Traite Medico-Philosophique sur L'Alianation Mentale.
By Ph. Pinel, Consulting Physician to his Majesty the Emperor, &c.
1809. Second Edition.


to the Salpetriere, witnessing the order and calmness which reign there, are struck with astonishment, and sometimes cry out with surprise, "But where are the mad'" They are ignorant that they thus pay the highest compliment to the institution, and that their question denotes the very remarkable difference between this and other Hospitals, where the miserable insane are crowded together pell-mell and without any distinction; exasperated by the brutal rudeness of the attendants, and subject to the vain caprices and arbitrary orders of an unfit or negligent superior, they are in a constant state of agitation, and continually utter complaints, lamentations, and tumultuous cries. An insane hospital should unite advantages of locality with spaciousness and a large enclosure. A fundamental object would be absent if the different sorts of patients were not kept in a kind of isolation, and if it was not capable of separating entirely the more agitated and furious from those who are tranquil. It is necessary, above all, that the insane should be directed by principles of humanity and the results of a full experience ; that their sallies should be repressed with firmness, and that each one should enjoy the degree of liberty accordant with his personal security and that of others ; that, in fine, in all cases which are susceptible of it, the director should be the confidant of their troubles and solicitudes.

II. Means of Repression.

The uninterrupted use of chains is an admirable invention to perpetuate the fury of maniacs to supply the want of- zeal in an ignorant superior, to nourish in the heart of the insane a constant exasperation with an intense desire for revenge, and to foment in a hospital uproar and tumult. I long saw these inconveniences, while physician to the Bicetre during the first years of tile Revolution, and having taken all due precaution, put an end to the system with entire success. Forty patients, in chains for many years previous to this time, were set at liberty, and permitted to traverse the courts freely, their movements being merely restrained by the strait waistcoat : in the night they were unrestrained in their lodges. We may remark that this period was the p42 termination of the accidents happening to the attendants, often struck or killed in an unexpected manner by patients kept in chains, and always in a state of intense fury. One of these patients had been thirty, and another forty years in this melancholy condition. Lunatics should not be regarded as criminals, but as diseased persons inviting our utmost compassion, and whom we should seek by the most simple means to restore to reason. They may obey but a blind impulse urging them to violence, and we ought here only to provide for the safety of the individual and that of others, and simply restrain him in his lodge : if there is extreme violence, a strait waistcoat should restrain the movements of his feet and hands, and he should be fixed upon tho bed by bands attached to the posterior parts of his garment, and which he cannot perceive. But this condition should be transient, in order to shun the effects of an anger concentrated against those who surround him, which would aggravate his disease. Certain important and urgent circumstances may call for a repression more energetic, but of less duration; this is best shown by examples. Case.- A young female whom great misfortunes and deep grief had thrown into a state of torpor and a sort of idiocy, had been cured, and had even gained flesh, but during her convalescence she refused labour with obstinacy: the supervisor, to punish her, had her led one day to a court in the midst of idiots, but she appeared to sport with this sort of repression, and did but dance about and turn everything into ridicule. A strait waistcoat was then applied, moderately drawing the shoulders back; she laughed at this, and sustained the trial for a whole day; but the constraint which she felt made her beg pardon, and she no more refused sewing. If she relaxed in this, they recalled to her, smiling, the "velvet waistcoast," and she became docile immediately. Case.-A female, aged 40, was so furious and indomitable that she struck all the female attendants, and was on the point of killing one of them in the lodge at the time that she gave ber food ; on another occasion she threw at her head an earthen pot, and inflicted a deep wound. The strait waistcoat was immediately applied, producing a strong retraction of the shoulders ; she was not able to sustain this restraint above an hour; she asked pardon, and since that date has never struck any person, although she has continued a long time deranged. If she is abusive, it is sufficient to speak to her of the strait waistcoat, and she becomes orderly end tranquil. This sort of repression can only be borne during a very limited period ; it is, in fact, followed at first by an uneasiness and a great difficulty of respiration ; then comes sickness of stomach and an insupportable anxiety, insomuch that the patient is obliged to demand pardon, and he will not forget the occasion. But neither this, nor any other mode of repression, ought to be confided to the attendants ; the superior should have its whole management.

The douche, as a means of repression, often suffices to induce to the general law of labouring a patient who is capable of it, to conquer an obstinate refusal of food, and to subdue patients led away by a sort of fanciful turbulence, of which they are rationally conscious. In giving it, insulting terms are avoided ; on the contrary, the patient is made to understand that it is for his own good, and with regret to us, that we have recourse to these violent measures ; and sometimes pleasantry is used at the time, care being taken not to carry this too far. As soon as obstinacy ceases the repression is suspended, and a tone of affectionate p43 benevolence is made to succeed it. We may judge of the efficacy of this means, which is very common in this hospital, by the following observation. Case.-A patient of very strong constitution, liable during more than ten years to periodical and irregular attacks of mania, could not be restrained by the most energetic means, which did but exasperate her. She tore to pieces all sorts of garments and covering, and had to lie in straw ; she had been taken by her parents from another hospital. On her arrival she was excessively meager, although very voracious, and nothing could equal her intense fury. She was given a nourishing diet, and her habit of tearing being carried to its utmost extent, she was submitted to a rather strong douche, and the strait waistcoat was applied, which attached her to a bed until she should ask pardon. As soon as she was submissive, freedom of motion was accorded to her; a relapse was accompanied by a renewal of the same means of repression, which induced calmness and circumspection. Owing to the sickness of the director for twelve days, this patient forgot the lessons which she had received, and began to strike, and tear, and rave as before. The director renewed his threat of punishment, but she did not appear to regard it. She was then conducted to the bath, strongly douched with cold water, and kept in a motionless posture by the strait waistcoat ; this time she appeared humbled and cast down, and the director, to impress her with a feeling of terror, spoke with the most energetic firmness, but without anger, and announced that she should be thenceforth treated with the utmost rigour. Her repentance was exhibited by a torrent of tears, which she shed during nearly two hours. The next clay, and those following it, she was calm; the other symptoms diminished progressively, and after an entire convalescence of some months, leaving her in an unequivocal state, she was restored to her family.

Another instance, which I had formerly at the Bicetre, shows the advantage, occasionally, of strongly impressing the imagination of a patient, and of striking him with terror. A young man during the evolution was dismayed at the overthrow of the Catholic religion in France, and, overcome by his religious feelings, he became maniacal, and was transferred to the Bicctre after being treated at the Hotel Dieu. Nothing could equal his sombre misanthropy; he spoke only of the torments of another world, and he thought that, to escape them, he ought to imitate tire abstinence and macerations of the ancient anchorites. Thenceforth he abstained from all nourishment, and towards the fourth day of this inextinguishable resolution his state of languor made his life to be feared. All sorts of persuasion failed. M. Pussin, the director, then presented himself one evening at the door of his lodge with an array calculated to affright-with a fierce look, a loud voice, and a crowd of attendants clashing chains which they bore. Pottage was placed near him, and he was ordered in precise terms to take it during the night, if he did not wish to incur the most cruel treatment. After fluctuating between the fear of the present and of the future punishment for many hours, he at last determined to take the nourishment. By a proper regimen, he was afterward restored to health both of body and mind.

On the occurrence of a sudden outbreak of violent excitement on the part of a patient, most frequently occurring in maniacal cases of the nervous temperament, a great secret in subduing them, without either p44 giving or receiving any hurt, is to cause the attendants to advance, in order to impress them with a sort of fear by an imposing array, or to render vain all resistance by measures adroitly managed and combined. On such a sudden delirious paroxysm, and when the patient has in his hands some offensive weapon, as a knife, a stick, or a stone, the director, always faithful to the maxim of maintaining order in shunning acts of violence, himself advances with an intrepid air, but slowly and by degrees, towards the patient, and, to avoid exasperating him, lie does not hold any sort of weapon; he speaks to him while advancing in a firm and menacing tone, and by reiterated appeals continues to aim at concealing from him that which is passing at his sides ; he orders him to obey, and give himself up. E1 little disconcerted by the fierce aspect of the director, he loses every other object of sight, and, by a certain signal, finds himself suddenly surrounded by attendants, who had advanced slowly, and as if without his knowledge. Each one seizes a limb, one an arm, another a thigh or a leg, and he is thus lifted up and carried to his lodgo without any further difficulty. In the disorders occurring among the insane, as in those taking place in civil society, to repress them and renew tranquillity, measures are necessary which result from experience and knowledge of men, united with an energetic and prompt execution. Sometimes the murmurs and discontent of one will be communicated to others ; a party, as it were, will be formed, as in a popular insurrection, and evil results will ensue, unless the outbreak be avoided at its commencement. Under such circumstances, I have often seen the director brave, with a sort of audacity, this tumultuous effervescence, break through right and left, seize the most mutinous, conduct them to their lodges, and thus almost immediately renew tranquillity and calm.

III.The Necessity of Order and of Studying Character.

