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diff --git a/37057.txt b/37057.txt new file mode 100644 index 0000000..879c149 --- /dev/null +++ b/37057.txt @@ -0,0 +1,2595 @@ +The Project Gutenberg EBook of Observations on Insanity, by John Haslam + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org + + +Title: Observations on Insanity + With Practical Remarks on the Disease and an Account of + the Morbid Appearances on Dissection + +Author: John Haslam + +Release Date: August 13, 2011 [EBook #37057] + +Language: English + +Character set encoding: ASCII + +*** START OF THIS PROJECT GUTENBERG EBOOK OBSERVATIONS ON INSANITY *** + + + + +Produced by The Online Distributed Proofreading Team at +https://www.pgdp.net (This file was produced from images +generously made available by The Internet Archive.) + + + + + + + + + +OBSERVATIONS ON INSANITY. + + + + + OBSERVATIONS ON INSANITY: + + WITH PRACTICAL REMARKS ON THE + DISEASE, AND AN ACCOUNT OF THE + MORBID APPEARANCES ON DISSECTION. + + + BY JOHN HASLAM, + + LATE OF PEMBROKE-HALL, CAMBRIDGE, + MEMBER OF THE CORPORATION OF SURGEONS, + AND APOTHECARY TO BETHLEM-HOSPITAL. + + + "Of the uncertainties of our present state the + most dreadful and alarming is the uncertain + continuance of reason." + Dr. JOHNSON's Rasselas. + + + London: + + PRINTED FOR F. AND C. RIVINGTON, NO. 62, + ST. PAUL'S CHURCH-YARD; + AND SOLD BY J. HATCHARD, NO. 173, PICCADILLY. + 1798. + + + + + TO THE + RIGHT WORSHIPFUL THE + _PRESIDENT_, + THE WORSHIPFUL THE + _TREASURER, AND GOVERNORS_ + OF BETHLEM-HOSPITAL. + +MY LORDS AND GENTLEMEN, + +The following OBSERVATIONS are respectfully submitted to YOUR notice, as +the vigilant and humane Guardians of an _Institution_ which performs much +good to society, by diminishing the SEVEREST amongst human calamities, + + By, + My LORDS and GENTLEMEN, + + Your very obedient and humble Servant, + THE AUTHOR. + + + + +PREFACE. + + +As the office I hold affords me abundant means of acquiring information on +the subject of mental disorders, I should feel myself unworthy of that +situation, were I to neglect any opportunity of accumulating such +knowledge, or of communicating to the public any thing which might promise +to be of advantage to mankind. The candid reader is therefore requested to +accept this sentiment, as the best apology I can offer for the present +production. + +It has been somewhere observed, that in our own country more books on +Insanity have been published than in any other; and, if the remark be +just, it is certainly discouraging to him who proposes to add to their +number. It must, however, be acknowledged, that we are but little indebted +to those who have been most capable of affording us instruction; for, if +we except the late Dr. JOHN MONRO'S Reply to Dr. BATTIE'S Treatise on +Madness, there is no work on the subject of mental alienation which has +been delivered on the authority of extensive observation and practice. + +It is not intended to present the following sheets as a treatise, or +compleat disquisition on the subject, but merely as remarks, which have +occurred during the treatment of several hundred patients. As a knowledge +of the structure, and functions of the body, have been held indispensably +necessary in order to become acquainted with its diseases, and to a +scientific mode of treating them; so it would appear, that he who proposes +to write on Madness should be well informed concerning the powers and +operations of the human mind: but the various and discordant opinions, +which have prevailed in this department of knowledge, have led me to +disentangle myself as quickly as possible from the perplexity of +metaphysical mazes. + +As some very erroneous notions have been entertained concerning the state +of the brain, and more especially respecting its consistence in maniacal +disorders, I have been induced to examine that viscus in those who have +died insane, and have endeavoured with accuracy to report the +appearances. It seemed proper to give some general history of these cases; +perhaps the account which has been related of their erroneous opinions +might have been spared, yet some friends whom I consulted expressed a wish +that they had been more copiously detailed. + +Of the difficulty of enumerating the remote causes of the disease I have +been fully aware, and have mentioned but few, that I might be accused of +the fewer mistakes. The prognosis contains some facts which, as far as I +am informed, have not hitherto been made known, and appear to me of +sufficient importance to be communicated to the public. + +As it is my intention at some future period to attempt a more finished +performance on the subject of Insanity, I shall feel grateful for any +hints or observations, with which the kindness of professional gentlemen +may supply me. + + BETHLEM-HOSPITAL, + MARCH 14, 1798. + + + + +OBSERVATIONS ON INSANITY. + + + + +CHAP. I. + + +Readers in general require a definition of the subject, which an author +proposes to treat of; it is the duty therefore of every writer, to define, +as clearly as he is able, that which he professes to elucidate. + +A definition of a disease, should be a concentrated history, a selection +of its prominent features and discriminative symptoms. + +Of the definitions which have been given of this disease, some appear too +contracted; and others not sufficiently precise. + +Dr. Mead, after having treated largely upon the subject, concludes, "That +this disease consists entirely in the strength of imagination." If the +disease consisted entirely in the strength of imagination, the imagination +ought to be equally strong upon all subjects, which upon accurate +observation is not found to be the case. Had Dr. Mead stated, that, +together with this increased strength of imagination, there existed an +enfeebled state of the judgment, his definition would have been more +correct. The strength, or increase of any power of the mind, cannot +constitute a disease of it; strength of memory, has never been suspected +to produce derangement of intellect; neither is it conceived, that great +vigour of judgment can operate in any such manner; on the contrary it will +readily be granted, that imbecility of memory must create confusion, by +obstructing the action of the other powers of the mind; and that if the +judgment be impaired, a man must necessarily speak, and generally act, in +a very incorrect and ridiculous manner. + +Dr. Ferriar, whom, to mention otherwise than as a man of genius, of +learning, and of taste, would be unjust; has adopted the generally +accepted division of Insanity, into Mania and Melancholy. In Mania, he +conceives "false perception, and consequently confusion of ideas, to be a +leading circumstance." The latter, he supposes to consist "in intensity of +idea, which is a contrary state to false perception." From the +observations I have been able to make respecting Mania, I have by no means +been led to conclude, that false perception, is a leading circumstance in +this disorder, and still less, that confusion of ideas must be the +necessary consequence of false perception. + +By perception, I understand, with Mr. Locke, the apprehension of +sensations; and after a very diligent enquiry of patients who have +recovered from the disease, and from an attentive observation of those +labouring under it, I have not frequently found, that insane people +perceive falsely, the objects which have been presented to them. It is +true, that they all have false ideas, but this by no means infers, a +defect of the power by which sensations are apprehended in the mind. + +We find madmen equally deranged upon those ideas, which they have been +long in the possession of, and on which the perception has not been +recently exercised, as respecting those, which they have lately received: +and we frequently find those who become suddenly mad, talk incoherently +upon every subject, and consequently, upon many, on which the perception +has not been exercised for a considerable time. + +It is well known, that maniacs often suppose they have seen, and heard +those things, which really did not exist at the time; but even this I +should not explain by any disability, or error of the perception, since it +is by no means the province of the perception to represent unreal +existences to the mind. It must therefore be sought elsewhere, probably in +the senses, or in the imagination. + +I have known eight cases of patients, who insisted that they had seen the +devil. It might be urged, that in these instances, the perception was +vitiated; but it must be observed, that there could be no perception of +that, which was not present and existing at the time. Upon desiring these +patients to describe what