CASE XIX.
W. C. a man aged sixty-three, was admitted into the hospital January 21, 1797. The persons, who attended at his admission, deposed, that he had been disordered five months; that he never had been insane before, and that the disease came on shortly after the death of his son. He was in a very anxious and miserable state. No persuasion could induce him to take nourishment; and it was with extreme difficulty thatany food could be forced upon him. He paced about with an hurried step; was often suddenly struck with the idea of having important business to adjust in some distant place, and which would not admit of a moment’s delay. Presently after, he would conceive his house to be on fire, and would hastily endeavour to rescue his property from the flames. Then he would fancy that his son was drowning, that he had twice sunk: he was prepared to plunge into the river to save him, as he floated for the last time: every moment appeared an hour until he rose. In this miserable state he continued till the 27th, when, with great perturbation, he suddenly ran into his room, threw himself on the bed, and in a few minutes expired. The head was opened twenty-four hours after death. The pericranium was but slightly adherent to the scull: the tunica arachnoidea, particularly where the hemispheres meet, was of a milky whiteness. Between this membrane,which was somewhat thickened, and the pia mater, there was a very large collection of water: the pia mater was inflamed: the veins of this membrane were enlarged beyond what I had ever before observed: there was a striking appearance of air in the veins: the medullary substance of the brain, when cut into, bled freely, and seemed spungy from the number and enlargement of its vessels: in the ventricles, which were of a natural capacity, there was about half an ounce of water: the brain was of a healthy consistence.
CASE XX.
M. L. a woman aged thirty-eight, was admitted into the house June 11, 1796. From the information of the people who had attended her, it appeared, that she had been disordered six weeks, and that the disease took place shortly after the death of herhusband. At the first attack she was violent, but she soon became more calm. She conceived that the overseers of the parish, to which she belonged, meditated her destruction: afterwards she supposed them deeply enamoured of her, and that they were to decide their claims by a battle. During the time she continued in the hospital she was perfectly quiet, although very much deranged. She fancied that a young man, for whom she had formerly entertained a partiality, but who had been dead some years, appeared frequently at her bed-side in a state of putrefaction, which left an abominable stench in her room. Soon after she grew suspicious, and became apprehensive of evil intentions in the people about her. She would frequently watch at her door, and, when asked the reason, replied, that she was fully aware of a design, which had been formed, to put her secretly to death. Under the influence of these opinions she continued to her death,which took place on February 8, 1797, in consequence of a violent rheumatic fever. She was opened twelve hours after death. There were two opake spots on the tunica arachnoidea: the pia mater was slightly inflamed: there was a general congestion of blood in the whole contents of the cranium: the consistence of the brain did not differ from what is found in an healthy state.
CASE XXI.
H. C. a woman of about sixty-five years of age, had been admitted on the incurable establishment in the year 1788. I have not been able to collect any particulars of her former history. During the time I had an opportunity of seeing her, she continued in a very violent and irritable state: it was her custom to abuse every one who came nearher. The greatest part of the day was passed in cursing the persons she saw about her; and when no one was near, she usually muttered some blasphemy to herself. She died of a fever on February 19, 1797, on the fourth day after the attack. She was opened two days after death. The arachnoid membrane was, in many parts, without its natural transparency: the pia mater was generally suffused with blood, and its vessels were enlarged: the consistence of the brain was firm.
CASE XXII.
J. C. a man aged fifty, was admitted into the hospital August 6, 1796. It was stated that he had been disordered about three weeks, and that the disease had been induced by too great attention to business, and the want of sufficient rest. About four yearsbefore, he had been a patient, and was discharged uncured. He was an artful and designing man, and with great ingenuity once effected his escape from the hospital. His time was mostly passed in childish amusements, such as tearing pieces of paper and sticking them on the walls of his room, collecting rubbish and assorting it. However, when he conceived himself unobserved, he was intriguing with other patients, and instructing them in the means, by which, they might escape. Of his disorder he seemed highly sensible, and appeared to approve so much of his confinement, that when his friends wished to have him released, he opposed it, except it should meet with my approbation; telling them, in my presence, that although, he might appear well to them, the medical people of the house, were alone capable of judging of the actual state of his mind; yet I afterwards discovered, that he had instigated them to procure his enlargement,by a relation of the grossest falshoods and unjust complaints. In April 1797, he was permitted to have a month’s leave of absence, as he appeared tolerably well, and wished to maintain his family by his industry. For above three weeks of this time, he conducted himself in a very rational and orderly manner. The day preceding that, on which he was to have returned thanks, he appeared gloomy and suspicious, and felt a disinclination for work. The night was passed in a restless manner, but in the morning he seemed better, and proposed coming to the hospital to obtain his discharge. His wife having been absent for a few minutes from the room, found him, on her return, with his throat cut. He was re-admitted as a patient, and expressed great sorrow and penitence for what he had done; and said that it was committed in a moment of rashness and despair. After a long and minute examination, he betrayed nothing incoherent in his discourse. His wound, fromwhich it was stated, that he had lost a large quantity of blood, was attended to by Mr. Crowther, the surgeon to the hospital. Every day he became more dispirited, and at last refused to speak. He died May 29th, about ten days after his re-admission. His head was opened two days after death. There were some slight opacities of the tunica arachnoides, and the pia mater was a little inflamed: the other parts of the brain were in an healthy state, and its consistence natural.
CASE XXIII.
