I Digitized by tine Internet Arciiive in 2007 witii funding from IVIicrosoft Corporation http://www.arcliive.org/details/causationcoursetOOstoriala cJWedicine S" Society In d/^merica ciWedicine ^ Society In c/^merica Advisory Editor Charles E. Rosenberg Professor of History University of Pennsylvania THE CAUSATION, COURSE, AND TREATMENT REFLEX INSANITY IN WOMEN BY HORATIO ROBINSON STORER, M. D., LL. B. m o^RNO ^REss & The A(ew York Times New York 1972 Reprint Edition 1972 by Amo Press Inc. Reprinted from a copy in The Library of The College of Physicians of Philadelphia LC# 71-180592 ISBN 0-405-03974-3 Medicine and Society in America ISBN for complete set: 0-405-03930-1 See last pages of this volume for titles. Manufactured in the United States of America THE CAUSATION, COURSE, AND TREATMENT REFLEX INSANITY LN WOMEN. BY HORATIO ROBINSON STORER, M. D., LL. B., OF BOSTON, Burgmn to 8c. Eliubeth'i iind Si. Francit't Hoipitala for Women ; Contulting Surgeon to th« Carnej (Gentnl) Hospital ; formerly Assistant in Obstetrics and Medical Jurisprudence in Harvard Unirersity, Frofeaior of Obstetrics and tbe Diseases of Women in Berlcshire Medical College, and Pb/sician to tbe Boston Ljtng-in'Hospital ; lace Vice-President of tbe American Medical Association ; Member of tht GjDSecological Society of Boston, the New York Medico-Legal Society, tbe Obstetrio aikd Mcdico-Cbirurgical Societies of Edinburgh ; Correspouding Member of th« Obstetrical Society of Berlin ; Honorary Member of the LouIstUU Obat«ui«al Society, and of tli« CaoadiaD Medical AsweiatioB. Sublatd causd, tollitur fffectus. BOSTON: LEE AND SHEPARD, PUBLISHERS. NEW YORK: LEE, SHEPARD AND DILLINGHAM. 1871. Entered, according to Act of Congress, in the year 1870, By lee AKD SHKPAUl), In the Office of the Librarian of Congress, at Washington. STEREOTYPED AT THB BOSTON STKRF.OTYPE FOUNDBT, 19 Spring Lane. MEMBERS OF THE GYNiECOLOGICAL SOCIETY OF BOSTON, THOUGHTFUL, WORKING, FEARLESS GENTLEMEN, ALREADY A POWER IN THE LAND, IS AFFECTIONATELY INSCRIBED. PREFATORY NOTE. The following pages were communicated to the American Medical Association in 1865, at its session in Boston, and were printed in its Transactions for that year. The writer has been requested to republish his memoir by physicians interested in gynaecology, who have desired a copy in a sep- arate form for their book-shelves, or have thought the topic deserving more general attention ; and he was duly author- ized to do so by a formal vote of the Association,* at its session at Cincinnati in 1867. Many causes have combined to prevent accedence to the wish of his friends and the repeated request of his publish- ers, chief among them, perhaps, the feeling that, as he had so.wn the seed, it should be for others to develop the tender growth of a better practice. He has cherished the lingering hope, moreover, that he might some time find leisure to pre- pare a work upon this interesting subject of reflex insanity more worthy its intrinsic and practical importance. That leisure, however, has not yet arrived ; and the publi- cation by Professor Louis Mayer, of Berlin, in the last vol- ume of the Transactions of the Obstetrical Society of that city, of an elaborate paper upon the relations of the fe- * Transactions of the Association, vol. xviii., 1867, p. 43. By its constitution, all scientific communications made to the Association become its exclusive prop* erly, and cannot be published by their authors without express permission. (S) 6 PREFATORY NOTE. male sexual organs to mental disease, has seemed to afford a suitable moment for simultaneously presenting the two memoirs to the medical public in this country.* It will be perceived that, approaching the subject from a somewhat different stand-point, and in entire ignorance that he had been anticipated in the investigation by several years, Pro- fessor Mayer affords unanswerable proof of the correctness of every point made in the following pages. The writer has preferred, in view of his inability to revise and extend the paper, to make no material changes in it whatsoever. Hotel Pelham, Boston, i November, 1870. • A translation of Prof. Mayer's memoir, by Dr. George H. Bixby, with notes by Dr. Storer, will be found in the Journal of the Gynacological Society of Boston, commencing with the number for May, 1870. Discussions upon the gen- eral subject of insanity in women have been held at several of the meetings of the Society, reports of which have also been published in its JoumaL CONTENTS. PAOI I. Selection of Special Topic 9 II. Point previously attained 21 III. Work to be done 30 IV. The Brain the Seat of Insanity, not always of its Cause 36 V. Explanations of distant Causation 62 VI. Causation of Insanity often Pelvic in Women. . 77 VII. Rationale of Pelvic Causation of Insanity. . . 127 VIII. Indications of Treatment 157 (7) THE CAUSATION, COURSE, AND TREATMENT OF REFLEX INSANITY IN WOMEN. I. — Selection of special Topic. It was decided at the meeting of the American Medical Association, held at St. Louis, in 1854, to ^^' tablish a standing committee, annually to be chosen, and regularly to report " upon the subject of insanity as it prevails in this country, including its causation, as hereditary transmission, educational influences, — .physical and moral, — social and political institutions, &c. ; its forms and complications, curability, means of prevention, &c." In 1865, eleven years had elapsed since the com- mittee was first appointed, and to that time there seems to have been rendered no report. Special committees, it is true, upon particular points, selected by the Association, and connected with the general subject of insanity, had twice attended to the duties assigned to them, preparing the excellent papers upon the Medical Jurisprudence of Insanit}^, by Dr. Cov- entry, of Utica, N. Y., and upon Moral Insanity in its Relations to Medical Jurisprudence, by the late (9) lO REFLEX INSANITY Dr. D. Meredith Reese, of New York city, — both of them rendered to the meeting: held at Washington in 1S58, and contained in the pubHshed volume of the Transactions of the Association for that year. A similar report upon the Morbid and Therapeutical Effects of Mental and Moral Influences had been promised by Professor Palmer, of Michigan. As re- gards, however, the regular standing committee upon insanity, the fact remains as stated : it had uniformly failed to accomplish its work.* This is the more surprising when we consider to what extent the subject had already been studied in this country, the excellence to which our general sys- tem of hospital arrangement had been brought, and the eminence attained by many American superin- tendents. These gentlemen had been freely placed upon the committee appointed by the Association in years past, if not, indeed, in each previous instance selected from them alone, and it is a matter of extreme regret that they should not have responded to the call ; for there are few subjects attended with the interest to • Dr. Hills, of Ohio, at that time superintendent of the Central Lunatic Asy- lum at Columbus, who was charged with the duty of reporting at the New York meet'ng, as chairman of the committee on insan'ty for 1C64, was prevented from fulfilling that trust; among other causes, by "the breadth of foundation he had laid for an elaborate report. " At his request, he was granted an extension of time, with the understanding, however, that this arrangement did not interfere with the appointment of the new committee for 1S65, which it was understood by the nominating committee was then annually required by the organic law of the Association. IN WOMEN. H the profession at large that pertains to this of insani- ty ; few with such important bearings upon the wel- fare of the community, and its relations to medical men, — few with such fruitful fields for labor and success. It will undoubtedly be alleged, that in the fact that the hospital superintendents of the several States had united themselves into a separate organization, — the so-called Association of Superintendents, meeting an- nually for purposes of conference, and publishing a journal devoted to the interests of their speciality, — there was enough accomplished for all the purposes of science and practical art, leaving it unnecessary for any annual contribution to either to be made through other channels. We, however, of the profession at large, can hardly acknowledge the justice of such reasoning. Special journals, however ably conduct- ed, and with whatever extent of circulation, do not reach every general practitioner. As well ought it be said that any contribution to the science of oph- thalmology — which, of all the departments of medi- icine, now seems to boast the largest and most enthu- siastic number of skilled devotees — would be out of place or unden'alued with ourselves, simply because that branch has now its own national organization and its special journals. Every specialist, no matter what his favorite study, whether insanity, ophthalmology, or the diseases of 12 REFLEX INSANITY women, owes his first duty to the profession at large, for it is through it that his observations or his discov- eries must really become effective. It is through those that apply upon the widest scale theories to practice, and practice to its ultimate demonstrations, that the largest results are to be gained ; and, in this matter of insanity, for every patient that is carried to an asylum for treatment, scores are treated in their earlier stages, wherein the chances of success are al- lowed to be infinitely the greater, by the profession outside asylum walls ; and for every patient that is ultimately cured in an asylum, in hundreds the de- rangement threatening is warded off by judicious general or special treatment at home, or in changed localities. Now, be it distinctly understood that no man can put a higher value than I do upon our public hospi- tals for the insane. There are few of the profession, not directly connected with these institutions as phy- sician or trustee, who have studied them more care- fully, or upon a larger scale, both in their minute details and their comparative plans and methods of management. I believe them to be excellently con- ducted, and most of their medical officers to be men well selected, of skill, and worthy the highest trust. The records of the Association of these gentlemen show the most painstaking and extended efforts at improvement, and reflect, as does the Journal con- IN WOMEN. £3 ducted in its behalf,* much credit upon itself collec- tively, and its individual members. Had, however, the Society of Superintendents but put itself into more direct connection with the General Association, of which its members were, and still are, almost every one of them in fellowship, it would have effected more towards establishing the high standard and ac- complishing the good it has intended. The opinion has prevailed in many quarters — it has, to a certain extent, been inculcated, as in the most excellent work upon the medical jurisprudence of insanity, by my friend. Dr. Isaac Ray — that no one can possibly know much of insanity, or at any rate be accepted as of any authority upon the subject, unless he is a member, as superintendent or ex- superintendent, of this inner circle. But a man cannot study a special point in medicine with interest, assiduity, and good faith for many years, without forming decided conclusions thereon. If, moreover, his position, by accident or other advan- tage, has been such as to render him perfectly inde- pendent of all party or individual bias, nullius ad- dictus jurare in verba magistri^ these conclusions should have the greater weight ; and if, in addition, he approaches the subject from a standpoint compar- atively new, certainly so far as previous employment of it to attain a practical end has been concerned, and if he is able to show that measures which in one * The American Journa] of Insanity, Utica, N. Y. 14 REFLEX INSANIT"^ quarter, namely, in civil practice, are found very ef- fective for cure, in another quarter, namely, in asylum practice, are as yet generally and practically unrecog- nized, his conclusions should be very apt to carry with them conviction. Such, I would respectfully submit, is my own posi- tion with regard to the present report. It is ofiered as a plain, straightforward statement of facts, com- mending themselves to the good sense of every mem- ber of the profession. Upon the general subject of insanity volumes upon volumes have already been written, some of them of interest, and very practical use, much of them of none. I have no desire to add to the host of abstruse and abstract discussions of metaphysical points in psychology, already far too numerous. Were I an asylum superintendent, I might delight the Associa- tion by a discourse upon the excellent systems by which hospitals are now heated and ventilated, or the question as to whether, as regards economy, it is better for superintendents to raise or to purchase their own supplies ; upon the psychological characteristics of Milton, Shakspeare, Dante, and the several dra- matis personcc^ supernal, mortal, or demoniac, of these and other writers ; upon the comparative merits of restraint and non-restraint, and as to where the lat- ter is supposed to begin and to end ; whether Auba- nel or Brigham invented the crib, and its advantages IN WOMEN. 15 as compared with the bedstrap of Wyman, and this again with the fingerless gloves of Parkmann, the handless sleeves and muff of Haslam, the belts of Reil, and of the York Retreat, the manacles of Ruer, and the chains of time immemorial, the bifurcated sack of Horn, the knee breeches of Neu- mann, and the buckled straps of Nostitz, the leathern mask of Autenrieth, the pear-shaped frame for the mouth, and the gag, the wicker basket of Guislain, the suspended box of Hayner, the cord and the re- straining chair, the dark chamber and the padded room, the rotary machine of Darwin, the suspended seat of Cox, the hanging mat of Hallaran, the hol- low wheel of Hayner, the swing of Chiarruggi, the douche and the surprise bath, the proposal of our own Rush, whose treatise had for many years a more extensive circulation among American physicians than all other works upon mental disorders together, that because refractory horses are subdued by being kept from lying down or sleeping, and because ele- phants, when first captured, are tamed by depriving them of food until they discover signs of great ema- ciation, therefore the insane should be kept in a standing posture, and awake, for four and twenty hours, and fasting for several days ! These might be discussed, and other methods of subduing violent maniacs, and whether a little etherization is not, after all, much the best ; upon l6 REFLEX INSANITY whether, in insanity, the mind is or is not diseased, or is only partially hidden by a transient cloud ; upon the pathological results of insanity, and why it is that in every affection of the mind, no matter how diverse or opposite, we may find identical conditions of the brain, or no trace of disease whatever, and in eveiy lesion whatever of the brain we may find an entirely unaffected mind ; and the host of other theoretical, practical, and transcendental questions so fully and so ably discussed in the pages of the American Journal of Insanity, of the Asylum Journal of Men- tal Science, of the Journal of Psychological Medi- cine, and the other periodicals devoted to the inter- ests of the insane. As it is, having been chosen by the Association to this work in consequence, as I suppose, of having long been delving in the spe- cial field of hysteria, and the reflex nervous and neuralgic demonstrations of invalid women, I take it for granted that what is expected at my hands is, to a certain extent, of a special character, although of necessity, as all specialism rests upon general princi- ples, I shall endeavor not to lose sight of the general basis upon which it lies. The causation and the cure of insanity are its Alpha and Onicga. The last of these has usually been sought the first ; and it is because the other, upon which it wholly depends, is so often unsearched for wisely, if at all, that both are so seldom attained. IN WOMEN. 17 In deciding, therefore, to devote the major part of this report to an attempt at an elucidation of the true causation of mental disturbance in a large proportion of the cases in which it obtains in women, and of a more rational treatment than is generally adopted, I took early occasion to consult my colleagues upon the committee, who were all of them superintendents, and, without a single exception, of public and State hospitals for the insane. They were Drs. Bancroft, of New Hampshire ; Van Deusen, of Michigan ; Patterson, of Iowa ; Woodburn, of Indiana ; and Worthington, of the Friends' Asylum at Frankford, Pennsylvania. With reference to the opinions of these gentlemen as expressed in letters from which I shall quote, it may be stated that I had previously avowed it as my be- lief that very many cases of mental disturbance in women are of reflex character, arising from pelvic irritation, and that local treatment would prove of advantage in very many more cases than those for which as yet it had ever been employed. Dr. Bancroft wrote me as follows : — " I freely admit that a large proportion of cases of insan- ity, even in both sexes, are of reflex origin, and not the re- sult, primarily, of cerebral change. " I am well aware, also, that many attacks of insanity in females originate in uterine disturbance of some sort, and are cured bj treatment directed to that organ. " A part of these cases, 1 have no doubt, require topica treatment, and, of course, demand examination by tact and 2 l8 REFLEX INSANITY the speculum. No one would be more thankful than myselj for better facilities than are at present afforded for investi- gating and teaching these cases.* " What would be the best method of accomplishing this object, I have not yet a settled opinion. " I have read jour published articles in the Boston Med- ical and Surgical Journal; f and, if I correctly understand you, you hold that the principal cause of insanity in fe- males is uterine disorder of some kind, and that the princi- pal treatment in females is therefore to be directed to the uterus; and I infer further from your writings that topical treatment stands, or should stand, most prominent. " Although admitting, to a more limited extent, the truth of 3'our positions, yet I am not prepared to give that form of disease so prominent a place as to give to it the whole report, to the exclusion of other topics. "Although your idea is one of importance, and should receive a due share of attention, I think to allow it to absorb the whole report would but partially and imperfectly discuss the great points of interest pertaining to insanity in this country." From Dr. Worthington I received a communica- tion of similar import. *' I believe it is the general opinion among asylum physi- cians," he said, " that insanity, in a great majority of cases, is unattended with any organic cerebral change; and the large number of cases of the disease attributable to ill health, in the reports of hospitals for the insane, is evidence of the belief of their authors that the disease is very com- monly consecutive to disorders of the general system. Among these disorders, I have no doubt that those of the genital apparatus, in both sexes, are productive of a consid- erable number of cases of insanity. I can call to mind a • The Italics above are my own, and are iised because of the importance of ihe admission here made, in reference to incidental points hereafter to be con- sidered. ♦ Loc. cit., April 7, October 13, and November 24, 1864. IN WOMEN. 19 case where a simple displacement of the uterus was the cause of an attack of insanity of two years' duration, which was remedied in this institution, in a short time, by confin- ing the patient to bed, and applying a suitable pessary. In all cases under my care, where there is reason to believe that uterine disease may be the cause of the mental disorder, I have always been in the habit of making special examina- tions, and I have sometimes called in the assistance of medical friends who have made these diseases an especial study. "On the other hand, I have gradually become convinced that we may attach too much importance to these disorders as a cause of insanity, and that in our willingness to refer the mental symptoms to irritation reflected from the uterus, we may overlook the more serious idiopathic cerebral dis- ease. I have known the latter occur coincident with uterine disorder, and yet entirely independent of it; and have my- self lost valuable time in treating the uterine aflfection, and afterwards, on addressing my remedies to the true seat of the mental disorder, have had the satisfaction of seeing my patient speedily recover. Such cases may not be very nu- merous, but they are very important to bear in mind, and I would beg leave to call your attention specially to them. It appears to me to be particularly desirable to discover in the character of the mental disorder itself, without reference to other symptoms, some marks by which we may be able to decide whether a case is one of idiopathic or sympathetic cerebral disorder." Dr. Van Deusen confined himself to the discus- sion of a single point only, and that merely an inci- dental one as compared with the broad subject upon which I addressed him, and concerning which we have seen Drs. Bancroft and Worthington so fully ex- pressing their opinion. The matter to which his com- munication is limited is that upon which I had read 20 REFLEX INSANITY a paper at the previous meeting of the Association, which will be found published in the volume of its Transactions for 1864, namely, the necessity, for the more thorough elucidation of each case of insanity in females, that consulting physicians should be ap- pointed to every hospital for the insane. To Dr. Van Deusen's letter I shall hereafter refer. Dr. Woodburn wrote me as follows : — "I read your articles, published some time since in the Boston Medical and Surgical Journal, and was well pleased with the contents ; but would venture to suggest that prob- ably insanity is not so frequently caused by female diseases as the papers would seem to indicate. My opinion is, that mental derangement is always caused, either by physical disease or bodily injury (accidental cases), or by malforma- tion (hereditary cases'). The malformation may be appar- ent, or may possibly be only of the elementary cells. "I had intended to write a short paper, which you might incorporate with your report if you thought proper, but in the press of other duties I have been compelled to aban- don it." From Dr, Patterson I received an interesting com- munication upon the general causes affecting the mental health, more particularly of women in country districts, which will be found in another portion of the present memoir. Willing as I should have been to have incorporated the opinions of my colleagues to a greater extent in this report, whether or no they were confirmatory of my own, it will be seen that I am compelled in great meastire to assume its sole responsibility. IN WOMEN. 21 II. — Point previously attained. Reference has been made in the letters of these gentlemen to views concerning the causation of in- sanity in women that I had already expressed. These will be found in full, or in abstract, in the published proceedings of the American Academy of Arts and Sciences for 1864-5, and in various numbers of the Boston Medical and Surgical Journal for the same period. It may be that the experience of others, if carefully analyzed, will not wholly confirm me in the position that I have assumed ; the lapse of many months (now several years), however, since I first threw out a hint of my convictions, in the report of the Massachusetts State Commission on Insanity for 1863-4, has but served to render me the more decided in my every assumption, and I believe it will be found, just as it was with my statements concerning the frequency of criminal abortion, — a report upon which, as chairman of the special committee upon this sub- ject, I had the honor to render to the American Medi- cal Association in 1859,* — that though my premises * To my colleagues upon that committee, Drs. Blatchford, of New York, Hodge, of Pennsylvania, Pope, of Missouri, Barton, of South Carolina, Lopez, of Alabama, Semmes, of the District of Columbia, and Brisbane, of Wisconsiti, all of them gentlemen much older and of higher standing in the profession than myself (and three or four of whom have now deceased), I shall always feel under deep obligations for the brave and sympathetic alacrity with which they indorsed views that at the time seemed to many, of an earlier school, heretical or un. founded. 33 REFLEX INSANITY were so startling, and of so practical results as to be by many denied, more careful and more general in- vestigation has shown that they were in reality very much understated. Preliminarily, I wish it distinctly understood, — 1 . That I assert for the insanity of women neither a universality of causation or of treatment. As I have already been misinterpreted upon both these points in my previous writings, clearly as I en- deavored to express myself, the disclaimer now made is not unnecessary. 2. I have shown that in the writings of alienists, there is comparatiyely very little to be found in acknowledgment of the part played by her sex in the causation and prolongation of insanity in women. As regards suggestion, approbation, or demand of a con- sequent and rational treatment, even less than this can be produced from the authors referred to. I do not state, however, that the key to insanity in women has not long been in possession of these gen- tlemen, but I prove by the facts adduced, that though they may have possessed it, they have not appreciated that the theory referred to would unlock, what has always been in every asylum, as in every psychologi- cal text-book, a sealed question and an opprobrium. They have not used it for this purpose in their annual reports, in their memoirs, in their published statistics, or in their medical treatment. IN WOMEN. 23 3. I have alleged that in a very large proportion of the cases of insanity occurring in woman, her sex is in reality the predisposing, the exciting, or the con- tinuing cause of the malady ; but I do not assert that there are never present other predisposing, exciting, or continuing causes at work efficiently in women as in men. 4. I have claimed that from the above premises it follows that the treatment of insane women should, in many instances, be of a direct and physical charac- ter ; but this, it will be allowed, is a very different thing from teaching that the treatment of insane wo- men should always and only be local ; which I have never advised, and which I should myself be the first to condemn. 5. As a means, and only as a means, towards the end at which we all are aiming, namely, the cure of the patient, I have endeavored to exhibit the necessity at every asylum of a board of consulting physicians, skilled in the diagnosis and treatment of uterine dis- ease, which is now acknowledged to especially require erudite tact and an appreciative mind ; but I have distinctly stated that such aid was only to be made use of at the discretion of the superintendent, whose monarchical and exclusive sway, legislative and ex- ecutive, economical and financial, spiritual and cor- poreal, could thus in nowise be lessened or interfered with. 24 REFLEX INSANITY If superintendents are not in reality afraid of a shadow, if they are not disinclined to allow the pro- fession at large to participate in the study of mind diseased, why this tone of suspicion, or jealousy, or fear that a simple, needed, and practical suggestion by a medical man who knows whereof he is speaking, has in certain quarters called forth ? I have ventured to direct the attention of the pro- fession to the results then and now again to be placed before them, as in every respect important, and in some respects novel. Their right to this last attribute has been challenged, and in a quarter where, in view of all the circumstances, we should have last looked for any counter claim. I refer to a statement by the editor-in-chief of the official organ of American Superintendents, Dr. John P. Gray, of the Utica Asy- lum.* Abundant evidence will be afforded in the present paper to settle all doubt upon this score. I merely wish thus beforehand to define my position ; asserting as new only the attempt to apply upon the large scale to the treatment of insane women, in asylums as in private practice, views that in theory were partially recognized even by Hippocrates, though they have been practically acted upon by few or none of his successors. My position is rather that of the pioneer than of the discoverer. There is little positively new in • MS. Letter of December, 1864. IN WOMEN. 25 medicine ; there is much that is comparatively so. Not a statement, however original, to which a pre* vious clew has not existed and cannot be found. Not a psychologist, however practically he may disbelieve in a local origin for mental derangement, and may have put his disbelief on permanent record, but might aver that such origin were perfectly familiar to him ; that he learned it in his mother's womb, or imbibed it from her bosom, even that he inherited its knowl- edge from his ancestors, for cases enough were on rec- ord in their day and from time immemorial. I have referred to a disposition on the part of cer- tain individuals, apparently very few in number, to misinterpret or to undervalue facts that may be stated, or deductions that may be draw^n, by any one who is not professedly a psychological specialist, and upon that ground. I shall therefore take the liberty of fortifying some of the points that I shall make, by the evidence or the language of gentlemen whose position within the inner circle alluded to is such as to render their authority unquestioned. For instance — and as it is a question that met me upon the very threshold of this report, I have little hesitation in presenting it. What shall be allowed to render a man conversant with the various phases of mental disturbance? One superintendent, the phy- sician to the Utica Asylum, considers that it can only be attained by prolonged residence In an insane hos- 26 REFLEX INSANITY pital. Under date of January, nth ult. (1865), he writes me as follows, and in expressing an opinion as to views of my own, unless it was arrived at very superficially or at second hand, he must have been aware that they were based upon no isolated case or two, but upon a dozen years of almost exclusive observation, upon the most extended scale, of sick women. He says, — " It certainly appears to me that some practical experience in the management and treatment of the insane, acquired not from an isolated case or two, but in some large hospital, would greatly modify your ideas. You would then have an opportunity of ascertaining what is really known on the subject, and what treatment is actually practised in these institutions." On the other hand, it is possible that careful com- parisons of the actual working detail of many hos- pitals, of the plans, medical and in other respects, under which they are conducted, and of the ideas of their respective superintendents as afforded Ijy their various systems of treatment, seen in operation, and described personally by the gentlen>en themselves, may perhaps give even a better knowledge of what is really known on the subject, and what treatment is actually practised in these institutions, than a resi- dence, no matter for what length of time, at any asylum in the land. In no matter is the old saying of Morgagni more true than in this : Perpendenda^ tion numerandcB^ sunt observationes. TN WOMEN. 27 Is a knowledge of psychological literature sufficient to make one a safe guide? There is, I will venture to say, no department of medicine, save the closely- allied and more properly considered pseudo-science, phrenology, whose literature is so crowded with contradictory statements and conflicting theories, with utterly baseless generalizations and facts misinter- preted, as this department of insanity. Each suc- cessive text-book has repeated the errors, or many of them, of its predecessors. There are, it is true, notable exceptions, the various works of Ray, for in- stance — which are all of them, for originality of thought, for closeness of obsen^ation, and for justness of reasoning, veritable oases in this most barren of deserts ; but even Bucknill and Tuke, whose book is in many respects one of the best of modern medi- cine, still retain the old, and that ought to be obso- lete, artificial classification ; which, last relic of an ancient nosology, would separate all the forms of insanity in accordance with their several symptoms, and by ignoring the great and fundamental question of their causation, would reduce to a matter of unsafe and blind routine their chance of cure. Each author, moreover, and often without a word of credit, repeats the details, insufficient or irrelevant though they may be, of cases that seem to have been handed down from time almost immemorial, judging from the dis- 28 REFLEX INSANITY tance backward to which in several instances I have traced them. It was my first intention to have presented in this report a summary of all the cases on record, so far as I could collect them, illustrative of the diagnosis, pos- itive and differential, that had been formed, and of the treatment of insanity in women by past and present masters in psychological medicine ; and for this pur- pose I had tabulated or made minutes of a mass of cases, amounting probably to several hundreds ; but, upon more carefully examining them, they were found so faulty, or so imperfectly reported, as for all prac- tical purposes to be useless. What, for instance, shall I say of the fact, that while in scores and in hundreds of cases great care has been taken to say whether the woman had or had not had the itch, — for this affection was formerly considered an important agent in the causation of insanity, — in scarcely any, on the other hand, however plainly con- nected with pelvic derangement, is any physical examination mentioned or its results given ; a method of studying and reporting that does not seem to have ceased with the yeafs bygone. Or, what of the simi- lar fact that, in the autopsies of the insane, it has seldom seemed necessary to critically examine other organs of the body than the brain, even though that showed no trace whatever of lesion. Or what, again, of the other fact, still almost universal, that in the cases IN WOMEN. 29 of undoubted pelvic origin or influence, — at least, in those that have been reported, — where attempts at physical exploration have been made, precise men- tion is omitted of the exact species of local disease that was ascertained to be present, so important in deciding as to whether the means resorted to for its relief were exactly what were required, without which correspondence it is evident a cure could not be hoped, and a failure to effect it could prove no error as to the ultimate causation of the mental dis- turbance. A mind that has been trained in the arena of modern general practice, and is accustomed to de- pend only upon the most rigid and rigorous methods of diagnosis, finds little in such faulty material that either satisfies or is edifying. Let me give, upon this point, a single forcible word from one of the best psychological authorities in this country, Dr. Workman, of Toronto, the superintend- ent of the immense government asylum of Canada West. He writes me as follows : — " So much has been written on insanity, as I am sure you know, the tendency of which has only been to becloud the subject, that even when one is fortunate enough to command a good proportion of the works, he has to wade through ter- rible cesspool accumulations, or scramble over piles of for- saken habitations, before he dare venture to say to the world that he has begun to study." With this word of explanation, which will have been seen to be necessary, I proceed. 30 REFLEX INSANITY III. — Work to be done. I had intended to have presented in this report a carefully prepared and somewhat complete essay upon the insanity of women, it being my opinion, as stated in my paper published in the volume of tlie Transactions of the Association for 1865, — I. That in women mental disease is often, perhaps generally, dependent upon functional or organic dis- turbance of the reproductive system. II. That in women the access or exacerbation of mental disease is usually coincident with the catame- nial establishment, its periodical access, temporary suppression, or final cessation. And, therefore, — III. That the rational and successful treatment of mental disease in women must be based upon the preceding theories, which I have claimed are estab- lished, — 1. By many analogies, physiological and pathologi- cal, in the cerebral manifestations of the human fe- male and that of the lower mammals. 2. By clinical observation ; and, — 3. By the results of autopsies of the insane, both in private practice and, where made with equal care and impartiality, in insane asylums. To cover, however, properly all the ground that I had marked out would occupy a larger space than, IN WOMEN. 31 perhaps, one has a right to claim for a single report ; and since it was commenced, I have received com- munications, published and private, of such a charac- ter as have satisfied me that it is better at this time and in this place to strike boldly at the very root of the present S3'stem of theory and management of in- sanity in women, before attempting to train a health- ier and sturdier growth in its stead. Convinced of being correct in this, I intend, health permitting, to pursue it ; and, to prove that I am in earnest, now subjoin a sketch of the essay that I have already par- tially prepared for submitting to the Association. I. Causation. The insanity of woman proved generally peripheral and reflex — 1. By evidence negative. a. Admissions of psychologists. a. Cerebral disease without insanity. /?. Insanity without cerebral disease. b. Omission of autopsies. c. Neglect at autopsies. d. Results of autopsies. a. At asylums. /J. At general hospitals. y. In civil practice. 