Medical Inquiries and Observations Upon the Diseases of the Mind
Benjamin Rush
"The father of modern psychiatry"
1812 AD

In 1812 AD, Benjamin Rush, a doctor known as the "father of modern psychiatry", believed that madness was caused by blood vessels in the brain and cured it by threatening to kill the insane if they did not cure themselves! Rush suffers from "scholastic schizophrenia" because he devotes an entire section to, "The causes which induce intellectual derangement, by acting upon the body through the medium of the mind". From an etiological viewpoint, it is clear that Rush believed that the human spirit through emotion, feelings and guilt for sin actually "induced" insanity. So in one breath he says insanity is caused by blood vessels and in the other the human spirit. The only way to cure Rush of his "scholastic schizophrenia" is to suggest that the human spirit affected the blood vessels in the brain, which then caused madness. Of course his medical views were quackery because blood vessels in the brain have nothing to do with insanity. So lets take a closer look at the hero and founder of chemical psychiatry that today believes insanity is caused by mythical chemical imbalances of the brain that are as much quackery as Rush's idea that blood vessels cause madness! Rush believed that voluntary sins like murder, theft, lying and drunkenness, progressed into a disease where the person committed these sins involuntarily the same way a spasm affects a muscle. He concluded that these kinds of sins, became involuntary, they became a disease which needed a medical doctor to treat. Rush therefore believed that insanity was outside a person's will and that they are "not cognizable by law". This is the earliest forms of the insanity laws we see today, where everyday sins are called "diseases of the will". [insanity] acts without a motive, by a kind of involuntary power. Exactly the same thing takes place in this disease of the will, that occurs when the arm or foot is moved convulsively without an act of the will, and even in spite of it ... I have called it MORAL DERANGEMENT. I have selected those two symptoms of this disease (for they are not vices) from its other morbid effects, in order to rescue persons affected with them from the arm of the law, and to render them the subjects of the kind and lenient hand of medicine. But there are several other ways, in which this disease in the will discovers itself, that are not cognizable by law. I shall describe but two of them. These are, LYING and DRINKING. Because the insane were not acting on free will, Rush set up "Sober House", (for drunks) where they could be "held against their will". Incredibly, he reasoned: "Let it not be said, that confining such persons in a hospital would be an infringement upon personal liberty, incompatible with the freedom of our governments." He was fully aware that many viewed insanity as a spiritual problem that affects the body: "I know it has been said in favour of madness being an ideal disease, or being seated primarily in the mind". But he considered all the medical views of madness and rejected them all: "liver, spleen, intestines, nerves, Madness has been placed exclusively in the mind" in favor of, "the cause of madness is seated primarily in the blood-vessels of the brain". From autopsies, he noted that mad people had brains that were "hardness and dryness ... softness ... enlargement or reduction of the skull bone thickness." This echoes the views of Giovanni Morgagni, who in 1761 AD concluded from autopsies, that madness caused "considerable hardness in the brain" Amazing what you can conclude by poking your finger in the brain of dead madmen! Rush notes specific spiritual causes of madness induced by the human spirit: "Intense study", "frequent and rapid transition of the mind from one subject to another", "constant exercises of the imagination in poets", memorization: "undue labour in committing his [clergyman] sermons to memory", "Extravagant joy produced madness", " Charles the Sixth, of France, was deranged from a paroxysm of anger", " Terror has often induced madness in persons who have escaped from fire, earthquakes and shipwreck", " Fear often produced madness", " Distress often produced this disease", " Public humiliation: "A player destroyed himself in Philadelphia, in the year 1803, soon after being hissed off the stage", " Homesickness: "Swiss soldiers sometimes languish and die from that form of madness which is brought on by absence from their native country", " Africans become insane, ... soon after they enter upon the toils of perpetual slavery in the West Indies", " Hundreds have become insane in consequence of unexpected losses of money", " clergyman in Maryland became insane in consequence of having permitted some typographical errors to escape in a sermon which he published upon the death of general Washington", "Several instances of madness, induced by the cruel or unjust conduct of schoolmasters and guardians", "persons who destroyed themselves immediately after drawing high prizes in a lottery", " A conscience burdened with guilt, whether real or imaginary, is a frequent cause of madness", " Intellectual derangement is more common from mental than corporeal causes. Of 113 patients in the Bicetre Hospital in France, at one time, Mr. Pinel tells us 34 were from domestic misfortunes, 24 from disappointments in love, 30 from the distressing events of the French Revolution, and 25 from what he calls fanaticism. Of course all the above proves that Rush was very aware that the choices of the human spirit, guilt, sin and circumstances were the real etiology of madness. He then makes observation as to who is predisposed to insanity: "A predisposition to madness is said to be connected with dark coloured hair", " Women ... are more predisposed to madness than men", " Certain occupations predispose to madness more than others. Pinel says, poets, painters, sculptors and musicians, are most subject to it", " mechanics to be more affected with madness than merchants and members of the learned professions.", " Certain climates predispose to madness. - It is very uncommon in such as are uniformly warm", And last but not least, "Different religions, and different tenets of the same religion, are more or less calculated to induce a predisposition to madness. ... There are certain tenets held by several protestant sects of Christians which predispose the mind to derangement". In a section called, "Remedies of Mania" he spells out his cures and controls for the insane including his famous tranquillzer chair that calmed down the madman and relieved the stress on the blood vessels in his brain: "Confinement by means of a strait waistcoat, or of a chair, which I have called a tranquillzer." The Tranquilizer Chair forced the person to calm down by restricting movement. It indeed worked by bring the unruly into submission the same way Cesar Millan, the Dog Whisperer, pins a violent pit bull to the ground on its side until it surrenders. Rush further suggested: "Privation of their customary pleasant food [no pizza and cigarettes]", "Pouring cold water under the coat sleeves, so that it may descend into the arm pits, and down the trunk of the body. [probably more effective on women who make you roll the windows up on your car and turn the heat up, than men...]" "Low DIET, consisting wholly of vegetables, and those of the least nutritious nature." "Salivation induced by mercury with calomel (teething powder) was seen as a "cure of hypochondriac derangement". "We come next to mention the remedies that are proper to act upon the body through the medium of the mind: absurdity, folly, cruelty ... music ... terror ... fear, accompanied with pain, and a sense of shame"

"In Rush's day, psychiatry was a newborn infant. Many madhouse keepers were clergymen, not physicians. Madness, as the term still implies, was associated with anger, lack of self-control, and suicide ("self-murder") -in short, with behaviors then regarded as sinful. In 1774, when Rush was only twenty-eight years old, he revealingly declared, "Perhaps hereafter it may be as much the business of a physician as it is now of a divine to reclaim mankind from vice." To distinguish himself from the doctor of divinity, the doctor of medicine could not simply claim that he was protecting people from sin or, as Rush put it, from vice. After all, vice is a moral concept. As a medical scientist, the physician had to reframe badness as madness, and represent madness as a bona fide medical malady. He had to demonstrate, by his language and actions, that his object of study was not the immaterial soul, but a material object, a bodily disease." (Coercion as Cure, Thomas Szasz, 2007 AD, p 71)

"Long ago men tried to shock the insane back into sanity by throwing them into a snake pit- a drastic treatment which by its sudden terror was sometimes successful. Modern methods, though superficially more civilized, often rely on the same brutal shock to achieve their results." (The Snake Pit, Mary Jane Ward, 1947 AD, Dust Jacket)

In a spectacular grand finale of cures from the Father of modern psychiatry himself, when all else fails threaten to murder the insane! On page 181 Rush gives this account: "If all these modes of punishment should fail of their intended effects, it will be proper to resort to the fear of death. Mr. Higgins proved the efficacy of this fear, in completely subduing a certain Sarah T , whose profane and indecent conversation and loud vociferations, offended and disturbed the whole hospital. He had attempted in vain by light punishments and threats, to put a stop to them. At length he went to her cell, from whence he conducted her, cursing and swearing as usual, to a large bathing tub, in which he placed her. "Now, (said he) prepare for death. I will give you time enough to say your prayers, after which I intend to drown you, by plunging your head under this water." She immediately uttered a prayer, such as became a dying person. Upon discovering this sign of penitence, Mr. Higgins obtained from her a promise of amendment. From that time no profane or indecent language, nor noises of any kind, were heard in her cell." It is clear that Rush, followed the practice of the day to torture the insane into submission as was currently in practice at Bedlam, for he says, "By the proper application of these mild and terrifying modes of punishment, chains will seldom, and the whip never, be required to govern mad people. I except only from the use of the latter, those cases in which a sudden and unprovoked assault of their physicians or keepers may render a stroke or two of a whip, or of the hand, a necessary measure of self-defense." So although Rush believed madness was caused by brain vessels, we today, know he was wrong. His observations about how the human spirit can induce madness though emotion and his corporal methods of controlling and curing the insane are good and valid. Clearly these effective treatments would never be used today for a long list of obvious reasons, but the fact remains that they did work! Modern chemical psychiatry believes insanity is cause by a chemical imbalance but cannot account for how such "moral treatments" cured the insane. These "moral cures" prove it is not a bodily disease but a spiritual choice of freewill moral agents. So this is the "hero of modern psychiatry" with his Tranquillizer Chair and threats of murder and bloated brain blood vessels! (Medical Inquiries and Observations Upon the Diseases of the Mind, Benjamin Rush 1812 AD)

"The most celebrated eighteenth-century teacher of these speculations was Heimann Boerhaave (166N-1738), the son of a Dutch clergyman. His name as such that a letter—it is related—was sent to "Dr. Boerhaave, Europe," and was delivered to him in Leiden. Boerhaave himself, however, did not make any lasting contributions to medicine, but his teaching influenced dozens of prominent physicians. Although he attempted to maintain a rather eclectic point of view, Boerhaave was partial to Hippocratic doctrines and methods. Like Hippocrates, he instructed his students to observe and learn from their patients at the bedside, but his emphasis upon the Hippocratic doctrine of the four humors was a decisively retrogressive step in the history of psychiatric theory. To this most renowned teacher of the day, melancholia was nothing but a disease caused by black juices; and his students Girard Van Swieten (1700-1772), and Anton de Haen ( 1704-1776), who founded the medical school at Vienna, and William Cullen (1712-1790) and John Pringle (1707-17821, who helped found the schools of medicine at Glasgow and Edinburgh, spread this doctrine throughout Europe. To Boerhaave psychotherapy consisted of bloodletting and purgatives. dousing the patient in ice-cold water, or using some other method to put hint in near-shock. Boerhaave gave the medical profession one of its first shock instruments, a spinning chair that rendered the patient unconscious. His gyrating chair was used by Charles Darwin's grandfather, Erasmus Darwin (1731-1802), a physician who believed that all diseases arose out of "disordered motions" of the nervous tissues of the body and that the rotating chair would correct the disharmony. Benjamin Rush (1745- 1813), the founder of American psychiatry, was a firm advocate of the gyrating chair, since he believed that congested blood in the brain produced mental illness and that this condition would be relieved by rotary movement." (The History of Psychiatry, Franz Alexander, Sheldon Selesnick, 1966 AD, p 109)

Dr. Burton recommends, in the highest terms, the reading of the BIBLE to hypochondriac patients. He compares it to an apothecary's shop, in which is contained remedies for every disease of the body. I have frequently observed the languor and depression of mind which occur in the evening of life, to be much relieved by the variety of incidents, and the sublime and comfortable passages, that are contained in that only true history of the origin, nature, duties and future destiny of man. A captain Woodward, of Boston, who lately suffered all the hardships of shipwreck on an inhospitable island in the East Indies, found great comfort in revolving the history of Joseph and his brethren in his mind. A captain Inglefield revived his spirits, and those of his crew, in a similar situation, by telling them pleasant stories. (Medical Inquiries and Observations Upon the Diseases of the Mind, Benjamin Rush 1812 AD, p122)

CHAPTER 1

In entering upon the subject of the following Inquiries and Observations, I feel as if I were about to tread upon consecrated ground. I am aware of its difficulty and importance, and I thus humbly implore that Being, whose government extends to the thoughts of all his creatures, so to direct mine, in this arduous undertaking, that nothing hurtful to my fellow citizens may fall from my pen, and that this work may be the means of lessening a portion of some of the greatest evils of human life.

Before I proceed to consider the diseases of the mind, I shall briefly mention its different faculties and operations.

Its faculties are, Understanding, Memory, Imagination, Passions, the principle of Faith, Will, the Moral faculty, Conscience, and the sense of Deity.

Its principal operations, after sensation, are Perception, Association, Judgment, Reasoning and Volition. All its subordinate operations, which are known by the names of Attention, Reflection, Contemplation, Wit, Consciousness, and the like, are nothing but modifications of the five principal operations that have been mentioned.

The faculties of the mind have been called, very happily, internal senses. They resemble the external senses in being innate, and depending wholly upon bodily impressions to produce their specific operations. These impressions are made through the medium of the external senses. As well might we attempt to excite thought in a piece of marble by striking it with our hand, as expect to produce a single operation of the mind in a person deprived of the external senses of touch, seeing, hearing, taste and smell.

All the operations in the mind are the effects of motions previously excited in the brain, and every idea and thought appears to depend upon a motion peculiar to itself. In a sound state of the mind, these motions are regular, and succeed impressions upon the brain with the same certainty and uniformity that perceptions succeed impressions upon the senses in their sound state.

In inquiring into the causes of the diseases of the mind, and the remedies that are proper to relieve them, I shall employ the term derangement, to signify the diseases of all the faculties of the mind.

As the understanding occupies the highest rank of those faculties, and as it is most frequently the seat of derangement, I shall begin by considering the causes, and all the states and forms of its diseases.

By derangement in the understanding, I mean every departure of the mind in its perceptions, judgments, and reasonings, from its natural and habitual order; accompanied with corresponding actions. It differs from delirium, whether acute, or chronic, in being accompanied with a departure from habitual order, in incoherent conduct, as well as conversation. The latter, however, is not necessary to constitute intellectual madness, for we sometimes meet with the most incongruous actions without incoherent speech, and we now and then meet with incoherent speech in mad people, in whom the disease does not destroy their habits of regular conduct. This is evinced by the correctness with which they sometimes perform certain mechanical and menial pieces of business. Madness is to delirium what walking in sleep is to dreaming. It is delirium, heightened and protracted by a more active and permanent stimulus upon the brain.

Let it not be supposed that intellectual derangement always affects the understanding exclusively in the manner that has been mentioned. Far from it. Two or more of the faculties are generally brought into sympathy with it, and there are cases in which all the faculties are sometimes deranged in succession and rotation; and now and then they are all affected at the same time. This occurs most frequently in the beginning of a paroxysm of intellectual madness, but it rarely continues to affect the other faculties of the mind after two or three weeks, or after the liberal use of depleting remedies. Thus fever, in its first attack, affects the bowels and nervous system, and in a few days settles down into a disease chiefly of the blood vessels.

