3 ADDRESS ON INSANITY BEFORE THE NEW YORK STATE MEDICAL SOCIETY. BY SAMUEL WHITE, M. D. Gentlenen: In retiring from my official station as your presiding offi- cer, and in compliance with the rules of your Society, it be- comes my duty to address you on some subject connected with medical science. For this purpose, I submit for your conside- ration some reflections on Insanity. "Know thyself," was the wise maxim of a Seneca and a Socrates. Hence it is said that the greatest study of man, is man. From the cradle to the grave, his life will be found a series of antecedents, and consequents, having a direct bear- ing on his physical and moral powers. To investigate the constitution and properties of the human mind, we must trace its history from its infant development, through manhood, to decrepitude. When the vital organs are fully and equally developed, with due exercise and proper culture, we may safely look for health of body, and energy of mind. It is therefore by the study of the entire man, wrought upon by external causes, that we are to learn the deviations from the healthy standard, prostrating those energies and mental endowments. To judge correctly, and draw the line of demarkation dis- 2 Dr. White on Insanity. tinctly, which bounds the healthy torn the unhealthy action of the vital organs, requires a discriminating mind, well vers- ed in the sciences of anatomy, physiology, and pathology, with a due regard to the temperaments. Without this prior culture, we should be ill prepared to determine the faint glimmerings under impaired functions, which often lie be- tween eccentricity and aberration of mind. The first we learn by a general acquaintance with the character of the individu- al, the latter now occupies our more immediate attention. It cannot be expected that I should attempt to unfold to you on this occasion that which never has been, and probably ne- ver will be, revealed to finite beings, the mysterious union of mind with matter. What science more elaborate ? Who can comprehend the extent of the unceasing influence of mind upon matter, and matter upon mind ? Within its sphere would be embraced the entire history of our being, from our first to our latest breath. In vain should we attempt to solve one problem of the mysterious agency of those sympathies of the vital organs, ever acting, and ever ready to be acted upon by external causes, without comparing critically that line which bounds distinctively the healthy from the unhealthy gradations of our being. Intellectual culture is attainable only through the discipline of the mind : yet the energies of that mind cannot be brought to a full development of its powers, without a corresponding exercise of the body. It is therefore one of the laws of the constitution of our minds, that employment is essential to its preservation or physical action. So with the physical powers, ever so perfect in their constiuction, to preserve them in healthy subservience, requires the essential elements in their purity with a perfect control of the appetites and passions as well as due attention to the non-naturals. Man may be said *n one sense to be the arbiter of his own destiny; for being endowed with reason to guide, with sympathies to alarm, with appetencies to receive, and with power to reject mav avoid danger, palliate disease, and thereby sweeten the streams of his earthly existence. The freedom of the will the impulse of reason and moral responsibility, will ever stir Dr. White on Insanity. 3 that monitor within which looks to the future, and should-- cause us with watchful eye, and untiring effort, to scan mi- ^ nutely the physical, intellectual, and moral developments of our nature. Every science has its data. First principles and ultimate truths are its legitimate authority. There is no such thing as a diseased mind without its con- nection with matter. From the intricacy of the cause, and the untowardness of its manifestations, mental pathology has been greatly neglected until within the last quarter of a centu- ry. It is now, however, generally conceded by the talented wri- ters abroad, and the able conductors of asylums in this country, that we are to look for the proximate cause of Insanity in the physical, and not in the metaphysical portion of our being. Hence, organic lesion, that which specifically dethrones the intellect, under exciting causes, is a theme demanding our unceasing scrutiny, if happily we may implant one ray of hope where unmitigated anguish reigned. There are modifications and manifestations of the mind : the first regard our inmost thoughts, the latter control our ex- ternal acts; the one the exercise of the will, the other the motive impulse. We are so engrossed with the laws of matter, as to forget that mind, the evidence of our consciousness, is distinct in principle. " God formed man of the dust of the ground, and breathed into his nostrils the breath of life." He also made him an ac- tive being, as well as a responsible agent. Hence our phy- sical powers are brought into action for the sustenance of our animal existence ; so are we commanded to provide for the higher interests of the immortal soul. Strict obedience to these distinct requirements would wisely lead to health of body and consequently to unimpaired manifestations of mind. Concentration of mind can alone accomplish our highest designs. A mind unimpaired by extraneous causes, conver- ges, and judgment is sound; impaired, it