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Title: Observations on Madness and Melancholy
       Including Practical Remarks on those Diseases together
       with Cases and an Account of the Morbid Appearances on
       Dissection

Author: John Haslam

Release Date: August 21, 2011 [EBook #37144]

Language: English

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  OBSERVATIONS ON MADNESS AND MELANCHOLY:

  INCLUDING PRACTICAL REMARKS ON THOSE DISEASES;

  TOGETHER WITH CASES:

  AND AN ACCOUNT OF THE MORBID APPEARANCES
  ON _DISSECTION_.


  BY JOHN HASLAM,

  LATE OF PEMBROKE HALL, CAMBRIDGE;
  MEMBER OF THE ROYAL COLLEGE OF SURGEONS,
  AND APOTHECARY TO BETHLEM HOSPITAL.

  _The Second Edition, considerably enlarged._

  "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 J. CALLOW, MEDICAL BOOKSELLER,
  CROWN COURT, PRINCES STREET, SOHO;
  BY G. HAYDEN, BRYDGES STREET, COVENT GARDEN.
  1809.




  AS A GRATEFUL ACKNOWLEDGMENT
  FOR MANY FAVOURS,
  AN OBLATION TO SUBSISTING FRIENDSHIP,
  AND A TRIBUTE TO SUPERIOR JUDGMENT,
  EXERCISING THE PROFESSION OF MEDICINE WITH
  SKILL AND LIBERALITY:
  THE PRESENT VOLUME IS RESPECTFULLY
  DEDICATED TO
  DR. THOMAS MONRO,
  A FELLOW OF THE COLLEGE, AND PHYSICIAN
  TO BETHLEM HOSPITAL.




Preface.


_The alarming increase of Insanity, as might naturally be expected, has
incited many persons to an investigation of this disease;--some for the
advancement of Science, and others with the hope of emolument._

_More than ten years having elapsed since the publication of the
"Observations on Insanity," a trifle, which the Profession has held in
greater estimation than its intrinsic merits could justify: the present
work is modestly introduced to the public notice, as a corrected copy of
the former, with considerable additions, which the extensive scope of
Bethlem Hospital would have furnished more liberally to a more intelligent
observer._

_To have taken a comprehensive survey of the human faculties in their
sound state; to have exhibited them impaired by natural decay, and
transformed by disease, would have implied an ability to which I cannot
pretend; would have required many volumes to unfold, and perhaps more
patience than any rational experience could have attributed to the reader.
The contents of the following pages are therefore to be considered as an
abbreviated relation, and condensed display of many years observation and
practice, in a situation affording constant opportunities and abundant
supplies for such investigations._

_It is natural to presume, that amongst my professional acquaintance the
subject of Insanity must have been frequently introduced as a topic of
discourse; and I am ready to acknowledge, that I have often profited by
their remarks and suggestions: but I should be ungrateful were I not to
confess my particular obligations to my esteemed friend, Anthony Carlisle,
Esq. Surgeon to the Westminster Hospital, for many corrections, and some
communications, which I shall ever value as judicious and important._

  BETHLEM HOSPITAL,
  NOV. 21, 1808.




ERRATA.


  _Page_ 3, _line_ 7, _for_ controverted, _read_ converted.
         5,        2, _for_ phrenitic, _read_ phrenetic.
        90,        3, _for_ hyatids, _read_ hydatids.
       254, _in the Table_, _for_ manical, _read_ maniacal.




OBSERVATIONS ON MADNESS, &c. &c.




CHAPTER I.

DEFINITION.


There is no word in the English language more deserving of a precise
definition than madness: and if those who have treated on this subject
have been so unfortunate as to disagree with each other, and consequently
have left their readers to reconcile their discordant opinions; yet it
must be confessed that considerable pains have been bestowed, to convey a
clear and accurate explanation of this term. Although this contrariety of
sentiment has prevailed concerning the precise meaning of the word
madness, medical practitioners have been sufficiently reconciled as to the
thing itself: so that when they have seen an insane person, however
opposite their definitions, they have readily coincided that the patient
was mad.

From this it would appear that the thing itself, is, generally speaking,
sufficiently plain and intelligible; but that the term which represents
the thing is obscure. Perhaps, we might be somewhat assisted, by tracing
back this word, in order to discover its original meaning, and shewing
from its import the cause of its imposition.

If the reader, as is now the custom, should turn to Johnson's Dictionary
for the meaning and etymology of this word, he will find that the Doctor
has derived it both from the Anglo-Saxon gemaad and the Italian
_matto_; but without giving any meaning as the cause of its employment.
The word is originally Gothic, and meant anger, rage, [Gothic: Mod].
[Mod]. It is true that we have now controverted the o, into a, and write
the word mad: but mod was anciently employed.