E. L. was a man about seventy-eight years of age; had been admitted on the incurable establishment January 3, 1767. By report, I have understood that he was formerly in the navy, and that his insanity was caused by a disappointment of some promotionwhich he expected. It was also said that he was troublesome to some persons high in office, which rendered it necessary that he should be confined. At one time he imagined himself to be the king, and insisted on his crown. During the time I had an opportunity of knowing him, he conducted himself in a very gentlemanly manner. His disposition was remarkably placid, and I never remember him to have uttered an unkind or hasty expression. With the other patients he seldom held any conversation. His chief amusement was in reading, and writing letters to the people of the house. Of his books he was by no means choice; he appeared to derive as much amusement from an old catalogue as from the most entertaining performance. His writings always contained directions for his release from confinement; and he never omitted his high titles of God’s King, Holy Ghost, Admiral and Physician. He died June 13, 1797, worn outwith age. He was opened two days after death. The scull was thick and porous. There was a large quantity of water between the different membranes. The membrana arachnoidea was particularly opake: the veins seemed to contain air: in the medullary substance the vessels were very copious and much enlarged: the lateral ventricles contained two ounces of pellucid water: the consistence of the brain was natural.
It has been stated by a gentleman of great accuracy, and whose situation affords him abundant opportunity of acquiring a knowledge of diseased appearances, that the fluid of hydrocephalus appears to be of the same nature with the water which is found in dropsy of the thorax and abdomen[3]. That this is generally the case, there can be no doubt, from the respectable testimony of theauthor of the Morbid Anatomy. But in three instances, where I submitted this fluid to experiment, it was incoagulable by acids and by heat: in all of them its consistence was not altered even by boiling. There was, however, a cloudiness produced; and after the liquor had stood some time, a slight deposition took place of animal matter, which, prior to the application of heat or mineral acids, had been dissolved in the fluid. This liquor tinged green the vegetable blues: produced a copious deposition with nitrat of silver, and on evaporation afforded cubic crystals (nitrat of soda). From this examination it was inferred, that the water of the brain, collected in maniacal cases, contained a quantity of uncombined alkali and some common salt. What other substances may enter into its composition, from want of sufficient opportunity, I have not been enabled to determine.
CASE XXIV.
S. W. a woman thirty-five years of age, was admitted into the hospital June 3, 1797. It was stated that she had been one month disordered, and had never experienced any prior affection of the same kind. The disease was said to have been produced by misfortunes which had attended her family, and from frequent quarrels with those who composed it. She was in a truly melancholy state; she was lost to all the comforts of this life, and conceived herself abandoned for ever by God. She refused all food and medicines. In this wretched condition she continued until July 29th, when she lost the use of her right side. On the 30th she became lethargic, and continued so until her death, which happened on August the 3d. She was opened two days after death. There was alarge collection of water between the different membranes of the brain, amounting at least to four ounces: the pia mater was very much inflamed, and was separable from the convolutions of the brain with unusual facility: the medullary substance was abundantly loaded with bloody points: the consistence of the brain was remarkably firm.
CASE XXV.
D. W. a man about fifty-eight years of age, had been admitted upon the incurable establishment in 1789. He was of a violent and mischievous disposition, and had nearly killed one of the keepers at a private madhouse, previously to his admission into the hospital. At all times he was equally deranged respecting his opinions, although he was occasionally more quiet and tractable: these intervals were extremely irregular as totheir duration and period of return. He was of a very constipated habit, and required large doses of cathartic medicines to procure stools. On August 3, 1797, he was in a very furious state; complained of costiveness, for which he took his ordinary quantity of opening physic, which operated as usual. On the same day he ate his dinner with a good appetite; but about six o’clock in the evening he was struck with hemiplegia, which deprived him completely of the use of his left side. He lay insensible of what passed about him, muttered constantly to himself, and appeared to be keeping up a kind of conversation. The pulse was feeble, but not oppressed or intermitting. He never had any stertor. He continued in this state until the 12th, when he died. He was opened twelve hours after death. There was some water between the tunica arachnoidea and pia mater: the former membrane was opake in many places; bearing the marks of formerinflammation: in the veins of the membranes of the brain there was a considerable appearance of air, and they were likewise particularly charged with blood: the vessels of the medullary substance were numerous and enlarged. On opening the right lateral ventricle, which was much distended, it was found filled with dark and grumous blood; some had also escaped into the left, but in quantity inconsiderable when compared with what was contained in the other: the consistence of the brain was very soft.
CASE XXVI.
J. S. a man forty-four years of age, was received into the hospital June 24, 1797. He had been disordered nine months previous to his admission. His insanity was attributed to a violent quarrel, which had taken place with a young woman, to whom he wasattached, as he shortly afterwards became sullen and melancholy.
During the time he remained in the house he seldom spoke, and wandered about like a forlorn person. Sometimes he would suddenly stop, and keep his eyes fixed on an object, and continue to stare at it for more than an hour together. Afterwards he became stupid, hung down his head, and drivelled like an ideot. At length he grew feeble and emaciated, his legs were swollen and œdematous, and on September 13th, after eating his dinner, he crawled to his room, where he was found dead about an hour afterwards. He was opened two days after death. The tunica arachnoidea had a milky whiteness, and was thickened. There was a considerable quantity of water between that membrane and the pia mater, which latter was loaded with blood: the lateral ventricles were very much enlarged, andcontained, by estimation, about six ounces of transparent fluid: the brain was of its natural consistence.
CASE XXVII.
T. W. a man thirty-eight years of age, was admitted into the house May 16, 1795. He had then been disordered a year. His disease was stated to have arisen, from his having been defrauded, by two of his near relations, of some property, which he had accumulated by servitude. Having remained in the hospital the usual time of trial for cure, he was afterwards continued on the incurable establishment, in consequence of a strong determination he had always shewn, to be revenged on those people who had disposed of his property, and a declared intention of destroying himself. He was in a very miserable state, conceived that he had offendedGod, and that his soul was burning in Hell. Notwithstanding he was haunted with these dreadful imaginations, he acted with propriety upon most occasions. He took delight in rendering any assistance in his power to the people about the house, and waited on those who were sick, with a kindness that made him generally esteemed. At some period of his life he had acquired an unfortunate propensity to gaming, and whenever he had collected a few pence, he ventured them at cards. His losses were borne with very little philosophy, and the devil was always accused of some unfair interposition.