diverges, judgment is fallacious, and the will perverted. It shall now be our aim to throw out some hints, with the 4 Dr. White on Insanity. hope that they may possibly prove practically useful, rather than abstractly metaphysical. To divest this subject of the mysterious veil which has too long deterred from a just in- vestigation of its claims, or a due appreciation of its merits, to examine with freedom its causes, to place a due estimate upon preventives, as well as point out some of the more ap- proved methods of cure. Also, to disabuse our asylums of the unfounded prejudices of the misinformed as to placing their friends under the supervision of strangers. I shall prefer no claim to intuitive knowledge, nor have I any specific for the cure of Insanity. Nearly half a century's pupilage in every branch of medical science, teaches me to be less positive of ample acquirements, than some of our modern sophomores. We only claim to have diligently endeavored by observation and induction to keep pace with the improve- ments of the age, that we might meet promptly every exigen- cy in practice. I am no advocate for specialities, as calculated to expand the intellect. We must lay a broader foundation if we intend to give order, and beautify our superstructure. Should motives of circumstance or choice, however, lead to special acts in any branch of medical or surgical practice, let it be but a divergence from the cultivated field of general science. By the cultivation of cardinal principles such as at- tention and memory, with a due exercise of the discriminating faculty in the selection of our reading, taking note of time, as well as our reflections, we may possibly, during an ordinary life, catch up with some of the Solons of our age, who from instinct and three weeks' study, taking their own account of themselves, can look through the human system as we would a transparency, and at a single glance comprehend all its ha- bitudes, sympathies, temperaments, and idiosyncrasies, and furnish a specific " for every disease flesh is heir to." Such mockery may stifle conscience for a time, but can never evade that final and divine requirement, " give an account of thy stewardship." No writer has as yet satisfactorily exhibited to our view, that coincidence of action ever maintained between the arte- Dr. White on Insanity. 5 rial and nervous system, and which is, in my opinion, the brightest link in the chain of human sympathies. Irritation specifically acting on the brain, and nervous sys- tem, and sympathetically on the vascular, may define the phenomena of Insanity. The brain and nervous system being primarily excited, increased vascular action is its necessary concomitant. Hence increased pulse, turgescence of blood vessels, and pain in the head, are the ordinary attendants of incipient Insanity. With great deference I have here ventured to reverse the order of Doctor Rush, who says, " the cause of madness is seated primarily in the blood vessels of the brain." This theory, I apprehend, has loo often, in incipient Insanity, led young practitioners into the fatal error of treating, by bold depletion, irritation for inflammation, than which, as a gene- ral rule, nothing is more prejudicial to the radical cure of the patient. From early professional life I have ever maintained irrita- tion to be the proximate cause of inflammation, exciting the muscular coats of the arteries to undue action, thereby dilat- ing the capillary vessels, and augmenting the quantity of red blood, with increased velocity, redness and pain; yet the source of irritation being early removed, these vessels are restored to their healthy action. Great errors have been committed, also, in post-mortem ex- aminations, by placing consequence for cause, forgetting that protracted disease had wrought insidiously these physical changes—conclusively proving that the brain is not, in its incipient, but in its chronic stage alone, organically affected. If it were not so, how could we account for radical cures of nine cases in ten, of incipient Insanity, under judicious loca- tion, with suitable medical and moral treatment. Whereas, disordered functions, by neglect, having taken on diseased structure, little more can be done than palliate and render comfortable. These are self-evident truths, and amply con- firmed by every one conversant with the treatment of this malady. Who then can answer for the mawkish antipathy of parting for a time Avith a friend, in imminent danger of 6 Dr. White on Insanity. becoming incurable ; augmenting, in a ten-fold degree, by such neglect, the expense of their support, endangering fatu- ity, and destroying every prospect of future enjoyment or use- fulness. That noble organ the heart, the centre of circulation, and fountain of vitality, here claims our attention. The good book tells us that " the life of the flesh is in the blood." Hence Hunter's doctrine of the vitality of the blood may be said to be predicated on the anatomy of Truth. As the lac- teals absorb and convey nutriment to the blood, and the arte- ries transmit it to supply the perpetual wastes of the minutest portions of the human system, and as every artery has its ac- companying nerve, we thereby learn the unceasing depend- ance and sympathy of vital and sensitive action. While the brain, therefore, the seat of the mind, may become inordinate- ly excited by external causes, the heart, in a moral sense the seat of the affections, may