases it is attended with the same general 
result, yet it assumes most varied forms, and great 
care and discrimination are required in the treat- 
ment : indeed, it is universally acknowledged to be 
a most difficult and mysterious disease, and yet it is 
almost the only one on which the medical student 
receives no particular instruction. In his attendance 
on the hospitals he will, in all probability, have met 
with almost every other variety of disease which 
afflicts human nature ; at all events, his lectures will 
have supplied him with some information as to their 
treatment : but I believe that my friend and col- 
league, Dr. Morison of Cavendish Square, is the 
only lecturer in London, expressly on insanity ; and 
I understand that he has not a large class. Indeed, ex- 
cept as being i ncidentally touched upon in the lectures 



254 ON THE TREATMENT OF INSANITY. 

on forensic medicine, it appears almost entirely 
neglected in the course of a medical education ; and, 
as the subject does not form a branch of examination, 
the pupils naturally employ their time in those stu- 
dies which will be directly available, and assist them 
in the obtaining their medical certificates : the result 
is, that professional men, in other respects well edu- 
cated, commence practice almost in a state of total 
ignorance on the subject. This is an evil from which 
every individual, whatever be his rank or fortune, is 
liable to suffer in his own person, and in that of his 
friends : and a man of ingenuous mind can hardly be 
placed under more painful circumstances, than to find 
the father or mother of a family, in a state of insanity, 
entrusted to his care, and to feel conscious that upon 
him depends the restoration of the patient to reason 
and happiness, whilst his want of acquaintance with 
the disease renders him unfit for the task, and he 
knows not where to apply for advice. This is by no 
means an imaginary evil, it is one of frequent occur- 
rence ; and numerous are the instances, where amia- 
ble and valuable members of society are consigned 
for life to a perpetual banishment from their friends, 
in the gloom of a madhouse, solely from ignorance 
on the part of the medical adviser. This ought to be 
remedied : — the first step would be, not to permit any 
student to be qualified to pass an examination, either 
as a physician, surgeon, or apothecary, without pro- 
ducing certificates of having previously attended a 
course of lectures on insanity ; and it ought to form 



ON THE TREATMENT OF INSANITY. 255 

as usual a subject of examination as any other disease. 
There would be considerable difficulties at the first, 
especially in obtaining teachers properly qualified, in 
the provincial schools ; but in this, as in other things, 
the demand will create the supply. When the time 
and labour required for the acquisition of knowledge 
of the subject receive an adequate remuneration, 
men of the greatest ability in the profession will de- 
vote their attention to it ; and the investigation which 
it will receive from those who are about to deliver 
lectures upon it will, eventually, throw much light 
upon the disease. In connexion with insanity I 
should strongly recommend the study of phrenology : 
the tendency which it gives carefully to note, and the 
facility with which it enables us easily to distinguish 
variations in conduct, which, though minute, and ap- 
parently of little consequence, are, in reality, the 
marks of important changes of action in the brain, 
would alone be sufficient to recommend it to our most 
serious attention. But I have no hesitation in saying, 
that in addition to its being indirectly useful, in thus 
helping us to a more accurate acquaintance with the 
state of the patient, it may be applied directly to most 
valuable purposes. One instance of its use has al- 
ready been detailed : I could mention others, where 
the mere examination of the head, without any pre- 
vious knowledge or information whatever as to the 
habits of the patient, has suggested the trial of a par- 
ticular course of moral treatment, which subsequent 
events have fully proved to be correct. Nor will this 



256 ON THE TREATMENT OF INSANITY. 

be a matter of surprise, when we remember that those 
organs, through the action of which the grand distinc- 
tions of character are produced, form large masses 
of brain, and that to distinguish their relative size 
and natural operation, it is not necessary to have re- 
course to callipers, or to determine their extent to a 
hair's breadth. A single glance will show, to a per- 
son in the habit of observing, whether the formation 
of the head indicates a naturally bold and passionate, 
or a timid and retiring man ; will enable us to distin- 
guish between one highly gifted with the intellectual 
and nobler faculties, and consequently proportionally 
responsible for their active and continued employ- 
ment, with direct reference to the glory of God, and 
his neighbour, less liberally endowed, who has to 
struggle against a constitutional tendency towards 
mere animal gratification,— a struggle of a different 
kind, but not more difficult to be overcome, than the 
natural disposition to divert the higher powers of the 
mind from their true end, and to devote them to the 
contemplation and service of the creature instead of 
the Creator. 

I am aware that the instruction obtained from the 
mere attendance upon lectures would not be suf- 
ficient to qualify a professional man for undertaking 
the moral as well as the medical management ; but 
the knowledge that would, by this means, be gained 
of the premonitory symptoms, would frequently pre- 
vent an attack of insanity coming on : at all events, 
it would relieve the patient from the danger of being 



ON THE TREATMENT OF INSANITY. 257 

exposed to permanent loss of reason from injudicious 
treatment, on its commencement. Clinical lectures 
have been very strong-ly recommended ; and, if the 
instruction of the pupils were the only object, there 
can be no doubt that they ought to be adopted : but 
it must be remembered, that the first things to be 
considered are the cure and welfare of the patients ; 
and, any one practically conversant with the disease 
will, I am sure, acknowledge, that the excitement 
which would be produced in the minds of the patients 
by a number of pupils going round an asylum, in the 
same manner as they go round an hospital, would 
be most prejudicial ; in many cases it would entirely 
prevent recovery. This, therefore, as a general prac- 
tice, can never be adopted ; but there would be no 
objection to permit such members of the profession, 
as determined to apply themselves exclusively or 
more particularly to the study of this disease, to at- 
tend public asylums daily. They might be valuable 
auxiliaries in the institution : they would become 
acquainted with the details of its management, and 
conversant with every varied form of the disease, and 
the treatment, both moral and medical, which ought 
to be adopted. They would be fitted either to take 
the management of public institutions, or, in addition 
to their private practice, to deliver lectures, and to 
impart useful and valuable knowledge to others. 
But, in order that the insane may really be placed 
under the most favourable circumstances, the in- 
struction ought not to be confined to our sex. Strong 

s 



258 ON THE TREATMENT OF INSANITY. 

prejudices, and very improper feelings, have long 
existed against females in any degree above the class 
of servants, being employed so as to obtain a liveli- 
hood for themselves, except as governesses. Any 
other occupation has been considered as degrading. 
But I hope a brighter day is dawning upon society, 
and that the application by females of the higher 
classes of their abilities to useful purposes, will soon 
cease to be a matter of surprise. There can be little 
doubt of the effect of such a change upon their own 
happiness. They would be cheerful and contented, 
they would escape ennui, and would no longer have 
occasion to avail themselves of the thousand contri- 
vances, to which the idle are obliged to resort, to get 
rid of time : and the result of such an addition of 
useful labour would be a great increase to the hap- 
piness of mankind. I know no way in which female 
kindnesG and ability could be more beneficially em- 
ployed, than in obtaining the requisite information, 
and then taking charge of the insane. A wife, a 
sister, or a daughter exhibits an alteration in man- 
ner, which indicates the existence of diseased action 
in the brain — there is a morbid sensitiveness of feel- 
ing—it is essential that she should at once be taken 
from her home, and be entrusted to strangers. Can 
any one doubt the advantage of securing as her com- 
panion, a lady of tender feelings, of refined and culti- 
vated mind, and who has had such a portion of 
nstruction on the disease, as to enable her carefully 
and judiciously to apply, under the direction of the 



ON THE TREATMENT OF INSANITY. 259 

professional man, proper medical and moral treat- 
ment? Is there a husband, a father, or a brother 
who would not hail as a benefactress, a female so 
endowed and so instructed, who would take the 
charge of his relative ? If such be the obvious utility 
of a well-informed and judicious ladv to take the 
charge of a single patient, it is unnecessary to point 
out the importance of those who are the matrons of 
public asylums, being properly educated for the pur- 
pose. I do not mean that females should attend a 
dissecting-room, or enter upon a course of the study 
of medicine, but it would be most desirable that they 
should have an opportunity of obtaining a sound and 
fundamental knowledge of the various modes in 
which diseased action of the brain exhibits itself 
in the conduct, and of the dangers to be guarded 
against, and of the moral treatment which ought to 
be adopted. 



.s2 



CHAPTER VII. 

ON APOPLEXY, EPILEPSY, AND THE DISEASES OF 

THE INSANE. 

I STATED, in the early part of this work, that I 
rather consider apoplexy to be a variety of that dis- 
ease of the brain and nervous system, which produces 
insanity in one person, epilepsy in another, and con- 
vulsions in a third, than a frequent, direct cause of 
insanity itself. Apoplectic attacks alone, however, 
when purely sanguineous, are undeniably often fol- 
lowed by insanity. This arises from the injury the 
brain has sustained either from fulness in the vessels, 
or, more likely, from some extravasation on a part 
capable of bearing it without fatal consequences ; 
though death is generally the immediate result in the 
latter case. The insanity which follows apoplexy is 
usually attended with some degree of paralysis, espe- 
cially in the organs of speech. Sometimes only a very 
little stammering is observed, but this by degrees 
increases until the nerves, both of motion and feel- 
ing, lose their action. The prognosis in all these 
cases is unfavourable : the patient very soon sinks 
under extensive sloughings. The integuments in 



ON THE DISEASES OF THE INSANE. 261 

every part, especially in the extremities, lose their 
vitality to such a deg-ree, that the mere pressure of 
one part of the body against another is sufficient to 
destroy its structure. 

I do not pretend to understand how these things 
are, nor can I suggest a remedy ; but it is to be 
hoped, from the diligent researches into the nervous 
system now making by Sir C. Bell, Dr. Marshall 
Hall, and other intelligent gentlemen, that more 
light will soon be thrown upon it. 

One of the most distressing, because one of the 
most incurable forms of insanity, is that in which it 
is combined with epilepsy. I am totally at a loss to 
explain how it is that we find morbid structure of 
the bones, hydatids, pus, and other extraneous sub- 
stances in the brain, producing in one patient' a 
continued state of insanity ; in another epilepsy, 
recurring at regular periods, and attended with no 
defect of intellect after the convulsions cease ; in an- 
other, epilepsy, followed by the most furious mania 
for pi any successive days, even after the fits have 
ceased altogether ; but these varieties in the disease 
are well known. Postmoi^tem examination usually 
discovers much cerebral disease, several ounces of 
serum are also found in the ventricles, and under 
the membranes. In all large establishments the epi- 
leptic form a considerable portion of the inmates : 
in the asylum at Hanwell, sixty-three out of six 
hundred and eight are affected with it. I have my- 
self tried, and seen my medical colleagues try, all 



262 ON APOPLEXY, EPILEPSY, AND 

the usual remedies, such as setons, blisters, vomits, 
purges, bleedings, sedatives, mercury, and numerous 
other things, likely and unlikely ; but I do not re- 
collect ever seeing any benefit arise from the use of 
them, when the seat of disease appeared in the head, 
and accompanied insanity. In most cases, both the 
frequency and the violence of the fits may be pre- 
vented by strict attention to diet, keeping the bowels 
open, and avoiding all sources of mental irritation. 
In the instance of a female about eighteen years of 
age, where the cause of irritation appeared to be in 
the intestines, turpentine was of great use ; and she 
perfectly recovered after taking it for some time. 
But it is well known, that whenever epilepsy arises 
from the irritation of teething, worms, or other dis- 
eases in the stomach and intestines, the removal of 
the cause will very probably cure the disease. 

The insane are of course liable to accidents 
and illness, in common with the rest of mankind ; 
but with the exception of their being constantly 
subject to diseases peculiarly connected with the 
nervous system, and which, notwithstanding what 
has been said to the contrary, I am decidedly of 
opinion tend to shorten life, they are not, when 
under proper management, a sickly class. It is pro- 
bable that this may, in a great measure, arise from 
the regularity of their diet, habits, &;c. Another 
reason may be, that cold, damp, and other circum- 
stances which, in the sane, bring on sore throats, 
inflammation of the lungs, or other complaints. 



THE DISEASES OF THE INSANE. 263 

according" to the particular idiosyncrasies, frequently 
produce in the insane diseased action of the brain : 
but, independently of diseases peculiarly connected 
with the nervous system, the insane seem particu- 
larly subject to others, such as chronic inflammation 
of the mucous membrane of the bowels, diarrhoea, 
and dysentery. These diseases appear to depend a 
good deal on locality : in the Asylum at Wakefield, 
a large proportion of the deaths was at one time 
owing to them ; whilst, in the one at Hanwell, they 
are comparatively of rare occurrence ; this probably 
may be accounted for, by the former being on a cold 
clay soil, and the latter on a fine bed of dry gravel. 
Consumption, too, is a very frequent cause of the 
termination of their existence ; and very large and 
numerous tubercles are often seen on dissection, 
when no expectoration of pus whatever had previ- 
ously taken place. As the treatment of any disease 
by which the insane are attacked is the same as that 
pursued with the sane, it is unnecessary to say more 
on the subject : it should, however, always be borne 
in mind, that as the nervous system in general is 
under diseased action, all the remedies applied should 
be used with caution, and this ought to be particu- 
larly attended to in the use of depletions, and in the 
exhibition of vegetable poisons. 



CHAPTER VIII. 

ON THE CONSTRUCTION OF ASYLUMS, AND THE 
MODE OF THEIR MANAGEMENT. 