* The reader will find several other distinguished marks between madness and delirium, applicable to legal purposes, in the author's Introductory Lecture upon Medical Jurisprudence, published in a volume of Lectures, by Bradford knd Inskeep, in the year 1810.

Derangement in the understanding, has been divided into partial and general. The causes of both are the same. I should proceed immediately to enumerate them, but as the seat or proximate cause of a disease is generally the first object of a physician's inquiry on entering a sick room, it shall be the first subject of our consideration in the present inquiry.

1. The most ancient opinion, of the proximate cause of intellectual derangement, or what has been called madness, is, that it is derived from a morbid state of the liver, and that it discovers itself in a vitiated state of the bile. Hippocrates laid the foundation of this error by his encomium upon Democritus, whom he found employed in examining the liver of a dumb animal in order to discover the cause of madness.

2. Madness has been said to be the effect of a disease in the spleen. This viscus is supposed to be affected in a peculiar manner in that grade of madness which has been called hypochondriasis. For many years it was known in England by no other name than the spleen, and even to this day, persons who are affected with it are said to be spleeny, in some parts of the New England states.

3. A late French writer, Dr. Prost, in an ingenious work entitled " Medecine Eclairee par Observation et 1'Overture des Corps," has, taken pains to prove that madness is the effect of a disease in the intestines, and particularly of their peritoneal coat. The marks of inflammation which appear in the bowels in persons who have died of madness, have no doubt favoured this opinion; but these morbid appearances, as well as all those which are often met with in the liver, spleen, and occasionally in the stomach, in persons who have died of madness, are the effects and not the causes of the disease. They are induced either, 1st, by the violent or protracted exercises of the mind attracting or absorbing the excitement of those viscera, and thereby leaving them in that debilitated state which naturally disposes them to inflammation and obstruction. Thus diseases in the stomach induce torpor and costiveness in the alimentary canal. Thus too local inflammation often induces coldness and insensibility in contiguous parts of the body. Or, 2d, they are induced by the reaction of the mind from the impressions which produce madness, being of such a nature as to throw its morbid excitement upon those viscera with so much force as to produce inflammation and obstructions in them. That they are induced by one, or by both these causes, I infer from the increased secretion and even discharge of bile which succeed a paroxysm of anger; from the pain in the left side, or spleen, which succeeds a paroxysm of malice or revenge; and from the pain, and other signs of disease in the bowels and stomach which follow the chronic operations of fear and grief. That the disease and disorders of all the viscera that have been mentioned, are the effects, and not the causes of madness, I infer further from their existing for weeks, months and years in countries subject to intermitting fevers, without producing madness, or even the least alienation of the mind.

4. Madness, it has been said, is the effect of a disease in the nerves. Of this, dissections afford us no proofs; on the contrary, they generally exhibit the nerves after death from madness in a sound state. I object further, to this opinion, that hysteria, which is universally admitted to be seated chiefly in the nerves and muscles, often continues for years, and sometimes during a long life, without inducing madness, or if the mind be alienated for a few minutes in one of its paroxysms, it is only from its bringing the vascular system into sympathy, in which I.shall say presently the cause of madness is primarily seated. The reaction of the mind from the impressions which produce hysteria, discovers itself in the bowels, in the kidneys, and in most of the muscular parts of the body.

5, and lastly. Madness has been placed exclusively in the mind. I object to this opinion, 1st, because the mind is incapable of any operations independently of impressions communicated to it through the medium of the body. 2d, Because there are but two instances upon record of the brain being found free from morbid appearances in persons who have died of madness. One of these instances is related by Dr. Stark, the other by Dr. De Haen. They probably arose from the brain being diseased beyond that grade in which inflammation and its usual consequences take place. Did cases of madness reside exclusively in the mind, a sound state of the brain ought to occur after nearly every death from that disease.

I object to it, 3, because there are no instances of primary affections of the mind, such as grief, love, anger, or despair, producing madness until they had induced some obvious changes in the body, such as wakefulness, a full or frequent pulse, costiveness, a dry skin, and other symptoms of bodily indisposition.

I know it has been said in favour of madness being an ideal disease, or being seated primarily in the mind, that sudden impressions from fear, terror, and even ridicule, have sometimes cured it . This is true, but they produce their effects only by the healthy actions they induce in the brain. We see several other diseases, particularly hiccup, headach, and even fits of epilepsy, which are evidently affections of the body, cured in the same way by impressions of fear and terror upon the mind.

Having rejected the abdominal viscera, the nerves, and the mind, as the primary seats of madness, I shall now deliver an opinion, which I have long believed and taught in my lectures, and that is, that the cause of madness is seated primarily in the blood-vessels of the brain, and that it depends upon the same kind of morbid and irregular actions that constitutes other arterial diseases. There is nothing specific in these actions. They are a part of the unity of disease, particularly of fever; of which madness is a chronic form, affecting that part of the brain which is the seat of the mind.

My reasons for believing the cause of madness to be seated in the blood-vessels of the brain are drawn,

I. From its remote and exciting causes, many of which are the same with those which induce fever and certain diseases of the brain, particularly phrenitis, apoplexy, palsy and epilepsy, all of which are admitted to have their seats in a greater or less degree to the blood-vessels. Of thirty-six dissections of the brains of persons who had died of madness, Mr. Pinel says he could perceive no difference between the morbid appearances in them, and in the brains of persons who had died of apoplexy and epilepsy. The sameness of these appearances, however, do not prove that all those diseases occupy the same parts of the brain: I believe they do not, especially in their first stage: they become diffused over the whole brain, probably in their last stages, or in the paroxysm of death. Dr. Johnson, of Exeter, in speaking of the diseases of the abdominal viscera, mentions their sympathy with each other, by what he very happily calls " an intercommunion of sensation." It would seem as if a similar intercommunion took place between all the diseases of the brain. It is remarkable they all discover, in every part of the brain, marks of a morbid state of the blood-vessels.

II. From the ages and constitutions of persons who are most subject to madness. The former are in those years in which acute and inflammatory arterial diseases usually affect the body, and the latter, in persons who labour under the arterial predisposition.

III. I infer that madness is seated in the blood vessels,

1. From its symptoms. These are a sense of fulness, and sometimes pain in the head; wakefulness, and a redness of the eyes, such as precede fever, a whitish tongue, a dry or moist skin, high coloured urine, a frequent, full or tense pulse, or a pulse morbidly slow or natural as to frequency. These states of the pulse occur uniformly in recent madness, and one of them, that is frequency, is seldom absent in its chronic state.

I have taken notice of the presence of this symptom in my Introductory Lecture upon the study of Medical Jurisprudence, in which I have mentioned, that seven-eighths of all the deranged patients in the Pennsylvania Hospital in the year 1811, had frequent pulse,* and that a pardon was granted to a criminal by the president of the United States, in the year 1794, who was suspected of counterfeiting madness, in consequence of its having been declared, by three physicians, that that symptom constituted an unequivocal mark of intellectual derangement.

* This fact was ascertained, at my request, with great accuracy, by Dr. Frederick Vandyke.' It is probable the pulsations of the arteries in the brain were preternaturally frequent in the brain in the few cases in which they were natural at the wrists. Dr. Cox, of Bristol, informs us that he had found the carotid artery to be full and tense, when the radial artery was weak and soft.

The connection of this disease with the state of the pulse, has been further demonstrated by a most satisfactory experiment, made by Dr. Coxe, and related by him in his Practical Observations upon Insanity. He gave digitalis to a patient who was in a furious state of madness, with a pulse that beat 90 strokes in a minute. As soon as the medicine reduced his pulse to 70, he became rational. Upon continuing it, his pulse fell to 50, at which time he became melancholy. An additional quantity of the medicine reduced it to 40 strokes in a minute, which nearly suspended his life. He was finally cured by lessening the doses of the medicine so as to elevate his pulse to 70 strokes in a minute, which was probably its natural state. In short, there is not a single symptom that takes place in an ordinary fever, except a hot skin, that does not occur in the acute state of madness.

IV. From its alternating with several diseases which are evidently seated in the blood-vessels. These are consumption, rheumatism, intermitting and puerperal fever, and dropsy, many instances of which are to be met with in the records of medicine.

V. From its blending its symptoms with several of the forms of fever. It is sometimes attended with regular intermissions, and remissions. I have once seen it appear with profuse sweats, such as occur in certain fevers, in a madman in the Pennsylvania Hospital. These sweats, when discharged from his skin, formed a vapour resembling a thick fog, that filled the cell in which he was confined, to such a degree as to render his body scarcely visible.

Again, this disease sometimes appears in a typhus form, in which it is attended with coldness, a feeble pulse, muttering delirium, and involuntary discharge of faeces and urine. But it now and then pervades the whole country in the form of an epidemic. It prevailed in this way in England in the years J355 and in 1373, and in France and Italy in the year 1374, and Dr. Wintringham mentions its frequent occurrence in England in the year 1719.

A striking instance of the union of madness with common fever is mentioned by Lucian. He tells us that a violent fever once broke out at Abdera, which terminated by hemorrhages, or sweats, on the seventh day. During the continuance of this fever the patients, affected with it, repeated passages from the tragedy of Andromeda with great vehemence, both in their sickrooms and in the public streets. This mixture of fever and madness continued until the coming on of cold weather. Lucian ingeniously and very properly ascribes it to the persons affected, having heard the famous player Archilaus act a part in the above tragedy in the middle of summer in so impressive a manner, that it excited in them the seeds of a dormant fever which blended itself with derangement, and thus produced, very naturally, a repetition of the ideas and sounds that excited their disease.

VI. From the appearances of the blood which is drawn in this disease being the same as that which is drawn in certain fevers. They are, inflammatory bufF, yellow, serum and lotura carnium.

VII. From the appearances of the brain after death from madness. These are nearly the same as after death from phrenitis, apoplexy, and other diseases which are admitted to be primary affections of the blood-vessels of the brain. I shall briefly enumerate them; they are, 1, the absence of every sign of disease. I have ascribed this to that grade of suffocated excitement which prevents the effusion of red blood into the serous vessels. We observe the same absence of the marks of inflammation after several other violent diseases. Dr. Stevens, in his ingenious inaugural dissertation, published in 1811, has called this apparently healthy appearance, the "aimatous" state of inflammation. Perhaps it would be more proper to call it the " aimatous" state of disease. It is possible it may arise in recent cases of madness which terminate fatally, from the same retrospection of the blood from the brain, which takes place from the face and external surface of the body just before death. But,

2. We much oftener discover in the brain, after death from madness, inflammation, effusions of water in its ventricles, extravasation and intravation of blood, and even pus. After chronic madness, we discover some peculiar appearances which have never been met with in any other disease of the brain, and these are a preternatural hardness, and dryness in all its parts. Lieutaud mentions it often with the epithets of " durum," " prsedurum," "siccum," and " exsuccum." Morgagni takes notice of this hardness likewise, and says he had observed it in the cerebrum in persons in whom the cerebellum retained its natural softness. Dr. Baillie and Mr. John Hunter have remarked, that the brain in this state discovered marks of elasticity when pressed by the fingers. Mr. Mickell ,says a cube of six lines of the brain of a maniac, thus indurated, weighed seven drachms, whereas a cube of the same dimension of a sound brain weighed but one drachm, and between four and six grains. I have ascribed this hardness, dryness, elasticity and relative weight of the brain to a tendency to schirrus, such as succeeds morbid action or inflammation in glandular parts of the body, and particularly that early grade of it which occurs in the liver, and which is known by the name of hepitalgia. The brain in this case loses its mobility so as to become incapable of emitting those motions from impressions which produce the operations of the mind.

3. We sometimes discover preternatural softness in the brain, in persons who die of madness, similar to that which we find in other viscera from common and febrile diseases. This has been observed to occur most frequently in the kidneys and spleen. The brain in this case partakes of its texture and imbecility in infancy, and hence its inability to receive and modify the impressions which excite thought in the mind.

4. and lastly. We sometimes discover a preternatural enlargement of the bones of the head from madness, and sometimes a preternatural reduction of their thickness. Of 216 maniacs whose heads were examined after death, Dr. Creighton says, in 160 the skull was enlarged, and in 38 it was reduced in its thickness. Now the same thing succeeds rheumatism, and many other febrile diseases which exert their action in the neighbourhood of bones.

I might add further, under this head, that the morbid appearances in the spleen, liver, and stomach, which are seen after death from madness, place it still more upon a footing with fevers from all its cases, and particularly from koino-miasmatic exhalations, and in a more especial manner when they affect the brain, and thereby induce primary, or idiopathic phrenitis. In short, madness is to phrenitis, what pulmonary consumption is to pneumony, that is, a chronic state of an acute disease, ft resembles pulmonary consumption further, in the excitement of the muscles, and in the appetite continuing in a natural, or in a preternatural state.

VIII. I infer madness to be primarily seated in the blood-vessels, from the remedies which most speedily and certainly cure it, being exactly the same as those which cure fever or disease in the blood-vessels from other causes, and in other parts of the body. They will be noticed in their proper place.

I have thus mentioned the facts and arguments which prove what is commonly called madness to be a disease of the blood-vessels of the brain. All the other and inferior forms of derangement, whether of the memory, the will, the principle of faith the passions, and the moral faculties, I believe to be connected more or less with morbid action in the blood-vessels of the brain or heart, according to the seats of those faculties of the mind.

In placing the primary seat of madness in the blood-vessels, I would by no means confine the predisposition to it exclusively to them. It extends to the nerves, and to that part of the brain, which is the seat of the mind, both of which, when preternaturally irritable, communicate more promptly deranged action to the blood-vessels of the brain. I have called the union of this diffused morbid irritability, the phrenitic predisposition. It is from the constant presence of this predisposition, that some people are seldom affected with the slightest fever, without becoming delirious; and it is from its absence, that many people are affected with fevers and other diseases of the brain without being affected with derangement. I am aware that it may be objected to the proximate cause or seat of madness, which has been delivered, that dissections have sometimes discovered marks of arterial diseases in the brain, similar to those that have been mentioned, which were not preceded by the least alienation of mind. In these cases, I would suppose the diseases may have existed in parts of the brain which are not occupied by the mind, or that the mind may have been translated to another, and a healthy part of the brain. The senses of taste and hearing, we know, when impaired by disease, are often translated to contiguous, and sometimes to remote parts of the body. But did we admit the objection that I have met, to militate against madness being an arterial disease, it would prove too much, for we sometimes discover the same morbid appearances, which produced apoplexy and palsy, to be present in the brain after death, without any of the common symptoms of those diseases having been preceded by them.