they had seen, they all represented him as a +big, black man, with a long tail, cloven feet, and sharp talons, such as +is seen pictured in books. A proof that the idea was revived in the mind +from some former impressions. One of these patients however carried the +matter a little further, as she solemnly declared, she heard him break the +iron chain with which God had confined him, and saw him pass fleetly by +her window, with a truss of straw upon his shoulder. + +It must be acknowledged, that in the soundest state of our faculties we +sometimes perceive things which do not exist. If the middle finger be +crossed over the forefinger, and a single pea be rolled under their +extremities, we have the perception of _two_. By immersing one hand into +warm, the other into cold water, and afterwards suddenly plunging them +both into the same fluid, of a medium temperature, we shall derive the +sensations of heat, and cold from the same water, at the same time. + +The power, by which the mind perceives its own creations and combinations +is perhaps the same, as that by which it perceives the impressions on the +senses from external objects. We possess the faculty of raising up of +objects in the mind which we had seen before, and of prospects, on which +we had formerly dwelt, with admiration and delight; and in the coolest +state of our understanding we can even conceive that they lie before us. +If the power which awakens these remembrances in a healthy state of +intellect, should stir up distorted combinations in disease, they must +necessarily be perceived; but their apprehension, by no means appears to +imply a vitiated state of the faculty by which they are perceived. In +fact, that which is represented to the mind, either by a defect or +deception of the senses, or by the imagination, if it be sufficiently +forcible and enduring, must necessarily be perceived. + +That "confusion of ideas" should be the necessary consequence of false +perception, is very difficult to admit. Perhaps much may depend, in the +discussion of this point, on the various acceptations in which confusion +of ideas may be understood. + +It has often been observed that madmen, will frequently reason correctly +from false premises, and the observation is certainly true: we have indeed +occasion to notice the same thing in those of the soundest minds. It is +very possible for the perception to be deceived in the occurrence of a +thing, which, although it did not actually happen, yet was likely to take +place; and which had frequently occurred before. The reception of this as +a truth in the mind, if the power of deducing from it the proper +inferences existed, could neither create confusion, nor irregularity of +ideas. + +Melancholy, the other form in which this disease is supposed to exist, is +made by Dr. Ferriar to consist in "intensity of idea." I shall shortly +have an opportunity, in the definition I propose to give, of attempting to +prove, that this division of Insanity, is neither natural nor just, upon +the ground that the derangement is equally complete in both forms of the +disease. We ought to attend more to the state of the intellect, than to +the passions which accompany the disorder. + +By intensity of idea, I presume is meant, that the mind is more strongly +fixed on, or more frequently recurs to, a certain set of ideas, than when +it is in a healthy state. But this definition applies equally to mania, +for we every day see the most furious maniacs suddenly sink into a +profound melancholy; and the most depressed, and miserable objects, +become violent and raving. We have patients in Bethlem Hospital, whose +lives are divided between furious, and melancholic paroxisms; and who, +under both states, retain the same set of ideas. + +Insanity may, in my opinion, be defined to be _an incorrect association of +familiar ideas, which is independent of the prejudices of education, and +is always accompanied with implicit belief, and generally with either +violent or depressing passions_. It appears to me necessary, that the +ideas incorrectly associated, should be _familiar_, because we can hardly +be said to have our ideas deranged upon subjects, concerning which we have +little or no information. A peasant, who had heard that superior comforts +of life, with fewer exertions, were to be obtained by emigrating to +America, might saddle his beast with an intention of riding thither on +horse-back, without any other imputation than that of ignorance; but if +an old and experienced navigator, were to propose a similar mode of +conveyance, I should have little hesitation in concluding him insane. + +Respecting the prejudices of education, it may be observed, that in our +childhood, and before we are able to form a true, and accurate judgment of +things, we have impressed upon our minds, a number of ideas which are +ridiculous; but which were the received opinions of the place in which we +then lived, and of the people who inculcated them; such is the belief in +the powers of witchcraft, and in ghosts, and superstitions of every +denomination, which grasp strongly upon the mind and seduce its credulity. +There are many honest men in this kingdom who would not sleep quietly, if +a vessel filled with quicksilver were to be brought into their houses; +they would perhaps feel alarmed for the chastity of their wives and +daughters; and this, because they had been taught to consider that many +strange and unaccountable properties are attached to that metal. If a +lecturer on chemistry were to exhibit the same fears, there could be no +doubt that he laboured under a disorder of intellect, because the +properties of mercury would be known to him, and his alarms would arise +from incorrectly associating ideas of danger, with a substance, which in +that state is innoxious, and whose properties come within the sphere of +his knowledge. + +As the terms Mania, and Melancholy, are in general use, and serve to +distinguish the forms under which insanity is exhibited, there can be no +objection to retain them; but I would strongly oppose their being +considered as opposite diseases. In both, the association of ideas is +equally incorrect, and they appear to differ only, from the different +passions which accompany them. On dissection, the state of the brain does +not shew any appearances peculiar to melancholy; nor is the treatment +which I have observed most successful, different from that which is +employed in Mania. + + + + +CHAP. II. + +SYMPTOMS OF THE DISEASE. + + +With most authors, this part of the subject has occupied the greatest +share of their labour and attention: they have generally descended to +minute particularities and studied discriminations. Distinctions have been +created, rather from the peculiar turn of the patients propensities and +discourse, than from any marked difference, in the varieties, and species +of the disorder: and it has been customary to ornament this part of the +work with copious citations from poetical writers. As my plan extends only +to a description of that which I have observed, I shall neither amplify, +nor embellish my volume by quotations. + +In most public hospitals, the first attack of diseases is seldom to be +observed; and it might naturally be supposed, that there existed in +Bethlem, similar impediments to an accurate knowledge of madness. It is +true, that all who are admitted into it have been a greater, or less time +afflicted with the complaint; yet from the occasional relapses to which +insane persons are subject, we have frequent and sufficient opportunities +of observing the beginning, and tracing the progress of this disease. + +Among the incurables, there are some who have intervals of perfect +soundness of mind; but who are subject to relapses, which would render it +improper, and even dangerous, to trust them at large in society: and with +those who are upon the curable list, a recurrence of the malady very +frequently takes place. Upon these occasions, there is ample scope for +observing the first attack of the disease. + +To enumerate every symptom would be descending to useless minutiae, I shall +therefore content myself with describing the more general appearances. + +They first become uneasy, are incapable of confining their attention, and +neglect any employment to which they have been accustomed; they get but +little sleep, they are loquacious, and disposed to harangue, and decide +promptly, and positively upon every subject that may be started. Soon +after, they are divested of all restraint in the declaration of their +opinions of those, with whom they are acquainted. Their friendships are +expressed with fervency and extravagance; their enmities with intolerance +and disgust. They now become