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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«/<?r-added — very generally I 
 think not. This fact is surely one of much significance. 
 
 " In all emotional insanity of women, and especially in 
 the religious forms, I am persuaded the generative organs 
 play a most important part. I would almost say, they give 
 the ground-tone." 
 
 I shall now proceed to show, — 
 
 1. That while the brain is undoubtedly the seat of 
 insanity, yet it is not necessarily the seat of its cause. 
 
 2. And that this is proved by a priori reasoning, 
 and, both negatively and positively, by the results of 
 autopsies. 
 
 3. That while idiopathic insanity, requiring direct 
 cerebral or simply moral treatment alone, is very rare, 
 sympathetic or reflex insanity, requiring treatment of 
 a special character, is extremely common. 
 
 4. And that, on the one hand, such reflex causation 
 is and should be much more common in females than 
 in males, while, on the otlier hand, of tlie various 
 forms of it occurring in females, the majority of them 
 are owing to functional or organic diseases of the 
 
IN WOMEN. 39 
 
 uterus and its appendages ; in other words, that they 
 are of a sexual character. 
 
 These facts I shall support at this time only by the 
 evidence of superintendents themselves, by no means 
 exhausting the testimony of this character that I have 
 at hand, nor drawing upon the extensive material that 
 is afforded me from other quarters, which I shall re- 
 serve for a future communication upon the subject, 
 that may hereafter be made by me to the profession. 
 
 The first witness whom I call is Dr. Ray, of the 
 Butler Hospital, at Providence, R. I. (now, 1870, of 
 Philadelphia). 
 
 "It can hardly be necessary, at the present time," says 
 this gentleman, " to prove the fact of the dependence of the 
 mind on the brain for its external manifestations; that, in 
 short, the brain is the material organ of the intellectual and 
 effective powers. Whatever opinion may be entertained of 
 the nature of the mind, it is generally admitted, at least by 
 all enlightened physiologists, that it must of necessity be 
 put in connection with matter, and that the brain is the part 
 of the body by means of which this connection is effected. 
 Little as we know beyond this single fact, it is enough to 
 •warrant the inference that derangement of the structure, or 
 of the vital actions, of the brain, must be followed by abnor- 
 mal manifestations of the mind, and, consequently, that the 
 presence of the effect indicates the existence of the cause. 
 "Whether the morbid action arises in the digestive or some 
 other system, and is reflected thence to the brain by means 
 of the nervous sympathies, or arises primarily in the brain, 
 the soundness of the above principle is equally untouched. 
 This leads us to the source of the hesitation that has been 
 evinced by pathologists to consider the brain as the seat of 
 insanity. 
 
4© REFLEX INSANITY 
 
 " From the fact that organic lesions are not always dis- 
 coverable after death in the brains of the subjects of insan- 
 ity, it has been inferred that the brain is not the seatof tkis 
 disease; though, if this fact were true, — it being also true 
 that no other organ in the body invariably presents marks 
 of organic derangement in insanity, — the only legitimate 
 inference would have been, that, in some cases, it is impos- 
 sible to discover such lesions by any means in our power. 
 The strangest theoretical error which this soundness of the 
 brain in some cases has occasioned, is that of denying the 
 existence of any material affection at all, and attributing the 
 disease entirely to an affection of the immaterial principle. 
 If the same pathological principles had guided men's rea- 
 soning, respecting this disease, that they have applied to the 
 investigation of others, this error would never have been 
 committed. It will scarcely be contended, at the present 
 day, at least, that the structural changes found after death, 
 from any disease, are the primary cause of the disturbances 
 manifested by symptoms during life, or that, if the interior 
 could be inspected at the beginning of the disease, any of 
 these structural changes would be discovered. It is now a 
 well-recognized principle that such changes must be pre- 
 ceded by some change in the vital actions of the part where 
 they occur. This vital change is now generally expressed 
 by the term irritation^ and nothing is implied by it relative 
 to the nature of this change more than an exaltation of ac- 
 tion. Irritation, then, is the initial stage of disease — the 
 first in the chain of events, of which disorganization is the 
 last; and, of course, nothing can be more unphilosophical 
 than to attribute disturbances of function exclusively to any 
 structural changes that may take place during the progress 
 of these successive stages." ♦ 
 
 To what pathological actions or structural changes 
 is the brain then liable? And here I present the 
 evidence of Dr. Bucknill, of England, medical super* 
 
 * Medical Jurisprudence of Insanity, pp. laS-ija 
 
IN WOMEN. 41 
 
 intendent of the Devon County Lunatic Asylum. He 
 
 tells us, — 
 
 '* As an organ abundantly supplied with blood vessels, the 
 brain is obviously liable to all abnormal conditions, which 
 irregularities in the quality or quantity of the blood, and the 
 relation thereof to its tissue, can occasion ; it is liable to 
 anaemia and to hyperaemia, both passive and active, and to 
 the latter accompanied by organizable and unorganizable 
 exudates. It is also more readily acted upon by various 
 chemical changes in the blood than any other organ. Ex- 
 cess of carbon or defect of oxygen tells first upon it; and 
 many substances in the blood which affect other organs little, 
 or not at all, affect this noblest of the organs with intense 
 force. All diseases, therefore, which depend upon the move- 
 ment or quantity of the blood, and many of those which 
 depend upon its quality, are the fruitful source of abnormal 
 cerebral conditions. There are, it is true, many blood- 
 poisons and diseases which do not affect the brain. Thus, 
 it is strange, that although the gout-poison affects the tem- 
 per strongly, and often endangers the intellect, that of 
 rheumatism has no effect thereon. Tuberculosis, moreover, 
 while attacking every other organ of the body, very rarely 
 affects the adult cerebrum. But the brain is liable to a 
 species of disturbance, apparently quite unconnected with 
 the quality, quantity, or movement of the blood, a species 
 of disturbance to which other organs are liable only in a 
 modified and unimportant degree. We allude to the dis- 
 turbance caused by sympathy with injuries of, or noxious 
 influences applied to, peripheral portions of the nervous 
 system.* 
 
 These sympathetic disturbances, however, occa- 
 sioned by the irritation of some part of the distal 
 nervous system, do not necessarily produce any ana- 
 tomical changes, if the examination is made during 
 
 * Manual of Psychological Mediclue, p. 349. 
 
^2 REFLEX INSANITY 
 
 the early period of the disease.* After a while, the 
 brain may pass from the state of physiological excite- 
 ment into that of pathological change, and altera- 
 tions in its structure then be found on examination, 
 although this is by no means necessarily the case. 
 
 " The condition of the cerebral substance is the prime 
 question in the pathology of mental disease. Frequently 
 this condition can only be judged of by the state of its blood 
 vessels, or can only be guessed at by that of its membranes, 
 or some still more remote indication. Not unfrequently, in 
 partial and sympathetic insanity, it appears to be perfectly 
 sound in structure, although the deductions of science assure 
 us that this soundness is in appearance only, and is solely 
 attributable to the imperfection of our means of observing 
 and investigating. 
 
 " To the pathologist the substance of the brain is as yet 
 practically structureless. Although the microscope reveals 
 cells and tubes, and intervening stroma, up to the present 
 time it is unable to indicate when they are in a normal or 
 abnormal state ; and although it may prove that in so»ne 
 cases the smaller arteries are diseased, that in a few others 
 there are exudation-corpuscles, or an increase of fatty parti- 
 cles in the substance itself, it has not yet enabled us to 
 distinguish between the states of the whole organ, which 
 must be diametrically opposite — for instance, between the 
 state of hypertrophy and atrophj'."! 
 
 Let us again listen to Dr. Ray. 
 
 " It has been stated by Fodere, in explanation of the 
 pathological causes that produce the alternation of parox- 
 ysms and lucid intervals so constantly seen in certain fom.a 
 of insanity, that the former are attended by an excessive 
 plethora of the blood vessels of the brain, and the latter by a 
 relaxed, atonic condition of these vessels, which is an effect 
 
 • Manual of Psychologica] Medicine, p. 403. 
 t Tbid., p. 431. 
 
IN WOMEN. 43 
 
 of their previous forcible distention. In this condition the^ 
 are liable to be suddenly engorged hy exciting causes, such 
 as intemperance in eating or drinking, anger, violent exer- 
 cise, insolation, &c. ; or in consequence of a certain predis- 
 position of constitution. It is, indeed, well known that the 
 return of the paroxysms is often retarded bv regulated diet, 
 bleeding, quiet, seclusion, kind treatment, and the absence 
 of the above named stimuli. It is thus shown conclusively 
 that in every lucid interval there remains some unsoundness 
 of the material organ of the mind, which may be designated 
 generallj- as a morbid irritability, which, on the application 
 of the slightest exciting cause, may produce an outbreak of 
 mania in all its original severity." • 
 
 " But," asks Andral, in his Clinique Medicale, 
 " when we have referred the symptoms to hyperaemia 
 in one case, and to anaemia in another, are we to come 
 to the bottom of the subject.'' By no means," he re- 
 plies to his own question ; for this hyperaemia and 
 this anaemia are themselves mere effects, which — a 
 thing very remarkable — the same influence can very 
 often produce. 
 
 In Esquirol's great work upon maladies of the 
 mind, published so recently as 1838, his opinions on 
 pathology, which had been in accordance with those 
 still so generally held concerning the insane, will be 
 found to have been considerably modified. Referring 
 to the case of a recent maniac, who was killed by one 
 of her companions, and in whose body he and his 
 pupils were surprised to find no lesions of the brain 
 or its meninges, he declares that pathological anato* 
 
 • Medical Jurisprudence of Insajiity, p. 339. 
 
44 REFLEX INSANITY 
 
 my, in spite of the very important labors of Foville, 
 
 Calmeil, Bayle, Guislain, and others, has not been 
 
 able to make us acquainted with the organic cause 
 
 of mania. He says, — 
 
 "Thirty years ago I would willingly have written upon 
 the pathological cause of madness. At the present day I 
 would not attempt a labor so difficult, so much of incertitude 
 and contradiction is there in the results of the necroscopy of 
 the insane made up to this time. But I may add that mod- 
 ern researches permit us to hope for ideas more positive, 
 more clear, and more satisfactory." 
 
 We are now naturally conducted to the actual re- 
 sults of post-mortem examinations of the insane. I 
 again quote Esquirol : — 
 
 *• From this announcement, every one might expect that 
 we should be able to point out the seat of insanity, and to 
 make known the nature and seat of the organic lesion, of 
 which insanity is the expression. This we can by no means 
 accomplish. The examinations of the dead have, to the 
 present period, been barren of practical information. The 
 facts observed by Willis, Manget, Bonnet, Morgagni. Gunz, 
 Meckel, Greding, Vicq d'Azyr, Camper, Chaussier, Gall, 
 and others, have produced only negative or contradictory 
 results. 
 