  "Yet sawe I MODNESSE laghyng in his _rage_."
          _Chaucer. Knight's Tale, fol. 1561, p. 6._

There is so great a resemblance between anger and violent madness, that
there is nothing which could more probably have led to the adoption of the
term. Dr. Beddoes, who appears to have examined the subject of insanity
with the eye of an enlightened philosopher, is decidedly of this opinion,
he says, HYGEIA, _No. 12, p. 40_, "Mad, is one of those words which mean
almost every thing and nothing. At first, it was, I imagine, applied to
the transports of rage; and when men were civilized enough to be capable
of insanity, their insanity, I presume, must have been of the frantic
sort, because in the untutored, intense feelings seem regularly to carry a
boisterous expression."

MAD is therefore not a complex idea, as has been supposed, but a complex
term for all the forms and varieties of this disease. Our language has
been enriched with other terms expressive of this affection, all of which
have a precise meaning. Delirium, which we have borrowed from the latin,
merely means, _out of the track_, de lira, so that a delirious person, one
who starts out of the track regularly pursued, becomes compared to the
same deviation in the process of ploughing. _Crazy_, we have borrowed from
the French _ecrasé_, crushed, broken: we still use the same meaning, and
say that such a person is crack'd. Insane, deranged, or disarranged,[1]
melancholic, out of one's wits, lunatic, phrenitic, or as we have
corrupted it, frantick, require no explanation. _Beside one's self_ most
probably originated from the belief of possession by a devil, or evil
spirit.

The importance of investigating the original meaning of words must be
evident when it is considered that the law of this country impowers
persons of the medical profession to confine and discipline those to whom
the term mad or lunatic can fairly be applied. Instead of endeavouring to
discover an infallible definition of madness, which I believe will be
found impossible, as it is an attempt to comprise, in a few words, the
wide range and mutable character of this Proteus disorder: much more
advantage would be obtained if the circumstances could be precisely
defined under which it is justifiable to deprive a human being of his
liberty.

Another impediment to an accurate definition of madness, arises from the
various hypotheses, which have been entertained concerning the powers and
operations of the human mind: and likewise from the looseness and
unsettled state of the terms by which it is to be defined.

Before treating of the intellect in a deranged state, it will perhaps be
expected that some system of the human mind, in its perfect and healthy
condition, should be laid down. It will be supposed necessary to establish
in what sanity of intellect consists, and to mark distinctly some fixed
point, the aberrations from which are to constitute disease.

To have a thorough knowledge of the nature, extent, and rectitude of the
human faculties, is particularly incumbent on him who undertakes to write
of them in their distempered state; and, in a legal point of view, it is
most important that the medical practitioner should be enabled to
establish the state of the patient's case, as a departure from that which
_is_ reason.

The difficulty of proposing a satisfactory theory of the human mind, must
have been felt by every person, who has touched this delicate string since
the days of Aristotle, and failure must be expected in him who attempts
it: yet the endeavour is laudable, and miscarriage is not linked with
disgrace. Every contribution, to illustrate what are the powers of mind we
possess; how we are acted upon by external circumstances in the
acquisition of knowledge; and concerning the manner in which we use this
knowledge for the purposes of life; ought to be candidly received.

Enquiries of this nature have been usually conducted by commenting on the
numerous and discordant authorities which have treated on metaphysical
subjects; these persons, however they may differ on many points, appear to
be pretty generally agreed, that the human mind possesses certain
faculties and powers; as imagination, judgment, reason, and memory. They
seem to consider these, as so many departments, or offices of the mind,
and therefore class men according to the excellence or predominance of
these powers. One man, is said to be distinguished by the brilliancy of
his imagination; another, by the solidity of his judgment; a third, by the
acuteness of his reason; and a fourth, by the promptitude and accuracy of
his recollection.

As far as I have observed respecting the human mind, (and I speak with
great hesitation and diffidence,) it does not possess, all those powers
and faculties with which the pride of man has thought proper to invest it.
By our senses, we are enabled to become acquainted with objects, and we
are capable of recollecting them in a greater or less degree; the rest,
appears to be merely a contrivance of language.

If mind, were actually capable of the operations attributed to it, and
possessed of these powers, it would necessarily have been able to create a
language expressive of these powers and operations. But the fact is
otherwise. The language, which characterizes mind and its operations, has
been borrowed from external objects; for mind has no language peculiar to
itself. A few instances will sufficiently illustrate this position. After
having committed an offence it is natural to say that the mind feels
contrition and sorrow.

Contrition is from _cum_ and _tero_, to rub together, which cannot
possibly have any thing to do with the operations of the mind, which is
incapable of rubbing its ideas or notions together. Contrition is a
figurative expression, and may possibly mean the act of rubbing out the
stain of vice, or wearing down by friction the prominences of sin.