be found to participate specifically before reason is dethroned. Thus we have a spiritual, and physical being, and though distinct in principle, they are nev- ertheless essentially dependent on each other for the healthy exercise of their functions. Again: We are to bear in mind other vital organs, sympa- thetically exercising their influence in every physical change and mental aberration. For instance the respiratory appara- tus and capillary system—the liver, digestive organs, and re- nal glands, may one and all participate in cerebral disturban- ces. How important is it, then, that we acquire a thorough knowledge, physiologically and pathologically, of the action of each and every organ, so as fully to comprehend the changes they are incident to. So also, season, climate, age, education, diet, and exercise__ atmospherical influences, temperaments, and idiosyncrasies under sudden vicissitudes and exposures, all have a direct bearing upon the constiution of every individual of the hu- man family. With these preliminary remarks, it will Ve our aim to as- sist those who may incidentally be called upon to decide, as to the sanity or insanity of a patient, and in making out the requi- Dr. Wliite on Insanity. 7 site prescription, embracing the amount of restraint, when ne- cessary to be imposed, while under their care; rather than offering any opinions confirming or contravening systematic authors, whose able commentaries are in the hands of those who are daily conversant with the treatment of the insane. It is not my intention at this time to enter minutely into the divisions and subdivisions of Insanity. They may be found ably discussed by such writers as Esquirol, Rush, Ellis, Spur- zheim, Burrows, Pritchard, Conolly, and many others. From the last of these named writers, we may soon expect a more extensive, highly polished, and elaborate work, embracing his course of experiments at Hanwell, on his non-restraint sys- tem. In this I am happy to say he may draw some useful hints from this country, in confirmation of his benevolent en- terprise. In addition to the before mentioned authors, I feel greatly indebted in my researches to the comprehensive and talented reviews of Dr. Johnson. Many are the terms used to designate a disordered mind, such as madness, lunacy, craziness, mental derangement, ab- erration, alienation, hallucination, phrenzy, &c. I prefer In- sanity to all others, as comprehending the various forms of intellectual disorder. As the cerebral part of the brain may be considered the seat of the primitive faculties, and the cerebellum of the ani- mal passions, so are we to look for the varied external causes of Insanity, as they preponderate, or impair these distinct functions. That there are national resemblances, and family likeness- es no one will deny. Children not only inherit the contour of the face, fashion of the body, and disposition of the mind of the parent, but frequently exhibit a constitutional diathesis, singularly marked through many generations, and none more so than in hereditary predisposition to Insanity. It is through the bodily organs that the powers and properties of the mind are manifested. Hence I infer, that insanity is the result of corporeal causes, and may be excited into action by whatever disturbs the nervous system inordinately, or weakens the vital functions; destroying that balance of power so essential to the preservation of health. 8 Dr. White on Insanity. Nor can we deny that peculiarities of constitution and tern-. perament predispose to disordered intellect. I have known such excited to inordinate action by intense study, without corresponding physical exercise. Such folly is highly reprehensible, and shows a want of judgment in many of the teachers of our youth, forgetting that our highest attainments are acquired under alternate ex- ercise of body and mind. So also the enthusiastic avidity with which fictitious writings are sought after and devoured, bewildering weak minds and giving a false estimate of the sober realities of life. " Life is no fiction," and the earlier this sentiment is indelibly impressed upon youthful minds, the sooner will they become healthful ornaments of society. Again, whatever exhausts the vital organs predisposes to In- sanity. Hence, dissipation, and indulgent passions, under rapid growth, and before the body has acquired its wonted strength, like the shorn locks of Samson, are fast enervating some of the pride and promise of our country, and hurrying their votaries to a premature and inglorious grave. To simplify is the beauty of every science. I shall there- fore predicate my remarks on the simple division of moral, physical, and intellectual manifestations, and in treatment of incipient and chronic Insanity. All attempts to classify into genera, order, and species, will prove abortive, and are calculated to confuse and mislead the mind. The ancients were content with dividing mental disorders into mania, and melancholia. While the moderns use the terms mania, monomania, melancholia, and dementia. Subdi- visions might be carried to an indefinite number, assuming characters as endless and dissimilar as the expression of their faces; no two being precisely alike. The analysis of the human mind has tried the expansive and philosophic intellect of a Locke, a Descartes, and a Ba- con. So also Reid, Dugald Stewart, Brown, Mill, and others have laboriously scanned this intricate subject for the benefit of their followers. Metaphysical researches to the neglect of corporeal pheno- mena, have greatly retarded the pathology of Insanity. Dr. White on Insanity. 