 " All the labor that has been expended upon the anatomy 
 of the brain has produced no other result than a more exact 
 description of this organ, and the despairing certainty of our 
 being forever unable to assign to its parts the uses from 
 whence we ma}- derive information with reference to the 
 exercise of the thinking faculty, whether in health or 
 disease. 
 
 " Before drawing any conclusions," continues this great 
 authority, "from these organic lesions observed among the 
 insane, will it not be well to acquaint ourselves with all the 
 varieties, both of the cranium and of the brain, which are 
 
IN WOMEN. 45 
 
 compatible with the integrity of the faculties of the under- 
 standing? Would not this be the true point of departure fot 
 all our pathological researches? Now, says the learned 
 Chaussier, there is no organ in which we find greater vari- 
 eties, with respect to volume, weight, density, and its re- 
 spective proportions, than the brain. Have we carefully 
 distinguished the results of concomitant maladies, or those 
 diseases which terminate the life of the insane, from those 
 which belong to mental alienation? 
 
 " Organic lesions of the brain reveal themselves by other 
 signs than insanity. Thus, chronic inflammation of the 
 meninges produces compression, which reveals itself by 
 paralysis; cerebral hemorrhage is also manifested by paral- 
 ysis. Tubercle, cancer, and softening of the brain pre- 
 sent peculiar characters, which cannot be confounded with 
 mental alienation. Have we reflected on the sudden and 
 instantaneous cures of insanity? It is in consequence of 
 having neglected these considerations that we reason so 
 erroneously respecting the seat of this malady." * 
 
 Let us see what light upon these points has been 
 aflbrded by actual study of the dead. 
 
 Autopsies are comparatively seldom made of the 
 insane who die at asylums. The reason, or one rea- 
 son, of this will have been already made evident — 
 examination of the brain, so barren of result, having 
 usually alone been made. Upon this point I will 
 reproduce evidence that I have already elsewhere 
 presented.! 
 
 " Many who have professed familiarity with these sub- 
 jects have asserted that the morbid appearances found in 
 the bodies of the insane were unworthy of record ; they 
 should rather have confessed that they were unable to 
 
 * Mental Maladies, p. 69. 
 
 t Boston Med. and Surg. Journal, April, 1864, p. 198. 
 
46 REFLEX INSANITY 
 
 appreciate their value. With the more thorough and com* 
 plete investigation of these matters, we may hope eventually 
 to arrive at some correct views as to the nature of those laws, 
 the transgression of which leads to sensorial disturbance, but 
 no approach to the truth can be made except through the 
 portal of morbid anatomy, which has revealed this important 
 fact, that the record of post-mortem examinations, as pre- 
 served in an asylum for the insane, differs in most striking 
 and essential particulars from that preserved in a general 
 public hospital." * 
 
 " Autopsies," said Dr. Douglass to me, when visit- 
 ing the Government Asylum of Lower Canada at 
 Beaufort, near Quebec, then under his charge, " au- 
 topsies of the insane no one ever thinks of making in 
 Canada, save that enthusiast whom you have been 
 visiting at Toronto." While, on the other hand, it is 
 from this very enthusiast at Toronto, Dr. Workman, 
 to whom I have already alluded, that the profession 
 is indebted for some of the most important of the 
 steps towards elucidating the real pathology and ulti- 
 mate causation of insanity in its reflex manifestations, 
 that have ever yet been made. 
 
 Dr. Hunt, formerly of the Hartford Asylum, has 
 
 put the following admission on record : — 
 
 " The number of post-mortem examinations made m the 
 hospitals for the treatment of insanity in this country is very 
 few, and of this number fewer still are ever published. 
 The cause is evident, and is not likely very soon to be ob- 
 viated." t 
 
 • Holmes Coote : Journal of Psychological Medicine, vol. iv. p. 384. 
 
 t I freely acknowledge that in some instances, as was stated by Drs Choata 
 and Bemis at the meeting of Superintendents held at Providence (Am. Jour, 
 of Insanity, July, tS6a), it is di£Bcult or impossible to obtain the consent of 
 
IN WOMEN. 47 
 
 The examination, which was permitted me, of the 
 very extended, minute, and most suggestive patho- 
 logical records at Toronto, furnished proof that this 
 paucity of autopsies is owing neither to " want of 
 opportunity," * nor to dearth of practical results, when 
 properly looked for. 
 
 It is proved, however, from abundant evidence, that, 
 
 1. Insanity may exist without structural changes 
 of the brain, and that, 
 
 2. Structural changes of the brain may exist with- 
 out insanity. 
 
 " It must be admitted," says Dr. Bucknill, " that 
 we are not yet in a position, as regards our knowl- 
 edge of the morbid appearances of the brain, to base 
 our nosology upon the revelations of the dead-houses. 
 We can only wait an advance of knowledge which 
 will render this possible." f 
 
 The late Dr. Bell, of the McLean Asylum, at Som- 
 erville, justly considered one of our most reliable 
 authorities, has left no doubtful expression of his own 
 opinion, which was, that autopsies of the insane 
 generally present no material lesion of the brain ; 
 changes, indeed, there are to be seen, but only those 
 that may have occurred in articulo mortis.J 
 
 a patient's friends to have a post-mortem examination ; but this difficulty 
 obtains to neariy an equal degree at general hospitals, where, nevertheless, such 
 examinations are much more conunon. 
 
 * Translation of Esquirol, p. 233. 
 
 t X.OC. citat., p. 94. 
 
 t American Journal of Insanity, x. p. 79, 
 
48 REFLEX INSANITY 
 
 Upon another occasion he stated that my friend, 
 the hite Dr. Waldo I. Burnett, of Boston, one of the 
 most accomplished microscopists in the country, had 
 made examinations of the brain of persons who had 
 died in a state of chronic insanity, but had been un- 
 able to discover any change of structure whatever, or 
 any sign to indicate that it did not belong to an indi- 
 vidual whose mind was unaffected.* 
 
 Dr. Bucknill observes, — 
 
 " The brains of the insane appear to be certainly not more 
 liable than those of others to various incidental affections. 
 Thus, in four hundred autopsies of the insane, we have only 
 once met with a hydatid, only once with tubercular deposit 
 in the substance and meninges, only once with a fibro-cel- 
 lular tumor, and not once with malignant disease. The 
 arteries at the base do not appear to be more frequently or 
 extensively affected with atheromatous change than those 
 of sane persons of the same age ; and in the bodies of the 
 insane we have never yet met with that cretaceous deposit 
 in the coats of the small arteries, which makes them feel like 
 pieces of fine wire imbedded in the brain-substance. We 
 have never met with that leather-like and fibro-cartilaginous 
 hardness or resistance to which sclerosis of the brain is de- 
 scribed to attain. The two forms of ramollissement are not 
 found more frequently in the brains of persons dying insane 
 than in those of others. The same may be said of the cellular 
 infiltration described by Durand Fardel, with which in four 
 hundred autopsies we have met but twice. 
 
 "A large number of brains of the insane we have dili- 
 gently investigated with a first-rate microscope. The results 
 appear to us to have afforded no distinction between the sane 
 and the insane brain. We have found exudation corpuscles, 
 but only in instances where the existence of inflammatory 
 
 • Aincricin Journal of Insanity, xi. 1854, p. 53. 
 
IN WOMEN. 49 
 
 action was apparent without the use of the microscope; and, 
 therefore, this microscopic test of cerebral inflammation, 
 proposed bj Dr. Hughes Bennett, appears to be of little val- 
 ue. In inflammatory and softened parts of the brain-sub- 
 stance we have found fatty degeneration of the coats of the 
 small arteries; but it remains to be seen whether this change 
 is not as frequent in the brains of the sane. We have not 
 been able to discover fatty degeneration of the arteries where 
 the pathological changes more peculiar to insanity alone 
 existed. The same may be said of fatty degeneration of the 
 brain-substance, consisting in the abundant dissemination 
 of amorphous fat particles, which is found in some speci- 
 mens of cerebral softening. 
 
 " It seemed reasonable to expect that, by the aid of the 
 microscope, one would be able to ascertain whether any ex- 
 udation or addition to the stroma of the brain, or any change 
 in size, shape, or proportionate number of its cells, takes 
 place; and in the indurated brain of chronic insanity, 
 whether that finely fibrillated exudate, which has been de- 
 scribed by some writers, actually exists ; also, whether, in 
 extreme atrophy of the brain, any proportion exists in the 
 diminution or degeneration in the form of the cells or tubes. 
 In none of these points of inquiry have we been able to 
 attain the slightest success." * 
 
 It could hardly b'e expected, when the contents of 
 
 the cranial cavity throw so little light upon the 
 
 pathological character of insanity, that a study of its 
 
 exterior could be productive of fruitful results. Such, 
 
 however, has been assiduously attempted, but the 
 
 results are neither uniform nor undoubted. 
 
 *' Although we believe " — it is Bucknill who is now speak- 
 ing — "that the average dimensions of the head are below 
 those of the sane, when the comparison is obtained by the 
 examination of large numbers, still, in a great number of 
 
 • Loc citat., p. 430. 
 
5© REFLEX INSANITY 
 
 instances, they will be found to be good: and. indeed. th« 
 head is frequently not only large, but phrenologically well- 
 shaped. 
 
 *' We are not aware in what proportion of the ^ane the 
 shape of the head is peculiar, since it is rare that opportuni- 
 ties occur for making the observation among them ; but 
 among the insane a considerable proportion present decided 
 peculiarities in the shape of the cranium. The most fre- 
 quent one is a want of symmetry in the two sides. One 
 side is rather flatter or smaller than the other, or the whole 
 cranium is pushed over a little to one side, or one side is a 
 little more forward than the other, or the two anomalies co- 
 exist, giving the cranium a sort of twisted appearance. 
 These things will not be seen unless they are looked for, 
 with accurate and careful eyes, upon the shaven scalp. 
 