2. By evidence positive. a. Analogies from — a. Other sympathetic results. I. On nerves sensory. II. On nerves motor. III. On functions organic. * IV. On functions animal. V. On fcetus in utero. p. Madness in lower mammals. 3^ REFLEX INSANITY y. Admissions — I. Of psychologists. II. Of gynaecologists. III. Of women themselves. d. Cases on record. I. Psychical. II. Obstetrical. t. Cases now first given. C. Autopsies — I. On record. II. Now first given. 1/. Time of development. I. Fcjetal. II. Congenital. III. Puberal. IV. Catamenial. V. Nuptal. VI. Gestal. VII. Puerperal. VIII. Lacteal. IX. Climaxal. X. Senile. XI. Organic disease. 6. Effect of treatment — I. At asylums. II. In civil practice. ». Reflex induction of cerebral derangement. X. Reflex cure of cerebral derangement. X. Not necessary to expect uterine disease al- ways to produce insanity, even if it were allowed that insanity in women were usually induced by uterine disease. II. Theory of ultimate causation. I. Effect on general health — a. Of pain. d. Of abnormal flux. a. Hemorrhagic. |J. Leucorrhoeal. y. Lacteal. IN WOMEN. 33 a. Cerebral irritation. a. Direct. b. Reflex. 3. Circulation of carbon, uneliminated a. Bv lungs. b. By uterus. o. In virginitj. /?. In pregnancy. I. Healthy. 11. Diseased. 4. Dystocia. 5. Uterine inheritance. a. Metritic. /?. Placental. 6. Toxsemia. III. Indications of Prevention. IV. Indications of Rational Treatment. 1. To ascertain the primary lesion. 2. To prevent exacerbating influences. 3. To relieve physical symptoms. 4. To remove the exciting cause, it being of no slight moment — a. At what stage a patient is treated. b. And in vv^hat way she is treated, whether a. According to the individual case, or /S. By routine. It will be perceived that there is much that can be said that I believe has not been said upon this most interesting and practical topic, just as there is much that can be done that has not yet been done towards relieving or curing its unfortunate victims. I have now at hand a large mass of material, original and collected, concerning the various points above indi- cated, that I shall hope to present to the profession at some future period. 34 REFLEX INSANITY In the mean time I shall endeavor to take by the horns one or two little chimeras that have been shaken at me, or at any rate to look them in the face. It has been asserted, in communications addressed to me since I have been appointed upon this committee. or in publications intended to break down, to discred- it, or to ridicule my testimony, — 1. That insanity in women is seldom dependent upon a pelvic cause. 2. That it has so frequently been recognized as thus dependent, that any discussion of the subject is unne- cessary. 3. That thorough physical examinations of insane women are already generally made whenever required. 4. That such are not required. 5. That they would be positively injurious to the patient herself, and, if in an asylum, to the other patients, and to general discipline. It will be hardly possible for me to give to each of these contradictory points the attention their impor- tance deserves, although I am prepared, in each in- stance, to show their utter worthlessness. In what, however, I shall say, I shall endea^'or, so far as possible, to take my arguments from psycholo- gists themselves, using, in the main, their own words, originally written though these may have been for a different purpose, and in ignorance of the real char- IN WOMEN. 35 acter and meaning of the facts described. Were these gentlemen aware of the inconsistencies, both in theory and practice, that are everywhere recorded in their special literature, they would be much more careful than one or two of them have lately been ; for it is evident, — 1. That if my views are true, but yet long known, then local examination and treatment ought not to have been stated to be generally unnecessary or posi- tively injurious ; and, — 2. That, if they are false, then it cannot be claimed that they have long been recognized as well founded, and, in practice, daily carried out to the letter, both of which conflicting assertions have been made by gentle men claiming to be leaders in the specialty of insanity. Due allowances are, of course, to be made for a certain measure of professional conservatism, how- ever arrogantly expressed ; and I do not entirely in- dorse, though I quote, the following remarks by Dr. Gait, of Virginia, himself a superintendent, and then of the Eastern Asylum. They are none the less per- tinent, however, as coming from that source, and as made to rebuke the tendency of an older school to repress innovation, or even inquiry. *' The laudator temporis acti is so common, that we do not think it necessary to quote the opinions of the past on the present subject. As a general rute, wricers allow a change to be effected, if, as they say, it is feasible. But such a mode 36 REFLEX INSANITY of argument is no longer admissible. He who opposes the proposed arrangement, must be prepared to defend himself on the assertion of its intrinsic inferiority. Admitting, however, such fancies to stand for what they are worth, we still find the medical world divided as to the matter in ques- tion ; and this circumstance itself should induce us to lean to the new views, because every one is aware of the preju- dices which association weaves about established customs and regulations. It is said that when Harvey declared to the world his discovery of the circulation of the blood, no physician beyond forty years of age gave in his adhesion to the new views." ♦ IV. — The Brain the Seat of Insanity, not ALWAYS OF its CaUSE. I have dared to say, that, in my opinion, the an- cient and still usual classification of insanity, which artificially divides the forms of mental aberration according to their mental peculiarities, is faulty and erroneous. Such a method of classifying disease according to its symptoms alone, would not, at the present day, be tolerated in any other department of medicine. It is the more necessary to dwell for a few moments upon the question here involved, for it lies at the foundation of this report ; and upon its decision depends, in great measure, the truth of my views concerning the insanity of women, novel or trite as these may prove. Dr. Workman, of Toronto, to whom I have already alluded, seems to have argued more boldly and more * American Journal of Insanity, xi. 23> IN WOMEN. 37 ably for the extra-cerebral causation of insanity than, perhaps, any other writer in this country, both in his own writings and his late translation of Schroeder van der Kolk's little work upon the pathology and theraupeutics of insanity, in the American Superin- tendents' Journal.* He writes me as follows : — " What can be more exact, what more rational, what more practically suitable than the assignment of all cases of in- sanity to the two grand heads, idiopathic and sympathetic? in other words, fixing all insanity either in the brain or otit of it. It has long been my belief that, unless in confirmed low dementia and idiocy, insanity has no necessary connec- tion with diseased brain, properly so called. I believe that when appreciable, palpable disease exists in the brain, we always have something ^f's/t/^.v, and something e.wg»//<7//y dif- ferent from insanity. It does not satisfy me to be told that disease in the brain may exist and be undetectable. We do not admit this assertion in application to any other organ or structure. If you ask me to admit the presence of disease in the eye, or the ear, or the lungs, and fail, by scalpel or microscope to demonstrate it, am I sceptic because I refuse credence.? " The circular argument of starting with the premises, that, as the brain is the organ of the mind, and insanity is a disease of the mind, therefore the brain, in insanity, must be diseased, whether we detect the disease or not, has, it appears to me, been too long deferred to. The fallacy here may exist in any one, or in all, the terms of the syllogism. '' I. I would say I do not comprehend the term 'organ of the mind.' I understand the terms organ of sight, organ of taste, organ of digestion, of circulation, of urination, &c., &c. ; but where is the parallelism, or even the resem- blance, between these functions and thought.-* "2. What is meant by disease of mind? What is the * American Joiimal of Insanity, April and July, 1864, p. 63, &c 5S REFLBX INSANITY parallelism, or even remote resemblance, between any form of bodily disease and mental abnormality? "3. Why should a diseased brain be essential to insanity? If it is absent in a single case, its presence cannot be essen- tial. I believe it is absent in many cases, yea, in the major- ity of cases. Have you carefully noted the mental condition of persons dying under pulmonary consumption ? and, if so, have you not often been struck with its close approximation to insanity? Pulmonary disease is present in a very large proportion of cases of insanity, and I believe in incurable cases it is present in fully one half. We may, or we may not, discover cerebral lesion 5«/-385. 74 REFLEX INSANITY find an identical effect from a similar cause. Tlie fallacy of such an expectation has been commented upon by Dr. Williams in the following language, equally applicable to congestion and other morbid conditions of the brain : — " Congestion of the liver is sometimes accompanied by pain or tenderness; sometimes it is without either. Con- gestion of the stomach sometimes causes gastralgia, nausea, and vomiting, with altered appetite; but these symptoms are often absent when the amount of disease of the liver, or the heart, and the subsequent occurrence of haemateme- sis, leave no doubt that the stomach was congested. The same remark is applicable to the kidneys, the uterus, the brain, and other organs." * On the other hand, that in cases where mental dis- turbance is thus induced, it should often be extreme, varying alike in its type, its symptomatic characters, and its degree of intensity, is only what should a ■priori have been expected. Dr. Bucknill has clearly recognized this fact, and admits that the analogy from an organ whose function is simple, to one whose function is so complex as that of the brain, can afford but a slight insight into the effect of similar pathologi- cal conditions in the two instances. Of the abdom- inal and thoracic organs, the stomach is that whose functions are the least simple. Its muscular move- ments are as ingeniously adapted to an end as are those of the heart ; they are even more complicated and less mechanical. In addition to this, the functions ♦ Principles of Medicine. IN WOMEN. 75 of secretion and absorption, discharged by its several sets of glands, add to the complexity of its duties. Congestion, as we have seen, causes irregular excite- ment or depression of all its functions, nei-vous, mus- cular, and secretive ; yet, compared with the brain, how few and simple are its duties. The functions of the organ of the mind are more numerous than those of all other parts of the body put together ; nor less distinct in themselves and inter-distinct ifl their ac- tion. Consequently, any pathological state which destroys their equilibrium, producing irregular de- pression of some functions, with irregular excitement of others, must cause a wider and more intricate range of anomalies than is observable in a similar state of the more simple organs.* It is necessary to distinguish the distant affections which cause insanity from those that merely accom- pany or result from mental disturbance. I have already referred to Dr. Workman's estimate of the frequency and importance in the insane, of pulmo- nary phthisis, here so often latent or unnoticed, even to its extreme stages. The physician of the Devon Asylum would explain this and similar affections in the insane as follows: — "Diseases of the lungs occur in the insane in all their varieties. Thej are frequently latent from the absence of cough, and the patient's absorption of mind preventing com* • Loc. cit., p. 359. 76 REFLEX INSANITY plaint. The absence of cough in serious pulmonary disease is very peculiar. In dementia, it arises partly from torpor of the excito-motory system, partly from loss of attention; from the same cause, in fact, as the frequent dirty habits of the insane. In mania, it arises from the attention being intensely pre-occupied by the vivid ideas and delusions which absorb the mind. We have seen many patients in advanced stages of phthisis, who were never heard to cough 80 long as they were under the influence of maniacal excite- ment. When this underwent a temporary diminution, they were greatly troubled with cough, which was again arrested by the recurrence of excitement. The continuance of colli- quative diarrhoea and perspiration, and of emaciation, proved that there was no halt in the progress of the disease, as the absence of cough has led authors erroneously to sup- pose. The torpor of the nervous system in dementia leads to another peculiarity in the lung and in some other bodily diseases of the insane, namely, the absence of irritative or symptomatic fever; and hence it happens, that in a de- mented person whose strength is unimpaired, and whose constitution is tolerably' good, diseases will obtain a high degree of development, with symptoms so few or obscure as to be incredible to the general physician. It is on this ac- count that the numerous sloughing sores to which general paralytics are liable, produce so little suflfering or constitu- tional irritation. We have known the stomach disorganized by cancer, without the patient complaining of any pain until a few days before death, when perforation took place. The only case of true carditis we ever saw, occurred in an insane person who complained of no pain, and in whose heart disease was only suspected twenty-four hours before deaths in consequence of the failure of the pulse. This pe- culiarity in the intercurrent diseases of the insane should teach the physician to observe with watchful anxiety every physical indication from which he can derive knowledge of the attack of disease before it is so advanced as to be beyond control. Pulmonary gangrene is more common among the IN WOMEN. 77 insane than the sane ; but not to the same extent here as at Vienna, where it contributes largely to asjhun mortality."* To my own mind, it would be more scientific and in accordance with facts to explain the non-apprecia- tion of pain in the insane by a true state of general or local anaesthesia, a temporary and intermittent, or confirmed and permanent, paralysis of the nerves of sensation, local and limited or general as this may be, than to attribute it merely to lack of notice of the suffering, in consequence of pre-engagement or pre- occupation of the mind. That I am correct would seem to be shown, moreover, by the curious fact that there is often absent in the insane the febrile excite- ment and reaction, both nervous and arterial, that usually attend physical accident or disease. That intervals may occur, in which the patient becomes acutely sensible of bodily anguish, only implies that aesthesia or even hyperaesthesia may succeed to local or general anaesthesia, just as undue mental activity may at times alternate with apathy or even dementia itself. VI. — Causation of Insanity often Pelvic IN Women. I have claimed that while there are affections of many organs in the body in both sexes, that undeilie •Loc. cit., p. 433. jrS REFLEX INSANITY insanity, being in reality its cause, and the foundation upon which it rests, in women there is a depth be- yond — a source of excitation not existing, practically, in man ; for, allowing every latitude to the influence of the sexual system in the male, it must be allowed that in him the genital apparatus is merely subsidi- ary, and playing but an occasional and comparatively a very insignificant part in its relations to the general economy. In woman, the case is very different. Not only is she subject to a host of diseases peculiar to her sex, to which we find neither homologue nor analogue in man, but they are capable of so modifying herself as entirely to change her natural disposition and charac- ter. In health, we find her still obedient to a special law. The subject here also, we might even say the victim, of periodicity, her life is one perpetual change, and these changes even are still again subdivided. The uterus and appendages that, in the female em- bryo, while yet unborn, were being developed ;pari passu with the other organs of the body, become at birth arrested in their growth ; without other change than a slight and disproportionate enlargement in size, they remain in their foetal condition until pu- berty occurs. The child has now become a maiden. Immediately the emotions, desires, and passions that, though latent, have been gradually foreshadowing themselves, are now established, unrecognized though IN WOMEN. 79 they may be by the girl herself; yet, like the smoulder- ing fires of a volcano, ready to burst forth at any ex- citing moment. The short space of a lunar month is henceforward the field, for many years, of a triple change — preparation for ovulation, the discharge of a germ fit for impregnation, rest and recuperation. The instinctive yearning for the other sex, and its gratification in the excitement of coitus, the culmina- tion of sexual congress in effectual impregnation, are surely of no little import ; as they are affairs of con- stantly recurring occurrence, both in the married and in many of the unmarried, unless, as is too offien the case, they are interfered with by preventive or sub- versive measures, which may but increase their eflfects upon the woman's system by making them prejudi- cial rather than, as otherwise, of benefit. Pregnancy with its varying fortunes, childbed and lactation, and, finally, the grand climacteric, supervene, and a return to the second sexual childhood, which, though barren of further fruit to the womb, is yet by no means past desire and attempts at its gratification, or past uterine disease and its many dangers : with this the scene is closed. To man, these changes, these excitements, this special work, these diseases, these dangers, are all unknown. Why, then, is it called preposterous to seek in her sex the abstract fundamental influence impressed upon evei"y woman, even while an infant 8o REFLEX INSANITY in her mother's womb, the solution of much to which otherwise we have no key? Van Helmont was not far wrong when he contended that woman was what she is, in health, in character, in her charms, alike of body, mind, and soul, because of her womb alone. Nor am I so far wrong, I candidly believe, in at- tributing the major part, not all, of her characteristics in disease, mental as well as bodily, also to this self- same womb. Just as we have special diseases of the pelvic organs in the female, so we may have function- al diseases of the brain, of many and deceptive types, excited in her thereby ; and just as we may have other disease in woman, whether general in its character or of other than uterine localization, pulmonary, cardiac, renal, or hepatic, as the case may be, idiopathic in its inception, yet materially modified by the influence of the sexual system, even so there may exist states of mental disturbance in which we may recognize an originality of causation in the brain itself, but yet such an effect from a special physiological or pathological condition of the uterus or ovaries that may be present, as to require special examination, special considera- tion, and special treatment. To the gynaecologicil expert, these facts will be self-evident. I have found that to some psychological experts they have not been so. As my object is merely to change to a more ra- tional system the present private and public treatment IN WOMEN. 8 1 of SO many of the most interesting of patients, now practically untreated at all, I shall again present the testimony of psychologists rather than my own. In my previous writings I have contended that the prin- ciples to which I had called attention have long been known, though in practice constantly unappreciated or forgotten. I shall now go farther, and by the testi- mony presented, which is but a little fraction of that I now have at hand, show, as I think, conclusively, that in longer refusing for the female insane that study, special examination, and treatment, without which, in all other forms of disease, women cannot be properly cared for, any person laying claim to the honorable office of physician must be deemed guilty of gross neglect, blindness from too great conservatism, or inhumanity. This is strong language : it is not in- tended as personal, however. I am but working for a general principle in one of the many fields of its application, and in behalf of the sex, to the alleviation of whose sufferings some of us are devoting our lives. Should controversies be attempted to be forced upon me, as has already been the case in the discussion of this question, it is to the good sense and wisdom of the profession that I shall again appeal. I cannot do better, at this point of our inquiry, than introduce the testimony of a gentleman at present, or very lately, connected with the Utica Asylum. " When we contemplate the reproductive system, whether 6 83 REFLEX INSANITY in health or disease," says Dr. Kellogg, " in its relations to the cerebral system and to psychology, we are forcibly struck with the paucity and imperfection of our knowledge. The recorded facts which bear upon the reciprocal influence of these systems are widely scattered, and the attempt to collect, digest, and systematize them, and make the necessary scien- tific deductions, would be a work of some importance.* " The influence of excessive and unnatural excitement of the sexual organs upon the mental faculties," he continues, *' has long been recognized. In tables setting forth the sup- posed causes of insanity, this has long occupied a prominent place ; and though its influence as a cause of insanity has no doubt been overrated (or misinterpreted, in the absence of physical examinations in women, — H. R. S.), still it is un- doubtedly great.f Of the probable causes of derangement in three hundred and sixty-six cases of insanity, occurring in both sexes, — as recorded in the report of the superintend- ent of the New York State Lunatic Asylum, for the year 1852, — eighty-seven, or nearly one fourth of the whole num- ber of cases, are reported to have arisen from causes directly connected with the reproductive system. In the report of the superintendent of the- same institution for the year 1858, of the supposed causes of insanity in four hundred and twenty-four cases, one hundred and seventeen, or more than one fourth, appear to have had direct connection with some disturbance of the sexual organs. In the able and interest- ing report of Dr. Gray to the managers of this institution, for 1853, of three hundred and ninety cases, seventy-two are supposed to have had some direct connection with derange- ment of these organs. From the above, it would appear that in nearly one fourth of all the cases of insanity, occurring in both sexes, the disturbance of the generative organs was so marked as to be regarded as a primary cause of the mental derangement. • Considerations on the Reciprocal Influence of the Physical Organization and Mental Manifestations. — Amer. Journal of Insanity, April, 1856, p. 305 t See the testimony of the late Dr. Brigham, in the Philips' Will case. — Amer. Journal of Insanity, vol. vi. p. 183. IN WOMEN. 83 "Whether the primary cause in these cases had its seat in the cerebral or the generative system, is a question no less interesting than difficult of solution, and one which could only be determined by an attentive consideration of the his- tory of the cases reported, and a close observance of the true sequence of the symptoms in each, and, whether the primary link in the chain of morbid sympathies had its seat in the one system or the other, it is none the less important in re- lation to the reciprocal influence of the two. " As the functions of the reproductive system are far more important and intricate in the female than in the male economy, and as the pathological disturbances are, as a natural consequence of this, more frequent and interesting, we are, as a matter of course, to look to the female genera- tive system for the most important illustrations of the sym- pathetic disturbances and reciprocal influences dependent upon these pathological lesions. Hence, all the diseases which aflfect the female generative system have, at one time or another, been brought forward as causes of insanity. Even its most natural function, that of gestation, does, in some cases, by the peculiar change wrought in the female economy, and the train of inexplicable symptoms which re- sult, give rise to insanity ; and there are cases on record, of females who have been positively insane during the whole of each period of utero- gestation, but who recovered their mental health and strength soon after delivery. The cases in which some slight mental or moral disturbance during gestation has been observed are numerous; there are many on record, and every experienced practitioner is able, no doubt, to recall to mind such slight disturbances. " The influence which the menstrual function, even when performed apparently in a healthy manner, exercises upon the mental faculties and moral feelings of some females is exceedingly interesting to the intelligent and philosophical observer. In certain abnormal states of this function the influence is still more apparent. I have been told by in- telligent females, accustomed to analyze their own feelings, that they felt far less mental energy during this state than 84 REFLEX INSANITY in the intervals, and that they possessed far less control over the moral feelings than at other times, were more easily excited, and that the most trifling circumstances, which at other times would pass unheeded, have, in spite of every eflfort, greatly disturbed their equanimity. In some whom I have known, of a nervous, excitable temperament, their whole character appeared changed during the menstrual period, and from being cheerful, kind, firm, patient, and decided, they became morose, taciturn, wayward, fidgety, and impatient, frequently manifesting a certain nervous irritability bordering on hysteria, and were sometimes over- come by paroxysms of that interesting affection. " The changes which take place in the mental and moral faculties about the time of puberty, are in both sexes very interesting, particularly so with the female. These have been frequently alluded to by medical writers, as attendant upon a fuller development and higher manifestations of vitality in the sexual organs. During these changes the nervous system exhibits increased susceptibility and sensi- bility; and not only the whole frame, but also the mental manifestations, present greater activity of development." " The mind," says Dr. Copland, " acquires extended powers of emotion and passion, and the imagination becomes more lively. If, on the other hand, the uterine organs continue undeveloped, and the menstrual discharge does not appear, the mind is dull, weak, or depressed, and the emotions and passions are imperfect or altogether absent." * " The young female," resumes Dr. Kellogg, "who, up to the time of these changes, has appeared, comparatively speaking, a non-sexual being in her intercourse with her companions, playing in childlike innocence and unrestrained freedom with the opposite sex as with her own, — ignorant and unconscious of the powers within her, which are soon to be awakened from their slumbers, — begins, as she now approaches the verge of womanhood, to be animated with feelings and desires to which she was before a complete stranger, and which she regards with a deep interest as the * Dictionary of Medicine, art. Menstruation, vol. ii. p. 959. IN WOMEN. 85 forerunners of something, she scarcely knows what, which she feels inclined to cherish, yet shrinks from, as though she knew not whether they were of good or evil omen. " In her intercourse with her former playmates of the opposite sex, there appears gradually to have dawned upon her an interesting shyness and maidenly reserve. Ex- pressions which before conveyed no meaning to her pure mind, and which even now are but partially understood, are yet sufficiently so to tinge her cheek, and cause her to shrink back instinctively, as from some foul and pestilential pres- ence. Her likes and dislikes are stronger, and rendered more apparent to those around her. In short, the physical changes brought about in a limited period of time in the sexual system have wrought a complete change in the men- tal and moral character of the young girl, and this period of transition terminates in that of complete womanhood, with all its desires and its aspirations, its hopes and its fears, its joys and its sorrows. "But it is in connection with the various diseases inci- dent to the female generative system that we are to look for the more curious illustrations of this cerebral sympathy. The abnormal mental state of many patients laboring under hysteria, menorrhagia, dysmenorrhcea, amenorrhoea, and the aifections intimately associated with uterine derange- ment, has long been observed by medical men." "In at least three cases out of four," says Dr. Francis, " I have found hysteria associated with uterine derangement, and the resto- ration of the menstrual function to its healthy state has proved the precursor of the removal of the hysterical annoy- ance." Hysteria, again, may manifest itself chiefly by dis- order of the mental faculties, and the moral feelings and emotions. "The mental affections," observes Dr. Copland, " connected with hysteria may be referred, i. to certain states of monomania, among which excited desire, amount- ing in some cases to nymphomania, maybe enumerated; 2. to ecstasies and mental excitement, in some cases of a religious nature, in others of different descriptions; 3. to a state of somnambulism ; 4. to a form of delirium, generally 86 REFLEX INSANITY of a lively character, with which various hysterical symp- toms are often conjoined ; 5. to various delusions, generally of a hypochondriacal kind, to which the patient may become subject or even the victim, owing to the indulgence she may meet with from imprudently kind relatives; and, 6. to a desire to feign various diseases, sometimes of an anomalous or singular form." ♦ The subjoined remarks of this same acute and phil- osophical physician are so apposite that we cannot resist the temptation to transcribe them in this con- nection. " Hysterical females," says he, " are not merely capricious or whimsical, but they often become enthusiastic for a timft in the pursuit of an object, or in cherishing an emotion by which they have been excited. In many such cases the ner- vous excitement and vascular turgescence of the uterine or- gans determine the character of the mental disorder, elevat- ing certain of the moral sentiments, or of the intellectual manifestations, to a state of extravagance, passing in some instances into delusion or monomania. Many cases of puerperal mania are merely extremes of the hysterical dis- order of the moral and intellectual powers or states of the mind. All these more extreme forms of mental affection are observed only where, in connection with much local or uterine irritation, there is great deficiency of nervous energy generally, and of mental power in particular; or where, with such deficiency, there has been much injudicious cul- ture or perversion, or improper excitement of the imagina- tion. Females sometimes become passionately attached to an object, and this passion may advance even to nympho- mania or monomania. " The hypochondriacal feelings, the desire to deceive, or to simulate various diseases, or the delusions which sometimes possess the minds of hysterical females, may be classed with the foregoing, as requiring a similar plan of treatment. In * Loc. dtat, voL u. p. 321. IN WOMEN. 87 all of them the intentions of cure are to remove irritation or vascular turgescence of the uterine organs; to improve the general health ; to strengthen the nervous system ; to calm the imagination; and to guide the moral impulses of the patient. The most efficient, however, of these means are not likely to be adopted by the patient. Few will resort daily to the shower-bath, or even occasionally to terebinthi- nate enemata, or submit to a course of tonics, or to a suita- ble regimen, &c., while they believe their health but little aftected. Even when the hysterical disorder is of a very painful kind, the variability or capricious state of the pa- tient's mind leads her to run from one physician to another, before opportunity of administering aid is afforded to any. At last, the most notorious charlatans, particularly those who excite the body through the mind or the mind through the body, the animal magnetizers, the homoeopathists, the St. John Longs of rubbing celebrity, and the Campbells of celestial-bed notoriety, fix her attention. At such medical bagnios there is something promising gratification as well as excitement, and at such places hysterical as well as hypo- chondriacal patients ' most do congregate.' * " When we pass from the consideration of the influence of the reproductive system upon the cerebral, to take a view of the influence of the latter upon the former, we enter upon an inquiry possessing as profound an interest as any in the whole domain of science ; and here, again, as before, we have to look to the female economy for the most interesting facts and phenomena illustrative of this mysterious and in- explicable sympathy. The results of this influence, if we allow ourselves to believe the statements and receive as evi- dence what is brought forward as fact in illustration of it, are, indeed, sometimes most extraordinary; and the unmis- takable evidence of this, which is from time to time present- ed to the medical observer, is sometimes so curious as to make him pause before rejecting, as the workings of a mor- bid imagination, the statements which are sometimes made by intelligent females, whose veracity we cannot doubt, • Copland, loc. citaL, voL ii. p. 337. ^ REFLEX INSANITY and whose motives for deceiving us we are unable to dis- cover. " There are few physicians of experience who will not be able to call to mind some extraordinary statements made to them by females in reference to this sympathy, which at the time, no doubt, merely called forth a smile of incredulity or surprise at what was then regarded as the result of supersti- tion, or of a morbid imagination, but which, in after hours, has been seized upon as food for reflection." ♦ To these remarks of Dr. Kellogg, there would be little need of adding, had they but been practically accepted and acted upon. Such, however, has not been the case. Nearly ten years have elapsed since their publication, and, as yet, in the reports of no asylum do we find a change, either in the method of tabulating cases, of specifying causes, or of treatment. The organ of psychologists in this country, the Amer- ican Journal of Insanity, generally so ably conducted, in which Dr. Kellogg's paper appeared, and which emanates fr-om the asylum with which he is connect- ed, still ignores the conclusions he had advanced, as shown alike in its editorial papers and in its com- ments, or absence of comments, upon those by others, admitted to its pages. I need adduce but a single instance. Sir William Hamilton, in his celebrated work upon metaphysics, makes use of the following language : " A fact striking in itself," he says, " and not without significance in relation to the present in- quiry, is this, that these intruders " (parasitic animals * American Journal of Insanity, April, 1856, pp. 306-ia IN WOMEN. S9 of various kinds, worms in every loathsome diversity, reptiles armed with fangs, crawlers of a hundred feet, &c., &c.), " infest the (frontal) sinuses of women." This statement, so strange and astonishing as regards its application to most women, sane or insane, was reproduced in the Journal referred to, by a reviewer of Hamilton, but ten years ago, without a word of contradiction.* While a single fact like the above can take place, a single assertion of that character pass unchallenged alike by the Journal and the profession at large, it cannot be argued either that the conclusions presented in this report are generally known and acted upon, or that the investigation is one without a very plain and practical end. The notion that her sex plays an important part in the causation of insanity in women, is by no means a modern one. Like many of the most valuable theo- ries of medicine, it dates back to remotest antiquity. Aretaeus, of Cappadocia, held that a frequent cause of mania was to be found in suppression of the men- ses, or difficulty in their establishment in young wo- men, who needed only this condition of marriage.* Soranus enumerates, among other causes, the long continued use of medicines that excite the genital or- gans in women, and the suppression of their periodical • American Journal of Insanity, June, i860, p. 255. t Tr^lat : Recherches Historiques sur la Folia, 1839, p. tz. 9© REFLEX INSANITY discharge.