On September 14, 1797, he appeared jaundiced, the yellowness daily increased, and his depression of mind was more tormenting than ever. From the time he was first attacked by the jaundice he had a strong presentiment that he should die. Although he took the medicines which were ordered, as amark of attention to those who prescribed them, he was firmly persuaded they could be of no service. The horror and anxiety he felt was, he said, sufficient to kill him independantly of the jaundice.
On the 20th he was drowsy, and on the following day died comatose. He was opened twenty-four hours after death. In some places the tunica arachnoides was slightly opake: the pia mater was inflamed; and in the ventricles were found about two tea-spoonsful of water tinged deeply yellow, and the vesicles of the plexus choroides were of the same colour: in the whole contents of the cranium there was a considerable congestion of blood: the consistence of the brain was natural: the liver was sound: the gallbladder very much thickened, and contained a stone of the mulberry appearance, of a white colour. Another stone was also found in the duodenum.
CASE XXVIII.
R. B. a man sixty-four years of age, was admitted into the hospital September 2, 1797. He had then been disordered three months. It was also stated, that he had suffered an attack of this disease seven years before, which then continued about two months. His disorder had, both times, been occasioned by drinking spirituous liquors to excess. He was a person of liberal education, and had been occasionally employed as usher in a school, and at other times as a librarian and amanuensis. When admitted he was very noisy, and importunately talkative. During the greatest part of the day he was reciting passages from the Greek and Roman poets, or talking of his own literary importance. He became so troublesome to the other madmen, who were sufficiently occupied with their ownspeculations, that they avoided, and excluded him from the common room; so that he was, at last, reduced to the mortifying situation, of being the sole auditor of his own compositions.
He conceived himself very nearly related to Anacreon, and possessed of the peculiar vein of that poet. He also fancied that he had discovered the longitude, and was very urgent for his liberation from the hospital, that he might claim the reward, to which his discovery was intitled. At length he formed schemes to pay off the national debt: these, however, so much bewildered him that his disorder became more violent than ever, and he was in consequence obliged to be confined to his room. He now, after he had remained two months in the house, was more noisy than before, and got hardly any sleep. These exertions very much reduced him.
In the beginning of January 1798, his conceptions were less distinct, and although his talkativeness continued, he was unable to conclude a single sentence. When he began to speak, his attention was diverted by the first object which caught his eye, or by any sound that struck him. On the 5th he merely muttered; on the 7th he lost the use of his right side, and became stupid and taciturn. In this state he continued until the 14th, when he had another fit; after which, he remained comatose and insensible. On the following day he died. He was opened thirty-six hours after death. The pericranium adhered very loosely to the scull: the tunica arachnoidea was generally opake, and suffused with a brownish hue: a large quantity of water was contained between it and the pia mater: the contents of the cranium were unusually destitute of blood: there was a considerable quantity of water (perhaps four ounces) in the lateral ventricles, whichwere very much enlarged: the consistence of the brain was very soft.
CASE XXIX.
E. T. a man aged thirty years, was admitted a patient July 23, 1796. The persons who attended related, that he had been disordered eleven months, and that his insanity shortly supervened to a violent fever. It also appeared, from subsequent enquiries, that his mother had been affected with madness.
He was a very violent and mischievous patient, and possessed of great bodily strength and activity. Although confined, he contrived several times during the night to tear up the flooring of his cell; and had also detached the wainscot to a considerable extent, and loosened a number of bricks in the wall.When a new patient was admitted, he generally enticed him into his room, on pretence of being an old acquaintance, and, as soon as he came within his reach, immediately tore his clothes to pieces. He was extremely dexterous with his feet, and frequently took off the hats of those who were near him with his toes, and destroyed them with his teeth. After he had dined he generally bit to pieces a thick wooden bowl, in which his food was served, on the principle of sharpening his teeth against the next meal. He once bit out the testicles of a living cat, because the animal was attached to some person who had offended him. Of his disorder he appeared to be very sensible; and after he had done any mischief, always blamed the keepers for not having secured him so, as to have prevented it. After he had continued a year in the hospital he was retained as an incurable patient. He died February 17, 1798, in consequence of a tumor of the neck.He was opened two days after death. The tunica arachnoides was generally opake, and of a milky whiteness: the vessels of the pia mater were turgid, and its veins contained a quantity of air; about an ounce of water was contained in the lateral ventricles: the consistence of the brain was unusually firm and possessed of considerable elasticity: it is the only instance of this nature which has fallen under my observation.
CHAP. III.
ON THE CAUSES OF INSANITY.
When patients are admitted into Bethlem Hospital, an enquiry is always made of the friends who accompany them, respecting the cause supposed to have occasioned their insanity.
It will readily be conceived that there must be great uncertainty attending the information we are able to procure upon this head: and even from the most accurate accounts, it would be difficult to pronounce, that the circumstances which are related to us have actually produced the effect. The friends and relatives of patients are, upon many occasions, very delicate upon thispoint, and cautious of exposing their frailties or immoral habits: and when the disease is a family one, they are oftentimes still more reserved in disclosing the truth.
Fully aware of the incorrect statement frequently made concerning these causes, I have been at no inconsiderable pains to correct or confirm the first information, by subsequent enquiries.
The causes which I have been enabled most certainly to ascertain, may be divided intophysicalandmoral.
Under the first are comprehendedrepeated intoxication;blowsreceived upon the head; fever, particularly when accompanied with delirium; mercury largely or injudiciously administered; the suppression of periodical or occasional discharges and secretions; hereditary disposition, and paralytic affections.