The extreme importance is not surprising which I attach to the maintenance of calm and order in a hospital for lunatics, and to the physical and moral qualities which a supervisor demands, since it is one of the fundamental bases in the treatment of insanity, and without it there can be no permanent cure. Sagacity, ardent zeal, continued and indefatigable attention, are necessary qualities in watching narrowly each case, in seizing the curious features of the insane ideas, and the particular character of the derangement; for by age, constitution, habits, the complication of madness with other diseases, and the degree of lesion of the mental faculties, what varieties are created! In certain difficult cases, many months of alike study are scarcely sufficient to decide and fix on, with justice, the particular treatment which should be adopted; but in the greater number of cases-above all, in insanity arising from deep grief-the experience of each day attests the success which consoling conversation produces, by the happy expedient of renewing hope and gaining the confidence of the patient: to employ, then, bad treatment, or a very rigid mode of management, is to exasperate the evil, and render it incurable. Case.-A young man, following other depressing events, lost his father, and some months after, a tenderly-beloved mother: from that time there existed a profound and intense sadness, more sleep and more appetite, and shortly after an explosion of the most violent mania occurred. He was submitted to the usual treatment, as abundant and repeated bleedings, 45 the use of baths, and the douche; with these measures was united extreme rigour: all curative means failed. The same mode of treatment was renewed a second and a third time, and with as little success, or even with an exasperation of the symptoms. He is finally transferred to the Bicetre, and is described as very violent and dangerous. The superintendent, far from blindly deferring to this information, left him free from restraint in his lodge at his entrance, in order to study his character and the nature of his derangement. His sombre taciturnity, abasement, pensive air, and some disconnected remarks respecting his misfortunes, showed the essential character of his derangement through the incoherence of his ideas. They consoled him, they spoke to him with interest respecting his condition ; they succeeded, by degrees, in dissipating his gloomy distrust, and led him to hope for the re-establishment of his affairs. One encouraging circumstance followed this promise, for they obtained from his curator some slight monthly aid to render him more comfortable. The first payment drew him from his abasement, and aroused new hope ; his confidence and esteem towards the superintendent were boundless, and he, by degrees, recovered through the mild and conciliatory course of treatment which had been adopted.

Certain varieties of character may render a patient insusceptible of yielding but after repeated alternations of sallies more or less violent, and the employment of a wise and moderate repression. "In the moral treatment," say the compilers of the British Library, "we are not to consider the insane as absolutely deprived of reason, that is to say, as inaccessible to the motives of hope, fear, and the feeling of honour . . . . It is necessary to subdue them at first, to encourage them afterward." These general propositions are, no doubt, very true and very faithful in their application. Case.-The father of a family, a very estimable person, lost his fortune, and almost all his resources, by the events of the Revolution. The routine and ordinary treatment of insanity by means of baths, the douche, repeated bleedings, and the most inhuman means of repression, were employed. The symptoms, far from yielding, grew worse, and he was transferred to the Bicetre as incurable. The superintendent, without attending to the information that had been given, that this patient was very dangerous, attempted a deep study of his character. No patient had ever given freer rein to his acts of extravagance : swollen with pride, he believed himself to be the Prophet Mohammed, struck right and left all those who came in his way, and ordered them to prostrate themselves and render him homage. He passed each day in pronouncing pretended decrees of proscription and death ; he menaced the servants, and disdained the authority of the superintendent. One day, even when his disconsolate wife came to see him, he behaved contumeliously towards her, and she would have been killed if they had not run to her succour. Mildness and remonstrances would have been useless here. He was ordered to be quiet, and on his refusal to obey, they punished him with the strait waistcoat and a seclusion of about an hour, in order to make him feel his dependance. The superintendent soon took him from his lodge, spoke to him in an amiable tone, reproaching him with his disobedience, and expressed his regret at having been forced to adopt towards him rigorous measures. A return of his senseless conduct font color=blue>46 next day, and a renewal of the repression; the same illusory promises to be more tranquil in the future. A new and third relapse, followed by the punishment of an entire day's imprisonment, and a more marked calmness during the following days. An explosion, for the fourth time, of his haughty and turbulent humour, made the superintendent feel the necessity of producing a decided and more favourable impression. He addressed him with vehemence, and sought to make him lose all hope of reconciliation, and had him hastily shut up, declaring that he would be thenceforth inexorable. Two days passed, and during his rounds the superintendent answered but by a mocking smile to the reiterated entreaties which were uttered by him ; but, through a secret agreement between the superintendent and his wife, she set the prisoner at liberty towards the end of the third day, charging him expressly to restrain his violent behaviour, and not to expose her to reproaches for having exercised too much clemency. He continued calm during many days ; when he could scarcely restrain his dangerous sallies, a look of the lady sufficed to reduce him to order, and he ran and shut himself up in his lodge, from the fear of being again found fault with : all traces of his disease were thus gradually dissipated ; a six months' trial sufficed to render his cure complete, and he then occupied himself diligently in repairing his ruined fortune.

Living among the insane makes us familiar with their particular dispositions, and may suggest, in certain cases, means of seconding an energetic repression. Case.-A soldier, yet insane after submitting to the treatment of the Hêtel Dieu, was, all on a sudden, occupied by the exclusive idea of his departure for the army, and after attempting in vain all mild measures, force was resorted to in order to make him enter his lodge. He tore everything in pieces during the night, and was so furious that the strongest bonds were employed : they left him to dissipate his impetuous fury during the following days. Eight days were thus passed in constant and violent excitement. In the morning rounds of the superintendent he took a most submissive tone, and said that he would hold him to his promise of loosing him from close confinement if he was tranquil. He was answered kindly, all restraint was immediately removed, and he gradually recovered.

Reasoning with them applies only where there is not a complete irrationality. Where they are influenced by a blind fury, and led away by a tumultuous course of ideas without order or sequence, they are to be subdued by the strait waistcoat and strict seclusion; but if judgment yet remains, another important secret in terminating quarrels, in conquering their resistance, and in maintaining order, is, not to appear to perceive their sallies, not to utter a word savouring of reproach; to enter apparently into their views, and to adroitly communicate an impulse which they shall believe to be owing only to themselves. I have thus seen Mrs. Pussin, the matron, approach the most furious maniacs, calm them by a consoling conversation, and make them eat, after an entire refusal to do so. A patient, dangerously reduced from extreme abstinence, one day, setting himself in opposition to her, repulsed the aliment which she offered to him, and lavished upon her the most outrageous terms. She placed herself immediately in unison with his insane expressions; she leaped and danced before him, and, making some witty repartees, caused him to smile, and profited by the 47 favourable moment to make him eat. Three patients, each believing himself to be Louis XVI., energetically disputed one day concerning their rights to royalty: by approaching each one in turn and taking him aside, telling him that she wondered how he could dispute with persons obviously insane, and knowing that he was the king, she thus put an end to the contest, A young man who had been calm for many months, and at liberty in the interior of the hospital, all at once became excited ; he penetrated into the kitchen, armed himself with a knife used to chop vegetables, and leaped upon a table, bidding defiance to every one, threatening to kill the first that approached him. Mrs. P. then observed, "Why do you hinder this capable man from assisting me in work 2" She spoke to him kindly, engaged him to approach her, showed him the manner of cutting up herbs with the knife, and feigned to felicitate herself with having found such an assistant. The patient, thus deceived, and wholly occupied chopping, at a given signal was surrounded by the attendants, who carried him to his lodge, while the matron retained the instrument in her hands.

IV.Importance and Difficulty of strict Order..

A fundamental principle in preparing the cure of insanity, in a great number of cases, is to recur at first to an energetic repression, to be succeeded by kindness, in order to gain the confidence of the patient, and to convince him that only his advantage is consulted. It is the principal of the interior police who should show himself under these two different aspects, and the whole household of attendants should but second his plans, and no other authority should intervene, or evil results must ensue. A patient was only insane as to pretended persecutions; the principal seeking to dissipate such delusions, another au. thority intervened, and she became incurable.

VII. Exercise and Labour fundamental Rules.

It is not a problem, but a result of the most constant experience in all public asylums, as prisons, hospitals, &c., that the most sure, and, perhaps, the only guarantee for good manners and order, is the regulation of mechanical labour rigorously enforced. This truth is, above all, applicable to hospitals for the insane; and I am very strongly convinced that an establishment of the kind, to be durable and of sustained utility, should possess this fundamental basis. Very few of the insane, even in their state of fury, ought to be kept from all active occupation. Constant labour breaks the chain of false ideas, restores the faculties of the understanding in giving them exercise; above all, keeps order in any assemblage of lunatics, and dispenses with a crowd of minute and often useless regulations for maintaining the internal police. At Saragossa, the founders of a hospital have not bounded their provision for labour merely to that of a mechanical nature, but have sought to find a counterpoise to the wanderings of the mind in the attraction and charm which agriculture inspires, through the natural instinct which leads man to fertilize the earth, and thus provide for his wants by the fruits of his industry. In the morning, some fulfil the menial offices of the house, others go to their respective workshops; the greater number are divided into different companies, under the conduct of intelligent overseers; they cultivate wheat, vegetables, and pot-herbs, and are occupied 48 by turns with the harvest, in hedging, in the vintage, and in gath. ering olives. The most constant experience, in this hospital, has taught that this is the most sure and efficacious means of cure, while the nobles, who scorn labour, do not get well. This is an example for us which cannot be too well known. Labour or pleasant exercise arrests the wandering ideas of the insane, prevents the flow of blood to the head, and produces tranquil sleep. I was one day deafened by the tumultuous cries and acts of a patient; field-labour conformable to his taste was procured, and thenceforth I did not observe, in conversation with him, any confusion of ideas. Nothing is more worthy of remark than the calm and tranquillity which formerly reigned among the patients of the Bicetre when the merchants of Paris furnished a great number with manual labour, which fixed their attention, and proved agreeable by a slight attendant recompense. I have been always prevented by circumstances from procuring land, and have been limited to subsidiary means, choosing the attendants from among the convalescent patients. In the hospitals of Holland much expense is saved by giving the duties of attendants to convalescents. The object of labour would be fulfilled in its whole extent by adjoining to a hospital a vast enclosure, or, rather, to convert it into a sort of farm, of which the labourers should be under the care of convalescents, and the products from the culture of which should go to their use.