 "Sometimes the skull is high and domelike; more fre- 
 quently it is as if it had been compressed laterally, and 
 elongated from before backwards — heel-shaped, in fact, 
 like the skulls figured by Dr. Minchin,* in which the centres 
 of ossification of the parietal bones are increased in num- 
 ber. Sometimes the forehead is preternaturally flat, nar- 
 row, or receding, or very large and bulging, or the occipital 
 region is deficient, and the back of the head rises in a 
 straight line with the nape of the neck. Sometimes the 
 skull has a remarkably square configuration. The square 
 and carinated form of skull we have most frequently seen in 
 connection with mania; the domelike and high, vertical 
 skull, and also the unsymmetrical skull, most frequently in 
 melancholia. In mania the anterior cranium is more fre- 
 quently of good shape and size than in melancholia. In 
 the latter the forehead is often small and mean, but some- 
 times it is disproportionately large and globose. The shape 
 of the head, indicated by the rules of phrenologists, can 
 only fairly be expected to coincide with the mental symp- 
 toms in those somewhat rare instances in which insanity is 
 the mere development in excess of natural character; and 
 in some such instances we have found the shape of the head 
 
 • Dublin Medical Journal. 
 
IN WOMEN. 51 
 
 tally, in its general outline, with the indications of phre* 
 nology. 
 
 " Occasionally depressions are found in the outer skull, 
 which sometimes do, and sometimes do not, correspond 
 with the bulging of the inner table of the cranium. When 
 they do not correspond, we have found that they indicate a 
 local absorbtion of the diploe. 
 
 "It is an interesting question how far the shape of the 
 skull alters in insanity. If the forehead expands, even in 
 mature age, under the influence of intellectual development, 
 it is likely that it will contract under the influence of intel- 
 lectual decay. Some writers have asserted that the shrink- 
 ing of the brain in atrophy is commonly, and to a consider- 
 able extent followed, and the cranium filled, by a flattening 
 and shrinking of the cranial bones.* Rokitansky also af- 
 firms that atrophy of the brain frequently gives rise to de- 
 posit of bone on the inner table of the skull, especially 
 about the anterior convolutions. 
 
 "We have not satisfied ourselves that the increased thick- 
 ness of the cranium, which is frequently met with in the in- 
 sane, is in any way connected with atrophy of the brain. 
 Some of the thickest and heaviest craniums which we have 
 met with have occurred in instances in which there was 
 little or no cerebral atrophy ; and the condition of the cra- 
 nium, where there is undoubted atrophy of the brain, is not 
 unfrequently one of abnormal tenuity." f 
 
 Thus it is seen not merely that there is no direct 
 correspondence between the exterior of the skull and 
 mental integrity, any more than between the exterior 
 of the skull and the shape and consistence of its con- 
 tents. We constantly see all the degrees of irregu- 
 larity and excess or deficiency of cranial development 
 that have been described, in every-day life, and coin- 
 
 * Paget : Lectures on Pathology, 
 t Loc citat, p. 41CX 
 
5a RHFLEX IXSANITY 
 
 cident with perfect sanity, while even in idiocy it ia 
 not necessary that the normal symmetry shall at all 
 be lacking, though this is undoubtedly frequently the 
 case. 
 
 It must not be concluded, from the examples of 
 microcephalous idiots, that a small head is a necessa- 
 ry accompaniment of idiocy. " On the contrary," 
 says Dr. Tuke, Medical Officer to the York Retreat, 
 " many idiots have large heads, leaving out of the 
 question instances of hydrocephalus." Parchappe 
 has stated, as the result of very careful inquiry, that 
 if there exist a general relation between the volume 
 of the brain and the degree of intelligence, " facts 
 are wanting to deduce rigorously, from this relation, 
 the different degrees of intellectual and moral capaci- 
 ty." Of one hundred idiotic heads examined by 
 Belhomme, eighty-four presented more or less decid- 
 ed malformations of the forehead, occiput, and lateral 
 portions. Twenty-five per cent, had a well-marked 
 want of symmetry. On bringing together a hundred 
 well-proportioned heads, he did not find a single idiot 
 among the number. Gallice, after making a large 
 number of observations, came to the conclusion, that 
 the more intelligent the idiot is, the larger will be his 
 head ; but that this results from a greater develop- 
 ment of the occiput. And this certainly accords with 
 what Leuret had previously recorded, that the occi- 
 put in idiots is remarkably small. 
 
IN WOMEN. 53 
 
 Desmaisons, in his Memoir on the Form of the 
 Head in Idiots, concludes that idiocy sometimes exists 
 without any malformation ; that it is impossible to fix 
 upon any malformation peculiar to idiocy, when the 
 volume of the head and its symmetry are retained ; 
 and that, in cases of this kind, flattening of the pos- 
 terior portion of the head is as common as that of 
 the forehead.* Gall laid it down as an axiom, that 
 idiocy must exist when the head is not more than 
 thirteen inches in circumference ; and he says that 
 the measurement of heads, in cases of complete im- 
 becility, up to the ordinary exercise of the intellectual 
 faculties, is comprehended between the following lim- 
 its : The circumference varies from fourteen to seven- 
 teen inches, and the arc, between the root of the nose 
 and the occipital foramen, measures nearly twelve. 
 These dimensions, he adds, are accompanied with a 
 greater or less degree of stupidity or fatuity, inability 
 (more or less complete) of fixing the attention on a 
 determinate object, vague sentiments, an irregular 
 train of ideas, speech consisting of broken phrases, 
 &c., and blind and irregular instincts.f 
 
 Esquirol's statements appear to be somewhat con- 
 tradictory ; for while a table of measurements, which 
 he gives, exhibits a decided decrease in the size of the 
 heads of idiots, he says, " The dimensions of the 
 
 • Manual of Psychological Medicine, p. 108. 
 t The Functions of the Brain, ii. p. 214. 
 
54 REFLEX INSANITY 
 
 crania of idiots are equal to those of other men,** 
 and concludes by exclaiming, " How much work 
 there remains to accomplish, how much research, 
 before we can state the coincidence of the volume 
 and form of the head with the intellectual capacity ! " 
 From the author last quoted I present the following 
 conclusions : — 
 
 1. Vices of conformation in the cranium are met 
 with only, or chiefly, among imbeciles, idiots, and 
 cretins. 
 
 2. Organic lesions of the encephalon and its en- 
 velopes have been observed only among those whose 
 insanity was complicated with paralysis, convulsions, 
 and epilepsy, or rather these lesions appertain to the 
 malady which has caused the death of the patients. 
 
 3. The sanguineous or serous effusions, the injec- 
 tions or infiltrations, which we meet with in the cra- 
 nial cavity, the thickening of the meninges, their ad- 
 hesions among themselves, with the cranium and the 
 gray substance, the partial or general softening of the 
 brain, the density of this organ, the fibrous, knotty, 
 and cancerous tumors observed within the cranium. 
 — all these alterations indicate either the causes or 
 effects of insanity, or rather the effects of a compli- 
 cation to which the patients have yielded. 
 
 4. The alterations within the thorax, abdomen, and 
 pelvic cavity are evidently independent of insanity. 
 These alterations may, nevertheless, indicate the 
 
IN WOMEN. 55 
 
 source of mental alienation, by showing the organ 
 primitively affected, which has reacted upon the 
 brain. 
 
 5. All the organic lesions obsei"ved among the in- 
 sane are found to exist among those who have never 
 suffered from chronic delirium. 
 
 6. Many post-mortem examinations of the insane 
 have revealed no alteration, although the insanity 
 may have persisted for a great number of years. 
 
 7. Pathological anatomy shows us every part of 
 the encephalon altered, in a state of suppuration, and 
 destroyed, without chronic lesion of the understanding. 
 
 8. From the above data we may conclude that there 
 are cases of insanity whose immediate cause escapes 
 our means of investigation ; that insanity depends 
 upon an unknown modification of the brain ; that it 
 has not always its point of departure in the brain, 
 but rather in the foci of sensibility, situated in differ- 
 ent regions of the body, as disorders of the circula- 
 tion do not always depend upon lesions of the heart, 
 but upon those of some other portion of the vascular 
 system.* 
 
 Lelut, who has also closely investigated this sub- 
 ject, sums up the result of his researches in the fol- 
 lowing words : — 
 
 " I. Numerous alterations of the brain and its envelopes 
 are met with in delirium and insanity, especially in extreme 
 
 * Mental Maladies, p. 7a 
 
56 REFLEX INSANITY 
 
 forms of the latter; but these alterations are neither con« 
 stant nor exclusive. 
 
 "2. Hence it mustbe allowed that the more or less local and 
 coarse alterations in the skull, the brain, and its membranes, 
 cannot be held to be the proximate causes of insanity. They 
 are, doubtless, capable of existing with a delirious or insane 
 condition; but they do not constitute this condition, and 
 frequently they are only the exaggeration, the effect, or the 
 transl<jimation of it. 
 
 "3. That which may be given as the nearest approach to 
 the proximate cause of delirium, and to the most acute form 
 of insanity, is inflammatory lesion of the brain and its tu- 
 nics. But this alteration neither does nor can constitute the 
 state which is anterior to it, and may even destroy life with- 
 out producing lu 
 
 " 4. The conditions of the brain which approach the most 
 closely to the proximate cause of the chronic forms of men- 
 tal alienation, with or without impairment of motion, are 
 without doubt chronic inflammation of the substance and 
 of the membranes of the brain, its atrophy and induration, 
 which may be accompanied by variations in its specific 
 gravity. But yet these alterations are not the proximate 
 cause of these forms of insanity, because they are neither 
 constant nor exclusive, and they do not make themselves 
 apparent except in an advanced period of the disease." * 
 
 These generalizations are carried to a still further 
 extent by another writer upon the subject (Leuret), 
 who states, — 
 
 I. That the authors who believe it possible to es- 
 tablish an anatomical chano^e as the cause of insanity 
 diflbr greatly among themselves. Thus Greding as- 
 serted that thickness of tlie bones of the cranium 
 occurs in seventy-seven out of one hundred patients, 
 
 * Essay on the Value of Cerebral Alterations in Acute Delirium and Insanity. 
 
IN WOMEN. 57 
 
 while Haslam found this condition in ten only out of 
 one hundred patients. Hyperasmia of the brain is 
 recorded by Parchappe in forty-three cases out of one 
 hundred, and by Bertoleni only in fourteen out of one 
 hundred. 
 
 2. That some of the cerebral alterations to which 
 insanity is attributed are by no means well established. 
 Thus, in the cases which are cited of hypertrophy of 
 the brain, it ought to have been shown that this was 
 not owing to fulness of its vessels, or to the presence 
 of a serosity in its tissue. These observations have 
 not been made. Again, that which is called dense 
 brain, or a soft brain, expresses nothing distinctly, 
 except in extreme cases. 
 
 3. That the value attributed to certain alterations is 
 deduced from a number of observations by far too 
 small, so that one result frequently invalidates anoth- 
 er. Thus Parchappe has deduced the average normal 
 weight of the healthy brain from thirteen observa- 
 tions upon men, and nine upon women, and on this 
 average he establishes the rule for atrophy of the 
 brain. This average is evidently too small, and, in- 
 deed, Parchappe himself gives different averages else- 
 where. 
 