By the second class of causes, which I have termedmoral, are meant those which are applied directly to the mind. Such are the long endurance of grief, ardent and ungratified desires, religious terror, the disappointment of pride, sudden fright, fits of anger, prosperity humbled by misfortunes[4]: in short, the frequent and uncurbed indulgence of any passion or emotion, and any sudden and violent affection of the mind.
There are, doubtless, many other causes of both classes which may tend to produce the disease. Those which have been stated are such as I am most familiar with; or, to speak more accurately, such are the circumstances most generally found to have preceded this affection.
The greatest number of these moral causes may, perhaps, be traced to the errors of education, which often plant in the youthful mind those seeds of madness, which the slightest circumstances readily awaken into growth.
It should be as much the object of teachers of youth, to subjugate the passions, as to discipline the intellect. The tender mind should be prepared to expect the natural and certain effects of causes: its propensity to indulge an avaricious thirst for that which is unattainable should be quenched: nor should it be suffered to acquire a fixed and invincible attachment to that which is fleeting and perishable.
Of the more immediate, or, as it is generally termed, the proximate cause of this disease, I profess to know nothing. Whenever the functions of the brain shall be fullyunderstood, and the use of its different parts ascertained, we may then be enabled to judge, how far disease, attacking any of these parts, may increase, diminish, or otherwise alter its functions. But this appears a degree of knowledge which we are not likely soon to attain. It seems, however, not improbable that the only source from whence the most copious and certain information can be drawn, is a laborious attention to the particular appearances which morbid states of this organ may present.
From the preceding dissections of insane persons, it may be inferred, that madness has always been connected with disease of the brain, and of its membranes. These cases have not been selected from a variety of others, but comprize the entire number which have fallen under my observation. Having no particular theory to build up,they have been related purely for the advancement of science and of truth.
It may be a matter affording much diversity of opinion, whether these morbid appearances of the brain be the cause or the effect of madness: it may be observed, that they have been found in all states of the disease. When the brain has been injured from external violence, its functions have been generally impaired if inflammation of its substance, or more delicate membranes has ensued. The same appearances have for the most part been detected when patients have died of phrenitis, or in the delirium of fever: in these instances the derangement of the intellectual functions appears evidently to have been caused by the inflammation. If in mania the same appearances be found, there will be no necessity of calling in the aid of other causes to account for the effect; indeed it would be difficult to discover them.Those who entertain an opposite opinion, are obliged to suppose,a disease of the mind. Such a morbid affection, from the limited nature of my powers, perhaps I have never been able to conceive. Possessing, however, little knowledge of metaphysical controversy, I shall only offer a few remarks upon this part of the subject, and beg pardon for having at all touched it.
Perhaps it is not more difficult to suppose that matter peculiarly arranged maythink, than to conceive the union of an immaterial being with a corporeal substance. It is questioning the infinite wisdom and power of the Deity to say, that he does not, or cannot arrange and organize matter so that it shall think. When we find insanity, as far as has hitherto been observed, uniformly accompanied with disease of the brain, is it not more just to conclude, that such organic affection has produced this incorrect association ofideas, than that a being, which is immaterial, incorruptible and immortal, should be subject to the gross and subordinate changes which matter necessarily undergoes?
But let us imaginea disease of ideas. In what manner are we to effect a cure? To this subtle spirit the doctor can apply no medicines. But though so refined as to elude the force of material remedies, some may however think that it may be reasoned with. The good effects which have resulted from exhibiting logic as a remedy for madness, must be sufficiently known to every one who has conversed with insane persons, and must be considered as time very judiciously employed: speaking more gravely, it will readily be acknowledged, by persons acquainted with this disease, that if insanity be a disease of ideas, we possess no corporeal remedies for it: and that to endeavour to convince madmen of their errors, by reasoning,is folly in those who attempt it, since there is always in madness the firmest conviction of the truth of what is false, and which the clearest and most circumstantial evidence cannot remove.
ON THE PROBABLE EVENT OF THE DISEASE.
The prediction of the event in cases of insanity must be the result of accurate and extensive experience; and even then it will be a matter of very great uncertainty. The practitioner can only be led to suppose that patients of a particular description will recover, from knowing, that under the same circumstances, a certain number have been actually restored to health.
The practice of an individual, however active and industrious he may be, is insufficientto accumulate a stock of facts, necessary to form the ground of a regular and correct prognosis: it is therefore to be wished, that those who exclusively confine themselves to this department of the profession, would occasionally communicate to the world the result of their observations. Physicians attending generally to diseases, have not been reserved in imparting to the public the amount of their labours and success; but with regard to this disorder, those who have devoted their whole attention to its treatment have either been negligent or cautious of giving information respecting it. Whenever the powers of the mind are concentrated to one object, we may naturally expect a more rapid progress in the attainment of knowledge; we have therefore only to lament the want of observations upon this subject, and endeavour to repair it. The records of Bethlem Hospital have afforded me some satisfactory information, though farfrom the whole of what I wished to obtain. From them and my own observations the prognosis of this disease is, with great diffidence, submitted to the reader.
In our own climate women are more frequently affected with insanity than men. Several persons who superintend private mad-houses have assured me, that the number of females brought in annually considerably exceeds that of the males. From the year 1748, to 1794, comprizing a period of forty-six years, there have been admitted into Bethlem Hospital 4832 women, and 4042 men. The natural processes which women undergo, of menstruation, parturition, and of preparing nutriment for the infant, together with the diseases to which they are subject at these periods, and which are frequently remote causes of insanity, may, perhaps, serve to explain their greater disposition to this malady. As to the proportion in whichthey recover, compared with males, it may be stated, that of 4832 women affected, 1402 were discharged cured; and that of the 4042 men, 1155 recovered. It is proper here to mention that in general we know but little of what becomes of those who are discharged, a certain number of those cured occasionally relapse; and some of those who are discharged uncured afterwards recover: perhaps in the majority of instances, where they relapse, they are sent back to Bethlem. To give some idea of the number so readmitted, it may be mentioned, that, during the last two years, there have been admitted 389 patients, 53 of whom had at some former time been in the house. There are such a variety of circumstances, which, supposing they did relapse, might prevent them from returning, that it can only be stated, with confidence, that within twelve months (the time allowed as a trial of cure) so many have been discharged perfectly well.