If a love of the fine arts, of the sciences, or of letters has characterized the individual when sane, it is often at the dawn of returning reason that this becomes renewed, and the first revelation of talent should be seized with avidity by a superintendent for the purpose of encouraging it. A musician whose insanity exhibited itself in monosyllabic discourse and senseless actions, on his approach to convalescence called to mind his violin; it was given him, and, with marked beneficial results, he played on it for eight months, and with his former skill. At this epoch he met in the garden a newly-received patient who was highly excited; he was so much affected that he broke his instrument and became incurable-a memorable lesson of the necessity of classification and isolation. The insane are apt to feel deeply the least sign of indifference, forgetfulness, or contempt. A sculptor at the Bicetre, who had been in a most violent maniacal condition for many months, had become calm, and was given the privilege of freely going through the interior of the hospital; with a feeble state of intellect, a desire of painting (which art he had cultivated) came over him. After attempting two portraits with success, but with distrust of his skill, being asked to finish a picture, his request for a design was eluded, and in his indignation he tore to pieces his materials, and declared that he renounced the fine arts forever: a state of languor approaching dementia followed an access of fury of many months' duration. I made him pass into the infirmary to try the combined use of some simple remedies and a tonic regimen, familiar conversation, advice, and consoling discourse. The love of the fine arts seemed lost forever, an apathetic melancholy succeeded, and a colliquative diarrhoea put an end to his existence. The general law of mechanical labour is equally important for idiots of both sexes as for the insane. At the Salpétrière there is a large work-room for sewing adjoining the dormitories of the convalescents, and where these assemble to pass the whole day together, encouraged by a light 49 recompense which they derive, giving to the most active a certain resource on their discharge, besides habituating them to occupation on entering again on their household affairs. We cannot sufficiently express the happy influence on the return of reason exerted by this regular assemblage of so many persons, conversing freely upon their concerns. The superintendent often visits them, to be a witness of their active industry, &c. It is here that, by familiar conversation and benevolent exhortations, certain sad and melancholy ideas become dissipated, in comparing the females who are not yet well with those who are happily restored, and whom, as an object of emulation, they take for models. It is very rare to see these persons, who are constantly laborious, subsequently experience a relapse. The natural propensity of the insane to paroxysms of anger, their tendency to give to circumstances the most unfortunate meaning, and to indulge in complaints, makes us feel the necessity of an invariable order that their condition may not be rendered worse; hence the measures which we put vigorously in execution at the Bicêtre. The hour for opening the lodges is fixed, according to the variations in the seasons, at five A.M. in summer, and at half past seven in winter, and so on in ratio; the extreme attention to remove the filth of the night, and to provide fully for cleanliness; the general visits of the superintendent in the morning, to assure himself that nothing has been neglected; the meals at a certain hour, and cleaning after them-at a little after rising, at eleven, and at four or five; the closure of the lodges at twilight; the night-watch to succour the sick and control the furious ; the assiduity and presence of the servants at every ho cur of the day imperiously exacted to maintain order, to act in concert if the patients quarrel, or on an explosion of insanity; their express direction never to strike a patient; and their tactics, as it were, by signs, preventing all the audacious efforts of the maniacal: in one word, the general direction of a hospital assimilates to that of a great family composed of violent and turbulent beings, whom it is necessary to repress, but not to exasperate ; to restrain rather by sentiments of respect and esteem than by servile fear, when they are susceptible of it, and to manage them most frequently with mildness, but always with an inflexible firmness.

VIII. General Precepts to follow in the Moral Treatment.

One of the principal rules in a well-regulated hospital is to have a central authority, who shall decide without appeal, haying the sole control over both domestics and patients, and being never interfered with either by any other officer or by the friends of the patients. A young melancholic female, in a condition almost entirely convalescent, was thrown completely back by a permission to visit her, obtained surreptitiously. It is very important, says Haslam, to gain their confidence, to excite in them sentiments of respect and enedience ; these are, perhaps, but the fruits of superiority of talents, discipline of temper, and dignity of manners. Imbecility, misconduct, and empty consequence, though enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt. The superintendent who has onoeaitcb ned an ascendency may direct and regulate the conduct as his judgment points out. He should possess firmness, and when occasion may require, should exercise his authority in a peremptory manner. He should never threaten, but execute; and when the patient has 50 misbehaved, should confine him immediately. When he is a powerful man, two or more should assist in securing him, in order to inspire fear, and obtain prompt obedience without any difficulty or danger. The same author does not the less proscribe all acts of violence, all corporeal punishment, as absurd cruelty where the patient cannot comprehend it, and as exciting a desire for vengeance when he is conscious of his fault. Case.-A man at the Bicêtre, in the vigour of his age, believed himself a king, and spoke very authoritatively: the treatment at the Hôtel Dieu, with the roughness of the attendants, had but made him more violent and dangerous. Constraint and condescension appeared alike inapplicable here : it was necessary, then, to watch for some mode of influencing this difficult case. One day he wrote to his wife a letter full of ill feeling and abuse : on showing it to another patient, he was reproved in a friendly manner, as seeking to drive his wife to despair; he therefore replaced it by another full of moderation and regret. The superintendent, regarding this as a favourable symptom, went immediately to his lodge, and led the conversation to the subject of his derangement. If you are a sovereign, he observed, why are you detained among the insane ? He renewed the conversation in a friendly manner the next day, and pointed out a ridiculous patient affected with similar false ideas: in fifteen days he acknowledged his delusion, and in a few months was discharged. Case.-A patient in the Bicêtre, who had. no other delusion but that of believing himself a victim of the Revolution, constantly repeated that he was willing to submit to his lot, refused to lie on his bed, and remained stretched out on the moist pavement. After measures of mildness, he was finally tied upon his bed, but he sought revenge by refusing all nourishment. On the fourth day of his fast, thirst made him take cold water in abundance from hour to hour; towards the twelfth day the superintendent announced to him that he should substitute soup for the water, since he was so obstinate; his thirst made him swallow it with avidity, and he was given cold water. He consented to take, the same evening, another dose of broth, and subsequently he passed on to the use of rice, pottage, and other solid aliments. It is extremely necessary in melancholia for patients to communicate their deep grief, and for us to make a powerful diversion from their false ideas, and act upon their senses by energetic and long-continued impressions. At the two extremities of ancient Egypt were temples dedicated to Saturn, to which the melancholy resorted in crowds, and the priests, under the pretext of a miracle, cured them by a resort to all the natural means which hygiene can suggest. Games, and recreative exercises of all kinds, were instituted in these temples; voluptuous paintings and seducing images were exposed to the eye on all sides; the most agreeable singing, and the most melodious sounds forever charmed the ear; they promenaded in flowery gardens, and in groves ornamented with exquisite art; sometimes they sailed on the Nile in gayly-adorned boats; at others, they were conducted to laughing isles, where, under the symbol of some protecting deity, they procured for them new and ingeniously devised spectacles and choice society. Every moment, in fine, was consecrated to some comic scene, to grotesque dances, to a system of amusements diversified and sustained by religious ideas. A particular and scrupulously observed regimen; the journey necessary to carry them to the sacred spots; the continual fetês designedly instituted along the route ; hope, fortified by superstition 51 and the talent of the priests, had power to suspend the feeling of grief, to calm their disquiet, and to produce oftentimes salutary changes, which went to the credit of the tutelary divinities. In the measures adopted in these antique establishments lies imbodied the end which should be aimed at in all institutions for the melancholy patience, firmness, sentiments of humanity in management, constant assiduity to prevent excitement and exasperation of spirit, agreeable occupations, and suited to the difference of tastes, various exercises of the body, and a spacious habitation planted with trees, the pleasant tranquillity of rural manners, and, at intervals, a music sweet and harmonious, and the more easy to obtain, as there is almost always in these establishments some distinguished artist of this kind whose talents languish for want of exercise and cultivation. Severity, seclusion, and strict restraint are condemned by the results of experience, which prove that a cure is to be achieved, in the greatest number of cases, by granting the patient a limited liberty in the interior of the hospital; by permitting all the movements of a harmless excitement, or, at least, limiting the repression to the use of the strait waistcoat, without omitting the other rules of moral treatment of which their condition is susceptible. Nothing is more constant than the powerful influence which a superintendent exerts who is guided by the true principles of philanthropy. Willis, Fowler, Haslam, Dicquemare, Poution, Pussin, and the steward of the asylum at Amsterdam, are examples of this. Case.A patient in the vigour of age, and very strong, who had been brought to the just-namied asylum bound upon a cart, alarmed all those who had brought him, and nobody durst unloose him to conduct him to his lodge the steward sent away the crowd, talked with him some time, gained his confidence, and, after untying him, conducted him to his new abode. Every day his influence over him increased, restored him to reason, and returned him to his family. He who is wise and enlightened views the outbreaks of insanity as proceeding from blind impulse, or, rather, the necessary effects of a nervous excitement, against which we should no more be indignant than against the fall of a stone induced by specific gravity. He grants to the insane freedom of motion, to as full an extent as can comport with their own safety and that of others ; he adroitly conceals from them the means of constraint which are employed, as if they do but obey the laws of necessity; he is indulgent to them, but he also knows how to resist their inconsiderate importunities with force, or elude them by address. The stormy period at the commencement of the spent in studied management, and the intervals of calm are profitably employed to render the paroxysms less intense and less durable. I can rightly judge of the advantage of shunning a too strict seclusion; for while the most wild and furious patients of the Bicêtre were kept chained in their lodges, they were in continual agitation day and night: there were continual vociferations, tumult, and uproar; but after the strait waistcoat had been adopted, these patients walked freely in the courts, their excitement was dissipated in continual efforts during the day, and at night they were more calm and tranquil.

IX.Precautions as to Religious Opinions.