9 Hallucinations of mind are but symptoms, not causes of the disorder. Numerous are the mistakes made on this very point, of treating consequence for cause. We may as well follow an ignis fatnus, or mark the change of the chameleon's hue, as to give a distinctive character to a mental delusion, irrespective of its physical phenomena. For while the brain is the seat of the sentient and intellectual principles, it is governed by the same general laws as other vital organs; and acted upon by the same morbid causes. As prevention may be said to be better than cure, too little attention has been paid to the remote or predisposing causes of Insanity. Hence, predispositions whether hereditary or original are important subjects of enquiry. Education, based upon moral discipline restraining violent emotions and passions, bringing the will under due subor- dination ; placing suitable guards on the extremes of hopo and disappointment, will go far to lessen the moral, and phys- ical causes of Insanity. So on the other hand, as the insane are good barometers, expressive of the vicissitudes of atmo- sphere, climate, seasons of the year, sedentary habits, modes of living, occupations and professions, intensity of thought, and study on some intricate subject may impair the digestive functions, and through sympathy lead to aberration of mind. I shall not attempt any precise definition of Insanity. That the brain assumes a morbid action sui generis, functional or structural, is evidenced by symptoms peculiar in themselves, denoting lesion of its substance, or turgescence of the surface of its investing membranes. Moral Insanity in which the moral feelings are perverted, while the intellect, in a great degree, remains unaffected; is receiving considerable attention at the present day. The moral perversions of the will, I hold are accessory to phys- ical causes, depending on irritation of the sensorium for a full development of their morbid manifestations. Among its causes we will name some of those which operate primitive- ly, and consecutively, as remote and proximate on the he^rt brain. The chylopoietic viscera in a state of disorder from defective nervous energy, ungoverned passions, and appetites, 10 Dr. White on Insanity. pride, disappointed ambition, fright, fear, a nervous tempera- ment, terror, and horror, followed by a deathlike paleness, the consequence of a receding of blood from the surface, and concentration about the heart, sympathetically disturbing the cerebral energies. Sudden transitions, such as joy to grief, and deep rooted sorrow, domestic disquietudes, unexpected wealth, leading the possessor to inordinate indulgences and idleness, faulty education, sexual passions, and solitary vice, as well as habitual drunkenness, by disturbing the vital func- tions tend strongly to Insanity. So also I would here name Millerism, Mormonrsm, Swed- enborgenism, Mesmerism, Perfectionism, and all other mis- takeisms, and fanaticisms that can be named, calculated to pervert the will, and mislead the judgment of the credulous, as among the fruitful sources of distempered imaginations. While religious maniacs, improperly so called, from the habi- tual fear of death, may dwell upon their delusion so as to ex- cite the sneer of the infidel, leading him, and others to as- sert, that religion more than any other cause tends to Insani- ty ; I have uniformly found it to be the consequence, and not the cause of their hallucination. If mankind sought after truth, as zealously as they seek after error, we might hail it as the dawn of millennial day. I shall here unhesitatingly assert, that while I have had under treatment those affected with all these fanatical delu- sions, I have never yet seen a patient insane from pure una- dulterated religious truth, such as repentance towards God, and faith in the Lord Jesus Christ; its fruits, love to God and love to man, its principles based upon the rock of ages and towering into the heavens, around which virtue ever green entwines itself, and from its lofty summit beholds its order perfect, its prospect boundless, its joys unspeakable, its duration eternal. Is there any thing here calculated to confuse, or distract the intellect ? In elucidating physical phenomena of Insanity, whether idiopathic, or symptomatic, we are to bear in mind that the human system is unceasingly influenced by internal and exter- nal sensations, pleasurable, or painful, in accordance with Dr. White on Insanity. 11 the degree of health in which those actions are performed. There are also actions of the body, and actions of the mind. Those of the body consist essentially of fibrous contractions, of which the nerves are the immediate instruments. As for instance, the stimulus of light upon the retina of the eye. So also the contact of air producing a system of sensations and contractions, pervading every portion of the surface of our bodies. In examining internal sensations, let us consider for a mo- ment the stomach, the laboratory of digestion, the portal se- cretion with the peristaltic action, assimilating to provide nu- triment for the lacteals, rejecting the residuum. So also the contraction of the heart in throwing the blood from the tricuspid to the mitral valve, imparting through the stimulus of the blood upon