Many other organic diseases are occasionally devoid of their usual characteristic symptoms. Neither vomiting, nor want of appetite, have taken place in stomachs in which mortification has been discovered after death; and abscesses have been found in the livers of persons, who have died without any one of the common symptoms of hepatitis. By allowing the same latitude to the " confused and irregular operations of nature," in the brain, in the production of madness, that we observe in the production of all the other diseases that have been mentioned, we can reconcile its occasional absence, with the existence of all the organic affections in the brain which usually produce it.

In reviewing the numerous proofs of madness, being seated primarily in the blood-vessels, and its being accompanied so generally with most of the symptoms of fever, we can not help being struck with the histories of the disease that have been given by many ancient and modern physicians. Galen defines it to be "delirium sine febre." Aritseus says it is " semper sine fcbre." Dr. Arnold quotes a group of authors, who have adopted and propagated the same error. Even Dr. Heberden admits and reasons upon it. The antiquity and extent of this error should lead us never to lose sight of the blood-vessels in investigating the causes of diseases. They are, to a physician, what the meridian sun is to a mariner. There are but few diseases in which it will be possible for him to preserve the system in a healthy course, without daily, and often more frequent observations of the state of the blood-vessels, as manifested by the different and varying states of the pulse.

chapter 2

II. The causes which induce intellectual derangement, by acting upon the body through the medium of the mind, are of a direct and indirect nature.

The causes which act directly upon the understanding are,

1. Intense study, whether of the sciences or of the mechanical arts, and whether of real or imaginary objects of knowledge. The latter more frequently produce madness than the former. They are, chiefly, the means of discovering perpetual motion; of converting the base metals into gold, of prolonging life to the antediluvian age; of producing perfect order and happiness in morals and government, by the operations of human reason; and, lastly, researches into the meaning of certain prophecies in the Old and New Testaments. I think I have observed madness from the last cause, to arise most frequently from an attempt to fix the precise time in which those prophecies were to be fulfilled, or from a disappointment in that time, after it had passed.

2. The frequent and rapid transition of the mind from one subject to another. It is said booksellers have sometimes become deranged from this cause. The debilitating effects of these sudden transitions upon the mind, are sensibly felt after reading a volume of reviews or magazines. The brain in these cases is deprived of the benefit of habit, which prevents fatigue to a certain extent, from all the exercises of the body and mind, when they are confined to single objects. It is worthy of notice, that this cause of madness accords exactly with a symptom of one of its forms, and that is, a constant and rapid transition of the mind to a variety of unrelated subjects. But the understanding is affected chiefly in an indirect manner.

1. Through the medium of the imagination. It is conveyed into the understanding from this faculty, in all those people who became deranged from inordinate schemes of ambition or avarice. Mad-houses in every part of the world, exhibit instances of persons who have become insane from this cause. The great extent and constant exercises of the imagination in poets, accounts for their being occasionally affected with this disease.

2. The understanding is sometimes affected with madness through the medium of the memory. Dr. Zimmerman relates the case of a Swiss clergyman, in whom derangement was induced by undue labour in committing his sermons to memory.

3. But madness is excited in the understanding most frequently by impressions that act primarily upon the heart. I shall enumerate some of these impresssions, and afterwards mention such instances of their morbid effects as I have met with in the course of my reading and observations. They are joy, terror, love, fear, grief, distress, shame from offended delicacy, defamation, calumny, ridicule, absence from native country, the loss of liberty, property, and beauty, gaming, and inordinate love of praise, domestic tyranny, and lastly, the complete gratification of every wish of the heart.

Extravagant joy produced madness in many of the successful adventurers in the South-Sea speculation in England, in the year 1720.

Charles the Sixth, of France, was deranged from a paroxysm of anger.

Terror has often induced madness in persons who have escaped from fire, earthquakes and shipwreck. Two cases, from the last cause, have occurred under my notice.

Where is the mad-house that does not contain patients from neglected, or disappointed love ?

Fear often produced madness, Dr. Brambilla tells us, in new recruits in the Austrian army.

Grief induced madness, which continued fifty years, in a certain Hannah Lewis, formerly a patient in the Pennsylvania Hospital.

Distress often produced this disease, Mr. Howard tells us, in the prisoners of the town of Liege.

An exquisite sense of delicacy, Dr. Burton says, produced madness in a school-master, who was accidentally discovered upon a close-stool by one of his scholars.

The Bedlams of Europe exhibit many cases of madness from public and private defamation, and history informs us of ministers of state and generals of armies having often languished away their lives in a state of partial derangement, in consequence of being unjustly dismissed by their sovereigns.

A player destroyed himself in Philadelphia, in the year 1803, soon after being hissed off the stage.

The Swiss soldiers sometimes languish and die from that form of madness which is brought on by absence from their native country.

An ingenious modern poet mentions this disease, as well as its exciting cause, with peculiar elegance.

" The intrepid Swiss that guards a foreign shore,
" Condemn'd to climb his mountain-cliffs no more,
" If chance he hear the song, so sweetly wild,
" Which, on those cliffs, his infant hours beguil'd,
" Melts at the long lost scenes, that round him rise,
" And sinks a martyr to repentant sighs."

It is remarkable, that this disease is most common among the natives of countries that are the least desirable for beauty, fertility, climate, or the luxuries of life. They resemble, in this respect, in their influence upon the human heart, the artificial objects of taste which are at first disagreeable, but which from habit take a stronger hold upon the appetite than such as are natural and agreeable.

The Africans become insane, we are told, in some instances, soon after they enter upon the toils of perpetual slavery in the West Indies.

Hundreds have become insane in consequence of unexpected losses of money. It is remarkable this disease occurs oftener among the rich, who lose only a part of their property, than among persons in moderate circumstances, who lose their all.

An American Indian became deranged, and destroyed himself, in consequence of seeing his face in a looking glass soon after his recovery from a violent attack of the small-pox. The loss of one eye, by an affray in a country tavern, which materially affected the beauty of the face, produced derangement in a young man who was afterwards my patient in the Pennsylvania Hospital. There are other facts, which show the depth of this attachment to beauty in the human mind, and the poignancy of the distress occasioned by its loss or decay. The once beautiful lady Mary Wortley Montague tells a friend, in one of her letters, that she had not seen herself in a looking glass for eleven years, solely from her inability to bear the mortifying contrast between her appearance in the two extremes of her life.

A clergyman in Maryland became insane in consequence of having permitted some typographical errors to escape in a sermon which he published upon the death of general Washington.

The son of a late celebrated author in England became deranged in consequence of the severe treatment he received from his father in the course of his education. Several instances of madness, induced by the cruel or unjust conduct of schoolmasters and guardians to the persons who were the subjects of their power and care, are to be met with in the records of medicine.

Sir Philip Mordaunt shot himself immediately after succeeding to a great estate, and to the faTour of his prince, and while he appeared to be in possession of every thing that could constitute the plenitude of human happiness. The eldest son of a Scotch nobleman, of high rank and large fortune, destroyed himself in the same way, a few weeks after the consummation of all his worldly prospects and enjoyments by his marriage to a most accomplished and amiable young lady.

Two instances are upon record, of persons who destroyed themselves immediately after drawing high prizes in a lottery. In all these cases death was the effect of derangement.

4. The understanding is sometimes deranged through the medium of the moral faculties. A conscience burdened with guilt, whether real or imaginary, is a frequent cause of madness. The latter produces it much oftener than the former.

An instance of insanity occurred in a married woman in this city some years ago, of the most exemplary character, from a belief that she had been unfaithful to the marriage bed. An accident discovered that the supposed criminal connection was with a man whose very person was unknown to her. There is further a morbid sensibility in the conscience in some people, that predisposes to madness from the most trifling causes. A young man, of great piety, died of this disease in our Hospital a few years ago, in consequence of his believing that he had offended his Maker by refusing to say grace at the table of a friend.

The most distressing grade of derangement under this head is, where real guilt, and a diseased imagination concur in producing it. The occasional act of self-mutilation which deranged patients sometimes inflict upon themselves, and the painful and protracted austerities voluntarily imposed upon the body in Catholic countries, appear to be the effects of the combined operation of these two causes upon the understanding.

But we sometimes observe intellectual derangement to occur from the moral faculties being unduly excited by supposed visions and revelations, instances of which will be mentioned in another place.

Let not religion be blamed for these cases of insanity. The tendency of all its doctrines and precepts is to prevent it from most of its mental causes; and even the errors that have been blended with it, produce madness less frequently than love, and many of those common and necessary pursuits, which constitute the principal enjoyments and business of life.

To the history of the causes of derangement which has been given, I shall add, that that form of it which has been called hypochondriasis, is sometimes induced without either the patient or his friends being able to ascribe it to any cause. Dr. Nicholas Robinson, a physician who lived in the beginning of the last century, complains, in a treatise which he has published upon melancholy, of his sufferings from it in the following words:

"When no air has blown across my affairs, and no shade obscured my sun, then am I most miserable." I have heard similar declarations from several of my patients, and particularly from a clergyman of the most exemplary life and conversation. In all such cases, it would be absurd to suppose the disease existed without a cause. Many diseases take place in the body from causes that are forgotten, or from sympathies with parts of the body that are supposed to be in a healthy state. In like manner, depression of mind may be induced by causes that are forgotten; or by the presence of objects which revive the sensation of distress with which it was at one time associated, but without reviving the cause of it in the memory. The former pupils of the author will recollect several instances of mental pleasure, as well as pain, from association, mentioned by him in his physiological lectures upon the mind, in which the original causes of both had perished in the memory.

Intellectual derangement is more common from mental than corporeal causes. Of 113 patients in the Bicetre Hospital in France, at one time, Mr. Pinel tells us 34 were from domestic misfortunes, 24 from disappointments in love, 30 from the distressing events of the French Revolution, and 25 from what he calls fanaticism, making in all the original number. I have taken pains to ascertain the proportion of mental and corporeal causes which have operated in producing madness in the Pennsylvania Hospital, but I am sorry to add, my success in this inquiry was less satisfactory than I wished. Its causes were concealed in some instances, and forgotten in others. Of fifty maniacs, the causes of whose diseases were discovered by Dr. Moore and his assistant, Mr. Jenny, in the month of April, 1812, 7 were from disappointments, chiefly in love; 7 from grief; 7 from the loss of property; 5 from erroneous opinions in religion; 2 from jealousy ; 1 from terror; 1 from insolation; 1 from an injury to the head; 2 from repelled eruptions; 5 from intemperance ; 3 from onanism ; 2 from pregnancy; and 1 from fever; making in all 34 from mental, and 16 from corporeal causes. A predisposition to the disease was hereditary in but five of them.

I shall now mention all those circumstances in birth, certain peculiarities of the body, age, sex, condition and rank in life, intellect, occupation, climate, state of society, forms of government, revolutions, and religion, which predispose the body and mind to be acted upon by the remote and exciting causes that have been mentioned, so as to favour the production of madness.

I. A peculiar and hereditary sameness of organization of the nerves, brain and blood-vessels, on which I said formerly the predisposition to madness depended, sometimes pervades whole families, and renders them liable to this disease, from a transient or feeble operation of its causes.

Application was made some years ago for the admission of three members of the same family into the Pennsylvania Hospital on the same day. I have attended two ladies, one of whom was the fourth, and the other the ninth, of their respective families, that had been affected with this disease in two generations.

The following letter to the author, from Dr. Stephen W. Williams, of Deerfield, jn Massachusetts, contains the history of two cases oi hereditary madness, which, from the singular resemblance in their subjects, symptoms, and issue, have seldom perhaps been met with in the records of medicine.

June \ 6th, 1812. Dear Sir,

" Believing that' the science of medicine is related to every thing,' I am induced to transmit to you the following incidents which have lately occurred in the vicinity of this place, hoping that some useful inductions may be drawn from them, for the benefit of our profession.

" Captains C. L. and J. L. were twin brothers, and so great was the similarity in their countenances and appearance, that it was extremely difficult for strangers to know them apart. Even their friends were often deceived by them. Their habits and manners were likewise similar. Many ludicrous stories are told of people mistaking one for the other.

" They both entered the American revolutionary army at the same time. Both held similar commissions, and both served with honour during the war. They were cheerful, sociable, and in every respect gentlemen. Thoy were happy in their families, having amiable wives and children, and they were both independent in their property. Some time after the close of the war, captain J. removed to the state of Vermont, while captain C. remained in Greenfield, in the vicinity of Deerfield, and 200 miles from his brother. Within the course of three years, they have both been subject to turns of partial derangement, but by no means rising into mania, nor sinking into melancholy. They appeared to be hurried and confused in their manners, but were constantly able to attend to their business. About two years ago, captain J, on his return from the general assembly of Vermont, of which he was a member, was found in his chamber, early in the morning, with his throat cut, by his own hand, from ear to ear, shortly after which he expired. He had been melancholy a few days previous to this fatal catastrophe, and had complained of indisposition the evening previous to the event.

" About ten days ago, Captain C. of Greenfield, discovered signs of melancholy, and expressed a fear that he should destroy himself. Early in the morning of June fifth he got up, and proposed to his wife to take a ride with him. He shaved himself as usual, wiped his razor, and stepped into an adjoining room, as his wife supposed, to put it up. Shortly after she heard a noise, like water or blood running upon the floor. She hurried into the room, but was too late to save him. He had cut his throat with his razor, and soon afterwards expired.

" The mother of these two gentlemen, an aged lady, and their two sisters, the only survivors of their family, have been subject, for several years, to the same complaint."

There are several peculiarities which attend this disease, where the predisposition to it is hereditary, which deserve our notice.

1. It is excited by more feeble causes than in persons in whom this predisposition has been acquired.

2. It generally attacks in those stages of life in which it has appeared in the patient's ancestors. A general officer, who served in the American army during the revolutionary war, once expressed a wish to a brother officer, from whom I received the information, "that he might not live to be old, that he might die suddenly, and that if he married, he might have no issue." Upon being asked the reason for these wishes, he said, he was descended from a family in which madness had sometimes appeared about the fiftieth year of life, and that he did not wish to incur the chance of inheriting, and propagating it to a family of children. He was gratified in all his three wishes. He fell in battle between the thirtieth and fortieth years of his age, and he left no issue, although he had been married several years before his death. A similar instance of the disease appearing at the same time of life, in three persons of the same family, occurred under my notice in the Pennsylvania Hospital. It came on in a father and his two sons between the sixtieth and seventieth years of their lives.

3. Children born previously to the attack of madness in their parents are less liable to inherit it than those who are born after it.

4. Dr. Burton, in his Anatomy of Melancholy, remarks, that children born of parents who are in the decline of life, are more predisposed to one of the forms of partial insanity than children born under contrary circumstances.