Case.-A young lady fell into the most furious derangement in consequence of extreme religious scruples, and at the least opposition to her will she invoked fire from heaven to consume the culprit. 52 her entrance into the hospital she was in violent motion: she menaced and struck blows: they conducted her to her lodge, and applied the strait waistcoat. The superintendent came to see her some hours after, and ridiculed her respecting her impotence to make fire fall from heaven, since she could not disengage herself from the waistcoat. She became more calm the third day, and was given the liberty of walking in the court during the remainder of her treatment. It is especially necessary to repress in madness excessive pride, disdain, and arrogance, particularly if inspired by a mistaken devotion. Case. -A young patient expressed herself, on her entrance into a hospital, with an extreme arrogance : she abused the superintendent because he appeared before her with his hat on; be regarded her with fierceness, and addressed her in a commauding bone ; he thundered, he menaced her if she dared to be rebellious against his supreme orders. Intimidated, she retired in silence into her lodge; the next day she became calm, and remained so during the rest of her treatment. But it must be acknowledged that thus subduing a case from devotion is perhaps applicable but in some particular instances, and that many others entirely resist repression, as being inspired by the Deity, whom it is worse to disobey than men. How can we succour a state of despair from imaginary unpardonable crimes but by consoling discourse and tact in gaining the confidence of the patient? An old nun, formerly an instructress, was brought to the hospital in a state of the most profound melancholy; different physical and moral means were all in vain ; she incessantly repeated to the superintendent that he ought to consider and punish her as the greatest of criminals. At last, one day, to such an observation she was answered sharply that he did not wish to hear her speak again, as her ideas were always the same, and she showed no confidence in him : she retired in silence, and reflecting deeply upon her ideas of criminality on tire one hand, and, on the other, the amiable remonstrances of a man who must be influenced by the best motives, she finished by becoming fully convinced that her scruples were chimerical, and did not ask but to labour ardently for recovery by the use of some other physical means. Experience teaches that patients deranged from a religious cause have their disease perpetuated by keeping their books of piety, and may thus even be rendered incurable. Religious ceremonies have also sometimes a bad effect.

X. Restriction as to Communication with Persons out of the Hospital.

Experience has taught that the insane are scarcely ever cured in the bosom of their families. Willis, in his establishment, placed extreme restrictions on the interviews of patients with their relations he only granted them in certain cases, under the title of encouragement and recompense, and then very rarely. In Bethlehem Hospital a permission of entry is indispensable, and on the admission of a patient they give to his family the power of visiting him only once a week. In France, aiso, the disadvantage from the visits of too many strangers has been sensibly felt; and at the Salpétrière a permission is necessary. I have seen a patient, in the decline of a paroxysm, conduct himself with the highest degree of fury and violence against one who had provoked him through the window, causing him to suffer a relapse of more than a year's duration. Another patient, a merchant, 53 who had become deranged from loss of fortune, was rapidly convalescing, when he learned that a certain part of his property had been made away with, and a female came to see him wearing ornaments which had belonged to him: he became melancholy, and by degrees demented, and is now incurable. Both in England and France experience has proved the necessity of asylums: Haslam, for instance, may be cited in their favour. It is universally observed that the insane are scarcely•ever restored under the immediate direction of their friends and neighbours. Their visits even augment the patient's excitement. However, in the progress of convalescence, some visits at intervals appear to have the most happy influence : they console and open to them in the future a new prospect of happiness and hope. Many lunatics, who were furious and intractable at home, are calm and docile in a hospital. The visits of persons of whom patients have reason to complain, or who excite disagreeable recollections, may have very hurtful effects : a widow in a convalescent state, although wholly uninjured by the visits of two of her daughters who had acted well, was so affected by seeing a third who had acted badly, that she relapsed, and became incurable. I could multiply sad instances of bad effects from the premature visits of relatives or others who had previously held peculiar relations towards the patients. It ought not to be forgotten that, even during convalescence, the empire of reason is yet feeble, and that in the visits which are permitted to relatives and friends, they should beware of exciting lively emotions, and thus tending to produce a relapse. The precise period of convalescence when their friends may see them without danger is difficult to settle: many circumstances must here be taken into consideration, as, for instance, whether the person to be seen is an object of aversion to the patient or not. Insane mothers should never be suffered to see children who are strangers to them : this sometimes excites the most stormy scenes. A patient in the decline of the recent stage escaped through tire door of the court, found a child, seized it, and violent efforts were necessary to get it from her: she was, after this, violent and furious for many months.

XI. Measures of Vigilance Exacted by Certain Perverse or Violent Patients. .

In the paroxysms of periodical mania, if the patient is dangerous, it only remains to keep him shut up; or to fix him upon his bed by the aid of the strait warstcoat~ and a girth ; but a wise and experienced superintendent sometimes seizes happy means to render himself master of the patient, even from the first days, by mild management, and causes the fury and delirium to cease simultaneously. Case.-A very sensitive person, aged twenty-eight, experienced profound grief and a sudden suppression of the menses; the two following periods were marked by slight delirium. In the third month the disorder of her ideas was extreme, and she fully believed that certain perverse inclinations which subdued her could only be attributed to the suggestions of the demon. She went about begging to be exorcised, and incessantly crying out, the devil, the seven angels of the Apocalypse, &c. Her face was red, her voice strong, her eyes brilliant and wandering; she attributed a spasmodic oppression of the throat to the efforts of the evil spirit to strangle her. Chaplets and mystic images were suspended around her neck to dispel her evils. On her admission in this state at the Salpétrière, 54 the director spoke to her in a firm and energetic tone. He assured her that the demon never entered into this asylum, and took away the chaplets, &c. She made no resistance, laid down and slept a tranquil sleep. The next day she could not conceive how she could have believed herself possessed, and recognised her error. The twelfth day there were free excretions, and tranquil sleep a part of the night. The fourteenth clay a little sleeplessness, thirst, and perspiration. Warm baths seconded the return of the menses, which took place the twenty-eighth day. Her melancholy ideas, and irregular and transient delirium, gradually disappeared. Towards the end of the third month reason was entirely established. Case.-A young country girl, of great purity of manners, was grossly insulted at the moment of menstruation by another female and fell into a furious delirium; nine female attendants could with difficulty shut her up on her arrival. Three days had scarcely passed, when the superintendent examined her with care, spoke to her mildly, and gained her confidence : she became calm and tranquil the same day, and from the day after she was able to pass to the dormitory of the convalescent. An old nun in the Salpétrière, affected with mania without delirium, in its pure form, that is, with scarcely any lesion of the understanding, offered a good example of this variety of insanity : she continually struck, and loaded with the most insulting epithets all those around her; she would throw her clothes in the fire, and complain of being left naked; would throw her food at the attendants or hide it, and then complain of being starved. Being dangerous to the other patients as a source of confusion and discord, she was kept sequestrated in a solitary lodge. Against the secret plots of such patients it is necessary to guard with care. A patient of this kind, a female of rank, by promises of wealth, &c., to the attendants of the hospital, had so gained them over to aid her, that the wall of the asylum had been surmounted before an escapa was discovered. The hospital was delivered by the police of so dangerous a female, who had no disease of the understanding except reflections resulting from an intense immorality. It is important to distinguish a sort of reflecting wickedness, which is connected with the free use of reason, as in the preceding cases, from that consciousness that appertains to a diseased condition, which should be submitted to regular treatment; although the patient reasons with exactitude, yet he is sensible of his condition, and of the irresistible propensity which bears him forward to disorder, or even to the most culpable actions. At the Bicetre, under the old system, a patient, subject to periodical attacks of insanity, asked himself that they should put off his deliverance from his chains until he felt himself able to subdue the blind impulse that led him on to acts of violence. The humane means of repression which I have detailed are now established at the Salpetriere, and in the private asylum of M. Esquirol. The difficulty of adopting elsewhere these measures consists in the fact that two objects are united which seem incompatible: the repression of a patient by resisting with energy his senseless will, and the happy gift of gaining his confidence by convincing him that we use severity merely for his good, in order the more surely to obtain a cure. Case.-A young person, aged 27, brought up with care, but with great indulgence, without determinate cause, fell into a lively and wanton madness; at the hospital she leaped, danced, and delivered herself to a thousand irregular movements. She was 55 given some laxative drinks, and baths; and the director and his wife treated her with the utmost mildness, and did everything to obtain her confidence; but she always retained her presumptuous character, and did not speak of her parents but with bitterness, reproaching them for having confined her in a hospital. The superintendent, at the moment of bathing, expressed himself strongly against certain unnatural persons who disobeyed their parents and despised their authority. He forewarned her that she would be thenceforth treated with merited severity, since she opposed her own cure, and concealed the cause of her malady. She was deeply moved, reflected on the subject, and in a day or two acknowledged her bad conduct, and confessed that her derangement had been caused by disappointed love. The most favourable change then took place : she expressed gratitude to the superintendent, and her convalescence made rapid progress. The means of repression sometimes excite the dislike of the patient, which is only removed by convalescence. Case.-A young female, indulged from her youth, experienced in her family a furious attack of madness. At the hospital, in this condition, the use of acidulated and laxative drinks made her pass for many days a blackish matter, and the symptoms diminished; but the energetic means of repression--baths, the douche, and the strait waistcoat, were insupportable, and inspired her with an intense hatred for the superintendent, who was, on the other hand, constantly desired by her parents to continue these measures. The exasperation of the patient sensibly retarded convalescence. The parents, on a fixed day, came to the hospital, and announced that they had earnestly solicited the treatment which she had received. She immediately recognised the true value of the care which had been lavished upon her, remained calm, took a smiling air, and her convalescence made a rapid progress. Difference of temperament, taste, age, &c., necessarily induces variety in our modes of management, and in the choice of means proper to gain their confidence, and to mantain constant order in a hospital. It is sometimes necessary to know how to take suitably the tone of authority and command, in order to arrest a paroxysm of petulance or of exaggerated pretensions. Case.-The old cook of a person of quality was transferred to a hospital, with all the signs of mania without delirium: some time after, she was agitated, impatient, in turn shed tears, and flattered herself that she would shortly regain her place; she believed herself a privileged person, became very indocile, and took little heed of the orders given to her; she even struck an attendant who waked her too quickly in the morning; she replied with haughtiness to the superintendent, who reproached her with her conduct. Force was then resorted to, and after some hours' seclusion she felt her dependance, and remained afterward calm and docile. Case.-A female, in the decline of the maniacal state, retained still, at intervals, fits of passion, which she could not subdue. She one day seized a knife and threatened to kill all those who opposed her will. The superintendent being informed of this, caused the attendants to interfere successfully and without accident, and he had her carried to the bath. As she had already regained the use of her reason, he represented to her the danger of her sallies, and made her receive a strong douche on the head, which was repeated the next day. He showed her, at the same time, other persons around her who took the baths, but to whom the douche was not given, because they were 56 tranquil, and never sought to wound with a dangerous weapon. After the third day, the fear of the douche, through its moral influence, produced a calming effect, and, after the trial of three months' treatment, she was restored to her family. A case from religion had become less incoherent, but was unsociable: she incessantly got angry from the most frivolous causes: it was a crime to sing, speak, or move near her, and these were subjects of great complaint. The superintendent had her led to the bath, represented how much her presence created everywhere confusion and disorder, and explained in a very precise manner the motives which determined him to give her a stong douche in order to repress her passions, while he abstained from giving it to others who were also at the bath. Three similar operations during a week sufficed to render her calm and moderate, and she thereafter worked assiduously in the sewing-room. The necessity of the most strict and impartial justice in repressive measures, and the importance of making the insane understand our motives, when they are capable of doing so, in order to merit more and more their esteem and confidence, and to induce in them the calmness so necessary to obtain a solid and durable cure, are, in general, points fully settled between the physician and the director. Incessant and careful attention is requisite in the general distribution of the insane in different departments, to make them pass from one to the other, according as they are changing for the better or the contrary ; to always encourage, sometimes to repress, to inspect in detail every part of the internal management, to guard against the contagion of bad manners, to foster quietude everywhere, and to remove all objects of confusion and discord. Daily experience teaches the necessity of having, at some distance from a hospital, seven or eight lodges, where may be kept in isolation and seclusion, for a greater or less length of time, certain of the insane who are not furious, but very turbulent and very indomitable. In this number are, 1. Those who cannot be induced to labour, and who, being always in a state of mischievous activity, take pleasure in harassing the other patients, and in provoking and exciting- incessantly subjects of discord, while the ordinary means of repression do not produce in them the least reform. 2. Devotees, who believe themselves inspired, who seek constantly to make proselytes of others, and who take a perfidious pleasure in exciting the patients to disobedience, under the pretext that it is better to obey God than men: mildness, menaces, and repressive measures fail equally with characters always ready to act in an inverse sense to the impressions which it is proper to make upon the insane in order to restore them. 3. Females who have during their paroxysms an irresistible propensity to take away everything that falls in their hands, who go into the rooms of other patients, bear off everything found there, and create disputes of interminable altercation. It would, doubtless, be very easy to abandon every patient to the bottom of his lodge as an unconquerable being, to load him even with chains, and to treat him with extreme severity; but constant experience cries out against this. An inviolable law in establishments for the insane should be to grant to the maniac that extent of freedom which his own safety and that of others permits; to proportion the repression to the importance, more or less great, or to the danger. of his bad conduct; to rigorously prevent roughness and acts of violence in the attendants; to collect all the facts which may serve to enlighten the physician as to treatment ; 57 to study with care the particular varieties of manners and temperament, and to employ, according to the indication, mildness or firmness, a conciliatory course, or the imposing tone of authority and of an inflexible severity.