impatient of contradiction, and scorn +reproof. For supposed injuries, they are inclined to quarrel, and fight +with those about them. They have all the appearance of persons inebriated, +and people unacquainted with the symptoms of approaching mania, generally +suppose them to be in a state of intoxication. At length suspicion creeps +in upon the mind, they are aware of plots which had never been contrived, +and detect motives that were never entertained. At last, the succession of +ideas is too rapid to be examined; the mind becomes crouded with thoughts, +and indiscriminately jumbles them together. + +Those under the influence of the depressing passions, will exhibit a +different train of symptoms. The countenance, wears an anxious and gloomy +aspect. They retire from the company of those with whom they had formerly +associated, seclude themselves in obscure places, or lie in bed the +greatest part of their time. They next become fearful, and, when irregular +combinations of ideas have taken place, conceive a thousand fancies: +often recur to some former immoral act which they have committed, or +imagine themselves guilty of crimes which they never perpetrated; believe +that God has abandoned them, and with trembling, await his punishment. +Frequently they become desperate, and endeavour by their own hands to +terminate an existence, which appears to be an afflicting and hateful +incumbrance. + +The sound mind seems to consist in a harmonized association of its +different powers, and is so constituted, that a defect, in any one, +produces irregularity, and, most commonly, derangement of the whole. The +different forms therefore under which we see this disease, might not, +perhaps, be improperly arranged according to the powers which are chiefly +affected. + +I have before remarked, that the increased vigor of any mental faculty +cannot constitute intellectual disease. If the memory of a person were so +retentive, that he could re-assemble the whole of what he had heard, read, +and thought, such a man, even with a moderate understanding, would pass +through life with reputation and utility. Suppose another to possess a +judgment, so discriminating and correct, that he could ascertain +precisely, the just weight of every argument; this man would be a splendid +ornament to human society. Let the imagination of a third, create images +and scenes, which mankind should ever view with rapture and astonishment, +such a phaenomenon would bring Shakespear to our recollection. + +If in a chain of ideas, a number of the links are broken, the mind cannot +possess any accurate information. When patients of this description are +asked a question, they appear as if awakened from a sound sleep; they are +searching, they know not where, for the proper materials of an answer, +and, in the painful, and fruitless efforts of recollection, generally +lose sight of the question itself. + +In persons of sound mind, as well as in maniacs, the memory is the first +power which decays, and there is something remarkable in the manner of its +decline. The transactions of the latter part of life are feebly +recollected, whilst the scenes of youth, and of manhood, remain more +strongly impressed. To many conversations of the old incurable patients to +which I have listened, the topic has always turned upon the scenes of +early days. In many cases, where the faculties of the mind have been +injured by intemperance, the same withering of the recollection may be +observed. It may perhaps arise, from the mind at an early period of life +being most susceptible and retentive of impressions, and from a greater +disposition to be pleased with the objects which are presented: whereas, +the cold caution, and fastidiousness with which age surveys the prospects +of life, joined to the dulness of the senses, and the slight curiosity +which prevails, will, in some degree, explain the difficulty, or rather +impossibility, of recalling the history of later transactions. + +Insane people who have been good scholars, after a long confinement lose, +in a wonderful degree, the correctness of orthography; when they write, +above half the words are generally mis-spelt--they are written according +to the pronunciation. It shews how treacherous the memory is without +reinforcement. The same necessity of a constant recruit and frequent +review of our ideas, satisfactorily explains, why a number of patients +lapse nearly into a state of ideotism. These have, for some years, been +the silent and gloomy inhabitants of the Hospital, who have avoided +conversation, and sought solitude; consequently have acquired no new +ideas, and time has effaced the impression of those formerly stamped upon +the mind. Mr. Locke well observes, "that there seems to be a constant +decay of all our ideas, even of those which are struck deepest, and in +minds the most retentive; so that if they be not sometimes renewed, by +repeated exercise of the senses, or reflection on those kind of objects, +which at first occasioned them; the print wears out, and at last there +remains nothing to be seen." + +As it has been attempted to explain, how an imbecility or loss of memory +will obstruct the operation of the other powers of the mind: the next +object is to shew, how necessarily our ideas must be disarranged where the +determination on their comparison is wrong, or where the mind determines, +or judges, with little previous examination or comparison. An example or +two will illustrate this more satisfactorily than any length of +reasoning. I remember a patient who conceived, that, although dead men +told no tales, yet their feeling was very acute. This assumed principle he +extended to inferior animals, and refused to eat meat, because he could +not endure to be nourished at the expence of the cruel sufferings, which +beef steaks necessarily underwent in their cookery. Another madman, who +pretended to extraordinary skill in surgery, contrived to steal the wooden +leg of an insane patient, and laid upon it for a considerable time, with a +firm belief of hatching it into a limb of flesh and blood. + +If a man shall form such ideas, and conceive them to be true, either from +a defect in the power of his judgment, or without any comparison or +examination shall infer them to be so, such defect will afford a +sufficient source of derangement. + +Some who have perfectly recovered from this disease, and who are persons +of good understanding and liberal education, describe the state they were +in as resembling a dream; and, when they have been told how long they were +disordered, have been astonished that the time passed so rapidly away. +Others speak of their disorder as accompanied with great hurry and +confusion of mind, where the succession of ideas is so rapid and +evanescent, that when they have endeavoured to arrest or contemplate any +particular thoughts, they have been carried away by the tide, which was +rolling after them. + +All patients have not the same degree of memory of what has passed during +the time they were disordered: but for the most part they recollect those +ideas which were transmitted through the medium of the senses, better than +the combinations of their own minds. I have frequently remarked that, +when they were unable to give any account of the peculiar opinions which +they had indulged during a raving paroxysm of long continuance, they well +remembered any coercion which had been used, or any kindness which had +been shewn them. + +Insane people are said to be generally worse in the morning; in some cases +they certainly are so, but perhaps not so frequently as has been supposed. +In many instances (and, as far as I have observed) in the beginning of the +disease they are more violent in the evening, and continue so the greatest +part of the night. It is however a certain fact, that the majority of +patients of this description have their symptoms aggravated, by being +placed in a recumbent posture. + +They seem themselves to avoid the horizontal position as much as possible +when they are in a raving state: and when so confined that they cannot be +erect, they will keep themselves seated upon the breech. + +Many of those who are violently disordered will continue particular +actions for a considerable time: some are heard to gingle the chain, with +which they are confined, for hours without intermission; others, who are +secured in an erect posture, will beat the ground with their feet the +greatest part of the day. Upon enquiry of such patients, after they have +recovered, they have assured me, that these actions afforded them +considerable relief. We often surprize persons who are free from +intellectual disease in many strange and ridiculous movements, +particularly if