 4. That the pathological alterations referred to in- 
 sanity are met with in patients who have never been 
 insane. 
 
 5. That all authors confess that there are insane 
 
58 REFLEX INSANITY 
 
 persons in whose brains no pathological changes are 
 found. 
 
 6. That the lesions which are frequently met with 
 among the insane, to which any value can be at- 
 tached, are only met with in cases in which insanity 
 has been complicated with paralysis ; and that, in 
 order to decide if any lesion is the cause of insanity, 
 it is at least necessary to find it in a case of simple 
 mental aberration, in which there has been no affec- 
 tion of motion or sensibility.* 
 
 The only answer that has been made, or that can 
 be made, to these arguments, namely, that more mi- 
 nute methods of examination may perhaps be discov- 
 ered which may show what the most powerful micro- 
 scope as yet does not, is very unsatisfactory ; the 
 more so in view of the fact that the supposition of 
 reflex causation is sufficient to account for every mys- 
 tery, as it is allowed to do in neuralgia, tetanus, cho- 
 rea, and hysteria. Dr. Bucknill is here at fault, and, 
 like every other writer who falls back upon the brain 
 as tlie seat of causation in insanity, proves inconsist- 
 ent with himself.f It is possible that Brown-Sequard 
 and John Dean, of Boston, may yet localize more 
 disturbance in the brain, as they have so much in the 
 spinal cord ; but they cannot all. 
 
 What conclusion, then, with Esquirol, shall we 
 
 * The Moral Treatment of Insanity, 
 t Loc cit., pp. 398-400. 
 
IN WOMEN. 59 
 
 draw from the facts that have now been presented ? 
 That the changes observed in the brain and its mem- 
 branes are found in subjects who have given no indi- 
 cation of delirium ; that organic lesions of the en- 
 cephalon appertain to paralysis and convulsions rather 
 than to dementia ; and that the character and intensity 
 of the delirium are not in proportion to the extent of 
 the organic lesion. What shall we conclude ? That 
 the examinations of the bodies of the dead, which 
 have so often furnished important information respect- 
 ing the seat of disease, present no result which is sat- 
 isfactory respecting the source and immediate cause 
 of insanity. If in dementia there are indications of 
 compression, sinking and collapse of the encephalon, 
 is this state caused by the engorgement of the vascu- 
 lar system, or by the lessening of the cerebral circu- 
 lation? Do not the arteries, having lost their elasti- 
 city or being ossified, propel with sufficient energy the 
 blood which flows languidly in veins already too 
 greatly dilated? Does not the inflammation of the 
 meninges, by thickening the membranes, or by pro- 
 voking a too abundant serous exhalation, induce the 
 compression .'' Does not the contracting of the cranial 
 cavity, by the separation of the internal table, partic- 
 ularly of the cranial portion, contribute to compress 
 the brain ? Post-mortem examinations teach us little 
 in this respect ; all the organic alterations of the 
 
60 REFLEX INSANITY 
 
 brain or its dependencies appertaining less to the 
 delirium than to its complications.* 
 
 Dr. Nichols, of Washington, Superintendent of the 
 Government Hospital for the Insane, has expressed 
 his opinion upon this subject in no uncertain lan- 
 guage, " believing it highly important both to science 
 and humanity. Therapeutists and pathologists," we 
 are told, " are approaching, from different starting- 
 points, a like rational, and what is much the most 
 important, the true theoy of the proximate cause of 
 insanity, upon which better defined and more rational 
 principles of a more successful treatment of the dis- 
 ease will be based." 
 
 Recent English writers upon this subject have 
 taken a middle ground between certain German au- 
 thors, who believe in a disorder of the mental entity 
 itself, and that much larger class who have vainly ex- 
 pected to connect special forms of mental aberration 
 with pathognomonic changes of cerebral structure, 
 and tell us that " microscopical appearances ought to 
 be regarded more as the effect than the source of the 
 malady " (Hitchman ) ; that " insanity is a disease 
 of nervous origin " (Munro) ; and that it is " a neu- 
 ralgia of the sensory fibres of the brain " (Dewey). 
 
 "And I venture to predict," says Dr. Nichols, "that we 
 are on the eve of the demonstrable discovery, that all insan- 
 ity, whether of physical or moral semeiology, is proxiniate- 
 
 * Mental Maladies, p. 433. 
 
IN WOMEN, 6l 
 
 ]y owing to a derangement of the functional activity of 
 the cerebral organ as a generator of what we are accustomed 
 to call nerve power, nervous fluid, &c. 
 
 " That function may be exalted or depressed, through the 
 whole or a part of the brain, as we have general mental ex- 
 citement or general depression, or one or more of the infi- 
 nite variety of intervening shades and forms of aberration. 
 This purely functional derangement may, and probably not 
 unfrequently does, run into inflammation, but they have no 
 necessary connection, and the more furious mania ttiay, in 
 my opinion, exist without any more inflammatory origin or 
 organic change than obtains in a fit of jumping' tooth- 
 ache, which occurs in a moment and goes in the next, with- 
 out leaving any trace of its existence.'' * 
 
 VVe are thus compelled, at times, to seek the ulti- 
 mate causation of insanity outside the brain. 
 
 "The special student of insanity," says Bucknill, "will 
 do well to study the causes of delirious thought and per- 
 verted feeling, in all classes of bodily disorder where they 
 are observable. If he studies insanity alone, he will be apt 
 to fall into the common error of attributing its causation to 
 some single pathological state, and his views will be as 
 wrong as they are narrow. But, if he studies perverted feel- 
 ing as occasioned b}' gouty or hepatic disease or loss of in- 
 tellectual power, and fatal coma occasioned by suppression 
 of the urine, and the delirium of fevers, he will be led to 
 appreciate the full extent of blood-change in the produc- 
 tion of purely mental affections. In the delirium of cere- 
 britis, he will see a form of insanity undoubtedly produced 
 by inflammation; and in delirium tremens, he will see an- 
 other form of insanity, as undoubtedly produced by nervous 
 exhaustion. He will thus be enabled to reject exclusive the- 
 ories of insanity, and be prepared to admit the [truth] of 
 the broad principle, that insanity may be occasioned by any 
 and every pathological state which is capable of taking 
 
 • Amer. Journ. of Insanity, xi. s^- 
 
63 REFLEX INSANITY 
 
 place within the substance of the brain, however ultimately 
 occasioned."* 
 
 The various evidences that I have now adduced 
 should tend to convince that, as I have nowhere found 
 expressed so clearly as by Morel, the brain is al- 
 ways THE SEAT OF INSANITY, BUT IT IS NOT ALWAYS 
 THE SEAT OF ITS CAUSE, t 
 
 V. — Explanations of Distant Causation. 
 
 Whence else, then, can insanity arise than in the 
 brain ? 
 
 It has been supposed by some that it is generally 
 the effect of toxaemia. This is undoubtedly at times 
 the cause, and probably much more often than has 
 been generally supposed. Besides the instances 
 where its existence is self-evident, there are others. 
 Simpson, of Edinburgh, has of late shown, with his 
 usual masterly skill, the important relations held by 
 that condition of the blood evinced by albuminuria, 
 whether occasioned or not by pressure of the en- 
 larged uterus upon the kidneys, to the existence and 
 causation of puerperal mania. J Esquirol, long ago, 
 called attention to the active effect produced by the 
 inhalation of carbonic acid towards the induction of 
 insanity, § and Dr Workman, in the letter from which 
 
 ' * Loc. cit., p. 349. 
 
 t Trait* des Maladies Mentiles, p. 69. 
 t Clinical Lectures on Diseases of "Women, 1863, p. 443. 
 § "We have already seen that those occupations which expose the person to 
 
IN WOMEN. 63 
 
 I have quoted, speaks of the tendencies towards de- 
 lirium in organic pulmonary disease, and the fre- 
 quency that has been observed of latent phthisis in 
 the insane ; points, both of them, that are probably 
 to be explained by deficient elimination of carbon 
 from the blood. It will not be strange, moreover, if 
 it is found that in a similar manner may be inter- 
 preted much of the insanity that obtains in women, 
 although I am not aware that this suggestion has 
 before been made. It is well known that there is a 
 close sympathy between the uterine and pulmonary 
 systems, depending in part, it may be presumed, 
 upon the varying quantities of carbon discharged by 
 respiration and through the catamenial fluid. The 
 evidences of this sympathy are manifold, and familiar 
 to every gynaecologist ; they are furnished alike in 
 health and disease, explaining many types of the 
 latter that were otherwise inexplicable, and account- 
 ing, as, for the first time, I have endeavored to show, 
 for the fact that even were we to allow chloroform to 
 be dangerous or deadly for the purposes of general 
 surgery, it becomes as safe as ether, to which it is for 
 this purpose so superior, in childbed, being here 
 perfectly innocuous, if properly given.* 
 
 The so frequent uterine asthma, coincident or con- 
 
 the fumes of charcoal, predispose to insanity. We ought to add, that asphyxia 
 by carbon, is very liable to cause dementia, and that too in its incurable form." 
 — Mental Maladies, p. 54. 
 • Eutokia ; the employment of Anaesthetics in Childbirth, 1863, p. aa 
 
64 REFLEX IWSAMTY 
 
 nected with the catamenial period, is an instance not 
 irrelevant. I have long believed and taught, that in 
 women the access or progress of pulmonary phthisis 
 is frequently dependent upon and to be controlled by 
 the menstrual condition, and I find that Dr. Work- 
 man has announced that more insane women than 
 men die of pulmonary disease,* which is so far con- 
 clusive evidence. 
 
 ^^It has been noticed," I now quote from Robinson, 
 the physician to the Bensham Asylum at Gateshead, 
 but every one is familiar with the fact, " that among 
 the insane generally, the circulation of the blood is 
 feebly performed, and in melancholia more particu- 
 larly, the extremities are, from this cause, cold and 
 benumbed, while the surface of the head is often 
 unnaturally heated. Again, in acute mania notably, 
 and also in other recent forms of mental disorder, 
 the quality of the blood is evidently much impaired. 
 Our means of chemical analysis are too crude to 
 enable us to express in scientific formulae the precise 
 additions and subtractions which constitute this par- 
 ticular cachexia. Suffice it to state that the peculiar 
 odor and the unequivocal symptoms of disordered 
 digestion, secretion, and excretion present in these 
 cases, clearly show that the blood cannot be properly 
 formed and purified, and that its condition and quality 
 
 • American Journal of Insanity, July, 1862. 
 