5. A predisposition to certain diseases seated in parts contiguous to the seat of madness, often descends from parents to their children.—Thus we sometimes see madness in a son whose father or mother had been afflicted only with hysteria, or habitual headach. The reverse of this remark likewise sometimes takes place. I attended a respectable mechanic in this city in two attacks of madness, the last of which terminated his life. All his children, six in number, and now all adults, are afflicted with headach, but none of them have ever discovered any sign of madness in their conduct or conversation.

6. There are instances of families in which madness has existed, where the disease has passed by the understanding in their posterity, and appeared in great strength and eccentricity of the memory and of the passions, or in great perversion of their moral faculties. Sometimes it passes by all the faculties of the mind, and appears only in the nervous system, in persons descended from deranged parents; again we see madness in children whose parents were remarkable only for eccentricity of mind.

There are several diseases which attack the children of the same family, which did not exist in their ancestors. I have called them filial diseases. They are chiefly consumption and epilepsy. I have attempted to discover whether madness never appears in this way, and have heard of but two instances of it. One of them occurred in a family on the Island of Barbadoes, in which four children, descended from parents of habitual sound minds, became deranged. Perhaps in these cases the disease had existed in their remote ancestors, or possibly it was translated from a disease in some of the contiguous systems of the body. I have wished to discover whether there be any peculiarity of shape in the skulls of mad people that are predisposed to derangement, for which purpose I requested Dr. Vandyke, in the year 1810, to examine the dimensions of the heads of all the insane patients in our hospital, in several different directions, and afterwards to measure in the same way the heads of a number of patients belonging to the hospital, with other diseases. The result of this inquiry was a discovery that there was no departure but in one instance from the ordinary and natural shape of the head, in between sixty and seventy mad people.

II. A predisposition to madness is said to be connected with dark coloured hair. Mr. Haslam informs us that this was the case in two hundred and five out of two hundred and sixty-five patients in the Bethlehem Hospital. He intimates that it was possibly from their consisting chiefly of the natives of England, in whom that colour of the hair is very general; but the same connection between madness and dark colour has been discovered in the maniacs in the Pennsylvania Hospital, who consist of persons from three or four different countries, or of descendants who inherit their various physical characters. Of nearly seventy patients, who were examined at my request, by Dr. Vandyke, in our Hospital, in the year 1810, with a reference to this fact, all, except one, had dark-coloured hair. In the month of April, 1812, I requested Dr. Vandyke to direct his inquiries more particularly to the colour of the eyes in the maniacal patients in our hospital. He executed my request with great care and correctness, and discovered that fifty-six out of seventy-nine of them had light-coloured eyes, of which number but six had fair hair.

III. There is a greater predisposition to madness between twenty and fifty, than in any of the previous or subsequent years of human life. Of the correctness of this remark, Mr. Pinel has furnished us with the following proof. Of 1201 persons who were admitted into the Bicetre Hospital in France, between the years 1784 and 1794, 955 were between the two ages that have been men tioned, 65 were between fifteen and twenty, 131 were between fifty and sixty, and 51 between sixty and seventy-one. Mr. Haslam has furnished additional evidence of the correctness of this remark. Of 1664 deranged patients who were admitted into the Bethlehem Hospital in London, between the years 1784 and 1794, he tells us 910 of them were between the ages mentioned by Mr. Pinel. But the proportion of maniacal patients, above twenty and under fifty years of age, was much greater in the Pennsylvania Hospital in the month of April, 1812. It was ascertained by Dr. Vandyke to be 68 out of 79, that is, nearly seveneighths of their whole number. From the state of the body and mind within those periods, it is easy to account for this being the case. The blood-vessels and the nerves are then in a highly excitable state, and the former readily assume morbid or inflammatory action from the remote and exciting causes of disease. The mind too, within those years, possesses more sensibility, and of course is more easily acted upon by mental irritants, the sources of which, from family afflictions, and disappointments in the pursuits of business, pleasure and ambition, are more numerous in those years, than in any of the previous or subsequent stages of life.

Madness, it has been said, seldom occurs under puberty. To the small number of instances of it, that are upon record, I shall add four more. Two boys, the one of eleven and the other of seven years of age, were admitted into our Hospital with this disease (the latter during the time of my attendance in 1799) and both discharged cured. I have since seen an instance of it in the year 1803, in a child of two years old, that had been affected with cholera infantum; and another in a child of the same age, in the year 1808, that was affected with internal dropsy of the brain. They both discovered the countenance of madness, and they both attempted to bite, first their mothers, and afterwards their own flesh. The reason why children and persons under puberty are so rarely affected with madness, must be ascribed to mental impressions, which are its most frequent cause, being too transient in their effects, from the instability of their minds to excite their brains into permanently diseased actions. It is true, children are often affected with delirium, but this is a symptom of general fever, which is always induced, like the few cases of madness in children that I have mentioned, only by corporeal causes.

From the records of the Bicetre Hospital, in France, it appears that madness rarely occurs in old age. Doleus and Dr. Greding, mention several cases of it; the latter in a man of eighty-five. I have attended two men between sixty and seventy, and one woman between seventy and eighty, in the Pennsylvania Hospital, and a private patient in the eighty-first year of his age, in this disease. It has been said that maniacs seldom live to be old. I have known but few exceptions to this remark, and they were of persons in whom the extinction of the mind, in idiotism, had protected the body from being worn out prematurely by its constant and preternatural excitement or depression. One of the persons was Hannah Lewis, formerly mentioned, in whom the disease was induced by grief, in middle life, from the loss of her husband. She died in our Hospital in the year 1799, in the eightyseventh year of her age. A predisposition to longevity, which she derived from her ancestors, predominated over the tendency of her long protracted disease to destroy her life. She lost one sister in the eighty-second year of her age, and at the time of her death had another living who was ninety-four, neither of whom had ever been affected with madness. There are two reasons why this disease so rarely attacks old people. Their blood-vessels lose their vibratility from age, and hence they are less liable to fevers than in middle life; and from the diminution of sensibility in their nerves and brains, the causes of madness make but a feeble and transient impression upon their minds. In the latter condition of their bodies, they revert to that state which takes place in children, and which I have said protects them from the frequent occurrence of this disease.

V. Women, in consequence of the greater predisposition imparted to their bodies by menstruation, pregnancy, and parturition, and to their minds, by living so much alone in their families, are more predisposed to madness than men. A woman was admitted into our Hospital many years ago, who was deranged only during the time of her menstruation, and who in one of those periods, hung herself with the string of her petticoat. Of 1664 patients admitted into the Bethlehem Hospital, between the years 1784 and 1794, eighty-four of them were women in whom madness followed parturition. I have been consulted in two cases, and I have heard of a third, in which madness was induced by the solitude of a country life, in women who had been accustomed to live in a large social and domestic society. Of 8874 patients admitted into the Bethlehem Hospital in London, between the years 1748, and 1794, four thousand eight hundred and thirty-two were women; nearly a fifth more than men. In St. Luke's Hospital in London, the proportion of women to men who have been admitted in a given number of years, is in the ratio of three to two. But this disproportion of women to men, who are affected with madness, is by no means universal. In a Hospital for mad people in Vienna, one hundred and seventeen men were admitted in a given number of years, and but ninety-four women. In a Hospital of the same kind at Berlin, twice as many males were admitted in a given time as females. More of the former than of the latter have been admitted into the Pennsylvania Hospital. In all these cases accidental circumstances, such as the want of accommodations suited to female delicacy, or deep rooted prejudices against public mad-houses, and a preference of such as are private, may have lessened the proportion of women in the above instances, while the evils of war, bankruptcy, and habits of drinking, which affect men more than women, and which vary in their influence upon the mind in different countries, may have produced more instances of madness in the former than in the latter sex. Perhaps it would be correct to say, women are more subject to madness from natural causes, and men from such as are artificial.

What has been said under this head, applies more particularly to general madness; but, from many facts, I am led to believe that men are more subject to that grade of derangement, which has been called hypochondriasm, than women. The distressing impressions made upon the minds of women frequently vent themselves in tears, or in hysterical commotions in the nervous system and bowels, while the same impressions upon the minds of men pass by their more compact nervous and muscular fibres, and descend into the brain, and thus more frequently bring on hypochondriac insanity. If this remark be correct, it will confirm Dr. Heberdcn's assertion, that men are more disposed to suicide than women, for it necessarily follows their being most subject to that state of madness. Where the instances of suicide are more frequent among women than men, it is in those cases only in which the former are exposed to sudden paroxysms of vexation and despair.

VI. Single persons are more predisposed to madness than married people. Of seventy-two insane patients in the Pennsylvania Hospital, whose condition relative to this question was ascertained by my young friends, Dr. Moore and Mr. Jenny, in the month of April 1812, forty-two had never been married, and five were widows and widowers, at the time they became deranged.

The absence of real and present care, which give the mind leisure to look back upon past, and to anticipate future and imaginary evils, and the inverted operation of all the affections of the heart upon itself, together with the want of relief in conjugal sympathy from the inevitable distresses and vexations of life, and for which friendship is a cold and feeble substitute, are probably the reasons why madness occurs more frequently in single, than in married people. Celibacy, it has been said, is a pleasant breakfast, a tolerable dinner, but a very bad supper. The last comparison will appear to be an appropriate one, when we consider further, that the supper is not only a bad quality, but eaten alone. No wonder it sometimes becomes a predisposing cause of madness.

VII. The rich are more predisposed to madness than the poor, from their exposing a larger surface of sensibility to all its remote and exciting causes. Even where mental sensibility is the same in both those classes of people, the disease is prevented in the latter, by the constant pressure of bodily suffering, from labour, cold, and hunger. These present evils defend their minds from such as are past and anticipated; and these are the principal causes of madness. When it occurs in poor people, it is generally the effect of corporeal causes.

VIII. " Great wit, and madness," are said by Dryden " to be nearly allied." If he meant by this, affinity between wit and madness, the rapid exercises of the mind in associating similar and dissimilar ideas of words which are peculiar to both, the remark is a correct one; but if he meant that great wits are more predisposed to madness than other people, the remark is opposed by all that is known of the solidity of understanding, and correctness of conversation and conduct of Butler, Chesterfield, Franklin, Johnson, and many other distinguished men who possessed the talent of wit in an eminent degree. Nor is the remark true if the term wit be intended to designate men of great understandings. Their minds are sometimes worn away by intense and protracted study, but they are rarely perverted by madness. The vigorous mind of Dean Swift perished gradually only from the former cause. Where madness has been induced by intense and protracted application to books, it has generally been in persons of weak intellects, who were unable to comprehend the subjects of their studies.

IX. Certain occupations predispose to madness more than others. Pinel says, poets, painters, sculptors and musicians, are most subject to it, and that he never knew an instance of it in a chyniist, a naturalist, a mathematician, or a natural philosopher. The reason of this will be understood by recollecting what was said under the preceding head. The studies of the former exercise the imagination, and the passions, while the studies of the latter interest the understanding only. Dr. Arnold tells us, he has observed mechanics to be more affected with madness than merchants and members of the learned professions. This may arise from the vague and distracting exertions of genius, unassisted by education; or from corporeal causes, to which their employments expose them more than the classes of men that have been mentioned. Of the effects of the former of those causes, I once saw an instance in a house-carpenter, who became deranged in consequence of an unsuccessful attempt to contrive a new kind of staircase. More farmers, it has been said, become deranged than persons of the same grade of intellect and independence in cities. If this be the case, it must be ascribed to the greater solitude of their lives, more especially in the winter season, and to their being more exposed from labour and accidents, to its corporeal causes.

X. Certain climates predispose to madness.— It is very uncommon in such as are uniformly warm. Dr. Gordon informed me in his visit to Philadelphia in the year 1807, that he had never seen nor heard of a single case of madness during a residence of six years in the province of Berbice. It is a rare disease in the West Indies. While great and constant heat increases the irritability of the muscles, it gradually lessens the sensibility of the nerves and mind, and the irritability of the blood-vessels, and in these I formerly supposed the predisposition to madness to be seated. It is more common in climates alternately warm and cold, but most so in such as are generally moist and cold, and accompanied at the same time with a cloudy sky. Instances of it are said to be most frequent in England in the month of November, at which time the weather is unusually gloomy from the above causes. Even the transient occurrence of that kind of weather in the United States, has had an influence upon this disease. In the month of May in the year 1806, it prevailed to a great degree, during which time three patients in the Pennsylvania Hospital made unsuccessful attempts upon their lives, and a fourth destroyed himself. Two instances of suicide occurred in the same month in Philadelphia.

XL Certain states of society, and certain opinions, pursuits, amusements, and forms of government, have a considerable influence in predisposing to derangement. It is a rare disease among savages. Baron Humboldt informed me, that he did not hear of a single instance of it among the uncivilized Indians in South America. Infidelity and atheism are frequent causes of it in Christian countries. In commercial countries, where large fortunes are suddenly acquired and lost, madness is a common disease. It is most prevalent at those times when speculation is substituted to regular commerce. The mad-houses in England were crowded with patients before, and after the bursting of the South Sea bubble in the year 1720. In the United States, madness has increased since the year 1790. This must be ascribed chiefly to an increase in the number and magnitude of the objects of ambition and avarice, and to the greater joy or distress which is produced by gratification or disappointments in the pursuit of each of them. The funding system, and speculations in bank-scrip, and new lands, have been fruitful sources of madness in our country. Sixteen persons perished from suicide in the city of New York, in the year 1804, in most of whom it was supposed to be the effect of madness, from the different and contrary events of speculation.

Even the profit and losses of regular trade and agricultural labour, now and then pervert the understanding. A respectable merchant died of madness in the Pennsylvania Hospital, in the year 1794, induced by a successful East India voyage. A farmer, near Albany, who refused to take twenty shillings a bushel for a large quantity of wheat, in the year 1798, became insane from the sudden reduction of its price. Suicide was induced in a farmer of great wealth, in York county, in Pennsylvania, in the spring of 1812, by a similar disappointment, in obtaining a less price than he had been previously offered for a quantity of clover seed. Gaming is an occasional cause of madness in some countries. At Penang in the East Indies, where men often stake their wives upon the issue of a game, this disease is very common. The unfortunate gambler often rises from his seat in a fit of derangement, and sallies out into the street with instruments of murder in his hands ; a bell is rung at this time, which drives people into their houses, to avoid being killed. A late German writer has remarked, that nervous diseases increase in the cities of Germany in proportion to the fondness of their citizens for seeing tragedies. It is easy to conceive they may extend their effects a little further, so as to excite morbid commotions in the blood-vessels of the brain. I have heard the greater frequency of madness in England, than in some other countries, ascribed in part to its inhabitants preferring tragedy to comedy in their stage entertainments.

