Observations on Madness and Melancholy Part 8

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.[22]

It will be seen by the preceding table, that a greater number of patients have been admitted, between the age of 30 and 40, than during any other equal period of life. The same fact also obtains in France, as may be seen from the statement of Dr. Pinel, (_Traite Medico-Philosophique sur la Manie, p. 109_,) and which, from its agreement with that of Bethlem Hospital, is here introduced to the notice of the reader.

+--------------------------------------------------------------+ Manical Patients AGE BETWEEN admitted into ----------------------------------------- Total the Bicetre, 15 & 20 & 30 & 40 & 50 & 60 & in the Years 20 30 40 50 60 70 +-------------- ------ ------ ------ ------ ------ ------ ----- 1784 5 33 31 24 11 6 110 1785 4 39 49 25 14 3 134 1786 4 31 40 32 15 5 127 1787 12 39 41 26 17 7 142 1788 9 43 53 21 18 7 151 1789 6 38 39 33 14 2 132 1790 6 28 34 19 9 7 103 1791 9 26 32 16 7 3 93 1792 6 26 33 18 12 3 98 1793 1 13 13 7 4 2 40 1794 3 23 15 15 9 6 71 +--------------------------------------------------------------+

There may be some reasons a.s.signed 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 persons 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 able 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 circ.u.mstances, 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 a.s.sumes a serious character; and religion, as it is justly or improperly impressed, imparts comfort, or excites apprehension and terror.

By misfortunes the habit of intoxication is readily formed. Those who in their youth have shaken off calamity as a slight inc.u.mbrance, at the middle age feel it corrode and penetrate; and when fermented liquors have once dispelled the gloom of despondency, and taught the mind to provoke a temporary a.s.semblage of cheerful scenes, or to despise the terror of impending misery, it is natural to recur to the same, though destructive cause, to re-produce the effect.

Patients, who are in a furious state, recover in a larger proportion than those who are depressed and melancholic. An hundred violent, and the same number of melancholic cases were selected: of the former, sixty-two were discharged well; of the latter, only twenty-seven: subsequent experience has confirmed this fact. The same investigation, on the same number of persons has been twice inst.i.tuted, and with results little varying from the originally stated proportions. When the furious state is succeeded by melancholy, and after this shall have continued a short time, the violent paroxysm returns, the chance of recovery is very slight. Indeed, whenever these states of the disease frequently change, such alteration may be considered as very unfavourable.

After a raving paroxysm of considerable duration, it is a hopeful symptom, if the patient become dull, and in a stupid state; inclined to sleep much, and feeling a desire of quietude. This appears to be the natural effect of that exhaustion, and, if the language be allowable, of that expenditure of the sensorial energy, which the continued blaze of furious madness would necessarily consume. When they gradually recover from this state there is a prospect that the cure will be permanent.

In forming a prognosis of this disease, it is highly important to establish a distinction between derangement and decline of intellect: the former may frequently be remedied; the latter admits of no a.s.sistance from our art. Where insanity commences with a loss of mental faculty, and gradually proceeds with increasing imbecility, the case may be considered hopeless.

When the disorder 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, and they are also a very common effect of madness; more maniacs die of hemiplegia and apoplexy than from any other disease.

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, independently of their insanity: the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capability of being moved by the will: and in most of them the memory is particularly impaired. Persons thus disordered are in general not at all sensible of being so affected. When so feeble, as scarcely to be able to stand, they commonly say that they feel perfectly strong, and capable of great exertions. However pitiable these objects may be to the feeling spectator, yet it is fortunate for the condition of the sufferer, that his pride and pretensions are usually exalted in proportion to the degradation of the calamity which afflicts him. None of these patients have received any benefit in the hospital; and from the enquiries I have been able to make at the private mad-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 gradually dwindled away.

The paralytic require to be kept warm, and to be allowed a more nutritious diet and cheering beverage than insane patients of any other description.

In the winter months they suffer extremely, and ought to be treated as hot-house plants. The fare of the workhouse is ungenial to this wretched state of existence, and therefore they seldom long continue a burden to the parish.

When insanity supervenes on epilepsy, or where the latter disease is induced by insanity, a cure is very seldom effected. In two instances I have known madness alternate with epilepsy: one, a man about forty-eight years of age, was a pauper in the Cripplegate workhouse, where he had been kept about three years on account of his epileptic fits, but, becoming insane, was admitted into Bethlem Hospital, therein he continued a year, without being at all benefited; during that time he had no epileptic fit.