To shew how frequently insanity supervenes on parturition, it may be remarked, that, from the year 1784 to 1794 inclusive, 80 patients have been admitted, whose disorder shortly followed the puerperal state. Women affected from this cause recover in a larger proportion than patients of any other description of the same age. Of these 80, 50 have perfectly recovered. The first symptom of the approach of this disease, after delivery, is want of sleep; the milk is afterwards secreted in less quantity, and, when the mind becomes more violently disordered, it is totally suppressed.
From whatever cause this disease may be produced in women, it is considered as very unfavourable to recovery, if they are worse at the period of menstruation, or have their catamenia in very small or immoderate quantities.
At the first attack of the disease, and for some months afterwards, during its continuance, females most commonly labour under amenorrhœa. The natural and healthy return of this discharge generally precedes convalescence.
From the following statement it will be seen, that insane persons recover in proportion to their youth, and that as they advance in years, the disease is less frequently cured. It comprizes a period of about ten years, viz. from 1784 to 1794. In the first column the age is noticed, in the second the number of patients admitted; the third contains the number cured; the fourth those who were discharged not cured.
From this table it will be seen, that when the disease attacks persons advanced in life, the prospect of recovery is but small.
From the very rare instances of complete cure, or durable amendment, among the class of patients deemed incurable, as well as from the infrequent recovery of those who have been admitted, after the complaint has been of more than twelve months standing, I am led to conclude, that the chance of cure is less, in proportion to the length of time which the disorder shall have continued.
Although patients, who have been affected with insanity more than a year, are not admissible into the hospital, to continue there for the usual time of trial for cure, namely, a twelvemonth, yet, at the discretion of the committee, they may be received into it from Lady-day to Michaelmas, at which latter period they are removed. In the course of the last ten years, fifty-six patients of this description have been received, of whom only one has been discharged cured. This patient, who was a woman, has sincerelapsed twice, and is, at present, in the hospital.
When the reader contrasts the preceding statement with the account recorded in the report of the committee, appointed to examine the physicians who have attended his majesty, &c. he will either be inclined to deplore the unskilfulness or mismanagement which has prevailed among those medical persons who have directed the treatment of mania in the largest public institution, in this kingdom, of its kind, compared with the success which has attended the private practice of an individual; or,to require some other evidence, than the bare assertions of the man pretending to have performed such cures[5]. It was deposed by that reverend and celebrated physician, that of patients placed under his care within three months after the attack of the disease, nine out often had recovered[6]; and also that the age was of no signification, unless the patient had been afflicted before with the same malady[7].
How little soever I might be disposed to doubt such a bold, unprecedented, and marvellous account, yet, I must acknowledge, that my mind would have been much more satisfied as to the truth of that assertion, had it been plausibly made out, or had the circumstances been otherwise than feebly recollected by that very successful practitioner. Medicine has generally been esteemed a progressive science, in which its professors have confessed themselves indebted to great preparatory study, and long subsequent experience, for the knowledge they have acquired; but in the case to which we are now alluding, the outset of the doctor’s practice was marked with such splendid success, that time and observation have been unable to increase it.
This astonishing number of cures has been effected by the vigorous agency of remedies, which others have not hitherto been so fortunate as to discover; by remedies which, when remote causes have been operating for twenty-seven years, such as weighty business, severe exercise, too great abstemiousness and little rest, are possessed of adequate power directly tomeet and counteractsuch causes[8].
It will be seen by the table that a greater number of patients have been admitted between the age of thirty and forty, than during any other equal period of life. There may be some reasons assigned for the increased proportion of insane persons at this age.
Although I have made no exact calculation, yet, from a great number of cases, itappears to be the time, when the hereditary disposition is most frequently called into action; or, to speak more plainly, it is that stage of life when persons, whose families have been insane, are most liable to become mad. If it can be made to appear, that at this period people are more subject to be acted upon by the remote causes of the disease, or that a greater number of such causes are then applied, we may be enabled satisfactorily to explain it. At this age people are generally established in their different occupations, are married, and have families; their habits are more strongly formed, and the interruptions of them are, consequently, attended with greater anxiety and regret. Under these circumstances, they feel the misfortunes of life more exquisitely. Adversity does not depress the individual for himself alone, but as involving his partner and his offspring in wretchedness and ruin. In youth, we feel desirous only of present good;at the middle age, we become more provident and anxious for the future; the mind assumes a serious character, and religion, as it is justly or improperly impressed, imparts comfort, or excites apprehension and terror.
By misfortunes the habits of intoxication are readily formed. Those, who in their youth have shaken off calamity as a superficial incumbrance, at the middle age feel it corrode and penetrate: and when fermented liquors have once dispelled the gloom of despondency, and taught the mind either to excite a temporary assemblage of cheerful scenes, or to disdain the terror of impending misery, it is natural to recur to the same, though destructive cause, to reproduce the effect.
Patients, who are in a furious state, recover in a larger proportion than those who are depressed and melancholick. An hundred violent, and the same number of melancholickcases were selected. Of the former, sixty-two were discharged well; of the latter, only twenty-seven. When the furious state is succeeded by melancholy, and after this shall have continued a short time, the violent paroxysm returns, the hope of recovery is very slight. Indeed, whenever these states of the disease frequently change, such alternation may be considered as unfavourable.