* Before the expedition of the Argonauts, and before Hippocrates, it is said that the daughters of King PrcEtus, whose savage lowingsf remind one of certain historical and modern epidemics of insanity complicated with hysteria, were cured by means of hellebore, which was then supposed to exercise a peculiar influence upon the uterus.J The theory of pelvic causation, like all others, however good, did not even at that early period escape criticism. Coe- lius Aurelianus, for instance, affirmed that women were less subject to insanity than men ; but his re- viewers and admirers of more modern times, and at the present day, however they undertake to explain the fact, yet think that he was mistaken. This state- ment is true of Esquirol, Copland, Brown, and many others, some of whom I shall hereafter quote. Thus, Dr. Haslam has averred, speaking of England, that *' in our own climate, women are more frequently af- flicted with insanity than men." On the other hand, to bring this disputed question down to the present moment. Dr. Thurnam, in his paper upon the relative liability of the two sexes to insanity, expresses himself as follows : — " Having thus shown that in the principal hospitals for the insane in these kingdoms, the proportion of men admit- ted is nearly always higher, and, in many Instances, much • Morel : Trait* des Maladies Mentales, p. 4. t " Proetides implerunt falsis mugitibus agros." Ibid., p. 19. t Griffith: Medical BoUny.p. 86. IN WOMEN. 91 higher than that of women, and as we know that the pro- portion of men in the general population, particularly at those ages when insanity most usually occurs, is decidedlj' less than that of women, we can have no ground for doubt- ing that men are actually more liable to disorders of the mind than women."* Dr. Bucknill, also, is of opinion that it is clearly proved that, in general, fewer women become insane than men.f Upon this side the water, this question of the com- parative liability of males and females to insanity, has been carefully investigated by Dr. Edward Jarvis, of Dorchester, in a paper published in the Journal of Insanity several years since. He also has arrived at the conclusion that males are somewhat more liable to insanity than females. There are, it will be perceived, several very differ- ent questions here involved, as the following : — 1. Do more women, abstractly, than men, become insane ? 2. Do more women become insane, in proportion to the number of each sex existing in a given hospi- tal, city, state, or country? 3. Do more women than men become insane from sexual causes? The latter question, it will be perceived, is the only one that concerns us in the present inquiry. It is to the two former, however, that attention has gen- * Quarterly Journal of the Statistical Society of London, December, 1844. t Loc. cit., p. 245. 92 REFLEX INSANITY erally been given. As the attempt at their solution, though this must evidently be almost impossible, has been made, I will give it a moment's notice. Dr. Bucknill has admitted that there are many points that observers have practically lost sight of. " SuflScient care," he says, '* does not appear to have been taken to ascertain the relative number of males and females in the general population, a point obviously necessarj' to determine, before any just conclusion can be drawn as to the relative liability of the sexes to insanity. Writers upon the subject have found the existing number of female lunatics greater than that of the males, and hence, have arrived at the conclusion that the female sex is more subject to insan- ity than the male. Dr. Thurnam. however, has pointed out this source of fallacy, as well as that which arises from the fact that the mortality of insane men exceeds that of insane women by fifty per cent. Hence it is obvious that Esquirol erred, in comparing the existing instead of the occurring cases of insanity in the male and female sexes. If. in our asylums, women live longer than men, they will of course proportionately accumulate." " In order that the comparison of the occurring cases be a strictly accurate one," observes Thurnam, " the propor- tions of the two sexes at the several ages, attacked with insanity for the first time, should be compared with the pro- portions in which the two sexes at the same ages exist in the community in which such cases occur. The nearest approx- imation to this method which we have the means of employ- ing is, by assuming that the proportions of men and women admitted into public institutions during extensive periods represent — as, on the whole, they probably do represent — the cases which occur for the first time." " From an examination of a table prepared by this writer, it was ascertained that, in twenty-four of the thirty-two asy- lums, which it comprises, there had been a decided excess of men in the numbers admitted. In many British asylums, IN WOMEN. 93 the excess amounts to twentj-five, thirty, and even forty per cent., and, in the whole number of thirty- two asylums, there is an average excess on the side of the male sex of thirteen and seven one hundredths per cent. In the nine English county asylums contained in the table, the excess amounts to twelve per cent. " From the same tables, it appears that, in the asylums of the metropolis, the proportion of females admitted is much greater than in the provinces. This appears to be in part accounted for by there being a considerable excess per cent, (thirteen per cent, at all ages, and nineteen per cent, at all ages above twenty) of women over men in the metropolis.* Hence, the experience of Bethlem and St. Luke's led Dr. Webster to the conclusion, that no doubt can exist regarding the greater frequency of mental alienation among females than males. Dr. Thurnam appears to regard it as probable, that the statistics of insanity in France resemble in this par- ticular those of London, although, as has been pointed out, the method of inquiry adopted by Esquirol was vicious. " Jarvis has shown," continues Bucknill, " that the causes of insanity which act upon males are more extensive than those which act upon females, and has added that the above statement, in regard to the liability of the sexes, must vary with different nations, different periods of the world, and different habits of the people. " It would be difficult to establish that the female sex is intrinsically less susceptible to the causes of insanity than the male, since the former is less exposed to those causes than the latter; at least, to establish the greater intrinsic liability of females, it must be shown that they are exposed to the predisposing and exciting causes of insanity to as great an extent as males." f * On the other hand, in some parts of this country, in Massachusetts for in- stance, the excess of women is much greater than in London, being estimated of late at fifty per cent., or even higher ; and yet there seems to be no proportion- ate excess of famale admissions at asylums. t Loc. cit.; p. 245. This "last sentence is expressive only of Bucknill's opinion; I think it will appear that women are exposed constantly to the action of these causes to a greater extent than are men. 94 REFLEX INSAXITY In this connection, as in many others, it must not be forgotten that the statistics of the insane, whether derived from hospitals or from the general popula- tion, are very liable to be faulty or to give rise to erroneous conclusions. I shall subsequently give evidence to this effect, and the opinions of Luther V. Bell and others ; here merely asking, — " What can be the value of medical statistics in any dis- ease, under which sixty per cent, of the entire cases must be left unaccounted for? Probably too, not five out of twenty of the assigned causes are justly chargeable with the mental disease ascribed to them." * In the present instance, writers seem to have lost sight of the facts that in almost all countries more males than females are born ; that this percentage of excess, which would be veiy much greater were all the males that are conceived born living, is to a cer- tain extent kept down by the number of boys who die in infancy and during childhood in consequence of various affections to which the comparatively larger size of the head in the male foetus has given rise, from the greatei pressure to which it was neces- sarily subjected during parturition ; f and that in this * Workman : Report of the Provincial Lunatic Asylum at Toronto, 1863, p. 5. t Dr. Simpson, in his memoirs upon the sex of the child as a cause of diffi- culty and danger in human parturition, has shown conclusively, that — 1. Of the mothers that die under parturition and its immediate consequences, a much greater portion have given birth to male than female children. 2. Among labors presenting morbid complications and difficulties, the child is much oftener male than female. 3. Among the children of the mothers that die from labor or its consequences, IN WOMEN. 95 same excess of cerebral compression, is undoubtedly to be found an efficient cause of insanity in man in after life. This point does not appear to have been before observed. It has also been forgotten that males everywhere, save perhaps in the most crowded cities, are much more likely than women to be carried from home and the care of relatives to the seclusion of an asylum ; that in women, the attacks are more seldom persistent, more frequently intermittent, par- oxysmal, periodical, and therefore more likely to be endured by friends, and to be more constantly looked upon as merely hysterical, nervous or feigned, while no one at all familiar with the subject would undertake to prove, as Bucknill has supposed a larger proportion of those that are still-born are male than female : and, on the contrary, of those that are bom alive a larger proportion are female than male. 4. Of still-bom children, a larger proportion are male than female. 5. Of the children that die during the actual progress of parturition, the num- ber of males is much greater than the number of females. 6. Of the children bom alive, more males than females are seen to suffer from the morbid states and injuries resulting from parturition. 7. More male than female children die in the earliest period of infancy, and the disproportion between the mortality of the two sexes gradually diminishes from birth onwards, until some time subsequently. 8. Of the children that die in utero and before the commencement of labor, as large a proportion are females as males. 9. In laborious labor with the head presenting, in proportion as the order of labor rises in difficulty, the amount of male births rises in number. 10. Of the morbid accidents that are liable to happen in connection with the third stage of labor, after the head has passed the brim of the pelvis, as many take place with female as with male births. 11. More dangers and deaths occur both to mothers and children in first than in subsequent labors. 12. The average duration of labor is longer with male than with female (iiil« dren. — Obstetric Works. Edited by Drs. Priestley and H. R. Storer. Edin burgh edition, i. p. 394. 96 REFLEX INSANITY possible, that women are intrinsically less susceptible to the same causes of insanity that affect men. On the contrary, we would claim that these very produc- tive and efficient causes do act, so far as women are exposed to them, and a thousand-fold more besides. It has been supposed that moral influences, and those purely mental in their character, have exercised an important part in the causation of insanity. In the case of women, in the absence of a predisposition to insanity by inheritance, I believe that these moral causes seldom efficiently act unless in the presence of physical disturbance. Be this as it may, much attention has been paid by psychologists to the classification of these alleged moral excitations. Thus Tuke, from an analysis of some thirty thousand cases, admitted into a large number of asylums in England, France, and Amer- ica, found that among them domestic troubles or grief stand first in the list in every instance ; next in order, religious anxiety or excitement ; then disap- pointed affections, political and other excitements, fear and fright ; and lastly, excessive study and wounded feelings, as impaired self-love, etc.* There is, of course, no doubt that men are more exposed tlian women to political excitement and the harassing anxieties of business ; but these we find Esquirol considering as more than counterbalanced by the • Manual, p. as8. IN WOMEN. 97 vices of female education ; the preference given to acquirements purely ornamental ; the reading of ro- mances, from which arises a precocious activity of the intellect and premature desires, together with ideas of an imaginary excellence that can never be realized ; the frequenting of plays and society ; the abuse of music and the want of occupation — these, he thinks, are causes sufficient to make insanity most frequent among women.* Dr. Conolly, of the Hanwell Asylum, but reiterates this opinion when he says that — "All who have peculiar opportunities of ascertaining the menial habits of insane persons of the educated classes well know that, with some exceptions, their previous studies and pursuits appear to have been superficial and desultory, and often frivolous; the condition of the female mind, especially of the minds of those who are to be the mothers of another generation, is, even in the highest classes, too often more deplorable still. Not only is it most rare to find them famil- iar with the best authors of their own country, but most common to find that they have never read a really good author, either in their own or in any other language; and that the few accomplishments possessed by them have been taught for display in society, and not for solace in quieter hours. All this has been said before, and often, and in vain. But there is a frequent perversion of intellectual exer- cise more fatal than its omission, which fills asylums with lady patients, terrified by metaphysical translations, and bewildered by religious romances, and who have lost all custom of healthful exertion of body or mind, all love of natural objects, all interest in things most largely influen- cing ihe happiness of mankind. All the higher pleasures * Mental Maladies, p. 235. 98 REFLEX INSANITY of human beings have always been unknown to these pa- tients. Minds so feeble, or so spoiled, are unfit for the or- dinary emergencies of a checkered life. Every stronger shock quite discomposes them. These evils have generally taken deep root before the patient's manifest want of rea- sonable control induces a resort to an asylum ; but a large portion of the moral treatment resorted to in asylums con- sists in the discouragement of the evil habits of mind into which such frivolous and unhappy beings have fallen. Ex- ercise in the open air; customary and general activity; regular hours; a moderate attention to music and other accomplishments, instead of an extravagant devotion of time to such excitements; protection from fanatical exhor- tations ; and the substitution of sensible books for the worthless tracts and volumes with which their well-meaning friends have generally loaded their boxes, and which are thenceforth locked up as so much mental poison, contribute largely to the patient's advance towards rationality. The same kind of care might, in many cases, have preserved the mind from derangement; but the attention of parents and teachers is seldom directed to the important object of the prevention of insanity." * These and many others that might be mentioned, are undoubtedly predisposing causes of insanity in women. Asks Esquirol, — "Are not the extreme susceptibility and sedentary life of women, their peculiarities even, the predisposing cause of this malady? The numerous passions which among them are so active; religion, which is a veritable passion with many when love does not exclusively occupy their heart and mind, jealousy, fear, do not these act more energetically on the minds of women than men? As, said Zimmerman, ' insanity comes often to girls from love, to women from jealousy, while from pride to men.' Moreover," continues • Treatment of the Insane, p. i6a IN WOMEN. 99 Esquirol, "women yield to the causes of insanity proper to the sex; physical causes acting more frequently upon them than upon men. Are not women under the control of influ- ences to which men are strangers ; such as menstruation, pregnancy, confinement, and nursing?"* That healthful though continued mental excitement may prevent the tasdium vitae which over-indulgence in the dissipations of society so often brings to women is no paradox, and we should, therefore, have no rea- son for wonder, if there had in reality been " a de- crease of cases of insanity occurring in women since the present war commenced, from the various chari- table and benevolent operations which have so largely excited their sympathies and received their support," although, upon the other hand, there would seem to have been at least a counterbalancing number of shocks from sudden bereavement and fright. That the predisposing or proximate causes, whether moral, mental, or not, — and the physical or ultimate causes rarely act alone, — is no proof of the non-exist- ence of either. They unite and become complicated in many cases where they produce insanity. A fright occasions the suppression of the menses, and this becomes the cause of mania, which ceases with the return of the menstrual evacuation. A woman dur- ing her confinement experiences a severe disappoint- ment ; the lochia are suppressed, and an eruption of mania takes place. We may with truth affirm that * Mental Maladies, p. 211. lOO REFLEX INSANITY insanity in women rarely takes place without the concurrence of both physical and moral causes.* It is well known that much of the insanity of women has been attributed, both in asylum reports and else- where, to previous general ill health, as owing, in some instances, to the effects of climate, hard work, etc. Upon this point I will subjoin a few remarks that have been communicated to me by my colleague, Dr. Patterson, of the Iowa Asylum. *' It will be seen that among the assigned causes, ' ill health' of various kinds is most prominent. It will seem strange that among the rural population of Iowa, away from the excitements, temptations, excesses, and poverty of large cities, alike remote from the malarious fevers of the South, and the pinching cold of the North, while quietly engaged in the peaceful pursuits of agriculture, any considerable number of our people should ever become insane. And yet such is the fact. Many of them, especially the wives and daughters of farmers, become insane. Probably three fourths of the adult people of Iowa are connected with agricultural pursuits. ^^ A vast majority of all cases of insanity arise from causes and circumstances vjhich depress or exhaust the nervous power. Grief, domestic unhappiness, disappointed affec- tion, the puerperal state, perplexities in business, all tend to depress, and, if long continued, to exhaust the vital force, and are therefore prolific causes of insanity. *' The farmers of Iowa have not yet learned how to live comfortably. Their dwellings are badly constructed, often in low, damp, poorly-drained locations, with either no venti- lation, or too much. They are badly warmed by direct radiation of heated iron, so that the process of partial roast- ing and freezing is at once experienced by the same person * Mental Maladies, p. 382. IN WOMEN. lOI Their surroundings are too often unpropitious, their physical comforts and social enjoyments too much neglected. In inclement seasons, amid exposures to cold and rain, their bodies probably receive less care and protection than those of any other class. With abundant supplies at command, their diet is too limited in variety, often unskilfully pre- pared, and the whole science of gastronomy set at nought. The laboratory, in which are manufactured the life blood and the vital forces, is too often lumbered with ill-assorted, indigestible, badly-cooked food. "The wives and daughters of farmers, during inclement seasons, have fewer comforts connected with out of doors life, and less adequate protection from cold and humid air, than the women who live in our towns and cities, and it is probable, taking prairie farm life, with all of its surround- ings, as it exists in Iowa, that the average standard of the vital force in those who live upon farms, is beloAv that of those who live in the towns and cities. It must not, how- ever, be inferred from these suggestions that the noble and pleasing pursuits of agriculture favor the production of in- sanity. The errors of living, and the discomforts alluded to, are not necessarily connected with, and certainly not limited to farm life. *' Much of our insanity results from our ignorance or dis- regard of the laws of animal life. Much of it might be avoided by the exercise of proper care and good judgment in forming alliances, and in the care of our bodies, which are so 'fearfully and wonderfully made;' by ruling the passions and appetites ; by lives of prudence ; by modera- ting the extravagant expectations of this life; by using in- nocent recreations and the bounties of a kind Providence as not abusing them ; by regular hours and favoring circum- stances for refreshing sleep ; by well-regulated households ; by an abiding religious faith, and by the avoidance of iliose indulgences and habits of life -which favor a deterioration of the blood, depress and exhaust the nervous power, and break doivn the defences which Nature has set up for our ■protection.'"'' I02 REFLEX INSANITY There can be no doubt that influences, such as have been above described, do, in many instances, exert a powerful influence upon the nervous system in wo- men, especially if accompanied by disturbance of the pelvic organs, which, indeed, tliey are so likely to occasion. The point to which we have now so naturally been brought, — the physical causes of insanity peculiar to women, and their preponderance and efficiency as compared with those of the male sex, — is one that is allowed by many writers, but by most of them is either forgotten or practically contradicted in treatment. Thus Tuke, in his analysis of physical causes, in both male and female, upon a basis of many thousands of cases, places first intemperance, and next epilepsy and disorders more or less connected with the uterus, considering these last as equally productive of insan- ity, and far more frequently so than all other diseases, or vicious indulgences, or affections of the head and spine, whether idiopathic or traumatic* A most important allowance has here been made, when it is recollected that of the causes above enumerated, a large proportion of the intemperance of women ini- tiates in or is kept up by alcoholic stimulants, for the purpose of relieving functional or organic ute- rine disease ; that a large proportion of the epilepsy • Loc cit., p. 258. IN WOMEN. 103 in women is of uterine causation, and that a large proportion of the vicious indulgences of women, especially those of sell-abuse, are dependent upon uterine or other local irritation, and so the effect 'Ol disease. 1 shall present another admission to the same effect from the same author, as it more than corroborates the conclusions to which we shall eventually be brought. He says, — " When we reflect on the very large number of cases of insanity more or less connected with functional or organic disease of the uterus, and remember that among barbarous nations these disorders are unquestionably of less frequent occurrence than in civilized society, we shall not fail to recognize in this difference one reason why more mental disease might be looked for in the one condition than in the other. Parturition itself, according to the general testimony of travellers, interferes much less, and for a shorter period, with the healthy action of the body and mind among savage nations than among the luxurious daughters of artificial life." * Dr. Bucknill says, — *' There can be no doubt that uterine disorders constitute one of the most frequent remote causes of insanity with which we are acquainted. If, therefore, the physician can ascertain that his patient has suffered, or is suffering from gastric, hepatic, intestinal, or uterine disease, he will have discovered a well-known and frequent cause, the existence of which must be allowed to exercise its due influence in the diagnosis." "Disordered states of the abdominal viscera," he again remarks, " are of such frequent occurrence, that the veteran * Loc. cit., p. 57. lO^ KEFLEX INSANITY Jacobi and some other physicians of eminence, have believed that they altogether account for the causation of mental dis- ease. We are far from being able to concur in this narrow view of the etiology of insanity; but no physician of much experience in this department of medical science will be likely to deny, that disordered states of the stomach, the intestines, and the liver, frequently constitute the remote causes of cerebral disease." * It will be remembered that many of the disordered states of the stomach, the intestines, and the liver in women are directly dependent upon uterine derange- ment, being either caused or kept up by this. We are told by another writer, that — " The functions peculiar to the female sex, and the natural sensitiveness of the nervous system in the latter, render them very liable to disturbance of the mind when those functions are irregularly performed. From the commence- ment of puberty to the approach of old age, this source of disordered nervous and mental action exists, and in every case of insanity occurring in females, the possibility of some bodily functional derangement existing simultaneously with, and, perhaps, operating as the exciting cause of, the mental affection, should never be forgotten. Amenorrhcea, dys- menorrhoea, menorrhagia, pregnancy, miscarriages, partu- rition, the puerperal state, lactation, the cessation of the menstrual function, are each occasionally productive of mental disorder, which can only be cured by attention to the exciting cause. This consequence of such ailments is naturally rendered much more probable when moral dis- turbing causes are also in action." f The frequent coincidence of an uterine crisis or of uterine disease with insanity in woman, must be • Loc. cit., p. 280. t Robinson: Physical Causes of Mental Disorders, p. 115. IN WOMEN. 105 allowed. It has been claimed, however, that this co< incidence is one only of time and not of character, that there exists between them no relation of cause and effect. By no one has this assertion been made more succinctly or more emphatically than by the present superintendent of the hospital at Northamp- ton, and late Professor of Psychological Medicine in Berkshire Medical College, Dr. Pliny Earle, whorn I therefore quote. He says, — " It is well known by persons who have much experience in insanity, that in females there is no constant relationship between the pathological mental condition and the mensual exudation. Some women become insane, continue so for months, and recover, without any interruption of the regu- larity of their monthly periods. In some the mental disorder precedes, while in others it follows the suppression of the menses. When these have been suppressed, either before or after the invasion of insanity, they may return without having any curative effect upon the mental disease. Some patients recover soon after the reappearance of them, others before their reappearance. When the menses continue regularly through the progress of insanity, in some cases there is an exacerbation of the physical and psychical excite- ment at the periods, but in others, and I believe it may be said the majority, no such exaltation occurs." * The above statement, which was made only as part of an argument against the then too frequent resort to bleeding at asylums, might be fully allowed, and };et in no way materially affect the truth of the theory, that upon the state of the uterine system often depends • American Journal of Insanity, x. 398. Io6 REFLEX INSANITY the cerebral or mental integrity of women. The oc- currence or non-occurrence of the menses, their ex- istence, deficiency, or excess, are but a single one of the many important questions involving a reflex influ- ence by the uterus or ovaries. But even here it will be seen that there is room in every case for much careful investigation, regarding the frequency of the discharge and its coincidence witli the usual standard, as to time of appearance, its duration and the length of the interval ; its abundance or deficiency ; its con- sistence as to fluidity, and the presence or not of clots, and its odor ; its bland or irritating character ; its accompaniment or not by pain as a precedent, accom- paniment, or consequent ; its alternation, connection, or supplantation with or by a leucorrhoeal discharge ; all these are points without due attention to which all expressions of doubt or discredit are plainly unfound- ed. If it be, as I have suggested, that the depurative character of the catamenia as eliminating, alternately or in conjunction with the lungs, any excess of carbon from the system, is here efficiently in action, we can- not by a stroke of the pen destroy its influence upon the causation of insanity. Allowing tlie coincidence of mental and uterine disturbance, and that the two are in some way con- nected, it may be asserted that the latter is the conse- quence of the former, rather than its cause. Thus IN WOMEN. 107 Di. Kellogg points out that the influence of strong mental emotion upon the menstrual secretion is very marked. There are few women of intelligence who have not noticed the fact, and this influence is partic- ularly marked in any of the usual disorders of men- struation. Menorrhagia is almost invariably aggra- vated by powerful mental emotions. Some forms of dysmenorrhoea are not only caused, but rendered more painful, by mental or moral disturbance.* " Acute suppression of the menses may arise," says Churchill, " from a bodily or mental shock received either just previous to, or during menstruation ; " and he gives, in a note, the following interesting illustration of this : — " Almost all the women who are sent up to the Richmond Penitentiary, after being tried at the Recorder's Court, labor under suppression of the menses, in consequence of the mental agitation and distress they have undergone " f The frequent occurrence of this result, I am ready to freely allow ; but it is no proof that the converse may not more frequently obtain. The twofold possi- bility of action and reaction is only additional evi- dence that the sympathy, which is so constantly to be observed between the womb and the stomach or the breasts, also exists, and to a marked degree, between the womb and the brain. This interchange of reflex effect, when admitted, tends to throw light upon the * Am. Journal of Insanity, Apr. 1856, vol. xii. p. 315. t Diseases of Women, p. 153. loS REFLEX INSANITY paradox that had puzzled Dr. Earle, who apparentl)i could not understand how functional derangement oi functional crisis could in one instance exist as effect and in another as cause. The coincidence at the same time of moral influences, differing or identical, would tend still further to complicate the question, which is, however, usually easily enough solved by recollecting that more than one derangement or lesion may at one time be present in a single organ. It will be noticed, moreover, as Dr. Brown-Sequard has claimed for the epileptic aura, when originating from an otherwise healthy womb,* that the irritation, though propagated from that organ, may result from an abnormal change in the quality of the blood with- in its vessels, or of its secretions other than periodical. Upon these points, as they are all of great practical importance, I shall add a few words from Dr. Buck- nill. It will be seen that in more than one connec- tion he clearly mistakes an eflect for the cause, and the cause for its eflect. He says, — " There can be no doubt that the sexual instinct is not unfrequently thrown into a state of extreme excitement by pathological changes taking place in the nervous system. This painful form of disease not unfrequently presents itself during the semi-pathological changes of old age. Those who have been distinguished, during a long life, for prudence and propriety in their relations with the other sex, when, from old age, they have one foot in the grave, are sometimes seen to throw off all restraint, and to rush into the most • Medical Times and Gazette, March, 1863. IN WOMEN. 109 reckless and disgusting libertinism. Whether or not this change of manners is accompanied by diseased processes in the brain, we have not yet been able to ascertain by observa- tion. This, however, seems highly probable, since we have seen nymphomania end fatally in young women ; and in these cases, in addition to false corpora lutea, we have found great cerebral congestion.* Excitement of the sexual func- tions may depend upon spinal irritation alone, the lascivious ideas being secondary results, just as ideas of food are the results and not the causes of hunger. Nymphomania, as an example of monomania, is, therefore, liable to the objec- tion that it may be a spinal or cerebro-spinal affection, and independent of that part of the brain which is the organ of the mental [functions]." f The same author, in another connection, again re- fers to the matter just now under consideration, which is but one of the many and as yet but imperfectly dis- cussed peculiarities I might mention of insane women. He says, — "Every medical man has observed the extraordinary amo,unt of obscenity in thought and language which breaks forth from the most modest and well-nurtured woman under the influence of puerperal mania; and although it may be courteous and politic to join in the wonder of those around, that such impurities could ever enter such a mind, and while he repudiates Pope's slander, that ' every woman is at heart a rake,' he will nevertheless acknowledge that religious and moral principles alone give strength to the female mind; and that, when these are weakened or removed by disease, the subterranean fires become active, and the crater gives forth smoke and flame." + * Dr. Bucknill forgets that the corpora lutea of menstruation, the cicatrices of ovulation without impregnation, are a normal occurrence, and that nympho- mania, however extreme, may result from the pruritus reflexly produced by ute- rine disease, as for instance carcinonia. t Loo. cit., p. 321. t Ibid., p. 273. no REFLEX INSANITY Esquirol tells us that women in a state of demono- mania experience a thousand peculiar sensations. " They believe they are transported to the midnight assem- blies of wizards, where they are witnesses of the strangest extravagances. They have intimate communications with the devil or his subordinates, after which, a collapse bring- ing an end to the attack, they find themselves again in the same place from whence they believed they had been taken. Who does not see in this the last stage of what, perhaps, commences with hysteria.'' Amidst the obscenities of these meetings, which we shall be cautious about describing, who does not recognize the turpitude of an imagination polluted by the vilest, most obscene, and disgusting debauchery? Who does not recognize a description of the most extrava- gant, shameful, and ribald dreams.? The frequent ecstasies which take place in nervous affections partake of a sublime and contemplative character, if, during its waking hours, the soul is elevated to the contemplation of noble and divine objects. They are erotic, if the mind and heart lull them- selves in reveries of love. They are obscene, if when awake one indulges in lascivious thoughts, and if the uterus, irri- tated and excited, gives place to illusions which are regarded as diabolical practices." * Some psychologists have attempted to develop the hints given above, by separating from hysteria what they have termed hystero-mania, this being described as " a true mania developed upon a state of hysteria." f In practice, however, it will be found very difficult to draw the border line. The fact just before alluded to has not escaped the notice of observers outside of our own profession. * Mental Maladies, p. 245. t American Journal of Insanity, October, i860, p. laa IN WOMEN. Ill "It is not all persons," laments Archbishop Sharp, "that do complain of these wicked and blasphemous thoughts and other extravagant fancies, nor all good persons that are thus haunted, but chiefly those that are of a melancholy consti- tution, or those of the devout sex; women are more thus affected than the other sex. It concerns, therefore, all these persons to look after their bodies, for upon the cure and health of them the cure and health of the mind doth, in a manner, all in all depend." * Biierre de Boismont very sensibly remarks, — " It would be very surprising, if with sensations different to those which are experienced by persons in health, the in- valid should continue to reason the same as such persons do ; it is true, indeed, that the reason would be perverted and strange." f He elsewhere, in alluding to the fact that erotic hallucinations are far more common in women than in men, endeavors to explain this difference by the greater facility man possesses for gratifying his de- sires.J He should have added to this, that it is more especially owing to the greater and more constant predominance in women of the sexual system. There is an old proverb that women advanced in life become either angels or devils. The change re- ferred to is owing to the eflect upon them of the con- ditions occurring at the grand climacteric, as effective for good or evil, alike as regards mental, moral, or physical health, as is the establishment of puberty. Attempts at explanation of these phenomena have * Casuistical Sermons, vol. iii., London, 1716. t Work on Hallucinations, p. 367. t Ibid, p. 313. 112 REFLEX INSANITY been made upon other grounds, but upon examination it is found that the difference is one of words rather than of ideas. Thus Bucknill would lay it down as a general rule that in pure dementia, the sexual in- stinct is greatly weakened or destroyed. He says, — " This will be found to be the case even in instances where indecent conduct is observable, for such conduct would seem to arise, not from activity of the instinct, but from the loss of modesty, and from inability to appreciate the rules of decorum. In those cases of senile insanity which are at- tended by lascivious conduct, the form of mental disease more nearly approaches that of mania than that of demen- tia. There is a mixture of the two states, but the maniacal element preponderates." * It would seem that there was here present a bias to erotic ideas, without their becoming efficient in act through exertion of the will, just as we frequently see in general practice, where from ovarian, uterine, va- ginal, or vulval irritation, the most lascivious dreams and day-dreams may occur, being confessed to upon inquiry ; and yet the patient, though restrained by no apparent check, evinces no symptoms of nympho- mania, just as a patient may be homicidal without giving sign of what is passing in her mind, or may breathe threatenings and slaughter, though in act per- fectly harmless. There has still another explanation been offered ; only occasionally, however, possible of correct ap- plication. It is thus stated by Esquirol, who says • Loc. cit., p. 291. IN WOMEN. 