Being returned to the workhouse, he there recovered his senses in a few months, when his epileptic attacks returned, and continued with their usual frequency. About two years afterwards he was re-admitted into the hospital, his insanity having recurred, and continued there another year without experiencing any attack of epilepsy. The other was a young woman, who had been epileptic for many years until she became insane, when she lost her epileptic fits; these, however, were said to have returned in a short time after she had recovered from her insanity.

All authors who have treated this subject appear to agree respecting the difficulty of curing religious madness. The infrequent recoveries in this species of insanity, have caused thinking persons to suppose, that this disorder is little under the dominion of the medical pract.i.tioner; and, that restoration to reason in all cases is more the effect of accident, or of circ.u.mstances not "dreamt of in our philosophy," than the result of observation, skill, and experience. The idea that RELIGION; that which fastens us to the duties of this life; that which expounds the laws of G.o.d and of his creation to the ignorant; that which administers consolation to the afflicted; that which regulates man's conduct towards his fellow creatures, to exercise charity among them, and, from such benevolence, to purchase happiness to himself: to believe, that the cultivation of such exalted sentiments would decoy a human being into madness, is a foolish and impious supposition.

"Thou, fair Religion, wast design'd, Duteous daughter of the skies, To warm and chear the human mind, To make men happy, good, and wise; To point, where sits in love array'd, Attentive to each suppliant call, The G.o.d of universal aid, The G.o.d, the Father of us all.

"First shewn by Thee, thus glow'd the gracious scene, 'Til Superst.i.tion, fiend of woe, Bad doubts to rise and tears to flow, And spread deep shades our view and heaven between."

_Penrose._

It is therefore sinful to accuse RELIGION, which preserves the dignity and integrity of our intellectual faculty, with being the cause of its derangement. The mind becomes refreshed and corroborated by a fair and active exercise of its powers directed to proper objects; but when an anxious curiosity leads us to unveil that which must ever be shrouded from our view, the despair, which always attends those impotent researches, will necessarily reduce us to the most calamitous state.

Inst.i.tuting a generous and tolerant survey of religious opinions, we see nothing in the solemn pomp of catholic worship which could disorganize the mind; as human beings, they have employed human art to render the impression more vivid and durable. The decorous piety, and exemplary life of the quaker has signally exempted him from this most severe of human infirmities. The established church of this country, of which I am an unworthy member, will delude no one, by its terrors, to the brink of fatuity: the solid wisdom, rational exposition, and pure charity, which flow through the works of Taylor, Barrow, Secker, and Tillotson, will inspire their readers with a manly confidence: the most enlightened of our species will advance in wisdom and in happiness from their perusal; and the simplicity and truth of their comments will be evident to those of less cultivated understanding. The pastors of this church are all men of liberal education, and many have attained the highest literary character; they are therefore eminently qualified to afford instruction. But what can be expected, when the most ignorant of our race attempt to inform the mult.i.tude; when the dregs of society shall a.s.sume the garb of sanct.i.ty and the holy office; and pretend to point out a privy path to heaven, or cozen their feeble followers into the belief that they possess a picklock for its gates? The difficulty of curing this species of madness will be readily explained from the consideration, that the whole of their doctrine is a base system of delusion, rivetted on the mind by terror and despair; and there is also good reason to suppose, that they frequently contrive, by the grace of cordials, to fix the waverings of belief, and thus endeavour to dispel the gloom and dejection which these hallucinations infallibly excite.

Although the faction of faith will owe me no kindness for the disclosure of these opinions, yet it would be ungrateful were I to shrink from the avowal of my obligations to methodism[23] for the supply of those numerous cases which has const.i.tuted my experience of this wretched calamity.

When the natural small-pox attacks insane persons it most commonly proves fatal. I was induced to draw this conclusion from consulting the records of Bethlem, where I found that few of those who had been sent to the Small-pox Hospital recovered; but subsequent experience has enabled me to point out this distinction: that those who have been in a furious state have generally experienced a fatal termination, and that those who recovered had the small-pox when they were in a state of convalescence from their insanity.

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. But it should also be observed, that many, who become stupid, and in a state, verging on ideotism, are very much disposed to obesity: these cases are not to be remedied.