It has been already stated, as essential to the cure 
of the disease, that some place should be provided 
for the insane, where they can be kept separate from 
their relatives, and those persons whom they have 
been in the habit of commanding ; and where they 
will be removed from all objects likely to re-produce 
the same train of thinking which accompanied, if it 
did not bring on, the attack. For the poor, no place 
can be found which will bear any comparison with a 
County Lunatic Asylum : their wants are there 
provided for in the most substantial manner, and at 
an expense which is but little felt by each individual 
who contributes to it : and, as no one in such esta- 
blishments has the least advantage by the patients 
remaining in them, they are sure to be discharged 
as soon as they are sufficiently recovered to justify 
such a step. Wherever there are one hundred 
lunatic paupers in one county, there ought to be an 
Jisylum ; or, if two small counties, adjoining each 
other, can agree to build one according to the 
provisions of the 9 Geo. IV., it would be still more 
advantageous, as the expense of providing for them 



ON THE CONSTRUCTION OF ASYLUMS. 265 

necessarily decreases in the ratio of the number in 
the institution. Having determined upon the build- 
ing, the next consideration is the site. It is of great 
importance that it should be elevated, and by no 
means in a cold or exposed situation : the soil ought, 
if possible, to be gravel or chalk. It is absolutely 
essential that there should be such an abundance of 
water, that it should be perfectly immaterial whether 
a thousand gallons, or a thousand hogsheads, a day 
are used. In addition to any supply of spring water 
that may be furnished, I strongly recommend, that 
all the rain w^ater should be collected from the roof, 
in a separate tank ; it will be at all times valuable for 
washing, brewing, or other domestic purposes. The 
building should be at such a distance from any town 
that a very considerable portion of land around it 
may be purchased at a cheap rate. The quality of 
the ground, if it be improvable, is not of so much 
consequence as the quantity ; the manual labour of 
the patients, in a few years, rendering almost any 
ground productive, if the soil and manure from the 
establishment be properly secured. With respect to 
the form of the building, I rather prefer three sides 
of a rectangular parallelogram to any other, with the 
centre about double the length of the sides. The 
residence of the superintendent and matron, with 
the various business offices, should be placed in the 
middle of the centre ; and behind these should be 
the kitchens, sculleries, washhouse, bakehouse, brew- 
house, &c. &c., so as to admit of easy access from the 
centre. The wards for the males should occupy one 



266 ON THE CONSTRUCTION OF ASYLUMS, 

side, those for the females, the other side of the 
building". If the whole of the ground-floor is ele- 
vated, which it ought to be, in order that it may be 
perfectly dry at all seasons, a passage may very easily 
be made in the basement, from the kitchen to the 
extreme corners of the central part of the building, 
along which the provisions, &c. &c. may be conveyed 
from the various domestic offices, and from these 
corners, to the different wards of both the male and 
female patients. The gardens, farm-yard, and all 
other buildings connected with the out-door labour, 
should be placed at the back of the various offices, 
from which there should be easy access to them. 
The airing courts for the wards, in the centre of the 
building, will be on each side of the domestic of- 
fices, and, of course, completely separated from each 
other ; those for the side-wings ought to be placed 
on the east and west sides. If it can be conveniently 
managed, the entrance to the building should be on 
the north side, as it is much more cheerful to have 
the galleries in which the patients walk to front the 
south ; and it is never well for them to be so placed 
as to be able to see all the persons coming and going 
to the asylum. Having thus given a general outline 
of the building, let us now proceed to enter a little 
more into detail. I am afraid that this will be dry 
and uninteresting ; although, from my having been 
continually in the habit of receiving letters from 
persons concerned in the erection of asylums, both 
at home and abroad, requesting an opinion on the 
minutiae, I hope it will not be altogether useless. 



AND THE MODE OF THEIR MANAGEMENT. 267 

The arrangements here mentioned are by no means 
thought incapable of improvement ; but they are 
selected after visiting and seeing the plans of a great 
number of lunatic asylums, both at horae and on 
the continent, and after twenty years' residence in 
two of the largest in England. 

The first object that should be kept in view, after 
providing for the comfort and health of the patients, 
is economy: for, after all that can be said of the 
feelings of humanity towards this unfortunate class 
of our fellow-creatures, their sufferings are too much 
out of sight to create that sympathy for them which 
is felt for others, whose wants are more known. It 
becomes necessary then to show, that to render them 
efficient assistance need cost very little more than to 
neglect them : indeed, if the probability of cure be 
taken into consideration, it is in reality to the pecu- 
niary advantage of each county to provide asylums 
sufficiently large to hold all their lunatics. 

But whilst we keep economy in view, we must take 
care that we are not misled in supposing that things 
procured for the least money are always the cheapest. 
In purchasing the site of ground for the building of 
the asylum at Hanwell, a high price was given for it, 
in comparison with that for which land could have 
been bought at Fryarn Barnet, the only other place 
in which any was offered at all likely to answer the 
purpose ; but yet, from its proximity to the Grand 
Junction Canal, which will be observed by referring 
to the Plan at the beginning of this work, all the 
materials wanted for the erection of the building 



268 ON THE CONSTRUCTION OF ASYLUMS, 

were brought by water. It will, therefore, be easily 
comprehended, that the ground selected for the site 
was by far the cheaper place of the two ; indeed, I 
am informed by Mr. Sibley, who was the county 
surveyor at that time, that the difference of cost to 
the county, in having the materials by that convey- 
ance, instead of the mode by which they must have 
been conveyed to Fryarn Barnet, amounted to more 
than the fee simple of the land. The permanent 
advantage, too, of receiving by canal all the heavy 
materials in daily use, in so large an establishment, 
is found to be a great saving : in the coals alone, the 
difference of the expense between the carriage of the 
quantity consumed, to Hanwell, instead of to Fryarn 
Barnet, is nearly equal to the interest of the money 
expended in the purchase of the land. 

But in the choice of a site for the building, one 
consideration ought to weigh more even than eco- 
nomy, that is health. The advantage of having a 
healthy situation for establishments of this kind, is 
of the utmost importance ; and the benefit of it has 
been felt, in a peculiar manner, at Hanwell. Not- 
withstanding few patients are received there until 
organic disease of the brain has taken place, to such 
an extent that they are incurable when admitted, 
yet the air is so salubrious, that the deaths, in pro- 
portion to the average number of patients in the 
house, are fewer than in any other large pauper 
establishment in the kingdom, where all who come 
in remain until they die, or are discharged cured, or 
cease to be paupers. 



AND THE MODE OF THEIR MANAGEMENT. 269 

The following is a list, for the last six years, of 
the average number of patients at Lancaster, Wake- 
field, and Han well, the largest asylums in the king- 
dom, and of the corresponding deaths. These annual 
averages could not be taken from an earlier period, 
as the asylum at Hanwell was not opened for the 
reception of patients until the 15th of May, 1831. 
The salubrity of the air at Hanwell seems to avert 
much of the virulence of epidemics. During the 
period in which the patients laboured under the 
Cholera, the mortality from that awful disease was 
comparatively small ; and, although the Influenza 
prevailed for some time, only one or two patients 
died in consequence of it. 

Average number of Patients and number of their deaths in the 
following years^ at the County Lunatic Asylum at Lancaster. 



Year ending 
23 March. 


Average 
number of 
Patients. 


Deaths. 


Males. 


Females. 


Total. 


Per Cent. 


1832 
1833 
1834 
1835 
1836 
1837 


343 S 

313.5 

319S 
360-^ 

400 S 

411^ 


42 
87 
41 
30 
40 
56 


27 
60 
24 
25 
36 
54 


69 
*147 
65 
55 
76 

fiio 

522 


20.09 
46.92 
20.32 
15.27 
18.96 
26.73 




2148 g. 


= 2148.7 nearly 





And 2148.7 : 100 : : 522 : 24.29. 
Average annual per centage of deaths during the last six years, 

24.29. 



* Of whom 94 died from Cholera. 

•f- Of whom 46 died from Phthisis after Influenza. 



270 



ON THE CONSTRUCTION OF ASYLUMS, 



Average number of Patients, and number of their Deaths in the 
following years, at the County Lunatic Asylum, at fVaJcefield. 



Year ending 
31 Dec. 


Average 
number of 
Patients. 


Deaths. 


Males. 


Females. 


Total. 


Per Cent. 


1832 
1833 
1834 
1835 
1836 
1837 


286 
302 
303 
303 
309 
321 


35 
31 
22 
30 
32 
34 


18 
21 
21 
30 
24 
28 


53 
52 
43 

60 
56 
62 


18.53 
17.21 
14.19 
19.80 
18.12 
19.31 


1824 




326 



And 1824 : 100 : : 326 : 17.87. 
Average annual per centage of deaths during the last six years, 

17.87. 



Average number of Patients, and the number of their Deaths in the 
following years, at the County Lunatic Asylum at Hanwell. 



Year ending 
31 Dec. 


Average 

number of 

Patients. 


Deaths. 


Males. 


Females. 


Total. 


Per Cent. 


1832 


427 


46 


53 


*99 


23.18 


1833 


537 


46 


31 


77 


14.33 


1834 


564 


35 


23 


58 


10.28 


1835 


580 


45 


26 


71 


12.24 


1836 


611 


43 


22 


65 


10.63 


1837 


608 


24 


24 


48 


7.89 




3327 


418 





And 3327 : 100 : : 418 : 12.56. 
Average annual per centage of deaths during the last six years, 

12.56. 

* Of whom 1 1 died from Cholera. 



AND THE MODE OF THEIR MANAGEMENT. 271 

It will be seen from these tables, that taking the 
average per centage of deaths, for the last six years, 
it is, at 

Lancaster 24.29 fand taking the relative pro-"^ 4 
Wakefield, 17.87 -s portion in round numbers, y 3 
Hanwell, 12.56 Lit differs very little from J 2 

From the professional skill and zeal of the medical 
gentlemen at Lancaster and Wakefield, this differ- 
ence in the mortality can only be accounted for 
from the singularly healthy situation of the asylum 
at Hanwell. 

The building should be as plain as possible ; at the 
same time, a plan displaying taste, with an imposing 
appearance, at no more cost than one without these 
qualifications, ought certainly to be preferred. The 
first entering into the confines of such establishments 
often produces a salutary effect upon the mind of a 
patient, if the aspect is agreeable, and the contrary 
when otherwise. The building itself ought to be of 
brick or stone, and in every part fire-proof: the roof 
should be of iron ; indeed an iron roof can now be 
procured at as cheap a rate as a wooden one of the 
same strength. In the roof should be placed cisterns 
for hot and cold water, which ought to be distributed 
by pipes to all the wards and offices. 

An important saving may be effected by having 
the building three stories high. I am aware that 
great objections have been made to this arrange- 
ment, particularly in France ; but I think, without 
sufficient reason : the epileptic, and those likely to 



272 ON THE CONSTRUCTION OF ASYLUMS, 

injure themselves in going down stairs, may be 
placed on the ground-floor. Any objection to the 
plan from its fancied inconvenience to the servants 
is perfectly futile ; there are, and very properly, so 
many contrivances to prevent the necessity of their 
leaving their wards, that their journeys up and dow^n 
stairs are much less frequent than those of servants 
in private families. This plan was found to answer 
exceedingly well in the asylum at Wakefield, where 
I resided for many years ; and, as it effects a con- 
siderable saving, I have no hesitation in recom- 
mending it. One keeper ought not to have under 
his charge more than twenty, or twenty-five, patients 
at the most ; and it is more convenient for each ward 
to contain that number only, than for them to be 
larger, with two keepers to each. There ought to 
be a dining room for every fifty patients. When the 
building is sufficiently large to admit of two wards, 
each containing from twenty to twenty-five patients 
on the same floor, in each of the side wings, and of 
two male and of two female wards, of similar size, in 
the centre, there should be a dining room on each 
floor, in the centre of each side wing, for the two 
side wards ; and one on each floor, between the two 
male wards, in the centre of the building, and a 
similar one between the two female wards. These 
rooms can also be used for the patients to work in ; 
and from this position the keepers can easily inspect 
the patients whilst walking in the galleries. In a 
building of this magnitude, two of the adjoining 



THE MODE OF THEIR MANAGEMENT. 273 

wards on each side of the house ought to be thrown 
into one, for the purpose of being converted into a 
walk for spinning string. This occupation is, indeed, 
so conducive to the comfort of the patients, that 
where the size of the building will not admit of such 
a spinning walk being in the galleries, a covered way- 
ought to be erected for the express purpose. Where 
each wing contains only one ward on a floor, having 
twenty-five patients in each, the dining room for the 
fifty patients ought to be at the corner, and should 
be so constructed as to give easy inspection into the 
side, and also into the centre ward. The tables in the 
dining rooms should be fixed in such a manner, that 
the patients can sit at their seats, fastened into the 
walls of the room : they need not be wide, as it is 
convenient for one side not to be occupied by the 
patients. There ought to be a proportion of about 
sixty-six separate sleeping apartments for every hun- 
dred patients. The sleeping apartments, for single 
patients, should not be less than eight feet six inches 
long, and six feet nine inches wide, and twelve feet 
high. At Hanwell each sleeping apartment contains 
six hundred and sixty cubic feet. As a general prin- 
ciple, I should prefer having the sleeping apartments 
only on one side of the gallery ; but in a county 
asylum for paupers, there will always be a consi- 
derable portion in so helpless a state of fatuity, as 
to be unable to appreciate any of the advantages 
of a cheerful aspect ; and, if they have a pure air to 
breathe, are kept clean, kindly attended to, and well 

T 



274 ON THE CONSTRUCTION OF ASYLUMS, 

fed, nothing more can be done for them. For this 
class of patients, the more economical plan of having 
the sleeping apartments on each side of the galleries 
may be adopted with propriety : to obviate however, 
the darkness, and to give even these galleries a de- 
gree of cheerfulness, open spaces, sufficiently large 
to contain beds, may be left on each side of the gal- 
lery ; in which windows should be placed for light 
and air. The patients may dine as well as sleep in 
these spaces, the bedding being removed, during the 
day, to an adjoining apartment : this arrangement 
will save the expense of a separate dining room for 
patients of this class. Each ward ought to contain 
a small warm bath, and also a sink and a water-closet. 
Though the matter may appear trifling, the altera- 
tion of these, if not made on a good plan at the 
first, is afterwards a source of considerable annoy- 
ance and expense : the sinks have usually a trap, 
made immediately on the pipe descending from the 
stone ; and, as the trap is seldom more than one inch 
deep, it very soon becomes choked up ; and it must, 
therefore, be continually taken up, which is very 
troublesome ; or it must be left loose, in which case 
we find, that the patients cram various articles down 
the pipe, and in this mode prevent the water running 
off. The best plan to obviate this nuisance^ is to have 
a proper grating fixed upon the mouth of the pipe, 
with a trap a little lower down, made in the shape of 
the letter S. Any thing that will pass through the 
grating can then easily go through the rest of the 



AND THE MODE OF THEIR MANAGEMENT. 275 

pipe. With respect to the water-closets, unless great 
care is used, both by the architect in forming" them, 
and by the keepers afterwards, in watching the pa- 
tients, it will cost a considerable sum to keep them 
in order ; and they will be frequently choked up, and 
create a great nuisance. A long trough, placed at a 
convenient inclination under the seat, with a grate 
about one foot from that end of it which communi- 
cates with the descending pipe, seems to answer very 
well. Over the part between the grate and the de- 
scending pipe is a door, fastened down, which may be 
opened, to take out any thing which may be pushed 
through the grating, before it gets to the descending 
pipe. Attached to the door of the closet is a spring, 
which, every time the door is opened, acts upon a 
valve, connected with a water cistern, from which a 
large rush of water immediately passes through the 
trough. An S trap is fixed to the descending pipe 
in the same way as described above. In addition to 
these contrivances, to keep the building sweet, all the 
drains attached to it ought to be of an extra large 
size, with a good fall ; for, after every precaution, 
the patients do, and will contrive to cram things into 
them. 