their minds be intently occupied:--this does not appear to +be the effect of habit, but of a particular state of mind. + +Madmen do not always continue in the same furious or depressed states: the +maniacal paroxysm abates of its violence, and some beams of hope +occasionally cheer the despondency of the melancholick patients. We have +some unfortunate persons who are obliged to be secured the greatest part +of their time, but who now and then become calm, and to a certain degree +rational: upon such occasions, they are allowed a greater range, and are +permitted to associate with the others. In some instances, the degree of +rationality is more considerable; they conduct themselves with propriety, +and in a short conversation will appear sensible and coherent. Such +remission, has been generally termed a _lucid interval_. + +When medical men are called upon to attend a commission of lunacy, they +are always asked, whether the patient has had a _lucid interval_? A term +of such latitude as _interval_ requires to be explained in the most +perspicuous and accurate manner. In common language it is made to signify, +both a moment and a number of years, consequently it does not comprize +any stated time. The term _lucid interval_ is therefore relative. I should +define a _lucid interval_ to be _a complete recovery of the patient's +intellects, ascertained by repeated examinations of his conversation, and +by constant observation of his conduct, for a time sufficient to enable +the superintendant to form a correct judgment_. Unthinking people are +frequently led to conclude that, if during a conversation of a few +minutes, a person under confinement shall betray nothing absurd or +incorrect, he is well, and often remonstrate on the injustice of secluding +him from the world. Even in common society, there are many persons whom we +never suspect from a few trifling topics of discourse to be shallow +minded; but, if we start a subject, and wish to discuss it through all +it's ramifications and dependances we find them incapable of pursuing a +connected chain of reasoning. In the same manner, insane people will +often, for a short time, conduct themselves, both in conversation and +behaviour, with such propriety, that they appear to have the just exercise +and direction of their faculties; but let the examiner protract the +discourse, until the favourite subject shall have got afloat in the +madman's brain, and he will be convinced of the hastiness of his decision. +To those unaccustomed to insane people, a few coherent sentences, or +rational answers would indicate a lucid interval, because they discover no +madness; but he who is in possession of the peculiar turn of the patient's +thoughts, might lead him to disclose them, or by a continuance of the +conversation they would spontaneously break forth. A beautiful +illustration of this is contained in the Rasselas of Dr. Johnson: where +the astronomer is admired as a person of sound intellect and great +acquirements by Imlac, who is himself a philosopher, and a man of the +world. His intercourse with the astronomer is frequent; and he always +finds in his society information and delight. At length he receives Imlac +into the most unbounded confidence, and imparts to him the momentous +secret. "Hear Imlac what thou wilt not without difficulty credit. I have +possessed for five years the regulation of weather, and the distribution +of the seasons. The sun has listened to my dictates, and passed from +tropic to tropic by my direction. The clouds at my call have poured their +waters, and the Nile has overflowed at my command. I have restrained the +rage of the Dog-star, and mitigated the fervours of the Crab. The winds +alone of all the elemental powers have hitherto refused my authority, and +multitudes have perished by equinoctial tempests, which I found myself +unable to prohibit or restrain. I have administered this great office with +exact justice, and made to the different nations of the Earth an impartial +dividend of rain and sunshine. What must have been the misery of half the +globe, if I had limited the clouds to particular regions, or confined the +sun to either side of the equator?" + +A real case came under my observation a few months ago, and which is +equally apposite to the subject. A young man had become insane from +habitual intoxication, and during the violence of his complaint had +attempted to destroy himself. Under a supposed imputation of having +unnatural dispositions he had amputated his penis, with a view of +precluding any future insinuations of that nature. For many months after +he was admitted into the hospital, he continued in a state which obliged +him to be strictly confined, as he constantly meditated his own +destruction. On a sudden he became apparently well, was highly sensible of +the delusion under which he had laboured, and conversed as any other +person upon the ordinary topics of discourse. There was, however, +something in the reserve of his manner, and peculiarity of his look, which +persuaded me that he was not well, although no incoherence of ideas could +be detected in his conversation. I had observed him for some days to walk +rather lame, and once or twice had noticed him sitting with his shoes off, +rubbing his feet. On enquiring into the motives of his doing so, he +replied, that his feet were blistered, and wished that some remedy might +be applied to remove the vesications. When I requested to look at his +feet, he declined it and prevaricated, saying, that they were only tender +and uncomfortable. In a few days afterwards, he assured me they were +perfectly well. The next evening I observed him, unperceived, still +rubbing his feet, and then peremptorily insisted on examining them. They +were quite free from any disorder. He now told me with some embarrassment, +that he wished much for a confidential friend, to whom he might impart a +secret of importance. Upon assuring him that he might trust me, he said, +that the boards on which he walked, (the second story) were heated by +subterraneous fires, under the direction of invisible and malicious +agents, whose intentions, he was well convinced, were to consume him by +degrees. + +From these considerations I am inclined to think, that a _lucid interval_ +includes all the circumstances which I have enumerated in my definition of +it. If the person who is to examine the state of the patient's mind be +unacquainted with his peculiar opinions, he may be easily deceived, +because, wanting this information, he will have no clue to direct his +enquiries, and madmen do not always, nor immediately intrude their +incoherent notions into notice. They have sometimes such a high degree of +controul over their minds, that when they have any particular purpose to +carry, they will affect to renounce those opinions which shall have been +judged inconsistent: and it is well known that they have often dissembled +their resentment, until a favourable opportunity has occurred of +gratifying their revenge. + +Among the bodily particularities which mark this disease, may be observed +the protruded, and oftentimes glistening eye, and a peculiar cast of +countenance which, however, cannot be described. In some, an appearance +takes place which has not hitherto been noticed by Authors. This is a +relaxation of the integuments of the cranium, by means of which they may +be wrinkled, or rather gathered up by the hand to a considerable degree. +It is generally most remarkable on the posterior part of the scalp; as far +as my enquiries have reached, it does not take place in the beginning of +the disease, but after a raving paroxysm of some continuance. It has been +frequently accompanied with contraction of the iris. + +On the suggestion of a medical gentleman, I was induced to ascertain the +prevailing complexion and colour of the hair in insane patients. Out of +265 who were examined, 205 were of a swarthy complection, with dark, or +black hair; the remaining 60 were of a fair skin, and light, brown, or red +haired. What connection this proportion may have with the complection and +colour of the hair of the people of this country in general, and what +alterations may have been produced by age or residence in other climates, +I am totally uninformed. + +Of the power which maniacs possess of resisting cold the belief is +general, and the histories which are on record are truly wonderful. It is +not my wish to disbelieve, nor my intention to dispute them; it is +proper, however, to state, that the patients in Bethlem hospital possess +no such exemption from the effects of severe cold. They are particularly +subject to mortifications of the feet; and this fact is so well +established from former accidents, that