XII.Management of the Melancholy.

The management of patients labouring under melancholia requires equal talent and zeal as m mania, to dissipate the exclusive ideas and to arouse the courage. Case.-A very rich, middle-aged man remains sedentary during many months,becomes morose, and subject to the most pusillanimous fear:. A great voracity succeeds to a loss of appetite. He sleeps little, and passes the night in continual fright; believes himself to hear words spoken in a low tone of voice, and an instant after, carefully shutting his door, thinks that lie has not shut it, and goes back again and again. He experiences great irritability in his ideas and in his will; wishes and does not wish and is always tormented by suspicion and mistrust; he complains often of spasms, and of what he calls nervous shootings in the abdomen; fears to respire the external air, and keeps himself always shut up; knows that he is not doing as he ought, but avows that he is unable to change his manner of living. Firmness, the continued use of mild laxatives, and riding on horseback, have made this melancholy to cease. Case.-A young person fell, without any known cause, into a sombre moroseness, and suspected all around of wishing to poison her; the same fear pursued her after quitting the paternal mansion and taking refuge with one of her aunts. Her suspicions were so great as to make her refuse all sorts of nourishment at a boarding-house the same symptoms existed. At the Salpétrière, as she was tranquil, she was placed in the dormitory of the convalescents. She was so noisy in the night that she had to be moved, and was confined in a lodge, where she continued to exercise her suspicions. The visit of a stranger exasperated her melancholy, and from that day she refused with obstinacy all sorts of nourishment. The strait waistcoat was ineffectually applied to induce her to eat; the douche was then employed: at the moment she promised, but away from the bathing-place renewed her refusal. The next day food was carried to her while in the bath, with the injunction to partake of it or have the cold water poured on her bead: she obeyed without repugnance. The tokens of interest felt in her, and consoling and pleasant conversation, finished by gaining her confidence; she commenced working assiduously, and by degrees her illusions and chimerical fears vanished. Case.-A mother, noted for her extreme attachment to her family, and whom domestic griefs had thrown into the most profound melancholy, regarded the aliments offered to her as being food intended for her children, and repulsed it with indignation; recourse was found expedient to the douche many times, to ward off starvation. The absolute refusal of nourishment in a good asylum calls for the greatest perseverance and a multiplicity of endeavours. Recourse is first had to mild means, to pressing invitations to open the mouth, which is kept closely shut. If the patient perseveres in his resistance, and is unwilling to chew solid nutriments, a trial is made of nourishing drinks, broth.with rice, vermicelli, or milk, introduced by an iron spoon to separate the teeth. Should this means prove insufficient, recourse is had to the spout of M. Pussin : the nostrils are closed, and when the patient opens his 58 mouth to breathe, he is made to swallow some substantial liquid, which proceeding, oftentimes repeated daily, is continued many days. In one of these cases, when other means had failed, I had an elastic sound passed through the nostrils, through which liquids were passed into the stomach. The most active care is requisite in removing all the external signs of religion, such as books of devotion, images, crosses, and relics, since the most repeated experience has shown that relapses often result from them, and that they are always a very great obstacle to successful treatment. The suicidal propensity frequently accompanying melancholy calls for strict watchfulness. Case.-A very amiable female, tenderly beloved by her husband, fell into this atrabiliarious condition subsequent to childbed, and made repeated suicidal attempts. She had, on her admission, excessive disgust for life, and made constant efforts to destroy herself: she took verdigris, she bruised her breast severely by blows with a stone, and she tried to strangle herself with a lacing cord; but all her efforts were in vain. From time to time she made other attempts, but was finally dissuaded from them by mild methods, the continued use of tepid baths, diluting drinks, and assiduous employment. In melancholy, we must accommodate our moral treatment to the character which the patient assumes; for some of the melancholy are not timid and sensitive, but deceitful and haughty, and would become entirely incurable from misplaced indulgence. Complaisance to such patients makes them more conceited and imperious, and ends in rendering them incurable. The necessity for a supreme head in institutions for the insane becomes still more important with regard to the management of the melancholy, as they are always disposed to seek a protector, and if such a one is found, their erroneous ideas are only confirmed, and they become incurable. The attendants should be carefully prevented from being rough with the melancholy, although they ought to be ready at the moment to combine against any sudden explosion on the part of a patient. Case.-A patient at the Bicetre, labouring under mania without delirium, marked by a blind fury, had each paroxysm attended by a strong flow of blood towards the head : during the access he felt an irresistible sanguinary propensity, and if at hand, he would seize any cutting instrument to wound the first person that came in his way. He felt his situation, and had the use of his reason even in the access of fury. The contest between his reason on the one hand and his blind propensity on the other reduced him sometimes to despair, and he one day seized the knife of the shoemaker of the hospital and gave himself a severe wound in the right breast. Strict seclusion and the strait waistcoat arrested his suicidal projects.

Onanism is often contracted before puberty, but in the most discreet and decent young persons it sometimes springs up in a maniacal attack; it may be perpetuated and become a sort of chronic affection, or may become communicated by a sort of contagion to other patients, if this is not prevented by an extreme watchfulness. For those who have lost all modesty, who are completely shameless, nothing remains but confinement in retired lodges, in order that other patients may not be infected by their example.

Medical Treatment..

Two methods are in use for the treatment of insanity : the one, very 59 ancient, consists in interrupting the malady in its progress by repeated bleedings, by strong douches, by cold baths, or even baths of surprise, and in a strict seclusion. The other, which is adopted at the Salpétrière, regards insanity as an acute disease, which has its successive periods of intenseness, of decline, and of convalescence; whose order should not be disturbed, but whose symptoms it is necessary to calm by mild means, as warm baths, laxative drinks, and sometimes sedatives or very light douches; in certain cases an energetic repression, but short, and constantly kind manners, or the happy art of gaining the confidence of the patient.