The real emotions excited by these exhibitions of imaginary distress, are never accompanied with an effort to relieve it, by which means there is an accumulation and reflux of sensation in the mind, that cannot fail of affecting the nerves and brain, and thereby to predispose to, or induce madness. Certain forms of government predispose to madness. They are those in which the people possess a just and exquisite sense of liberty, and of the evils of arbitrary power, against which complaints are stifled by a military force. The conflicting tides of the public passions, by their operation upon the understanding, become in these cases a cause of derangement. The assassination of tyrants and their instruments of oppression, is generally the effect of this disease. That madness is thus induced, I infer from its occurring so rarely from a political cause in the United States. I have known but one instance of it, and that was in a gentleman who had been deranged some years before from debt, contracted by extravagant living. In a government in which all the power of a country is'representative and elective, a day of general suffrage, and free presses, serve, like chimnies in a house, to conduct from the individual and public mind, all the discontent, vexation, and resentment, which have been generated in the passions, by real or supposed evils, and thus to prevent the understanding being injured by them.

In despotic countries, where the public passions are torpid, and where life and property are secured only by the extinction of the domestic affections, madness is a rare disease. Of the truth of this remark I have been satisfied by Mr. Stewart, the pedestrian traveller, who spent some time in Turkey; also by Dr. Scott, who accompanied lord M'Cartney in his embassy to China; and by Mr. Joseph Roxas, a native of Mexico, who passed nearly forty years of his life among the civilized but depressed natives of that country. Dr. Scott informed me that he heard of but a single instance of madness in China, and that was in a merchant who had suddenly lost 100,000/. sterling by an unsuccessful speculation in gold dust.

Mr. Carr, in his Northern Summer, tells us, that madness is an uncommon disease in Russia. It is a rare thing, says this professional traveller, to see a Russian peasant angry. He even persuades and reasons with his horse, when he wishes him to quicken his gait. It is to the long protracted civil and ecclesiastical tyranny of the late government of Spain, that we must ascribe the small number of maniacs in all the hospitals in that country. They amounted, according to Mr. Townsend, in the year 1786, to but 664, in a population, Avhich produces in Great Britain between 4,000 and 5,000; 2,600 of whom are in the city and neighbourhood of London. Habits of oppression in all those cases expend the excitability of the passions, and prevent their reacting upon the brain. But in some instances the understanding decays with the passions, in despotic countries. This state of the mind has been called fatuity. It is very common in Turkey and China. The inirritable or non-elastic state of the brain upon which this disorder depends, is induced in those countries without previous morbid excitement, in the same manner that the disorder called hepatalgia is induced, without previous hepatisis or obvious and sensible inflammation in the liver, in the East and West Indies.

XII. Revolutions in governments which are often accompanied with injustice, cruelty, and the loss of property and friends, and where this is not the case, with an inroad upon ancient and deep-seated principles and habits, frequently multiply instances of insanity. Mr. Volney informed me, in his visit to this city in the year 1799, that there were three times as many cases of madness in Paris in the year 1795, as there were before the commencement of the French Revolution. It was induced, I shall say hereafter, in several instances, by the events of the American Revolution.

XIII. Different religions, and different tenets of the same religion, are more or less calculated to induce a predisposition to madness. Dr. Shebbeare says there are fewer instances of suicide (which is generally the effect of madness) in catholic, than in protestant countries. He ascribes it to the facility with which the catholics relieve their minds from the pressure of guilt, by means of confession and absolution. This assertion, and the reasoning founded upon it, are rendered doubtful by 150 suicides having taken place in the catholic city of Paris in the year 1782, and but 32 in the same year in the Protestant city of London. It is probable, however, the greater portion of infidels in the former, than in the latter city at that time, may have occasioned the difference in the number of deaths in the two places, for suicide will naturally follow small degrees of insanity, where there are no habits of moral order from religion, and no belief in a future state. Dr. Shebbeare's assertion is rendered still less probable, by considering the usual effects of solitude upon the human mind, and this we know acts with peculiar force in the cells of monks and nuns. This remark is not the result of reasoning a priori. Of between 240 and 250 deranged people, who were confined at one time in a mad-house, in the city of Mexico, Mr. Roxas informed me, in a great majority of them the disease had been contracted in those recluse and gloomy situations.

There are certain tenets held by several protestant sects of Christians which predispose the mind to derangement. They shall be noticed in another place.

I shall conclude the history of the remote exciting and predisposing causes of madness by the following remarks.

1. Its remote causes generally induce predisposing debility. Its exciting causes more commonly induce that morbid excitement in the blood vessels of the brain in which madness is seated, but the sudden and violent action of a remote cause is often sufficient for that purpose without the aid of an exciting cause.

2. Both the remote and exciting causes of madness produce their morbid effects more certainly, promptly or slowly, according as the system is more or less predisposed to the disease by the causes formerly mentioned.

3. The predisposing causes of madness sometimes act with so much force, as to induce it without the perceptible co-operation of either a remote or an exciting cause. The remote causes of madness likewise act with so much force in some instances, as to induce it without the perceptible co-operation of a predisposing or exciting cause.

4. The predisposing causes of madness in like manner sometimes act with so much force as to induce it without the perceptible co-operation of a remote or an exciting cause.

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chapter 7, p172

CHAPTER VII.

Of the Remedies for Mania.

BEFORE we proceed to mention the remedies for mania, or the highest grade of general madness, it will be necessary to mention the means of establishing a complete government over patients afflicted with it, and thus, by securing their obedience, respect, and affections, to enable a physician to apply his remedies with ease, certainty and success,

The first thing to be done, to accomplish these purposes, is to remove the patient from his family, and from the society of persons whom he has been accustomed to command, to a place where he will be prevented from injuring himself and others. If there be objections to removing him to a public or private madhouse, or if this be impracticable, the patient should be confined in a chamber, in which he has not been accustomed to

1. This preliminary measure being taken, the first object of a physician, when he enters the cell, or chamber, of his deranged patient, should be, to catch his EYE, and look him out of countenance. The dread of the eye was early imposed upon every beast of the field. The tiger, the mad bull, and the enraged dog, all fly from it : now a man deprived of his reason partakes so much of the nature of those animals, that he is for the most part easily terrified, or composed, by the eye of a man who possesses his reason. I know this dominion of the eye over mad people is denied by Mr. Halsam, from his supposing that it consists simply in imparting to the eye a stern or ferocious look. This may sometimes be necessary ; but a much greater effect is produced, by looking the patient out of countenance with a mild and steady eye, and varying its aspect from the highest degree of sternness, down to the mildest degree of benignity ; for there are keys in the eye, if I may be allowed the expression, which should be suited to the state of the patient's mind, with the same exactness that musical tones should he suited to the depression of spirits in hypochondriasis. Mr. Halsam again asks, " Where is the man that would trust himself alone with a madman, with no other means of subduing him than by his eye?" This may be, and yet the efficacy of the eye as a calming remedy not be called in question. It is but one of several other remedies that are proper to tranquilize him ; and, when used alone, may not be sufficient for that purpose. Who will deny the efficacy of bleeding for the cure of madness ? and yet who would rely upon it exclusively, without the aid of other remedies ? In favour of the power of the eye, in conjunction with other means, in composing mad people, I can speak from the experience of many years. It has been witnessed by several hundred students of medicine in our hospital, and once by several of the managers of the hospital, in the case of a man recently brought into their room, and whose conduct for a considerable time resisted its efficacy.

2. A second means of securing the obedience of a deranged patient to a physician should be by his v (He E. Milton calls the human face "divine." It would be more proper to apply that epithet to the human voice, from its wonderful effects upon the mind of man, whether employed in simple tones, in music, or in speech. Even brutes feel and obey it. In governing mad people, should be harsh, gentle, or plaintive, according to circumstances. I have observed with great pleasure the most beneficial effects produced by it in all those ways. A patient in the Pennsylvania Hospital, who called his physician his father, once lifted his hand to strike him. " What !" said his physician, with a plaintive tone of voice, " strike your father !" The madman dropped his arm, and instantly showed marks of contrition for his conduct.

In Java, madness of a furious kind is often brought on by the intemperate use of opium. The poor, when affected with it, are put to death ; but the rich, who are able to purchase the services of female nurses, generally recover. May not their recovery be ascribed, in part, to their ears being constantly exposed to the gentleness and softness of a female voice ?

3. The COUNTENANCE of a physician should assist his eye and voice in governing his deranged patients. It should be accommodated to the state of the patient's mind and conduct. There is something like contagion in the different aspects of the human face, and madmen feel it in common with other people. A grave countenance in a physician has often checked the frothy levity of a deranged patient in an instant, and a placid one has as suddenly chased away his gloom. A stern countenance in like manner has often put a stop to garrulity, and a cheerful one has extorted smiles even from the face of melancholy itself.

4. The CONDUCT of a physician to his patients should be uniformly dignified, if he wishes to acquire their obedience and respect. He should never descend to levity in conversing with them. He should hear with silence their rude or witty answers to his questions, and upon no account ever laugh at them, or with them.

5. Acts of justice, and a strict regard to truth, tend to secure the respect and obedience of deranged patients to their physician. Every thing necessary for their comfort should be provided for them, and every promise made to them should be faithfully and punctually performed. I once lost the confidence of a maniac, by simply failing to enlarge him on an appointed day, in consequence of an unexpected revival of some of the symptoms of his disease.

6. A physician should treat his deranged patients with respect, and with all the ceremonies which are due to their former rank and habits of living. Carpets upon the floors of their rooms or cells, curtains to their beds, taste in the preparation and manner of serving their meals, will all serve to prevent distress and irritation, from a supposed change in their condition in life. I have known a deranged gentleman complain of being addressed without the title of Mr. ; and I have seen several others turn with an indignant look from their food, when served to them upon a table not covered with a cloth, or in vessels they had not been accustomed to in their own families. With this habitual attachment to forms in behaviour, and taste in living, there is in this class of patients a similar respect for former habits of society, for which reason they should always eat, sit, and partake of amusements, by themselves. The great advantage which private madhouses have over public hospitals is derived chiefly from their conforming to this principle in human nature ; which the highest grade of madness is seldom able to eradicate.

7. and lastly. A physician acquires the obedience and affections of his deranged patients by ACTS Of KINDNESS. For this purpose, all his directions for discontinuing painful or disagreeable remedies, and all his pleasant prescriptions, should be delivered in the presence of his patients ; while such as are of an unpleasant nature, should be delivered only to their keepers. Small presents of fruit or sweetcake will have a happy effect in attaching maniacal patients to their physicians, far it is a fact, that in proportion to the intensity of misery, the subjects of it feel most sensibly the smallest diminution of it. Perhaps the recovery of the madmen in Java, just now mentioned, may be ascribed, further, to their being nursed by women, in whom kindness to the sick and distressed is so universal, that it forms an essential and predominating feature in the female character.

As an inducement to treat mad people in the manner that has been recommended, I shall only add, that in those cases in which the memory has been greatly impaired, they seldom forget three things after their recovery, viz. acts of cruelty, acts of indignity, and acts of kindness. I have known instances in which the two former have been recollected by them with painful, and the last with pleasant associations for many years. In gratitude for kindness and favours shown to them, they exceed all other classes of patients after their recovery. A physician once asked a yonng woman of the society of friends...

If all the means that have been mentioned should prove ineffectual to establish a government over deranged patients, recourse should be had to certain modes of coercion. These will sometimes be necessary in order to prevent their destroying their clothes and the furniture of their cells, as well as to punish outrages upon their keepers and upon each other. The following means will generally be found sufficient for these purposes.

1. Confinement by means of a strait waistcoat, or of a chair, which I have called a tranquillzer. —He submits to them both with less difficulty than to human force, and struggles less to disengage himself from them. The tranquilizer has several advantages over the strait waistcoat or mad shirt. It opposes the impetus of the blood towards the brain, it lessens muscular action every where, it reduces the force and frequency of the pulse, it favours the application of cold water and ice to the head, and warm water to the feet, both of which, I shall say presently, are excellent remedies in this disease; it enables the physician to feel the pulse and to bleed without any trouble, or altering the erect position of the patient's body; and, lastly, it relieves him, by means of a close stool, half filled with water, over which he constantly sits, from the foetor and filth of his alvine evacuations. (A chair, such as has been described, may be seen in the Pennsylvania Hospital, and an engraving of it in the last volume of Dr. Coxe's Medical Museum.)

2. Privation of their customary pleasant food.

3. Pouring cold water under the coat sleeve, so that it may descend into the arm pits, and down the trunk of the body.

4. The shower bath, continued for fifteen or twenty minutes. If all these modes of punishment should fail of their intended effects, it will be proper to resort to the fear of death. Mr. Higgins proved the efficacy of this fear, in completely subduing a certain Sarah T , whose profane and indecent conversation and loud vociferations offended and disturbed the whole hospital. He had attempted in vain, by light punishments and threats, to put a stop to them. At length he went to her cell, from whence he conducted her, cursing and swearing as usual, to a large bathing tub, in which he placed her. " Now (said he) prepare for death. I will give you time enough to say your prayers, after which I intend to drown you, by plunging your head under this water." She immediately uttered a prayer, such as became a dying person. Upon discovering this sign of penitence, Mr. Higgins obtained from her a promise of amendment. From that time no profane or indecent language, nor noises of any kind, were heard in her cell.

* A chair such as has been described may be seen in the Pennsylvania Hospital, and an engraving of it in the last volume of Dr. Cole's Medical Museum.

By the proper application of these mild and terrifying modes of punishment, chains will seldom, and the whip never, be required to govern mad people. I except only from the use of the latter, those cases in which a sudden and unprovoked assault of their physicians or keepers may render a stroke or two of a whip, or of the hand, a necessary measure of selfdefence.

To encourage us in the use of all the means that have been mentioned for subduing the tempers of mad people, and acquiring a complete government over them, I shall only add to the history I have given of their disease, that there is a predisposition in their minds to be acted upon by them, founded in their timidity. They are not only afraid of their keepers and attendants, but of one another. Some years ago a madman of the name of Hoops disturbed the whole village of Chester, in this state, by his conduct. A person more mad than himself came into the town. Hoops instantly ran from him, and took shelter in the court house while the court was sitting. There was an instance of the same timidity in a madman in our hospital, in the month of February 1810. In consequence of the house being unusually crowded with mad people, two men were confined in one cell. One of them, who was very noisy, was instantly silenced by the rebukes of his less deranged companion. He even crept into a corner of the cell to avoid him.

