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