113 that "women of hysterical tendencies have sometimes seen the devil under the form of a handsome and well-made young man. Doubtless libertines, abus- ing the weakness of such invalids, may thus have borrowed from the devil his form and power.* But it is not women alone who are here in dan- ger. The erotic fancies of the insane may well be looked for in some of the trials for bastardy, rape, and adultery that are brought before courts of law. These are no groundless fears. There are many erotic patients who are convinced that they have had intimate relations with men to whom they have scarcely ever addressed a word, but by whom their imagination has been fired. A case to the point is familiar to most psychologists. It is that of a lady who attended the botanical course of a celebrated French professor. After a few lectures she persuaded herself that she was pregnant by this gentleman, ad- vanced though he was in life, and to whom she had never spoken. Nothing dissuaded her from the belief. The menses were suppressed. She became emaciated and lost her appetite. She spent the eighth month in preparing child-bed linen. The ninth and tenth months were passed without confinement. She thought that the reason of this was that there were no labor pains present, so she stood for a long time upon her naked feet in order to provoke them. She * Esquirol, loc. cit., p. 246. 114 REFLEX INSANITY thought that she heard the professor exhorting her to patience, and encouraging her to support the throes favorable to parturition. In other respects she was perfectly rational.* Brierre de Boismont says, — "While supposed intercourse with demons is less common than formerly, the hallucinations generally assume the form of an angel, or of men gifted with all the charms which the imagination can bestow upon them. They frequently refer to the head of the asylum." f We have thus far been speaking, it is true, more particularly of a single class of cases of mental de- rangement, those attended with peculiar delusions, distressing to the last degree to all the friends of the patient. The remarks are equally applicable to many other forms of insanity, but here their special causa- tion is often and clearly enough to be distinguished. Esquirol says, — "Irritations, pains, and lesions of the organs of genera- tion are, in some women more particularly, the frequent cause of illusions. They have sometimes, indeed, caused * Esquirol, loc. cit., p. 246. t Hallucinations, p. 122. The last sentence of this quotation is not uninter- esting in connection with some comments made by my colleague, Dr. Van Deu- sen, upon the communication made by myself to the American Medical Associa- tion at the previous meeting. He says, in a letter dated June 28th, 1864, " I was not before aware of the risks and difficulties experienced in making the examina- tions referred to. I was not aware that any superintendent had been charged with any of the improprieties intimated ; that there had been any legal examina- tion, or anything of the kind, to suggest as a parallel the Beale case, or any oc- currence in this country or elsewhere to call for the appointment of an advisory medical board, upon that ground. " The quotations from the learned authorities whom I have cited, prove the possibility of the charge, and of its actual occur- rence, and at least one case in this country has come to my own knowledge. IN WOMEN. 115 the insane to mutilate themselves. Erotic female monoma- niacs experience all the phenomena of a union of the sexes. They think themselves in the arms of a lover or ravisher. Cancers and ulcers of the uterus are not uncommon among them. The hysterical insane are disposed to attribute to enemies, to the jealous, and to the devil, the constriction of the throat which suffocates them. The flying pains which they experience in the limbs and viscera, give rise to the most painful illusions."* Contrary to my general intention, I will present, from the same unexceptionable authority, a few cases of this character, plainly illustrating, as they do, the physical cause of the mental disturbance. A. D. first menstruated at fourteen. The discharge was always scanty and irregular, and permanently ceased at thirty. She was disappointed in love at this time, and became melancholic. Subsequently there occurred the sensation of painful constriction of the throat, and she was constantly rolling up the skin of the neck with her fingers, and crowding it beneath the sternum. There was considerable tension of the abdomen, and this she attributed to the devil having extended a cord from the sternum to the pubes, and another around her neck, upon which he drew, endeavoring to strangle her. In the notes of the autopsy it is merely mentioned that the abdominal viscera were found agglutinated by an old peritonitis ; no examination of the pelvic viscera seeming to have been made.f * Loc. cit., p. us. t Esquirol, loc. cit., p. 239. Il6 REFLEX INSANITY M., aged forty-nine, was first unwell at fifteen. The menses ceased at forty. From this period she commenced to have headache, and gradually became insane. The abdomen was hard and voluminous, and the patient had constantly her hand upon it. She stated that she had in her uterus an evil spirit in the form of a serpent, which left her neither by day nor by night, and that her organs of generation were not like those of other women, although apparently normal.* L. was a laundress, and had always been very devout. The menses commenced at fifteen. She married at seventeen, and became the mother of fif- teen children. At forty-six the menses became very irregular, but did not cease until fifty-two, her insan- ity commencing during this interval. She sufiered constantly from uterine pains, and alleged that the devil had been her husband for a million years, and that he was the father of her children ; that her body was a sack made of the devil's skin, and filled with serpents, toads, and other unclean creatures. f A woman, who had been subject to dysmenorrhoea, became the mother of an illegitimate child. She af- terwards experienced gastro-intestinal disturbances, and, as so often occurs, became a bigot. At the final cessation of the catamenia she became maniacal, and entered an asylum. She now believed that Pontius * Ibid., p. 34a t Ibid., p. 24a. IN WOMEN. 117 Pilate had been the father of her child, and that he had taken up permanent residence in her bowels, where also the popes held frequent council, being visited at times by the prophets and evangelists, and all the illustrious personages of the Testaments. At the autopsy, the pelvic viscera were found close- ly united by peritonitic adhesions, but were not prop- erly examined. Another patient, in whom the same lesion was dis- covered after death, believed that she had several devils in her belly, who were constantly tempting her to destroy herself. A female monomaniac, previously affected with hysteria, was convinced that serpents and other ani- mals, and even the devil, introduced themselves into her body through the genital organs. Another patient, in confinement at an asylum, imagined that she had in her bowels a regiment of soldiers, and that she could feel them fighting and struggling with each other. When the pains were exacerbated she became excited, crying out that the soldiers were giving blows to each other with their weapons, and at the same time were wounding her entrails.* A woman insisted that she was pregnant by the devil. She died, and her womb was found distended by a mass of hydatids.^ * Esquirol, loc. cit., p. 114. t Ibid, p. 2H. Il8 REFLEX INSANITY H. did not menstruate until twenty-four years of age, and since then had been subject to headache and colicky pains. At her third and last confinement, she had a difficult labor, which was followed by at- tacks of syncope. From this period she imagined that the devil had stolen her body, leaving only a phantom.* " In many cases of monomania," says Ray, " the hallucination is excited and maintained by impres- sions propagated by diseased parts, the presence of which has been revealed by dissection after death." f Such instances as these are not uncommon. I have myself seen several of them, but shall not narrate them at the present time, as I wish here to draw my data from superintendents themselves, whose author- ity and whose admissions cannot be gainsaid. A case almost identical with that last given, and clearly de- pendent upon uterine disease, was sent to the Somer- ville Asylum, by my direction, during the last year. Instances of supposed pregnancy by the devil, or criminal intercourse with his majesty, are probably more common than was thought by Brierre de Bois- mont. A case has been referred to by many writers, where exorcism was successfully practised by St. Bernard. A precisely similar instance came into my own hands several years since, in which an equally beneficial result was produced with the aid of a priest. • Ibid., p. 241. t Medical Jurisprudence of Insanity, p. 159. IN WOMEN. 119 In certain instances, it would not be surprising if such delusions were entertained by superstitious minds, otherwise perfectly sound. I refer to the not uncom- mon cases of the so-called pseudo-cyesis or spurious pregnancy, to which attention has so forcibly been called by Simpson.* In this affection, as is well known, there are present many of the signs of preg- nancy, enlargement of the abdomen and breasts, arrest of the menstrual function, sympathetic derange- ment of the stomach, and oftentimes a spasmodic and irregularly clonic contraction of the recti and other muscles of the abdomen, closely resembling in their effect the movements of a foetus in utero. It is some- times as difficult in these instances to persuade the patient herself that she is not pregnant, as it is her friends ; and if she is conscious of never having had intercourse with man, she readily imagines that it has been an immaculate or otherwise supernatural conception. But I must defer to another occasion my comments upon this and similar points in utero-mental patholo- gy, though the explanations that I would offer are, I believe, in their application original and of very prac- tical importance. There are one or two matters, however, of such medico-legal bearing that I should do wrong to omit * Obstetric Works, Scotch Ed., vol. i. p. 300; Clinical Lectures on Disease* of Women, p. 276. I20 REFLEX INSANITY them. Believing as I do that obstetric jurisprudence has been one of the most neglected, as it is one of the most important, of the branches of State medi- cine, I desire, by the investigation of these questions relating to insanity in women, to contribute somewhat to its advance, as I have previously endeavored to do in my treatise upon criminal abortion.* The first point to which I shall allude may seem a trivial one. It is that of a morbid and extreme fond- ness for pets, among women living solitary or se- cluded lives, and is most commonly brought out in courts during the decision of civil cases. In one suit, for instance, that is on record, it was charged that the testatrix was insane, because she kept fourteen dogs of both sexes, with their kennels, in her drawing- room ; two of them slept in her chamber, and one of them, which was blind, in the same bed with her ; f another lady kept her sitting-room filled with mon- keys, to the great annoyance of her visitors ; others have not been happy unless surrounded by parrots, or their room converted into aviaries for all kinds of birds. In one celebrated case, that of Mrs. Cum- mings, there was exhibited a propensity for cats, which were provided with their meals at table at regular hours, and were furnished with napkins.J * Criminal Abortion in America : Philadelphia, Lippincott & Co., i86a Criminal Abortion ; its Nature, its Evidence, and its Laws : Boston, Little, Brown & Co., 1869. t Yglesias v. Dyke, Prerog. Court, 185c % Taylor, Medical Jurisprudence, p. 658. See also Dryden v. Fryer, Q. B., Dec. 1850; Journal of Psychological Medicine, 1851, p. 285. IN WOMEN. 121 " This propensity for animals proves nothing in relation to the existence of insanity," says Taylor, "unless there is good evidence of mental aberration." On the other hand, it has often been illustrative of decided monomania, and I believe is generally de- pendent upon ovarian or uterine irritation. Within a few years a class of cases has made its appearance, exceedingly embarrassing to the medical jurist. These cases are not uncommon. Their de- scription I shall now submit, from Dr. Ray. "The woman, after preparing for a union to which her head and heart had apparently fully consented, and going through the marriage ceremony with the utmost propriety, manifesting all the while nothing unusual in her deport- ment, immediately after imbibes an insuperable aversion towards her husband, shuns his company, and perhaps re- fuses to live with him. In some of the cases, other singu- larities of conduct soon appear, one after another, till at last the woman becomes a subject of unequivocal insanity. In others, however, this strong repugnance towards the husband continues to be the principal, if not the only, symptom of mental disorder; but so closely do they resem- ble the former in other respects, that we can have no hes- itation in regarding them as merely varieties of the same affection. The pathological character of these cases seems to be sufficiently obvious. From some cause or other, the patient has been affected with a cerebral irritation, not suffi- cient to disturb the mental manifestations, and which, under favorable circumstances, might have entirely disappeared. In this condition, marriage, with the crowd of new thoughts and feelings by which it is preceded, operates as a power- fully exciting cause, and under its influence the pathological affection is completely developed. It is not strange, cer- tainly, that marriage should occasionally find a female brain 122 REFLEX INSANITY ID this morbid condition ; nor that, in case of such a con- junction, the result here mentioned should follow. The legal relations of these cases are not so satisfactorily settled. In some of them, a close scrutiny of the conduct and con- dition previous to marriage may detect indubitable signs of insanity; while in others no such signs can be discovered, though subsequently the mental disorder may have become no less obvious. Now, are we prepared to make a distinction between them.? To grant divorce in one class and refuse it in the other.? This, no doubt, would be highly convenient, but we are not sure that it would be strictly just. While we see not how legal relief can be withheld in the former class, yet in regard to the latter, we recoil from the idea of de- priving a woman of her protection and support at the very moment when the severest of earthly calamities has over- taken her, merely on the strength of what we may call a pathological abstraction." * To the explanation above given by Dr. Ray, I will add two others, which seem to have escaped his notice. In some of these cases the woman gets her first intimation, at or soon after the time of marriage, that her husband has previously had to do with others of her sex, and, as in more than one instance that has come to my knowledge, she shows her disappoint- ment and her disgust accordingly. In other cases, as is well known, the conjugal approach is attended with excessive pain. This effect, normal with the first coitus, at times becomes persistent and a veritable disease ; exhibiting itself either in the hyperaesthesia of the vulva, which has been termed vaginismus by Dr. * Medical Junsprudence of Insanity, p. 340- IN WOMEN. 123 Marion Sims, or In an extreme sensibil;ty to touch on the part of the uterus itself. Of both these affections I have seen many cases ; in one of the former, the husband had applied for a divorce on the ground that his wife is an hermaphrodite, whereas she is in reality perfectly formed. In one of the latter, the patient having been sent to me by Dr. Walker, of the City Lunatic Hospital at South Boston, on the ground that insanity was threatened, the husbandj he said, had been driven to adultery by the practical uselessness, for marital purposes, of his wife. I have spoken of obscenity and lascivious conduct in women, as the result of disease. There is no doubt that the same explanation is applicable to a large proportion of the cases of so-called self-abuse, which are not uncommon, and are frequently carried to an insane extreme ; though insanity, as its consequence, is less freqrently occasioned than in men, from the absence of a corresponding exhaustive discharge. So far from being considered and treated as a vice, or from being considered and treated only by moral means, these cases should very frequently be con- ducted as any others of physical disease. The imta- tion of ascarides, haemorrhoids, or mere constipation, of morbid states of the catamenia, of the urine, or of the vaginal secretions, or lesions of the organs them- selves, may each and all of them rest at the foundation 124 REFLEX INSANITY of the habit, as efficient causes, without whose removal no cure can be hoped for or obtained.* There are other cases, to a still greater degree in- volving the mental integrity and the moral responsi- bility of women. Cases of intemperance, habitual or periodical, of mendacity, of theft, of jealousy, of homi- cide. Had I not already trespassed so largely upon the patience of the Association, I would present at this time the valuable material I have in my possession relating to what I consider should be the true legal responsibilities of woman, their extent, and whether they should be confined, either as regards their charac- ter, or the time of their occurrence, to any particular periods or epochs of her life. This subject has not escaped the observation of Michelet,t and in reference to its relations with pregnancy has attracted the at- tention of Sedgwick J and others. § I believe not only that the execution of pregnant women should be stayed for the sake of the life of the child, examina- tion by a jury of matrons, instead of by skilled medical men, being a farce, whose occurrence at the present day is alike a disgrace to the law and to civilization ; but that no pregnant or parturient woman, for a crime committed during her gestation, or shortly after her confinement, should ever be executed at all. * Seethe Journal of the Gynxcological Society of Boston, August, 187a p. 100. t L' Amour, p. 334. t Medical Critic and Psychological Journal, October, 1863, p. 694. J American Journal of Insanity, January, 1856. p. 295- IN WOMEN. 125 A few words upon this point, based upon sound analogy, I shall extract from the work of a well- known and well-educated veterinary surgeon, and shall incidentally refer to the subject again in the course of this report. Mayhew says, — " Some bitches cannot be induced to suckle the pups they have given birth to, and others, though less frequently, wrill eat their progeny. The disposition to desert or destroy their young seems to prevail among the parentage of this world. In the female of the dog the maternal instinct is most power- ful ; but under certain conditions of the animal's body, the natural impulse seems to be perverted, and she takes the life she would else have perished to preserve. It is painful, knowing this, to reflect that on his own species man inflicts the highest punishment for an act that possibly may be, in the human being as in brutes, the consequence of a mental excitement accompanying the period of parturition. Women not in distress and otherwise aflflicted, rarely indeed are guilty of infanticide; and I have observed annoyance of ill health precede or accompany the like act in animals. If the rabbit be looked at, her alarm seems to change her nature ; and the bitch that devours her pups will, upon inquiry, be generally found to have suffered some species of persecution. That the brain is affected there can be no doubt. The un- natural propensity is itself a proof; but the strange appear- ance and altered looks of the creature sufficiently denote her state. She is not then savage, her ferocity has been grati- fied, and she seems rather to be afflicted with a remembrance of the acts she was unable to resist. She is the picture of shame; she shrinks away at our approach, and her eye no longer confidently seeks that of her master; her aspect is dejected, but I think more with sorrow than with crime. I would not plead for sin ; but what I have beheld in dogs in- duces me to think that the majority of those who have been hung for infanticide were legally murdered. There is dan- 126 REFLEX INSANITY ger in admitting such an opinion; but seeing all animals at certain periods exhibit a certain propensity, it is "ery doubt- ful whether the morbid feeling, as txemplified in the human race, is really one that calls for moital punishment." ♦ Jorg, of Leipsic, who erred in his estimate of the legal and real value of the human fcetus, as I have elsewhere shown,! has expressed a very sensible opinion upon the responsibility of women during pregnancy and parturition, believing that pregnancy can so disturb the intellectual faculties that the patient becomes unable to control her propensities. J Mont- gomery, on the other hand, one of the most profound and most classical writers of modern medicine, be- lieves that " this doctrine is as abhorrent from truth and nature, as it is calculated to lead to the most serious consequences," § thus indorsing the views of Capuron and Devergie, who considered that such an opinion as I have described " would, by taking away all moral responsibility, be fraught with most dis- astrous results to society ; " \\ although, as I shall now show, the Irish physician, like many another close observer who does not dare to follow his own data to their legitimate conclusions, most emphatically con- tradicts himself. • Dogs: their Management, p. 217. t Criminal Abortion in America, p. 58. t Die ZurechnungsfShigkeit der Schwangem und Gebarenden. § Signs and Symptoms of Pregnancy, p. 39. I M^decine Legale, L p. 433. IN WOMEN. 127 VII. — Rationale of Pelvic Causation of Insanity. As throwing some light upon the theory of ihe causation of insanity in woman by reflex uterine ac- tion, or what Forbes Winslow has called the dynam- ical sympathies of the reproductive organs,* it may not be amiss if I present a few remarks concerning the nervous derangements of pregnancy, from the iauthor I have just quoted, my friend, the late Dr. Montgomery of Dublin. I have selected the period of pregnancy rather than the puerperal state, con- cerning the mental disturbances of which we have had so much light from the pens of Dr. Gooch, and more recently Drs. Gundry of the Dayton Asylum, and Simpson of Edinburgh : because pregnancy, in itself considered, is rather a normal and physiological, than a pathological condition, its mental abnormal manifestations being of almost identical character with those attending the catamenial crises and climacteric epochs, lesser or greater, not more frequently evinced than at these times, nor more decidedly, if indeed they are not softened down and palliated by the influence of gestation, as sometimes seems to be the case. W^hether this, however, or the converse be true, there can be no doubt that the manifestations to which I • Journal of Psychological Medicine, April, 1854, p. 474. 128 REFJ.EX INSANITY would refer are clearly and undoubtedly of sexual origin. Montgomery says, — "When speaking of the physical changes which the uter ine system undergoes in consequence of impregnation, it was remarked that the nerves distributed to the organ and its appendages were augmented in size and number, and having their sensibility exalted,* diffused throughout the system generally an increase of nervous irritability, which, affecting both mind and body, displays itself under a great variety of forms and circumstances, rendering the female much more excitable and more easily affected by external agencies; especially those which suddenly produce strong mental or moral emotions, whether of the exhilarating or depressing kind, as fear, joy, sorrow, anger. The powerful influence of such impressions over the functions and actions of the uterus, in every stage of female life after puberty, is recognized in a multiplicity of circumstances, whether as deranging menstruation, inducing abortion, modifying the energy of parturient action, or affecting the recovery from childbed. t Hence the importance of preventing, as far as possible, pregnant women from being exposed to causes likely to distress, or otherwise strongly impress their minds. Sights of an affecting kind, books, pictures, or theatrical representations, which may deeply excite the imagination, or engage the feelings, are decidedly unsafe, and, in illus- tration of the dangers which may thence arise, I shall men- tion one or two instances. " I was once urgently called to see a lady who had gone to the theatre, when two months pregnant, to witness some grand spectacle, in which armed knights on horseback were to cross a bridge and storm a castle ; while doing so, the bridge gave way, and the besiegers were precipitated into the torrent beneath, and some of them much hurt. The * It is not necessary to suppose the uterine nerves augmented, either in siz'j or in number, to account for an exaltation of their sensibility. t Burrows: Conuiientaries on Insanity, p. 378; Merriman: Synopsis, etc., pp 33.324- IN WOMEN. 129 lady was dreadfully terrified, screamed, fainted, and was carried home almost insensible, when it was discovered that she was flooding profusely; under the influence of which, and the previous fright, she soon became alarmingly ex- hausted. However, by the adoption of proper measures, she was restored and tranquillized ; but she miscarried before morning. Another case was that of a lady, who, after pass- ing several years of her life in straitened circumstances, and actively employed, married when no longer very young, and was thereby placed in a position of comparative affluence, which, unfortunately for herself, enabled her to dispense with any further exertion, and to indulge a natural inclina- tion to indolence and sedentary habits. She soon became pregnant, and spent her whole time lying on a sofa at the fireside, or with her feet on the fender, reading novels, eat- ing and drinking heartily, and having a discharge from the bowels perhaps once or twice in the week. Amongst the books which she thus daily devoured, was one containing a highly-wrought description of one of the Maisons de Sante in France, and of its inmates; this aff'ected her strongly, and took great hold on her mind, and she expressed the greatest desire to visit one of the large lunatic asylums in this city, that she might assure herself of the reality of such things as she had been reading of. In this wish she was indulged, as in everything else, whether right or wrong, to which she took a fancy; and the consequence was, that the appearance of the persons she had seen, and their extrava- gant expressions and gesticulations, continued to haunt her imagination incessantly up to the time of her delivery; on the third day after which she showed sj^mptoms of insanity, which became rapidly confirmed, and continued for many months. During her illness, and after her recovery, she re- peatedly told me that from the time of reading the book and visiting the asylum, she felt as if she would certainly become deranged.* "The irritation of the nervous system is in some most obviously perceived in the change induced in the moral * Signs aivd Symptoms of Pregnancy, p. 17. 9 130 REFLEX INSANITY temperament,* rendering the individual depressed and de- spondent, or, perhaps, she who was naturally placid and sweet-tempered, becomes peevish, irritable, and capricious to a degree as distressing to herself as it is disagreeable to others ; yet over this she has little control, and, therefore, much allowance must be made for such waywardness, which, instead of exciting opposition, resentment, or reproach, sliould claim our utmost indulgence and commiseration,' and our best endeavors to comfort, soothe, and cheer. A lady of rank and very superior acquirements told me," he con- tinues, " that for the first two or three months of her preg- nancies, she became so irritable that, to use her own words, she was a perfect nuisance in her house, and was so pain- fully conscious of it herself, that she would sometimes re- main in bed all day, or confine herself to her room, to avoid displaying her irritability to the annoyance of others. This lady has since died of cancer uteri, under the most deplora- ble circumstances. " I have known the effect produced to be the reverse of this, and a decided amelioration take place in the temper, as we sometimes also see happen in the exercise of the bodily functions during pregnancy, A gentleman once in- formed me that, being afflicted with a stepmother naturally more disposed to practise the fortiter in re than to adopt the suaviter in modo, he and all the household had learned, from experience, to hail with joyful anticipations the lady's pregnancy as a period when clouds and storm were imme- diately exchanged for sunshine and quietness. " Some sufter most from this irritability depriving them of sleep, night after night, especially if they have not guarded against feverishness by pro|>er attention to the state of the bowels, or sleep in rooms too warm or insufficientlv ventilated; and yet it is singular how little they appear to suffer from this loss of rest, seeming really as much re- cruited by the short snatches of sleep which they obtain as they would, at other times, when enjoying unbroken repose. Others sleep, but suffer even more from painful and distress • Har\ey, 4to. edition, p. 593. IN WOMEN. 131 ing dreams; while some are liable to annoyance of a to- tally different kind, being constantly so drowsy, that it is with difficulty they can keep awake, even in company. " I suppose many have noticed a curious fact connected *vith the state of mind in pregnant women, when their bod- ily health is at the sanie time good, namely, that however depressed or dispirited with gloomy forebodings they may have felf in the early part of their pregnancy, they, in general, gradually resume their natural cheerfulness as gestation advances, and, a short time before labor actually commences, often feel their spirits rise and their bodily activity increase to a degree that they had not enjoyed for months before. I have known instances in which this took place so regularly and distinctly, in successive pregnancies, that the patients were able, from its occurrence, to anticipate and announce the near approach of their labor. This must strike us as a wise and beautiful arrangement by which, on the eve of suffering, the mind rises with a spring to meet the trial with cheerfulness and fortitude, which experience proves so materially to contribute to a happy result. " Occasionally, however, the depression assumes a more serious aspect, and the woman is constantly under the influ- ence of a settled and gloomy anticipation of evil, sometimes accompanied with that sort of apathetic indifference which makes her careless of everj- object that ought naturally to awaken an interest in her feelings; a state which we some- times observe in fever and other severe disorders, in which it is justly considered a most unfavorable symptom. When this occurs in pregnancy, it will generally be found accom- panied by very evident derangements in bodily health; a dull heaviness, or aching of the head, a loaded tongue with bitter taste in the mouth, constant nausea, costiveness, and a foul state of the alvine discharges, with not unfrequently a bilious tinge in the skin, and other symptoms indicating hepatic derangement, together with a quick pulse and a dry, hot skin, constitute the group of symptoms likely to be present, and which urgently demand attention for their removal before the time of labor, otherwise serious con- 133 REFLEX INSANITY sequences are to be apprehended. Sometimes this state appears to depend on some peculiar condition of the brain, the nature of which we probably cannot appreciate, and which our treatment will but too often fail to correct; in one strongly-marked instance of this kind, which was some time ago under my care, the lady became maniacal on the fifth day after delivery, and continued deranged for many months." Reasoning by analogy from such considerations as those we have just been engaged in, we should be led to expect as probable, what experience confirms as certain, that occasionally the cerebral disturbance during pregnancy, which, in most instances, only shows itself in unevenness of spirits, or irritability of manner or temper, amounts in some to absolute disorder in the intellectual faculties, especially in habits naturally very excitable, or where there is an hereditary predisposition. Dr. Pilchard says, — " If we consider the frequent changes or disturbances occurring in the balance of the circulation from the varying and quickly succeeding processes which are carried on in the system during and soon after the periods of pregnancy and childbirth, we shall be at no loss to discover circum- stances under which a susceptible constitution is likely to suffer. The conversions, or successive changes in the tem- porary local determinations of blood, which the constitution under such circumstances sustains and requires, appear sufficiently to account for the morbid susceptibility of the brain." * •' One cannot deny," says Roussel, " that the minds of pregnant women are singularly modified ; " f and • Treatise on Insanity, p. 31a. t Systeme de la Feinme, p. i6a IN WOMEN. 133 this susceptibility to mental disturbance, on the part of the mother, has been recognized on high authority as giving rise to one species of congenital predisposi- tion to insanity in the offspring. In some, this sen- sorial agitation may be confined to the more strongly marked forms of hysteria, or only exhibit itself in those unaccountable phantasies called longings, " which," says Dr. Burrows, " are decided perver- sions or aberrations of the judgment, though perhaps the simplest modifications of intellectual derange- ment," * but in others it is truly, and even violently, maniacal. " I have, on one occasion," says Mont- gomery, " noticed a case where mania occurred in eight successive pregnancies, and another in which the woman was three times similarly affected soon after conception, and remained deranged until within a short time of her labor, when she became sane, and continued so until the recurrence of pregnancy." f " Some," again remarks the author last quoted, " are insane in every pregnancy or lying-in, others, only occasionally." J Marc, writing on the same subject, says, " I recall a patient in Esquirol's Asylum, in whose case the commencement of each pregnancy was characterized by an attack of transient insanity." § Goubelly relates a case of an opposite kind, in which the lady was of sound mind only during her • Commentaries on Insanity, p. 147. t Dublin Medical Journal, v. p. 52. t Loc cit., pp. 364-378. § Diet, de Sc. Med., xix. p. 489. 134 REFLEX INSANITY pregnancies, but was then deficient in memory ; of which latter defect the following is a remarkable instance : — " A fright produced by the dangerous situation of her only son when eighteen months old, brought on, in Mrs. Durant, an alarming illness, attended with some singular phenome- na, the most singular of which respected her memory. The illness happened in July, when she was advanced six months in a state of pregnancy, and was, when perfectly insensible, delivered of a child. On awaking from her insensibility, which had continued for three days, she imagined it was the month of January. Her mental powers generally were but slightly impaired, and soon regained their former perfection ; nor was her memory affected, except as regarded the pre- ceding six months. Of that time she had forgotten all the events : some accidental circumstance might afterwards oc- casionally produce a train of thought, which would bring an event of those six months to her recollection ; but several of the most important were never regained, nor could she, to the hour of her death, remember that she had then been preg- nant. I have met with a few instances in which the memory was similarly effaced, and under apparently similar circum- stances, but for much shorter periods of time."* It has been asserted that manifestations such as those we have now seen described, whether occurring in pregnancy, at or after childbed, or during any other time of a woman's life, are merely attacks of hysteria, as distinguished from actual insanity, more or less aggravated as these may be. The error of such a supposition has been allowed by more than one psy- chologist. I have already called attention to the similar error of endeavoring to separate in all cases * Montgomery, Signs and Symptoms of Pregnancy, pp. 32-37- IN WOMEN. 