there is an express order of the +house, that every patient, under strict confinement, shall have his feet +examined morning and evening by the keeper, and also have them constantly +wrapped in flannel; and those who are permitted to go about are always to +be found as near to the fire as they can get, during the winter season. + +Having thus given a general account of the symptoms which I have observed +to occur most commonly in persons affected with madness, I shall now lay +before my readers a history of all the appearances which I have noticed on +opening the heads of several maniacs, who have died in Bethlem Hospital. + + +CASE I. + +J. H. a man twenty-eight years of age, was admitted a patient in May 1795. +He had been disordered for about two months before he came into the +hospital. No particular cause was stated to have brought on the complaint. +It was most probably an hereditary affection, as his father had been +several times insane and confined in our hospital. During the time he was +in the house, he was in a very low and melancholic state; shewed an +aversion to food, and said he was resolved to die. His obstinacy in +refusing all nourishment was very great, and it was with much difficulty +forced upon him. He continued in this state, but became daily weaker and +more emaciated until August 1st when he died. Upon opening the head, the +pericranium was found loosely adherent to the scull. The bones of the +cranium were thick. The pia mater was loaded with blood, and the medullary +substance, when cut into, was full of bloody points. The pineal gland +contained a large quantity of gritty matter[1]. The consistence of the +brain was natural; he was opened twenty-four hours after death. + + +CASE II. + +J. W. was a man of sixty-two years of age, who had been many years in the +house as an incurable patient, but with the other parts of whose history I +am totally unacquainted. He appeared to be a quiet and inoffensive person, +who found amusement in his own thoughts, and seldom joined in any +conversation with the other patients: for some months he had been +troubled with a cough, attended with copious expectoration, which very +much reduced him; dropsical symptoms followed these complaints. He became +every day weaker, and on July 10th, 1795, died. He was opened eighteen +hours after death. The pericranium adhered loosely to the scull; the bones +of the cranium were unusually thin. There were slight opacities in many +parts of the tunica arachnoides; in the ventricles about four ounces of +water were contained--some large hydatids were discovered on the plexus +choroides of the right side. The consistence of the brain was natural. + + +CASE III. + +G. H. a man twenty-six years of age, was received into the hospital July +18th, 1795. It was stated that he had been disordered six weeks previous +to his admission, and that he had never had any former attack. He had been +a drummer with a recruiting party, and had been for some time in the habit +of constant intoxication, which was assigned as the cause of his insanity. +He continued in a violent and raving state about a month, during the whole +of which time he got little or no sleep. He had no knowledge of his +situation but supposed himself with the regiment, and was frequently under +great anxiety and alarm for the loss of his drum, which he imagined had +been stolen and sold. The medicines which were given to him he conceived +were spirituous liquors, and swallowed them with avidity. At the +expiration of a month, he was very weak and reduced; his legs became +oedematous--his pupils were much diminished. He now believed himself a +child, called upon the people about him as his playfellows, and appeared +to recall the scenes of early life with facility and correctness. Within +a few days of his decease he only muttered to himself. August 26th, he +died. He was opened six hours after death. The pericranium was loosely +adherent. The tunica arachnoides had generally lost its transparency, and +was considerably thickened. The veins of the pia mater were loaded with +blood, and in many places seemed to contain air. There was a considerable +quantity of water between the membranes, and as nearly as could be +ascertained about four ounces in the ventricles, in the cavity of which, +the veins appeared remarkably turgid. The consistence of the brain was +more than usually firm. + + +CASE IV. + +E. M. a woman, aged sixty, was admitted into the house, August 8th, 1795; +she had been disordered five months; the cause assigned was extreme +grief, in consequence of the loss of her only daughter. She was very +miserable and restless; conceived she had been accused of some horrid +crime, for which she apprehended she should be burned alive. When any +persons entered her room she supposed them officers of justice, who were +about to drag her to some cruel punishment. She was frequently violent, +and would strike and bite those who came near her. Upon the idea that she +should shortly be put to death, she refused all sustenance; and it became +necessary to force her to take it. In this state she continued, growing +daily weaker and more emaciated, until October 3d, when she died. + +Upon opening the head there was a copious determination of blood to the +whole contents of the cranium. The pia mater was considerably inflamed; +there was not any water either in the ventricles or between the +membranes. The brain was particularly soft. She was opened thirty hours +after death. + + +CASE V. + +W. P. a young man aged twenty-five, was admitted into the hospital +September 26, 1795. He had been disordered five months, and had +experienced a similar attack six years before. The disease was brought on +by excessive drinking. He was in a very furious state, in consequence of +which he was constantly confined. He got little or no sleep--during the +greater part of the night he was singing, or swearing, or holding +conversations with persons he imagined to be about him: sometimes he would +rattle the chain with which he was confined for several hours together, +and tore every thing to pieces within his reach. In the beginning of +November the violence of his disorder subsided for two or three days, but +afterwards returned; and on the 10th he died compleatly exhausted by his +exertions.--Upon opening the head the pericranium was found firmly +attached; the pia mater was inflamed, though not to any very considerable +degree; the tunica arachnoides in some places was slightly shot with +blood; the membranes of the brain, and its convolutions when these were +removed, were of a brown, or brownish straw colour. There was no water in +any of the cavities of the brain, nor any particular congestion of blood +in its substance--the consistence of which was natural. He was opened +twenty hours after death. + + +CASE VI. + +B. H. was an incurable patient, who had been confined in the house from +the year 1788, and for some years before that time in a private madhouse. +He was about sixty years of age--had formerly been in the habit of +intoxicating himself. His character was strongly marked by pride, +irascibility, and malevolence. During the four last years of his life he +was confined for attempting to commit some violence on one of the officers +of the house. After this he was seldom heard to speak; yet he manifested +his evil disposition by every species of dumb insult. Latterly he grew +suspicious, and would sometimes tell the keeper that his victuals were +poisoned. About the beginning of December he was taken ill with a cough, +attended with copious expectoration. Being then asked respecting his +complaints, he said he had a violent pain across the stomach, which arose +from his navel string at his birth having been tied too short. He never +spoke afterwards, though frequently importuned to describe his +complaints. He died December 24, 1795. + +Upon dividing the integuments of the head, the pericranium was found +scarcely to adhere to the scull. On the right parietal bone there was a +large blotch, as if the bone had been inflamed: there were others on +different parts of the bone, but considerably smaller. The glandulae +Pacchioni were uncommonly large: the tunica arachnoides in many places +wanted the natural transparency of that membrane: there was a large +determination of blood to the substance of the brain: the ventricles +contained about three ounces of water; the consistence of the brain was +natural. He was opened two days after death. + + +CASE VII. + +A. M. a woman aged twenty-seven, was admitted into the hospital August 15, +1795; she had then been eleven weeks disordered. Religious enthusiasm, and +a too frequent attendance on conventicles, were stated to have occasioned +her