Where the complaint has been induced from remote physical causes, the proportion of those who recover is considerably greater, than where it has arisen from causes of a moral nature. In those instances where insanity has been produced by a train of unavoidable misfortunes, as where the father of a large family, with the most laborious exertions, ineffectually struggles to maintain it, the number who recover is very small indeed.
Paralytic affections are a much more frequent cause of insanity than has been commonly supposed. In those affected from this cause, we are, on enquiry, enabled to trace a sudden affection, or fit, to have preceded the disease. These patients usually bear marks of such affection, independent of their insanity: the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capacity of being moved by the will: and in by far the greatest number of these cases the memory is particularly affected. Very few of these cases have received any benefit in the hospital; and from the enquiries I have been able to make at the private houses, where they have been afterwards confined, it has appeared, that they have either died suddenly from apoplexy, or have had repeated fits, from the effects of which they have sunk into a stupid state, and have gradually dwindled away.
When the natural small-pox attacks insane persons, it most commonly proves fatal.
When insanity supervenes on epilepsy, of where the latter disease is induced by insanity, a cure is very seldom effected: from my own observation, I do not recollect a single case of recovery.
When patients during their convalescence become more corpulent than they were before, it is a favourable symptom; and, as far as I have remarked, such persons have very seldom relapsed.
METHOD OF CURE.
This part of the subject may be divided into management, and treatment by medicine.
As most men perceive the faults of others without being aware of their own, so insane people easily detect the nonsense of other madmen without being able to discover, or even to be made sensible of the incorrect associations of their own ideas. For this reason it is highly important, that he who pretends to regulate the conduct of such patients, should first have learned the management of himself. It should be the great object of the superintendant to gain the confidence of the patient, and to awaken in him respect and obedience: but it will readily be seen, that such confidence, obedience, andrespect, can only be procured by superiority of talents, discipline of temper, and dignity of manners. Imbecility, misconduct, and empty consequence, although enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt.
In speaking of the management of insane persons, it is to be understood that the superintendant must first obtain an ascendency over them. When this is once effected, he will be enabled, on future occasions, to direct and regulate their conduct, according as his better judgment may suggest. He should possess firmness; and, when occasion may require, should exercise his authority in a peremptory manner. He should never threaten, but execute: and when the patient has misbehaved, should confine him immediately. As example operates more forcibly than precept, I have found it useful, toorder the delinquent to be confined in the presence of the other patients. It displays authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. It also prevents the wanton exercise of force, and those cruel and unmanly advantages which might be taken when the patient and keeper are shut up in a private room. When the patient is vigorous and powerful, two, or more should assist in securing him; by these means it will be easily effected; for, where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger.
As management is employed to produce a salutary change upon the patient, and to restrain him from committing violence on others and himself, it may be proper here to enquire, upon what occasions, and to what extent, coercion may be used. The termcoercion has generally been understood in a very formidable sense, and not without reason. It has been recommended, by very high medical authority, to inflict corporal punishment upon maniacs, with a view of rendering them rational by impressing terror[9]. What success may have followed such disgraceful and inhuman treatment I have not yet learned, nor should I be desirous of meeting with any one who could give me the information. If the patient be so far deprived of understanding, as to be insensible why he is punished, such correction, setting aside its cruelty, is manifestly absurd. And if his state be such, as to be conscious of the impropriety of his conduct, there are other methods more mild and effectual.
Would any rational practitioner, in a case of phrenitis, or in the delirium of fever,order his patient to be scourged? He would rather suppose that the brain or its membranes were inflamed, and that the incoherence of discourse, and violence of action, were produced by such local disease. We have seen, by the preceding dissections, that the contents of the cranium, in all the instances that have occurred to me, have been in a morbid state. It should therefore be the object of the practitioner to remove such disease, rather than irritate and torment the sufferer. Coercion should only be considered as a protesting and salutary restraint.
In the most violent state of the disease, the patient should be kept alone in a dark and quiet room, so that he may not be affected by the stimuli of light or sound, such abstraction more readily disposing to sleep. As in this violent state there is a strong propensity to associate ideas, it is particularly important to prevent the accession of such as might betransmitted through the medium of the senses. The hands should be properly secured, and the patient should also be confined by one leg: this will prevent him from committing any violence. The straight waistcoat is admirably calculated to prevent patients from doing mischief to themselves; but in the furious state, and particularly in warm weather, it irritates and increases that restlessness, which patients of this description usually labour under. They then scorn the incumbrance of cloathing, and seem to delight in exposing their bodies to the atmosphere. Where the patient is in a condition to be sensible of restraint, he may be punished for improper behaviour by confining him to his room, by degrading him, and not allowing him to associate with the convalescents, and by withholding certain indulgences he had been accustomed to enjoy.
As madmen frequently entertain very high, and even romantic notions of honour, they are rendered much more tractable by wounding their pride, than by severity of discipline.
Speaking of the effects of management on a very extensive scale, I can truly declare, that by gentleness of manner, and kindness of treatment, I have never failed to obtain the confidence, and conciliate the esteem of insane persons, and have succeeded by these means in procuring from them respect and obedience. There are certainly some patients who are not to be trusted, and in whom malevolence forms the prominent feature of their character: such persons should always be kept under a certain restraint, but this is not incompatible with kindness and humanity.
Considering how much we are the creatures of habit, it might naturally be hoped, and experience justifies the expectation, that madmen might be benefited by bringing their actions into a system of regularity. It might be supposed, that as thought precedes action, that whenever the ideas are incoherent, the actions will also be irregular. Most probably they would be so if uncontrouled; but custom, confirmed into habit, destroys this natural propensity, and renders them correct in their behaviour, though they still remain equally depraved in their intellects.