In asylums designed for paupers only, it is unne- 
cessary to have any plaster on the walls ; lime-wash 
on the bricks is all that is required ; it is easily ap- 
plied, whenever and wherever it is wanted : in a short 
time, indeed, it forms of itself such a covering over 
the bricks, that the absence of the plaster is not 

t2 



276 ON THE CONSTRUCTION OF ASYLUMS, 

observed; and in a large building the saving of money- 
is considerable. The doors, both of the galleries and 
rooms, should be made substantially strong ; none of 
them panelled. Doors of this description are burst 
open, by a madman, without the slightest difficulty. 
As it sometimes happens that a patient will get his 
bedstead to the door of his cell, and thus barricade 
the entrance, it would be convenient for some of the 
doors to open outwards instead of inwards : these 
may be protected, by bolts, from being forced open 
from the inside. The plan usually adopted, of having 
the window-frames made of iron, and the windows 
small, is a sufficient protection against the patients 
getting out through them ; and the prison-like ap- 
pearance of iron bars is avoided. The sleeping rooms 
for the refractory patients should be fitted up with 
shutters, and it would be convenient for these to be 
made to slide within the walls : the windows in the 
refractory galleries should be protected with a wire 
net-work. Much inconvenience will be experienced 
if the locks are not on a good principle : they ought 
to be strong, and of a simple construction ; and, if 
made with the pin to go into the key, it should not 
be made so large as to weaken the key : keys made 
so as to admit the pin are very apt to break. One 
key should open all the locks in the male wards, and 
another all those in the female wards. 

It has been already stated, that the best situation 
for the kitchen, and all the domestic offices, is at the 
back of the centre ; and this should be their place. 



AND THE MODE OF THEIR MANAGEMENT. 277 

whatever be the size of the buildmg-. The plan of 
having two kitchens, one for the males, and another 
for the females, is perfectly ridiculous : it would ne- 
cessarily create the necessity of having a double set of 
servants, and double minor oiBces of every descrip- 
tion, and would greatly increase the labour of the 
superintendents. This error was unfortunately com- 
mitted both in the Wakefield and Middlesex Asy- 
lums ; the consequence has been, that one kitchen at 
each place is appropriated to other purposes : and 
the other kitchen, in which all the provisions for both 
sides of the house are obliged to be cooked, being at 
one corner of the building, is very inconveniently 
situated. This would of course be obviated, if the 
kitchen were placed in the centre. From what has 
already been stated, relative to the employment of 
the patients in the different domestic concerns, it will 
be obvious that the offices should be of ample size. 
Where the cooking, washing, baking, &c. are all done 
by the patients, instead of being done by hired ser- 
vants, of course a greatly increased number of per- 
sons will be employed in these works ; and, to prevent 
their interfering with each other, abundant room is 
required. These offices ought to be double the size 
that it would be requisite for them to be built if sane 
persons only were employed. It is particularly desir- 
able for them all, in the first instance, to be rather 
too large for the number intended to be admitted, as 
there is scarcely an asylum in the kingdom which has 
not required enlargeuient, to meet the wants of the 



278 ON THE CONSTRUCTION OF ASYLUMS, 

insane, whose numbers augment as the population 
increases. Another very material consideration is, 
the ventilation and warming : one mode is by admit- 
ting the atmosphere through a tunnel under ground, 
and then passing it over plates of heated iron, and 
distributing the warm air, by pipes, throughout the 
building. In the only asylum in which I have seen 
this plan tried it did not answer ; and the air seems 
to lose something of its purity and wholesomeness, 
by being passed over the hot iron. The plan of 
warming, by hot water passing along pipes, in the 
same manner as many hot-houses are warmed, may 
be conveniently used in small buildings ; but it does 
not answer when the water has to traverse a consi- 
derable distance of piping before it returns to the 
boiler. As the whole of the water contained in the 
boiler and pipes must be heated, before sufficient 
warmth can be produced, too much time is occupied 
in getting the hot water into circulation : I am, how- 
ever, by no means certain that a complete apparatus 
of this kind, for each ward, would not be the most 
desirable, the most economical, and the most efficient 
mode of heating the building : it would also be at- 
tended with this great advantage, that the heat could 
be completely regulated, according to the different 
wants of the patients. Where the whole building is 
heated by one or two apparatuses, the wards through 
which the pipes first pass receive a greater portion of 
heat than is required, and there is great difficulty in 
keeping the tem[)erature sufficiently high in those 



AND THE MODE OF THEIR MANAGEMENT. 279 

which are at the extremities of the building ; wherein 
are usually placed the dirty and imbecile patients, 
who really require the greatest degree of warmth. 
Pipes heated by steam, and passing under the floor 
of the galleries, after many experiments, appear the 
readiest and best mode of heating any very extended 
building, by one or two apparatuses. Mr. Bramah 
has recently invented a plan to exclude the heat, at 
pleasure, from the wards through which the pipes 
pass : a pipe is laid under the floor of each ward, 
along the side of the range of sleeping apartments, 
in a covered brick air-passage, sufficiently large to 
admit, from the external atmosphere, as much air as 
is required for the purposes of ventilation ; openings 
are made in the sides of the cells towards the wards, 
three or four inches above the floor, capable of being 
closed, either partially or entirely, by an iron slide. 
It is expected that this arrangement will obviate the 
objection, of having the wards near the apparatus too 
hot, whilst those at a distance from it are not suf- 
ficiently heated. Where the building is large, and 
more than one or two heating apparatuses cannot, 
from any circumstances, be fixed, I decidedly prefer 
steam to warm water. Upon a trial of the two plans 
at the asylum at Hanwell, it w^as found that the pipes 
heated by steam attained the temperature of tw^o 
hundred degrees of Fahrenheit in an hour and a 
half; and eight hours elapsed before the same length 
of pipes, heated by hot water, reached the tempera- 
ture of one hundred and thirty degrees. One objec- 



280 ON THE CONSTRUCTION OF ASYLUMS, 

tion has been made to the use of steam, which at first 
appears considerable ; it is, that the joints are conti- 
nually giving way, and the apartments consequently 
wet and uncomfortable. This is easily obviated by 
making all the joints with iron-cement, instead of 
cotton and paint, which are too frequently used. In 
long ranges of pipes there should be one made of 
wrought iron, and considerably bent, into the shape 
of almost two-thirds of a common oval, four feet 
long : this will allow of the expansion and contrac- 
tion of the pipes, when heating and cooling. Another 
great advantage of the heating by steam is, that in 
an asylum containing three hundred patients, not 
more than one steam boiler need be in use at the 
same time : if of a proper size it will warm all the 
building, heat the water for the washing, and the 
water in the cisterns in the roof, and heat the dry- 
ing closets, and also supply all the cooking apparatus 
with steam. Though it must be admitted that a con- 
siderable quantity of coal is consumed by the one 
boiler, yet, as no fires will be wanted in the w^ards, 
the plan is thought rather to diminish than to in- 
crease the expense of fuel. When proper care is 
taken to secure due ventilation, it has one very great 
advantage over the open fire ; which is, that all the 
patients, the weak as well as the strong, are placed 
upon an equal footing with respect to warmth. With 
open fires, when secured by proper guards, all the 
space round and near them is occupied in cold wea- 
ther, by the patients least requiring extra warmth ; 



AND THE MODE OF THEIR MANAGEMENT. 281 

and the feeble, and those whose circulation is most 
languid, are pushed away : quarrels and blows are 
not unfrequent, as may be supposed, under such cir- 
cumstances ; nor can these evils be prevented, unless 
the attention of one keeper is entirely devoted to 
watching- the fire-place. 

When all the patients who can be trusted are kept 
in regular employment, the airing courts, attached 
to the different wards, need not be so large or so 
numerous as is generally thought necessary ; two or 
three at the most, for each sex, will be sufficient. In 
fine weather, the farm and the garden ought to be 
the airing courts for the healthy, and in wet weather 
they must remain within- doors. One airing court 
for each sex should be larger than the other, and the 
walls sufficiently high to prevent one patient being 
able to assist another to escape. In all establish- 
ments there will be found some, whose contrivances 
to accomplish this purpose, and whose dexterity in 
carrying it into execution, are surprising ; and, 
notwithstanding the greatest vigilance, they often 
succeed. For such cases there remains only the alter- 
native, of either keeping them constantly locked up, 
which would be injurious to their health, or having 
the airing-court walls so high as to be inaccessible. 
The corners ought not to be rectangular ; for, though 
it does not frequently happen, I have had patients 
under my care, who could get up to the top of a 
wall by the square angles, with the aid only of their 
elbows and knees. The walls of the other courts 



282 ON THE CONSTRUCTION OF ASYLUMS, 

need not exceed ten feet, and the division walls may 
be still lower. In each of the courts there should be 
an awning- to protect the patients from the sun. In 
all institutions for paupers, workshops should be pro- 
vided, in which the patients may perform different 
branches of mechanical labour, to which they have 
previously been accustomed ; but, where the appa- 
ratus is very expensive, and the labour not likely to 
be useful to the institution, or profitable, the patient 
may, by kind perseverance, be induced to learn 
some mechanical art, which he had never previously 
attempted. At the asylum at Hanwell, there are no 
less than six shoemakers now at work, who never did 
any thing of the kind before their admission ; and 
three, who have been discharged cured, also learnt 
the trade during their residence in the asylum. Spin- 
ning of twine and rope-making are also generally liked; 
many of the patients prefer them to any other occupa- 
tion, and they have all been taught to do these works at 
the asylum. The awnings before spoken of, as shelter 
from the sun in the airing courts, ought to be suf- 
ficiently long to permit these works to be carried on 
under them. It will be unnecessary to enter more 
fully into an abstract account of Pauper Lunatic 
Asylums, as it is proposed to give a description of 
the one at Hanwell, and to point out how far it does 
not accord with our views, in those details which 
remain to be noticed. An account of the mode in 
which it is actually conducted, will be combined with 
this description, and form the best commentary on 



AND THE MODE OF THEIR MANAGEMENT. 283 

the chapter on Treatment. The Plan at the com- 
mencement of the work shows the situation of the 
building : it stands on an estate of about fifty-five 
acres, of which the subsoil is gravel ; and is beauti- 
fully situated on the rise of a hill about eight miles 
and a half from London, with its front at a distance 
of two hundred and fifty yards to the south of the 
Uxbridge road, which forms the northern boundary 
of the estate : the river Brent is the eastern boun- 
dary ; a farm of the Earl of Jersey the western ; and 
the Grand Junction Canal, which communicates with 
a dock on the premises, the southern. The whole 
estate is abundantly supplied with water. The prin- 
cipal part of the building is two stories high : the 
portion between the two dotted lines is that which 
w^as originally built. It was designed for three hun- 
dred patients ; but, with greatly economizing the 
room, and making use of a part of the basement, it 
has been fitted so as to accommodate six hundred 
and fifteen. The part of the building on the outer 
sides of the dotted lines has been recently built for 
the reception of three hundred additional patients. 
The entire front from east to west, including the 
new part, is nine hundred and ninety-six feet in 
length. 

It will be observed that the central part of the 
building projects a little beyond each of the side 
galleries : the length of this projection is thirty-four 
feet, and the length of the similar projection of the 
side galleries, to the south of the centre of the 



284 ON THE CONSTRUCTION OF ASYLUMS, 

building, is also thirty-four feet ;* the whole length of 
the central part of the building, with its lateral pro- 
jections, is five hundred and seventy-six feet ; the 
extreme length of each of the side galleries, which 
run from north to south, including the tower and 
abutment, is three hundred and sixty-two feet. 
There is in the centre, and also in each of the side 
wings, an octagonal tower, eighty feet in diameter, 
and three stories high ; each side of which is thirty- 
four feet long. Thus it will be seen that a small 
wing, which is two stories high, is carried out from the 
south side of the central tower ; this wing is thirty- 
four feet long. Previous to the recent addition to the 
building, the wings, springing from the side towers, 
were of the same dimensions ; the new portion 
added to each is one hundred and eighty-seven feet 
long. The transverse part, at each of the extremi- 
ties of the new building, is three stories high ; and 
extends from north to south seventy-five feet. The 
principal entrance is in the front tower, which con- 
tains the committee-room, the superintendent and 
matron's apartments, with domestic offices, the 
chapel, and the day rooms or dining rooms of a 
male and female ward. On the east of this tower 
are the wards for the male, on the west those for 
the female patients : the old building contains fifteen 
of these wards, seven for the males and eight for the 

* I am indebted to the Clerk of the Works for the New Build- 
ing for these measurements ; I have therefore no doubt of their 
accuracy. 



AND THE MODE OF THEIR MANAGEMENT. 285 

females ; the numbers in each vary from twenty-six 
to sixty. Each of the wards consists of a gallery 
ten feet wide, and ten feet and a half high, with 
sleeping apartments on the side of it looking towards 
the building, the other side affording a cheerful view 
into the surrounding country. In the new building 
there are sleeping apartments on both sides of the 
galleries, but openings are left abundantly sufficient 
for light and air, and they are intended to be prin- 
cipally occupied by violent patients. A day room, 
in which the patients dine, is also attached to each 
of the wards in the old building ; in the new build- 
ing the openings in the galleries will be used for that 
purpose. The western octagonal tower contains 
the apartments for the surgeon and sub-matron, 
with a waiting and receiving room, and dining 
and sleeping rooms for the insane : the bazaar also 
is in a room in this tower. The eastern tower is 
appropriated to the residence of the surgeon, who, 
when the new building is occupied, will be appointed 
more immediately to attend to the male patients : it 
also contains the surgery and office. In the base- 
ment of this tower are the shops for the joiners, 
painters, glaziers, brush-makers, and coopers : there 
are staircases from the top to the bottom of the 
house in each of the octagonal towers ; and there is 
also one at each corner of the central part of the 
building ; there are also smaller staircases commu- 
nicating from the wards to the airing court. The 
situation and size of the airing courts are sufficiently 



286 ON THE CONSTRUCTION OF ASYLUMS, 

pointed out in the engraving. The two portions of 
the building in a line with the wings, running from 
north to south, which project beyond the southern 
front of the building, were originally designed to be 
used as kitchens for the two sides of the house ; but 
as the having two kitchens would have increased the 
number of the servants, and would also have been 
attended with additional expense and trouble, the 
portion of the building intended for the western 
kitchen has been altered into a ward, so as to accom- 
modate a considerable number of patients, and the 
cooking for the establishment is entirely carried on 
in the eastern kitchen. 