The remedies for general mania come next under our consideration. In enumerating them, I shall adopt the same order that I followed in treating upon partial insanity, by mentioning,

I. Such as should be applied to the mind, through the medium of the body ; and,

II. Such as should be applied to the body through the medium of the mind.

I. The first remedy under this head should be bloodletting.

This evacuation is indicated,

1. By all the facts and arguments formerly mentioned, in favour of this grade of madness being an arterial disease, of great morbid excitement or inflammation in the brain, particularly by the state of the pulse, and, when this is natural, by the state of the countenance, by wakefulness, and by a noisy and talkative disposition.

2. By the appetite being uninterrupted, and often unrestrained, whereby the blood vessels become overcharged with blood.

3. By the importance and delicate structure of the brain, which forbid its hearing violent morbid action for a length of time, without undergoing permanent obstruction or disorganization. The danger from this cause is much increased by the wakefulness, hollowing, singing, and strong muscular exertions of persons in this state of madness.

4. By there being no outlet from the brain, in common with other viscera, to receive the usual results of disease or inflammation, particularly the discharge of serum from the blood vessels.

5. By the accidental cures which have followed the loss of large quantities of blood. Many mad people, who have attempted to destroy themselves by cutting their throats, or otherwise opening large blood vessels, have been cured by the profuse haemorrhages which have succeeded those acts. Of this, several instances have occurred within my knowledge.

6. By the morbid appearances of the blood which has been drawn for the cure of this form of madness. It is generally diseased beyond that grade in which it exhibits a buffy coat. Of 200 patients bled by Mr. Halsam, in the Bethlehem Hospital, the blood was fizy in but six cases, and from the cause that has been assigned. I have seen nearly all the morbid appearances of the blood which I have enumerated in my defence of bloodletting, and never a single instance in which it put on a natural appearance.

7. Bloodletting is indicated by the extraordinary success which has attended its artificial use in the United States, and particularly in the Pennsylvania Hospital.

In the use of bleeding in this state of madness, the following rules should be observed :

1. It should be copious on the first attack of the disease. From 20 to 40 ounces of blood may be taken at once, unless fainting be induced before that quantity be drawn. It will do most service if the patient be bled in a standing posture. The effects of this early and copious bleeding are wonderful in calming mad people. It often prevents the necessity of using any other remedy, and sometimes it cures in a few hours.

2. It should be continued not only while any of those states of morbid action in the pulse remain which require bleeding in other diseases, but in the absence of them all, provided great wakefulness, redness in the eyes, a ferocious countenance, and noisy and refractory behaviour continue, all of which indicate a highly morbid state of the brain. We bleed in the same natural state of the pulse in the pneumonia notha. We do the same thing in a similar form of hepatitis.

The propriety of bleeding in this mania notha, if I may be allowed to use a term founded upon the unity of its cause (that is, congestion of blood without inftmmation) with the causes of the above diseases of the lungs and liver, has often been demonstrated in the Pennsylvania Hospital. Its advantages, I well recollect, attracted the attention of the pupils of the hospital in the year 1805, in a more than ordinary manner, in the case of a man of the name of Pickins. His madness was recent, his skin was cool. and his pulse natural, but his eyes suffused with blood, and he was unable to sleep. I bled him copiously, after which his pulse became frequent and tense. I repeat ed the bleeding, and gave him several doses of purging physic, which cured him in a few days.

3. It should be more copious in phrenimania and synochomania, than in simple madness. Its liberal use is particularly indicated in the latter, when it is formed by the union of madness with pregnancy, or with the autumnal or puerperal fever, in all which the blood vessels labour under disease in other parts of the body, as well as the brain.

4. It should be less copious in madness from drunkenness, than from any of its other causes, all the circumstances that call for it being equal. For the reasons for this caution, the reader will please to consult the defence of bloodletting, in the third volume of the author's Medical Inquiries and Observations.

5. It is indicated no less in the seventh and eighth firms of general mania, formerly' described, than in those which preceded them. I think I once prevented suicide by it, in a young gentleman descended from a family in which several of its members had perished by their own hands.

6. The quantity of blood drawn should be greater than in any other organic disease. This is indicated not only by most of the reasons for bleeding formerly given, but by the strong and uncommon hold which the disease takes of the brain. Many circumstances prove this to be the case, but none more than its not being cured, and scarcely suspended, by the acute and painful disease of parturition, several instances of which have come under my notice. From among many cases of the successful issue of profuse bleeding in this form of madness, I shall select but two : the former was in Mr. T. H. of the state of New Jersey, a man of sixty-eight years of age, from whom I drew nearly 200 ounces of blood, between the 20th of December and the 14th of February in the year 1807: the latter was in Mr. D. 1'. of the state of New York, who lost about 470 ounces, by my order, by 47 bleedings, between the months of June 1810 and April 1811. Both these gentlemen were my private patients in the Pennsylvania Hospital. Were it necessary I could add to these cases several others, communicated to me by my pupils, particularly by Dr. Wallace, of Virginia, and Dr. Annan, of Maryland, in which a similar practice had been attended with the same success.

After all the symptoms which call for bloodletting have disappeared, we sometimes observe the disease to continue. In this case morbid excitement becomes insolated, but still so considerable as not to yield to purges or blisters. Here CUPPING is indicated. The cups should be applied to the temples, behind the ears, and to the nape of the neck. Leeches may be used for the same purpose, and to the same places. They may likewise be applied to the hzemorrhoidal vessels with advantage, in persons who have been subject to the piles. The sympathy of the brain with these vessels is so intimate, that the disease yields as readily to the loss of blood from them, as from the parts that have been mentioned near the brain.

Arteriotomy performed upon the temporal artery, it is said, is more useful than venesection, or local bleeding with cups and leeches. I can say nothing in its favour from my own experience.

I have only to add to these remarks upon the use of cups and leeches, that they are not only useless, but often hurtful, if applied before the action of the pulse is reduced. By inducing debility in the blood vessels of the brain, they invite morbid excitement to it from the blood vessels of the trunk and extremities of the body, provided they retain a predominance, or even an equality of action with the blood vessels of the brain.

3. SOLITUDE is indispensably necessary in this state of madness. The passions become weak by the abstraction of company, and by refraining from conversation. For this reason visitors should be excluded from the cells and apartments of highly deranged people, and there are times in which the visits of a physician, and of the cellkeeper or nurse, should be as seldom and short as are consistent with the proper treatment and care of the patient.

4. DARKNESS should accompany solitude in the first stage of this disease. It invites to silence, and it induces a reduction of the pulse, by the abstraction of the stimulus of light, and by the influence of fear which is naturally connected with darkness. There are four cells in the Pennsylvania Hospital, so formed that it is possible to render them dark with but little trouble. I have seen the happiest effects from confining noisy patients in them.

5. An ERECT position of the body. There is a method of taming refractory horses in England, by first impounding them, as it is called, and then keeping them from lying down or sleeping, by thrusting sharp pointed nails into their bodies for two or three days and nights. The same advantages, I have no doubt, might be derived from keeping madmen in a standing posture, and awake, for four and twenty hours, but by different and more lenient means. Besides producing several of the effects of the tranquillizing chair, it would tend to reduce excitement, by the expenditure of excitability, from the constant exertion of the muscles which support the body. The debility thus induced in those muscles would attract morbid excitement from the brain, and thereby relieve the disease. That benefit would arise from preventing sleep, I infer from its salutary effects in preventing delirium, and from delirium" being always increased by it in fevers of great morbid excitement.

6. Low DIET, consisting wholly of vegetables, and those of the least nutritious nature. What would be the effect of fasting for two or three days in this state of madness ? I am disposed to think favourably of it, from a fact communicated to me by a gentleman who resided twenty years in the interior parts of India He informed me that the wild elephants, when taken, are always tamed by depriving them of food, until they discover signs of great emaciation. They are then fed with mild aliment, and soon acquire their usual flesh, but without the least return of their ferocity. Fasting is calculated to act in two ways, in the cure of tonic madness ; 1, by lessening the quantity of blood by the abstraction of aliment ; and, 2, by exciting the disease of hunger in the stomach to such a degree, as to enable it to predominate over the disease of the brain; and by that means attract it to a less vital part of the body. Theeffects of this severe remedy in curing inflammatory dropsy, render it still more probable that it might be employed, with advantage, in this disease of the brain. Against its use it may be said, that the ferocity of certain wild animals is increased by hunger ; this is true, but ferocity is not derangement. It is possible it might exist for a little while, and be attended with symptoms totally different from those which take place in madness, and of a nature that would yield more easily to the power of medicine. The drinks of a patient in this state of madness should be of the most simple kinds.

7. PURGING. Cremor tartar, salts, senna, calomel and jalap, have all been employed for this purpose. Their use is indicated by the obstructions in the viscera, and torpor of the alimentary canal, which generally accompany this form of madness. There are cases in which the purges should be given daily, so as to excite an artificial cliarrheea. Nature, as I shall say presently, sometimes cures madness in this way. It is much in favour of this chronic mode of purging, that few persons are ever delirious in their last moments; who die of discharges srom their bowels. In the mixture, which sometimes takes place, of mania with the synochus form of bilious fever, purging should be employed more freely than in simple madness. Calomel and jalap should be preferred for that purpose.

8. EMETICS are spoken of very differently by authors. Some commend, while others condemn, them. When they have done harm, it must have been by giving them before, or after, the system was reduced below the emetic point. When given at that point, they have done good in many cases. I mentioned formerly their manner of operating, in treating of their efficacy in partial derangement.

9. NITRE has done the same service in this disease, that it has done in other diseases which affect the blood vessels. Its efficacy is increased by such additions of tartarized antimony and calomel to it, as shall increase its disposition to act upon the bowels and skin.

10. BLISTERS, like emetics, have been considered as remedies of doubtful efficacy ; but it is only because they have not been employed in the manner, or at the precise time, that was necessary to obtain benefit from them. In a letter which I received in the year 1794, from Dr. Willis, senr. he informed me that he always applied them to the ankles in this disease, instead of the head or neck. He gave no reason for this practice, but it immediately suggested a principle to me, from which I have derived great advantages, not only in the treatment of madness, but of several other diseases. In the first stage of tonic, or violent, madness, the disease is entrenched, as it were, in the brain. It must be loosened, or weakened, by depicting remedies, before it can be dislodged, or translated to another part of the body. When this has been effected, blisters easily attract it to the lower limbs, and thus often convey it at once out of the body. The same reasoning applies, with equal force, and the same practice with equal success, to all the violent diseases of the breast and bowels. The blisters do the same service, when applied to the wrists, and still more, when applied at the same time, or alternately, to both extremities. After the complete reduction of the pulse, they may be applied with advantage to the neck and head.

11. COLD, in the form of air, water and ice. The cold air should be applied both partially and generally. To favour its partial action, the hair should be cut off, and shaved from every part of the head. Dr. Moreau, a French physician, has related a cure of madness performed by this simple remedy alone. How far the hair, by its sympathy with the brain, which it discovers by preternatural dryness in the forming state of many diseases, and by the alteration in its figure, colour, and quantity, from the influence of certain emotions and passions of the mind, may increase this disease, we know not ; but we are certain, by cutting it off, we not only expose the head to a greater degree of cold, but we favour by it, at the same time, depletion from the brain, by means of insensible perspiration ; for, however strange it may appear, there is a grade of action in the perspiring vessels in which their discharges are increased by the sedative operation of cold.

Cold air, by its action upon the whole body, has likewise done service in this state of madness. I have heard of two instances, in which it was cured by the patients escaping from their keepers in the evening, and passing a night in the open air in the middle of winter. One of them relapsed ; in the other the cure was permanent.

Cold water should be applied in like manner to the 'head, and the whole body. To the former it should be applied by means of cloths, or a bladder, to which ice, when it can be obtained, should be added ; for the head, from its greater insensibility to cold than any other part of the body, feels, in but a feeble degree, the coldness of simple water. I have found this to be a more effectual, as well as a more delicate, mode of applying cold to the head, than by means of the clay cap, as advised by Dr. Cullen. The water, or ice, should be frequently renewed, and they should be continued for several days and nights. The signal for removing them should be, when they produce chilliness, and sobbing or weeping in the patient. The advantages of these cold applications to the head will be much increased, by placing the feet at the same time in warm water. The circulation is thereby more promptly equalized. The reader will find a striking instance of the efficacy of using cold and warm water in this manner to the two extremities, by my advice, in a case of mania published by Dr. Spence, of Dumfries, in Virginia, in Dr. Coxe's Medical Museum.

In order to derive benefit from the application of cold water to the whole body, it should be immersed in it for several hours, by which means we prevent the reaction of the system, and thus render the sedative effects of the water permanent. Pumping for an hour or two upon a patient acts in the same way ; but as it has sometimes been employed in curing a fit of drunkenness, and may be considered as a punishment, rather than a remedy, immersion of the body should be preferred to it. The patience and insensibility of the system to cold, in this state of

the system, is illustrated by a striking fact, mentioned by Dr. Currie in his Medical Reports. He tells us, a deranged young woman slept upon a cold floor during a whole night, so cold as to freeze water and milk upon her table, without suffering the least inconvenience from it.

11. A SALIVATION. I mentioned the manner in which this remedy operated upon the brain, the bowels, and the mind, in treating of the cure of hypochondriac derangement. Too much cannot be said in its favour in general madness. I once advised it in a case of this disease from parturition, in which the patient conceived an aversion from the infant that had been the cause of her suffering. On the day she felt the mercury in her mouth, she asked for her infant, and pressed it to her bosom. From that time she rapidly recovered. It is sometimes difficult to prevail upon patients in this state of madness, or even to compel them, to take mercury in any of the ways in which it is usually administered. In these cases I have succeeded, by sprinkling a few grains of calomel daily upon a piece of bread, and afterwards spreading over it a thin covering of butter.

12. The PERUVIAN BARK. In all those cases in which mania is complicated with the intermitting fever, or with those prostrate states of fever in which bark is usually administered, this medicine may be given with advantage.

I have thus enumerated the principal remedies, which have been employed in reducing the preternatural excitement of the system which takes place in tonic madness. There are some others which have been employed for the same purpose, upon which I shall make a few remarks.

12. OPIUM. From an erroneous belief in the supposed sedative power of this medicine, it has been prescribed in this state of derangement, but I believe always with bad effects. When given in small doses, so as to prevent sleep, and by that means gradually to waste the excitability, or what Dr. Darwin calls the sensorial power of the system, it may be useful.

14. DIGITALIS. I have occasionally administered this medicine in tonic madness, but never with any radical or permanent success.

15. CAMPHOR has been supposed to possess specific virtues in this state of madness. I have often prescribed it when a young practitioner, but without any obvious advantage. I should feel some hesitation in bearing a testimony against this, and the preceding medicine, had I not lately discovered that my experience of their inefficacy in this disease, accords with that of the ingenious Dr. Ferriar. They have both derived their credit in madness from their lessening the frequency of the pulse, in which, disease has very improperly been supposed to consist. But the frequency of a pulse may be lessened, without a reduction of its force, and even both may be effected by these medicines upon the pulse on the wrist, and yet irregular action in the blood vessels of the brain, which constitutes the disease, still continue, and until this be removed, they are calculated to do harm, by inducing obstructions in the brain, and thereby perpetuating the disease.