We have a number of patients in Bethlem Hospital whose ideas are in the most disordered state, who yet act, upon ordinary occasions, with great steadiness and propriety, and are capable of being trusted to a considerable extent. A fact of such importance in the history of the human mind, might lead us to hope, that by superinducingdifferent habits of thinking, the irregular associations may be corrected.
It is impossible to effect this suddenly, or by reasoning, for madmen can never be convinced of the folly of their opinions. Their belief in them is firmly fixed, and cannot be shaken. The more frequently these opinions are recurred to under a conviction of their truth, the deeper they subside in the mind and become more obstinately entangled: the object should therefore be to prevent such recurrence by occupying the mind on different subjects, and thus diverting it from the favorite and accustomed train of ideas. As I have been induced to suppose, from the appearances on dissection, that the immediate cause of this disease probably consists in a morbid affection of the brain, all modes of cure by reasoning, or conducting the current of thought into different channels, must be ineffectual, so long as such local disease shallcontinue. It is, however, likely that insanity is often continued by habit; that incoherent associations, frequently recurred to, become received as truths, in the same manner as a tale, which, although untrue, by being repeatedly told, shall be credited at last by the narrator, as if it had certainly happened. It should likewise be observed, that these incorrect associations of ideas are acquired in the same way as just ones are formed, and that such are as likely to remain, as the most accurate opinions. The generality of minds are very little capable of tracing the origin of their ideas; there are many opinions we are in possession of, with the history and acquisition of which, we are totally unacquainted. We see this in a remarkable manner in patients who are recovering: they will often say such appearances have been presented to my mind with all the force and reality of truth: I saw them as plainly as I now behold any other object, and can hardly be persuadedthat they did not occur. It also does not unfrequently happen, that patients will declare, that certain notions are forced into their minds, of which they see the folly and incongruity, and complain that they cannot prevent their intrusion.
It is of great service to establish a system of regularity in the actions of insane people. They should be made to rise, take exercise, and food, at stated times. Independently of such regularity contributing to health, it also renders them much more easily manageable.
As the patient should be taught to view the superintendant as a superior person, the latter should be particularly cautious never to deceive him. Madmen are generally more hurt at deception than punishment; and whenever they detect the imposition, never fail to lose that confidence and respect, whichthey ought to entertain for the person who governs them.
Confinement is always necessary in cases of insanity, and should be enforced as early in the complaint as possible. By confinement, it is to be understood that the patient should be removed from home. During his continuance at his own house he can never be kept in a tranquil state. The interruptions of his family, the loss of the accustomed obedience of his servants, and the idea of being under restraint in a place where he considers himself the master, will be constant sources of irritation to his mind. It is also known, from considerable experience, that of those patients who have remained under the immediate care of their relatives and friends, very few have recovered. Even the visits of their friends, when they are violently disordered, are productive of great inconvenience, as they are always more unquiet andungovernable for some time afterwards. It is a well-known fact, that they are less disposed to acquire a dislike to those who are strangers, than to those with whom they have been intimately acquainted; they become therefore less dangerous, and are more easily restrained.
It frequently happens, that patients who have been brought immediately from their families, and who have been said to be in a violent and ferocious state, become suddenly calm and tractable, when placed in the hospital. On the other hand, it is equally certain, that there are many patients, who have for a length of time conducted themselves in a very orderly manner under confinement, whose disorder speedily recurs after being suffered to return to their families. When they are in a convalescent state, the occasional visits of their friends are attended with manifest advantage. Such an intercourseimparts consolation, and presents views of future happiness and comfort.
Many patients have received considerable benefit by change of situation, and this sometimes takes place very shortly after the removal. In what particular cases, or stages of the disease, this may be recommended, I am not enabled by sufficient experience to determine.
MEDICINE.
It is only intended, in this part of the subject, to speak of those medicines which I have administered, by the direction of Dr. Monro, the present celebrated and judicious physician to Bethlem Hospital, (to whom I gratefully acknowledge many and serious obligations) without descending to a minute detail of the hospital practice, or of the order in which they are commonly exhibited. Of the effects of such remedies, I am able to speak with considerable confidence, as they have come immediately under my own observation.
Bleeding.—Where the patient is strong and of a plethoric habit, and where the disorder has not been of any long continuance, bleeding has been found of considerableadvantage, and, as far as I have yet observed, is the most beneficial remedy that has been employed. The melancholic cases have been equally relieved with the maniacal by this mode of treatment. Venesection by the arm is, however, inferior in its goods effects to blood taken from the head by cupping. This operation, performed in the manner to which I have been accustomed, consists in having the head previously shaven, and six or eight cupping glasses applied on the scalp; By these means any quantity of blood may be taken, and in as short a time, as by an orifice made in a vein by the lancet. When the raving paroxysm has continued for a considerable time, and the scalp has become unusually flaccid; or where a stupid state has succeeded to violence of considerable duration, no benefit has been derived from bleeding; indeed these states are generally attended by a degree of bodily weakness, sufficient toprohibit such practice independently of other considerations.
The quantity of blood to be taken, must be left to the discretion of the practitioner: from eight to sixteen ounces may be drawn, and the operation occasionally repeated, as circumstances may require.
In the few cases where blood was drawn at the commencement of the disease from the arm, and from patients who were extremely furious and ungovernable, it was covered with a buffy coat; but in other cases it has seldom or never such an appearance. In more than two hundred patients, male and female, who were let blood by venesection, there were only six, whose blood could be termed sizy.
In some few instances hemoptysis has preceded convalescence, as has also ableeding from, the hemorrhoidal veins. Epistaxis has not, to my knowledge, ever occurred.
Purging.—An opinion has long prevailed, that mad people are particularly constipated, and likewise extremely difficult to be purged. From all the observations I have been able to make, insane patients, on the contrary, are of very delicate and irritable bowels, and are well and copiously purged by a common cathartic draught. That which is commonly employed in the hospital is prepared agreeably to the following formula.