This is forty-five feet long, by thirty-four wide, 
externally. It contains four steam-tables, two steam- 
boilers, a stew hearth, a common kitchen cooking 
grate, with the necessary tables, drawers and binns for 
salt, rice, oatmeal, &c. Contiguous to it is the scullery, 
fitted up wdth the usual appendages and coppers for 
boiling vegetables. The dairy and larder are conve- 
niently situated in ample cellars near the kitchen. At 
the back of the kitchen and scullery is a closed yard, 
around the sides of which are the bake-house, brew- 
house, poultry-house, gas-house, and the house for 
the boiler, which supplies the cooking apparatus with 
steam, and heats the eastern side of the building ; 
there is also a large bath, with proper apparatus for 
filling it either with hot or cold water. Around a 
yard similarly situated on the western side of the 
house, are placed the wash-house, drying closets. 



AND THE MODE OF THEIR MANAGEMENT. 287 

laundry, and foul-linen room. This yard is used 
for drying linen out of doors when the weather will 
permit : the wash-house is seventy-three and a half 
feet long, by twenty-five wide, externally, and 
furnished with fixed washing-tubs, into which hot 
and cold water is conveyed by taps. It is filled 
with large wooden steeping-troughs, and with a most 
useful washing-machine, worked by steam power 
upon the principle of a fulling-mill. It also con- 
tains an hydraulic press, which squeezes out the 
water from the clothes with much less injury to the 
fabric, and less labour than the hand wringing. It 
is not thought that these fitments can be improved. 
The drying closet is seven feet six inches high, to 
the wall plate, twenty-two feet nine inches long, and 
eleven feet two inches wide. It is heated by steam- 
pipes, and furnished with an opening at the top for 
the passage of the condensed vapour thrown off 
from the wet clothes. The laundry is fifty-nine and 
a half feet long, and twenty-five feet wide, externally; 
it contains a large ironing-board, extending the 
whole length of the room, various tables, an iron- 
ing stove, two mangles on the rotatory principle, 
and a smaller drying closet for the purpose of com- 
pletely airing the clothes. The wash-house and 
drying closet for Vet sheets, and other foul linen, 
are, at Hanwell, as they ought to be in all asylums, 
detached from the general wash-house. This wash- 
house is fitted up with a common washing-machine ; 
and whatever be the state of the weather, wet mat- 



288 ON THE CONSTRUCTION OF ASYLUMS, 

tresses and clothes are exposed to the atmosphere, 
previously to being* completely dried in the closet. 
In this yard is also placed the store room, a reposi- 
tory for the clothing and other articles ; and it con- 
tains a bath for the females similar to that already 
described. Behind this yard, and at a short distance 
from the wash-house, are placed the steam-engine 
and the house containing its boiler, and another for 
the production of steam to supply the laundry and 
dry closets, and also to warm the western side of 
the building. Adjacent is the blacksmith's shop, 
with a lathe ; and a few feet from it is the tinner's 
workshop. The engraving will show the situation 
of the dock ; around it are coal-sheds. The cow- 
house, piggery,' and stables are conveniently placed 
at the back of the house. There are two kitchen 
gardens : the one on the east side of the house con- 
tains upwards of four acres ; the other, which is at 
the south-western corner of the estate, appears in the 
engraving, enclosed with two walks at right angles 
to each other, and with a curvilinear wall. This 
curvilinear wall, extending four hundred and seventy- 
five feet in length and ten feet in height, was en- 
tirely built by the patients ; it contains about two 
acres and three quarters. 

We must now, in pursuance of our plan, give 
an account of the mode in which the Asylum at 
Han well is actually managed. The detail will be 
to many uninteresting ; but it is hoped that it may 



AND THE MODE OF THEIR MANAGEMENT. 289 

suggest useful hints to those about to undertake the 
superintendence of similar institutions. 

The Asylum, having- been erected according to 
the provisions of the act of parliament, 9 Geo. IV., 
is necessarily under the management of a Com- 
mittee of county magistrates : this consists of fifteen 
members, five of whom go out every year, but are 
eligible to be re-elected. The times of their hold- 
ing meetings are uncertain, varying with the busi- 
ness to be transacted : when any thing particular is 
going forward, or is wanted, they are held as often 
as once in a week or fortnight : in the winter season 
they usually take place at the Sessions House, 
Clerkenwell. From April to September, a meeting 
is always held on the second Monday in every 
month at the Asylum, in addition to those held at 
the Sessions House, for entering into contracts for 
provisions, coals, &c. every three months: inde- 
pendently of these regular meetings for business, 
the members of the committee, particularly those 
residing in the neighbourhood of the Asylum, are 
in the habit of very frequently visiting it at uncer- 
tain times, and inspecting sometimes a part, some- 
times the whole of the building : a plan that cannot 
be too much commended and imitated. These visits 
are of much more importance to the real well-being 
of the establishment, than those which take place 
at regular and stated periods ; they ought never to 
be relaxed, even if good order and propriety be 
uniformly found in every department. They will 



290 ON THE CONSTRUCTION OF ASYLUMS, 

always afford gratification to those who do their 
duty, when made in the usual spirit and manner 
practised by gentlemen, who are in general appointed 
county magistrates ; and they are a great incentive 
to activity to those who might be disposed to be 
negligent if entirely freed from such useful inspec- 
tion. They are also very much calculated to 
strengthen the hands of the Superintendents. The 
subordinate officers and servants, knowing that the 
members of the committee are in the habit of going 
round the Asylum, will be kept alert, and attention 
and diligence, on their parts, will be the result. 

Once a quarter the books and accounts of the 
establishment are very carefully examined ; any two 
or three of the gentlemen, who may happen to be 
present, assisting the chairman to inspect them, and 
compare the bills and vouchers for the articles pro- 
cured since the last examination. A statement is 
then laid before them of such things as are expected 
to be wanted before the next meeting : they give 
their orders for these in writing, their own clerk 
being in attendance to take down the transactions 
of the meeting. 

The execution of the different orders made by the 
committee is entrusted to the resident medical super- 
intendent, a physician, and the matron, who are man 
and wife. When the peculiar circumstances of these 
establishments are taken into consideration, it seems 
a most desirable arrangement that the direction of 
them should be in the hands of married persons ; it 



AND THE MODE OF THEIR MANAGEMENT. 291 

gives a home feeling- to the parties, and prevents 
the little petty quarrelling- and jealousies which are 
found continually to exist where single persons pre- 
side, and each has a separate interest to attend to. 
These officers have the entire management, under 
the control of the committee, of the details of the 
institution, and give the orders for such things as 
they have received instructions for from the com- 
mittee, and for any works of necessity that may arise. 
The medical and moral treatment of all the patients 
is under the immediate direction of the resident 
physician and matron : the resident physician also 
acts as the treasurer to the institution. The resident 
physician and matron are assisted by the house sur- 
geon and his wife ; the former of whom, immediately 
after the patients have breakfasted, goes round the 
wards on both sides of the house, and carefully exa- 
mines into the state and general health and comfort 
of the patients, and makes a report of any new case 
of sickness to the physician, whom he subsequently 
accompanies in his rounds : he also makes up the 
medicines, and keeps the medical case-book. In the 
afternoon this officer again regularly goes round the 
wards ; in fact, his duty consists in the exercising a 
constant watchfulness over the servants, particularly 
over the male keepers, and in the becoming inti- 
mately acquainted with the character and circum- 
stances of each individual patient, so as to contrive, 
with the physician and matron, that not an oppor- 
tunity may be lost of taking advantage of any favour- 

u 2 



292 ON THE CONSTRUCTION OF ASYLUMS, 

able turn in the disease. This duty is unceasing* ; it 
embraces occasional visits, at uncertain times, to the 
different male wards, before the servants rise in the 
morning-, to see that the keepers do not permit the 
patients to get up before they themselves are dressed 
and ready to attend them, and similar visits after 
the patients are put to-bed at nig-ht ; to take care 
that the patients' clothes are taken out of their 
bed-rooms ; and that the epileptic patients are 
so secured as to be unable to turn upon the face, 
without which precaution they are liable to die from 
suffocation, in case of a fit coming* on. It of course 
also embraces an attendance, in conjunction with the 
physician, on any special cases of sickness, as often 
as may be needed. This officer and the clerk, in each 
week, inspect the stock of linen, bedding, clothes, 
&c. in each of the male wards ; and, comparing it 
with the inventory, report any deficiency to the 
matron. When the institution receives the additional 
number of three hundred patients, which it has been 
recently enlarged to contain, an additional house 
surgeon will be appointed, who will have under his 
charge the male patients ; and the attention of Dr. 
Button, the present house surgeon, will be more 
particularly confined to the females. A consulting 
physician and consulting surgeon are appointed, who 
render their services in cases of difficulty and emer- 
gency, and whenever the committee of visiting 
magistrates think necessary. 

The wife of the house surgeon, in the first place. 



AND THE MODE OF THEIR MANAGEMENT. 293 

takes care that the female sick are properly and 
kindly attended to ; that the medicines and food 
ordered for them are duly administered : she also 
attends to the general comfort of the female wards, 
and minutely examines into the state of the beds, 
linen, &;c. She also sees that the regulations given 
to the female keepers are complied with, and takes 
care that no permission of absence is given which 
would leave any particular department without a 
due number of female attendants. This is easily 
arranged, as no servant is allowed to go out of the 
lodge gate without a pass ticket, signed by the super- 
intendent, and left at the lodge, and brought up the 
next morning by the porter for inspection. To her 
is entrusted the distribution of the pass tickets to the 
female servants. She also takes care that the break- 
fasts and dinners for the females are of good quality, 
and sufficient in quantity, and that they are duly distri- 
buted according to the proper rations for each ward. 
The afternoon is spent by her amongst the female 
wards, and she assists in carrying out the little plans 
formed by the physician and matron, for the employ- 
ment and moral treatment of the females ; and she 
communicates to them any information which, from 
conversation with the patients, or with their friends, 
or from any other source, she may think likely to be 
valuable. After the female patients have gone to 
bed, during each week, she examines one-third of 
the bed-rooms : this examination takes place at un- 
certain times. A similar examination is made of the 
other bed-rooms by the workwoman and the female 



294 ON THE CONSTRUCTION OF ASYLUMS, 

store-keeper. The store-keeper and Mrs. Button 
take the stock of the female wards every week. 
The clerk to the institution keeps the various books 
of account relating to the receipts and disburse- 
ments of the establishment, and to the ordering and 
receipt of goods from the various tradesmen. No 
orders for goods are permitted to be sent to any 
tradesman without the express authority of the su- 
perintendent or matron for each individual article. 
Every Tuesday morning, at nine o'clock, the officers 
and the keeper from each ward, who is entrusted 
with the mechanical work carried on by the patients 
in it, and one of the female nurses from each ward, 
meet the superintendent and matron in the com- 
mittee room, and give an account of the work which 
has been executed under their direction during the 
past week, and receive instructions as to their em- 
ployment until the next meeting ; and they mention 
the various articles which are wanted, and such of 
them as on inquiry and examination are ascertained 
to be proper, are ordered by the superintendent and 
matron. The clerk enters their orders into the 
order book, and on the arrival of the goods they are 
carefully examined ; the invoice, if correct, copied, 
and a receipt corresponding with the copied invoice 
is given to the tradesman. No goods are received 
without such an invoice ; and, on the coming in of 
the tradesmen's bills, each item charged is carefidly 
checked with the copies of the invoices. The clerk 
also keeps the books relating to the patients, and 
examines and files the warrants and certificates which 



AND THE MODE OF THEIll MANAGEMENT. 295 

are sent with them on their admission ; and receives 
orders from the house surgeon as to the ward to 
which each patient is to be sent. If the patient be 
a female, he furnishes an account in writing* of the 
particulars mentioned in the warrant, and the house 
surgeon endeavours to procure from the overseers, 
or the friends who accompany the patient, such in- 
formation as may be useful in the treatment. The 
clerk also takes care that the male side of the 
house, and the outer doors are properly secured 
with the master-key at the conclusion of the evening 
prayers. 

In contemplation of the additional number of 
patients, a provision store-keeper is appointed. He 
receives the meat from the butcher, and sees that 
it is of due weight and quality, and immediately 
reports any deficiencies in either respect. The 
receipt of the groceries is also entrusted to him ; 
and the daily weighing the provisions, and the dis- 
tributing the raw material, by weight and measure, 
to a part of the manufactories^ also falls to his 
duty ; and however unappropriate such a term might 
appear, when applied to lunatics, it is strictly cor- 
rect, and the attending to it occupies a considerable 
portion of time ; for manufactures are carried on 
by the patients, and to a great extent ; and the hemp 
for the band and twine-spinning, the coir for the 
teasing, the leather for the shoe-making, the pottle- 
wood for the pottle-making, the straw for the hat- 
making, the willows for basket-making, bristles for 
brush-making, are duly given out by measure, and 



296 ON THE CONSTRUCTION OF ASYLUMS, 

accurate note is taken of the quantity of the mate- 
rial used, and of the manufactured article returned. 
This officer also takes care that the conduct of the 
servant in the kitchen is orderly and respectable. 

The housekeeper takes care that the female 
servants, in her department, are in due time in the 
morning- at work with their patients. She receives 
the milk for the breakfasts of the patients, and sees 
that they are duly prepared according to the diet- 
table, a copy of which will be found in the Appen- 
dix. She has the entire responsibility of the cook- 
ing for the patients and officers. Her only sane 
assistant in the kitchen is the dairy-maid, when not 
engaged in her milking and other duties. She has 
also the distribution of the butter, bread, and such 
other of the provisions as are not under the keeping 
of the provision store-keeper. In the evening she 
takes care that the domestic servants, with such of 
the patients as remain up to help them, attend the 
family prayers, which are regularly held in the chapel 
at half {)ast nine. 

The female store-keeper has under her charge 
the entire stock in hand of all the clothing and 
bedding for the men and women, not given out 
to the keepers and nurses of the respective wards ; 
and in each week she takes an account of all the 
linen wanting repair. This she receives from the 
laundry-maid, and provides for its being duly re- 
paired in the female wards, and out of her stores 
substitutes other articles in good order. She also 
receives the bread and groceries for the females. 



AND THE MODE OF THEIR MANAGEMENT. 297 

in bulk, from the provision store-keeper, and duly 
apportions them ; and in like manner she duly 
apportions to the respective female nurses, the 
articles for the employment of their patients, and 
collects them and takes an account of them in 
detail w^hen manufactured. Every morning and 
afternoon, she collects the female patients, to be 
employed in out-door work, and sends them, under 
the charge of proper female nurses, to the gardener, 
with a w^ritten paper containing their numbers. 
He employs them, under the care of the nurse, in 
such portion of the out-door work as may be desir- 
able ; and the female store-keeper, each morning 
and afternoon, visits the females at work out of 
doors, and takes care that they are properly attended 
to by the nurse, under whose immediate charge 
they are placed. She gives out such of the stores 
under her care as are wanted for the week's con- 
sumption, and examines and compares the goods, 
previous to their being deposited in her room, with 
the nurses ; and gives the clerk a written acknow- 
ledgment of having received them, and duly enters 
them in her account-book : and no articles are given 
out of her room without an account of them being 
also kept. By this means the entire stock of articles 
in the house can be immediately ascertained. The 
store-keeper, with the assistance of the patients, cuts 
out all the linen for the house and patients ; she 
also has the charge of the patients' library, for which 
they are principally indebted to the kindness of Mr. 