135 from hysteria the so-called hystero-mania. In some cases, however, of hysteria, the mania may be coun- terfeited. Dr. Bucknill says, — *' The diagnosis between exaggerated hysteria and in- complete primary mania must be made by observing the sex, age, consthtution, and character of the patient, which, to the experienced physician, will generally reveal the nature of hysterical attacks, whatever form they may assume. They do sometimes assume the form of mania, with violent general excitement and strongly pronounced moral per- versions. These may be looked upon as the proper symp- toms of the disease ; but hysterical patients have been known to feign delusions and hallucinations, just as they will feign everything else. The hysterical type of the patient, the paroxysmal nature of the excitement, and the contradictions in which she may be detected when closely examined upon the circumstances of her supposed delusions, will rarely fail to detect the comparatively harmless nature of the affection. This will be the more easy, if the effect of remedies appro- priate to hysteria can be tried. But hysteria does some- times pass into real mania, and carry with it some of its own peculiarities. In all the instances in which we have observed this transition, there has been a strong hereditary tendency to insanity. The transition has been marked by an obvious febrile crisis, and by that most important symp- tom of early mania, loss of sleep. The medical man must, therefore, exercise due caution, in avoiding to pronounce any case to be purely hysterical because it has once been so. If, in a young woman of hysterical temperament, the per- verted sentiments and desires, the strange conduct and ex- cited demeanor pass into a febrile stage, accompanied by a rapid pulse, by loss of sleep, and by delusion or hallucina- tion, hysteria has passed into mania. Patients are even met with, in whom periods of hysterical and maniacal excite- ment alternate; and it is not difficult to distinguish in them the period when the superficial disorder presents 136 REFLEX INSANITY itself, and when it yields to the more profound and serious disease." ♦ With respect to hysteria, we are told by Dr. Mont- gomery, although in its ordinary or slighter forms, it is not perhaps properly deserving the name of mental disturbance, its more aggravated conditions are so closely allied thereto, that it must be extremely diffi- cult to draw^ the line of distinction. " Cases of this kind," says Dr. Conolly, " approach near to insanity ; and, indeed, a mind subject to the violent agitations incidental to the hysteric constitution cannot be con- sidered as perfectly sane ; " f ^ state of which Syden- ham has given so admirable and graphic a descrip- tion, in which he says, the patients " observe no mean in anything, and are constant only to inconstancy ; so unsettled is their mind that they never are at rest." J Montgomery says, — " Of one fact, at least, my own experience and that of others afford sufficient evidence, that when the aggravated form of hysteria prevails throughout pregnancy, puerperal mania is much to be apprehended. § I have also observed, in not a few instances, that women who, at other times, have been the subjects of that slight form of mental unsteadiness which goes by the name of extreme nervousness, and is evinced in an unreasonable susceptibility of impressions from slight causes affecting their moral feelings, but without any perceptible lesion of the intellectual faculties, and con- stituting probably the simplest form of moral insanity, have * Manual of Psychologica] Medicine, p. 301. t Cyclopaedia of Practical Medicine, ii. p. 563. t Swan's Translation, ed. 1769, p. 414. 5 Purrows, loc. cit., p. 378. IN WOMEN. 137 had their state of mind greatly improved during pregnancy; but soon after the termination of that condition, have ex- hibited, for a time, a greater degree of mental disquiet than was habitual with them, which, however, again settled down into their ordinary state. •'I desire now to observe that, in thus noticing some of the more remarkable phenomena occasionally displayed during pregnancy, it is not intended to imply that such are the usual concomitants of that condition ; on the contrary, most of them are to be considered as rare occurrences, some of them remarkably so, and all as exceptions to the general rule ; but, for this very reason, deserving of particular notice, as probably connected with a morbid state of the system, either absolutely existing at the time, though perhaps not otherwise clearly appreciable, or about to be developed, as in the case I have already related, where memory of the whole time of pregnancy was a complete void; my object being to point out forcibly, what experience seems to have fully established, that during pregnancy the system is in a state of unusual susceptibility; the activity of both the ner- vous and circulating systems being at that time greatly exalted, by which the female is rendered much more liable to be injuriously affected, even by ordinary causes, and still more so by any of a more impressive kind."t The peculiar manifestations which demonstrate this exaltation of the nervous system are of the most varied character. They are familiar to every obstetrician, and to many of them attention has been called by Montgomery. Some women, for instance, are much troubled with frightful dreams whenever they are pregnant. Dr. Lowder used to relate the case of a lady who was obliged to have a nurse sitting at her bedside all night, to watch her countenance while she • Signs of Pregnancy, p. 41. 138 REFLEX INSANITY slept, and to awaken her as soon as she perceived hel exhibiting distress under the influence of her dreamy terrors. Disorder of the ahmentary canal, disturbing the already irritated nervous system, is, probably, the most frequent cause of this affection ; it may also be induced by irregular or undue circulation of blood in the brain ; relief has been obtained by acting upon such a presumption, administering aperients, and ab- stracting blood by cupping on the nape of the neck. According to Beccaria, there is a peculiar kind of headache accompanying pregnancy, which he describes as an acute pulsating pain in the occipital region ; * occupying particularly the part in which Gall places the organ of the instinct of reproduction. " This pain," he says, " is accompanied with giddi- ness on the least motion of the head, and with diffi- culty in supporting the light ; it comes on suddenly, and, continuing for some time, is succeeded by an inclination to sleep." f It is often perceived. There is another variety of headache, familiar to all who are conversant with the symptoms of sick women, as almost pathognomonic of uterine disease. It is generally attended with a peculiar and almost indescribable sensation of outward pressure at the vertex, and was excellently described, some years since, • Annali Universal, de MeA, September, 1830; Archives G^n^rales d« Medicine, xxiv. p. 443. t Montgomery, loc. cit., p. 384. IN WOMEN. 139 by Dr. Tyler, the present Superintendent of the McLean Asylum.* Strange appetites, moreover, or longings, as they are called, and antipathies, are well known as frequent attendants on pregnancy in many persons ; some of whom will long to eat unusual, and even revolting articles, while others, immediately after conception, are seized with an unconquerable aversion to species of food which were previously particularly agreeable to them. Montgomery says, — " I have seen several well-marked instances of this, and, in particular, one in the case of a lady who assured me that she always knew when she was with child, by feeling a vio- lent antipathy for wine f and tea, which, at other times, she took with pleasure. I had an opportunity of observing the accuracy of this indication, in the successive pregnancies of the lady alluded to. A patient of Dr. Dewees used to consume enormous quantities of chalk when pregnant; and Capuron knew a woman whose principal food was long pepper, which she used to swallow by handfuls ; J under the same circumstances, one patient of mine eats quantities of cloves, for the first three or four months ; and another in- dulges with equal freedom in eating dry oatmeal. " There is a curious and interesting coincidence between such facts as these, and others not unfrequently observed in certain states of uterine disturbance, connected with sup- pressed or deranged menstruation ; especially about the time when that function is first established, when it is not unusual to find girls eat with avidity the most uninviting * New Hampshire Journal of Medicine, November, 1851, p 62. See also the Journal of the Gynajcological Society of Boston, May, 1870, p. 262. t This particular aversion was expressly noticed by Hippocrates as a sign of pregnancy, " viuum odio habent." De Infecundis, Cap. 6. t Trait^ des Accouchemens, p. 42. 140 REFLEX INSANITY substances, such as cinders, dry mortar, or clay; and in a case, about which I was some time ago consulted, the young lady used to pick the bog-wood out of the grate and eat it. " This morbid state of the appetite did not escape the no- tice of Ben Jonson, who thus alludes to it : — * She can cranch A sack of small coal, eat you lime and hair, Soap, ashes, loam, and has a dainty spice Of the green sickness. ' * '♦ Such caprices of appetite may at first, perhaps, only excite a smile, but experience appears to have sufficiently shown that their indulgence cannot always be permitted without imminent risk of injury to the mother, or child, or both." t These propensities, in their essence maniacal and in their demonstratious often clearly so, have received special attention from anotlier British observer, J to whom, however, I should hardly refer at this time had not his explanations of the phenomena in ques- tion been evidently accepted as valid by a noted psychologist. Dr. Forbes Winslow, from whose inter- esting though somewhat poetical article upon woman in her psychological relations, I shall accordingly present a few extracts. "The modifications of the appetite, says Dr. Laycock, necessary in the female of the lower animals, for the proper nutrition and development of the ovum or foetus, are occa- sionally reproduced in the pregnant human female as morbid appetites. " It has been obseryed by naturalists that birds will eat lime or chalk while laying — obviously that the shell may b'J * The Magnetic Lady, Act I. Sc. x. t Montgomery, pp. 278, 27^ t Laycock : Treatise on the Nervous Diseases of Women. IN WOMEN. 141 duly formed ; for, if hens be deprived of the opportunity of obtaining it, the eggs have only a membranous covering, or an imperfect shell. So, also, female carnivorous animals have the appetite for their natural food more ravenously ex- cited during utero-gestation and lactation, to the same end : namely, that of duly perfecting the nutrition of the young animal. These morbidly excited appetites are known as 'longings' in the pregnant woman, and in the young un- married woman as pica and bulimia. This change in the appetites has always attracted popular attention, and given rise to much astonishment, but we are now euabled to trace them to their origin. Dr. Laj'cock observes, that although during pregnancy some good wives 'long' for handsome dresses, furniture, &c., yet these longings are spurious, since the morbid feelings belong exclusively to the appetite for food. Ben Jonson notices these spurious longings, as fol- lows : — " ' Littleivit. — O yes. Win : you may long to see as well as to taste, Win : as did the 'pothecary's wife, Win, that longed to see the anatomy, Win. Or the lady, Win, that desired to spit in the great lawyer's mouth, after an eloquent pleading.' — Bartholomew Fair, Act III. Sc. 1. "Ben Jonson, indeed, seems to have had some experience in this form of morbid appetite, for he refers to it again and again in his plays. Thus, in Act I., of that just quoted, he makes the same character say, — " ' Win, long to eat of a pig, in the fair, do you see, in the heart of the fair, tiot at Pye-comer. Your mother will do anjrthing, sweet Win, to satisfy your longing, you know ; pray thee, long presently, and be sick 'o the sudden, good Win,' &c. "The things desired in this ovarian perversion of the ap- petite are sometimes very extraordinary, and outrageously absurd. Dr. Laycock quotes Dr. Elliotson as mentioning in his lectures that a patient has longed for raw flesh (the carnivorous appetite), and even for live flesh, so that some have eaten live kittens and rats. Langius, a German wri- ter, tells a story of a woman who lived near Cologne, who had such a cannibalish longing for the flesh of her husband, 142 REFLEX INSANITY that she killed him, ate as much of him as she could while fresh, and pickled the remainder. Another longed for a bite out of a baker's arm. More marvellous masticators than the case described in the play of 'The Magnetic Lady,' from which we have already quoted ; although Dr. Laycock quotes the case of a German woman who would eat a bon- bonniere of charcoal. "The 'dainty spice of the green-sickness* is known by some pathologists under the term of ' Temper Disease.' It is attended by the impaired digestion and defective assimila- tion which characterize chlorosis, and by the most extraor- dinary perversions of temper, very frequently with regard to diet, the patient persisting in a system of starvation, or only taking the most improper food, or that which she can get by stealth. Here, again, we trace a link of the mysterious chain which connects organism together, and can have little doubt that this form of psychological change is due to a morbid action of the reproductive organs, such as occurs occasionally in pregnancy. " There are other alterations in the mental character of women belonging to this class of perverted instincts, which are of greater importance, because they involve the social and moral relations. The hysterical cunning of the youhg female is traced by Dr. Laycock to the same ovarian source. Referring to the development of certain instincts in the fe- male at the period of procreation, and when the care of off- spring is the great end of life, he compares the artfulness of the lower animals with this hysterical cunning, and attributes it -to the influence of the ovaria on the nervous system.* " He also observes," continues the reviewer, " that astute- ness is as much the characteristic of woman as courage is of man, but that these characteristics are not morbidly de- veloped except under given circumstances. It is not until puberty that these peculiar qualities of the constitution of woman are distinctly brought out; and in brutes it is only when the business of reproduction is carried on, that this artfulness is so exalted as to rival the highest attempts of • Joam.al of Psychological Medicinr, Jan., 1851, p. 31. IN WOMEN. H3 human sagacity. The skill they display in the choice of a secret place in which to deposit their eggs or young, and the finesse with which the latter are protected from discovery or injury, are well known to the most inexperienced student of natural history. The lioness, for example, ferocious and powerful as she is, when she fears the retreat in which she has placed her cubs will be discovered, will hide her foot- marks, by retracing the ground, or brushing them out with her tail. When the young female suffers from irregular ac- tion of the ovaria on the system, the natural astuteness and quickness of perception degenerate into mere artfulness, or monomaniacal cunning; and it is to this morbid influence of the ovaria on the organ of the mind, that Dr. Laycock attributes the extraordinary instances of monomaniacal cun- ning in females, on record. He observes, on this head, 'Of all animals, woman has the most Jlcute faculties; and when we consider how much these ;nay be exalted by the influence of the reproductive organs, there is not much ground for surprise at the grotesque forms which cunning assumes in the hysterical female, although they have cauvsed much speculation and astonishment. Insane cunning is usually exhibited in attempts at deception, but occasionally in a propensity to steal, or rather to steal slyly. It may be re- marked that, when it occurs, it may be as much a symptom of hysteria as any corporeal affection whatever. It is a true monomania, and is most likely to occur in the female who is hysterical from excess of sexual development — one pos- sessing the utmost modesty of deportment and grace of figure and movement, for the modesty itself springs out of that feminine timidity to ivhich I have just alluded. Sly stealing, however, is most frequently observed in pregnant women.' The Italics in the above quotation are our own," says Dr. Winslow, "as we wish to direct the reader's special atten- tion to the impox'tant principle pointed out by Dr. Laycock. The propensity, in such case, is dependent solely on the ex- citement of the nervous system \>y the ovaria; hence it is that when, in consequence of an active condition of those structuies, the graces peculiar to the feminine character are 1^14 REFLEX INSANITY peculiarly developed, and gentleness, modesty, and timidity are prominent characteristics, often in those identical cases it is, that there is this morbid excitation of the instinct of artfulness or cunning; and it is these endowments which explain the influence that hysterical girls have upon all that come near them, and which is really astonishing; parents, women, physicians, all yielding to them. It is also the marked excitation of this sexual artfulness, which renders nugatory all the experiments and labors of those mesmer- ists, whose principal subjects are young females or youths about the age of puberty. Psychologists, practically ac- quainted with this subject, can place no reliance upon the statements of the hysterical females upon whom mesmerists experiment, however well educated, gentle, good, and truth- loving they may be naturally, and really are in all other matters. Physicians have recorded numerous instances of strange and motiveless deceptions, thefts, and crimes prac- tised by young women, even by ladies of unexceptionable morals, excellent education, and high rank. Fasting wo- men, ecstatica, sly poisoners, pilfering lady-thieves, &c., present examples of this kind; particular instances we need not mention, as they may be found in most works on hyste- ria, and often occupy a niche in the newspapers. When cunning is combined with a morbid excitation of the pro- pensity to destroy, such as is manifested in the females of brutes, the effect is sometimes dreadful, and is seen in the perpetration of secret murders by wholesale poisoning, or in secret incendiarism ; and if other natural instincts be per- verted, the objects of woman's warmest and most disinter- ested affections may perish by her hand. It is a singular fact in natural history, and remarkably illustrative of our views, that parturient domestic animals sometimes suffer from the same morbid condition of the nervous system as the human mother, and they also destroy their offspring. Thus," as we have already had pointed out by Mayhew, "cats, sows, and bitches have been known to eat their litter; cows to butt their calves to death, hens to chase their chickens, &c. IN WOMEN. 145 "When cunning is combined with a morbid state of the temper, the misery inflicted upon domestic peace is mex- pressible. The ingenuity in malice and falsehood displayed by the patient, is most extraordinary; so extraordinary, in- deed, that it is never credited until it is experienced. Cases are by no means infrequent in which the sufferer from thi* sad derangement is the most intellectual and most amiable of the family; beloved by all, respected, almost worshipped. Hence, when, after numerous struggles to repress them, the propensities, excited into such fearful and almost super- natural activity by the ovarian irritation, burst forth beyond all control, and the pet of the family is seen to be the op- posite, morally, in every respect to what she had been, — irreligious, selfish, slanderous, false, malicious, devoid of afl'ection, thievish in a thousand petty ways, bold, may be erotic, self-willed, and quarrelsome ; the shock to the family circle and friends is intense ; and if the case be not rightly understood, great, and often irrepai-able mischief is done to correct what seems to be vice, but is really insanity. " Perhaps in the whole range of psychology there is no subject so deeply interesting as this; for it is in so-called moral insanity that man's spiritual and moral nature is the most awfully and most distressingly subjected to his cor- poreal frame. It is a disease, undoubtedly, much more frequent in the female sex than in man." * Dr. Montgomery says, — " Dr. Harvey mentioned the case of a lady who, whenever she was pregnant, became affected with the most uncon- trollable passion for building; this had taken place several times, and always subsided when pregnancy ceased. A marked change in the temper is very commonly observed, so that a woman who was, under ordinary circumstances, extremely mild and sweet-tempered, immediately becomes, when pregnant, irritable and capricious, an effect which in some women attends each recurrence of pregnancy." t * Journal of Psychological Medicine, January, 1851, pp. 31, 43. ♦ Loc. cit., p. 278. 10 146 REFLEX INSANITY These are clearly and distinctly, to the extent to which each of them goes, cases of a monomaniacal character; which character, in itself considered, is not affected by the possibility of the affection in some cases being intermittent, paroxysmal, or periodical, while in others it is chronic and persistent. There are other abnormal manifestations, even of special sense, of whose occurrence abundant evidence can be aflbrded. There is a simulation of disease which occasion- ally accompanies pregnancy, and depends apparently on disturbance of the nervous influence, which some- times very remarkably afiects the functions of some of the organs of the ejxternal senses, in which no appreciable organic change can be at the time dis- covered ; and that none such does really take place, seems sufficiently evident from the fact that the affec- tion lasts only during gestation. Thus, instances of temporary amaurosis induced by pregnancy are by no means uncommon.* Dr. Montgomery says, — *' I saw a lady thus affected; she could see certain objects distinctly, as a line drawn on paper; others appeared con- fused, and some she could hardly discern at all; occasion- ally she imagined she saw objects which were not present, as a person crossing the room, or flower-pots, or bunches of flowers on her table, when nothing of the sort was there. Salmutius relates a case in which a lady became blind every time she was pregnant, and recovered her sight as soon as * Good : Study of Medicine, iv. p. 247 ; Cooper : Surgical Dictionary irt. Amaurosis. IN WOMEX. 147 she lay in.* Beer saw a young Jewess, who at the very be- ginning of her first three pregnancies, which followed each other quickly, regularly became amaurotic, and continued blind till after delivery ; but on the third occasion she did not recover her sight.f Chambon ascribes these affections to plethora; but such an explanation is scarcely consistent with the occurrence of amaurosis from protracted or undue laetation, when the constitution is in a state of great debility and exhaustion ; two well marked instances of which I saw in two sisters, who quickly recovered their sight by weaning their children. Dr. Mathews, of Moate, has just informed me of the case of a lady who, when five months pregnant, for the first time sustained total loss of voice, which she re- covered at the time of her labor. Gardien notices this part of our subject fully, and mentions a variety of affections which I have not met with. J Dr. Bennewitz has detailed the particulars of a case, in which a young woman was, in three successive pregnancies, afiected with diabetes mellitus ; which, each time, completely ceased on delivery, but again returned when she became pregnant." § These physical derangements, of reflex and uterine causation, are sometimes extreme. Thus it is not un- usual, during the existence of pregnancy, to find the power of one or both of the lower limbs more or less impaired ; and, in some few rare instances, they have bcome partially or completely paralytic, and even hemiplegia has been obsei-ved. Montgomery says, — " To what degree the mere enlargement of the uterus is the agent in the production of such a state (by mechanical pressure) seems very doubtful, especially as we som(;times • Cent. in. Obs. 27. t Lchre von den Augenkrankheiten. t Tr.T.te des Accouchemens, i. p. 437, and ii. 76. § Osam: Clinical Report for 1823; Edinburgh Medical Journal, xxx. p. 217 Mortgomery, loc. cit., p. 4.7. 148 REFLEX INSANITY find the paralysis affecting the upper extremities;* the blood drawn under such circumstances has been observed to present highly inflammatory characters; but whatever measures may be adopted, the affection is never perfectly removed until after delivery, from which it would appear to depend on cerebral disturbance, originating probably in uterine irritation, and referable to the state of pregnancy as its specific cause." f Of course such cases are to be distinguished from those of paralysis occurring during or after labor, in consequence of apoplectic convulsions, or from undue or long-continued pressure upon the pelvic nerves by the foetal head. The evidence that I have now presented proves more than that the state of pregnancy is one subject to grave mental and physical derangement, giving rise to serious anxieties, and requiring judicious treat- ment. It proves, also, that at the foundation of the whole matter lies an excited uterus. The irritation that, during pregnancy, may coexist, as a normal and physiological state, with the usual or improved health, may, in other cases, assuming a pathological type, or in the presence of pathological adjuncts, cause the inception or development of severe disease. In other words, the tendency to reflex derangement, whether of body or mind, usually attending uterine disturb- ance, but also usually controlled during pregnancy by the vis medicatrix of impregnation, may at times • Edinburgh Monthly Journal, xii. p. 492. t Loc. cit., p. 5. IN WOMEN. 149 during this period assume its primal sway, and pro- duce effects, under other circumstances naturally to be expected. If we change the premises, the same result obtains. I have assumed the excited uterus as a natural cause of reflex disease, as is proved by its conduct at times other than pregnancy, and have shown that the dis- eases of pregnancy are but the special diseases of other times allowed to exhibit themselves here. Let us now shift the scenes of proof, and assuming preg- nancy, however occasionally permitted to occur, as the normal condition of the adult woman, and its processes uninterfered with, and as usually presenting themselves to be strictly physiological in their char- acter, we will compare its diseases, physical and mental, with the special affections of women occur- ring at other times. They are found to be nearly identical in type, in detail, in their general course and result : a similarity of effect argues an identity of cause. Whichever horn of the dilemma is then selected, its point is the same. If an excited uterus causes the derangements of pregnancy, so it does those of other special times and seasons. If an. ex- cited uterus causes the latter, it is by the same mech- anism and same reflex causation as that by which the former are occasioned. As to puberty, for instance : I will quote a worii from Dr. Ray. 150 REFLEX INSANITY " That the evolution of the sexual functions is very often attended by more or less constitutional disturbance, espe- cially in the female sex, is now a well-established physio- logical truth. The shock seems to be felt chiefly by the nervous system, which experiences almost every form of ir- ritation, varying in severity from the slightest hysterical symptoms to tetanus, St. Vitus's dance, and epilepsy. And when we bear in mind, also, that general mania is some- times produced by this great physiological change, it cannot be deemed an extraordinary fact that partial mania, excit- ing to acts of incendiarism or murder, should be one of its effects." ♦ Just as puberal mania may thus be produced, so may there occur the first explosion at any other of the periodic crises, of longer or shorter interval, to which we have seen woman is constantly liable. The climacteric invasion of insanity has lately been studied by Dr. Francis Skae, formerly attached to the Royal Asylum at Morningside,t and it is to be hoped that we may soon have memoirs upon each of the other developmental types to which I have already alluded. I have now shown that both a priori^ and from the evidence of experts in insanity, there is reason to believe that their sex lies at the foundation, physio- logically and pathologically, of much of the mental derangement that occurs in women. I am well aware that the work has been but imperfectly performed. Had space and a fair allowance for the patience of the Association permitted, I should have presented • Medical Jurisprudence of Insanity, p. aoo. t Edinburgh Medical Journal, Feb., 1865, p. 703. IN WOMEN. 151 much additional proof that I am, at present, com- pelled to withhold. Negative evidence, no matter what its amount or from what quarter aflbrded, should not, I would re- spectfully submit, be allowed to weigh against the positive proof that I have afforded ; yet the argu- ments that can alone be brought to disprove my posi- tion are strictly and merely negative in their charac- ter. It will be sufficient if I refer to merely one or two of them. From an example we may understand its class. It has been stated by several writers, — I have al- ready quoted Dr. Earle's opinion upon the subject, — that the regular occurrence, absence, or suppression of the catamenia seems in many cases to have made no difference as to the causation, continuance, or cure of insanity in women, and that therefore the uterus and ovaries are proved incapable of exerting any ap- preciable influence as an agent in the production of the mental disease. The error that is here present is an evident one : it is in considering that in all uterine or ovarian diseases there must be derangement of a single function, that of menstruation, or that the pres- ence and partial or complete performance of this func- tion argues uterine health. Such an argument only proves most lamentable ignorance, even of the most common and simplest of the diseases of women, and of which the youngest medical student of the present day vyould be ashamed. 152 REFLEX INSANITY Again, it must not be forgotten that the diseases special to women are now recognized to embrace a vast variety of simple and complex lesions, equalHng in number, if not excelling, those of any other organ or system of organs in the body. The wise physician of old was not far wrong in his judgment : " What is woman ? Disease, says Hippocrates." * The absence of one affection, of whatever class, in any given pa- tient, is no evidence that another may not exist. Am I wrong, then, in advising more careful examinations than are commonly made, even in general practice? Still further, it has been asserted, that because many insane women make no complaint of pelvic pain, we ought, from that fact, to take for granted the non- existence of uterine disease. This statement would hardly be made were it recollected — for every medi- cal man, however long retired from active practice, must once have known — that even among sane pa- tients cases are not so very uncommon of advanced and decided uterine disease when the only pains pres- ent are reflex, and exhibited merely as distant neural- gias of the back, face, breast, or other location. In- deed, I may state that I have seen, in quite a number of instances, the uterus nearly destroyed by malignant disease, without a trace of the lancinating pain that authors have too much insisted upon as necessary, however generally pathognomonic when it does exist, * Michelet: L' Amour. IN WOMEN. 153 and the patient hardly aware of any local discomfort. That such cases do occur in the sane, only strengthens the argument I have elsewhere dwelt upon, quoting Bucknill and other authorities ; that while the pecul- iar tolerance of pain, so often observed in the insane, is now allowed frequently to veil the existence of phthisis and similar forms of organic disease, just as it does of wounds and injuries, so must it be granted that at times there may exist and progress any and every form of uterine and pelvic lesion without its coming to the knowledge of the physician or asylum superintendent, unless he suspect its occurrence, and search therefor. As a single instance from many that might be given, I append a statement by Dr. Tuke, attached to the Royal Lunatic Asylum at Morningside, near Edin- burgh. In presenting to the Edinburgh Obstetrical Society, at its meeting in January, 1865, specimens of fibroid tumor and polypus of the uterus, removed, post-mortem, from a woman who had been in the asylum for twenty years, without ever making com- plaint of pelvic disturbance, this gentleman remarks, — " I was not aware of the existence of the tumor until I examined her amongst other patieuts, making a careful in- vestigation into the bodily health of all the old inmates, with the view of discovering diseases which are liable to lie latent in the insane, to an extent hardly to be credited by any but those accustomed to their treatment." * • Edinburgh Medical Journal, March, 1865, p. 857. 154 REFLEX INSANITY And, finally, 1 have been told by some gentlemen, that because many women have disease of the uterus, detected during life, without insanity, and by others, that because at autopsies of sane patients, similar disease, undetected during life, because unlooked for, has been discovered ; so must it therefore be ad- mitted, that it is impossible that diseased conditions of the pelvis and of the brain can have any depend- ence upon each other. Upon just such absurdities as these — for I can honestly apply to them no milder epithet — have many of the dogmas of psychologists been founded. As well might it be asserted, that be- cause some persons with musket wounds have recov- ered, therefore a bullet never kills ; or, because in some others, as in the late eminent geologist, Hugh Miller, for instance, extreme cerebral disorganization has, for a while, coexisted with apparent mental in- tegrity, that, therefore, such disorganization is the normal condition of the brain, or can never be, at any rate, the cause of mental disturbance. And yet it is by just such baseless objections, that gentlemen, professing to seek only the advance of medicine and the cure of patients, have endeavored to prevent a more rational treatment of insane women than that now generally obtaining. There are many questions directly presenting them- selves in this connection, interesting equally in their practical and their scientific relations, upon which I IN WOMEN. 155 have much to say, but whose discussion I must defer to another occasion. Such, among others, are the following : — 1. The effect of celibacy, of marriage, of widow- hood, as causing insanity in women. 2. The transmissibility of insanity as an inheritance by the mother, as compared with it by the father. 3. The occurrence of uterine disease in the mother, as rendering the transmission of any family taint of insanity more probable to her offspring. 4. The frequency of organic cerebral disease in in- sane women as compared with it in insane men.* 5. The epidemics of Tarentism, convulsions, sui- cide, exhortation, &c., which, occurring among fe- males, have at times so vexed the religious and pro- fane worlds. 6. The special propensities of invalid women to breach of the law or of propriety, as in the so-called pyromania, klepto-, dipso-, erotomania ; whether this last be for a real or imaginary object, and their re- sponsibility therefor. 7. The possibilities of a longer incubation of in- sanity, from special causes, in invalid women than would probably be thought credible. 8. The periodicity of insanity in women, and the * *■ Female insanity is in a large proportion of cases merely a reflex disturbance of the brain. Insanity in men much more extensively involves cerebral lesion, and their mortality is proportionately increased. " Workman : Toronto Report, i860 ; American Journal of the Medical Sciencesi April, 1863, p. 437. 156 RKFLKX INSANITY various lengths of the attack and the interval ; in some instances bounded by a single catamenial peri- od, in others by the space of gestation, of lying-in, of lactation, or the whole cycle of uterine life, from pu- berty to the final climacteric. 9. The time of development or explosion of an hereditary predisposition to insanity ; its frequent co- incidence with a special epoch in woman's life. 10. Epilepsy in women, with or without the addi- tion of decided insanity, or its previous existence as a family taint, and tlie legal responsibilities of female epileptics. I had prepared from my own note-books the histo- ries of quite a number of cases, illustrating several of the special points now indicated, which I had in- tended here to present, in connection with the very interesting series published not long since by Dr. Azam, physician to the asylum for insane women at Bordeaux ; but my paper is already so long that I must omit them. I cannot, however, refrain from quoting the last of Dr. Azam's conclusions, so com- pletely does it coincide with my own conviction and my own experience. " Every other treatment than physical will prove useless so long as the organic lesion persists, and this will have so much the greater chance of being effectual as it is resoi-ted to at a time approaching the commencement of the dis- ease." * * De la folic sympathique provoqu^e et entretenue par les 16sions de I'lit^rui et de ses annexes. IN WOMEN. 