This author further remarks, that he has frequently accompanied melancholics to the theatre and afterwards to the hospitals, wishing to compare the effect produced on them by these opposite exhibitions. He found that the visits to the really afflicted were most useful; for they suggested the idea that themselves were not the most miserable of beings. I must here, however, remark, that the description or sight of the sufferings of others has sometimes a depressing effect on the melancholic suicide, and therefore the experiment of taking them to visit hospitals is not to be tried on all with impunity.

Commonly, those with a propensity to suicide are melancholics, and quiet in their deportment. Such do not perhaps require any personal restraint during the day, and while they are watched; but during the night, although an attendant or other patient sleep in the same room, they ought not to be allowed the free use of their hands. A young lady, very quiet in conduct, and who would amuse herself with needle- work all day, found means to secrete a pair of scissors, and while in bed with her nurse, pierced her heart with them without disturbing her companion.

Sometimes all the fury of mania accompanies the desire of self-destruction; and to accomplish it they will dash their heads against the wall, pitch head foremost from a window, or down stairs, and commit a thousand violences. These must be straitly constrained. In 1821, I saw a lunatic in the Quaker's Retreat, at York, the worst and most determined on suicide I ever heard described. Besides attempting all other means of destroying himself, he would tear his flesh with his teeth, and desperately resist all who wished to restrain him. The confinement imposed on him was proportionably, but properly, severe. On a second visit, the following year, I inquired the fate

of this miserable being, and learnt that he had died of apoplexy.

What further may be advisable for the moral or medical treatment of suicide being equally applicable to insanity generally, I must refer for information to the fifth part of these Commentaries.

H H

COMMENTARY IX.

HYPOCHONDRIASIS.

THIS affection clearly ranks among the vesania. It is characterised by lesion of the judgment respecting personal feelings, with mental depression, without fever or coma. Hence I consider it cannot be omitted when treating on disorders of the intellectual faculties.

The anatomical compound hypochondria denotes the site of the disease; but the synonyms, which are numerous, singularly indicate the incertitude which has at all times prevailed both as to the seat and cause of this malady.

Sydenham and others have considered it and hysteria as identical. Some conceive that hysteria in females is hypochondriasis in males. I think, however, that an attentive consideration of their respective phenomena will prove that they are distinct diseases. Without entering into a closer examination, one fact perhaps will decide this question. Hysteria is an affection almost confining its range of attack from puberty to thirty years of age, and is a local affection. Hypochondriasis never shews itself before the age of twenty-five, is more common in middle life, extends to the age of sixty, and rarely beyond it. Hoffman mentions a case at the age of ten; but it is, if correct, a solitary instance. This affection may be complicated with, alternate, and terminate also in insanity: thus proving that they are of the same family, though distinct in their primary stages.

Hypochondriasis presents many varieties and shades,

of which nostalgia perhaps is one. It were superfluous here to enumerate other modifications of it. All the old, and, with few exceptions, modern authors, have coincided in assigning the seat of hypochondriasis to the abdominal viscera, and this still biases public opinion. Each viscus has had its advocate; but most think that the stomach is the ordinary site and focus.

Villermay, one of the most recent and elaborate writers on hypochondriasis, cites many examples, and ascribes the primitive seat of it to the abdominal viscera, and especially to the stomach;* and that these are affected in their sentient or vital properties. Stahl, however, has particularly noticed the disorder of the circulation among the symptoms of this disease, and ascribes to it much influence. And Villermay himself, in his arrangement of the various causes of hypochondriasis, assigns numerous irregularities in the sanguineous system, and even a state of plethora, general or local, as active or passive agents in its production.

Dr. Parry+ alleges that hypochondriasis, although one effect of that morbid sensibility which characterises the nervous temperament, yet is occasioned by excessive determination of blood to the brain; and in proof of it, refers to the symptoms, flushing of the face, and heat about the head and forehead, with preternatural impulse of blood through the carotid arteries, and a feeling of weight, fulness, or constriction; which sensations are often followed and greatly relieved by a flow of tears; and not only these symptoms, he says, but the accompanying mental distress is thereby removed. The head, indeed,

in this case, is often the centre of defluxions. Violent grief produces the same train of feelings, and sometimes in an equal degree; and will originate sudden madness,

* Traité des Maladies Nerveuses, &c. tom. ii. chap. x.

+ Elements, &c. pp. 325, 326.

unless the surcharged vessels of the head find vent by a copious discharge of tears, or are relieved by timely evacuation of blood.

Georget and Falret both adopt nearly the same view. The latter, in his observations on hypochondriasis, presents a very sensible critique on Villermay's opinions and deductions, and very successfully points out proofs, that it most frequently originates in a disordered state of the circulation, and that the seat of it is in the encephalon.*

Before Parry's work was published, in 1815, I confess I was influenced by the prevalent opinion in the visceral origin of this disease, and treated it according to the existing pathological views of it: but I remember scarcely a case so treated that recovered. Disheartened by the continuance of the disease, the patient generally sought other advice, or it degenerated into melancholia; and in two or three instances I heard that life had been ended by suicide.

Longer and more extensive experience has satisfied me that Parry's views of the pathology of hypochondriasis are generally correct, though I am not prepared to concede that the primary cause is always in a disorder of the circulation. On the contrary, I am convinced this disease is frequently sympathetic, from a morbid condition or action of the organs engaged in the offices of digestion, assimilation, and excretion. The stomach, liver, pancreas, and intestines, may often be primarily in fault, and soon implicate the heart and vascular system: the brain then is consecutively affected.

Palpitation of the heart is one of the first symptoms of this affection. Now the movements of this important organ are well known to be sympathetically increased in force and velocity by a disorder of the digestive functions.

* De l'Hypochondrie, &e. 1822.