298 ON THE CONSTRUCTION OF ASYLUMS, 

Gurney. It consists of interesting* biography, voy- 
ages, travels, short historical accounts of different 
parts, and amusing- anecdotes. These, with tracts, are 
distributed every Saturday amongst the different 
keepers, for the use of the patients for the ensuing 
week ; or are lent to the individual patients, at their 
personal request ; and an account of them is care- 
fully kept. A copy of the Penny and Saturday 
Magazine is also taken in by the Institution, for the 
use of the patients. The library is a source of great 
amusement ; and as the books are distributed on 
Saturday, the reading them sometimes to one 
another, sometimes alone, serves to occupy the 
mind, and keep the patients quiet on Sunday — by far 
the most difficult day in the week to manage them. 
The patients, on that day not having their ordinary 
employment, and not being previously accustomed 
to amuse themselves with mental occupations, suffer 
from ennui; and the result of their idleness is a 
greater quantity of vice and mischief on that day 
than on any other in the week. 

In the afternoon the men and women assemble 
together in the chapel, and practise singing the 
hymns and psalms which are to form a part of the 
evening services : but as the singing takes up a con- 
siderable portion of the afternoon, of course it is not 
confined to these. At six o'clock in the evening, 
Dr. Stoddard, the chaplain, performs divine service, 
and there is as much anxiety amongst the patients to 
be permitted to attend, and to come in their best 



AND THE MODE OF THEIR MANAGEMENT. 299 

dresses, as there is among-st the sane, previous to an 
attendance on the most fashionable congregation in 
London; and it would be difficult to find in the 
metropolis one more orderly or devout. In fact, 
from the chaplain only attending once on the Sunday, 
the privilege of being permitted to join in the wor- 
ship conducted by him is more valued, than if he 
performed the service more frequently : and the 
effect upon the patients is, I think, better than if it 
were less estimated, as it would be if there were more 
frequent opportunities of enjoying it. The chap- 
lain very judiciously varies the portions of the prayers 
selected for the service, which he does not permit 
to extend much above an hour and a quarter. This 
is quite as long as their attention can be profitably 
occupied ; and by this arrangement the patients be- 
come acquainted with the whole of the Liturgy. The 
chaplain, once each quarter, administers the sacra- 
ment, and many of the patients derive great conso- 
lation from being partakers of this ordinance. 

The female workwoman is a very important per- 
son in the institution ; every alternate week she 
relieves the female store-keeper of the distribution 
before breakfast of the bread and groceries : after 
breakfast she is always employed in cutting out, 
arranging, superintending the making, and selling 
the various articles, which are to be disposed of in 
the bazaar. Many of the patients in the Asylum 
at Hanwell have been reduced to pauperism solely 
from their insanity ; and others of them have been 



300 ON THE CONSTRUCTION OF ASYLUMS, 

in the habit of employing themselves in fine needle- 
work. A considerable difficulty was felt in finding- 
suitable occupation for such patients ; the ordinary 
sewing and mending, which were wanted for the 
institution, were disliked, and there appeared no 
means of procuring for them work suited to their 
tastes. With a view to obviate the evils of idleness 
in this class, the matron hit upon the plan of esta- 
blishing a bazaar. She borrowed of the treasurer 
twenty-three pounds eighteen shillings : this she 
laid out in the purchase of a few articles in the first 
instance as patterns, and in the buying the requisite 
materials. These are made up and worked by the 
patients, and sold by the workwoman to visitors at 
the bazaar, or are sent off to order. The scheme 
has answered beyond the most sanguine expecta- 
tions. At the end of the first year, the whole 
amount borrowed from the treasurer, was returned 
out of the profits of the sale of the goods ; and the 
matron was left with a small stock on hand, and 
with money due to her. The plan has been persevered 
in, and the workwoman has now between fortv and 
fifty female patients, daily employed in the making 
useful and fancy articles for sale. The greatest 
difficulty was felt, in the first instance, in obtaining 
a market for the goods. But as they are good and 
cheap of the kind, this obstacle is gradually being 
overcome. It is hardly possible to conceive the 
benefit which the patients have derived from this 
employment : it is congenial to their previous habits. 



AND THE MODE OF THEIR MANAGEMENT. 301 

it excites a great interest ; many of them select 
and contrive with as much anxiety the various pat- 
terns, as if they were exclusively to derive all the 
profit from their sale. One poor woman who had 
been insane a long time previous to her admission 
in 1831, and who was subject to frequent and vio- 
lent paroxysms, and whom no persuasion could 
previously induce to work on the establishment of 
the bazaar, spent her time in minutely work- 
ing collars and ladies* dresses. This employment 
was of her own selection, and it so absorbed her 
attention that the irritability by degrees wore off; 
and after having for a long time past exhibited no 
symptom of insanity, she was discharged cured. 
Others take the charge of particular portions of the 
work, and employ under them patients, with less 
mental powers than themselves. In fact there have 
been many contrivances for the happy occupation of 
the patients, but I do not think that any have been 
more beneficial to them than the bazaar. In a pe- 
cuniary point of view, the speculation has been very 
profitable. An exact account is kept of the cost of 
every article used, from the pins upwards, and of 
the produce of the sale of the goods. The details 
of them are furnished to the matron every Saturday 
by the workwoman. The matron then duly enters 
these in her book, the bazaar account being kept 
totally distinct from the other accounts of the insti- 
tution. At the end of the second year, the profits 
have enabled the committee, out of them, to purchase 



302 ON THE CONSTRUCTION OF ASYLUMS, 

an organ for the patients. The instrument is most 
excellent ; it is a complete finger organ, per- 
fect in all its notes, and of beautiful workmanship. 
It is also fitted with barrels capable of playing 
twenty-four tunes. As it is principally intended to 
assist in divine service, the music set upon the bar- 
rels is sacred ; but the patients assemble one evening 
in each week to enjoy a little concert. The patients, 
by the profits of whose labour the organ has been 
purchased, and others equally industrious, though in 
another way, who take an interest in the musical 
performances, have been consulted on the selection 
of the tunes : this creates an interest in them about 
the organ, and the establishment generally, which it 
is very desirable to keep up ; it adds a little too to 
their self-respect, and raises them in the moral scale ; 
and God forbid that the time should ever arrive 
when any thing, little or great, should be neglected, 
which would tend to soothe their feelings, or to 
make less bitter the nauseous, though necessary cup 
of confinement ! The musical meetings are looked 
forward to with great pleasure. A similar plan was, 
and still is, adopted at Wakefield. I remember one 
of the patients there, an exceedingly violent man, 
who was obliged to be kept almost constantly in con- 
finement, on whom the music had such an influence, 
that on being allowed to attend, which was per- 
mitted at his request and promise of good behaviour, 
he always conducted himself with the greatest pro- 
priety: unfortunately, neither the promise nor the 



AND THE MODE OF THEIR MANAGEMENT. 303 

good behaviour extended after the time of his return 
to his ward. In his case the insanity was, as far as 
I remember, brought on by a blow on the head ; and 
I have no doubt, that organic disease in the brain 
was the cause of his violence, which was, however, 
suspended by the " concord of sweet sounds." The 
patients, who are attached to the bazaar, are not 
permitted to remain in the house during the whole 
day ; but they are sent out, in many cases much 
against their inclinations, when the weather is 
fine, for a short time every morning and after- 
noon, into the grounds ; where they assist in 
any work which does not require much muscular 
strength. This has a great tendency to keep them 
in health. It is hoped that the profits of the bazaar 
will be exclusively appropriated to the increase of 
the comforts of the patients. 

It has been already stated that the building is 
heated by steam. The water is pumped into a cis- 
tern in the roof by a steam-engine, which also works 
the washing machine previously described. The 
whole of the machinery is under the charge of an 
engineer : he regulates the temperature of the wards 
by adjusting the admission of the proper quantity of 
steam. Much of his time is occupied in repairing 
and keeping the machinery in order : he also takes 
charge of the stock of iron, and of the blacksmith's 
shop. He is assisted by the fireman, who attends to 
the various boilers, and works, with two or three 
patients under his charge, in the blacksmith's shop. 



304 ON THE CONSTRUCTION OF ASYLUMS, 

There are two gardeners. The head gardener is 
responsible for the finding of the vegetables which 
are required by the housekeeper, to whom he de- 
livers, by weight and measure, each day's consump- 
tion : he also keeps an account of all the male and 
female patients who go out to work, and he is respon- 
sible for their safe return : he apportions their work 
to them, and takes care that each set of patients 
shall be under the charge of proper persons. He is 
principally occupied in the eastern garden ; the 
assisting gardener attends more particularly to the 
western. He receives from the head gardener a 
number of male and female patients, with their 
names, who are employed under his direction. The 
supply of vegetables is abundant. 

The cropping and cultivating the parts of the 
land not included in the gardens devolves upon the 
farming man : he also has the management of the 
cows and pigs. He is assisted by a number of male 
patients, for whom he is accountable whilst they are 
under his employment : this number varies, accord- 
ing to circumstances, from twelve to forty. He has 
also the help of a carter, who delivers the coals from 
the sheds, when they are landed at the dock side, to 
the different offices. He also goes to London once 
a week with a cart, to fetch the goods ordered for 
the use of the institution. This arrangement effects 
a considerable saving to the establishment. There 
are usually about fifty-five male and thirty-three 
female patients employed in gardening and farming. 



AND THE MODE OF THEIR INIANAGEMENT. 305 

A dairy-maid, with her staff of from four to six 
female patients, assists the farming-man in the milk- 
ing-. The 612 patients, now in the house, daily 
consume the milk of about sixteen cows : she also 
assists the housekeeper in the kitchen, and in the 
taking up and apportioning the dinners. 

The bread and beer of the establishment are made 
by one sane female, assisted by eight patients. The 
regularity of the system laid down for her enables 
this servant to accomplish the whole of the baking 
and brewing for the 660 persons, of whom the 
family now consists. 

The washing for the 612 patients and servants is 
managed by one laundry-maid, who has under her 
charge from sixteen to twenty patients. Their time 
is, as may be supposed, sufficiently occupied by the 
washing and getting up the linen of all the patients, 
servants, and officers in the establishment. 

There are two keepers to each ward, one of 
whom is a mechanic. Before breakfast, both are 
employed in getting up, washing, and shaving the 
patients. After breakfast, the one, who is a mechanic, 
leaves the ward in charge of the other ; and he 
selects from his own ward, and from the other male 
wards, such patients as are able to work with him at 
his trade, and whom the superintendent and surgeon 
may think proper to be entrusted to him. These 
patients either go with him to his shop, or are 
employed about the building, wherever their services 
may be w^anted. The keeper who is left in the 

X 



306 ON THE CONSTRUCTION OF ASYLUMS, 

ward, attends to the patients, takes care that the 
beds are made, the rooms and gallery thoroughly 
cleaned, and employs the patients in picking coir, 
twine-spinning, or any other in-door employment, 
which is carried on in his ward. 

Each female ward has two nurses : at nine o'clock 
the junior nurse, whenever the weather permits, 
collects those patients in her ward who are to be em- 
ployed out of doors, and assists and watches over 
them whilst in the cultivation of the ground. The 
necessary ward duties, mending the clothes for the 
male and female patients, the making the whole of 
the house linen, and assisting in sewing the men's 
clothes (cut out by the tailor), the superintending the 
twine-spinning, basket-making, pottle-making and 
other works, carried on in the wards, afford sufficient 
occupation to the nurse who is left in charge of it. 
In the Appendix will be found a copy of the Rules 
which apply to the keepers and nurses. 

Each parish has the privilege of sending into the 
institution a number ofpatients, in proportion to the 
sum contributed by it to the building the Asylum ; 
the cost of which, including cost of the fifty-five acres 
of land, and of the furnishing, and also law and all 
other expenses, was 124,456/. lis. bd. As the 
Asylum has long been quite full, it unfortunately 
happens, that a long time frequently elapses before 
patients can be received, after the application for 
their admission. The days for their reception are 
Tuesdays and Fridays, between the hours of eleven 



AND THE MODE OF THEIR MANAGEMENT. 307 

and one. On the arrival of each patient, the war- 
rant for his admission is seen to be correct, and 
inquiries are made of the overseers and friends, in 
order to obtain such information as may enable the 
surg-eon to select the most appropriate ward, and to 
warn the keeper or nurse, in case of there being- any 
disposition to violence or suicide. After the ward 
has been chosen, the patient is entrusted to the 
keeper or nurse, and is immediately stripped, tho- 
roughly cleaned, and clothed in the asylum dress. 
The clothes in which the patient comes, are taken 
away by the overseer. The patient is seen in the 
afternoon by the house surgeon, who ascertains the 
general state of the health, and, if requisite, calls in 
the advice of the physician : if not, on accompany- 
ing the physician in his rounds, on the next morning, 
he reports the case to him, and the patient is ex- 
amined by them, and the moral and medical treat- 
ment prescribed. If the case be recent, the plan 
previously pointed out is according to the varying 
circumstances adopted, and this necessarily prevents 
the patient from immediately falling into the ordinary 
course pursued, where nearly all are old and incurable 
cases. But if the case be, as it generally turns out, 
an old case, after a few days' careful watching, in 
order to ascertain the peculiarities of the patient, an 
attempt is made to induce him to employ himself, 
and to become, as it were, one of the family. The 
chapter on Treatment has already developed the 
principle on which these attempts are made. The 

X 2 



308 ON THE CONSTRUCTION OF ASYLUMS, 

superintendent usually examines the head of the 
patient phrenologically, and forms his own conjec- 
tures as to the character : but he never allows 
this examination to lead to any diminution of cau- 
tion ; althoug-h, in many cases, the conformation of 
the head induces the use of beneficial means, which 
would not have been suggested from any informa- 
tion received with the patient ; this is generally very 
defective. In the first instance, out-of-door employ- 
ment is generally tried ; the patient is put under the 
especial charge of one of the servants, and set to 
work on the ground in such a way as to avoid any 
danger of his injuring himself or others. By-and- 
by, as his character becomes more known, and it is 
considered safe to trust him, in case of his being a 
mechanic, he is taken to the keeper, who has the 
same occupation with which he is acquainted, and is 
induced to work at his trade. And as there are 
bricklayers, joiners, tinners, blacksmiths, shoemakers, 
tailors, brushmakers, twine-makers, pottle-makers, 
basket-makers and coopers, all at work about the 
institution, it is most probable that a mechanic 
will be able to select from amongst them some 
occupation with which he has been previously 
acquainted, or which he may like to learn : at all 
events, the reward of a little tea, tobacco, beer, or 
some other luxury, congenial to his taste, will, with 
a little management, generally be sufficient to induce 
him to occupy himself, either in his ward or out of 
doors. Indeed, on an average, 454 patients, out of the 



AND THE MODE OF THEIR MANAGEMENT. 309 

612, are daily employed: and of the others, who are^ 
idle, some are fatuous, others in such a state of de- 
bility as to be unable to work, and only very few 
idle solely from disinclination to employment. The 
patients rise at six in the morning, at eight they assem- 
ble in the chapel for family prayers, and immediately 
afterwards they breakfast. At nine they go to their 
work ; at eleven the workers out of doors have an 
allowance of one-third of a pint of beer ; at one 
they dine ; at four they have a similar allowance of 
beer ; and at seven they sup. Each patient goes 
into the warm bath, for a thorough washing, every 
week. 