I. Striking the Insane as a Means of Treatment.

I am opposed, for many reasons, to blows as a means of cure; which measure has been in constant use; which has been recommended by Celsus ; which has been partially sanctioned by Willis; which was the strict discipline of a celebrated monastic institution in the south of France; and which was used by a farmer in Scotland, who worked patients sent to him as beasts of burden, and who was famous for the cure of insanity. Blows are incompatible with the character of the French nation, and would rather suit those who had been always slaves. Patients transferred from elsewhere to the Bicetre, and designated on their arrival as very violent and dangerous, because they had been exasperated by blows and bade treatment, seemed suddenly to assume an opposite nature when they were spoken to with mildness, when their misfortunes were commiserated, and when they were given the consoling hope of a better lot. Convalescence then progressed rapidly without any other device. The most constant experience does but teach that, to render the effects of fear solid and durable, this feeling should be allied with esteem in proportion as reason resumes its away. When a maniac, led on by a blind fury, delivers himself unceasingly to piercing cries and menaces, being sleepless, and in constant agitation for many months-when he tears to pieces even the straw of his couch, an antispasmodic, in a greater or leas dose, will sometimes calm him, and cause even the symptoms of violence to cease; but observation teaches, also, that in a great number of cases we may obtain a sure and permanent cure by mild and moderate means, by leaving the patient to his tumultuous excitement, by using no greater repression than that for which his own safety and that of others calls, which is obtained oftenest by the strait waistcoat; by guarding against exasperating him from a misplaced severity and provoking conversation; by shunning all possible refusals, all sharp replies, when he unreasonably solicits to be set at liberty, merely differing from him under plausible pretexts; finally, by keeping up the most strict police in the interior of the hospital, and, above all, profiting by the intervals of calm to induce regular occupation and hard labour.


Is the frequent use of bleeding founded upon full experience ? Upon the admission of patients into the hospital we have always interrogated their friends as to their being bled : the moat constant answer was, that immediately after the bleeding the patient was worse. Two young parsons, of the same age and analogous temperament, arrived at the hospital the same day ; one of them had not been bled, and she was, 60 cured in two months ; the other had been copiously bled, and had been reduced to a sort of idiocy ; she did not recover her speech until towards the fifth month ; her complete restoration only occurred at the end of the ninth. Case.-A female, aged 36, affected with maniacal delirium from fright, continually cried out; her menses were suppressed, her face very red, her eyes sparkling, and the vessels of the conjunctiva injected. She was bled moderately from the foot; shortly after, she fell into a complete state of idiocy, in which she remained two years. Among the patients received at the Salpétrière, those who have not experienced any previous treatment are precisely those most easily cured. A bleeding is a very rare event, and makes an epoch in the hospital since I have directed the treatment. I am far from wishing to pronounce an entire exclusion of blood-letting in insanity, but I believe that cases of its judicious use are exceedingly rare.


Van Helmont recommended submersion in water: this measure has been transmitted by Boerhaave through the schools of the last century; has been the practice of hospitals ; and plunging the patient by surprise in cold water is the advice of Cullen. This is a dangerous measure, and more apt to excite rage and the desire of revenge in the individual than to do him good. Case.-A man, aged 28, of a robust constitution, from reverses in the Revolution, exaggerated the evils of the future, fell into a profound sadness, lost sleep, and became suddenly a violent maniac. He fancied himself an Austrian general: the treatment of acute mania was used in the city of his department, and cold plunging-baths were frequently employed: he was only made worse, taking the tone of command at the time of the bath, and becoming furious at the palpable disregard of his supposed rank. He was then sent to my care in Paris; he appeared very passionate and violent, and I felt the necessity of lending myself to his delusion in order to gain his confidence. I paid him deference, treated him with mildness, restricted him to diluents, with the liberty of constantly promenading in an agreeable garden; I also conversed familiarly with him from time to time. He gradually grew calm, and towards the end of the month there was no remains of haughtiness or defiance : in three months all traces of his delusion had disappeared. But afterward, on the access of.a more animated look, and a little more loquacity and petulance, I made him take, at intervals, during fifteen days, whey rendered purgative, and then some warm baths, under the pretext of cleanliness,, to avoid arousing his old repugnance. An explosion was thus prevented, and after the stay of a year as a trial, he went out, and has been engaged for ten years in study and agriculture. We should always distrust reasonings, even the most specious, in favour of the direct action of any remedy; these, and the authority of celebrated men, have their proper value; but it is always a constant and well-sifted experience that can take away all uncertainty. I leave, therefore, the indications which baths are calculated to fulfil, such as relaxing the skin, &c., to pass for just as much as they are worth, and proceed to my own experience in the matter. At the Bicêtre, circumstances prevented the full use of baths; but at the Salpétrière, for eight years they have become the fundamental basis of treatment in both mania and melancholy: twelve bathing-tubs are in constant use during a greater part of the day. Patients in all stages of 61 the disease are in general admitted, and the baths are continued a longer or shorter time, or suspended, according to the intensity of the symptoms: for the sake of decency, the tubs are covered. A happy combination of the douche with the bath adds yet the more to its efficacy, and prevents even the least disadvantage which might otherwise arise. At each bathing-tub, and directly over the head of the patient, is a pipe, capable, by the aid of a cock, of letting fall from three feet high a thread of cold water, proportioned to the end proposed, and graduated according to the symptoms, but, in general, very small, and confined to a simple sprinkling. (The douche of repression, already spoken of, fulfils another purpose, and the head is then suddenly inundated.) It is only towards the end of the bath, and during some minutes, that the douche is administered, diminishing thereby the tendency to the head. The douche is even omitted frequently at the decline of the disease and during convalescence, when recourse is had to the bath at intervals, but it is renewed upon the approach of an access of mania, or when it has already burst forth; but douches from seven or eight feet, of many lines in diameter, and continued for a length of time at the will of the attendants, are wholly proscribed. The superintendent has the whole management of the measure. If there are marks of but slight excitement towards the organs of the head, the measure is restricted to letting fall drop by drop on the head of the patient, which, by its coolness from evaporation, is perhaps more advantageous than the English application of snow to the top of the head. M. Esquirol tried the douche upon himself: the reservoir was ten feet above his head, the water ten degrees below the temperature of the atmosphere, and the column four lines in diameter: it seemed to him as though a column of ice was split upon the part; the pain was very severe when the water fell on the fronto-parietal suture, and was more supportable on the occipital. The head remained as though numbed more than an hour after the douche. This is very different from the douche as used at the Salpetriere. Here care is taken to banish all associations of terror, and to familiarize the patients with the proceeding, by making the threat; in a smiling manner, of a slight sprinkling upon the head of those whose reason has not gone entirely astray, and who have given way to some sally. The superintendent himself, in going through the work-room of the convalescents, makes it sometimes an object of pleasantry. Moreover, the douche is not given until towards the end of a tepid bath, at from 22° to 24° (88° F.) Reaumur, and is never prolonged above one or two minutes, reducing it to a very small thread of cold water, which is made to fall successively upon different parts of the head. In winter the patient is placed immediately after in one of the beds of a little court adjacent to that of the baths, and in summer is conducted to her own bed. If the patient weeps, she is consoled and encouraged, and it is recalled to her mind that she suffers a little only to be more promptly cured. Acting always with an array to affright is a false system; so also is continual contradiction. At the Salpétrière, rigour and firmness are only displayed in order to subdue the patient, to lead her back to order, and to render her docile ; so soon as she is submissive and resigned, when reason begins to regain her empire, and to make her confess her faults., all is changed towards her, and she has to expect nothing else but mild and kind manners. 62

IV.Treatment in the first Period of Mania.