these sensitive tubes, a train of sensations extending to every fibre of the human system be- yond the power of conception. Next in train is respiration, and no function of the human body is more important; when we take into consideration the triple combination of lacteals, skin and lungs, in the process of assimilation of essential elements for the support of vital- ity, producing a train of physical links in muscular contrac- tions, the most important and remarkable of corporeal pheno- mena. Morbid affections and sympathies are among nature's ob- scure operations. Thus the brain may become sympatheti- cally affected by the diseased action of some remote organ. For instance, the liver, as regards the operations of health in its complex circulation, is second only in importance to that of the brain. Excess of stimulus disturbing the functions of the stomach, may engorge the vena portarum, and through the agency of connecting nerves, by implication, disturb the sensorium. So also the strong sympathy between the uterine system and brain, must be acknowledged by all. The tem- peraments likewise have their influence, the sanguine and nervous, more frequently become maniacal, the bilious melan- cholic. The powerful sympathy between the brain and the skin, is 12 Dr. White on Insanity. too often made manifest by ill-timed applications in suddenly suppressing eruptions, nature's safeguards. Scrofula, so ex- tensively affecting the glandular system, is a fruitful source of Insanity, and difficult to cure. Metastasis, the sudden translation of morbid action to parts more essential to life, is too little regarded in our diagnosis of disease ; like a masked battery if overlooked, it may prove de- structive in its aim. Thus, every vital function sympathising with, and depend- ing upon the cerebral organs as the mainspring of action, can we fail to wonder that a system so complicated, yet so de- pendant, under morbid manifestations and irritating causes affecting the balance of nervous and vascular action should dethrone the intellect ? In the therapeutical treatment of Insanity, every case must be considered and treated as an insulated one. Remedies must be applied to the constitution and peculiar features of each case. While the first indication is to remove or lessen, as far as possible, irritation as the immediate cause, pervading the cerebral and nervous system, and through sympathy the vascular, yet are we to bear in mind the condition of other re- mote organs morbidly excited, and participating in%the gene- ral disturbance. For instance, the associative powers of the stomach as a central organ are immensely important, as it regards the phenomena of disease. So also, through arterial agency, defective secretion of the gastric juice, and loss of power in the secerning system, we account for local conges- tion, impaired appetite, and waste in fevers. Remedial means when rightly applied need be but few. And what is the popular aim in the cure of diseases at the present day? but to sustain the conservative principle the strongest in nature, by the revulsion of excitement to parts less essential to life, and equalising circulation. Hence the importance that our first move in the treatment of incipient Insanity, should be based upon a correct diagnosis; critically regarding the necessary distinction ever to be maintained be- tween phrenitis, and active mania. The one concentrated in- flammation, affecting the substance and meninges of the brain Dr. White on Insanity. 13 the other irritation, specifically embracing the nerves of sen- sation and volition, sympathetically disturbing every function and fibre of the human system. The first demanding bold depletion as the anchor of safety, the latter to be approached cautiously, by milder and more comprehensive means, as we shall proceed to enumerate. Here then, permit me to remark that no one is competent to endure this searching ordeal who is not well versed, ana- lytically and pathologically in every branch of medical science. Copious abstractions of blood should ever be avoided in In- sanity as endangering dementia. Very few are the cases of Insanity, even in its incipient stage, that admit of venesection. In such only as are plethoric and in the vigor of life, is it ad- missible at all, and then only in a cautious degree. The pulse is deceptive, for though there may be increased im- petus of blood in the carotids, yet they will be found com- pressible, and the radial artery feeble in its action, showing an unequal distribution rather than congestion. In such cases where symptoms seem urgent, topical blood letting by leeching, or cupping, may safely be resorted to without dan- ger of collapse. In the treatment of six hundred cases, vene- section has not been resorted to in more than one in a hun- dred, after they entered the Institution, and then only mode- rate in quantity. Many however, have been brought to the Asylum, after two or three copious bleedings, undoubtedly with the best intentions; yet the results have proved a a prostraction of the vital energies, more difficult to over- come than the original disease. Puerperal Insanity, which generally comes on within a week after delivery, arises from a metastasis of morbid lac- teal and lochial secretions, is attended with rapid pulse and great prostration of strength. Hence bleeding is inadmissi- ble. If prudently managed it seldom terminates in permanent Insanity. The head and uterus