It will be unnecessary to add, that the keeping in 
order so complex a machine, even now that its parts 
are carefully arranged, requires the constant and 
anxious watchful attention of the superintendent and 
matron : there is not a single movement which does 
not directly emanate from them. Not a single article 
is permitted to be ordered without their express di- 
rection, and from them, individually, has originated 
each of the various occupations which are now car- 
ried on in the institution, to the comfort and happi- 
ness of the patients. The selecting the proper agents 
to assist them in accomplishing their design has been 
one of their most difficult tasks. If the choice and 
dismissal of these agents had not been entrusted to 
them, it would have been impossible that the present 
system could have been carried into execution : a 
minute personal attention is required for the success 



310 ON THE CONSTRUCTION OF ASYLUMS, 

of it, which can only be ensured by the personal 
superintendence of those who are immediately in 
authority. Many little thing's, the neglect of any one 
of which could not be made to appear to a com- 
mittee as a sufficient ground for the dismissal of an 
officer or servant, are essential to the comfort of the 
patients ; and some of these are in themselves so 
irksome, that nothing but the knowledge that the 
disregard of any orders, which affect the welfare of 
the patients, will at once be followed by some punish- 
ment, and, if persisted in, with a dismissal without 
appeal, can secure diligent and constant attention. 
It will easily be supposed, that the arranging the 
details previously pointed out, and the carrying into 
execution the varied employments of the patients 
were not accomplished without much labour and 
anxiety : in the first place, the servants naturally 
threw every obstacle in the way of their doing any 
thing ; it was much more trouble for the keepers to 
see that the patients performed the daily necessary 
household duties, on which their personal comfort 
in a great measure depended, than it would have 
been for them to have known, that whether the 
patients worked or not, their dinners would be 
cooked, their bread baked, their vegetables gathered 
by hired sane persons ; and of course they would 
have preferred a sufficient number of sane helpers 
in the wards to have kept these in order. The 
having the responsibility of seeing that a much 
greater portion of work was daily and properly 



AND THE MODE OF THEIR MANAGEMENT. 311 

performed than tliey could individually, however 
industrious, personally execute, compelled them, but 
most reluctantly, to call in the assistance of the 
patients : and at the time when the Asylum was 
opened, in 1831, the system, which was not at all 
unusual in many of the poor-houses, of paying" its 
inmates for all the services rendered, created, on 
the part of the patients, an unwillingness to work ; 
this, however, was easily overcome. If the patients 
are in g-ood health, and in a proper state to work, 
they are allowed no beer, and every little indul- 
gence is withheld, so long as they are idle. They 
soon find out that employment tends to their com- 
fort ; and when they see those about them happily 
engaged, and in the enjoyment of the little reward of 
their industry, they generally very soon petition for 
something to do. After the prejudices against em- 
ploying the patients about the house and grounds 
had in some measure been overcome, there was still 
an apparently insuperable objection to their making 
any thing for sale out of the institution. It was said 
and thought, that the making articles for sale would 
be an injury to those now employed in them ; and 
this feeling was not confined to the servants, but it 
still prevails, and, to a very great degree, amongst 
the shopkeepers in the metropolis. They, for some 
reason which I cannot devise, dislike to encourage 
our attempts : and the store-keeper, who has made 
inquiries of different tradesmen with a view to the 
sale of articles manufactured in the asylum, has been 



312 OxV THE CONSTliUCTiON OF ASYLUMS, 

abused as a *' thief," for attempting to rob of their 
profits those who are now employed in these manu- 
factures ; as if it were possible that the few articles 
brought into the market by the labour of the poor 
lunatics could really prejudice any one. If this dif- 
ficulty had not been overcome it must have put an 
end to the plan ; as, whatever benefit the patients 
might have derived from the labour, this is not the 
time when a consideration of their comfort would 
counterbalance the most trifling additional expense. 
The utilitarian feeling of the present day, which 
has no other measure for that which is good and 
valuable, than a pecuniary standard, renders it essen- 
tial that the manufactures should be so carried on as 
to be a source not of loss but of profit. By personal 
applications, by letter, by enlisting in the cause of 
humanity the active and benevolent, (whose services 
I here, on behalf of my poor patients, gratefully 
acknowledge,) the labour of the patients has been 
rendered available, not only to their own amuse- 
ment, but to the diminution of their expense, even 
after they have been permitted, from the profits, 
to enjoy some little comforts which the institution 
would not otherwise have provided : these consist 
of beer, tea, tobacco, and a variation in the ordinary 
dress, or some other indulgence suited to the 
tastes of the patients. Money is, on no account, 
permitted to be given them : notwithstanding that 
each patient, who fairly gains it, whatever be his 
capacity, has his reward^ the cost a week for their 



AND THE MODE OF THEIR MANAGEMENT. 313 

board, clothing, medical and other attendance, medi- 
cine and washing, and indeed for every expense in 
any way connected with them, is tis. 3d. ; and I am 
convinced, that a diminution of their comforts will 
not be attended with a saving to the institution. 
Once take away the inducement for them to em- 
ploy themselves, and you must immensely increase 
by far the most expensive part of the establishment, 
the servants ; and there would be no little addition 
to the expense in the injuries which would be done 
by the patients, by their applying, to mischievous 
purposes, that muscular or nervous energy, which 
is now profitably spent in useful labour. It would 
be tedious to detail the opposition which each new 
art has met with on its introduction : suffice it to 
say, that each, without any exception, has at its 
commencement been thwarted. It has only been 
by insisting, that whether the servants learnt or not, 
they should remain with the patients until they 
might have an opportunity of being taught, and by 
making a careful selection from amongst the patients 
to become the pupils, that these manufactures 
have been successively established. I will only add 
one observation : hitherto no accident of any con- 
sequence has happened from the patients being en- 
trusted with tools, and no unpleasant result has 
arisen from the female patients, imder proper charge 
of their nurses, working in the grounds or shops, 
where male patients, also under proper care, have 
been at the same time employed. And as far as 



314 ON THE CONSTRUCTION OF ASYLUMS, 

the greatest vigilance and precaution can avail, tlie 
benefit of the system, without suffering from any 
inconveniences to which it is exposed, will continue 
to be received. It is, however, possible that some 
untoward accident may happen : but even then I 
should be sorry for the system to be given up. The 
injuries, in one or two instances, are nothing in com- 
parison with the constant and daily happiness which 
it affords to hundreds ; and it is not possible, in 
this world, to have a great good, without some 
danger of evil arising from it. But as, in the ordi- 
nary events of life, we do not permit a little incon- 
venience to stand in the way of our enjoying great 
happiness, so ought we not, in this case, to be deterred 
from pursuing our plan, even should some unfore- 
seen calamity, vi^hich I pray God to forbid, over- 
take us. 

From what has been said on the treatment of 
the insane in Lunatic Asylums, it will be obvious, 
that, according to my notions, no one, except a 
medical man, and a benevolent one, ought to be en- 
trusted with the management of them. I deeply 
regret, that during the progress of the work, I have 
learnt that Government have sent out, as the super- 
intendent of the only public asylum in New South 
Wales, an individual, without any medical education 
whatever. The only knowledge of the disease pos- 
sessed by himself and his wife, the matron, has been 
derived from their being keepers in a private asylum. 
Now, I have nothing whatever to say in disparage- 



AND THE MODE OF THEIR MANAGEMENT. 315 

ment of the characters of these individuals: so far 
from it, as far as I could judg'e of the superintendent, 
whom I saw at Hanwell, I believe him to have a sin- 
cere desire to do good ; and I know that he regrets his 
want of knowledge. But surely there is not in the 
mighty empire of the south, which must eventually 
rival in importance, as it now exceeds Europe in 
extent, such a superabundance of light and know- 
ledge, that a Government, which has its welfare at 
heart, can afford to throw away an opportunity of 
establishing on a right principle, of setting up as a 
model for imitation, an institution for the cure of a 
disease, to which, it is to be feared, the habits and cha- 
racters of the inhabitants will render them peculiarly 
liable. This is not a light matter : the parliamen- 
tary investigation in 1815 showed us, that in Eng- 
land, in the midst of medical knowledge, and of a 
population advanced in morals, intellect and benevo- 
lence, there existed in Asylums evils, appalling and 
revolting to humanity. And by this appointment, 
Government have set the example of placing these 
institutions, in a country uninfluenced by moral 
checks, Under the control of a class of persons, 
entirely unqualified for their management. It is no 
answer to the objection, that the personal character 
of the individual appointed will, in the particular 
hospital, prevent the abuse. The nature of the 
appointment shows, that., in the opinion of Govern- 
ment, insanity is not a curable disease : and with the 
sanction of such authority, must we not expect, that 



316 ON THE CONSTRUCTION OF ASYLUMS, &C. 

asylums, to be built there, will be considered rather 
as prisons for the safe custody of the insane, than as 
hospitals for their cure ? If this opinion be once 
generally held, is it reasonable to hope, that there 
will not occur, in future asylums in New South 
Wales, scenes rivalling*, in wretchedness and in- 
famy, those brought to light in 1815? If such be 
the case, verily Government will not be guiltless. 



CHAPTER IX. 

ONr THE DISTINCTION BETWEEN CONDUCT WHICH IS 
THE RESULT OF MORAL EVIL, AND THAT WHICH 
ARISES FROM INSANITY. 

Having endeavoured to show, that insanity is a 
disease of the brain, or nervous system, producing* 
or accompanied by some injurious alteration in the 
intellectual manifestations, or in the conduct, it will 
be necessary for us to consider the moral condition 
of man in his natural state, independently of any 
physical disease, in order that we may not mistake 
the consequence of moral evil for derangement, 
and refer to mental disorder acts which are really 
only the result of vicious propensities. 

Whatever be the origin of moral evil, its existence, 
both amongst the sane and the insane, is universally 
acknowledged. The mode in which it exhibits it- 
self, varies according to the natural character. 
Education and the forms of society will do much to 
prevent its displaying itself in a way so greatly in_ 
jurious as to make personal restraint necessary. 
Indeed with most, the immediate suffering produced 
by a certain measure of vicious indulgence imposes 



318 ON THE DISTINCTION BETWEEN CONDUCT 

a limit to the gratification of the natural propen- 
sities, Avhatever these may be : but where the passions 
are violent, and the habitual indulgence of them has 
been unchecked by education or religion, they gra- 
dually become more and more powerful ; and even 
where no physical disease exists, acts are committed 
so entirely opposite to the feelings of a good and 
virtuous man, that he is unable to account for them, 
and he attributes them from kind, but mistaken 
views, to insanity. But such acts differ essentially 
from those which arise from mental derangement : 
they are not the result of any morbid action in the 
brain, or nervous system, or of any diseased organi- 
zation there ; and they are entirely optional. The 
mere fact, that the temporary gratification of the 
particular passion is purchased at a most unwise ex- 
pense of subsequent pain, is no proof of the existence 
of insanity. To a holy man, who feels that he is 
constantly in the presence of a God, who " hateth 
iniquity," every wilful violation of his laws must, 
when calmly considered, be deemed contrary to 
right reason. But it would be perfectly absurd to 
characterize every sinful act as an act of madness. 
Mankind are too apt to make their own notions of 
morals the standard by which they measure the 
actions of othei's, and to consider, that any step 
much beyond the bounds, which they have marked 
out as the limit within which vice may be indulged 
in with comparative impunity, is to be attributed to 
insanity. It is, however, obvious, that a standard. 



ARISING TROM MORAL EVIL AND INSANITY. 319 

which would vary not only with individuals but with 
entire nations, furnishes no test that can be de- 
pended upon to disting-uish between moral evil and 
derangement. The error arises from the same 
source, which causes conduct merely eccentric to be 
considered the result of insanity. We are apt to 
refer all actions to the test of our individual con- 
sciousness ; and if we know, that, under similar cir- 
cumstances, the doing them would be so entirely 
contrary to our dispositions as to cause us positive 
pain, we cannot account for them on any reasonable 
principles, and therefore satisfy ourselves by the con- 
clusion, that the man must be mad. Indeed some, 
and with greater consistency, go so far as to say that 
they consider all men, more or less, mad : this, how- 
ever, is a mere verbal fallacy. The persons who so 
use the term, know that it is totally inapplicable to 
any practical purpose, and they admit the neces- 
sity of distinguishing between those '' mad acts," 
which deserve to be punished as vicious, and those 
for which they consider the state of mind of the indi- 
vidual a sufficient excuse. I cannot think that any 
act, however vicious or eccentric, ought to be con- 
sidered as the result of insanity, unless it is involun- 
tary, and arising from some disease in the brain or 
nervous system. In many of the insane, particular 
sets of feelings and propensities are excited into 
such undue action, that they exercise uncontrollable 
dominion over the conduct. This is the case some- 
times during the whole attack, and at others only 



320 ON THE DISTINCTION BETWEEN CONDUCT 

(luring- particular paroxysms : in either of these 
cases, the actions are entirely out of the control of 
the patients, and of course they are not morally 
responsible for them. They are frequently most 
opposite to the usual habits of the patient, and this is 
the natural consequence of the powerful excitement 
of one set of feelings, wliilst those which in a healthy 
state counteract and reg'ulate their action, are com- 
paratively dormant. But in many cases, those who 
are really insane on some subjects, are as capable of 
disting-uishing between right and wrong as the sane. 
I remember a patient, who was at work with a 
sharp instrument, telling me, in a fit of passion, that 
** if he killed me he knew he should not suffer for it, 
because he was mad." From my knowledge of the 
man's disposition, I had no fear of such a cata- 
strophe : but if violence be committed under such 
circumstances, is it consistent with common sense, 
that the man should be considered not a responsible 
being, because he happens to have some erroneous 
notions about property, and fancies that he is entitled 
to an estate which belongs to another ? Where the 
act is the result of the disease, the case is perfectly 
different. Martin, whose mind was morbidly im- 
pressed with the notion, that it was his duty to burn 
York Minster, was justly acquitted on the ground 
of his insanity. In many of the insane, there is 
a great combination of moral evil with cerebral 
disorder ; and it is exceedingly difficult to distinguish 
between that which is the result merely of vice and 



ARISING FROM MORAL EVIL AND INSANITY. 321 

perverseness, and that which is the consequence of 
disease. Where it is clear that an improper act 
arises solely from wickedness, the patient ought to 
be dealt with as a moral agent, and its recurrence 
should be prevented by making it understood that 
repetition will be attended with some positive incon- 
venience, or with the deprivation of some enjoy- 
ment. But we must remember, with the insane as 
well as with the sane, that although fear of punish- 
ment, moral discipline, and the experience of the 
present advantages of virtuous conduct will do much 
to check the actual indulgence in vicious propensi- 
ties, yet nothing but religion, and the operation of 
the Spirit of God upon the heart can eradicate the 
evil inclinations. 

