A treatise on the nature, symptoms, causes, and treatment of insanity

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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.