principally suffer, tension and pain of the abdomen being less than in puerperal fever. Gcne- rallay ushered in by sudden impressions of cold from a higher to lower temperature. Hence the retrocession, and the necessity of restoring the secretions 14 Dr. White on Insanity. Active emetics are seldom admissible as tending to a deter- mination to the brain. Where there is great derangement of the digestive organs, ipecac and calomel combined, in such quantities as to produce a emetico-cathartic effect, may prove salutary in their operation. So also the blue mass with one fourth part of ipecac, adds to its efficiency in restoring the functions of the liver. Drastic purges are seldom advisable. Laxatives to keep up a steady action of the intestinal tube are far preferable, and may be aided by injections, due excercise, and a well regulated diet. No particular formula can here be laid down. The judgment of the physician must decide on the quantity and appropriateness of the article, according to the constitu- tion and peculiarities of the patient. Narcotics and sedatives are next in order. Opium, cam- phor, morphia, stramonium, conium, belladonna, and aconite are most to be relied upon, but require great prudence as to the time and manner of their administration. These are of- ten improved by combination with other remedies. For in- stance, opium, ipecac, and soap, equal parts, forms a pill much easier given than Dover Powders. Camphor mixture, with half a grain of tart, antimony, and five drops of laudanum to the ounce, given in half ounce doses, is a powerful sedative and adjuvant in allaying nervous excitement. Morphia with colchicum, when there is a gouty, or rheumatic diathesis, en- dangering metastasis, is a valuable auxiliary in treatment. Stramonium acts specifically on the sensorium, stimulating the absorbents. A saturated tincture of the seeds in camphor mixture, is the best mode of administering it. Conium is best combined with the different preparations of iron. Belladonna and aconite are often improved by combination. Extracts of these vegetables can only be relied upon when evaporated by solar heat. Counter irritants, revulsive in their effects are valuable auxiliaries, more especially in metastasis and suppressed erruptions; and are more cheerfully submitted to when allayed with some of the vegetable narcotics endermically applied. Bathing. One of the most powerful remedial agents in Dr. White on Insanity. 15 equalizing circulation, is the warm bath. The patient should be immersed from twenty to thirty minutes, the heat at 96 Far- henheit, refrigerating the head while in the bath, when the heat of the part should indicate its necessity. Warm bathing will be found particularly beneficial and appropriate in me- lancholia and delirium tremens. Fixed alkaline salts added to the water, are useful in removing the sebaceous oil from the surface of the body. The nitro-muriatic bath is a valu- able and effective agent in a congestive state of the liver, and should be repeated in connection with the usual remedies, until we have evidence of a healthy secretion of bile. The value of the shower bath is known to all, yet it is too indis- criminately used. Great prudence and watchfulness is neces- sary in its application. Should atony prevent a suitable re- action and Avarmth over the surface, it may do serious and lasting injury. A pitcher of cold water poured over the back part of the head is often grateful as well as useful to the patient. In the second stage of Insanity, a more tonic treatment be- comes necessary, and it is to be regulated according to the age, constitution, and temperament of the patient. The va- rious preparations of iron, nitrate of silver, followed with a solution of iodine to prevent a discoloration of the skin, con- joined with suitable moral treatment, will often decide the future prospects and destiny of the patient. In moral treatment, no more restraint should be used than is absolutely necessary for their own and others' safety. Chains are never necessary in an institution. You cannot chain the human mind, nor cure a patient in chains. I have never used one. Pinel is entitled to an enduring monument of fame, for having been the first who dared to break off the chains of the maniac, throw open his prison door, bring him forth to the light of heaven, and to the enjoyment of the es- sential elements in their purity. Whenever they have been brought to the Asylum in chains, I have made it a point to remove them with my own hands, as I am sure by so doing, to gain permanently the confidence of the patient. 16 Dr. Wliite on Insanity. I once took by the hand a furious son of the Emerald Isle, and held an exciting dialogue respecting the heavy chain cast round his ankle, and bolted to the floor. Though warned of my danger, as I approached him with a pleasant salutation, he as cordially responded, and received me as his friend. We at once made a binding contract—I was to knock off his chains, when he should be placed under my care, and he was to become my body guard, and be obedient to all the rules of my house. A few days after, the bargain was consummated, and he remained faithful to his trust. The day after he entered the Institution, while engaged with others at a game of ball on the lawn, as I approached him, he heartily saluted me with " God bless the doctor." I asked him how he liked such exercise, compared with that within the circle of a chain. "Oh!" said