The two following examples will make the distinc- 
tion, which I have endeavoured to draw between 
vicious and insane acts, perfectly intelligible. A 
young man, who had been respectably brought up, 
was engaged in the wine trade, a business which 
affords considerable temptation to intemperance : he 
unfortunately indulged in his potations to such an 
extent that he brought on a low degree of delirium 
tremens. Whilst under the influence of this disease 
he procured a pistol, as it subsequently appeared, 
without any evil design, but from mere folly; and 
he went to see a young woman with whom he was 
acquainted : he was refused admission into the house, 
and, acting under the excitement caused by the 
diseased action of the brain, he fired at the per&oti 

Y 



322 ON THE DISTINCTION BETWEEN CONDUCT 

who came to the door. Happily he missed her, and 
the ball was found in the door-post. He was tried 
for the offence, and although, after he recovered 
from the attack of delirium tremens, he never exhi- 
bited the slightest symptom of insanity, he was, and 
very properly, if the distinction previously pointed 
out be correct, acquitted on the ground of insanity. 
The act in this instance arose purely from the 
morbid irritability of the brain, produced by disease. 
If it had been the result of intoxication, according 
to the distinction pointed out in the second chapter, 
as the immediate cause of the act would then have 
been in his own power, he must have been dealt with 
as responsible for it. The delirium tremens was the 
immediate cause of the act ; but this was a perma- 
nent one, and not within his own control ; although 
it is quite true that this continuous cause might have 
been avoided, had the young man not been guilty 
of excess. On his acquittal he was ordered into 
confinement, where, I believe, he remains to this 
day. 

The other case is of a very different complexion. 
A man had a quarrel with his employer ; he thought 
himself much injured by him, and he had no means 
of redress. This man also procured a pistol, which he 
carefully kept about him for some days : he met the 
gentleman, fired at him, and wounded him, though 
not mortally. He was immediately taken into cus- 
tody, and subsequently tried. He exhibited much of 
the recklessness which is often seen to follow the 



ARISING FROM MORAL EVIL AND INSANITY. 323 

gratification of revenge, but, if the report of the 
trial be to be depended upon, no symptoms whatever 
of any diseased action of the brain. As this man was 
acquitted by the jury on the plea of insanity, I should 
hope that some circumstances were disclosed at the 
trial, with which I am unacquainted, to lead them 
to that verdict. But if no material facts appeared, 
sufficient to evidence the existence of diseased ac- 
tion in the brain, the conduct in this instance must, 
according to my notions, be traced to moral evil, and 
not to insanity. Is it uncharitable to think, that 
under the circumstances, the jury might have been 
led to the conclusion they came to, from the con- 
sciousness that the ground of offence, even if true 
to the uttermost, could not have so worked upon 
their minds as to have led to so sanguinary a result ; 
and that they consequently conceived, that any man, 
who permitted so trifling a cause to lead to so out- 
rageous an act, must have been insane ? The fallacy 
of such a mode of reasoning has already been pointed 
out. 



Y 2 



CHAPTER X. 



CONCLUSION. 



From what has been already said on the subject, 
it appears that Insanity may be traced to three 
classes of causes,— viz. direct physical injuries of the 
brain, over-excitement from moral causes, and dis- 
eased action in it from sympathy with some other 
part of the body. It becomes a matter of very seri- 
ous inquiry to ascertain how far the circumstances 
which produce it, are either directly or remotely 
under our control. The instinctive dread of pain 
possessed by man, in common with other animals, is 
a sufficient guarantee for his using the greatest care 
to avoid the accidents which are likely to expose 
him to an attack of insanity from the first set of 
causes. The only means by which his liability to 
suffer from these could be diminished, would be by 
giving him more information as to the effects likely 
to be produced on the system by particular circiun- 
stances, in order to induce a greater caution on his 
part not to place himself where he is likely to be 
exposed to their injurious operation. Thus, in the 



CONCLUSION. 325 

case previously referred to, if the man who ran 
without his hat, exposed to a burning sun, had 
known enough of the structure of his body to have 
been aware that he was incurring great risk of an 
attack of phrenitis or of insanity, he would have 
preferred the lesser inconvenience of being too 
late for the coach, and would have preserved his 
reason. Something also might be done habitually 
to strengthen that faculty which is usually called 
presence of mind. Many of the accidents which 
destroy life, or injure the limbs, might be avoided 
by coolness ; and this is, to a very great degree, to 
be acquired by education. What makes the differ- 
ence in this respect between the sailor and the man- 
milliner? The fact, that the latter is not called 
upon to rely upon his own exertions in cases of 
sudden danger; whilst the former, from being obliged 
from early life constantly to exercise his coolness 
in cases of emergency, acquires such a habit of self- 
possession and confidence in his own powers, that 
he can actually pass through perils with compara- 
tively little risk to himself, which would overwhelm 
the other. But the cases of insanity arising from 
direct physical injuries are comparatively few, and 
but little can be done to avoid their occurrence : 
those which have their origin from moral causes are 
by far more numerous, and fortunately much more 
capable of being avoided : they are generally the 
result of our having an undue estimate of the 
things of this life. 



326 CONCLUSION. 

Let us, by way of illustration, briefly trace the 
progress of the operation on the mind, of a sudden 
reverse of fortune, one of the most usual of the 
moral causes of insanity. We will suppose that this 
has overtaken a man from circumstances entirely 
out of his power, although if it be inquired into, it 
will be found, that it frequently arises from the 
neglect of that commandment, which bids us not to 
make haste to be rich. Now if the mind be well 
disciplined, the wealth, which is no longer possessed, 
has not been an object of inordinate affection ; it 
has been habitually viewed as a talent, for the right 
use of which a great responsibility is incurred : and 
the mere loss of it creates no excessive uneasiness ; 
and even if its absence affects the personal comfort 
of those who are the dearest, this is submitted to 
with a full reliance, that it is ordered by a wise and 
merciful Providence, whose dealings with all his 
creatures are exactly such as are the most conducive 
to their real welfare. Under these circumstances, 
there would not be such an anxiety as to prevent 
sleep, and produce an excessive sanguineous action 
in the brain, to terminate in insanity. The mind 
would be kept in peace. But let us suppose, that 
such a reverse has happened to one who has looked 
upon riches, and the pleasures to be procured by 
them, as the chief good -, and whose life and powers, 
mental and bodily, have been constantly absorbed 
in their acquisition. To such an individual, — and 
unfortunately there are very many with whom this is 



CONCLUSION. 327 

the case, — the mere probability of the loss of that 
which he holds the dearest, produces a restlessness 
and anxiety, which weaken the nervous system, and 
incapacitate it from bearing up against the shock 
which he feels, when that which he most valued is 
suddenly torn out of his grasp. It cannot be a 
matter of surprise, that the mind not knowing where 
to look for consolation, should be overwhelmed, 
and that insanity should be the result. And we 
may, in a similar manner, trace to an over-estimate 
of the things of this life, insanity arising from loss 
of children, disappointed ambition, — in fact from any 
other moral cause. But this, painful as it is, is the 
result of the previous habits and conduct. With a 
view of making the nature of the evil more intelli- 
gible, it will be worth while to prosecute the inquiry 
a little further, and to endeavour to trace these 
habits to their origin. We shall find, that from 
infancy to manhood, the usual process of education 
is to foster that erroneous estimate of temporal 
things which is the general source of insanity from 
moral causes, and to weaken and predispose the 
body for its reception ; unfortunately the same sys- 
tem prevails with both sexes. In infancy, in the 
higher ranks of life, the child is in a great measure 
left to the tuition of ignorant nurse-maids ; and in 
many cases, with the first dawn of reason, it imbibes 
false and superstitious impressions, which are a 
source of torment to it for years ; and when the 
child is more immediately under the presence and 



328 CONCLUSION. 

management of its parents, the first lesson that is 
impressed upon its mind, is that the gratification of 
the senses is the chief good. And this too is not 
taught in the dull, uninteresting, formal manner, in 
which at a much later period, and after this prin- 
ciple has been well ingrafted, valuable truths are 
attempted to be imparted. This is instilled by 
practice and example. In females, the next prin- 
ciple which is systematically brought into exercise, 
is vanity. As soon as the child can speak, and is 
capable of understanding any thing, it is taught to 
set a high value upon its dress : the attention is 
directed to it, and from early infancy, it engrosses a 
considerable portion of its time and thought. After 
the principles of love of animal gratification, and in 
females the love of approbation, have been carefully 
fostered, the next step is to provide some education 
for the intellect. The two classes of motives which 
are acted upon, are fear and emulation. The 
natural result of the former, with many, is to pro- 
duce excess of timidity, dissimulation, and the 
other vices attendant upon an undue exercise of 
the organs of caution and secretiveness ; and the 
inevitable consequences of the latter are, to foster 
selfishness. The reward of success is a personal 
gratification, exactly in proportion to the superiority 
over others. The result is an over-value of the 
praise and good opinion of others : this is one of 
the most prolific sources of suffering which the 
human mind can possibly feel ; and it is also one of 



CONCLUSION. 329 

the greatest preventives to a man's daring inde- 
pendently to do that which his conscience teaches 
him to be right. Hence also results an excessive 
activity in a set of feelings which, when over- 
excited in after life, frequently terminate in insanity. 
So far then as the training affects the sentiment, it is 
from infancy prejudicial : it tends to foster the natural 
desire for the gratification of appetite, to induce 
inordinate ambition, and to create an over-esti- 
mate of wealth, and of the things of time and sense ; 
and in all these points it directly leads to insanity. 
It is also physically injurious, from causing at too 
early a period, excess of vascular action in the brain. 
The intellect is, by fear of disgrace, and hope of 
praise, stimulated to an unhealthy activity. The 
brain and nervous system absorb the blood, which 
ought in youth to be directed to the supply of proper 
muscular volume and energy. Females suffer in 
this respect more than males ; in fact, the entire 
want of proper exercise, and the excessive stimulus 
given to the mental faculties so affect the frame, 
that there is hardly a female, educated in the board- 
ing-schools conducted on the usual principles, whose 
spine is not more or less distorted. It is foreign 
to the object of the present work to inquire, 
whether this enormous expenditure of constitution, 
for the sake of intellect, is most judiciously laid out 
in securing the most valuable mental attainments. 
It is perfectly obvious, that even if it be, a system 
of education, which entirely neglects, as one of its 



330 CONCLUSION. 

primary objects, the imbuing the mind with right 
motives, and with a due estimate of the real value 
of the things of this life, leaves it exposed to such 
excessive anxiety, on any reverse or disappointment, 
as tends to insanity. How little too is the real wel- 
fare usually considered in the selection of a walk in 
life! A combination of circumstances affording a 
probability of the acquisition of wealth, is usually the 
only guide ; and, with both sexes, marriages are 
entered into or avoided on the same principle. — But 
the tracing the influence of education and the habits 
of society, in producing insanity, would form an 
ample subject for another volume. The evil would 
be prevented by a simple obedience to the pre- 
cepts of the Gospel. 

In many cases, insanity arising from sympathy is 
entirely brought on by bad management of the con- 
stitution : independently of those instances where 
it is the result of obvious excess, it frequently arises 
from a very slight moral cause, acting upon a highly 
irritable nervous system, habitually too much ex- 
cited by the use of stimulus. Indeed, as has been 
previously observed, the constant use of any stimu- 
lus ought, if possible, to be avoided by those who 
have a predisposition to the disease. In fact any 
circumstances, which tend to put the body out of 
order, ought to be guarded against ; and much of 
insanity might be avoided, if a practical knowledge 
of the human frame, and of the influence of external 
circumstances upon it, were made a branch of educa- 



CONCLUSION. 331 

tion, both amongst males and females. Indeed I am 
convinced, that with very few exceptions, a right and 
religious disciplining of the mind, with a judicious 
and careful selection of the walk in life, and a pru- 
dent management of the body, would exempt man- 
kind from the horrors of this painful and mysterious 
disease. 



APPENDIX. 



APPENDIX. 



NOTE.— Page 97. 



Masturbation, the cause alluded to, is a fertile source of 
insanity. I have no hesitation in saying, that in a very large 
number of patients in all public asylums, the disease may be 
attributed to that cause. The general debility, which is pro- 
duced by this disgusting habit, is more severely felt in the brain 
and nervous system in some constitutions than in others ; and 
whilst a pale face, general lassitude, drowsiness, cold extremities, 
trembling hands, and a voracious appetite, are the indications of 
its existence in one, the brain is the first part to give way in 
another, and insanity takes place. We must not, however, omit 
to mention that the practice is often the consequence, as well as 
the cause of the disease. I have no doubt, that when from any 
circumstance the cerebellum becomes in a high state of excite- 
ment, venereal desires are the result, and this practice is too 
often resorted to. 

NOTE.— Page 133. 

When in incipient insanity, or in particular exacerbations in 
chronic cases, an excess of libidinous feeling is exhibited, this is 
almost the only premonitory symptom. The cerebellum is the 
part where the greatest heat is to be found. Indeed, whilst the 
other part of the scalp remains of its jiatural temperature, this is 
often found excessively hot, and, perceptibly to the touch, of a 
greater heat than the parts of the body under the clothes. 