157 VIII. — Indications of Treatmentv My remarks, present and past, upon the causation of insanity in women have been elicited, as will long since have been perceived, by the need, as it seems to me, of urging upon the profession a more rational treatment, in public and private practice, of female lunatics. My views upon the subject are not the re- sult of any hasty and ill-based impression, but they are matured, and from somewhat extensive observa- tion. Without the slightest presumption, I think I may here say that I know whereof I do affirm. I cannot at this time go into the detail that I would gladly do, and that I have intended doing at no long subsequent period ; but I shall at least show, as I think indeed I have already done, that the field now endeavored to be opened to the practical purposes of the profession is one that, though hitherto neglected, is yet one of the most fruitful in medicine. As has hitherto been done in this communication, I shall endeavor to present the little I have time to say concerning treatment, through the language of super- intendents themselves. An author whom as yet I have hardly referred to. Dr. Conolly, of the asylum at Hanwell, while taking the general ground of non-restraint, seems to have been struck by the eminently sad condition, under the best of care, of lunatic women as compared with 158 REFLEX INSANITY lunatic men. I cannot better introduce the little I can say in this especial connection, than by the fol- lowing extract. Dr. Conolly says, — •'The precise condition of the brain in different patients is, it has been acknowledged, as little known as the mode and nature of its actions in health. The manner in which its functions are interrupted or disordered in insanity, lies in a region beyond the reach of man's senses, and seems scarcely a legitimate object for strictly philosophical imagi- nation, unaided by any means of appreciating it, and lead- ing merely to ' wandering thoughts and notions vain.' But the connection of these actions with material organs, and their evident sympathy with the body in health and in dis- ease, impart certain resources to the physician, who, if he can only act directly on the mind within narrow limits, finds that he can extensively and powerfully influence it by sedu- lous attention to the state of the temple in which, in this condition of existence, it is enshrined." * Let us see what until very lately has been this " sedulous attention to the state of the temple of the mind," so justly deemed necessary by Dr. Conolly. I shall first quote from an official English report of but a few years ago, with the simple comment that what then existed in Great Britain, still exists, to our disgrace, in many places in this country. " In one of the cells for the women, the dimensions of which were eight feet by four, and in which there was no table, and only two wooden seats, we found three females confined. There was no glazing to the window, and the floor of the place was perfectly wet with urine. The two dark cells which joined the cell used for a day-room, are the sleeping places for these three unfortunate beings. Two of * Treatment of the Insane, p. 164. IX WOMEN. 159 them sleep in two cribs in one cell. The floor in the cell with two cribs was actually reeking wet with urine, and cov- ered with straw and filth. There is no window, and no place for light or air except a grate over the doors." ♦ Ten years later than the date of the report from which the above is quoted, it was my fortune to be residing in Scotland, when its lunatic asylums, public and private, were subjected to the official scrutiny that had been instigated by Miss Dix. The descrip- tions already given and to follow are in no respect an exaggeration of what, in many quarters, was found to exist. Among the foremost in promoting that investigation was my instructor, the late Professor Simpson ; and it was the facts that then came to my knowledge, that first called my attention to the ne- cessity of more thoroughly studying the causation and treatment of insanity in women. I will present a true picture from an unbiassed observer. "The first common room you examine, measuring twelve feet long by seven wide, with a window which does not open, is [perhaps] for females. Ten of them, with no other cov- ering than a rag round the waist, are chained to the wall, loathsome and hideous, but, when addressed, evidently re- taining some of the intelligence, and much of the feeling, which, in other days, ennobled their nature. In shame or sorrow one of them perhaps utters a cry ; a blow, which brings the blood from the temple, the tear from the eye, — an additional chain, a gag, and an indecent or contemptuous expression, produce silence. And if j'ou ask where these creatures sleep, you are led to a kennel eight feet square, * Report of the English Commissioners in Lunacy for 1844. l6o REFLEX INSANITY with an unglazed air-hole eight inches in diameter; in this, you are told, five women sleep. The floor is covered, the walls bedaubed, with filth and excrement : no bedding but wet, decayed straw is allowed ; and the stench is so insup- portable, that you turn away, and hasten from the scene." ♦ Dr. Conolly says, — *' Indeed, it would almost seem as if, at the period from the middle to near the end of the last century,t the super- intendents of the insane had become frantic in cruelty, from the impunity with which their despotism was attended. Some of the German physicians meditated even romantic modes of alarm and torture; they wished for machinery, by which a patient, just arriving at an asylum, and after being drawn with frightful clangor over a metal bridge across a moat, could be suddenly raised to the top of a tower, and as suddenly lowered into a dark and subterranean cavern; and they avowed that if the patient could be made to alight among snakes and serpents it would be better still. People not naturally cruel became habituated to severity, until all feelings of humanity were forgotten. I used to be aston- ished, even seventeen years ago, to see humane physicians going daily round the wards of asylums, mere spectators of every form of distressing coercion, without a word of sym- pathy, or any order for its mitigation. But men's hearts had on this subject become gradually hardened. In medical works of authority, the first principle in the treatment of lunatics was laid down to be fear, and the best means of producing fear was said to be punishment, and the best mode of punishment was defined to be stripes. The great authority of Dr. Cullen, certainly one of the most enlight- ened physicians of his time, was given to this practice, al- though his theory of madness was, that it depended upon an increased excitement of the brain. * Browne : What Asylums were, are, and ought to be. Edinburgh, t We have seen that examples like those referred to have not entirely been un« known in the present century. IN V/OMEN. l6l "Thus, by degrees, restraints became more and more se- vere, and torture more and more ingenious. Among manj cruel devices, an unsuspecting patient was sometimes in- duced to walk across a treacherous floor; it gave way, and the patient fell into a bath of surprise, and was there half drowned and half frightened to death.* " In some continental asylums the patients were chained in a well, and the water was allowed gradually to ascend, in order to terrify the patient with the prospect of inevitable death. Other methods adopted, even within the last sixty years, for controlling the phenomena of insanity, can only be regarded as tacit acknowledgments of the general ineffi- ciency of medicine, and of the coarse determination of vain or ignorant men to effect by force what they could not ac- complish by science. We read with almost as much amuse- ment as wonder the respectful acknowledgment of Dr. Hallaran, that Dr. Cox made known to the profession the ' safe and effectual remedy ' of the circulating swing, the in- vention of which Dr. Cox ' generously gives the credit of to Dr. Darwin; this invention being one by means of which the maniacal or melancholic patient, fast bound on a sort of couch, or in a chair, was rotated at various rates up to one hundred gyrations in a minute. This machine was used with two indications; the horizontal position being adopted when the object was to procure sleep ; and the erect posture, the other failing, in cases of excitement, to procure intesti- nal action. It is acknowledged that patients once subjected to the swing were ever afterwards terrified at the mention of it; that it lowered the pulse and the temperature to such a degree as to alarm the physician ; that it occasioned a ' dis- agreeable suffusion of the countenance,' frequently leaving an ecchymosis of the eyes ; that it acted as an emetic, and as a hypercathartic; but still it was lauded as reducing the unmanageable, and, stranger still, as causing the melan- * It was with reference to this bath of surprise, which was said t patients, there were admitted 3273 males and 3390 females, and were discharged 2962 males, or 88 per cent, of the admissions, and 3078 females, or 89 per cent, of the admissions, a difference of I per cent, in favor of the women. If we add the years 1863 and '64, the percentage is but slightly changed. In a total of over 7000 patients, we now have as admitted 3503 males and 3601 fe- males, and as discharged 2910 males, or 81 per cent, of the admissions, a loss of 7 per cent., and 3005 females, or 81 per cent, of the admissions, a loss of 8 per cent. ; the proportions of discharges in the two sexes being rendered exactly identical by the com- parative loss of I per cent, by the women. Thirdly, I have also no doubt, and am willing to admit, that as many, or nearly as many women as men are discharged from our hospitals as recovered. This, it will be noticed, is, however, a very different thing from being discharged as cured ; and this again is by no means identical with being discharged cured. If my views as to the psycho-pathology of women are correct, not only as many women as men ought to be discharged cured, but very many more. This, however, does not occur in practice. To return to the question of relative recoveries. At IN WOMEN. 179 the Worcester State Hospital, during the thirty years first mentioned, and upon the basis of admissions then existing, namely, 3273 males and 3390 females, there were discharged as recovered, 1493 males, or 44 per cent, of the admissions, and 1618 females, or 45 per cent, of the admissions ; a difference of i per cent, in favor of the females. Adding again the years 1863 and '64, we have an admission of 3503 males and 3601 females, and a dis- charge as recovered, of 1612 males, or 45 per cent, of the admissions, a gain of i per cent., and 1751 females, or 49 per cent, of the admissions, a gain of 4 per cent. ; showing a difference of 4 per cent, in the females, and a comparative gain of 3 per cent. At the Southern Ohio Lunatic Asylum, for the nine years from 1855-64, there were admitted 497 males and 499 females ; of whom were discharged as recovered, 261 males, or 57 per cent, of the admissions, and 251 females, or 50 per cent, of the admissions ; a proportion of 7 per cent, in favor of the males. At the Taunton State Hospital, for the nine years from 1853-62, there were admitted 1044 males and 1004 females, and were discharged as recovered 404 males, or 38 per cent, of the admissions, and 335 females, or 30 per cent, of the admissions ; a propor- tion of 8 per cent, in favor of the males. If we tabulate the results of these three hospitals, we have for the years first considered, a total of nearly l8o REFLEX INSANITY 10,000 patients admitted, of whom 4814 were males, and 4933 were females. Of the former there were discharged as recovered 2158, or 42 per cent., and of the latter 2204, or 44 per cent. ; a difference of 2 per cent, in favor of the female. Adding to this the years 1863 and '64 at the Worcester Asylum, our total number of patients admitted becomes 12,000; 6844 being males, and 5104 females. There were discharged as recovered 2277 males, or 31 per cent., a loss of 11 per cent., and 2337 females, or 44 per cent., the proportion here remaining the same. The difference of 13 percent, which had been relatively gained by the women, and which at first sight might have seemed an absolute gain, being found upon comparison to be exactly neutralized by the loss in recoveries of the men. The statistics that have now been given were, as I have said, taken at random from many reports before me, and may undoubtedly be considered as represent- ing the truth, such as it is. They show, it will be noticed, an apparent variation of the ratio of recoveries in insane women at the different hospitals — ranging from 50 per cent, at Dayton to 30 per cent, at Taun- ton — a variation to be explained in part, by the different probable character and nationality of the patients at the two hospitals ; if at all attributable to difference in treatment, it may partly be owing to the fact, as is well known, that Dr. Gundry has paid much IN WOMEN. l8l attention to insanity as caused by or coincident with the puerperal state. These variations, however, but tend to make the mean that I have presented the more reliable in reference to the actual percentage of recoveries of insane women at asylums. I could have furnished a computation upon a very much larger scale had it been necessary ; that given is, however, sufficient for every practical purpose, more especially as I have granted all that could by any one be claimed ; namely, that at our hospitals as many insane women as men are discharged as re- covered. It will not be uninteresting, however, to compare these results with what obtains abroad ; a comparison that so far as I am aware has never yet been made. At the York Retreat, in England, as appears from a table furnished by Tuke, and covering a period of 51 years, from 1796 to 1857, ^^® average proportion of recoveries as compared with the admissions was 49.54 per cent, of males and 49.50 per cent, of fe- males, the numbers being almost exactly identical.* It was Dr. Thurnam's opinion, as we have already seen, that the proportion of recoveries of women ex- ceeded those of men by about 20 per cent. ; indeed, he is said to have estimated this excess as high as 50 per cent. A most surprising differdnce as compared with the results I am now presenting. * Psychological Medicine, p. aoi. I S3 REFLEX INSANITY At Bethlem, during ten years, 53.8 per cent, of the men recovered, and 54.4 per cent, of the women ; an excess of .6 per cent, in favor of the latter.* At St. Yon, near Rouen, in France, the difference in favor of the women has been rated at 3 per cent, f In most of the French asylums it has been thought that the males, discharged as recovered, exceeded the females by about 6 per cent. It is possible, however, that in some instances these computations may have been made by comparison with the total number of discharges, as was the case in the English statistical tables presented by Farr. The excess referred to has been noticed by nearly all the directors of asylums in France, and has been explained in various waj'S. By some it is regarded as due to " a humane sentiment, which induces the pliysicians of these establishments to shorten as much as possible the period of confine- ment for the men, whose labor is oftentimes indispen- sable to the maintenance of their families ; and, on the other hand, to detain the females, giving them the protection of the asylum as long as possible, in view of their greater helplessness, and of the dangers to which many would be exposed on their return to so- ciety ; " a detention which, besides, by preventing to a certain extent their marriage, would tend to check the • Hood : Statistics of Bethlem Hospital, p. 73 ; as corrected by Tuke, lot dt., p. 362. t Parchap^e : Notice Statistique sur les Ali^D^s de la Seine Inferieure, p. 44 IN WOMEN. 1S3 transmission of a predisposition to the disease by in- heritance. " But," says Legoyt, " ought we not rather to at- tribute this difference to the greater or less severity of the disease itself, depending upon the difference in causes which induce insanity in the two sexes ? " * I allow the validity of the explanation by which the apparent disparity is done away, calling attention only to the admission that insanity in the two sexes may be owing to a constantly frequent difference in cause. Thus far, it has been shown that the discharges of women from hospitals, as recovered, is about equal to that of men. Let it not be supposed, however, that this is necessarily a proof that, ist, these recoveries are always cures ; 2d, that they comprise all the women who might be cured ; or, 3d, that they are evidence that all justifiable resources of medical treat- ment have been put in requisition. I propose, on the contrary, by pursuing the investi- gation a little further, to show the opposite. I. Are these recoveries always cures? It is a deli- cate question that I am now approaching ; but I rely upon the good nature of those interested in the matter who are my personal friends, and upon the fairness of all others, that they take no offence where none is intended. * American Journal of Insanity, April, i86i,p. 424. 184 REFLEX INSANITY In view of the coincidence already shown to exist, as regards the relative recoveries of the two sexes in asylums, at home and abroad, I may be jDermitted to seek evidence from foreign sources, inasmuch as mi- nute data have not yet been afforded to any extent from within our own asylums. An identity of result may of course be supposed to have been occasioned by similarity of cause. At some foreign establishments, nearly one third of all the patients treated are set down as cures, while in others only three or four per cent, of the recoveries are claimed as the result of treatment.* As this state- ment is given from Legoyt's statistics, by his transla- tor, the well-known physician to the Long Island Asylum at Sanford Hall, without objection or other comment, the fact is probably not materially different from what may be supposed to obtain in this country also.f No exception seems to have been taken to the statement by any other of our writers on insanity during the nearly four years (1865) since these statis- tics were reproduced by Dr. Barstow. The difference, to which I have referred, is sup- posed to be due partly to accidental circumstances, appearing and disappearing at different asylums at difierent periods of time, partly to the diversity of curative measures or of the hygienic conditions by * Deductions from the Statistics of the Establishments for the Insane it France, for the twelve years from 1842 to 1853 inclusive, t American Journal of insanity, April, 1861, p. 433. IN WOMEN. 185 which patients are surrounded, and partly to the longer or shorter period of residence at the asylum which each physician may order as requisite for his patient. " This may be done on the part of the physician as a re- sult of enlightened experience and observation, or in view sometimes of the material interests of the institution of which he has the charge. We may suppose, for example, that where the number of beds is found inadequate to the wants of the service, and where maintenance of a very large number of patients is at the public expense, their discharge is more easily authorized at the first well-marked symptoms of returning health, than where such maintenance is a source of income to the establishment." * It is allowed, then, by alienists of acknowledged authority, that these so-called recoveries are not aU ways cures. Are they generally so.'' Before enter- ing upon this question, evidence may be interesting as to what has been supposed the curability of the insane, positive and comparative, as to sex. In the report of the Massachusetts Commissioners on Lunacy for 1854-55, which is a model of statis- tical research, it is stated that there were of insane men, native and foreign, in Massachusetts, 1259 ; and of insane women, 1373. Of the men, 181 were con- sidered curable, and 1005 incurable ; leaving 73 un- accounted for. Of the women, 225 were considered curable, and 999 incurable ; leaving 149 unaccounted • American Journal of Insanity, April, 1861, p. 423. l86 REFLEX INSANITY for.* Or, in other words, 14 per cent, of the men were considered curable, against the 44 per cent, dis- charged as recovered from the Worcester Hospital ; and 16 per cent, of the women, against 45 per cent. These facts are the more interesting, as the writer of that report was also a Trustee of the State Hospital at Worcester, whose statistics have therefore undoubted- ly passed under his own careful scrutiny. It may be urged that this is hardly a fair basis for comparisons, as Dr. Jarvis's estimates were of the whole insane in Massachusetts, whether at hospitals or at home. Fortunately, he has provided us with other and more pertinent elements of computation. At the time referred to, 1854-55, there were in tlie Massachusetts hospitals for the insane, 522 men and 619 women. Of the men, 85, or 16 per cent., were considered curable; and of the women, 109, or 17 per cent. ; the ratios being almost identically the same.f Is it proper, then, to compare these two classes of statistics — the proportion of discharges as recovered, with the whole number of admissions ; and the considered curable, with the whole number at the hospitals? In view of their apparently con- stant character, I think it should be allowed. It may be urged that the number of incurable insane perma- nently resident at our hospitals invalidates any calcu- * Report on Insanity and Idiocy in Massachusetts, 1855. House Doc Na 144, p. 78. tibid. IN WOMEN. 187 lation from which they are not eliminated ; but, on the other hand, it may be judged, from the constant character of the statistics I have already given, that this number is also constant ; and, besides, who has ever given us a standard by which to judge, or by which he has judged, of the incurability of insane women ? From the evidence given, it would appear that while some 44 per cent, of the women entering our hospitals are annually discharged as recovered, but 16 per cent, of the women at these hospitals were considered by the competent authority whom I have quoted, as at that time subjects of probable cure. It is possible, however, that Dr. Jarvis intended the word curability as synonymous with capability of recovery. What is this capability of recovery of in- sane women ? In women, as in men, it has been seen that of all admitted to asylums, nearly one half are discharged well or much improved. A very marked difference, however, will be found to exist between the sexes, if we compare the age, not of the patients, but of their disease. At the French asylums, it has been observed that for the first six months of asylum treatment, the re- coveries of males exceed those of females, while for 180 REFLEX INSANITY the next six months, on the contrary, the proportion is much gieater for females than for males.* Dr. Tuke has given, from the statistics of the York Re- treat, a table that throws much light upon this sub- ject. Like one of those that I have already present- ed, it is computed from a period of sixty-one years.f Proportion of Recoveries. Duration of disorder when admitted, Men. Women. First attack, and within three months, . . 72.97 7323 " from three to twelve months, . 43.07 44.20 Not first attack, and within twelve months, 59-44 67 01 First or not, and more than twelve months, 13.29 22.59 From the above, it appears that in the first of the classes named, the excess of recoveries in women was .26 per cent. ; in the second class, 1.13 per cent. ; in the third class, 7'57 P^^ cent. ; and in the fourtli class, 9.30 per cent. From sheets of the First Annual Report of the Massachusetts Board of State Charities, that were kindly afforded me, in advance of publication, by the Secretary, F. B. Sanborn, Esq., I was enabled to establish a computation to somewhat the same effect, namely, that while in acute and sudden, or explcsive attacks of insanity, the percentages of recoveries in the sexes are at present nearly identical, in chronic cases there is quite a balance in favor of the women. Thus, at the Worcester Hospital, during the thirt};- two years of its existence, there have been — • Legoyt, loc cit., p. 426. t Loc. cit., p. a6i. IN WOMEN. 189 Discharged recovered. Percentage to Admissions. Standing of Disease. Males. Females. Males. Females. I year or less, . . 1242 1372 .55 .54 I to 2 years, numbers not corresponding with each other, as reported.* 2 to 5 years. 112 124 .22 .24 5 to 10 (( . . 42 53 •15 .20 10 to 15 (( 12 20 .8 •13 15 to 20 (( 9 9 .13 .21 20 to 25 (( 7 6 .14 .18 Beyond the limit last named, recoveries practically cease. It appears, then, that in the first of these pe- riods the proportions of recovery between the two sexes was almost identical ; in the second and third, there was an excess of 2 per cent, in favor of the women ; in the fourth, of 5 per cent. ; in the fifth, of 5 per cent. ; in the sixth, of 8 per cent. ; and in the last, of 4 per cent. It is very much to be regretted that the tables, cal- culated in the Report of the Board of State Charities, which I have just quoted, drawn from the statistics of the Taunton Hospital, do not contain a statement of the relative numbers of the two sexes discharged as recovered, and of the relative numbers of admissions in the several periods stated, as I should thus have been able to have compared the statistics of the two hospitals more closely, and then, by combining them, * First Annual Report of the Massachusetts Board of State Charities, p. io6. In the printed tables from which I have deduced these computations, there ia given as discharged, recovered, not recovered, or dead, of the class referred to above, a total of 458 oatients, male and female, out of only 227 admissions. 190 REFLEX INSANITY have procured a much larger, and therefore much more reliable, basis.* Again, the relative mortality of the two sexes at asylums is very different, or, as it has been expressed by the director of an asylum, " the dangers and dis- comforts attending a residence in an insane asylum have a much less effect upon females than upon males." Thus, the smallest proportion of male deaths, reported at the French hospitals, during the twelve years whose statistics we have examined, was 15 per cent, while of females the minimum mortality was but 12 per cent.f The average mortality during the whole of this pe- riod was in males, 54 per cent., and in females, 45 per cent. ; the whole number of deaths being over 32,000, of which 17,390 were males, and 14,709 were * With reference to this discrepancy, to which I have above adverted, Mr. Sanborn writes me as follows: "The number discharged recovered, after an insanity of from one to two years, would naturally be greater than the number admitted with insanity of the same duration ; since of those admitted with in- sanity of less than one year's duration, a great many are not discharged until their malady has continued beyond a year. " With regard to the want of uniformity in the tables referred to, you must remember that I have not attempted to go beyond the tables given by each super- intendent. That would involve an amount of labor which you can, doubtless, appreciate, but which it has not been in the power of this department hitherto to perform. It is to be regretted that the superintendents do not agree upon a form of statistical record which will admit of perfect comparisons." t American Journal of Insanity, April, 1861, p. 433. Dr. Barstow copies Le- goyt's error of considering that these figures show an advantage for the women of 39 per cent. I have, however, detected the source of this fallacy in the punc- tuating of the decimals. Instead of .39, the calculation should have showed .039, or between 3 and 4 per cent., which corresponds with the percentage I have given above. This decimal would, it is true, show an excess of 39 in every thou' sand, but not in every hundred. IN WOMEN. 191 females. We have here an average deficit in favor of the females, of 9 per cent. " How is this diversity to be explained ? May it not be that woman, whose occupations are essentially sedentary, and whose habits more quiet, can accom- modate herself better than man to the uniform system and routine of an asylum ? " " This supposition," continues the thoughtful writer from whom I have derived many of the figures upon which I have reasoned, " is to a certain extent justi- fied by the small number of women who die during the first months of their admission." Is it not more reasonable, on the other hand, in view of correlative evidence, to attribute these differ- ences to a cause inherent in the fact of sex itself ? These differences in mortality, it may, moreover, be shown, depend not merely upon varying material and economical appliances for treatment, and the varying grades of society from which patients are furnished ; but they are constant. To prove this, let us compare several well-known special hospitals for either sex. At the Bicetre, which is exclusively for men, the mortality during the nine years from 1844 to 1852 was 263 per 1000. At the St. Lazare, which is also only for men, it was during the same period 303 per 1000 ; while at the Salpetridre, which is exclusively for women, the mortality during the same period was only 177 per 1000. 192 REFLEX INSANITY At the Worcester Asylum, during its thirty-two years, there were admitted 3503 males and 3601 fe- males, and died 426 males and 419 females ; in each instance about 11 per cent, of the total admissions. From this we should at first sight surmise that the mortality of the insane was with us very much lower than it is abroad, did we not compare also the relative proportion of supposed recoveries in the two locali- ties. If, as we have proved, these proportions do not materially vary, we have reason to suppose, if the history of our cases were carefully followed, that their mortality would not materially vary also. It is in questions like these, and more especiall}' in those per- taining to the causation of insanity, as I may show at another time, that statistics become so unreliable. In simple inquiries like those at the commencement of this discussion, a comparison of alleged recoveries with the number of alleged admissions, for instance, there is less opportunity for error, though even here, as will soon be seen, there is abundant cause for doubt. The more complicated the question becomes, the more unreliable the result from statistics. As these have been called for, however, I desire that they should not be withheld. In this connection, I may be pardoned for present- ing some very pertinent remarks upon the subject from an authority whose loss is yet fresh to us in Massachusetts. IN WOMEN. 193 At the tenth annual meethig of the Association of Medical Superintendents of American Institutions for tlie Insane, held at Boston, in May, 1S55, Dr. Bell observed that — " He had seen no reason to change the views urged by him so many years ago in reference to the worthlessness and inexpediency of attempting to present the facts of our hos- pitals for the insane in a numerical form. For many years he had protested against it, both as producing unjust infer- ences as to different institutions, and untrue expectations in the public mind. He had labored to effect a change in this matter, and, he believed, not without success. In fact, he had rendered himself somewhat notorious, at one time, he feared, by his annual diatribe against the existing system of reporting. When visiting the most excellent institution at York, in England, ' Art thou the Luther V. Bell who has written so severely about the statistics of the insane.'" was the salr.tation which preceded every attention and kindness rhich the distinguished host could gife his visitor. The lifficulties he feared were in the very nature of the sub- lect. One would think that the fact of a patient being dead, for instance, was as specific, unconfoundable a basis for a statistical return as could be conceived of; yet he would en- gage to make his returns of dead vary fifty per cent., without one deviation from truth. A simple suggestion to friends, that it might be more agreeable to them that the last days of a failing patient should be spent in the bosom of his fam- ily, would very frequently decide whether a case of death should be on the annual return." * At a subsequent meeting of the Association, Dr. Tyler, Dr. Bell's equally eminent successor at the McLean Asylum, took occasion to state that, though statistics might not lie, " still we know that the mor- * American Journal of Insanity, xii. p. 90 13 194 REFLEX INSANITY tals that make figures sometimes do." * Without in any way implying, or, indeed, believing, that this view of Dr. Tyler's is especially applicable to the point we are now considering, for the statistics that I have given were undoubtedly published in perfectly good faith by their collators, I may yet call attention to the peculiar force, in the present connection, of the last remark of Dr. Bell. Similar comments are as applicable to the reports afforded of death details. •' I do not see," says Dr. Ray, " how we can put forth as facts, of any statisti- cal importance, the apparent causes of death. It is the custom to publish in the reports of the institution the cause of death. Now, everybody knows that in many cases this must be a matter of guess-work. I should have far less confidence in the guess of any man in regard to the cause of death in an insane per- son, than in one not insane." f To return to the discussion. We may, then, justly consider, from the evidence that has been afforded, that " in those establishments which are devoted ex- clusively to females, the mortality, other things being equal, should be found less than in t\ ose devoted ex- clusively to males, the probabilities of death being, as we have already seen, greater among the latter." J This fact is corroborated by Dr. Lockhart Robert- * American Journal of Insanity, July, 1862, p. 44. t Ibid, July, 1862, voL xii. p. 38. t Legoyt, loc dt, p. 437. IN WOMEN. 195 son, superintendent of the Sussex Asylum, who says that " the mean annual mortality of the male sex among the insane exceeds that of the female by about 35 per cent., while among the general population the male mortality only exceeds the female by 8 per cent." * This last excess, it will be perceived, corre- sponds almost exactly with the normal rate of dispro- portion in the sexes, which, estimated by Qi'^telet as averaging 106 male births alive to 100 females in Europe, has been shown by Dr. Emerson, of Phila- delphia, in his excellent paper, formerly presented to this Association, to vary in this country from 107 to no males to 100 females.f There is also a difference in the progressive mor- tality of the two sexes, according to age. Thus, from a tabular exposition of the ages at which 3303 patients deceased in the French asylums, of whom 1755 were males and 1548 females, it appears that of females at insane hospitals dying under fourteen years, there are 92 per cent, as many as men. From 14 to 20 years, " 20 to 25 " 25 to 30 " 30 to 35 " 35 to 40 " 40 to 50 " 50 to 60 57 pe r c 63 73 64 65 60 90 * Notes on the Prognosis in Mental Disease, Asylum Journal of Mental Sd« ence, January, 1859, p. 287. t Transactions of American Medical Association, vol. iii. p. 93. 196 REFLEX INSANITY These differences are attributed by Legoyt to " the greater vitality " of the female sex. With reference to the same point, evidence concerning the relative vitality of patients considered incurable is not irrel- evant. The following table is given by Dr. Jarv'is as the probable duration of life in irrecoverably insane per- sons. It is based upon a calculation of the expecta- tion of life in the insane, made by the actuary of an English Life Assurance Company : — * Age. Males. Females. 20 21.31 y ears to live. 28.66 years to live. 30 20.64 26.33 40 17-65 21.53 50 13-53 17.67 60 1 1. 91 12.51 " 70 9-15 8.87 Or, in other words, the insane woman at twenty, supposed incurable, has 1.31 per cent, as many years to live as the insane man. At 30, 1.23 per cent. "40, 1.07 " "50, 1-30 " "60, 1.05 " "70, 88 From these facts it appears, and, as will have been seen, is acknowledged by competent authority, that — I. The relative mortality of insane women is less than of insane men. • Appendix to Report to Leg. of Mass., 1855, p. 19a. IN WOMEN. 197 2. Their expectation of life, even when supposed incurable, is greater ; and 3. Their percentage of recoveries, even when the mental disturbance has become chronic, is also in excess. But how does this evidence affect the question as to whether the recoveries of women at asylums are cures ? In several ways. In both sexes, many patients are sooner or later re- admitted to the hospital, their disease proving to have been merely palliated, not cured. The remedial discipline to which the two sexes are subjected at asylums is almost identical. It is chiefly that which is called moral ; the medical treatment in almost every instance being of a strictly general character. We are, therefore, compelled to one of two alternatives, not that more women recover at asylums than men, for this is beyond what has been claimed, or what statistics prove, but that either a certain larger proportion of insane women do not die at hospitals than men, and do recover from chronic insanity under the same general treatment, which is shown by statistical evidence, and which must arise from some primal difference in causation ; or else that the character of their insanity is different, and this also implies a difference of cause, not of moral and excit- ing causes merely, for these on the great scale and in 198 REFLEX INSANITY different countries will be found to be nearly the same, the excesses in the one instance counterbalancing all deficiencies in another, but of an intrinsic and physical character, probably sexual. Now it will be found that those writers who deny the existence of a different physical causation of in- sanity in the two sexes, are no better prepared to accept the other horn of this dilemma, for it will be found that a different result from the same general treatment implies a difference in disease ; and a dif- ference in disease arising from the excitement of simi- lar stimuli, implies a difference in predisposition, and therefore, in ultimate causation. The only escape from these conclusions, is by de- nying my premises as to the character and identity of the medical treatment resorted to for the two sexes. Upon this point, however, though I have already furnished sufficient evidence, I will add still more. Again, most writers on insanity acknowledge a frequent influence of the catamenia and of the cata- menial molimen in reference to the exacerbation of the mental disturbance ; this, to a certain extent, put- ting aside the question as to whether or no the in- sanity in any of these cases springs from a uterine origin. To the extent now stated, few will deny the fact, for an immense body of proof has been inci- dentally published in psychological text books, mono- graphs, and periodicals, and can be readily adduced, IN WOMEN. 