IN WOMEN. 65 
 
 must therefore be faulty. In some forms of insanitjf 
 there also exists an unnatural sensibility, or irritability 
 of ihe mind and nervous system, and, in a certain 
 proportion of cases, violent mental impressions have 
 originally induced the disease. 
 
 •• Moreover, we occasionally observe in every form 
 of mental disturbance a serious impairment of the 
 innate vitality of the bodily tissues generally, so that 
 a slight bruise or a degree of pressure, which, under 
 ordinary circumstances, would produce no morbid 
 effect whatever, will, in the insane, be followed by 
 mortification of the parts and ultimate death." * This 
 condition, however, is more apt to be the effect of the 
 insanity than its cause. 
 
 On the other hand, " it should also be remembered 
 that in many of the insane, in whom there is indis- 
 putable lesion of the understanding, the most careful 
 scrutiny will fail to discover any disorder of the cir- 
 culation, as indicated by the pulse and respiration, or 
 of the functions of secretion and excretion, as indicated 
 by the tongue, alvine evacuations, or the renal secre- 
 tion. And, with the exception of the class of cases to 
 be referred to, it may be safely affirmed, that among 
 those patients whose moral nature appears to be 
 specially invaded by disease, derangement of the phys- 
 ical health is almost as frequent as among those whose 
 
 • Prevention and Treatment of Mental Disorders, p, 153. 
 
 5 
 
66 REFLEX INSANITY 
 
 intellect is manifestly disordered. And the termination 
 of cases of moral insanity in some unmistakable phys- 
 ical disease, as general paralysis, will not unfrcquently 
 solve any doubt which may have been felt previously, 
 in regard to the disease of one or more of the bodily 
 organs. 
 
 " The exceptional class we have spoken of, includes 
 those cases of perverted moral feeling whose history 
 extends back to their earliest infancy, and probably to 
 congenital malformation of the brain,"* which, if not 
 of a foetal character, may be owing to the pressure 
 exerted upon that organ during the latter stage of a 
 difficult labor, or by the application of instruments 
 during delivery. 
 
 We are not then to find in diseases of the blood, or 
 derangement of its circulation, a causation sufficient 
 to account for all cases of insanity which are ulti- 
 mately of extra-cerebral origin. We must seek for 
 other methods of explanation, one of which is un- 
 doubtedly the hereditary tendency so often recognized, 
 and which may exist under very different circum- 
 stances than those ordinarily noticed. Thus, for in- 
 stance, the mental disturbance may depend not merely, 
 as I have said, upon the pressure to which the child's 
 head has been subjected during childbirth, a pressure 
 sufficient, in many cases, to effect its death, and in 
 others to produce convulsions or paralysis, eithei 
 
 • Tuke, loc. cit., p. 189. 
 
IN WOMEN. 67 
 
 during infancy, or, perhaps, at some long subsequent 
 period : but it may be owing to an effect produced in 
 utero, either by some mental aftection, however tem- 
 porary, of the mother, just as we know such to act, 
 during lactation, upon the nursing infant, or by some 
 functional or organic affection of the placental or 
 uterine system. Upon this point I could say much, 
 but shall content myself by again presenting evidence 
 from Dr. Tuke. 
 
 " Should it be said that disease involves a changed con- 
 dition or proportion of function or structure in one or more 
 parts of the body, it is to be observed that this change may 
 have taken place at a period when it would escape notice, or 
 even during fcetal life. During the latter period, diminished 
 nutrition of the body, or diminished nutrition of one part 
 and increased nutrition of another, may have occurred, and 
 thus resulted in the production of an undue proportion or 
 predominance of a function. Hypertrophy of some textures 
 has been observed, frequently coexisting with atrophy of 
 others, perverted nutrition being often combined with ex- 
 cessive or defective, and several of these different changes 
 often occurring in succession, in consequence of the opera- 
 tion of the same causes. There is, indeed, during foetal 
 life — and we may practically widen this period, and say 
 during that which elapses before the character is or can be 
 observed — abundant opportunity for the influence of per- 
 verted nutrition ; whether it be in the formation of cell- 
 germs, their passage into cells, or the subsequent processes 
 connected with the growth and organization of the tissues; 
 or, again, whether the elements of the circulating blood be 
 in an abnormal proportion; or, lastly, whether it be the 
 mysterious but well-recognized principle, in virtue of which 
 there is an hereditary predisposition to disease, which rules 
 over and perverts the nutritive processes. Thus, in a case 
 of what would probably be regarded as congenital moral im- 
 
68 REFLEX INSANITY 
 
 becilitj, the mother of the f)atient was the subject of malig- 
 nant disease of the uterus during gestation. Now it is pos- 
 sible that this condition of the mother interfered with the 
 proper nutrition of the cerebral tissue of the foetus, and was 
 one, among other causes, which contributed to the final 
 result. Persons born with talipes, or strabismus, owe their 
 defect to some defect of embryo life. In like manner, during 
 the same period of existence, the brain may undergo patho- 
 logical changes which induce defective mental or moral 
 power."* 
 
 " The emotional theory, which Bucknill believes to 
 be the true explanation of the metaphysical nature of 
 insanity, goes to prove only this — that emotional 
 disturbance is the frequent source and the constant 
 accompaniment of mental disease. It is so far prac- 
 tical as opposed to the theory upon which the dogmas 
 of courts of law have been founded, that insatiity is a 
 perversion solely of the thinking faculties, but it is 
 quite consistent with, and indeetl subservient to, the 
 opinion that the proximate cause of all mental disease 
 is to be referred solely to the abnormal state of the 
 brain," f the ultimate cause in many instances having 
 to be sought also in bodily and structural change, but 
 in parts far distant from that organ. 
 
 In justice to an earlier author, Pinel, it should be 
 remarked that, however mistaken his views upon the 
 pathology of insanity may have been, they had at 
 least the merit of referring a bodily disease to a bodily 
 origin. In the preface to the second edition of his 
 
 • Tuke, loc. cit, p. 186. t Ibid., p. 447- 
 
IN WOMEN. 69 
 
 work, he thus wisely expresses an emphatic condem' 
 
 nation of metaphysical theories on this point : — 
 
 " The most difficult part of natural history is, without 
 doubt, the art of well observing internal diseases, and of 
 distinguishing them by their proper characters. But mental 
 alienation presents new and diverse difficulties and obstacles 
 to surmount, either in the unusual gestures and tumultuous 
 agitations which it occasions, or in a kind of disordered and 
 incoherent chatter, or in a repulsive or savage exterior. If 
 one desires to account for the phenomena observed, one has 
 to fear another rock — that of intermingling metaphysical 
 discussions and divagations of ideology with a science of 
 facts." * 
 
 He goes still further, and with an acumen re- 
 markable in view of the limited method of diagnosis 
 then known, he foreshadows the great theory of a 
 frequent pelvic origin, for he refers the primitive seat 
 of mania '' to the region of the stomach and intestines, 
 from whence, as from a centre, the disorder of the 
 understanding is propagated by a species of irradia- 
 tion. A feeling of constriction, &c., manifests itself 
 in these parts, soon followed by a disorder and trouble 
 of ideas." t In that day, it will be remembered, the 
 methods, by which at the present time the differential 
 diagnosis of most of the diseases of the abdomen is 
 so clearly and so easily established, were in practice 
 almost wholly unknown. 
 
 We have thus been brought to the doctrine that 
 mental disturbance may be occasioned secondarily 
 
 • Tuke, p. 394 t Ibid., p. 393. 
 
70 REFI-EX INSANITY 
 
 and reflexly, by sympathy with disturbances of other 
 organs than the brain. Let us listen upon the gen- 
 eral subject, to Dr. Bucknill. 
 
 "That the organ of the mind is thrown into diseased 
 action by sympathy with, that is, by suffering with, other 
 diseased or injured parts, is scarcely less certain than that 
 the stomach, the heart, or the spinal marrow are so affected. 
 The modus operandi of this cause of disease is by no means 
 clearly intelligible, either in relation to the brain or to other 
 organs; the explanations usually offered being little more 
 than diversified verbal formularies of the fact. Thus, when 
 we say that the irritation of the cervix uteri is reflected upon 
 the stomach, occasioning vomiting and distress in that or- 
 gan, we come no nearer to an explanation of the mode of 
 action than when we say that the stomach sympathizes with, 
 or suffers in conjimction with, or in consequence of, irrita- 
 tion of the organ first affected. And, in like manner, when 
 we say that the brain suffers sympathetically with the uterus 
 or stomach, we use a mere verbal formula for the colligation 
 of two facts, with the intimate nature of whose connection 
 we are wholly unacquainted. The knowledge which we 
 actually possess on this subject may, in general terms, be 
 thus stated : the most important organs of the body are 
 liable to be thrown into states of functional disturbance by 
 irritation or injury of other, and frequently of distant parts. 
 The liability to this disturbance depends, in the first place, 
 upon what is called constitutional irritability, or a state of 
 the system in which slight causes of nervous action produce 
 great effects; and, in the second place, upon the intimate 
 connection of the organ secondarily affected, with the ner- 
 vous system, and its liability to be thrown into disorder by 
 any alteration or disturbance in the state of that system. 
 Any premature attempts to explain this important patho- 
 logical fact by hypothesis, respecting nervous currents, or 
 the exhaustion of nervous power, seem at present rathet 
 likely to obscure than elucidate the matter. We may, how- 
 ever, come one step nearer to the view of the fact, by con* 
 
IX WOxMEN. 71 
 
 sidering all sympathetic disturbance as taking place in the 
 nervous system itself; and in viewing the functional dis- 
 turbance of secreting and other organs, as merely the ex- 
 pression of abnormal states of the nerves in those organs. 
 Strictly speaking, therefore, sympathetic vomiting or palpi- 
 tation is as purely a nervous phenomenon as loss of 
 consciousness or convulsions; and the latter, as mental 
 excitement or delusion. 
 