In proportion as insanity has a.s.sumed a systematic character, it become more difficult of cure. It ought to be noticed, that this state of methodical madness implies, that the disease has been of some continuance; and, to use a figurative expression, has been more extensively rooted in the mind. Every occurrence is blended with the ruling persuasion, and the delusion becomes daily corroborated. As

--------------"Trifles, light as air, Are to the jealous, confirmations strong As proofs of holy writ;"

so in madness, circ.u.mstances wholly unconnected readily support the favourite system, and persons the most disinterested are supposed to form a part of the conspiracy.

CHAP. VII.

MANAGEMENT.

Our own countrymen have acquired the credit of managing insane people with superior address; but it does not appear that we have arrogated to ourselves any such invidious pre-eminence. Foreigners, who have visited the public or private inst.i.tutions of this country, may, perhaps, in their relations, have magnified our skill in the treatment of this disease: compared with a great part of the north of Europe, which I have visited, we certainly excel.

Whether it be that we have more mad persons in England than in other countries, and thereby have derived a greater experience of this calamity; or, whether the greater number of receptacles we possess for the insane, and the emoluments which have resulted from this species of farming, have led persons to speculate more particularly on the nature and treatment of this affection, may be difficult to determine. Dr. Pinel[24]

allows the reputation we have acquired; but, with a laudable curiosity, is desirous to understand how we became possessed of it.

"Is it," he says, "from a peculiar national pride, and to display their superiority over other nations, that the English boast of their ability in curing madness by moral remedies; and at the same time conceal the cunning of this art with an impenetrable veil? or, on the contrary, may not that which we attribute to a subtile policy, be merely the effect of circ.u.mstances? and, is it not necessary to distinguish the steps of the English empirics from the methods of treatment adopted in their public hospitals?

"Whatever solution may be given to these questions, yet, after fifteen years diligent enquiry, in order to ascertain some of the leading features of this method, from the reports of travellers; the accounts published of such establishments; the notices concerning their public and private receptacles, which are to be found in the different journals, or in the works of their medical writers, I can affirm, that I have never been able to discover any development of this English secret for the treatment of insanity, though all concur in the ability of their management. Speaking of Dr. Willis,[25] it is said, that sweetness and affability seem to dwell upon his countenance; but its character changes the moment he looks on a patient: the whole of his features suddenly a.s.sume a different aspect, which enforces respect and attention from the insane. His penetrating eye appears to search into their hearts, and arrest their thoughts as they arise. Thus he establishes a dominion, which is afterwards employed as a princ.i.p.al agent of cure. But, where is the elucidation of these general principles to be sought; and, in what manner are they to be applied according to the character, varieties, and intensity of madness? Is the work of Dr. Arnold otherwise remarkable than as a burdensome compilation, or a multiplication of scholastic divisions, more calculated to r.e.t.a.r.d than advance the progress of Science? Does Dr.

Harpur, who announces in his preface, that he has quitted the beaten track, fulfil his promise in the course of his work? and is his section on mental indications any thing but a prolix commentary on the doctrines of the ancients? The adventurous spirit of Dr. Crichton, may justly excite admiration, who has published two volumes on maniacal and melancholic affections, merely on the authority of some observations drained from a German Journal; together with ingenious dissertations on the doctrines of modern physiologists, and a view of the moral and physical effects of the human pa.s.sions. Finally, can a mere advertis.e.m.e.nt of Dr. Fowler's establishment for the insane in Scotland, throw any light on the particular management of such persons, although it profess the purest and most dignified humanity, successfully operating on the moral treatment of madness?"

Dr. Pinel is deserving of considerable credit for directing the attention of medical men to this very important point of the moral management of the insane. I have also heard much of this fascinating power which the mad doctor is said to possess over the wayward lunatic; but, from all I have observed amongst the eminent pract.i.tioners of the present day, who exercise this department of the profession, I am led to suspect, that, although this influence may have been formerly possessed, and even to the extent attributed to the late reverend doctor, it ought now to be lamented among the _artes deperditae_. Could the attention of lunatics be fixed, and could they be reduced to obedience, by

"Strong impression and strange powers which lie Within the magic circle of the eye,"

all other kinds of restraint would be superfluous and unnecessarily severe. But the fact is notoriously otherwise. Whenever the doctor visits a violent or mischievous maniac, however controlling his physiognomy, such patient is always secured by the straight waistcoat; and it is, moreover, thought expedient to afford him the society of one or more keepers.

