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had the corresponding organs very large. I could enumerate an abundance of cases, but I shall forego the consideration of the external figure of the head as an indication of character, in the present stage of the inquiry, and shall confine my observations to the following limited branch of the subject,--that the preponderance of any particular sentiment, passion, or faculty, constituting the character or genius of the healthy subject, is strongly marked in his insanity, and predisposes to the kind of symptoms : and that when the cerebral functions have been so disturbed by moral causes as to bring on the disease, the symptoms of derangement often appear in those passions or faculties which have been greatly called into action, and irritated by the aforesaid moral causes.
But the disordered vascular action is always the attendant on the disease; and hence I infer, that the madness consists in derangement of material organs. I dwell less on the proofs I have derived from examining the forms of cranium, because I am aware of the unwillingness of the public to admit facts that can only be accurately ascertained by a laborious and continued direction of the attention to this subject almost exclusively. I shall
, therefore, only allude to the cerebral organs casually, where the examples of the coincidence of forms of the head with the disease is particularly striking. If the present state and popularity of the science permitted me to speak in the strict language of my own opinion, I should say as follows:
The organs of the brain may be deranged. separately or together, any number of them at once, or one separately: hence, patients are insane in one particular faculty, and judge of it by another ; when the organ of cautiousness is the par.. ticular subject of cerebral irritation, the prominent characteristic of the insanity is fear and melancholy; the organ of ideality would , add whimsical and imaginary dangers; the mysterising faculty gives. a superstitious turn to the illusion, and the patient then sees visions, hears angels sing, voices calling him, &c.; or, when the upper parts are deranged, he is religiously mad; when the organ of combativeness is morbidly active, he is raving and furious ; or destructive if the part of the brain behind the ears be inordinately large, or be called into diseased action. When the symptoms vary or alternate, as fury, melancholy, &c., it is because the irritated' or inflamed state is shifted from one to another organ. But I forbear any further allusion to the separate organs, and proceed to relate a few cases in the order of their phenomena.
5. A patient of irritable and nervous constitution, with much ideality and cautiousness, became sensible of increasing irritability, and could not regulate his bowels by medicines. The circulation became more and more hurried ; he had successively headachs, nausea, vertigo, and irregular spirits, and was sensible of
monthly exacerbations of these symptoms : at length he felt a sudden and fixed melancholy, which, he assured me, came on as it were in a moment, and speedily went off after taking high food. He had, during the paroxysm, a maniacal fear of some far distant event, which he dreaded. About a month afterwards he was attacked again ; he took purgative medicines, as he said, “ this fear has a peculiar coloring ; it is morbid.” The disease became a continuous melancholy,' or insanity, with maniacal fear, varying in the sportive change of its object, with diurnal exacerbations. It subsided, during a change of weather, a month afterwards : bat he had slight periodical returns. Some years afterwards, when he thought himself cured, he had some violent cause of anxiety: after this cause was removed, he felt constitutional melancholy, and said it was morbid :-" The swell of the ocean is left after the storm has passed away.” He was so convinced himself that some organic part had been too much acted on, and had been left in a state of morbid activity in kind as well as in degree, that he made himself the subject of experiment, and, like many madmen, reasoned with metaphysical accuracy and precision on his halluci. nation. He took lowering medicines and diet, and great exercise, and by degrees lost the disease. But he had monthly returns in a slight degree, for about a year afterwards. This is a case in which, in a constitution predisposed, the violent excitement of a particular organ (or at least of a particular sentiment) led to a morbid and perverted activity of that organ after the exciting cause was removed ; in consequence, as it would seem, of a catenation of morbid bodily symptoms, marked by determination of blood to the head. This latter circumstance was confirmed, du: ring both the attacks, by a full and hurried pulsation of the carotids. The diurnal periodicity of the disease was shown by the flushing of the face and increase of action about noon; and it's metastasis by the consequent change of the flushing to melancholy and fear about two o'clock. Finally, during the time it was not continuous, it evinced monthly paroxysms at the periods of irritability. It seemed, in the first attack, to have been excited by atar mospherical influence, as it occurred during the time of an epidemic, and an irregular distribution of aerial electricity; and it showed its connateness by affecting the largest organs, after a high degree of
| Dr. Darwin has tried to establish a distinction between Hypochondriasis and Insanity. They appear to me only modifications of a diseased state of the Brain.
2-See my “ Observations on the Casual and Periodical Influence of Atmosphate on Insanity," to which I regard this paper as supplementary.
their ordinary excitement. I consider this case as instructive. I could advert to many others, with a similar history, wherein the symptoms varied according to the organisation.'
The knowledge of this partial cause of the symptoms seems as yet to promise no improvement in practice, since we know of no local bleeding capable of draining particular organs. But it leads us to employ moral agents, conjoined with medical treatment, since we can excite the antagonist faculties of the mind, and thus try to divert the irritation, and, by this means, the impetus of blood. The medical practice will remain the same as before this particular circumstance was known, and will consist of alterative medicines and depletion, with good air, and as much exercise as is compatible with circumstances. To this consideration I shall devote the next section. Suffice it to say, that the popular treatment of the disease in general appears wrong, while an alterative and depletory course seems highly beneficial. Indeed, this plan is generally the best for all nervous complaints. Tonics and stimulants afford temporary relief, but lead to a worse state of the patient in the end. In the periodical returns of insanity, tonics are excessively hurtful. I should have said more here about the alterative and depletory treatment, if the excellent remarks of Dr. Mayo had not been published. Founded on long and successful practice, it is hoped they will rouse the attention
of practitioners to the most important errors now committed in the medical treatment of nervous diseases. The facts I have hastily gathered from cases viewed in mad houses far distant asunder, and cursorily examined during a tour, cannot afford such substantial documents as observations made on the same cases in different consecutive stages.