complaint. She was in a very miserable and unhappy condition, and +terrified by the most alarming apprehensions for the salvation of her +soul. Towards the latter end of September she appeared in a convalescent +state, and continued tolerably well until the middle of November, when she +began to relapse. + +The return of her disorder commenced with loss of sleep. She alternately +sang, and cried the greatest part of the night. She conceived her inside +full of the most loathsome vermin, and often felt the sensation as if +they were crawling into her throat. She was suddenly seized with a strong +and unconquerable determination to destroy herself; became very sensible +of her malady, and said, that God had inflicted this punishment on her, +from having (at some former part of her life) said the Lord's Prayer +backwards. She continued some time in a restless and forlorn state; at one +moment expecting the devil to seize upon her and tear her to pieces; in +the next, wondering that she was not instigated to commit violence on the +persons about her. On January 12, 1796, she died suddenly. She was opened +twelve hours after death. The thoracic and abdominal viscera were +perfectly healthy. + +Upon examining the contents of the cranium, the pia mater was considerably +inflamed, and an extravasated blotch, about the size of a shilling, was +seen upon that membrane, near the middle of the right lobe of the +cerebrum. There was no water between the membranes, nor in the ventricles, +but a general determination of blood to the contents of the cranium. The +medullary substance when cut into was full of bloody points. The +consistence of the brain was natural. + + +CASE VIII. + +M. W. a very tall and thin woman, forty-four years of age, was admitted +into the hospital September 19, 1795. Her disorder was of six months +standing, and eight years before she had also had an attack of this +disease. The cause assigned to have brought it on, the last time, was the +loss of some property, the disease having shortly followed that +circumstance. The constant tenor of her discourse was, that she should +live but a short time. She seemed anxiously to wish for her dissolution, +but had no thoughts of accomplishing her own destruction. In the course +of a few weeks she began to imagine, that some malevolent person had given +her mercury with an intention to destroy her. She was constantly shewing +her teeth, which had decayed naturally, as if this effect had been +produced by that medicine: at last she insisted, that mercurial +preparations were mingled in the food and medicines which were +administered to her. Her appetite was voracious notwithstanding this +belief. She had a continual thirst, and drank very large quantities of +cold water. + +On January 14, 1796, she had an apoplectic fit, well marked by stertor, +loss of voluntary motion, and insensibility to stimuli. On the following +day she died. She was opened two days after death. There was a remarkable +accumulation of blood in the veins of the dura and pia mater; the +substance of the brain was loaded with blood. When the medullary +substance was cut into blood oozed from it; and upon squeezing it a +greater quantity could be forced out. On the pia mater covering the right +lobe of the cerebrum, were some slight extravasations of blood. The +ventricles contained no water; on the plexus choroides were some vesicles +of the size of coriander-seeds, filled with a yellow fluid. The +pericranium adhered firmly to the scull. The consistence of the brain was +firmer than usual. + + +CASE IX. + +E. D. a woman aged thirty-six, was admitted into the hospital February 20, +1795: she had then been disordered four months. Her insanity came on a few +days after having been delivered. She had also laboured under a similar +attack seven years before, which, like the present, supervened upon the +birth of a child. Under the impression that she ought to be hanged, she +destroyed her infant, with the view of meeting with that punishment. When +she came into the house, she was very sensible of the crime she had +committed, and felt the most poignant affliction for the act. For about a +month she continued to amend: after which time she became more thoughtful, +and frequently spoke about the child: great anxiety and restlessness +succeeded. In this state she remained until April 23, when her tongue +became thickly furred, the skin parched, her eyes inflamed and glassy, and +her pulse quick. She now talked incoherently; and, towards the evening, +merely muttered to herself. She died on the following day comatose. + +She was opened about twenty-four hours after death. The scull was thick, +the pericranium scarcely adhered to the bone, the dura mater was also but +slightly attached to its internal surface. There was a large quantity of +water between the dura mater and tunica arachnoidea; this latter membrane +was much thickened, and was of a milky white appearance. Between the +tunica arachnoidea and pia mater, there was a considerable accumulation of +water. The veins of the pia mater were particularly turgid. About three +ounces of water were contained in the lateral ventricles: the veins of the +membrane lining these cavities were remarkably large and turgid with +blood. When the medullary substance of the cerebrum and cerebellum was cut +into, there appeared a great number of bloody points. The brain was of its +natural consistence. + + +CASE X. + +C. M. a man forty years of age, was admitted into the hospital Dec. 26, +1795. It was stated, that he had been disordered two months previous to +his having been received as a patient. His friends were unacquainted with +any cause, which was likely to have induced the complaint. During the time +he was in the house he seemed sulky, or rather stupid. He never asked any +questions, and if spoken to, either replied shortly, or turned away +without giving any answer. He appeared to take little notice of any thing +which was going forward, and if told to do any little office, generally +forgot what he was going about, before he had advanced half a dozen steps. +He remained in this state until the beginning of May, 1796, when his legs +became oedematous, and his abdomen swollen. He grew very feeble and +helpless, and died rather suddenly May 19th. He was opened about +forty-eight hours after death. The pericranium and dura mater adhered +firmly to the scull; in many places there was an opake whiteness of the +tunica arachnoides. About four ounces of water were found in the +ventricles. The plexus choroides were uncommonly pale. The medullary +substance, afforded hardly any bloody points when cut into. The +consistence of the brain I cannot describe better than by saying, it was +doughy. + + +CASE XI. + +S. M. a man thirty-six years of age, was admitted as an incurable patient +in the year 1790. Of the former history of his complaint I have no +information. As his habits, which frequently came under my observation, +were of a singular nature, it may not here be improper to relate them. +Having at some period of his confinement been mischievously disposed, and, +in consequence, put under coercion, he never afterwards found himself +comfortable when at liberty. When he rose in the morning he went +immediately to the room where he was usually confined, and placed himself +in a particular corner, until the keeper came to secure him. If he found +any other patient had pre-occupied his situation, he became very +outrageous, and generally forced them to leave it. When he had been +confined, for which he appeared anxious, as he bore any delay with little +temper, he employed himself throughout the remainder of the day, by +tramping or shuffling his feet. He was constantly muttering to himself, of +which scarcely one word in a sentence was intelligible. When an audible +expression escaped him it was commonly an imprecation. If a stranger +visited him, he always asked for tobacco, but seldom repeated his +solicitation. He devoured his food with avidity, and always muttered as he +ate. + +In the month of July, 1796, he was seized with a diarrhoea, which +afterwards terminated in dysentery. This continued, notwithstanding the +employment of every medicine usually given in such a case, until his +death, which took place on September 23, of the same year. He was opened +twelve hours after death. The scull was unusually thin; the glandulae +Pacchioni were large and numerous: there was a very general determination +of blood to the brain: the medullary substance, when cut, shewed an +abundance of bloody points: the lateral ventricles contained about four +ounces of water: the consistence of the brain was natural. + + +CASE XII. + +E. R. was a woman, to all appearance about eighty