199 In many of these cases, the menses when absent have accidentally appeared without any direct aid from medical treatment, and the patient has immediately and in consequence recovered. Such cases are not spoken of as uncommon. They undoubtedly fre- quently occur. Many instances are also on record, where insanity has suddenly ceased on the woman's passing the grand climacteric, at the permanent and final cessation of the catamenia. It could hardly be alleged that these were cases of cure. They also, there is good reason to believe, are not uncommon. It will be seen that I here purposely avoid referring to other than published and acknowledged evidence furnished by the directors of asylums, for almost every work as yet issued upon the subject of insanity has been from such a source. There is one other point to which, in this connec- tion, I may be permitted to refer, and that, the com- parative infrequency in women of one of the most com- mon and most fatal of the forms of insanity. I refer to the so-called paralysis of the insane, the paralysie generale of the usual and artificial classification. This disease, one of the few mental disorders that is attended by organic lesion of the brain, or rather of the medulla oblongata and spinal cord, is com- paratively unknown in women. This fact has been acknowledged by Dr. Robertson, of the Sussex Asj^- 200 REFLEX INSANITY lum,* by Drs. Workman and Choatef in this country, and by many other competent authorities. " We know positively," says Morel, " that the number of the (general) paralytic insane is infinitely greater among men than among women." J In a table furnished by the author now quoted, it appears that of Soo insane women at the asylum of St. Yon, there were 25 afflicted with this disease, or 3 per cent. ; while at the asylum of Quatre Mares, devoted exclusively to males, there were of 500 in- mates no less than 100, or 20 per cent., affected with general paralysis. It is undoubtedly this disease that was referred to by Esquirol, when he says, — " Paralysis is more frequent among insane men than women. Eighteen years ago, when charged with the service of the division of the insane at the Bicctre, during the ab- sence of M. Pariset, who was sent to Cadiz to study the yellow fever which was prevailing there, I was struck, in comparing the number of men, insane and paralytic, at the Bict'tre, and the number of paralytic women at the Sal- petriere. The same observation may be made in every establishment into which both sexes are admitted. It has not escaped the notice of Dr. Foville. physician-in-chief at St. Yon. According to this physician, they amount to one eleventh at the institution over which he presides. Among 334 insane persons who were examined by him, 31 were paralytic, to wit, 22 men and 9 women. At Charenton, the proportion of paralytics is still more considerable. They constitute one sixth of the whole number of admissions. In • Asylum Journal of Mental Science, January, 1859, p. 276. t American Journal of Insanity, i860. t Traite des Maladies Mentales, p. 813. IN WOMEN. 20I truth, of 619 insane persons who were admitted during the three years, I826, 1827, and 1828. 109 were paralytics. But the proportion of men is enormous compared with that of women. Of 366 insane men admitted into the house, 95 were paralytics; while of 153 women, 14 only w^ere affected with paralysis. This complication is most frequently ob- served among that class of insane persons who have yielded to venereal excesses, or have been addicted to the use of alcoholic drinks; among those, also, who have made an in- ordinate use of mercurj', as well as those who, exercising the brain too vigorously in mental strife, have at the same time abandoned themselves to errors of regimen. Do not these circumstances explain sufficiently well how it happens that there are more men insane and paralytic than women.?"* The few cases of women who are affected by gen- eral paralysis are chiefly prostitutes,! so that in the ordinary classes of society, it is among women prac- tically absent. The fact to which I have referred is one that is now generally acknowledged. In a dis- cussion upon the subject at Philadelphia, in i860, it was fully admitted by Drs. Workman of Toronto, Bancroft of the New Hampshire State Asylum, Athon of that of Indiana, and Harlow of that of Maine. J The same comparative immunity for women has also been noted in the form of insanity now known as congestive mania, and so thoroughly described by my colleague, Dr. Worthington, of the Friends' Asylum at Frankford, Pa.§ * Esquirol, loc dt, p. 438. t Morel : Traites d< s Maladies Mentales, p. 828. t American Journal of Insanity, July, i860, p. 65. § Ibid, p. 64. — Oaober, 1850, p. X14. 202 REFLEX INSANITY We may, from the evidence that has now been offered, foirly conclude, that (i) while some at least of the women discharged from asylums as recovered, are not in reality cases of cure, (2) there are others not reported as having recovered, who yet ought, if we may believe the evidence of statistics, to have done so. If the mortality in insane women is less than in men, and if the most frequent of the incurable mental diseases in men is absent in women, a larger per- centage of them should recover than of men, unless they have some corresponding fatal disease which is absent in men. The existence however of such a dis- ease has never been acknowledged. If the facts above proved are admitted, it would seem (3) that all justifiable resources of medical treat- ment can scarcely have been put in requisition at asylums. I have alluded, in connection with the last point now referred to, to the admissions of gentlemen having asylums in charge. In a former communication upon this subject, I stated why it was that, as asylums are now^ constituted, the whole duty of a physician by his patient, if a woman, could not be performed.* The evidence was such as was thought conclusive by the American Medical Association, at its late meeting in New York. That there might be no room for cavil, I fortified my arguments by a frank and forcible letter * Boston Medical and Sui^cal Journal, October, 1864, p. 311. IN WOMEN. 203 from Dr. Butler, of the Hartford Retreat.* The force of this letter was subsequently sought to be weak- ened, by the assertion '^that it was only conclusive of the lack of a disposition on the part of its writer to make use of all the means of treatment considered proper to aid in restoring a patient." f That the position of Dr. Butler, as described by himself, is a very common one, I have good reason to believe.; and as it arises from causes over which superintendents have had no control, I have not been so unjust as to throw any blame upon them, as their own official brother seems to have done in the communication to which I have referred. The same charge of incompetence, implied if not directly made, against these gentlemen, has come to me from another quarter of their own precincts. Under date of nth January, 1865, Dr. Gray, of the New York State Lunatic Asylum at Utica, writes me as follows : — " Of the applicability of some of your strictures to some asylum superintendents, J it is not for me to judge. I, how- ever, contend that they do not apply to all, any more than would a sweeping charge of ignorance against the medical faculty of Harvard, on account of the incapacity of some of your professional brethren." § * Boston Medical #nd Surgical Journal, October, 1864, p. 214. t Ibid., November, 1864, p. 290. t It will have been noticed by those familiar with my former papers, that my strictures were upon no asylum superintendents, but upon the circumstance! which prevent their performing their whole duty by their patients. § Had Dr. Gray the gift of prophecy? might now, in 1870^ well be asked. 204 REFLEX INSANITY I can only say, in reference to this point, that the only instances in which evidence has been furnished me that what is generally styled special treatment for the diseases peculiar to women, such as is now con- stantly resorted to, and generally considered proper and necessary in civil practice, has ever been em- ployed at any of our insane asylums, save at the Butler Hospital, at Providence, and at the McLean Asylum, in consultation, have been at the Friends' Hospital, at Frankford, Pa., and at the Michigan State Asylum, at Kalamazoo, respectively under the charge of my colleagues, Drs. Worthington and Van Dcusen. I may in this matter do great injustice to the zeal of those eminent in this specialty, and to their moral courage, for this is needed in instituting what I have proved to be a radical change in treatment, but, as I have made minute inquiries, and have now heard from many of the gentlemen referred to, it is hardly possible. In the case of the Utica Asylum, from which one of the implications alluded to has come, I can only say that this is one of quite a number of asylums that I have had opportunity, officially, carefully to exam- ine ; that my visit to it was in September, 1863 ; that in the absence of Dr. Gray, the superintendent, I was most courteously received by his very intelligent as- sistant physicians, who freely and fully informed me concerning all points that I raised, which were chiefly IN WOMEN. 205 with reference to the medical treatment of the female patients ; that from what I was told, I have no reason to suppose that special treatment was thought neces- sary at that asylum for the so common special diseases of women, whether occurring as cause of the insan- ity, or its concomitant ; and that I had very good rea- son, on the contrary, to believe that such was seldom or never resorted to at the present time.* If, how- ever, 1 was mistaken in my impression, — and I shall be most happy to learn that I was in error, — then it will follow that Dr. Gray himself, and all gentlemen who are sufficiently enlightened to engage in the in- vestigations for which I am contending, and which, from the language I have quoted, he would seem to approve, it will follow that they all, equally with my- self, fall under the ban laid in the Boston Medical and Surgical Journal for 5th January, 1865, upon every one of us who would cure in insane women tlieir so- called " imaginary " physical disease ; f as supposed to be present, not by them, but by ourselves. I have said that my remarks do not apply to our own asylums alone, nor have I desired that they * Yet in the report of the New York State Asylum for 1852, by Dr. Gray, it appears that in nearly one fourth of all the cases of insanity reported, the dis- turbance of the generative organs was so marked as to be regarded as 71 primary cause of the mental derangement. (Amer. Journal of Insanity, xii. p. 306.) In the report of the same institution ten years later, for 1862, only a tenth of the women are thus reported, unless the forty-three cases stated as caused by pre- vious ill health are to be considered of this character, in wliich event, tlia proportion would rise to nearly one hal£ t Loc. cit., pp. 453 and 453. 2o6 REFLEX INSANITY should seem to do so. The similarity as to percent- ages of recoveries, &c., between our own and for- eign asylums, goes to prove what I have attempted to show by other evidence, that nowhere, at home or abroad, has the difference of causation which, I be- lieve, exists in many instances between the two sexes as to mental disease, been generally appreciated or acted upon. The view to which I refer explains the problems elicited by the statistics I have now pre- sented ; the}', on the other hand, are wholly inexpli- cable, save by this simple key. I may be told over and over again that my view is an old one. If appre- ciated in all its bearings, why then has it not been accepted ? That it has been so in the present, or in former times, I can find no evidence. The disturbance which my deductions seem to have caused in certain minds, would seem to imply, as I have indeed been told, that there was a chance that these inquiries, if pushed, would result in injuiy to the present unimpeded system of hospital manage- ment. Nothing, however, as I have already asserted in almost every paper I have written upon the sub- ject, is further from my own intention. The re- searches have been undertaken simply and solely for a scientific purpose, and the papers I have now pre- sented may serve as earnest that the investigations will be pushed to their legitimate result, it is almost unnecessary to state, without either fear or favor. IN WOMEN. 207 It was lately publicly intimated, that for one of the measures I have advocated, merely one item in the system of public and private treatment that is re- quired for insane women, the establishment of an Advisory Medical Board at asylums,* there can be found no one of any note among superintendents to approve. I will not weary my readers by carrying my evidence from statistics to any greater extent than I have already done, though I am well prepared even upon this point. I will, therefore, simply append the following letter, which was unsolicited, from Dr. Isaac Ray : — "Butler Hospital, Nov. 26, 1864. " My dear Sir : I have read your pamphlet with much interest, especially your remarks on the employment of Boards of Consulting Physicians in asylums for the insane. Your views strike me to be eminently just, and I am glad you have called public attention to the subject. The case, in fact, hardly admits of argument. What medical man now needs be persuaded that in a hospital of at least one hundred patients, for any disease, there must be occasions, more or less, when the single doctor in charge would or should gladly consult another physician.? And if so, it is * Trans. Amer. Med. Association, 1864. With regard to the suggestion now referred to, I would frankly state that my colleagues, Drs. Van Deusen and Worthington, like some others of the fraternity who have erroneously seen in the advisory board an end rather than a means, are disinclined to indorse it ; basing their oLjections, so far as communicated to me, upon the trite ground th < any assistance would be rather an interference with the superintendents. The former of the gentlemen, however, admits that "the subject of the appointment of a consisting physician and surgeon, with special reference to the examination and surgical treatment of female patients requiring it, is new" to him; and it is allowed by the latter that " there might be cases, here and there, that would (thus) be helped." 2o8 REFLEX INSANITY far better that he should resort to an established Board, made expressly for his benefit, ready to come gratuitously, than to some eminent man who expects and is justly entitled to a liberal compensation. To such a Board as I refer, the honor of the position would always be considered sufficient compensation for so light a duty. *' Your paper seems to be but part of a larger one, which, if published, I have not been so fortunate as to meet. Un- questionably, abnormal conditions of the sexual organs have often a very large influence in the development of insanity in women. I presume, however, my observations would hardly warrant me in attributing so much to them as, I sup- pose, from one or two expressions, you do. *' I admit that we asylum physicians cannot, necessarily, obtain that accuracy of diagnosis which is comparatively easy to other men; but the existence of sexual disorder of some kind need not be overlooked by any one who looks at all, provided it is sufficiently grave to affect the brain.* Not that I consider these affections as of little consequence, and unworthy, when present, of being accurately understood and properly treated, for I am well aware that mental dis- ease may sometimes be continued indefinitely by the persist- ent influence of sexual organic disorder. " We had here this summer a death in the earlier stage of mania, where the disease seemed to have been mainly excited by some venereal excrescences in the vagina, and we have now in the house a lady whose disease was unquestion- ably produced, as it is now kept up. by an ' irritable uterus.' "I repeat that I am glad you have called attention to this point, because, in the treatment of insanity, we are too apt to overlook or undervalue all collateral, subordinate condi- tions. "Yours, very respectfully, " I. RAY. "Dr. H.R. Storer." • Dr. Ray seems here hardly to appreciate the nice discriminations, so often productive of success in treatment, now made in the diagnosis, direct and differ* ential, of pelvic disease. IN WOMEN. 209 The following is the Report above alluded to : — "In late communications to the American Academy of Arts and Sciences, and to the Suffolk District Medical So- ciety of Massachusetts,* I have stated certain fundamental propositions or laws, whose acceptance is essential to any rational explanation or treatment of the mental diseases of women. These propositions are as follows : — "I. That in women mental disease is often, perhaps gen- erally, dependent upon functional or organic disturbance of the reproductive system. "II. That in women the access or exacerbation of mental disease is usually coincident with the catamenial establish- ment, its periodical access, or final cessation. "III. That the rational and successful treatment of men- tal disease in women must be based upon the preceding the- ories, which I claim are established, — " I. By many analogies, physiological and pathological, in the cerebral manifestations of the human female and of the lower mammals; "2. By clinical observation ; and "3. By the results of autopsies of the insane, both in private practice and, where made with equal impartiality, in insane asjdums. " I have worded the last expression with especial reference to the facts, that in autopsies by psychological specialists diseases of the brain are naturally those first sought for; and that in autopsies of insane women, as compared with those of insane men, disease of the brain, as a primary le- sion, very rarely exists. These facts are acknowledged; for further remarks upon them I must refer to the preliminary paper to which I have already alluded. " From the above propositions, corroborated, I believe, by the experience of every unbiassed observer, we advance to three plain and practical questions, which are to open up * Boston Medical and Surgical Journal, April, 1864, p. 189. 2IO REFLEX INSANITY a new, broad, and very fruitful field of gynaecological work These are, — " I. To what extent can the insanity of women be medi- cally or surgically treated ? " 2. Is such treatment at present generally effected, or even attempted, in insane hospitals? and, — " 3. How can it there be accomplished? " I am aware that I have broached a delicate topic. The comparison, however, of doubtfully insane, of almost insane, and of decidedly insane women, in all their range, from ag- gravated hysteria to actual madness, has so long been my daily occupation that I am enabled to express myself plainly upon this subject. It is one that has been hitherto neglect- ed, for the sole reason that its proper side of approach — that from a gynaecological point — happens, from circumstances beyond their control, almost always to have been closed to superintendents and others charged with the management of the insane- " The first question that I have now proposed, To what extent can the insanity of women be medically and surgi- cally treated? has as yet hardly been propounded in insane asylums at all, although its solution in active, everyday practice is, within certain limits, of common enough occur- rence. I have purposely limited my statement of the extent to which this treatment has as yet been carried in private practice. Instances in point, however, — the ordinary forms of the so-called puerperal mania, and of that other type of insanity to which in its different manifestations I would at- tach the equally legitimate title of catamenial mania, — are familiar to every observer. In these and in others of the host of deviations from mental sanity in women, there is some reflex transferrence of irritative action, the source of which, if searched for, is almost always to be discovered. It is just as unscientific here, and generally as futile, to treat merely or primarily the mental disturbance, which is usually a symptom only or a consequence, as it has been to ampu- tate an hysterical knee, to attempt the Caesarean section or to cut for ovariotomy in cases of the so-called spurious preg- IN WOMEN. 211 nancy, or, as is still constantly done, even at the present day, to stimulate or blister, or apply the moxa or actual cautery to spines irritated sympathetically and through reflex action by an abraded, displaced, or otherwise disturbed womb. The necessity of removing a cause, to prevent or to cure its eftect, is as decided in mental pathology as in physical. We recog- nize it everywhere else ; we must recognize it in the treat- ment of insane women, no matter whether, from quiet and inoffensive creatures, or chaste and pure, they have become habitually thievish, profane, or obscene, despondent or self- indulgent, shrewish or fatuous, or, as the parturient cat or sow, they have destroyed their offspring, or, in other cases, have attempted to destroy themselves. " In many of these instances, the relation of cause to effect, if otherwise doubtful, is at once shown by the result of the treatment. I might relate many cases in illustration of this fact from my own experience, but shall confine myself to a single one. " Case. During the past year I have had charge of a young lady afflicted with that not uncommon disease, me- chanical dysmenorrhoea. This patient, unmarried, and for- merly a school-teacher, was sent to me by a physician, and had previously consulted several others. She confessed to me that while she never had had sexual intercourse, she had experienced, from a period long preceding her first seeking medical aid, excessive sexual desire, amounting, indeed, to what is technically termed nymphomania — a symptom merely, as are most of the mental disturbances of women. The attacks of this were very clearly coincident with the menstrual period, and so extreme that the patient could with difficulty restrain herself from soliciting the approach of the other sex. She could not restrain herself from frequent and excessive masturbation. There was little irritability about the clitoris or other external organs, the patient herself be- ing inclined to recognize a deeper and inner origin for her suffering. The morbid desires, and the disgusting propen- sity thence arising, ceased together with the dysmenorrhceal pain, upon freely incising the cervix uteri, and dilating its 212 REFLEX INSANITY canal. They have not since returned, save in one singl? instance, when an acute attack of the erotic desire, plainly* resulting from indulgence in so-called pepper tea, was at once allayed by the application of potassa fusa to the cervix. Now, were not this treatment based, as it is, upon a broad and general physiological principle, its effect as a defence, in similar cases, to female chastity, threatened and undermined by sources of irritation within the patient herself, would be sufficient to entitle it to our respectful consideration. The above case must not be thought more pertinent than others of a similar reflex character, where, however, there is no erotic desire or other direct symptom of genital irritation. However masked, they all instance a single law. '* It would be difficult to state precisely to what extent ap- propriate medical and surgical treatment can be effectual in the cure of female insanity, the subject as presented in this light being comparatively new to the profession. There can be little doubt, however, that in so far as the mental disturb- ance retains its original reflex character, and has not merged into organic cerebral change, which, as I have said, is com- paratively rare in women, to this extent and so long should we have a reasonable hope of success, nearly as great, per- haps, as in relieving the other reflex disturbances to which the female is confessedly so prone. " As regards the second question I have broached, Is such treatment effected, or even attempted, in insane hospitals? the answer is patent. As hospitals are at present organized, the proper treatment cannot be afforded insane women, for sufficient reason. '"To the general organization of our public asylums, or to its details, so far as they go, I would take no exception. My complaint is, that their most excellent organizations do not go quite far enough to cover the important class of cases we are now considering. They stop just one step short of the mark. I am here speaking from personal observation of the working, theoretical and practical, of many asylums, among the best in this country — and there are in the world none in advance of the American hospitals for the insane; IN WOMEN. 213 SO that in my remarks upon this subject I speak with perfecf confidence. " The reason that mental disease in the female, dependent upon reflex uterine or ovarian irritation, is not generally treated at hospitals for the insane in the same manner, or as successfully, barring only the lessened risk of homicide or of suicide before cure, as in private practice, is in the main the following : — " The whole and sole charge of the patients, medical, moral, and economical, is thrown entirely upon the superin- tendent of the hospital. This is certainly an advantage in everything concerning the government of the establishment, for it prevents all clash of opinion, all evasions of duty. It is excellent in every respect, save alone as concerns the weight and the extent of medical responsibility. I would by no means lessen the superintendent's authority, but, as will be seen, would free him from his present involuntary em- barrassment. '' The superintendent, as at present situated, cannot make such examination of a female patient, or pursue such methods of treatment, as are absolutely required for the relief of many forms of gynaecological disease, upon the existence of which, as I have said, her mental malady not unfrequently depends. He is absolutely prevented from this alike by regard for the patient's welfare, for his own personal reputation, and for that of his hospital. So constantly compelled to see the pa- tient, he appreciates the importance, as regards other details of treatinent, moral, etc., that he should retain her confi- dence and escape her fears ; he recognizes the danger lest an endeavor to arrive at a proper diagnosis of her disease should seem to the disordered mind only an attempt at im- proper and unpardonable liberties with her person, and should she ever entirely recover her reason, be so represent- ed to friends and to the community by her perverted and imperfect memory. These risks, so great in sane patients under temporary aberration from anaesthesia, have been real- ized to the full by Dr. Beale, of Philadelphia, and others; with the insane they are increased. 214 REFLEX INSANITY " In this strait, upon whom is the superintendent to rely? Not upon his assistants, surely — younger men, and often merely pupils, at any rate placed in the same relations as himself to the patient, the hospital, and the outside world. Here is the strange and paradoxical example of a physician pledged by even higher than ordinary motives to the relief of his suffering patients, concerning a large proportion of whoni, however, his hands and his judgment are practically and entirely fettered. He cannot search for the manifesta- tions of disease, nor, were they known to be present, can he relieve them ; and yet we all contend, and strive to persuade the community, that our hospitals for the insane are no longer prisons; that they are not houses for detention, but for cure. The existence of these facts, and the justness of the above reasoning, superintendents have repeatedly ac- knowledged to me with regret, and a hope that the evil may be remedied. "A change is necessary: how can it be accomplished? By appointing to every asylum in the land a board of con- sulting physicians — useful in ordinary cases of insanity, but absolutely indispensable in the instance of insane wo- men. These gentlemen should be selected from practition- ers in the immediate neighborhood of each asylum, due re- gard, of course, being had to their character and to their professional fitness. The position should be an honorary one, and, like that at general hospitals, unattended by pecu- niary emolument; and the superintendent should be left en- tirely to use his own discretion as to calling or not upon the members of his board for advice, just as is allowed to attend- ing physicians or surgeons at general hospitals, the inten- tion being to render consultations and a division of medical responsibility possible, not compulsorj'. Strange as it may seem, there appears to exist but a single asylum in this country to which there is appended a board of medical con- sultation. I refer to that most admirable establishment, the Butler Hospital, at Providence. So far as I have been able to ascertain, — and I have been aided by those most excel- lent authorities in all matters pertaining to the insane, Drs. IN WOMEN. 215 Raj, of Rhode Island, and Edward Jarvis, of Massachusetts, — in no instance, save the one referred to, have boards of medical advice been included amongtheir officers and means of management at our insane hospitals. " The Connecticut Retreat has a Board of Medical Visit- ors, whose position is an anomalous one : as much super- visors of general administration, apparently, as advisory in the treatment of patients, they are, perhaps, in reality, more strictly honorary than either. " There was formerly an Advisory Board attached to the City Lunatic Hospital of New York, at Blackwell's Island, discontinued for no known reason. "The New York Hospital has Consulting Surgeons and Consulting Physicians; but they appear to have nothing to do with the Bloomingdale Asylum, although it is under the same general authority as the hospital. The case is similar to that of the McLean Asylum, which, though under the same trustees, is yet separate from the Massachusetts Gen- eral Hospital. The last has Consulting Physicians and Sur- geons, but they have nothing to do with the insane depart- ment. They may, it is true, have been occasionally consulted by Dr. Bell, and possibly by his successors, in cases of doubt^ ful sickness of a general character, just as other gentlemen, from time to time, have been called upon to give opinion. As matters now remain, such consultations are wholly un- official, and Dr. Ray's establishment, therefore, would seem at present to stand alone, and to furnish, with its skilful ad- visory staff of Drs. Mauran and Miller, an example to be followed. " So far these remarks have been based upon my own per- sonal observation of the needs and advantages of the meas- ure I have proposed. I am able to go farther than this, however, and to give corroborative evidence from superin- tendents themselves. " In a report recently rendered to the Legislature of Massachusetts, the views of the writer as oi^e of the State Commissioners in Insanity were embodied, he fully recog- nizing, however, and admitting the fact that the appointmenl 2l6 REFLEX INSANITY of boards of medical consultation, as a part of the internal management of hospitals, should devolve upon their boards of trustees, and in no way be controlled by the State. The various opinions and recommendations presented in the re- port alluded to were very properly submitted to the Super- intendents of the several State asylums by the Legislative Committee to which it had been referred, and almost without exception they were cordially indorsed. With respect to the propriety of appointing consulting physicians to the hospitals there was not a dissenting voice; Drs. Tyler, of the McLean Asylum, Walker, of that at South Boston, and Choate, of the Taunton Hospital, acknowledging that they had each felt the need of such assistance, and would gladly avail themselves of it were it afforded them, while Dr. Ray, of Providence, who alone could speak from personal experi- ence of its advantages, gave the Committee to understand that he considered his Board as at once comfort, relief, and safeguard. Such would probably be found to be the unani- mous opinion of gentlemen engaged in this most responsible specialty. " I have now presented the subject only in its relations to patient and superintendent, and have endeavored to show the advantages and necessity, alike to both, of the measure proposed. I might well cease here, confident that my re- marks have been sufficiently conclusive. The subject is no less important, however, to the community at large, in its relations to gynaecological practice and obstetric juris- prudence. '* Gynaecological practice, as I have already hinted, covers legitimately the greater number of cases of female insanity, but it is to hospitals for the insane that the profession must necessarily send many of these patients, and it is to hos- pitals for the insane that we must therefore look for the most effectual trial of rational methods of treatment, and from them trust for examples of successful cure. For this success they have already, with the single exception alluded to, every possible adjunct: seclusion of their patients from ex- citing causes ; their absolute control as to diet, habits, and IN WOMEN. 217 whole detail of life; the possibility, so far as skilled attend- ance is concerned, of carrying out any desired plan of treat- ment. Were such indorsed by men experienced in similar methods as applied in every-day practice, the superintendent's responsibilities, doubts, and risks would all be lightened, and the measures indicated be readily enough pursued. Before long there would be a mass of digested observations and medical reports issuing from these very hospitals, wliich would be of immense value to the profession in civil life. " I have referred, and I trust it will not be thought with disrespect, to the tendencies at asylums, in the search for cerebral lesion, to ignore all others. I could relate many instances corroborative of this fact, but it is unnecessary. The very nature of mental disturbance would of itself be sufficient to explain it, did we not have additional reason in the position in which I have shown hospital officers to stand in relation to their cases of insane women. It is evident in the very details of asylum autopsies as compared with those at general hospitals, in the statements of appearances found, and in the silence upon points not supposed essential. I would not imply that there are not most faithful and thorough pathologists among psychologists — a combination, of which Dr. Workman, of Toronto, is by far the most ex- cellent example with whom I am personally acquainted ; nor do I believe there are many superintendents in this country who sympathize with their other Canadian representative, Dr. Douglass, of the Lower Province, whose assertion to me of contemptuous disbelief in the need or advantage of autopsies of the insane, was only additional proof, had such been needed, that his Government Asylum at Beaufort, near Quebec, however fair in outside seeming, is based on an erroneous view of management; that it is conducted for private rather than for public good, and, by comparison with that of Canada West, that it should be abated as an error and a nuisance by Parliament.* This is no digression. * This was in 1864. I am informed (1870) that the suggestion above maia was effectual in producing the necessary change. 2l8 REFLEX INSANITY The topic, both personal and theoretical, is one intimately related to that we have been considering, and I shall discuss it more fully upon another occasion. "When autopsies of insane females shall have become more frequent and moic carefully studied, the importance of the doctrines now urged will become the more apparent. "I have intimated that the appointment of medical ad- visers to insane hospitals would be of advantage to obstetric jurisprudence. " We are all familiar with those difficult cases of supposed or alleged insanity in females that from time to time make their appearance in our courts of justice, on writs of habeas corpus or otherwise, from asylums, puzzling counsel, medi- cal experts, and judge. Such cases are common enough in private practice, and are found generally amenable to treat- ment. There is no reason that they should still be allowed to serve as excitants of public scandal, or to bring discredit upon hospital management, or to subject their officers to suspicion as venal. " There is a vast field above and beyond all this, which many writers have approached, none more boldly than lately Dr. Ray* — important beyond all estimate in its jurispru- dential relations, but which has hardly as yet been entered, certainly not to any extent, from the quarter in which we are now standing. I refer to the legal and moral responsibili- ties of women, whether maniacal or but partially aftected ; a matter of infinite interest, of ipfinite practical importance, I can now but allude to it. It is another proof to us of what may be the results, scientific and effective, from insane asylums when they shall have been made what they may more fully become, hospitals for research, for ratio'nal ex- periment, and for cure. " In accordance with the arguments now submitted, I would offer the following resolutions, which I trust the Association may unanimously see reason, in its wisdom, to adopt and to render effective : — • Treatise on Mental Hygiene ; Report of Butler Hospital for 1864. IN WOMEN. 