On the periods of insanity, which are irregular and regular, daily and monthly, and the terms or course of the disease, which may be shortened by lowering, and aggravated by tonic and nourishing medicines, I have already stated my opinion. I hope to publish cases, from time to time as I make them out, from the numerous notes I have collected, and from others which have been transmitted to me.
§ 6. There are several other phenomena, which I may call collateral, in insanity, which tend to show that the symptoms of madness depend on irritation and inflammation of particular or
" Whether the casual or epidemic influence of the atmosphere determines the seat of the cerebral indammation or not, in some cases, I do not yet know; but I suspect it, since this influence has such a great power over the symptoms in epidemical complaints in general.
gans of the brain. I speak of irritation and inflammation as being concomitant in the disease ; since, I believe, we may almost lay it down as a rule, that in inflammation there is always a high degree of nervous irritation previous to that increased action of the blood vessels which reacts on and maintains it. I must here advert to another fact in physiology, of almost equally general application, before I draw the parallel between affection of the organs of the brain and those of other parts ; namely,—that the increased activity of the nervous and sanguiferous systems of any part, at first only increases the natural action of that part; but afterwards, when it proceeds to a greater degree, it produces an erroneous or perverted action. We shall see this equally apply to the brain as to other organs, on the supposition I have advanced respecting the cause of particular insanity; and thus we shall be able to corroborate our doctrine by a sort of analogical proof, founded on the general laws of physiology.
First, with respect to the five senses ;-a certain quantity of activity in the retina, and of blood in the yessels of the eye, are necessary to sight; but if this quantity be increased, as in local inflammation of the eyes, vision is painful or distorted: the action of the optical organs is likewise perverted, and ocular spectres, musca volitantes, and other illusive phenomena, occur in consequence of irritation and the increased momentum of the blood to those parts. A similar example may be taken from the imaginary sounds of voices in the ears, or the morbid sensation of smells, which do not exist in reality, but which seem to arise from an inflammatory and irritable state of the respective organs in the auditory and olfactory apparatus: these disorders, as well as deafness from what is called relaxation of the Eustachian tube, have gone away inmany cases after accidental hæmorrhages, or cathartic medicines. The cause of these complaints, as well as of all diseases usually denominated nervous, have been ably illustrated by Dr. Parry in his “ Elements of Pathology." And I have seen the more obstinate cases of this kind cured eventually, by a course of depletory treatment, where tonic medicines have previously been used without benefit. I have seen also, in two cases, a similar treatment subdue obstinate melancholy, where the temporary relief afforded by tonics had already produced a worse state of the patient after the immediate effect of the stimulus had ceased. In both these cases, the part of the brain before alluded to as being the organ of cautiousness, was very large.
In many cases of insanity we can distinctly trace the disease through various stages, which illustrate its analogy to the diseases of other parts. At first, the increased activity of the organ of cautiousness' is manifested by an unusual look of anxiety, 'exaggerated fears, and other marks of irritability. As the disease advances, these fears become more irrational ; the melancholy sentiment becomes, as it were, fixed, and is associated with some maniacal delusion; the patient himself is even conscious of a change from an irritable to a perverted state of his feelings. The organs of digestion now appear more decidedly disordered, and the arterial action in the head is hurried. The same applies to other organs, according to the nature of the madness: those which are in nearer proximity seem to suffer the soonest, as it were from the general law of contiguous sympathy. Thus we find the Organs of Combativeness and Destructiveness" fall the most readily into the disordered state ; and maniacal fury, and a destructive dispos sition, alternate with, or accompany melancholy. In like manner, as the eyes and nose, the mouth, &c. are in catarrhal complaints affected with inflammation, either alternately or together." Another circumstance, which seems explainable on the same supposition, and tends also to justify me in regarding these kinds of insanity as having their particular seats in the organs alluded to, is, that we find those parts of the head which are most contiguous to the deranged Organs become most often affected with the disease in mania and melancholia. In these diseases the ears suffer more than the eyes : there are many more maďmen deaf than blind: Violent fits of anger, which is an affection of the cerebral organ behind the ear, have caused temporary deafness. Great bleeding from the nose, or a violent flood of tears, has sometimes produced a temporary relief from melancholy and irritation, which can only be referred to its relieving the patient from the fulness of the cerebral vessels. The effect of wounds of the occiput on the functions of the cerebellum, is too well known to leave a doubt about the sympathy between the exterior part of the head, and the parts of the brain under them. It is by contiguous sympathy that we can explain the effect on the brain of excessive venery, and its tendency to madness: the inordinate action into which the cerebellum (or organum amoris physici) is called, produces an irritable and inflammatory state of that organ, which is extended in time to the organs of the cerebrum. I have observed, that the external parts of the head most affected in erotomania are the parts behind the ears, and over the nape of the neck, where an inflammatory state isnot only observed, but found to be periodical. I could produce numerous other cases from the notes I have collected, did. I not