 "In early life, the cerebro-mental functions are more in- 
 timately connected with those of the spinal system than at 
 subsequent periods, and distant irritations are more frequent 
 and efficient causes of mental disturbance in the infant than 
 in the adult. Delirium and coma are, in children, fre- 
 quency produced by intestinal irritation. In the adult, in 
 comparison with convulsions, delirium is so rarely a conse- 
 quence of simple irritation, that it furnishes one strong 
 proof that the brain proper exercises its functions with 
 great independence of the excito-motory or spinal system. 
 The most frequent and unquestionable instances of cerebral 
 disturbance from distant irritation or sympathy, are afforded 
 in epilepsy and hysteria. In both of these diseases the 
 paroxysm is compounded of disturbance both of the cere- 
 bral and spinal functions; but during the interval, cerebral 
 disturbance alone is frequently present, and in the paroxysm 
 itself it is never wanting. In epilepsy, especially, is this the 
 case; for loss of consciousness, which is the primary and 
 leading feature of the paroxysm, is the most serious and 
 profound indication of cerebral disturbance, no less, in fact, 
 than the temporary abnegation of all cerebral function. In 
 hysteria, loss of consciousness is of less certain occurrence, 
 although sometimes it is doubtless complete. In the inter- 
 val of hysteria, however, cerebral disturbance is not less 
 marked than in epilepsy. The emotions are perverted, and 
 even delirium is by no means uncommon. Now both of 
 these diseases are frequently but the expression of sympathy 
 with irritation of distant parts of the nervous system. The 
 one is produced by irritation of the nerves of the uterus and 
 its appendages, and the other by the irritation of almost 
 
72 REPLBX INSANITY 
 
 any portion of the peripheral nerves, by worms in the intes- 
 tines, renal calculus, painful injuries, and diseases of the 
 limbs, &c. Therefore these diseases present unquestionable 
 instances of mental disturbance, occasioned by sympathy 
 of the brain with irritation of the distant nerves; of the 
 central organ of the system, suffering in its noblest func- 
 tions, in sympathy with some fibres of its peripheral ex- 
 tension. 
 
 "The most probable explanation of these sympathetic 
 disorders is, that injury to one part of the nervous system 
 interferes with the processes of secondary nutrition taking 
 place in other parts. The rapidity with which they occur 
 may. at first sight, seem adverse to this view; for instance, 
 in the case related by Dr. Gooch, and so familiar to psychol- 
 ogists, where Dr. Denman passed a ligature round a polypus 
 of the fundus of the uterus; as soon as he tightened it, he 
 produced pain and vomiting. As soon as the ligature was 
 slackened, the pain ceased; but whenever he attempted to 
 tighten it, the pain and vomiting returned. The ligature 
 was left on, but loose. The patient died about six weeks 
 afterwards, and, on opening the body, it was found that the 
 uterus was inverted, and that the ligature had included the 
 inverted portion. Sympathetic disturbances of the func- 
 tions of the brain are, in some instances, scarcely less rap- 
 idly occasioned, or capable of receiving more immediate 
 relief. Thus the irritation of a cutting tooth will sometimes 
 produce in a child delirium and coma; and the removal of 
 the irritation, by incision of the inflamed gum, will remove 
 the symptoms almost as speedily as in the examples above 
 quoted. But when it is considered that the processes of 
 secondary nutrit'on are those upon which the functions of 
 all organs immediately depend, and that any interference 
 with these processes must necessarily and immediately dis- 
 turb the normal course of the functions, the short interval 
 which is frequently observed to exist between the produc- 
 tion of irritation and its sympathetic consequences will pre- 
 sent no difficulty to the theory which explains the latter in 
 the manner here suggested. In our present state of igno- 
 
IN WOMEN. 73 
 
 ranee of the manner in which influences are communicated 
 from one part of the nervous system to other parts, it is im- 
 possible to explain how the processes of secondary nutrition 
 in the nervous structure are interfered with in distant parts 
 thereof. But this difficult^' scarcely diminishes the proba- 
 bility that the explanation offered is the true one; and, 
 indeed, only presents one of those imperfect links in reason- 
 ing, which the immaturity of physiological science renders 
 of such constant occurrence in all departments of medicine. 
 The operation of remedies is consistent with this view of 
 sympathetic disturbance, since those narcotic substances 
 which retard the processes of waste and repair in the ner- 
 vous system afford the most efficient means of preventing the 
 nervous function from suffering hi consequence of periph- 
 eral nervous injury. Moreover, this view 6f pathological 
 sympathy is consistent with the only rational view of phys- 
 iological sympathy. Secretions are the result of secondary 
 nutrition. Many secretions are normally excited by the 
 irritation of nerves more or less distant; that of the mam- 
 ma, for instance, of the testis, and, to some extent, of the 
 gastric glands. Here, then, at least, are processes of sec- 
 ondary nutrition, energetically influenced by the irritation 
 of distant nerves." * 
 
 Marshall Hall himself could scarcely have afforded 
 us a juster and more thorough argument for all the 
 effects I have claimed, of pelvic agencies as ulti- 
 mately causing insanity in w^omen, than the remarks 
 above given. 
 
 It has been argued that those of us who see in re- 
 flex action an explanation of what would be other- 
 wise inexplicable anomalies, must be in error on the 
 ground that, by allowing a distant lesion ever to pro- 
 duce disturbance of the brain, we ought always to 
 
 • Loc cit., pp. 38>-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<i have effected 
 actual cures, that Esquirol remarked, justly enough, " I should as soon think of 
 recommending patients to be precipitated from the third story of a house, be- 
 cause some lunatics have been known to be cured by a fa.l on the head." 
 
 II 
 
l63 REFLEX INSANITY 
 
 choly to take ' a natural interest in the affairs of life.' It is 
 curious to be told, also, that the inconvenient effects men- 
 tioned were induced more certainly when the patient was in 
 the erect position. Worse consequences occasionally re- 
 sulted, I believe, from this barbarous invention; which 
 probably rendered Dr. Hallaran's recommendation, that no 
 'well-regulated institution, intended for the reception and 
 relief of insane persons,' should be unprovided with a ma- 
 chine of that description, ineffectual. Allusion is made to 
 the practice in Esquirol's work,* in which he describes ' la 
 machine de Darwin ' as reseinbling the jeu de bague, or 
 treadmill, and he speaks of it as having passed from the 
 arts into medicine. It found some temporary favor on the 
 continent; but the violent evacuations produced by its em- 
 ployment, followed by fainting and excessive debility, led to 
 its disuse. Dr. Cox had advised its being used in some 
 'hopeless' cases, in the dark, with the addition of unusual 
 noises, smells, etc., that every sense might be assailed; but 
 I do not think that this advice was ever acted upon." f 
 
 In the women's galleries in Bethlem, the same au- 
 thor tells us, they found in one of the side rooms 
 " about ten patients, each chained by one arm or leg 
 to the wall ; the chain allowing them merely to stand 
 up by the bench or form fixed to the wall, or to sit 
 down on it." For a dress, each had only a sort of a 
 blanket-gown, made like a dressing-gown, but with 
 nothing to fasten it round the body. The feet were 
 without shoes or stockings. Some of these patients 
 were lost in imbecility, dirty, and offensive ; associa- 
 ted with them were others capable of coherent con- 
 versation, and sensible, and accomplished. Many 
 women were locked up in their cells, chained, with- 
 
 • Conolly, pp. 12-15. t Loc. cit., vol. i. p. 156. 
 
IN WOMEN. 163 
 
 out clothing, and with only one blanket for a cov- 
 ering.* 
 
 " At that time, when a young and accomplished woman, 
 for example, affected with acute mania, violent, noisy, mis- 
 chievous, regardless of cleanliness, arrived at a large asy- 
 lum, she was forcibly undressed, fastened down on loose 
 straw, had strong medicine forced down her throat, and was 
 then left and neglected for many hours. The straw tortured 
 her from head to foot, but she could not move her hands. 
 Her position galled and fretted her; but her feet were fas- 
 tened, and she could not change it. Sickness and purging 
 were produced by the medicine ; and she was permitted to 
 lie for twelve hours in a state of indescribable distress, then 
 taken up, laid on the stone pavement, mopped or broomed, 
 and, last of all, when quite subdued and half dead, had, 
 perhaps, a bath and some few decent attentions." f 
 
 And again : — 
 
 "The history of each patient, and the afflictions which 
 had caused their minds to give way, would now receive at- 
 tention in all good asylums. But the day had not arrived 
 for such kind sympathies, and on arriving at the large and 
 crowded house the patient was undressed, with small show 
 of gentleness, by several young women, and placed at once 
 in a crib, on straw, and fastened to it by the feet, her hands 
 being confined by iron hand-locks, and a tight waistcoat put 
 around the trunk of the body and round her arms, the offices 
 of the nurses concluding for the time with the administra- 
 tion of a dose of purgative salts. When the patient, not yet 
 forgetful of the decencies of life, asked what she was to do 
 if she wanted to get out of bed, the nurses, hardened by 
 their vocation, merely answered her in the most vulgar terms. 
 Having, in this miserable restraint, become dirty, which 
 was inevitable, the patient was taken out of bed, carried to 
 the pump, and pumped upon with cold water, and then, un« 
 
 • Loc. cit., p. 26. t Ibid., p. 48. 
 
164 REFLEX INSANITY 
 
 dried, taken back to her crib, and fastened down again, but 
 on fresh straw ; an attention not then in all cases considered 
 necessary. All her remonstrances to the women about her 
 were laughed at. Long afterwards she still remembered her 
 own expressions and theirs, her appeals to them as women, 
 her prayers for pity, and their too ready reply, which shut 
 out hope — 'You don't know what a mad-house is yet, but 
 we will teach you.' In the same room there were, she re- 
 membered, several maniacs, all in chains or restraints of 
 some kind, singing, swearing, beating the walls. This 
 scene, and her aggravated wretchedness, made her worse; 
 and as she could not get up and move about, she could only 
 sing or shout aloud like the rest. For six weeks siie was 
 kept in that place of torment, and in those restraints; and, 
 like most of the patients of those old asylums, the story of 
 her restraints was written in broad indelible scars on her 
 wrists, but in still worse characters on her memory." * 
 
 That such abuses, thus related by a superintendent 
 himself, were more common with women than with 
 men, there can be no question. It is still so, to the 
 degree, more or less marked as this may be, to which 
 they still exist. And there are reasons why it might 
 be expected that such should be the case, as is im- 
 plied by the author from whom we have been quoting. 
 
 Dr. Conolly says, — 
 
 " On the female side of the house, where the greatest 
 daily amount of excitement and refractoriness was to be 
 met and managed, the cases of recent insanity in young 
 women, and especially the cases of puerperal insanity, and 
 those arising from lactation, were, perhaps, the first to at- 
 tract particular notice in reference to the new system. Any- 
 where but where restraints are indiscriminately employed, 
 such cases would seem the likeliest to be regarded with 
 
 • Loc. cit., p. 124. 
 