219 " Resolved, That in the opinion of the American Medical Association it is expedient that there should be attached to every public hospital for the insane, one or more consulting physicians, who may be consulted at the discretion of the superintendent; such measure being alike for the interest of the hospital, its medical officers, and its patients. ^'^ Resolved, That a copy of the above resolution be trans- mitted to the Board of Trustees of each of our public hos- pitals for the insane ; and also to the Secretary of the Association of American Superintendents, with the request that it may be indorsed by that body, and the action pro- posed be urged upon the respective boards with which its members are officially connected."* I have thus, very imperfectly as I am aware, pre- sented a portion of my views as to the causation and treatment of a large proportion of the cases of insan- ity occurring in women. I have furnished evidence, in confirmation of these views, from many of the leading psychological experts of the present day. I have shown that my deductions are such as a priori ought to have resulted, and such as alone can explain admitted facts. I have proved that these views are not generally entertained by the specialty devoted to the insane, or if entertained, are not generally acted upon in practice. I have confined myself in the main to the general question of causation, for the present omitting the discussion of minor but scarcely less important questions and details ; upon all of which I have now a mass of evidence, that I shall hereafter * The above paper having been read before the Section on Obstetrics, and warmly approved by many of its members, the resolutions appended were re« ferred to the Association at large, and were indorsed by a unanimous vote. 220 REFLEX INSANITY most gladly adduce. I have refrained, save in what pertains to pregnancy, from using the testimony of gynaecologists, and of the profession at large, strongly corroborative as this would have been of my every position, preferring to meet the objections that have been made, by answers from a similar source. I have attempted to avoid all resort, or appearance of resort, to any special pleading, though such is apparent enough in these objections ; that, for instance, a gynas- cologist must necessarily be a practitioner of but one idea, and therefore incompetent — the truth being, that without at least one fundamental idea, no man should be deemed fit for the charge of any sick wo- men, whether insane or in their right mind. I have endeavored to deal fairly with gentlemen whose opinions, from a previous bias of perhaps many years' standing, may clash with my own, and have acknowledged my belief that, in most of the quarters of this important sphere, they have left little unaccomplished that was practicable for the good of their patients. I have striven sedulously to avoid ex- pressions or a tone that could possibly create undue offence — though not, I conceive, upon all occasions, myself treated as fairly. With reference to certain of the arguments with which I have been met, I might well have said, as did Blundell in answering the current criticisms upon ovariotomy, for our cases are in many respects very parallel : " These men are IN WOMEN. 221 butting their heads against a stone wall ; and the grimaces they make, on feeling the solidity of the materials, are as amusing as they are pitiable." Had I not, at this time at least, decided to fortify my plea by evidence that had been afforded solely by psychol- ogists, I might have adduced more trenchant com- mentaries than I have done, even indeed from the au- thorities I have made use of. But, on the other hand, it is a good rule in medi- cine that where there is a choice of measures, the harshest is always to be chosen the last. It is as true of the birth of a principle or of a method of practice, as of a child. In surgery, no incision is to be made longer or deeper than the occasion requires. Sin- cerely believing, as I do, that the only rational treat- ment of insane women must be based upon the same general medical and surgical principles as those that control the management of every other conceivable form of disease, I could say no less than I have done. To the profession I leave the decision of the questions involved. A few days subsequently to the meeting of the As- sociation at which the above report was presented, I attended, as its delegate, the Annual Meeting at Pitts- burg of the Association of American Superintendents, with instructions to urge upon these gentlemen the propriety, for the purposes of science and of effectual practice, of a more intimate union upon their part 223 REFI-EX INSANITY with our own body, representing as this does the pro* fession at large. The cordiality with which I was received by the large circle of Superintendents then present, the majority of them till then strangers to me, and the respectful attention with which my views, so far as I presented them, were met, have but served to confirm me in the opinion that those who have so ungraciously endeavored to stifle this discussion do not represent the main body of American psycholo- gists, and that the seeds of a more rational practice, now to be scattered by the aid of the press, will not fall upon wholly unfruitful soil. The following is the report which was rendered to the American Medical Association at its meeting the ensuing year, 1866. "At the last meeting of this Association the undersigned was appointed its delegate to the Association of Medical Superintendents of American Institutions for the Insane, for the purpose of urging upon that body the advantages of a more intimate union with your own, alike for the pur- poses of science and effectual practice. Having attended to the duty confided to him, he would render the following report : — " Four days after your own adjournment, 3'our delegate met the associated superintendents at Pittsburg, Pa., and communicated to them your expressed desire, urging, at the same time, the mutual advantage that would ensue to both parties interested, themselves and yourselves, from the ac- tion proposed. He was very courteously received and hos- pitably entertained by the Association of Superintendents, and your request was listened to with the respect that its importance demanded, many gentlemen seeming alive to the necessity that the proposed union should be effected. IN WOMEN. 223 When, however, the question was taken, your proposal was not acceded to, and a different time and place than your own were fixed for the meeting of the superintendents the present year. "By his action in the premises, your delegate might seem relieved from further remark. Having discussed this mat- ter, however, as he has done, with the gentlemen comprising the offstanding association, and become familiar with their temper and opinions upon this very important subject, he would have but half fulfilled his duty did he refrain from expressing his views concerning the present position. He does this the more cheerfully, from the fact that the recent meeting of the superintendents at Washington, though not held in accordance with your desire, has permitted a larger number of superintendents than usual to attend your own convocation; and though, by their action, it has been ren- dered impossible for you to send a delegate to their meeting of the present year, as you decided by vote to continue to do until the proposed union shall have been effected, the oppor- tunity has been afforded for j'ou to reiterate your opinion, not through a delegate merely, but in your own persons, as now assembled. " The views referred to naturally subdivide themselves according as they relate — ist, to the welfare of this Associ- ation; 2dly, to that of the profession at large; 3dly, to that of the great class of sick persons more directly interested in your action, namely, the insane; 4thly, to that of the com- munity; and it might be added, 5thly, to that of the super- intendents of asylums themselves. " I. Of what advantage is it to this Association that it represent, in reality, the profession of the country.? It would, at first sight, seem that this question could hardly have been soberly asked, its answer is so very evident; and yet, practically, its discussion at the present moment and in the present connection is well worthy your attention. In this brief report, however, there can be offered but a very few words. " That a house divided against itself cannot stand, is as 224 REFLEX INSANITY true in your affairs as in those of other men. The position of the Association of Superintendents towards your own organization is unlike that of the ordinary medical bodies represented in your councils by delegates. It is itself a great centralizing power, effectual, to a certain extent, no doubt, for good; effectual also for harm. Its conferences have been the means of eliciting an immense deal of im- portant information concerning the hygienic management and economic detail of asylums ; which could, however, with equal, and indeed greater, advantage have been presented through your own channel. On the other hand, these com- munications have not been presented directly to the profes- sion ; few of whom, indeed, do they reach at all. The Asso- ciation of Superintendents and its official publication — the one composed of, and the other conducted by, however com- petent men — constitute, in reality, a partition wall between the very important department of the profession they repre- sent and your own great body of workers, the profession at large. "In all specialties — and the care of the insane is but such — the practitioner has little reason to separate himself from his fellows. He is incompetent for his work unless he has himself been tried in the furnace of general practice; he is unfit for it if he is unwilling to freely communicate with the mass of his profession. Researches merely for the benefit of a limited circle, publications merely for a few se- lected readers, alike fail of the two great ends that alone should be sought by the true physician — the general edifi- cation of his professional brethren, and the general relief of those sick persons whom he professes to wish to cure. "Viewed in this light, the profession and this Association, its representative, have a right to claim, from every one of its members, individual and combined efforts for the general good ; and, looking upon separate and close organizations with a certain measure of very natural distrust, it is clearly your duty to use such measures as may afford themselves to claim for this body a more hearty allegiance. " However decided one's sympathy with efforts to advance IN WOMEN. 225 all legitimate specialties, still the good of the general prac* titioner must rise superior to all other considerations. Fol this reason, every attempt to directly separate any class of specialists from the mass of their fellows is to be deprecated. The ophthalmologists of this country, for instance, who comprise among their number some of your most worthy brethren, are doing much for the glory of medicine; yet it is to be lamented that they should desire, by organizing themselves into a separate Association, practically to disso- ciate their department from its legitimate and influential connection with the parent body, as one of its chief and strongest supports. "Through your so-called Sections, wisely and, if thought necessary, permanently organized, all the work of special organizations can be effected as thoroughly as by any other method, and with infinitely more advantage to the mass of the profession. " 2. Whatever redounds to the advantage of this Associa- tion, either as regards the respect and honor in which it is held or the influence it is enabled to exert, is necessarily also to the advantage of its individual members, and the institu- tions, whether hospitals, societies, or schools, that they rep- resent. This body should be considered, as was the aim of its founders, the exponent of American medical position and scientific acquirement. That the possibility of this actually taking place has been in some quarters inconsiderately made light of, is neither proof nor argument that it cannot be eftected. Selection you have from all worth the culling. It only requires a wise combination of forces to render these, your forces, eftective powers — efl'ective to raise the standard of medical education, practice, and result. You cannot afford to allow any of your main departments to attempt an independent crusade. In union alone is there the com- pletest strength, and the strength of the whole is in reality the strength of each individual of your numbers from the profession at large. " 3. There can be no doubt as to the advantage to the great class of the insane, of a more direct and personal in- 15 226 REFLEX INSANITY terest in their welfare on the part of physicians generally, than now obtains. Were it absolutely certain that there could be no possible advance in the knowledge anci treat- ment of insanity, the case might be difterent; but the expe- rience of the past with all its great changes, most of them reforms, teaches otherwise. That our asylums are so excel- lently managed, officered by such competent superintendents, and fruitful to the extent they are of improvement in their patients, affords undoubted cause for laudation ; but this is a very different thing from being perfect. The mere fact that so large a proportion of insane patients has thus far proved incurable is surely a reason for bending to the sub- ject the scrutiny of a larger and larger number of skilled investigators, and so perhaps eventually working for the in- sane of the present day as great a revolution in respect to improvement as was efl[iected by Pinel for those of the past. As one most efficient agent towards such increased interest in the study of insanity would be found a closer union of superintendents with your own Association. "4. To the community there would be gains, over and above these already enumerated, were the Association reiin- forced by those gentlemen who have practically seceded from its ranks. There exists still too prevalently the feeling that asylums for the insane are in reality but prisons, under a less repulsive nam.e. It is needless to deny the fact Ev- ery physician is aware of the impression to which reference is now made, and of the check it exerts in many unhappy instances upon the needed transferrence of a patient to a more suitable and healthful mental atmosphere. "Now asylums should be stripped of this odium still clinging to them, for which there was formerly but too good reason. They should be made and should be shown to be, first and foremost, not houses for detention, but hospitals for cure; and this can best be done by encouraging a more extensive knowledge of insanity in all its phases on the part of the general practitioner. Were this obtained, prejudices would be softened or efTaced, patients would often be earliei submitted to proper treatment, a point vital for their chance IN WOMEN. 227 of cure, and many more valuable members of the commu- nity saved to it, to their families, and to themselves. "5, and finally. In claiming that even the interests of psychology and of superintendents would be benefited by the measure you instructed your delegate to urge, no more is stated than the facts in the case prove to be true. At Pittsburg it was alleged, privately and publicly, by more than one superintendent, that if the proposed union were eff"ected, it would be the death-blow to their own Association. Such a result is not the object that yourselves have aimed to effect. Granting, however, that it should occur, would the dissolution referred to prove in reality detrimental to the best interests of medicine? That superintendents should desire to cultivate to a higher degree the brotherly feeling likely to exist among gentlemen engaged in a kindred occu- pation, where there is little or no possibility of their inter- fering with each other, is a very pleasant thing. Equally agreeable is it for one of their number each year to be able to exhibit his own establishment to his fellows, receive the encomiums certain in their generous rivalry to be deserved, and gain for himself the cumulative experience of so many kindly critics. But on the other hand, in medicine, the good of the greater number is sure, in the long run, to claim its own ; and here in your midst are hungry souls, craving for the cases, countless almost as the sands on the sea- shore, of partial, incipient, or confirmed insanity', that as yet have never been at an asylum, or have been discharged as fit to remain at home, or incurable, more satisfying food regarding their rational causation, their treatment, or the prevention of the disease. These hospital superintendents have been set apart from their fellows, in part at least, be- cause of their supposed illuminating power. Freed from the present self-imposed bushel of their own Association, then would their light shine so as to brighten the whole professional firmament. "The officers of hospitals are compelled to rest, for a certain measure of their reputation, their influence, their power, upon yourselves outside ; for it is by you that pa- 228 REFLEX INSANITY tients are advised to admission, their certificate of entrance signed, and the therapeutic judgment and conduct of those who take them in charge indorsed, in case, as so often hap- pens, an appeal is made from themselves to a more public tribunal. It is jou, moreover, who are to pronounce, year after year, and generation after generation, whether the same advance is made in the treatment of insanity that the divine mistress, whom we all serve, has a right to exact from her votaries. No branch of medicine can be dissevered from all others with safety to itself. Keeping aloof from the rest, it is easily distanced, and becomes eftete. Or, if arrogantly claiming for itself exclusive rights, it by that act challenges an examination into the grounds of its assumption ; if these prove lacking, then comes for it inevitably a fall from its high estate. *' Pregnant with practical and practicable idea, as is every relation of your profession to that great sickness, Insanity, worse than mortal, when incurable, there is one other point to which, in this connection, your delegate deems it well to draw your attention. " It is well known that of all the cases interesting to med- ical jurists that enter our civil and criminal courts, those of insanity are the most perplexing. From the general initia- tory question, In what does insanity consist? down to the special one of each particular occasion. Was or is this person insane.? there is often exhibited a great and very conflicting diversity of sentiment; much of it undoubtedly necessary, because inherent in the questions themselves, and much of it capable of being removed. There is an equal variance of sentiment as to who shall, and who shall not be per- mitted to express his opinion as an expert, and who shall be entitled to credence. There exist, upon this point, wide ex- tremes of opinion. Dr. Ray, for instance, in his "Medical Jurisprudence," and the able editor in chief of the American Journal of Insanity, Dr. Gray, of the Utica Asylum, as I have elsewhere shown, would confine this privilege or this ability to the few wise men who happen to hold positions at the head of an asylum. Sir Benjamin Brodie, on the other IN WOMEN. 229 hand, a psychologist of no mean repute, extends it even to those bejond the ranks of the general profession, and de- clares that * It is a great mistake to suppose that this is a question which can be determined only by medical prac- titioners. Any one,' he says, ' of plain, common sense, and having a fair knowledge of human nature, who will give it due consideration, is competent to form an opinion on it; and it belongs fully as much to those whose office it is to administer the law, as it does to the medical profession.' * "A similar opinion has been expressed by one of your own body, the distinguished American editor of the Cyclo- pedia of Practical Medicine, the late Dr. Dunglison, of Philadelphia. Says this gentleman, ' In regard to the na- ture of the testimony relied upon in cases of insanity, and the mode of judging of the same, there is much room for animadversion. Too great weight appears to be given to medical testimony in such cases. It has always been the expressed conviction of the writer, that medical men are no better judges of the existence of mental alienation than well- informed and discriminating individuals not of the pro- fession. The only advantage, at least, which they can be presumed to have, is from the constant habits of observation and discrimination, which the practical exercise of their profession requires. Yet, for no other reason than that they belong to the medical profession, inferior men, whose judg- ments on any other subject would be contemned, are often called upon to decide and establish the existence or non- existence of a mental condition which demands the most careful and rigid scrutiny.' "The same difference of opinion, shown above to obtain among medical men, exists also among the expounders of the law. Thus Wharton, justly celebrated alike for his treatise on Medical Jurisprudence and his several works upon Criminal Law, states that ' No juryman, if properly tender of his conscience and of public opinion, will base his verdict upon other evidence than that of those best able, from • Mind and Matter ; or, Physiological Inquiries, p. 105. 230 REFLEX INSANITY long training and close attention, to understand the features of the case. In some cases the difference between a scien- tific, or technical opinion, and that of a layman, is not so much in the results attained, as in the guarantee afforded by the superior attainments and more minute expertness of the man of science. The declaration of such a man is insured against the possibility of error to the full extent of the pro- tection of science in its present stage of development. Pro foro, this degree of certainty is sufficient, because it is the highest attainable ; but the same cannot be said of any other.' * " Carried into court, however, it is found that the rulings upon this point have been diametrically opposed to each other. In New York, the Court of Appeals has decided, though with a strong dissenting sentiment, that none but professional witnesses are competent to testify on the subject of insanity (Dewitt v. Barley & Schoonmaker, 5 Selden, 371), while the Supreme Court of the same State admits the opinions of laymen (Culver v. Haslem, 7 Barb., 3i4). In Pennsylvania the point has been settled in favor of admitting the testimony of non-professional witnesses (Rambler v. Tryan, 7 Serg. & Rawle, 90; Wogan v. Small, 11 Serg. & Rawle, 141). In Connecticut, decisions have been of a simi- lar character (Grant r. Thompson, 4 Conn., 203). In Indi- ana, provided the facts are stated upon which his opinions are founded, an unprofessional witness may express his opinion regarding the existence of insanity (Doe v. Reagan, 5 Black., 217). The same is true in Tennessee, North Caro- lina, and Ohio (Gibson v. Gibson, 9 Yerger, 329; Clary v. Clary, 2 Iredell's Law Rep., 78; The State v. Clark, 12 Ohio, 483) ; and in Vermont also (Lester v. Pittsford, 7 Verm., 158; Morse v. Crawford, 19 Id., 499). "In view of these facts, either of the above-mentioned extreme decisions being disadvantageous to the mass of your profession, as refusing to you, on the one hand, com- petence to express any opinion in cases which you maj • Medical Jurisprudence, § 91. IN WOMEN. 231 perhaps have watched closely for years, and extending, on the other, equal rights and privileges with yourselves, in purely professional matters, to the most unprofessional per- sons, it is not improper to urge upon you action, which, if taken, will also serve to render the measure you have thus far in vain proposed effective. The action advised is as follows : to render the study of medical jurisprudence, in which insanity holds so important a place, more prominent at our medical schools than it has ever yet been. " Of the propriety of such a step, few of our teachers have ever doubted. It has more than once been urged upon this Association, in the valuable reports upon the subject pre- sented to you by Drs. Coventry, of Utica, and Reese, of New York City. Now that the Association has again risen, with more than youthful vigor, from the ashes of the past, it should be no vain hope that the wise suggestions made to you nearly ten years since may be carried into effect. Long ago it was the complaint of that Nestor of American psy- chological writers, Dr. Pliny Earle, that this ' subject of insanity does not enter into_ the programme of lectures in any of our leading medical schools. It is safe, perhaps, to assert,' he says, ' that not one in ten of the graduates of those schools has ever read a treatise upon mental disorders.' ' Indeed,' says one of 3'our reporters to whom I have re- ferred, * the department of medical jurisprudence itself is either wholly ignored in the curriculum of our universities and colleges, or merely appended to some other chair or chairs, by way of formal recognition, and this, for the most part, 5/a/ notniyiis utnbra.'' And again: 'The demands of our civil and criminal courts all over the land, for competent and intelligent medical testimony, must be met by raising up an army of experts in every department of medical juris- prudence, and especially on this important topic of mental aberration. Else the ignorance of too manj^ physicians, displayed before the courts and juries, may lead to the undervaluation, if not the rejection, of medical evidence in all such cases.' * * Report on Moral Insanity in its Relations to Medical Jurisprudence Transactions of the American Medical Association, 1858. 232 REFLEX IXSAXTTY *' Attempts have been made, it is true, to initiate a change, but, at best, they have been but feeble and imperfect. At Harvard University the special subject of insanity is lectured upon by Dr. Tyler, and, at Pittsfield, Dr. Earle was called not long since to a similar duty, until forbidden to pursue the sub- ject by the trustees of his asylum, upon the ground that it took him from the more legitimate offices of his position as superintendent. As yet the evil upon which he himself so forcibly commented remains unchanged. In but a few of our schools, whether of medicine or of law, is the important subject of medical jurisprudence viewed with a tithe of the interest it deserves; in others, if touched upon at all, it is only as an appendage, like a caudal fin, as has well been said by one of its own professors, to some other chair, im- properly considered as of more importance. This indiffer- ence has, no doubt, in part been owing to the lack of competent instructors, who, to be properly fitted for their task, should themselves be masters alike of medicine and of the law. Teachers, however, would have been long since forthcoming, had the colleges called for them. As a strong proof of the argument now made, let your delegate state that in a letter lately received from that justly eminent and very competent instructor, Dr. John Ordronaux, of New York, the fact is mentioned that this gentleman now lectures upon medical jurisprudence in no less than five professional schools, to wit, two law and three medical ; and these, it is perhaps not too much to say, are almost the only instances in which this science is as yet at all properly taught in this country. " There is no class of experts against whom the bolts of legal practitioners, alike counsel and judges, have been so unsparingly hurled, as against those claiming to speak as medical jurists. Particularly does this occur in cases of insanity; and in none has so much real damage been done to the profession, not always, either, with entire injustice. The exigencies of the case, aggressive and defensive, have been so great, that the subject has lately been taken in hand, with a view to decided action, by one of the highest courts IN WOMEN. 233 of professional appeal in the country, the American Acade- my of Arts and Sciences, the whole matter having been under examination by a committee, of which the Chief Justice of Massachusetts was chairman, and of which your delegate has had the honor to be a member. As parties deeply interested in any movement that can better your- selves and advance the interests of the profession, it lies with you to assist in this work. "Your delegate would therefore, while trespassing no longer upon your patience by argument, offer for adoption two mutually dependent resolutions, the second of them being based, he would recall to your recollection, upon action taken at your last meeting, at the suggestion of Dr. Edward Jarvis, the well-known statistical psychologist, in accordance with which a Section of Psychological Medicine, Intended more particularly for the reception of the superintendents, was organized by this Association. It is a source of great satisfaction that yesterday, for the first time, the new section was formally convened. The high character of the half dozen gentlemen, all of them connected with the specialty of insanity, who took part in its deliberations, and the im- portant work that they accomplished, which was no less than assigning a special scientific investigation to the most celebrated member of their fraternity. Dr. Isaac Ray, are an earnest that your interests in this direction will not be allowed to languish. More is required, however, than has thus far been effected. It is necessary that the great body of superintendents should convene at the same time and place with yourselves, and thus, without in reality interfering with their enjoyment and their consentaneousness of action, that their interests should become more clearly identified with your own. " The resolutions now offered are the following; for their passage still additional arguments would have been pre- sented, had such seemed necessary : — " I. Resolved^ That the Association recommend to the several medical and law schools of the country the establish- ment of an independent chair of medical jurisprudence, to 234 REFLEX INSANITY be filled, if possible, by teachers who have studied both law and medicine; attendance upon one full course of lectures from whom shall be deemed necessary before the medical degree is conferred. " 2. Resolved, That while this Association regrets that the Association of Superintendents of American Asylums for the Insane has not yet thought fit to unite itself more closely with the representative body of American physicians, it still is of opinion that such union is for their mutual and re- ciprocal advantage, and that it ought to be effected without further delay. "All of which is respectfully submitted." The resolutions above presented were unanimously adopted by the Association. As the present leaf of this book is passing through the press, I have received a most interesting com- mentary upon its last few pages. At the annual meeting for the present year (1870) of the Association of Medical Superintendents of American Asylums for the Insane, the official report * of which has just reached me, these gentlemen were assured by the delegate from the American Medical Association, Dr. John L. Atlee, of Pennsylvania, that their union with the General Association would be impolitic, both for themselves and the profession at large. " We have enough to do," said Dr. Atlee, " in de- voting onr time to the other departments of medicine, without including the subject of insanity," — a remark as applicable to all other classes of disease whatso- • American Journal of Insanity, October, 1870, p. 129. IN WOMEN. 235 ever. Under these circumstances, Dr. Atlee was, of course, congratulated by the superintendents for his alleged good sense, and his remarks will, doubtless, be still further lauded by Dr. Tyler, of the Somervilk Asylum, in his report upon the subject, that his recent illness has delayed until next year. Notwithstanding all this, I still submit that the meetings of the two Associations, so long as they shall remain distinct, should at least be held at the same place each year, and nearly simultaneously, the one immediately preceding or following the other. In the immediate vicinity of all our large cities there are now insane asylums, to visit which it is naturally so pleasant to superintendents. It must not be forgotten, moreover, that Dr. Atlee is, and has long been, a manager of one of the Penn- sylvania State Asylums, and that, as he is therefore necessarily identified in feeling, as he has indeed shown himself to be, with the members of the spe- cialty, his opinion upon the question referred to must be received with a good deal of hesitancy. The remarks made at the same meeting, upon the relations of uterine disease to insanity, by Dr. James P. White, of Buffalo, also a manager of a State Asy- lum, and President of its Board, are in every way to be admired. Professor White, like Dr. Atlee, is well known as one of the best gynaecologists in the coun- try ; and from the efforts he has made, through the 236 REFLEX INSANITY IN WOMEN. American Medical Association, to procure the estab- lishment of professorships of mental disease at all our medical colleges, his opinions cannot but have great weight with those in charge of asylums. Thus it will be seen that there are signs that the great reform in the treatment of the female insane, for which we have so long been laboring, will, at no distant day, become accomplished. cyjfedicine & Society /n c/^merica An Arno Press/New York Times Collection Alcott, William A. The Physiology of Marriage. 1866. New Intro- duction by Charles E. Rosenberg. Beard, George M. American Nervousness: Its Causes and Conse- quences. 1881. New Introduction by Charles E. Rosenberg. Beard, George M. Sexual Neurasthenia. 5th edition. 1898, Beecher, Catharine E. Letters to the People on Health and Happi- ness. 1855. Blackwell, Elizabeth. Essays in Medical Sociology. 1902. Two volumes in one. Blanton, Wyndham B. Medicine in Virginia in the Seventeenth Century. 1930. Bowditch, Henry I. Public Hygiene in America. 1877. Bowditch, N[athaniel] I. A History of the Massachusetts General Hospital: To August 5, 1851. 2nd edition. 1872. Brill, A. A, Psychanalysis: Its Theories and Practical Applica- tion. 1913. Cabot, Richard C. Social Work: Essays on the Meeting-Ground of Doctor and Social Worker. 1919. Cathell, D. W. The Physician Himself and What He Should Add to His Scientific Acquirements. 2nd edition. 1882. New Introduction by Charles E. Rosenberg. The Cholera Bulletin. Conducted by an Association of Physicians. Vol. I: Nos. 1-24. 1832. All published. New Introduction by Charles E. Rosenberg. Clarke, Edward H. Sex in Education; or, A Fair Chance for the Girls. 1873. Committee on the Costs of Medical Care, Medical Care for the American People: The Final Report of The Committee on the Costs of Medical Care, No. 28. [1932]. Currie, William. An Historical Account of the Climates and Dis- eases of the United States of America. 1792. Davenport, Charles Benedict. Heredity in Relation to Eugenics. 1911. New Introduction by Charles E. Rosenberg. Davis, Michael M. Paying Your Sickness Bills. 1931. Disease and Society in Provincial Massachusetts: Collected Ac- counts, 1736-1939. 1972. Earle, Pliny. The Curability of Insanity: A Series of Studies. 1887. Falk, I. S., C. Rufus Rorem, and Martha D. Ring. The Costs of Medical Care: A Summary of Investigations on The Economic Aspects of the Prevention and Care of Illness, No, 27. 1933. Faust, Bernhard C. Catechism of Health: For the Use of Schools, and for Domestic Instruction. 1794, Flexner, Abraham. Medical Education in the United States and Canada: A Report to The Carneprie Foundation for the Ad- vancement of Teaching, Bulletin Number Four. 1910. Gross, Samuel D. Autobiography of Samuel D. Gross, M.D., with Sketches of His Contemporaries. Two volumes. 1887. Hooker, Worthington. Physician and Patient; or, A Practical View of the Mutual Duties, Relations and Interests of the Medical Profession and the Community. 1849. Howe, S. G. On the Causes of Idiocy. 1858. Jackson, James. A Memoir of James Jackson, Jr., M.D. 1835. Jennings, Samuel K. The Married Lady's Companion, or Poor Man's Friend. 2nd edition. 1808. The Maternal Physician; a Treatise on the Nurture and Manage- ment of Infants, from the Birth until Two Years Old. 2nd edi- tion. 1818. New Introduction by Charles E. Rosenberg. Mathews, Joseph McDowell. How to Succeed in the Practice of Medicine. 1905. McCready, Benjamin W. On the Influences of Trades, Professions, and Occupations in the United States, in the Production of Disease. 1943. Mitchell, S. Weir. Doctor and Patient. 1888. Nichols, T[homas] L. Esoteric Anthropology: The Mysteries of Man. [1853]. Origins of Public Health in America: Selected Essays, 1820-1855. 1972. Osier, Sir William. The Evolution of Modern Medicine. 1922. The Physician and Child-Rearing: Two Guides, 1809-1894. 1972. Rosen, George. The Specialization of Medicine: with Particular Reference to Ophthalmology. 1944. Royce, Samuel. Deterioration and Race Education. 1878. Rush, Benjamin. Medical Inquiries and Observations. Four vol- umes in two. 4th edition. 1815. Shattuck, Lemuel, Nathaniel P. Banks, Jr., and Jehiel Abbott. Report of a General Plan for the Promotion of Public and Per- sonal Health. Massachusetts Sanitary Commission. 1850. Smith, Stephen. Doctor in Medicine and Other Papers on Profes- sional Subjects. 1872. Still, Andrew T. Autobiography of Andrew T. Still, with a History of the Discovery and Development of the Science of Osteopathy. 1897. Storer, Horatio Robinson. The Causation, Course, and Treatment of Reflex Insanity in Women. 1871. Sydenstricker, Edgar. Health and Environment. 1933. Thomson, Samuel. A Narrative, of the Life and Medical Dis- coveries of Samuel Thomson. 1822. Ticknor, Caleb. The Philosophy of Living; or. The Way to Enjoy Life and Its Comforts. 1836. U.S. Sanitary Commission. The Sanitary Commission of the United States Army: A Succinct Narrative of Its Works and Purposes. 1864. White, William A. The Principles of Mental Hygiene. 1917. 3 1970 00730 2695 DATE DUE DEC i 9 11989 University of California SOUTHERN REGIONAL LIBRARY FACILITY 305 De Neve Drive - Parking Lot 17 • Box 951388 LOS ANGELES, CALIFORNIA 90095-1388 Return this material to the library from which it was borrowed.