336 APPENDIX. 

We have a case in the Asyhim at the present time of a young 
man, about twenty-eight years of age, who has been insane seve- 
ral years. He is naturally very libidinous, but exacerbation of 
these feelings comes on periodically. He is generally occupied as 
a shoemaker, and is industrious. The first premonitory symptom 
is a degree of restlessness and unwillingness to work. This is 
followed by his endeavouring to expose his person, and take 
improper liberties with any of the female servants who may have 
occasion to pass through the ward. 

On his head being carefully examined the other day by my 
colleague. Dr. Button, and myself, in going through the ward, 
the whole of the back part of it and the neck were found to be 
considerably hotter than any other part, not only of the head, 
but even of the chest under his clothes. 

Shaving the head, cupping, and cold applications, with small 
doses of nitre and of tartar emetic, materially tend to abate the 
paroxysm ; and I have no doubt that, in a few days, he will be 
in his ordinary state of health. 



NOTE.—Page 136. 

Cases of insanity arising from masturbation are most easily 
distinguishable from the appearance of the countenance, to those 
thoroughly conversant with the disease ; yet any attempt to 
describe the particular symptoms would be more likely to mis- 
lead than to be of any practical utility. It is probable that, in 
these cases, the cerebrum is weakened from the due supply of 
blood being withdrawn from it, and forced into other parts of 
the body ; and probably, also, from the cerebellum engrossing 
more tlian its share. 



NOTE.—Page 145. 

By far the most frequent cause of fatuity is debility of the 
brain and nervous systf^m, from the cerebrum not receiving a 



APPENDIX. 337 

due proportion of blood for the carrying on its functions, in 
consequence of the pernicious habit of masturbation. In the 
natural and healthy condition of man, every thing is so well 
ordered, that each part receives the due share of blood requisite 
for its nutrition, and for the performance of its regular and 
appointed functions. But man has, to a considerable extent, 
the power of increasing the rapidity of the circulation, either 
generally throughout the system, as by fermented liquors, or 
partially through particular portions of it, as by the excessive 
exertion of the part. 

Where the circulation is only accelerated through certain por- 
tions of the body, the mass of blood not being increased, the 
other parts are robbed of their due share, and their functions 
are consequently weakened and disturbed. But as over-exercise 
does not generally afford gratification, this excessive voluntary 
circulation through, particular parts of the body rarely takes 
place, except in the brain, where it produces insanity and the 
results already described, and in the parts which are affected 
by venery and masturbation. 

It is the latter practice which is most to be dreaded and depre- 
cated ; and however revolting to the feelings it may be to enter 
upon such a subject, it cannot be passed over in silence without a 
great violation of duty. Unhappily, it has not hitherto been 
exhibited in the awful light in which it deserves to be shown. 
A great deal has been said on dementia by previous writers on 
insanity ; but this, the true cause of its origin in by far the 
greater number of cases, has not been mentioned. It is often 
begun in very early youth : I have had under my care a child 
almost in a state of fatuity from this cause, at ten years of age, 
but who subsequently recovered ; and I have recently been 
informed, on authority, the accuracy of which I cannot doubt, 
of similar effects being produced from the same cause in a child 
not more than eight years old. In the present artificial state of 
society, where marriages are too frequently prevented only from 
the want of what are considered sufficient pecuniary means, and 
where scenes of dissipation are prevalent, and a highly stimu- 



338 



APPENDIX. 



lating and exciting mode of living is adopted, this vice, as it 
might be expected, is unfortunately continued in after life. 

Independent of this dreadful disease, of which it is alone 
frequently the cause, there are many others which may fairly 
be attributed to this practice ; they do not, however, fall within 
the province of this work. If the dread of falling a martyr to this 
worst form in which it ends should deter from the practice, all 
the rest will be escaped. 

The worst of it is, it is seldom suspected. There are many pale 
faces and languid and nervous feelings attributed to other causes, 
when all the mischief lies here ; and, when it is suspected, it is so 
delicate and painful a subject that it can scarcely be hinted at 
without a blush. It should not, however, be forgotten, that a 
great deal of misery in life, and insanity and premature death, is 
often the consequence ; and it therefore demands some sacrifice of 
feeling, especially from those who have the charge of youth : they 
ought to be warned, indirectly at least, of the consequences. It is 
seldom, in these cases, that any one faculty is observed to be more 
weakened than the rest ; there is no particular chord that on being 
touched denotes disorder, but a general languor and inability for 
either mental or bodily exertion. The exhaustion often occasions 
a great desire for food, and a large quantity is often taken, though 
there is no corresponding healthy appearance from it ; it is also 
attended with much drowsiness and irritability if roused, till death 
puts an end to the scene. Whenever I hear of these symptoms 
coming on, without any known hereditary or moral cause, I begin 
to suspect that something is wrong here. It is practised, too, by 
those who little think of its fatal results ; by persons otherwise 
most exemplary, and considered so highly moral, that any cause is 
looked for, as the occasion of the symptoms observed, rather than 
the real one. I have frequently been fortunate enough to detect 
it in time ; and, upon mentioning my suspicions, have had them 
confirmed by the parties, who themselves little suspected the 
cause. Some time ago I was consulted, by letter, on a case of 
this kind, of a young gentleman residing in Cambridge ; I com- 
municated my suspicion to his friend, who at once told him my 



APPENDIX. 339 

opinion : he acknowledged the truth of it, left off the practice, and 
in a month afterwards I had the satisfaction of hearing he was 
quite well. I wish I could add, that young gentlemen were the 
only transgressors. I hope I have said enough on this delicate 
and painful subject to excite that attention and alarm which its 
importance demands. 

The lassitude and general weakness of the brain from this cause 
gradually increase, the patient becomes fatuous, and dies. 

NOTE.—Page 244. 

It has been already stated, that the cases here referred to are 
much more numerous than it is generally supposed. Before the 
patients are taken to a Lunatic Asylum the disease has usually 
proceeded to a direful extent ; the first stage has passed away, 
and it has become one of such pure debility that invigorating 
means only are left to us. But it is lamentable to state how little 
hope there is of stopping its progress : the functions of the mind 
have usually become so torpid that all moral reasoning has lost its 
effect ; and, unless the practice is discontinued, no medical means 
can produce the least alleviation of the symptoms, and I have been 
unable to discover any mode of confinement which will effectually 
prevent it. When in Paris, I accidentally met a French surgeon, 
Monsieur A. Gerentet, who then resided in the Palais Royal, 
No. 36 : he informed me that he had discovered an effectual me- 
chanical preventive, and he promised to come to Hanwell and 
bring some of his fasteners with him. He has not yet fulfilled his 
promise. I have recently been informed that he has been in 
London, and that his contrivance is valuable : when I saw him he 
had not one made, and I understand from him, that, in order to 
be of any use, they must be fitted for the particular person 
intended to wear them. If the patient is alive to the deplorable 
consequences already caused by the practice, and to those still 
worse, which are to follow from its' continuance, so as to be 
induced to abstain from it, he may generally be restored. To 
assist his good resolution he ought, on going to bed every night, 



340 APPENDIX. 

to have his hands secured. He should sleep upon a hard mattress, 
without curtains, and the room should be particularly airy. Cold 
ablutions about the genitals and loins should be constantly ap- 
plied, and he should take exercise in the open air ; the diet should 
be nutritious, and the bowels should be kept moderately open by 
cooling aperients : but the Tincture of Cantharides is the most 
efficacious means of cure. I have long been in the habit of 
giving this medicine in doses of from twenty to thirty drops three 
times a day, increasing or diminishing them according to their 
effect. These patients usually exhibit great symptoms of debility, 
depressed spirits, a pale, languid countenance, a weak, quick pulse, 
cold clammy perspiration on the skin, and particularly on the 
hands ; great drowsiness, and often a voracious appetite. After 
the cantharides have been continued some time, provided the 
previous habit is actually left off, the cerebrum and other parts of 
the body are again supplied with their due share of blood, the 
general health and spirits begin to rally ; and, with them, the 
functions of the mind resume their accustomed power. 



mitt Calil^* 

Bread. — 14 oz. daily for each patient. 

Breakfast. 
1 J pint of rice, or oatmeal gruel, as is deemed most conducive 
to health. This is made in the following manner : — 2 gallons of 
milk, 2 gallons of water, 2| pounds of oatmeal or rice, and a 
J pound of wheat-flower, are boiled together one hour. 

Dinner. 
Sunday. — Roast beef; 6 oz. uncooked meat, free from bone; 
4 oz. yeast dumpling, with the addition of 6 oz. vegetables. 
Sometimes potatoes are substituted for the dumplings. 



APPENDIX. 341 

Tuesday. — Same as on Sunday, except that boiled mutton is sub- 
stituted for the beef. 

Thursday. — Boiled pork instead of beef. 

Saturday. — 14 oz. pie, made of the coarse beef, with potatoes. 

Soup, made from the meat boiled the day before, with the bones 
stewed, thickened with barley, rice, peas, and vegetables, and 
flavoured with onions, pot-herbs, and cayenne pepper, forms their 
dinners on the other days of the week. 

Supper. 
Same as breakfast. 

As the season affords, the patients are sometimes indulged with 
fruit pies : and every Christmas they participate in the usual fes- 
tivity of roast beef and plum-pudding. 

Beer. — One half-pint is the daily allowance at dinner for the 
industrious and infirm. The healthy, who do not work, are 
not allowed malt liquor. Those who labour out of doors, or 
are really efficient in the wards, also receive one-third of a 
pint of beer at eleven in the morning, and the same quantity 
at four in the afternoon. 

Many of the patients, who are engaged in the domestic offices, 
receive indulgences ; and several, who assist the servants, sit up 
and partake with them of supper. Various extras for the sick are 
also allowed : but their rations are not stopped, and, as they are 
frequently unable to participate in them, it necessarily increases 
the allowance for the actual consumers. In fact, this is sufficient, 
but I do not think, superfluous. 



342 APPENDIX. 

RULES AND REGULATIONS 

FOR THE MALE AND FEMALE KEEPERS AND SERVANTS. 



To be Printed, and hung up in each Keeper's and Servant's Room. 



First. — Every patient on admission is to be stripped and 
washed, and it is to be carefully observed if there be any swelling 
in any part of the body, vermin, or spots on the skin ; the hair is 
to be cut close and combed, and the patient is then to be clothed 
in the asylum dress. 

Second. — Every keeper and servant is expected to rise at six 
o'clock ; the keepers will then immediately wash and comb their 
patients, and observe if there be any soreness or discoloration of 
the skin in any part of the body. They are expected also to 
examine the stools and urine of the patients, so as to be able to 
report their state, and every other particular concerning them. 
On any patient appearing ill, information is immediately to be 
taken of it to the apothecary's shop. They must also pay the 
strictest attention to the administering of the medicines, &c. 
agreeably to the directions. 

Third. — -When the bell rings for prayers, they will attend with 
such patients as are in a proper state. At eight o'clock the 
patients will breakfast ; as soon as breakfast is over, the keepers 
will clean out the galleries and bed-rooms, lay the beds and bed- 
ding to air, and remove the wet straw and every kind of dirt or 
dirty linen, and, in fine weather, open the windows. It must be 
understood, that no place will be considered clean which can 
be made cleaner. 

Fourth. — The patients will dine at one o'clock, and sup at 
seven. They will go to bed as soon as supper is over, and no 
clothing is to be allowed to remain in the room. One hour before 
every meal, the keepers will take down their trays and tins to the 
kitchens, and at the same time take from the apothecary's shop 
the medicines ordered for their patients ; and when the bell rings 



APPENDIX. 343 

(but not before) the keepers, with a patient to assist them, will go 
to their respective kitchens for the provisions. After each meal, 
the dishes, trenchers, kits, &c. are to be carefully washed, and 
every knife, fork, and spoon is to be counted, and locked up. 
The male keepers will shave their patients on Wednesdays and 
Saturdays. 

Fifth. — The keepers will not be permitted to leave their ward 
except at the time appointed above, unless some very urgent busi- 
ness demand it, when he or she will inform the keeper in the next 
ward of the cause of their absence ; but they must, at no time 
whatever, leave their wards without having first locked up in their 
rooms, any patients who are liable to be violent, or strike another, 
excepting such patient is properly secured. Any male keeper 
wanting any thing from the housekeeper or kitchen, must apply 
in the office. No patient to be allowed either to deliver out the 
meat, beer, bread, or pottage, to the patients. No patient to be 
permitted to leave the wards in the morning, before breakfast, to 
assist the house-servants, without the servants personally fetch- 
ing them. No patient to be allowed to fetch either medicine, 
wine, or beer, from the apothecary's shop. 

Sixth. — The keepers are to be accountable for all bed and other 
linen, the patients' clothing, and the various articles belonging to 
the wards. 

Seventh. — Any keeper striking or ill-treating a patient will, 
for the first offence, be fined five shillings, and be dismissed for 
the second ; nor are the keepers to use any harsh or intemperate 
language, which tends to irritate or disturb them, as their duty is 
uniformly to be discharged in a mild, humane manner. They are 
at all times to appear clean and tidy in their persons, and strictly 
decorous in their behaviour. 

Eighth. — Any keeper found making a perquisite of any kind, 
or selling any thing to a patient, will be fined five shillings for the 
first offence, and dismissed for the second. Any servant, from 
whose custody a patient escapes, through negligence, shall pay 
such proportion of the expense of retaking the patient, as the 
magistrates at their next meeting shall order. 



344 APPENDIX. 

Ninth. — On Saturday, at eight o'clock in the morning, every 
keeper is expected to deliver a list, in writing, of the household 
utensils wanted in his or her ward for the following week, which 
will be delivered on the Monday morning. If at any time a knife, 
instrument, or tool, such as a brush, fire-irons, &c. shall be left 
unlocked up after using, or the door of the fire-guards left 
unlocked, each keeper shall forfeit a shilling. Any keeper leaving 
his or her ward or airing court, without giving notice to the 
keeper in the next ward, where he or she is gone, shall forfeit 
one shilling ; and any keeper permitting a patient to get up, and 
go about the ward or house, before he or she is up to take charge 
of, or deliver the patient to the care of others, shall forfeit one 
shilling. 

Tenth. — No person or relative, calling to see any keeper or 
servant, will be allowed to go into the kitchen or wards, but must 
remain in the receiving room appropriated for the males, on the 
east, and females on the west sides of the house. Each and every 
keeper, and out-door servant, to attend at prayers every evening, 
in the chapel, at half-past nine o'clock precisely, or forfeit six- 
pence each, for each default. It is expected that every keeper or 
nurse will examine the water taps in their wards, immediately 
after putting the patients to bed, so that no water be wasted, or 
forfeit five shillings. 



THE END. 



R. CLAY, PRINTER, BREAD-STREET-HILL.