An insane institution should be so constituted as completely to separate maniacs in the three periods of the disease; that is, when the symptoms are extremely intense, when their decline is very marked, and in convalescence. The most constant observation teaches that, when nothing interrupts the regular progress of insanity, and when this is happily seconded by appropriate management, the symptoms do not preserve all their intensity except during a certain time, more or less in duration ; and that the method of causing extreme debility by bleedings and rigorous abstinence does but disturb the course of the disease, render it longer, and sometimes periodical, or soon produce a state of stupor and a sort of idiocy. We should only attempt, if the patient is very violent, to subdue his impetuous fury, and to render his efforts vain, by the use of the strait waistcoat. The febrile symptoms which often manifest themselves early in the disease, such as paleness or redness of the face, frequency of the pulse, and a very fetid odour, quickly yield to diluents and acidulated drinks. The first object to fulfil on the arrival of a patient in a hospital is to furnish him with an abundant nourishment, and by this alone, in a fortnight, we often produce the most favourable change. Case.-A lady had been bled many times, and condemned at home for many months, by order of a physician, to so rigorous a diet, that she was not even allowed to take substantial soup, and was, on entering the hospital, in a state of extreme weakness. We commenced by giving her nourishment, with respect to which she appeared insatiable, and she made moderate but frequent repasts. Her delirium, which at home was so great as to require four men to hold her in bed, diminished very remarkably, so that towards the eighth day she was permitted to walk about in the strait waistcoat. We continued to furnish her with the most substantial aliments: milk and chocolate at breakfast; rich broth, fish, and milk at dinner, with vegetables; and in the evening, baked or preserved fruits. Towards the fifteenth day she was restored to freedom of motion, and was in a condition to walk through the court, as the convalescents are accustomed to do. The treatment of patients in the first period of the disease consists in the united effects of many means, both physical and moral: their isolation, the character of the restraint being adapted to the peculiar condition of each one ; attention to their eating, and to relieve the stomach if it be overcharged; the care to put an end to their confinement as soon as possible, and to make them breathe the external air during the whole day; the entire or limited freedom of motion granted to them, if they are not dangerous; the acidulated drinks, which diminish their thirst and internal heat; the art of seizing their first lucid moments to encourage and calm them; the particular study which is made of their individual character and their fantastic ideas; finally, an extreme watchfulness to remove all that can exasperate, but opposing, at the same time, an inflexible firmness to their sallies. Their agitation in general, however violent it may be, cannot disconcert us, as it belongs to the nature of the disease. We seek by mild medicines and a slow effect to produce a general relaxation, to diminish the vital energy by the use of mucilaginous drinks, milky or acidulated, simultaneously employing at intervals laxatives to prevent constipation, which is habitual to them, or some light 63 sedative to overcome the sleeplessness. We join to internal means the use of tepid baths, taken on alternate days, sometimes with a light douche towards the end of the bath. We do not hasten or precipitate anything; we suspend, from time to time, all medicine during many days, in order to leave to Nature the means of developing her conservative efforts, and we afterward return alternately to those which are capable of seconding her. The excessive agitation and rambling talk are thus diminished by degrees; the lucid moments are multiplied, and the patient, becoming susceptible of passing from the first division into the second, is prepared to receive even farther ameliorations of his condition. An exposition of the general rules of treatment is far from excluding the modifications of which they are susceptible, and the regard which is due in particular cases to a, crowd of accessory circumstances. A young and plethoric person, for instance, one subject to hemorrhages, requires a different treatment from that applicable to a feeble patient. Through all the modifications, however, of which the general method is susceptible, and which may exact, in turn, the use of antispasmodics, evacuants, tonics, or of some exutory, we think that there is always perceptible a fundamental principle, about which all measures rally. This is, that in this disease, as in many others, Nature tends to cure, and to establish in their regularity the functions of the understanding, except in incurable cases. We have only to be faithful to the general laws of hygiene, to second the conservative efforts, and to give them time to develop themselves. Thus, for instance, in mania from childbed, the secretion of the milk being disturbed, and turned upon the origin of the nerves, the necessity has been suspected of applying a vesicatory to the nucha, and the most reiterated experience confirms each day the efficacy of this practice. I1 erriar and Perfect in England, and Laughter in Germany, have made trial of some simple remedies, and they show sufficiently that we are upon the true track of research. Some bounds should be placed to the prescription of medicines, since oftentimes an expectant method, seconded by moral or physical management, suffices; and in other cases the disease is too much for all our resources. Such is the endeavour which I propose to fulfil in the actual state of our knowledge to give the greatest importance to the history of the mental alienation, and to make a severe distinction between its different species, in order not to try useless experiments, or to direct the treatment at hazard; to have precise rules for the direction and interior police of insane establishments, since it is impossible to treat patients with success at home; to make sensibly felt the necessity of local arrangements for their methodical distribution, according to the periods of the disease; to place in the first rank the precaution of an assiduous supervision, and the maintenance of the most strict discipline as to the servants; to indicate the simple remedies which experience seems to ratify; and, finally, to reserve for extreme cases (those regarded as almost incurable) the employment of certain active remedies, which other circumstances might render superfluous, hurtful, or rash. In the acute stage of mania, patients should remain isolated in an obscure and silent place until the re-establishment of tranquillity. Case.-Mania, first period, 4th day: visage pale; eyes fixed; voice strong; ideas very confused; subject of delirium, a discovery made in chemistry. "One idea alone," says he, "ought to replace all others. I am God! 64 I am the Father of the Universe!" Face heated; fury painted in his features; sparkling eyes; torrents of abuse against all those who approach him; menaces to exterminate everything. Restrained by the strait waistcoat, and takes an abundance of acidulated or milky drinks. Alternations of vociferations and oaths, with a comatose depression; an analogous state during the following day. 12th day: a great agitation during the night; false perceptions ; believes himself to see around him cats, dogs, and wolves; at intervals, a sort of transient tetanus ; eruptions of pimples upon the dorsal and costal regions. 15th day pimples full of a transparent fluid, opening on the next day; sleep for the first time. From this day a diminution in the convulsive tetanic movements which existed previously. Frequent lotions of oxycrate upon the head, which is shaved and naked; passages solicited by an emetised drink. 24th day: some lucid moments, but in general a state of delirium; false perceptions a sort of fury which impels him incessantly to break and tear everything to pieces. He speaks in turn of mysteries, the cabala, and the philosophical stone; he traces hieroglyphical figures upon the walls; hunger devouring; a drying away of the pimples. Second Period, 35th day: demands with interest news respecting his parents from one of his compatriots, and spoke of his friends; but shortly after, incoherent in his ideas. 46th day: a light promenade in the garden, as also on the following days. 52d day: obstinacy in remaining seated in the sun, which is hurtful to him; then a red face, eyes fixed or in quick motion, menacing looks, spasms in the muscles of the limbs, of the body, and the face, a sort of transient swooning. These symptoms renew themselves on exposing the face to the rays of the sun, and the prevention of this demands increased vigilance. Dejections more regular and less black; transient returns of the delirium, but the lucid intervals longer. Warm baths continued once in two days. Liquid dejections, hunger more moderate, but a constant involuntary impulse to break everything to pieces that falls into his hands. 73d day: riding for some hours (convalescence); a complete return of reason; a desire of returning to his accustomed habits when his understanding should be re-established; spasmodic contractions more rare. 76th day: salivation, which becomes each day more abundant, and continues during a fortnight; desire to see his lady-love, whom he had taken care to separate from him. 80th day fatigued by many visits which had been permitted him; the following days, certain extravagant ideas at intervals, the need of management for some time; the desire strongly expressed of returning to society and of marrying; thenceforth an unlimited liberty to go about out of doors. 90th day: returned to society, and was married a month and a half after his discharge. He has enjoyed since this period the entire use of his reason, in spite of the excessive heat of the following summer, the inquietudes inseparable to an unsuitable marriage, and very numerous engagements.

A great variety of expedients have been employed in hospitals in the endeavour to remove the singular ideas which affect the melancholy. One of them believed that his head had been amputated by order of a despot. Philodotus, his physician, had him made a leaden hat, whose weight convinced him that his head was yet on his shoulders. Sometimes, in melancholy, there is a certain physical derangement: this may yield to evacuants, but very often the consequent debility augments and 65 exasperates it. Melancholy marked by atony and extreme depression is to be remedied by the use of bark with opium, of which I can cite many examples. If there has been a suppression of a cutaneous erup tion, or of an exutory, a seton or cautery becomes necessary. Ferriar, in the case of a young man who had fallen into the deepest melancholy, learned that for many years the patient had been subject in the spring to a herpetic eruption, which occupied a part of the back, extending even to the shoulder, and that the drying up of this eruption had been the period for the invasion of the disease : he prescribed a seton to the nucha. On the third or fourth day, a flow of very fetid matter was established. From this time a change for the better took place, and a complete re-establishment became afterward the fruit of exercise of the body, sea-baths, and a tonic regimen. Melancholy offers the more obstacles to a cure, since we have nothing to expect from the spontaneous efforts of nature. The other physical means proper in melancholy, which have not yet been mentioned, need not be referred to, as they be long, for the most part, to those employed in mania. The hellebore of Anticvra was celebrated of old in this disease. We ought not to lose sight of the results of a long experience ; but we may now substitute other purgatives more or less active, and more fit to produce, with less inconvenience, analogous effects. It is oftener by moral means than by medicines, and, above all, by an active occupation, that we are able to make a happy diversion to the sad ideas of the melancholy, or even to change their vicious chain of ideas; but what difficulties in preventing relapses! Case.-A workman in the Revolution, from supposing that he was an object of suspicion, became filled with insane fears, and was transferred to the Bicêtre after the ordinary treatment at the Hôtel Dieu. He continually imagined himself a victim of the guillotine, and ever repeated that he was ready to submit to his lot. Being a tailor, he was given a moderate sum to mend the garments of the patients. He worked assiduously, and in two months had completely changed: he even spoke with a tender interest of a young child whom he had appear ed to have forgotten, and expressed an extreme desire to have him with him: this was granted, and with the happiest effects. Experience has settled the effects of some simple remedies to prevent the return of the melancholic paroxysm that leads to suicide; but often, also, it exhibits them as powerless, and, at the same time, the advantage of a lively and profound emotion in producing a solid and durable change. For in stance, a man of letters, about, with a suicidal impulse, to throw himself into the Thames, was relieved from his desire by an attack of robbers. At Besancon, formerly, the feast of Saint Suaire was celebrated by a crowd of the insane under the title of demoniacs : under the pretence of a miracle, cures wore performed through the pomp and magnificence of the ceremonies, &c. Case.-A convalescent empToyed as an attend ant was frightened at the menaces of a patient, and on one of the fol lowing nights was struck with the idea that the devil had given her four boxes on the car; she thought she saw him in a corner of the lodge, under the covering, which, by her disordered notions and extreme agi tation, had been rolled together on the floor. She was transfixed with fright, and uttered from time to time the most piercing cries, finding herself in a profound obscurity, and delivered up to all the delusions of her wandering mind. The superintendent opened her door, and by the light of a candle unrolled the covering and showed her that there was 66 no devil there; he spoke to her forcibly, recalled to her the testimonies of the confidence which she had ever given him, and exhorted her to be tranquil. She was placed in another cell, which she was made to examine thoroughly, to reassure her against the presence of the pretended demon; some baths, and the use of diluent drinks, have calmed, by degrees, this melancholic delirium, and she has returned to her ordinary duties.