he, "that was wicked !" His countenance then changing to a smile, he says to me, "Do you know Avhat that chain was ?" No, Johnny, please tell me. " That sir, replied he, was a safety chain, presented to me by the mayor of the city." No other restraint is put upon our refractory patients, under sudden impulses, than seclusion for the shortest possible period of time, and the use of a belt cast round the waist, with wrist bands, or a muff attached, to prevent them from tearing their clothes, and committing other mischievous acts while at large, I will here give a case of metastasis, extraordinary in its re- sults. G. M. aged about 26, became a patient of mine in May 1S06, having suffered for two years previous with a rheumatic white swelling of the knee joint, exostosis of the connecting tibia, accompanied with repeated attacks of rheumatism from trifling exposures. Much exhausted by these complicated, and renewed attacks'^while palliatives only were admissible, an imperfect crisis was formed, followed by a watchful deli- rium, and an artful disposition to procure some instrument for self-destruction. Being unable to turn himself in bed, and constantly watched, there was no suspicion of danger. July 7th, the night following this extraordinary change, he procured a full sized tea spoon with some fruit jelly, and im- practicable as it may appear, forced it down his throat so far Dr. White on Insanity. 17 that it passed into his stomach, while his attendant was gone, by his request, to the opposite side of the room for Avater. In this deplorable situation I was immediately requested to visit him. H3 Avas greatly agitated, talked much, and be- lieved he had gained his point, which at the time I considered too true. The second evening after, a spasmodic affection of the sto- mach alternated every fifteen minutes with a stupor, throwing himself as often as the spasm returned, with great violence from one side to the other, Avhile the spoon probably passed the pylorus, Avhen he suddenly fell into a sweet sleep, perspir- ing through the night, extending the disordered limb, the flex- or tendons of which had been greatly contracted, especially through the last complaint. He now became rational, his fe- ver formed a perfect crisis, he recounted the past transaction with extreme sensibility, and expressed great anxiety for relief. He contiuued to gain in health and strength, until the 25th day of July, fifteen days after the crisis, Avhen a cutting sen- sation, confirmed by pressure of the hand when in a stooping position, led to a discovery of the situation of the spoon in one of the circumvolutions of the intestines, near the line dividing the right iliac and hypogastric regions. It remained in this fixed position, Avith increased heat and irritation in the adja- cent parts, until August 7th. Fearing that any further delay might endanger success, and he resolutely determined to suffer anything for relief, I had recourse to an operation as the dernier resort. I made an incision of about three inches in length through the parietes of the abdomen, and peritoneum, raised a portion of the intes- tinum ilium containing the spoon, pierced it with a lancet at the obstructed point, and extracted the spoon with the forceps. I then laid the divided edges of the intestine directly opposite and secured them with the glover's stitch, dressing the exter- nal wound Avith adhesive straps and lint. In three Aveeks the patient was riding abroad in his carriage. This case was more minutely published in the New York Medical Repository, 1807. it is also referred to by Dr. Reese, in his edition of Cooper's Dictionary, under the head of Enterotomy. 18 Dr. Wliite on Insanity. I could here introduce cases enough to fill an octavo volume, with their ten thousand preposterous imaginings, such as the discoverer of perpetual motion, tying old spikes and slips of sheet iron to a Avire strung across his window, and striking them with his finger as proof positive. The aged matron of nearly seventy, with not a tooth in her head, decked out with her pantalettes, assuring us that she is just entering her sixth year, and is now cutting her milk teeth. The Emperor Napoleon refusing to ride in any vehicle but his gilded coach, drawn by six milk Avhite steeds. Cyrus Darius derives his title from the two kings of Persia, united in him as their right- ful successor—issues his daily prerogative, that no man shall take him by the hand, lest it should deprive him of his im- mense treasures, yet is constantly inquiring Avhy some one does not bring him a better suit of clothes. The farmer hav- ing discovered the secret of driving 1000 yoke of oxen as one yoke, his income therefore was just five hundred dollars daily— could build a city Avith pitch and ground plaster, as large as NeAv York, in one summer. Kings on their thrones issuing orders to their subjects— queens fantastically adorned—dukes ruling their dukedoms— the rich man dying from poverty—the poor man rich as Croe- sus—rulers of the earth—rulers of the seas—rulers of the planetary system—saints and sinners—angels of light and an- gels of darkness. But enough, time will not permit us to dwell longer on this branch of our subject. I will, however, give you one case of simulated Insanity, a practice becoming too common where other means fail to secure the guilty from the penalties of the laAv, while the irresponsible, from aberra- tion of mind, may be unjustly condemned. A forged draft was presented at the Hudson River Bank the forger detected, tried, and convicted. The idea of an apprenticeship at hard labor in Sing-Sing, illy comported with the sunny dreams of fortune more easily obtained. Before and after the trial, while in jail, his nervous system became wonderfully unstrung, assuming the character of a confirmed maniac. As he noAv showed symptoms of extreme exhausta- tion, great sympathy was manifested in his behalf, and the Dr. White on Insanity. 