IN WOMEN. 165 
 
 interest and compassion, and to be treated with gentleness. 
 But as thej are usually attended with a great degree of ex- 
 citement, and with a lively propensity to every kind of mis- 
 chief, and consequently occasion much trouble, these cases 
 had become more especially and constantly subjected to 
 severe coercion.* 
 
 " The subjects of this coercion were, some of them, wo- 
 men of middle age, who had been handsome, and who pos- 
 sessed considerable acuteness of intellect, ingenuity, and 
 activity, but whose lives had been a sort of troubled ro- 
 mance ; profligate, intemperate, violent, regardless of do- 
 mestic ties, their children abandoned to all the evils of home- 
 less poverty, themselves by degrees given up to utter reck- 
 lessness, they had been the cause of ruin and shame to their 
 families, and the history of their wild life had closed with 
 madness. Others, and not a few, were the victims of the 
 vices of those of a station superior to them, and left al 
 length to struggle with difficulties, and mortifications, an-d 
 remorse, beneath which reason gave way. In these patients 
 all violent methods produced greater obstinac}', greater de- 
 termination to give trouble, to do mischief, and to commit 
 all kinds of outrages. f 
 
 "Delicate young women, affected with mania, were tied 
 to the bed, or half-smothered by servant-women and men, 
 or fastened down by sheets twisted into the shape of cables, 
 and tightly bound round the body and round the bed. In 
 this miserable condition cleanliness is neglected, and the 
 patient suffers from heat and thirst, and becomes exhausted 
 by vain struggles. The patient becomes rapidly emaciated 
 and perfectly frantic. Nothing can allay the irritation cre- 
 ated by the useless crowd, by the disorder of the room, and 
 the closeness of the atmosphere, and all the horrors which 
 in the course of a few dreadful days have been needlessly 
 accumulated about the chamber of a patient laboring under 
 an excited brain, and whose malady all these things do but 
 increase. But in these unhappy cases the friends still often 
 
 • Loc. cit, p. 107. t Ibid, p. 127, 
 
l66 REFLEX INSANITY 
 
 oppose measures of a difterent kind, preferring the absolute 
 secrecy thrown over the malady before all sensible consid- 
 erations. Their prejudices and weakness find support in 
 the arguments or insinuations of the attendants, who are 
 glad to be relieved from trouble, and who commonly neglect 
 to provide against any danger, except by debarring the pa- 
 tient from muscular movement as much as possible, and as 
 long as possible. If, happily, such cases are transferred to 
 the care of attendants who have been taught not to rely 
 upon, or even to have recourse to, restraints, the alteration 
 effected in a day or two is such as to make it difficult to be- 
 lieve that the patient is the same person seen before. If the 
 patient is removed from home to a tranquil asylum, the 
 change is greater still. At home the patient is, perhaps, 
 the cause of indescribable confusion : all domestic regularity 
 is interrupted, the servants speak in whispers, the neighbors 
 avoid the house. Days and nights are passed in anxiety or 
 terror. But the patient who has unconsciously caused all 
 this disturbance becomes, when taken to an asylum con- 
 ducted on good principles, quite an altered person ; disturb- 
 ing nobody, and behaving peaceably, and even seeming 
 happy among new associates, and in scenes unconnected 
 with the real or imaginary griefs of the home so lately 
 quitted. Such sudden improvement certainly almost ex- 
 ceeds belief; but the instances of it are not even rare. Ev- 
 ery physician conversant with practice in cases of insanity, 
 must have witnessed these almost marvellous metamor- 
 phoses many times." * 
 
 Let it not be supposed that the fearful pictures I 
 have now shown of the attention paid the most sa- 
 cred of human temples by medical men are either 
 overdrawn or from a wholly by-gone age. They 
 merely represent what I have myself witnessed upon 
 more than one occasion here in Massachusetts w^ithin 
 
 • Loc cit, p. 329. 
 
IN WOMEN. 167 
 
 the past few years. Such cases, resulting irom the 
 neglect or omission of the profession to prevent their 
 occurrence, become in reality acts of commission 
 upon its part. I make no reflection upon the man- 
 agement of asylums, for it is well known that gross 
 abuses of the kind described are no longer permitted 
 to occur therein ; but there are hundreds of insane 
 women in each of our ' States, some of whom have 
 already been in hospitals, others of whom have never 
 received even the partial and necessarily imperfect 
 examination it is there customary to make, who are 
 now under treatment outside these hospitals, or rather 
 under no medical treatment whatever, but subject 
 only to the brutalities of the town's officials who 
 have them in charge. For further evidence upon this 
 subject, I need merely refer to the report of the Com- 
 mission of which I was then a member.* If such 
 outrages still exist in Massachusetts, there is reason 
 to believe they are not wholly unknown in other 
 States of the Union,t and it is the duty of the profes- 
 sion to look to it that they are at once made to cease. 
 I would not, however, while allowing the preven- 
 tion at hospitals of the open abuse of female patients, 
 be understood to admit that all is there accomplished 
 
 * Renort of the Commissioners (Quincy, Hitchcock, and H. R. Storer) on 
 Insanity to the Legislature of Massachusetts. Pub. Doc. 1864, Senate, No. 72. 
 
 t The facts in the case are but too patent. They were acknowledged to exist 
 in two other States at the moment the above was written (American Journal of 
 Insanity, Jan., 1865). They undoubtedly exist in everv State of the Union. 
 
l68 REFLEX INSANITY 
 
 that might and ought to be done. Far from this. 
 Neglect, systematic and customary though it may be, 
 of any means or measure that may tend to the cure 
 of a patient, or a class of patients, is in reality almost 
 as grievous a wrong as a harm intentionally inflicted. 
 Between omission and commission there is at times 
 but very little difference as regards the injury that is 
 done. 
 
 Let me here quote, as pertinent to this question, 
 from a late report of the State Hospital for the Insane 
 of California — a report characterized by Dr. Earle, 
 of the Northampton Asylum, as " essentially different 
 in character from any other from the California hos- 
 pital which has come under our observation, its par- 
 ticular object appearing to be an exposition of the 
 defects of the hospital as a curative establishment." * 
 
 " Its beautiful edifice," says Dr. Tilden, the super- 
 intendent, " its well-cultivated yards and gardens, its 
 wholesome food, its comfortable clothing, its scrupu- 
 lously clean halls, rooms, beds, and bedding, its ex- 
 cellent police regulations, combine in making a prison 
 of the first class ; and, if such was the original pur- 
 pose, I see not how it could have been more admira- 
 bly accomplished. If, however, in creating a charity 
 so munificent, so noble, it was intended to establish 
 an asylum, with hospital appliances, for the cure^ as 
 well as the care and safe-keeping of the insane, I am 
 
 * American Journal of the Medical Sdences, April, 1865, p. 445 
 
IN WOMEN. 169 
 
 free to say it is, in my opinion, a most signal failure.' 
 And again, he says, " If there is any marked differ- 
 ence between it and a well-conducted State prison, it 
 is in favor of the latter, from the fact that means of 
 employment are provided for its inmates, while the 
 inmates of the asylum spend their days in idleness." 
 And again, " It will hardly be contended, I think, 
 that our newspapers and a little gymnasium, with a 
 solitary swing in the female department, can give the 
 asylum of California a claim to the character of a 
 curative institution." 
 
 " The general use of mechanical restraint," says Dr. 
 Tuke, " arose from the idea impressed upon the keep- 
 ers of asylums, no less by the highest authorities than 
 by a venerable antiquity, that it was the necessary and 
 best mode of treatment. It was connected," he con- 
 tinues, ''• with a theoretical ignorance of the nature 
 and pathology of insanity." * The same should be 
 said of tlie neglect to extend to an insane woman the 
 same method of examination and of treatment which 
 would be considered imperative for the same woman 
 laboring under any other possibly reflex form of 
 disease. 
 
 I have quoted upon this point the pithy corollary 
 of Dr. Azam, that for organic causative disease, phys- 
 ical means only are effectual ; and I have given the 
 corroborative testimony of Dr. Tuke, regarding the 
 
 * Manual of Psychological Medicine, p. 76. 
 
lyo REFLEX INSANITY 
 
 chronic and supposed incurable cases of insanity in 
 women now at the Morningside Asylum. Let me 
 submit a word or two in addition from still other 
 superintendents. We are told that, — 
 
 "With regard to the detection of internal disease, great 
 care is required, as many of those symptoms on which the 
 practitioner generally relies as aids to diagnosis are wholly 
 suppressed. Insane persons frequently evince either great 
 insensibility to, or power of enduring pain, and hence the 
 light afforded by painful and morbid sensations is absent 
 in the internal and constitutional diseases affecting per- 
 sons of unsound mind. From this cause, examinations 
 after death occasionally reveal organic lesions and changes 
 which had not previously been supposed to exist, and it re- 
 quires careful attention to the physical'signs present, and a 
 close observation of disordered functions and constitutional 
 peculiarities, in order to discover the disease which is, per- 
 haps, secretly undermining the vital powers.* 
 
 " In the purely medical aspects of the subject," it has been 
 remarked by the same author, " there appears in some quar- 
 ters an indolent and ultra-expectant mode of regarding 
 mental diseases, which, if pursued to its legitimate conse- 
 quences, must end in the utter repudiation of medical sci- 
 ence and skill in their treatment. For in the reports of 
 some large asylums, I observe that medical treatment is in- 
 timated to be of little avail, one or two drugs being men- 
 tioned as the only medicinal agencies employed. If this be 
 the correct principle, if medical science can afford no greater 
 aid in the cure of insanity, it is surely incumbent on the 
 medical officers who entertain these views at once to resign 
 their appointments as such, and henceforth leave the care 
 of the insane to persons of ordinary education. For my 
 own part I entertain a very different opinion. I believe that 
 even in this apparently unpromising department of medi- 
 cine great results may be achieved ; and that by a more 
 
 * Kobinson: Prevention and Treatment of Mental Disorders, p. tSj. 
 