years of age, but of +whose history, before she came into the hospital, it has not been in my +power to acquire any satisfactory intelligence. She was an incurable +patient, and had been admitted on that establishment in February 1782. + +During the time I had an opportunity of observing her, she continued in +the same state: she appeared feeble and childish. During the course of the +day, she sat in a particular part of the common-room, from which she never +stirred. Her appetite was tolerably good, but it was requisite to feed +her. Except she was particularly urged to speak she never talked. As the +summer declined she grew weaker, and died October 19, 1796, apparently +worn out. She was opened two days after death. The scull was particularly +thin; the pericranium adhered firmly to the bone, and the scull-cap was +with difficulty separated from the dura mater. There was a very large +quantity of water between the membranes of the brain: the glandulae +Pacchioni were uncommonly large: the tunica arachnoidea was in many +places blotched and streaked with opacities: when the medullary substance +of the brain was cut into, it was every where bloody; and blood could be +pressed from it, as from a sponge. There were some large hydatids on the +plexus choroides: in the ventricles about a tea spoonful of water was +observed: the consistence of the brain was particularly firm, but it could +not be called elastic. There were no symptoms of general dropsy. + + +CASE XIII. + +J. D. a man thirty-five years of age, was admitted into the hospital in +October 1796. He was a person of good education, and had been regularly +brought up to medicine, which he had practised in this town for several +years. It was stated by his friends, that, about two years before, he had +suffered a similar attack, which continued six months: but it appears +from the observations of some medical persons, that he never perfectly +recovered from it, although he returned to the exercise of his profession. +A laborious attention to business, and great apprehensions of the want of +success, were assigned as causes of his malady. In the beginning of the +year 1796 the disease recurred, and became so violent that it was +necessary to confine him. + +At the time he was received into Bethlem hospital, he was in an unquiet +state, got little or no sleep, and was constantly speaking loudly: in +general he was worse towards evening. He appeared little sensible of +external objects: his exclamations were of the most incoherent nature. + +During the time he was a patient he was thrice cupped on the scalp. After +each operation, he became rational to a certain degree; but these +intervals were of a short continuance, as he relapsed in the course of a +few hours. The scalp, particularly at the posterior part of the head, was +so loose that a considerable quantity of it could be gathered up by the +hand[2]. The violence of his exertions at last exhausted him, and, on +December 11, he died. He was opened about twenty-four hours after death. +There was a large quantity of water between the dura mater and tunica +arachnoidea, and also between this latter membrane and the pia mater. The +arachnoid membrane was thickened and opake; the vessels of the pia mater +were loaded with blood: when the medullary substance was cut into, it was +very abundant in bloody points: about three ounces of water were contained +in the lateral ventricles: the plexus choroides were remarkably turgid +with blood: a quantity of water was found in the theca vertebralis: the +consistence of the brain was natural. + + +CASE XIV. + +J. C. a man aged sixty-one, was admitted into the hospital September 17, +1796. It was stated that he had been disordered ten months. He had for +thirty years kept a public house, and had for some time been in the habit +of getting intoxicated. His memory was considerably impaired: +circumstances were so feebly impressed on his mind, that he was unable to +give any account of the preceding day. He appeared perfectly reconciled to +his situation, and conducted himself with order and propriety. As he +seldom spoke but when interrogated, it was not possible to collect his +opinions. In this quiet state he continued about two months, when he +became more thoughtful and abstracted, walked about with a quick step, and +frequently started, as if suddenly interrupted. He was next seized with +trembling, appeared anxious to be released from his confinement: conceived +at one time that his house was filled with company; at another that +different people had gone off without paying him, and that he should be +arrested for sums of money which he owed. Under this constant alarm and +disquietude he continued about a week, when he became sullen and refused +his food. When importuned to take nourishment, he said it was ridiculous +to offer it to him, as he had no mouth to eat it: though forced to take +it, he continued in the same opinion; and when food was put into his +mouth, insisted that a wound had been made in his throat, in order to +force it into his stomach. The next day he complained of violent pain in +his head, and in a few minutes afterwards died. He was opened twelve hours +after death. There was a large quantity of water between the tunica +arachnoidea and pia mater; the latter membrane was much suffused with +blood, and many of its vessels were considerably enlarged: the lateral +ventricles contained at least six ounces of water: the brain was very +firm. + + +CASE XV. + +J. A. a man forty-two years of age, was first admitted into the house on +June 27, 1795. His disease came on suddenly whilst he was working in a +garden, on a very hot day, without any covering to his head. He had some +years before travelled with a gentleman over a great part of Europe: his +ideas ran particularly on what he had seen abroad; sometimes he conceived +himself the king of Denmark, at other times the king of France. Although +naturally dull and wanting common education, he professed himself a master +of all the dead and living languages; but his most intimate acquaintance +was with the old French; and he was persuaded he had some faint +recollection of coming over to this country with William the Conqueror. +His temper was very irritable, and he was disposed to quarrel with every +body about him. After he had continued ten months in the hospital, he +became tranquil, relinquished his absurdities, and was discharged well in +June 1796. He went into the country with his wife to settle some domestic +affairs, and in about six weeks afterwards relapsed. He was readmitted +into the hospital August 13th. + +He now evidently had a paralytic affection, his speech was inarticulate, +and his mouth drawn aside. He shortly became stupid, his legs swelled and +afterwards ulcerated; at length his appetite failed him; he became +emaciated, and died December 27th, of the same year. The head was opened +twenty hours after death. There was a greater quantity of water between +the different membranes of the brain than has ever occurred to me. The +tunica arachnoidea was generally opake and very much thickened: the pia +mater was loaded with blood, and the veins of that membrane were +particularly enlarged. On the fore-part of the right hemisphere of the +brain, when stripped of its membranes, there was a blotch, of a brown +colour, several shades darker than the rest of the cortical substance: the +ventricles were much enlarged, and contained, by estimation, at least six +ounces of water. The veins in these cavities were particularly turgid. +The consistence of the brain was firmer than usual. + + +CASE XVI. + +J. H. a man aged forty-two, was admitted into the house on April 12, 1794. +He had then been disordered two months: it was a family disease on his +father's side. Having manifested a mischievous disposition to some of his +relations, he was continued in the hospital upon the incurable +establishment. His temper was naturally violent, and he was easily +provoked. As long as he was kept to any employment he conducted himself +tolerably well; but when unoccupied, would walk about in a hurried and +distracted manner, throwing out the most horrid threats and imprecations. +He would often appear to be holding conversations: but these conferences +always terminated in a violent quarrel between the imaginary being and +himself. He constantly supposed unfriendly people were placed in different +parts of the house to torment and annoy him. However violently he might be +contesting any subject with these supposed enemies, if directed by the +keepers to render them any assistance, he immediately gave up the dispute +and went with alacrity. As he got but little sleep, the greatest part of +the night was spent in