When madness arises from drunkenness, those medicines are safer and more useful, than when it arises from those causes which require copious bloodletting. In addition to them, volatile salts, bitters, and small quantities of ardent spirits, may be given with advantage, provided the system be first moderately reduced by the use of depleting remedies.

I suspect many, and perhaps all, the cures that have been performed by opium, digitalis, and camphor, have been of madness from the intemperate use of strong drink. The disease in most of these cases partakes of the nature of a soap bubble. With all its apparent force, it is both feeble, and transient, and not only bears stimulants with safety, but sometimes requires them immediately after gentle evacuations of any kind.

16. HELLEBORE has been famed, for many centuries, as a specific for madness. It is generally admitted that it is useful, only, when it acts as a purge.

17. Dr. Gregory, senr. used to relate, in his lectures, a method of curing tonic madness, which was practised by a farmer in the neighbourhood of Aberdeen, in Scotland. It consisted in yoking a number of madmen in a plough, and compelling them, by fear or force, to plough his fields. This remedy acted, by reducing and expending the morbid excitement of the system. Refractory domestic animals are sometimes subdued in the same way ; but experience has taught us that they may be tamed by more gentle means, Experience has proved, in like manner, that the system in tonic madness may be reduced by remedies that offer less violence to huma nity, and that do not add to the affliction of the disease, by degrading the patient to a level with our domestic animals.

18. As soon as the disease shows signs of abatement, the patient should be relieved from his confinement, in order to partake of the benefits of fresh air and exercise. Swinging, riding in a carriage, and moderate walking, will be highly proper in this state of his disease. To these should be added,

19. The SHOWER BATH. This excellent remedy acts upon the head, by the stimulus arising from the weight and momentum of the water, and by the reaction of the blood vessels after the sedative effects of the water are over. I have seen very happy results from it. To do much service, it should be used two or three times a day.

20. The diet and drinks of the patient should now be of a cordial nature ; and where obstinate wakefulness or restlessness attends, opium may be given at bedtime with safety and advantage.

21. When the disease affects the nervous and muscular systems, in common with the blood vessels, with hysterical or convulsive symptoms ; assafcetida, castor, and the oil of amber, should be given with all the remedies that have been mentioned.

The first remedy under this head is to divert the ruling passion or subject which occupies the mind, if it be one, and fix it upon some other. Nothing effectual can be done without great attention to this direction. The author has endeavoured to show, in an inquiry into the influence of physical causes upon morals, how much the passions may be made to neutralize and decompose each other, and thus to lessen their influence upon the body. History furnishes several examples of the truth of this remark. I mentioned formerly the effects of opposing the fear of shame to a false opinion in religion, in preventing suicide in the virgins of Miletus. Achilles was diverted by his mother Thetys from gratifying his revenge upon the body of Hector, by sup. planting that baneful passion by the passion of love. Anger, and even rage, have often been opposed with success by terror and fear, and deliberate malice by a delicate stroke of wit. Where the mind is deranged upon all subjects, we should endeavour to fix it upon but one. In order to do this, it will be necessary to find out the favourite studies and amusements of our patients. The late Dr. Ash, Dr. Priestly informed me, was cured of derangement upon a variety of subjects, by seducing him to the study of mathematicks, of which he had been fond in early life. The distracted mind of the poet Cowper was composed, while he was employed in the single business of translating Homer ; and I have heard of a woman who was cured of madness, by keeping her constantly employed for several days in playing cards, to which it was known she had always had a strong attachment. There are few persons so much deranged, as not to exhibit, for a half an hour or more, marks of correctness of mind, when drawn into conversation upon some subject not connected with their derangement. I admit that this diversion of the passions and understanding cannot be effected, where the whole mind, and all the passions, are under the influence of madness. Thus the virgins of Miletus could not have been cured by an appeal to the female sense of shame, had their moral faculties partaken of the disease of their other passions ; nor could Dr. Ash have been cured of his intellectual derangement by the study of mathematicks, had he lost all his recollection of quantity and numbers.

2. A sudden sense of the ABSURDITY, FOLLY, or CRUELTY of certain actions, produced by conversation, has sometimes cured madness. The cure in this case bears a resemblance to the sudden reduction of a dislocated bone. Some years ago a maniac made several attempts to set fire to our hospital. Upon being remonstrated with, by Mr. Coats, one of its managers he said, " I am a salamander;" " but recollect (said Mr. Coats) all the patients in the hospital are not salamanders ;" that is true, said the maniac, and never afterwards attempted to burn the hospital. Many similar instances of a transient return of reason, and some of cures, by pertinent and well directed conversations, are to be met with in the records of medicine..

3. Madness has sometimes been cured by the influence of PLACE, TIME, and Company, upon the human mind. In favour of the benefits of as sociation from place, I shall mention the following facts. Vansweiten relates a story of a cabinet maker, who always recovered his reason as soon as he entered his workshop. A certain Mrs. of this city, formerly a patient of mine, on the 27th of March 1792, was suddenly seized with derangement on her way from market. She rambled for two hours up and down the city, and at length was conducted to her own house. The moment she looked around her, she recovered her reason, nor did she relapse afterwards. I have known one clergyman, and have heard of another, who were deranged at all times, except when they ascended the pulpit, in which place they discovered, in their prayers and sermons, all the usual marks of sound and correct minds. I once attended a judge, from a neighbouring state, who was rational and sensible upon the bench, but constantly insane when off it. Time, by its influence upon a deranged mind, sometimes produces healthy and regular associations of ideas and conduct. The late Rev. Dr. —, of Baltimore, was observed to be less deranged on Saturdays, than on any other day of the week, probably from that day being formerly devoted exclusively to retirement and study, in preparing for the exercises of the ensuing Sabbath. Company has a similar effect in restoring healthy and regular associations in the mind. It should always be of that kind which produced respect in former times. It will readily occur to the reader, that all these remedies, derived from association, will be proper only in the declining and moderate state of the disease.

4. Great care should be taken by a physician, to suit his conversation to the different and varying states of the minds of his patients in this disease. In its furious state, they should never be contradicted, however absurd their opinions and assertions may be, nor should we deny their requests by our answers, when it is improper to grant them. In the second grade of this disease, we should divert them from the subjects upon which they are deranged, and introduce, as if it were accidentally, subjects of another, and of an agreeable, nature. When they are upon the recovery, we may oppose their opinions and incoherent tales by reasoning, contradiction, and even ridicule. I attended a lady some years ago in our hospital, in whom this practice succeeded to my wishes. In the first and raving state of her disease, she said the spirit of general Washington visited and conversed with her every night. I took no notice of this assertion, but prescribed only for the excited state of her pulse. After this was reduced, I entered into conversation with her, and instantly obtruded a subject foreign to the nightly visits of the spirit of general Washington, whenever she mentioned it. One day, when she appeared rational upon all the subjects upon which we conversed, she lifted up the skirt of her silk gown, and said, " See what a present general Washing ton made me last night !" 0 ! fie ! said I, Madam, I thought you had more understanding than to suppose general Washington would leave his present abode, to bring a silk gown to any lady upon the face of the earth. She laughed at this rebuke, and never mentioned the name of general Washington to me afterwards, nor discovered any other mark of the remains of her disease.

From the history of this case, we see there are the same acquiescing, diverting, and opposing points in this grade of madness, that were mentioned in treating upon the cure of tristimania, and amenomania, all of which should be carefully attended to, in conversing with persons who are affected with it.

We see further from this case, that the cure of mental and bodily disease is to be effected by the same means. We first reduce the system, then create revulsive actions, and finally remove subsequent debility, or feeble morbid actions, by stimulating remedies. From the nature of the last of these remedies, the necessity of rescuing maniacal patients from solitude must be very obvious, in order to their producing a salutary effect. Indeed they should never be confined a day after they cease to be disposed to injure themselves or others.

5. The return of regularity and order in the operations of the mind will be much aided, by obliging mad people to read with an audible voice, to copy manuscripts, and to commit interesting passages from books to memory. By means of the first, their attention will be more intensely fixed upon one subject than by conversation. In this way only, they read when alone, and in this way only, they comprehend what they read. They revert in this respect to the state of childhood. By copying manuscripts, the attention will be still more fixed to one subject, and abstracted from all others. I have witnessed the most salutary effects from it, particularly in a gentleman from New England, whose cure was completed by transcribing a volume of lectures for a student of medicine. Committing select passages from books to memory will be more useful than either of them, inasmuch as it requires greater efforts of mind to accomplish it. To facilitate this mode of exciting and regulating the faculties and operations of the mind, a few entertaining books of history, travels, and prints, should compose a part of the shop furniture of every public and private madhouse.

6. Music has been much commended in this state of madness. History records two cures of royal patients being affected by it. Dr. Cox mentions a striking instance of its power over the mind of a madman. It should be accommodated to the state of the disease. In that grade of it which is now under consideration, the tunes should be of a plaintive, that is, of a sedative nature.

7. TERROR acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness. I once advised gentle exercise upon horseback, in the case of a lady in Virginia who was deranged. In one of her excursions from home, her horse ran away with her. He was stopped after a while by a gate. The lady dismounted, and when her attendants came up to her, they found her, to their great surprise and joy, perfectly restored to her reason, nor has she had since the least sign of a return of her disease. A fall down a steep ridge cured a mania of twenty years continuance. Dr. Joseph Cox relates three cures of madness by nearly similar means. Dr. M. Smith, of Georgia, informed me, that a madman had been suddenly cured in Virginia, by the breaking of a rope, by which he had been let down into a well that was employed as a substitute for a bathing tub. He was nearly drowned before he was taken out. The cures in all these cases were effected, by the new actions induced in the brain by the powerful stimulant that has been mentioned. In the use of it, great care will be necessary to suit its force to the existing state of the system.

8. FEAR, accompanied with PAIN, and a sense of shame, has sometimes cured this disease. Bartholitt speaks in high terms of what he calls "flagillation" in certain diseases. I have heard of sever al instances of its efficacy in tonic madness. Two soldiers were cured by it in the American army, during the revolutionary war. A madman, w ho escaped from his keepers in Maryland, ran to one of his neighbours with an intention to kill him. His neighbour met him with a heavy whip, and beat him until he fell upon his knees, and implored him to spare his life. He rose from his knees in a sound state of mind, and had no symptom of his disease afterwards. In mentioning the cures performed by the whip, let it not be supposed that I am recommending it in this state of madness. Fear, pain, and a sense of shame, may be excited in many other ways, that shall not leave upon the memory of the patient the distressing recollection, that he owes his recovery to such a degrading remedy.

9. How far artificial GRIEF might be employed with advantage in this disease, I shall not determine, but I have heard of its having been suspended for several days, in a clergyman now in the Pennsylvania Hospital, by the death of one of his children ; and of mania of five years standing, descending to manalgia, in a lady' in New York, by hearing of the death of her husband. It caused her to weep for several weeks. The disease in this case, which had been diffused through all her passions, was suddenly concentrated in but one of them, and in her understanding, from whence it gradually passed out of her system. If these facts should not be deemed a sufficient warrant to create artificial grief, they will show that relief may be expected, from communicating to persons affected with this grade of madness the intelligence of the death of their relations and friends.

10. Convalescents from derangement should be defended from the TERRIFYING or DISTRESSING NOISES of patients in the raving state of this disease, by removing the latter to small lodges, remote from the hospital, or private madhouses, or by confining them in cells that are made with double walls, doors, and windows, so as to obstruct the passage of sound. A relapse has often been induced by the neglect of this caution. bleeding, low diet, purges, and all the other remedies for reducing morbid excitement in the brain, recommended formerly for the cure of intellectual madness.

When the disease is periodical, bark, and other tonics, should be given in its intervals.

CHAPTER X.

On Derangement in the Will.

TWO opinions have divided philosophers and divines, upon the subject of the operations of the will. It has been supposed, by one sect of each of them, to act freely ; and by the others to act from necessity, and only in consequence of the stimulus of motives upon it. Both these opinions are supported by an equal weight of arguments ; and however incomprehensible the union of two such opposite qualities may appear in the same function, both opinions appear to be alike true.

The will is affected by disease in two ways.

I. When it acts without a motive, by a kind of involuntary power. Exactly the same thing takes place in this disease of the will, that occurs when the arm or foot is moved convulsively without an act of the will, and even in spite of it. The understanding, in this convulsed state of the will, is in a sound state, and all its operations are performed in a regular manner. When the will becomes the involuntary vehicle of vicious actions, through the instrumentality of the passions, I have called it MORAL DERANGEMENT. For a more particular account of this moral disease in the will, the reader is again referred to a printed lecture delivered by the author, in the university of Pennsylvania, in November 1810, upon the Study of Medical Jurisprudence, in which the morbid operations of the will are confined to two acts, viz. murder and theft. I have selected those two symptoms of this disease (for they are not vices) from its other morbid effects, in order to rescue persons affected with them from the arm of the law, and to render them the subjects of the kind and lenient hand of medicine. But there are several other ways, in which this disease in the will discovers itself, that are not cognizable by law. I shall describe but two of them. These are, LYING and DRINKING.

1. There are many instances of persons of sound understandings, and some of uncommon talents, who are affected with this LYING disease in the will. It disfers from exculpative, fraudulent and malicious lying, in being influenced by none of the motives of any of them. Persons thus diseased cannot speak the truth upon any subject, nor tell the same story twice in the same way, nor describe any thing as it has appeared to other people. Their falsehoods are seldom calculated to injure any body but themselves, being for the most part of an hyberbolical or boasting nature, but now and then they are of a mischievous nature, and injurious to the characters and property of others. That it is a corporeal disease, I infer from its sometimes appearing in mad people, who are remarkable for veracity in the healthy states of their minds, several instances of which I have known in the Pennsylvania Hospital. Persons affected with this disease are often amiable in their tempers and manners, and sometimes benevolent and charitable in their dispositions.

Lying, as a vice, is said to be incurable. The same thing may be said of it as a disease, when it appears in adult life. It is generally the result. of a defective education. It is voluntary in childhood, and becomes involuntary, like certain muscular actions, from habit. Its only REMEDY is bodily pain, inflicted by the rod, or confinement, or abstinence from food ; for children are incapable of being permanently influenced by appeals to reason, natural affection, gratitude, or even a sense of shame.

