Observations on Insanity Part 3

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 quant.i.ty 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 acc.u.mulated 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 G.o.d, and that his soul was burning in h.e.l.l. Notwithstanding he was haunted with these dreadful imaginations, he acted with propriety upon most occasions. He took delight in rendering any a.s.sistance 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 pa.s.sages 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 int.i.tled. 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 quant.i.ty of water was contained between it and the pia mater: the contents of the cranium were unusually dest.i.tute of blood: there was a considerable quant.i.ty 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 t.e.s.t.i.c.l.es 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 quant.i.ty 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 p.r.o.nounce, that the circ.u.mstances 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 cla.s.s 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 pa.s.sion or emotion, and any sudden and violent affection of the mind.

There are, doubtless, many other causes of both cla.s.ses 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 circ.u.mstances 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 circ.u.mstances readily awaken into growth.

It should be as much the object of teachers of youth, to subjugate the pa.s.sions, 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. .h.i.therto been observed, uniformly accompanied with disease of the brain, is it not more just to conclude, that such organic affection has produced this incorrect a.s.sociation 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 circ.u.mstantial 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 pract.i.tioner can only be led to suppose that patients of a particular description will recover, from knowing, that under the same circ.u.mstances, a certain number have been actually restored to health.

The practice of an individual, however active and industrious he may be, is insufficient to acc.u.mulate 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 a.s.sured 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 circ.u.mstances, 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 quant.i.ty, 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 quant.i.ties.

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 cla.s.s 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.