IN WOMEN. 171 
 
 perfect acquaintance with the laws regulating the phenom- 
 ena of the healthy mind, by a more extended knowledge of 
 the properties of the innumerable substances, natural and 
 artificial, which are capable of acting upon the nervous 
 structures, and through them upon the mental phenomena, 
 and by a more careful investigation of the circumstances 
 influencing the production of morbid changes in the ner- 
 vous system, a merely disordered and structurally uninjured 
 brain may be rendered as amenable to curative agencies as a 
 disordered liver or kidney." * 
 
 Bucknill says, — 
 
 " The medicinal treatment, therefore, must be founded, 
 not upon the general resemblance of symptoms in different 
 cases, t but upon their points of dissemblance, and upon the 
 discrimination of ultimate diagnosis; not the primary diag- 
 nosis which recognizes a case of insanity, but upon the ulti- 
 mate diagnosis which, as nearly as possible, refers the symp- 
 toms of each individual case to the exact pathological con- 
 dition from which they arise." J 
 
 Esquirol exclaims, — 
 
 " What misfortunes and obstacles must those practitioners 
 have encountered who have been only able to see one indi- 
 vidual disease in all the insanities which they have nad to 
 treat! They were not ignorant that, delirium being symp- 
 tomatic of almost all diseases when approaching a fatal 
 termination, insanity might be also entirely symptomatic; 
 they were not ignorant that there are instances of insanity 
 evidently sympathetic; they knew that a thousand exciting 
 and predisposing causes give rise to insanity; but paying no 
 attention except to the most obvious symptoms, they have 
 permitted themselves to be imposed upon by the impetuos- 
 ity, the violence, the mobility of these; they have neglected 
 the study of the causes of insanity, and that of the relation 
 of the causes with the symptoms. Under the domination 
 
 * Robinson : Prevention and Treatment of Mental Disorders, p. 225. 
 t It will be noticed wliat a blow is this remajk to the usual syFteni of classifi' 
 cation of the insane. t Loc. cit.. p 45j- 
 
172 REFLEX INSANITY 
 
 of theories, some have only been able to see the existence 
 of inflammation, have accused the blood, and abused the 
 lancet; others, believing in irritating bile, have checked the 
 secreting organs, and injured their functions. They have 
 been prodigal of emetics and drastics. Some, having only 
 taken into account the nervous influence, have given anti- 
 spasmodics in excess. All have forgotten that the practi- 
 tioner ought to have present to his mind grand general 
 views — the systematic ideas which dominate, which consti- 
 tute medical science, the art which ought especially to de- 
 vote itself to a thorough knowledge of the circumstances, 
 and of the symptoms, which are capable of disclosing the 
 causes, the seat, and the nature of the malady which it has 
 to combat. Often one must vary, combine, modify the 
 means of treatment; for there is no specific treatment of 
 insanity. As this malady is not identical in all persons, so 
 it has in every individual its different causes and characters; 
 so new combinations are required, and a new problem is to 
 be solved for each insane person under treatment."* 
 
 What grand general views, let me ask, what sys- 
 tematic ideas, what search for different causes and 
 characters, and for new combinations, the resort to 
 what means of solving the problem, do we find in 
 the usual and most ancient method of treating insane 
 women ? That I am neither doing injustice by this 
 question, nor venturing an opinion without a sufficient 
 reason, I may be permitted to refer the profession to 
 extended papers by leading authorities upon the sub- 
 ject, who may be supposed to have given a fair state- 
 ment of the present methods of medically treating 
 the insane. As instances in point, I will name Dr. 
 Forbes Winslow's articles on the Treatment of In- 
 
 * Maladies Mentales. 
 
IN WOMEN. 173 
 
 sanity, Ancient and Modern,* and on the Medical 
 Treatment of Insanity ; f those by Schroeder van der 
 Kolk, X even the excellent one to which I have already 
 referred in another part of this report, and that by 
 Dr. Ranney, Physician to the City Lunatic Asylum 
 of New York,§ which enjoyed the honor of being re- 
 produced, with the full discussion to which it gave 
 rise at the meeting of American Superintendents, to 
 whom it was first communicated, in one of the Eng- 
 lish psychological journals. || In none of them do we 
 find recognition of the claims of a decided and spe- 
 cial treatment for insane women, although, in the 
 case of Winslow, it will be recollected that he had 
 acknowledged the special causation of much of their 
 mental disturbance, as suggested by Laycock. 
 
 I would not deny the occurrence in psychological 
 literature of sentences like the following, for I have 
 already quoted many of them ; but they have as yet 
 fallen without fruit, and dead. " Sex," says Dr. Rob- 
 ertson, " is doubtless an indication of treatment in the 
 many cases connected with uterine disease." ^ 
 
 Dr. Conolly, as usual, here speaks sensibly and in- 
 telligibly. 
 
 * Journal of Psychological Medicine, Jan., 1850. 
 t Ibid, April, 1854. 
 
 t British and Foreign Medico-Chirurgical Review ; American Journal of In* 
 sanity, July, i860. 
 § Ibid,- July, 1857. 
 
 II Asylum Journal of Mental Science, April, 1858, p. 450. 
 H Ibid., Jan., 1859, p. 277. 
 
174 REFLEX INSANITY 
 
 " The physician's office is assuming in these times a higher 
 character in proportion as he ceases to be a mere prescnber 
 of medicines, and acts as the guardian or conservator of 
 public and of private health; studious of all agencies that 
 influence the body and the mind, and which, affecting in- 
 dividual comfort and longevity, act widely on societies of 
 human beings. Changes are gradually taking place even 
 in special walks of medical practice, in conformity to the 
 enlightened principles by which the exertions of the officers 
 of general health are directed; and these principles find an 
 application, and are strikingly illustrated, in the modern 
 asylums and modern treatment of the insane. Obscurity 
 may yet hang over the origin of mental derangement; the 
 explanation of sudden recoveries may continue difficult; the 
 alterations incidental to portions of nervous matter may 
 baffle investigation, and the possible varieties in the con- 
 dition of the blood, often apparently associated with mental 
 disturbance, may be yet unknown, or incapable of satisfac- 
 tory elucidation; but general means have been revealed to 
 men of science, conducing to important modifications and 
 ameliorations of mental malady."* 
 
 It is possible that I may be able to afford some light 
 as to the frequency with which these means are at 
 present resorted to in the case of insane women. I 
 have spoken of the neglect of special measures, as in 
 reality the prevalent treatment of insane women. Of 
 such a method as is the present, Dr. Bucknill speaks 
 as follows : — 
 
 "Although specific drugs are out of vogue, narrow and 
 stereotyped modes of treatment are scarcely less dangerous; 
 and in no class of disease does the treatment need to be 
 more infinitely varied than in insanity. In other wide 
 classes, some broad rules may be laid down for the treat* 
 
 • Treatment of the Insane, p. 79. 
 
IN WOMEN. 175 
 
 ment; and although physicians may differ respecting these 
 rules, they will be found to adhere to one or other set of 
 opinions respecting them. Thus, one feeds in fevers, another 
 depletes; but in insanity, cases which present symptoms, 
 at first sight, of close resemblance, demand most opposite 
 modes of treatment; and cases which at first present symp- 
 toms most unlike, sometimes require to be treated in the 
 same manner. An educated and exact observation is re- 
 quired to distinguish between the acute delirium which 
 arises from cerebral hyperaemia and that which arises from 
 cerebral excitement in sympathy with intense irritation of 
 some part of the periphery of the nervous system ; or from 
 the cerebral excitement which is but an expression of the 
 defective nutrition of the organ from poverty of the blood; 
 or cerebral excitement propagated to all parts of the organ 
 from some focus of irritation, some Joyer of disease in itself, 
 as a small portion of inflamed substance or membrane, or 
 the structural mischiefs surrounding an apoplectic clot. In 
 all these instances the symptoms may bear a strong resem- 
 blance to each other, and yet how different is the mode of 
 treatment demanded in each of them."* 
 
 It has been asserted, that in claiming for insane 
 women the same general principles of treatment by 
 which we would conduct disease to a successful issue 
 where the mind is unimpaired, I am myself endeavor- 
 ing to substitute for the present general neglect a 
 narrow and stereotyped method of practice. Every 
 one familiar with the modern treatment of the dis- 
 eases of women, will detect and deny this wretched 
 libel. It is just the man who does not treat symp- 
 toms, but searches faithfully and persistently for their 
 ultimate cause, who is the true general practitioner — < 
 
 * Loc. cit, p. 452. 
 
176 REFLEX INSANITY 
 
 he, alone, who can avoid the charge of blind groping 
 and routine. 
 
 In one of my previous communications upon in- 
 sanity as of reflex causation in v^omen, the statement 
 was made, with all respect for the ability and zeal of 
 those more especially engaged in the management of 
 the insane, that little has as yet been undertaken or 
 accomplished at our public hospitals for the cure of 
 insane women. 
 
 " Does he mean to say," asks an anonymous critic, 
 whom I have noticed only because he claims to have 
 been both Assistant Physician and Superintendent of 
 a New England Asylum, and to represent the opinion 
 of a large circle of his fraternity — "does he mean 
 to say that superintendents have not discharged, as 
 cured, as many women as men.'* Where are the 
 statistics?"* 
 
 To the statistics thus called for, although I have 
 already in this communication expressed an emphatic 
 belief as to their real value, I am yet not unwilling to 
 refer. 
 
 I should have produced them ere this, had I not 
 preferred that they should be called for by any gentle- 
 man who might venture to deny the justice of my 
 conclusions. Those who appeal to statistics, cannot 
 refuse to be governed by their evidence. 
 
 I proceed to draw additional proof of the correct 
 
 * Boston Medical and Surgical Journal, sth January, 1865, p 453 
 
IN WOMEN. 177 
 
 ness of my views concerning the management of 
 insane women : — 
 
 A. From the statistical evidence of asykims, and 
 
 B. From the direct evidence of those having asy- 
 lums in charge.* 
 
 A. In the first place, I would say that any remarks 
 I may have made respecting the medical management 
 of insane women at asylums, apply not merely to our 
 own American hospitals, but to those of other coun- 
 tries also — so that no argument in disproof can be 
 drawn from the comparisons I shall proceed to fur- 
 nish, inasmuch as these, being based upon nearly 
 identical data, can only afford identical results. 
 
 Secondly, I have no doubt, and I am willing to 
 allow, that as many, or nearly as many women as 
 men are yearly discharged from asylums. Any basis 
 that may be named, the number of admissions, for 
 instance, may be taken for the calculation. Selecting 
 
 * A portion of the evidence that will now be presented was read before the Suf- 
 folk District Medical Society of Boston on January 28, 1865. It was communica- 
 ted to the Medical and Surgical Journal of that city as Article IV. of the series I 
 had already initiated, upon the causation and treatment of insanity in women ; 
 the subject being one whose discussion many of the most distinguished phy- 
 sicians in this country are pleased to consider of the very highest importance. 
 On the 15th of February I received the fo'lowing note: "The editors of the 
 Journal came to the conclusion, after the publication of the last article relating 
 to this discussion, that enough space had already been given to it, and that they 
 would decline any further communication on the subject." With this decision I 
 have not found fault, the gentlemen referred* to best understanding their own 
 affairs. So many inquiries, however, concerning my enforced silence have been 
 made of me by their subscribers who had seen my former papers, and by the 
 gentlemen who were present at the reading of that herein embodied, that I 
 should certainly have published through some other medium the facts here pre- 
 sented, had they not been so relevant to the main subject of the present report. 
 
 12 
 
178 REFLEX INSANITY 
 
 at random from a pile of hospital reports, I will give 
 the results of the statistics of the Worcester State 
 Hospital for the space of thirty years, from 1833-62. 
 In a total of over 6cxx> 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. 
 
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