2. The use of strong drink is at first the effect of free agency. From habit it takes place from necessity. That this is the case, I infer from persons who are inordinately devoted to the use of ardent spirits being irreclaimable, by all the considerations which domestic obligations, friendship, reputation, property, and sometimes even by those which religion and the love of life, can suggest to them. An instance of insensibility to the last, in an habitual drunkard, occurred some years ago in Philadelphia. When strongly urged, by one of his friends, to leave off drinking, he said, " Were a keg of rum in one corner of a room, and were a cannon constantly discharging balls between me and it, I could not refrain from passing before that cannon, in order to get at the rum."

The REMEDIES for this disease have hitherto been religious and moral, and they have sometimes cured it. They would probably have been more successful, had they been combined with such as are of a physical nature. For an account of several of them, the reader is referred to the first volume of the author's Medical Inquiries and Observations. To that account of physical remedies I shall add one more, and that is, the establishment of a hospital in every city and town in the United States, for the exclusive reception of hard drinkers. They are as much objects of public humanity and charity, as mad people. They are indeed more hurtful to society, than most of the deranged patients of a common hospital would be, if they were set at liberty. Who can calculate the extensive influence of a drunken husband or wife upon the property and morals of their families, and of the waste of the former, and corruption of the latter, upon the order and happiness of society ? Let it not be said, that confining such persons in a hospital would be an infringement upon personal liberty, incompatible with the freedom of our governments. We do not use this argument when we confine a thief in a jail, and yet, taking the aggregate evil of the greater number of drunkards than thieves into consideration, and the greater evils which the influence of their immoral example and conduct introduce into society than stealing, it must be obvious, that the safety and prosperity of a community will be more promoted by confining them, than a common thief. To prevent injustice or oppression, no person should be sent to the contemplated hospital, or SOBER HOUSE, without being examined and committed by a court, consisting of a physician, and two or three magistrates, or commissioners appointed for that purpose. If the patient possess property, it should be put into the hands of trustees, to take care of it. Within this house the patient should be debarred the use of ardent spirits, and drink only, for a while, such substitutes for them, as a physician should direct. Tobacco, one of the provocatives of intemperance in drinking, should likewise be gradually abstracted from them. Their food should be simple, but for a while moderately cordial. They should be employed in their former respective occupations, for their own, or for the public benefit, and all the religious, moral, and physical remedies, to which I have referred, should be employed at the same time, for the complete and radical cure of their disease.

2. Besides the disease in the will, which has been described, it is subject to such a degree of debility and torpor, as to lose all sensibility to the stimulus of motives, and to become incapable of acting either freely, or from necessity. In this respect it resembles a paralytic limb. We sometimes say of persons who are governed by their friends, or a favourite, that " they have no will of their own." This is strictly true. If left to themselves, they would neither buy nor sell, nor transact any kind of business. They will and prefer nothing, and they do nothing, but what. is closely connected with their animal existence. It is from the habitual want of exercise in the will in slaves, that it is so apt to acquire this paralytic state ; and it is because we are deprived of its cooperation with our medicines in a desire of life, that we are less successful in curing their diseases under equal circumstances, than the diseases of freemen. Animal magnetism, Mr. Brisset informed me, performed many cures of light diseases upon the white people in the West Indies, but not a single slave was benefited by it, and probably from the cause that has been mentioned.

I have never been consulted in this disease of the will, but I have no doubt stimulating and tonic remedies, preceded by depletion, would be useful in it. Persons afflicted with this disorder of the mind should be placed in situations, in which they will be compelled to use their wills, in order to escape some great and pressing evil. A palsy of the limbs has been cured by the cry of fire, and a dread of being burned. Why should not a palsy of the will be cured in a similar way?

CHAPTER XI.

Of Derangement in the Principle of Faith, or the Believing Faculty.

As this faculty has not yet found its way into our systems of physiology, I shall briefly remark, that I mean by it that principle in the mind, by which we believe in the evidence of the senses, of reason, and of human testimony. It is as much a native faculty as memory or imagination. The objects of human testimony are extensive and important. St. Paul alludes to them in the following passage of the eleventh chapter of his Epistle to the Hebrews. " Through faith we understand that the worlds were framed by the word. of God, so that things which are seen were not made of things which do appear." The greatest part of all we believe of history, geography, and public events, and all that we believe of our relation to our parents, brothers and sisters, by the ties of consanguinity, are derived from it. Happily for us ! its operations are involuntary in its sound state. Happily for us, likewise ! a source of knowledge, so necessary to individual comfort and social existence, has not been made dependant upon our senses, nor left to the slow inductions of reason. The world could not exist in its present circumstances without it. It is no objection to its necessity and usefulness, that we are sometimes deceived by it. The same objection applies with equal force to our senses and reason, as sources of knowledge.

Persons affected with this disease in the principle of faith, as far as relates to human testimony, believe and report every thing they hear. They are incapable of comparing dates and circumstances, and tell stories of the most improbable and incongruous nature. Sometimes they propagate stories that are probable, but false ; and thus deceive their friends and the public. There is scarcely a village or city, that does not contain one or more persons affected with this disease. Horace describes a man of that character in Rome, of the name of Apella. The predisposition of such persons to believe what is neither true, nor probable, is often sported with by their acquaintances, by which means their stories often gain a currency through whole communities.

It is probable the confinement of persons afflicted with this malady, immediately alter they hear any thing new, might cure them. Perhaps ridicule might assist this remedy. I think I once saw it effectual in an old quidnunc during the revolutionary war.

This faculty of the mind is subject to disorder as well as to disease ; that is, to an inability to believe things that are supported by all the evidence that usually enforces belief. Mr. Burke has described the conduct of persons affected with this disorder in the following words: " They believe nothing that they do not see, or hear, or measure by a twelve inch rule." An Indian once expressed the state of mind in which this torpor in the principle of faith takes place, by saying, when a truth was proposed to his belief, " that it would not believe for him." This incredulity is not confined to human testimony. It extends to the evidence of reason, and (it has been said) of the senses. The followers of Dr. Berkley either felt, or affected, the last grade of this disorder in the principle of faith. That it is often affected, I infer from persons who deny their belief in the utility of medicine, as practised by regular bred physicians, believing implicitly in quacks ; also from persons who refuse to admit human testimony in favour of the truths of the christian religion, believing in all the events of profane history ; and, lastly, from persons who contradict the evidence of their senses in favour of matter, being as much afraid of bodily pain from material or sensible causes as other people.

The remedy for this palsy of the believing faculty, should consist in proposing propositions of the most simple nature to the mind, and, after gaining the assent to them, to rise to propositions of a more difficult nature. The powers of oratory sometimes awaken the torpor of the principle of faith. This was evinced, in a remarkable manner, in the speech which king Agrippa made to St. Paul, after he had heard his eloquent oration in favour of christianity ; " almost thou persuadest me to be a Christian." Perhaps great bodily pain would have the same, or a greater, effect in curing this disorder of the mind. It has often cured paralytic affections of the body, and of other faculties of the mind.

Sometimes a strong passion, or emotion, by preoccupying the mind, prevents the exercise of belief. Thus we read, that the disciples of our Saviour could not believe the news of his resurrection " for joy." In such cases the predominating passion, or emotion, should be abstracted, or weakened, before an appeal is made to the principle of faith.

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THE REMEDIES FOR MANIA

The first object of a physician, when he enters the cell, or chamber, of his deranged patient, should be, to catch his EYE, and look him out of countenance. The dread of the eye was early imposed upon every beast of the sield. The tyger, the mad bull, and the enraged dog, all sly from it . . . A second means of securing the obedience of a deranged patient to a physician should be by his VOICE . . . In governing mad people it should be harsh, gentle, or plaintive, according to circumstances . . . The CONDUCT ... should be uniformly dignified, if he wishes to acquire their obedience and respect. He should never descend to levity in conversing with them. He should hear with silence their rude or witty answers to his questions, and upon no account ever laugh at them, or with them . . . Acts of justice, and a strict regard to truth, tend to secure the respect and obedience of deranged patients . . . A physician acquires the obedience and affections of his deranged patients by ACTS of KINDNESS . . . I shall only add, that . . . they seldom forget three things after their recovery, viz. acts of cruelty, acts of indignity, and acts of kindness .. .

If all the means . . . mentioned should prove ineffectual to establish a government over deranged patients, recourse should be had to certain modes of coercion . . . 1. Confinement by means of a strait waistcoat, or of a chair which I have called a tranquillizer . . . 2. Privation of their custom-ary pleasant food. 3. Pouring cold water under the coat sleeve, so that it may descend into the arm pits, and down the trunk of the body. 4. The shower bath, continued for sifteen or twenty minutes. If all these modes of punishment should fail . . . it will be proper to resort to the fear of death . . . By the proper application of these mild and terrifying modes of punishment, chains will seldom, and the whip never, be required to govern mad people .. .

The remedies for general mania . . . : I. Such as should be applied to the mind, through the medium of the body; and, II. Such as should be applied to the body, through the medium of the mind.

I. The first remedy . . . should be blood-letting. This evacuation is indicated, i. By all the facts and arguments . . . in favour of this grade of madness being an arterial disease, of great morbid excitement or inflammation in the brain . . . 2. By the appetite being uninterrupted, and often unrestrained, whereby the blood-vessels become overcharged with blood. 3. By the importance and delicate structure of the brain, which forbid its bearing violent morbid action for a length of time, without undergoing permanent obstruction or disorganization . . . 4. By there being no outlet from the brain, in common with other viscera, to receive . . . the discharge of serum from the blood-vessels. 5. By the accidental cures which have followed the loss of large quantities of blood. Many mad people, who have attempted to destroy themselves by cutting their throats . . . have been cured by the profuse haemorrhages . . . 6. By the morbid appearances of the blood . . . 7. Blood-letting is indicated by the extraordinary success which has attended its artisicial use the United States, and particularly in the Pennsylvania Hospital . . . the following rules should be observed : It should be copious on the first attack . . . from 20 to 4o ounces may be taken at once . . . The effects of this early and copious bleeding are wonderful in calming mad people . . . It should be continued . . . The quantity of blood drawn should be greater than in any other organic disease . . . After all the symptoms which call for blood-letting have disappeared, we sometimes observe the disease to continue . . . Here CUPPING is indicated . . . to the temples, behind the ears, and to the nape of the neck. Leeches may be used for the same purpose . . . SOLITUDE is indispensably necessary . . . The passions become weak by the abstrac-tion of company . . . DARKNESS should accompany solitude . . . An ERECT position of the body . . . by the . . . constant exertion of the muscles .. . would attract morbid excitement from the brain . . . LOW DIET . . .

PURGING . . . EMETICS . . . NITRE . . . BLISTERS . . . COLD . . . A SALIVATION . . . The PERUVIAN BARK ... OPIUM . . . DIGITALIS . . . CAMPHOR . . . HELLEBORE . . . The SHOWER BATH . . . assafoetida,

castor, and the oil of amber .. .

We next come to mention the remedies that are proper to act upon the body through the medium of the mind. I. The sirst . . . is to divert the ruling passion or subject which occupies the mind, if it be one, and fix it upon some other . . . 2. A sudden sense of the ABSURDITY, FOLLY or CRUELTY of certain actions, produced by conversation, has sometimes cured madness . . . 3. Madness has sometimes been cured by the influence of PLACE, TIME, and COMPANY, upon the human mind . . . 4. Great care should be taken by a physician, to suit his conversation to the different and varying states of the minds of his patients . . . 5. The return of regularity and order in the operations of the mind will be much aided, by obliging mad people to read with an audible voice, to copy manu-scripts, and to commit interesting passages from books to memory .. . 6. MUSIC . .. 7. TERROR acts powerfully upon the body, through the medium of the mind, and should be employed in the cure of madness .. . 8. FEAR, accompanied with PAIN, and a sense of SHAME, has sometimes cured this disease . .. 9. How far artificial GRIEF might be employed with advantage . . . I shall not determine.

ON THE DIFFERENT SPECIES OF PHOBIA

Dr. Cullen has divided Hydrophobia into two species. The principal species is that diease which is communicated by the bite of a mad animal, and which is accompanied with a dread of water. Without detracting from the merit of Dr. Cullen, I cannot help thinking that the genus of the disease which he has named Hydrophobia, should have been PHOBIA, and that the number, and names of the species, should have been taken from the names of the objects of fear or aversion. In conformity to this idea, I shall desine Phobia to be 'a fear of an imaginary evil, or an undue fear of a real one'. The following species appear to belong to it.

1. The CAT PHOBIA. It will be unnecessary to mention instances of the prevalence of this distemper . . . 2. The RAT PHOBIA is a more common disease than the first species that has been mentioned: It is peculiar, in some measure, to the female sex . . . 3. The INSECT PHOBIA. This disease is peculiar to the female sex. A spider — a slea — or a musqueto, alighting upon a lady's neck, has often produced an hysterical fit .. . 4. The ODOR PHOBIA is a very frequent disease with all classes of people . . . 5. The DIRT PHOBIA. This disease is peculiar to certain ladies . . . They make every body miserable around them with their exces-sive cleanliness : the whole of their lives is one continued warfare with dirt . . . 6. The RUM PHOBIA is a very rare distemper . . . If it were possible to communicate this distemper as we do the small-pox, by inoculation, what an immense revenue would be derived from it by physicians .. .7. The WATER PHOBIA. This species includes not the dread of swallow-ing, but of crossing water. I have known some people, who sweat with terror in crossing an ordinary ferry . . . 8. The SOLO PHOBIA ; by which I mean the dread of solitude . . . 9. The POWER PHOBIA. This distemper belongs to certain demagogues. Persons afflicted with it, consider power as an evil — they abhor even the sight of an officer of government .. . io. The FACTION PHOBIA. This disease is peculiar to persons of an opposite character to those who are afraid of power . . . ii. The WANT PHOBIA. This disease is consined chiesly to old people . . 12. The DOCTOR PHOBIA. This distemper is often complicated with other diseases. It arises, in some instances, from the dread of taking physic, or of submitting to the remedies of bleeding and blistering. In some instances I have known it occasioned by a desire sick people feel of deceiving them-selves, by being kept in ignorance of the danger of their disorders .. . 13. The BLOOD PHOBIA. There is a native dread of the sight of blood in every human creature, implanted probably for the wise purpose of preventing our injuring or destroying ourselves, or others . . . 14. The THUNDER PHOBIA. This species is common to all ages, and to both sexes : I have seen it produce the most distressing appearances and emotions upon many people . . . 15. The HOME PHOBIA. This disease belongs to all those men who prefer tavern, to domestic society . . . 16. The CHURCH PHOBIA. This disease has become epidemic in the city of Philadelphia . . . 17. The GHOST PHOBIA. This distemper is most common among servants and children . . . 18. The DEATH PHOBIA. The fear of death is natural to man — but there are degrees of it which constitute a disease.

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