a very noisy and riotous manner. In this state he +continued until April 1796, when he was attacked with a paralytic +affection, which deprived him of the use of the left side. His +articulation was now hardly intelligible; he became childish, got +gradually weaker, and died December 28, 1796. He was opened twenty-four +hours after death. There was a general opacity of the arachnoid coat, and +a small quantity of water between that membrane and the pia mater: the +ventricles were much enlarged and contained a considerable quantity of +water, by estimation four ounces: the consistence of the brain was +natural. + + +CASE XVII. + +M. G. a woman about fifty years of age had been admitted on the incurable +establishment in July 1785. She had for some years before been in a +disordered state, and was considered as a dangerous patient. Her temper +was violent; and if interrupted in her usual habits, she became very +furious. Like many others among the incurables, she was an insulated +being: she never spoke except when disturbed. Her greatest delight +appeared to be in getting into some corner to sleep; and the interval +between breakfast and dinner was usually past in this manner. At other +times she was generally committing some petty mischief, such as slyly +breaking a window, dirtying the rooms of the other patients, or +purloining their provisions. She had been for some months in a weak and +declining state, but would never give any account of her complaints. On +January 5, 1797, she died, apparently worn out. The head was opened three +days after death. The pericranium adhered but slightly to the scull, nor +was the dura mater firmly attached. There was water between the membranes +of the brain; and the want of transparency of the tunica arachnoidea, +indicated marks of former inflammation. The posterior part of the +hemispheres of the brain was of a brownish colour. In this case there was +a considerable appearance of air in the veins; the medullary substance, +when cut, was full of bloody points: the lateral ventricles were small, +but filled with water: the plexus choroides were loaded with vesicles of a +much larger size than usual: the consistence of the brain was natural. + + +CASE XVIII. + +S. T. a woman aged fifty-seven, was admitted into the house January 14, +1797. It was stated by her friends, that she had been disordered eight +months: they were unacquainted with any cause, which might have induced +the disease. She had evidently suffered a paralytic attack, which +considerably affected her speech, and occasioned her to walk lame with the +right leg. As she avoided all conversation, it was not possible to collect +any further account of her case. Three days after her admission, she had +another paralytic stroke, which deprived her entirely of the use of the +right side. Two days afterwards she died. She was opened forty-eight hours +after death. There was a small quantity of water between the tunica +arachnoidea and pia mater, and a number of opake spots on the former +membrane. On the pia mater covering the posterior part of the left +hemisphere of the brain, there was an extravasated blotch, about the size +of a shilling: the medullary substance was unusually loaded with blood: +the lateral ventricles were large, but did not contain much water: the +consistence of the brain was very soft. + + +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 that any 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 her husband. 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 near her. 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 years before, 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, from which 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 promotion which 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 out with 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 the author 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 a large 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 to +their 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 former +inflammation: 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 was attached, 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 oedematous, 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, and +contained, 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 offended God, 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 a mark 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 own speculations, +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, which +were 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 this point, 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 into _physical_ and _moral_. + +Under the first are comprehended _repeated intoxication_; _blows_ received +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 termed _moral_, 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 fully understood, 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 may _think_, 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 of ideas, 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 imagine _a 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 insufficient to 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 +far from 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 +which they 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 amenorrhoea. 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. + + Age between Number admitted. Number discharged Number discharged + cured. uncured. + 10 and 20 113 78 35 + 20 and 30 488 200 288 + 30 and 40 527 180 347 + 40 and 50 362 87 275 + 50 and 60 143 25 118 + 60 and 70 31 4 27 + ----- ----- ----- + 1664 574 1090 + Total admitted. Total cured. Total uncured. + +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 since +relapsed 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 of ten 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 +to _meet and counteract_ such 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, it appears 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 melancholick cases 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, and respect, 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, to order 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 term coercion 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 be +transmitted 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 superinducing different 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 shall continue. 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 persuaded that 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, which they 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 and ungovernable 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 intercourse imparts 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 considerable advantage, 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 to +prohibit 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 +a bleeding 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. + + [Prescription]. Infusi sennae [ounce] iss ad [ounce] ij. + Tincturae sennae [dram] i ad [dram] ij. + Syrupi spinae cervinae [dram] i ad [dram] ij. + +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 diarrhoea and dysentery: +these are sometimes very violent and obstinate. + +Diarrhoea 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 a considerable 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 primae viae. + +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, are very 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, and +how 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 this medicine 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 this remedy +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 their use, 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 be +_phosphat 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. + + + + +Transcriber's Notes: + +Passages in italics are indicated by _italics_. + +The original text includes symbols that are represented in this text +version as [Precsription], [ounce], and [dram]. + + + + + + +End of the Project Gutenberg EBook of Observations on Insanity, by John Haslam + +*** END OF THIS PROJECT GUTENBERG EBOOK OBSERVATIONS ON INSANITY *** + +***** This file should be named 37057.txt or 37057.zip ***** +This and all associated files of various formats will be found in: + https://www.gutenberg.org/3/7/0/5/37057/ + +Produced by The Online Distributed Proofreading Team at +https://www.pgdp.net (This file was produced from images +generously made available by The Internet Archive.) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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