This seldom fails of procuring four or five stools, and frequently a greater number.
In confirmation of what I have advanced respecting the irritable state of intestines in mad people, it may be mentioned, that the ordinary complaints with which they are affected, are diarrhœa and dysentery: these are sometimes very violent and obstinate.
Diarrhœa very often proves a natural cure of insanity; at least there is every reason to suppose that such evacuation has frequently very much contributed to it. The number of cases which might be adduced in confirmation of this observation is considerable, and the speedy convalescence after such evacuation is still more remarkable.
In many cases of insanity there prevails a great degree of insensibility, so that patients have appeared hardly to feel the passing of setons, the application of blisters, or the operation of cupping. On many occasions I have known the urine retained for aconsiderable time, without the patient complaining of any pain, though it is well known that there is no affection more distressing than distention of the bladder. Of this general insensibility the intestinal canal may be supposed to partake: but this is not commonly the case, and if it should, would be widely different from a particular and exclusive torpor of the primæ viæ.
There are some circumstances unconnected with disease of mind, which might dispose insane persons to costiveness. I now speak of such as are confined, and who come more directly under our observation. When they are mischievously disposed, they require a greater degree of restraint, and are consequently deprived of that air and exercise, which so much contributes to regularity of bowels. It is well known, that those who have been in the habits of free living, and who come suddenly to a more spare diet, arevery much disposed to costiveness. But to adduce the fairest proof of what has been advanced, I can truly state, that incurable patients, who have for many years been confined in the house, are subject to no inconveniences from constipation. Many patients are averse to food, and where little is taken in, the egesta must be inconsiderable.
To return from this degression: it is concluded, from very ample experience, that cathartic medicines are of the greatest service, and ought to be considered as an indispensable remedy in cases of insanity. The good sense and experience of every practitioner must direct him as to the dose, and frequency, with which these remedies are to be employed, and of the occasions where they would be prejudicial.
Vomiting.—However strongly this practice may have been recommended, andhow much soever it may at present prevail, I am sorry that it is not in my power to speak of it favourably. In many instances, and in some where blood-letting has been previously employed, paralytic affections have within a few hours supervened on the exhibition of an emetic, more especially where the patient has been of a full habit, and has had the appearance of an increased determination to the head.
It has been for many years the practice of Bethlem Hospital, to administer to the curable patients four or five emetics in the spring of the year; but, on consulting my book of cases, I have not found that patients have been particularly benefited by the use of this remedy. From one grain and half to two grains of tartarized antimony has been the usual dose, which has hardly ever failed of procuring full vomiting. In the few instances where the plan of exhibiting thismedicine in nauseating doses was pursued for a considerable time, it by no means answered the expectations, which, by very high authority, had been raised in its favour. Where the tartarized antimony, given with this intention, operated as a purgative, it generally produced beneficial effects.
Camphor.—This remedy has been highly extolled, and doubtless with reason, by those who have recommended it. My own experience merely extends to ten cases, a number from which no decisive inference of its utility ought to be drawn. The dose was gradually increased from five grains to two drams twice a day; and in nine cases the use of this remedy was continued for the space of two months. Of the patients, to whom the camphor was given, only two recovered: one of these had no symptoms of convalescence for several months after the use of this remedy had been abandoned; the other, a melancholick patient,certainly mended during the time he was taking it; but he was never able to bear more than ten grains thrice a day. He complained that it made him feel as if he was intoxicated.
Cold Bathing.—This remedy having for the most part been employed in conjunction with others, it becomes difficult to ascertain how far it may be exclusively beneficial in this disease. The instances where it has been separately used for the cure of insanity, are too few to enable me to draw any satisfactory conclusions. I may, however, safely relate, that, in many instances, paralytic affections have in a few hours supervened on cold bathing, especially where the patient has been in a furious state, and of a plethoric habit: in some of these cases vertigo has been induced, and in others a considerable degree of fever. If I might be permitted to give an opinion on this subject, the benefit principally derived from thisremedy has been in the latter stages of the disease, and when the system had been previously lowered by evacuations.
Blisters have in several cases been applied to the head, and a very copious discharge maintained for many days, but without any manifest advantage. The late Dr.John Monro, who had, perhaps, seen more cases of this disease than any other practitioner, and who, joined to his extensive experience, possessed the talent of accurate observation, mentions, that he “never saw the least good effect of blisters in madness, unless it was at the beginning while there was some degree of fever, or when they have been applied to particular symptoms accompanying this complaint[10].”
In a few cases setons have been employed, but no benefit has been derived from theiruse, although the discharge was continued above two months.
Respecting opium, it may be observed, that whenever it has been exhibited during a violent paroxysm, it has hardly ever procured sleep; but, on the contrary, has rendered those who have taken it much more furious: and, where it has for a short time produced rest, the patient has, after its operation, awoke in a state of increased violence.
FINIS.
Footnotes:
[1]This gritty matter, subjected to chemical examination, was found to bephosphat of lime.
[2]This appearance I have found frequently to occur in maniacs who have suffered a violent paroxysm of considerable duration: and in such cases, when there has been an opportunity of inspecting the contents of the cranium after death, water has been found between the dura mater and arachnoid membrane.
[3]Morbid Anatomy, page 304.
[4]
“——Nessun maggior dolore,“Che ricordarsi del tempo felice“Nella miseria.”Dante.
[5]Vide Report, Part 2d, p. 25.
[6]Report, p. 59.
[7]Ibid. 57.
[8]Report, p. 54.
[9]Vide Cullen, first lines, vol. iv. p. 154.
[10]Vide Remarks on Dr.Battie’s Treatise on Madness.