V. The use of certain Remedies more or less Active, and proper to second the Measures of General Treatment.

Hellebore, so famous among the ancients, has, from the advance of medical science, been replaced by other purgatives and emetics, which are not attended with the danger accompanying the use of this medicine, as obstinate vomitings, &c., have been sometimes found to proceed from its employment; their action, also, is very simple, and more to be depended on. But we should always regard these medicines as accessories, of which a use so much the less indiscreet should be made, insomuch as our views are more extended, and our resources more certain, from the mass of other moral and physical means. I have remarked that a paroxysm of periodical mania is, for the most part, preceded by a sort of constipation, and an extreme sensibility of the intestinal canal; so that if we give, at the time, an abundant drink of chicory with some saline purgative, we keep open the bowels, and cause to disappear all the symptoms of an approaching paroxysm. This is so well known in hospitals, that a lunatic attacked by intestinal affections is scarcely conducted to the infirmary when be is submitted to the use of this laxative drink, and most frequently the impending attack is prevented, especially when the disease is subject to irregular periods, and correspondent to the variations of the seasons. The mutual action of the brain and the intestinal canal is acknowledged by both ancient and modern writers. Dr. Perfect, of England, combines, in general, sometimes the use of emetics, and often that of purgatives, with the other means of treatment and says that he has often remedied an obstinate constipation, which is an effect of the disease, and which, in its turn, foments it. It is thus that he administers, alternately with the warm bath, the tartrate of soda or potash, either in a decoction of barley, or united with a sweet and saccharine substance, as manna. He uses these drinks du ring two or three days, and suspends them during one or two weeks, in order to recur to them again in the same manner. Sometimes he administers them in an emulsion of almonds, according to the circumstances of age, &c. He speaks otherwise in moderate terms of these subsidiary means, and makes them to be regarded as a sort of an appendage to the other general means of treatment. The habitual drinks which he prescribes in the same cases are suggested by analogous views: these are whey, simply or with wine, barley-water, gum Arabic and sugar, and a light lemonade and orangeade; sometimes other like drinks, mucilaginous, saccharine, and acidulated. Observation has, without doubt, led in France to the same results, and by Esquirol a habitual use is made of the same mild drinks, and of baths, employing from time to time some laxative, or a cathartic more or less active, according to circumstances. In his private establishment the patients are in general rich, and they can be given in profusion agreeable drinks : sugar and water, lemonade, orangeade, barley-water with different syrups, the 67 emulsion of almonds, whey containing nitre, or associated with some saline and purgative substance, &c., which could not be the case in a national establishment, on account of economy. Still, in both France and England, the practice often consists in a confused mixture of many medicines. Ferriar reports an instance of a patient cured chiefly by an emetised drink, which had acted during several days as a purgative. A robust female, aged 25, maniacal for a few years, had fallen into a state of fury: she took tartar emetic in small doses, and merely to keep up a state of nausea; a blister was applied to the head, and continued during seven or eight days, with a marked alleviation of the disease; but recovery seemed yet far off; then the emetic was given in whey during fifteen days, and laxity of bowels was favoured by a little magnesia; a preparation of opium was afterward added at night, and a drastic purgative was given. Recovery took place by degrees, and after a month's trial she was sent back, cured, from the hospital at Manchester, four months after admission. We must distinguish a mild diarrhoea, either provoked or natural, from one of importance of symptomatic nature, which is very painful, and attended by a burning heat, that manifests itself sometimes during the maniacal paroxysms, or towards their decline in autumn. I have often had occasion to observe this affection among the patients of the Bicêtre, and it was so violent that I have seen them roll on the earth with signs of the most extreme anguish, and die some days after, both mucilages and sedatives being ineffectual. There was, at the same time, great dryness of the skin; and as, at the time, there were no baths there, I had only the use of internal drinks, which were insufficient. From a very favourable result on the first trial, I afterward used the leaves of the common bramble (Rebus dumetorum), giving daily one, or even two pints of the decoction. I ought, without doubt, to attribute to the frequent use made of baths, in all periods of their malady, the rarity in our insane of these fluxes, or the facility of stopping them when existent; but in some rebellious cases, especially when patients recently arrived in the hospital are attacked by the affection in consequence of a rigorous diet, or of an obstinate refusal of nourishment, we have made the most happy use of this simple remedy. Case.-A lady having puerperal mama had submitted to her family to the most rigorous diet for more than a month, and she had thereby contracted a colliquative diarrhoea, which, on her arrival at the hospital, was exceedingly dangerous, and which had already reduced her to the last degree of wasting and debility. Some days after, we commenced the above decoction, of which she took nearly a pint daily, and we remarked, eight days after, so manifest a diminution, that the diarrhoea continued no longer except at night, and it was shortly terminated. Dr. Locher, physician to the hospital at Vienna, employed musk without effecting any good result. Camphor he found efficacious, combined with vinegar in the form of mixture. He then tried distilled vinegar, taken in the afternoon, in doses of Ounce iss. daily, by spoonfuls, every quarter of an hour: nine patients have been cured in one, two, or three months at the most. Kenneir reports four examples of cure from camphor. Ferriar said he had employed it in all sorts of doses without success. Locher's experiment is the same. Perfect, who, of the English, has used it most, prescribes it most frequently combined with sugar and vinegar in the following manner: Rx, Camph., gr. L.; sac., Ounce vi-viij. ; acet. (warm), Ounce xii. M. To be taken by spoonfuls 68 from time to time, especially in the evening and at night. He employed the remedy in conjunction with so many others, however, that it is difficult to satisfy ourselves to what the reported results are to be properly attributed. Considering camphor as a sedative, I have employed the preceding mixture in cases of great maniacal excitement, and I have then made the patients take it by spoonfuls in the evening to calm the excitement, which has always produced favourable results; but, on account of the great repugnance of certain maniacs to this disagreeable remedy, I have substituted an emulsion of almonds, sweetened with sugar or honey, in which was dissolved half a grain or a grain of the aqueous extract of opium, proposed by Ferriar in melancholy with a sort of atony, and an extreme depression, as also in the accidental idiocy which succeeds the too active treatment of mania. He speaks of a young man of sixteen who had a sort of taciturn derangement, with altered features, yellow skin, feeble and languishing pulse; he prescribed two drachms of an electuary of bark, with two grains of opium, to be taken morning and evening: the change was very little perceptible during some days; but in the following fortnight the progress towards re-establishment was very marked, and the cure was complete. The remains of the disease, manifested by swelling of the legs, yielded to frictions with the flour of mustard.

VI. Medical Treatment in the Second and Tkird Periods of the Maniacal Delirium.

After the first stage of mania is over, the females at the Salpétrière remain in their lodges unrestrained, or promenade under the trees in the large enclosure; and some, approaching convalescence, partake in the labours of the attendants, first in drawing water, or in other duties requiring more or less action. If there is any return of the symptoms of excitement, or appearance of impending relapse, baths and diluting drinks are employed at once, and if this state still continues, they are made to pass again through a course of treatment. In this intermediate condition of the mind, constant experience has taught that one simple act of imprudence, the premature visit of a relative or friend, or some afflicting news, may produce the most keen emotions, and reproduce the mental alienation. M. Esquirol applies with skill the moral treatment in the decline of insanity: he consoles one, encourages another, converses with the melancholy, and seeks to dissipate their chimerical illusions; he studies the succession of their ideas, &c. So soon as a relapse declares itself, the means to arrest it should be applied; the patient should be made to take warm baths or a slight douche, mucilaginous or acidulated drinks, and slight evacuants, either an emetised drink or a solution of a saline purgative, in order to remedy constipation, which is usual here. Certain circumstances may also demand leeches or an epispastic, and sometimes a mild sedative, when the nervous excitement is very marked. It is in general by mild and consoling discourse that we ought to sustain hope, raise the courage, and, finally, remove every real subject of discontent and contention. Everything is right if, after a slight effervescence, the features preserve their harmonious agreement, and a taste for occupation remains; but if the convalescent continues to be inactive and silent, or if his features are inanimate, and nothing can restrain his incessant restlessness, especially if passionate and violent on matters of trifling import, the treatment 69 must be recommenced with all the modifications of which it is susceptible.

Relapses are often caused by premature discharge. The department for convalescents should be an agreeable residence in all respects, free from every source of disquietude, and conducted with the utmost order and avoidance of confusion ; and all excited or relapsing patients should be removed from it. One convalescent relapsing has, by her excitement, been known to cause several others to do the same. In periodical cases, a careful treatment may exercise a happy influence upon the paroxysms, and modify them in a very remarkable manner. One of the precious advantages of well-regulated hospitals is the strong impression upon the insane who are susceptible of it, that they are submitting to a superior strength; this arrests their erroneous conduct. A premature discharge takes away this impression, and suffers them to give way to their feelings; hence the danger of relapse from this. The season of heat, and sometimes that of cold, although much more rarely, may bring on an attack of irregular insanity: it is then prudent to use, towards these periods, some preservative means for convalescents discharged from hospitals, and to resort to some relaxing means. Case. -A very laborious husbandman became maniacal from exposure to the sun in harvest time, and was cured after about a year's stay at the Bicetre, and sent back to his family with the express recommendation to take each year, towards the spring, diluent drinks and laxatives, with baths. With these precautions he remained well until the third year, when he neglected them and relapsed; lie was then carried to the Bicêtre, after being treated at the Hôtel Dieu. He was violent for five months, and then recovered slowly. It was scarcely necessary to recommend preventive means farther. Case.-A husbandman, deprived by the conscription of one of his sons, became deeply melancholy, and manifested subsequently complete derangement. Another of his sons treated him with the utmost harshness, and thus carried his fury to the last degree of violence. His attack, when placed in the hospital, continued very violent during the warm season; but tranquillity succeeded towards the decline of autumn, and continued during the winter. In the spring, laxative drinks, given at the first indication of nervous excitement, prevented the coming paroxysm: the next year, through gratitude, he presented me with some fruit. Case.-I quote the following case from Valeriola, on account of the happy sagacity here exhibited in rejecting mere medical formulas. A young man became insane from disappointed love: he was transferred far from the beloved object to a house in the country, of an agreeable and smiling aspect: nothing of the delightful was here wanting; elegant gardens, an immense park, beautiful meadows, lakes, running streams; the air is loaded with the perfume of roses, myrtles, the flowers of the citron, and other aromatic plants, which renders a walk here very diversified. The ordinary society of the patient is numerous, and composed of chosen friends; there is an almost continual succession of games, amusements, and concerts of music. The erotic delirium yielded a little to so many objects of diversion, but old recollections plunged the patient at intervals into his first delusions. He is therefore transferred, farther, into an agreeable town, where every exertion is made to second the efforts of the physician; but he was then wasted away by a slow fever, and a sort of hectic consumption. Recourse 70 was had to sedatives, and a restorative and tonic regimen ; to these were often united the pediluvium, warm bathing, &c. : douches upon the head ; on certain days, concerts of music whilst he was in the bath, or even agreeable conversation. The paroxysms of his disease dimin. ished by degrees : his strength and embonpoint were re-established, and eventually reason regained her empire.

Note.-At the Salpétrière only female lunatics are received, and at the Bicêtre, males only. M. Aubanel says, that in about two years, Pinel was appointed physician to the Salpétrière, and left the Bicêtre.