19 court strenuously urged to compassionate his deplorable situa- tion, by permitting him to be conveyed to the county house nnder a viligant care taker, Avhere he could recruit for fur- ther disposal. Under these circumstances the court requested rae to visit him, and state my opinion of his case. They then put this question to me: Is this man insane ? My an- swer Avas no. By what means are you able to give this deci- sive opinion ? By the state of his pulse, and obtaining the full expression of his eye, I saw no insanity there. As to the propriety of sending him to the county house to regain his health and strength, I will venture to predict that his strength will so rapidly recover, that he will provide for himself after a very few days. Notwithstanding this positive opinion the experiment Avas tried, and the third night after his removal he eluded the vigilance of his trusty care taker. Whether he betook himself to Texas, or crossed the Atlantic to renew his honest calling has never been discovered. This case shows the importance of a practical acquaintance with the insane, to give a correct opinion in obscure cases or simulated insanity. To show Avith Avhat intense interest this subject is regard- ed by the community at large, followed by Legislative enact- ments, Asylums in this country have more than doubled in number since 1830. The unfounded prejudices, however, still remaining through ignorance, as to the beneficial effects of early removal of the insane from those sources of irritation so prevalent at their homes, to the enjoyment of a more quiet retreat under the kind supervision of strangers, possessing conveniences for every appliance Avith the least possible re- straint, must eventually be OA'ercome by the dissemination of sound principles and incontrovertible results. The sympathy of friends of the insane, too often lead them into irretrieArable errors in Avithholding them too long under experiments of their own, and when yielding at last to their removal to an Asy- lum, insisting upon the privilege of visiting them at their option, notwithstanding they are assured that such a course, if presisted in, will inevitably endanger the prospect of their recovery. Again, as soon as the patient is brought under suitable control, for every advantage of the best medical and 20 Dr. White on Insanity. moral treatment, and at a time, perhaps, when the most trifling incident may decide the future prospect of the "dividual contrary to the advice of the physician from caprice, or other motives, they will hurry them away to their former a»o : at on , exposing them to a relapse more dangerous than the first at- tack. To such I would say, select for your friend a location where you have entire confidence in the faithful management of those committed to their care, andab.de their judgment, not your own, as to the proper time for their removal Pa- tients half cured uniformity discredit an Institution; whereas if radically cured, no language is too strong to express their enduring gratitude for their recovery. Medical logic, based upon the sciences, is fast dissipating the mist of ignorance, superstition, and credulity. Nor will we despair of some towerino- genius, who rising from this fountain of vital and sensitive* action, shall attune to its highest bearing the finest fibre of the human tyre. , . . In conclusion, I cannot forbear a few remarks to the junior members of our profession. Never be satisfied Avith attaining only mediocrity; aim at a higher mark, nor fail to acquire the means of effecting it. Let your profession have your undivided attention. Never let a day pass without some improvement in medical science. A moderate sum will put any one in possession of a well se- lected library, in connection Avith the periodicals of the day. Read attentively, take notice of what you wish to retain, and you will soon be able to distinguish truth from error. Study character in every station and relation of life. Take counsel of the wise, nor fail to have an opinion of your own. Never mar your diploma with habits of intemperance or infidelity. Have no intercouse Avith quacks. Common sense will teach you to disregard the humbugs of the day. Having been extensively engaged forty-five years in every branch of medical and surgical practice, I know its trials, its fatigues, and its responsibilities, and Avhat it is to prepare for every exigency. If there is any prevailing sentiment of my heart, it is, that every member of the state and county socie- ties, like a Spartan band, should keep their armor bright, and when disease and danger invade march promptly to the rescue. Having faithfully done our utmost to avert the archer's aim, should it be our lot to wipe away the cold sweat of death, and close the eyes of departing nature Avhile Aveeping relatives bedew the pale cheek Avith their softest sorrows, we may there learn the monitory lesson— 'Tis not all of life to live, Nor all of death to die.