It has, on some occasions, occurred to me to meet with gentlemen who have imagined themselves eminently gifted with this awful imposition of the eye, but the result has never been satisfactory; for, although I have entertained the fullest confidence of any relation, which such gentlemen might afterwards communicate concerning the success of the experiment, I have never been able to persuade them to practise this rare talent tete a tete with a furious lunatic.

However Dr. Pinel may be satisfied of our superiority in this respect, it is but decorous to return the compliment, and if any influence were to be gained over maniacal patients by a.s.sumed importance, protracted staring, or a mimicry of fierceness, I verily believe that such pantomime would be much better performed in Paris than in London.

It is to be lamented, that general directions only can be given concerning the management of insane persons; the address, which is acquired by experience and constant intercourse with maniacs, cannot be communicated; it may be learned, but must perish with its possessor. Though man appears to be more distinguished from other animals by the capability he has of transmitting his acquirements to posterity, than by any other attribute of his nature, yet this faculty is deplorably bounded in the finer and more enviable offsprings of human attainment. The happy dexterity of the artisan, the impressive and delighting powers of the actor,

"And every charm of gentler eloquence, All perishable--like the electric fire, But strike the frame, and, as they strike, expire."

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 a.s.sociations 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 a powerful man, two or more should a.s.sist 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.

When the patient is in a furious state, and uncontrolable by kindness and persuasion, he will generally endeavour, by any means, to do as much mischief as possible to the person who opposes him; and instances are not rare where he has overcome the keeper. When the maniac finds his strength, or skill in the contest prevail, he is sure to make the most of such advantage, and the consequence of his victory has sometimes proved fatal to the keeper. On the other hand, it ought to be the object of the keeper to subdue the maniac without doing him any personal injury; and after he has overpowered, to confine him, and thus prevent him from attempting any further mischief. When the patient is a strong man, and highly irritated, it will be impossible for any keeper singly to overcome him without his most forcible exertions, and these cannot be put forth without great violence to the patient. But subduing the maniac, is not the only object, he must afterwards be secured by the straight-waistcoat, or by manacles.

It will be seen, that the keeper, who, by the great exertion of his bodily powers, has become faint and exhausted, will be very little in a condition to secure the patient, as his hands must be employed with the implements necessary to confine him; moreover, the patient will have additional strength from the temperate manner, in which he is made to live; whereas, it is but too common, for the keeper to indulge in a diet and beverage, which induce corpulence and difficulty of breathing.[26]

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 here be proper to enquire, upon what occasions, and to what extent, coercion may be used. The term coercion has 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.[27] From Dr. Mead's section on madness it would appear, that in his time flagellation was a common remedy for this disorder. "There is no disease more to be dreaded than madness. For what greater unhappiness can befal a man, than to be deprived of his reason and understanding, to attack his fellow creatures with fury, like a wild beast; to be tied down, _and even beat_, to prevent his doing mischief to himself or others."--_Medical Precepts and Cautions, page 74._

Dramatic writers abound with allusions to the whip, in the treatment of madness. "Love is meerely a madnesse, and I tel you, deserves as well a darke house, and a whip, as madmen do: and the reason why they are not so punish'd and cured, is, that the Lunacie is so ordinary, that the whippers are in love too."--_As You Like It, act III. scene 2._

Another instance to the same effect may be found in Mr. Dennis's comedy of Jacobite Credulity. "_Bull Junior._ Look you, old gentleman, I will touch this matter as gently as I can to you. Your friends taking notice, that you were grown something foolish, whimsical, absurd, and so forth, thought fit to have you sent to the College here, [Bedlam] that you might go through a course of philosophy, and be cudgel'd and firk'd into a little wisdom, by the surly Professors of this place."--_Select Works, vol. ii.

p. 363._ And again, in the next page; "If thou canst give but so much as a reasonable answer to any thing; if thou either knowest what thou art, or where thou art, or with whom thou art, then will I be contented to be thought mad, and dieted and flogged in thy stead."

It also appears from Mr. Douce's valuable dissertation, that the domesticated fool frequently underwent a similar castigation, to curb the licentiousness of his discourse, or, as a punishment for the obscenity of his actions. Indeed this system of corporal chastis.e.m.e.nt seems to have been general, and may afford some apology for introducing, from a very rare little book, an account of the manner of treating this malady in Constantinople, about the middle of the 16th century.[28]