If we were to analyze the word Sorrow, which is held to be a mental
feeling, we should find it to be transferred from bodily sufferance: for
the mind, is incapable of creating a term correctly expressive of its
state, and therefore, it became necessary to borrow it from _soreness_ of
body.--_See Mr. Tooke's Diversions of Purley, vol. ii. p. 207_, where
_sore_, _sorry_, and _sorrow_ are clearly made out to be the same word.

It is customary to speak of a man, of accurate perceptions, and of
another, who has grand and luminous conceptions of human nature.
Perception, from _per_, and _capio_ to take, seize, grasp, through the
medium of the organs of sense, being implied. But to take, seize, and
grasp are the operations of the hand, and can only, by extreme courtesy,
be attributed to mind.

Mr. Dugald Stewart, the most thoughtful and intelligent of modern
metaphysicians, has said, "By conception I mean that power of the mind
which enables it to form a notion of an absent object of perception, or of
a sensation which it has formerly felt."--_Elements of the Philosophy of
the Human Mind, 8vo. p. 133._

This definition means merely memory; and by perusing attentively the whole
chapter the reader will be convinced of it. Conception, from _cum_ and
_capio_, has been applied to mind from the physical sense of embracing,
comprehending, or probably from the notion of being impregnated with the
subject. It may be remarked, that these three terms, by which conception
has been explained, have been all applied to mental operation.

The words reason and reasoning, I believe, in most languages, strictly
imply numeration, reckoning, proportion; the Latin _ratio_, _ratiocinor_,
_ratiocinator_ are sufficient examples. A curious coincidence between the
Latin _ratio_ and the Gothic _rathjo_, together with some pertinent and
interesting observations, may be seen in Ihre's Glossarium Svio-gothicum,
_p._ 393, _art._ Rækna. As we now acknowledge the science of number to be
the purest system of reasoning, a system, on which all persons agree, and
so unlike medicine, politics, and divinity, concerning which there is a
constant, and hostile variety of sentiment, it adds some force to the
argument. Indeed, Mr. Locke, who almost personifies reason, after having
painfully sifted this matter, appears to be much of the same way of
thinking: he says, "Reason, though it penetrates into the depth of the sea
and earth, elevates our thoughts as high as the stars, and leads us
through the vast spaces and large rooms of this mighty fabrick, _yet it
comes far short of the real extent of even corporeal being_; and there are
many instances wherein it fails us: as,

"First: it perfectly fails us where our ideas fail: it neither does, nor
can extend itself farther than they do, and therefore, wherever we have no
ideas our reasoning stops, and we are at an end of our reckoning: and if
at any time _we reason about words, which do not stand for any ideas_, it
is only about those sounds, and nothing else.

"Secondly: our reason is often puzzled, and at a loss, because of the
obscurity, confusion or imperfection of the ideas it is employed about;
and there we are involved in difficulties and contradictions. Thus, not
having any perfect idea of the least extension of matter, nor of infinity,
we are at a loss about the divisibility of matter; _but having perfect,
clear, and distinct ideas of number, our reason meets with none of those
inextricable difficulties in numbers, nor finds itself involved in any
contradictions about them_."--_Works. 4to, vol. i, p. 431._

It can scarcely be necessary, longer to fatigue the patience of the
reader, by reverting to the etymology of those terms, which have been
considered as significant of mind and its operations. Every one will be
able sufficiently to develope imagination, reflection, combination, [as
applied to ideas, importing the amalgamation of _two_ into one]
abstraction, [_vide Mr. Tooke, from p. 15 to 426, vol. ii._] and a
variety of others; and to shew, that they have arisen from physical
objects, and the circumstances which surround us, and are independant of
any operation which mind has elaborated.

But as madness, by some, has been exclusively held to be a disease of the
imagination, and by others, to be a defect of the judgment; considering
these as separate and independant powers or faculties of the intellect; it
is certainly worth the trouble to enquire, whether such states of mind did
ever exist as original and unconnected disorders. With respect to
imagination, there can be but little difficulty; yet this will so far
involve the judgment and memory, that it will not be easy to institute a
distinction. If a cobbler should suppose himself an emperor, this
supposition, may be termed an elevated flight, or an extensive stretch of
imagination, but it is likewise a great defect in his judgment, to deem
himself that which he is not, and it is certainly an equal lapse of his
recollection, to forget what he really is.

Having endeavoured to give some reasons for not according with the
generally received opinions, concerning the different powers of the mind,
it may be proper shortly to state, that, from the manner in which we
acquire knowledge, the human mind appears to be composed of a sum of
individual perceptions: that, in proportion as we dwell by the eye, the
ear, or the touch on any object (which is called attention,) we are more
likely to become acquainted with it, and to be able to remember it. For
the most part, we remember these perceptions in the succession in which
they were presented, although, they may afterwards, from circumstances, be
differently sorted.

The minds of ordinary men are well contented to deal out their ideas, in
the order in which they were received; and, not having found the necessity
of bringing them to bear on general subjects, they are commonly minutely
accurate in the detail of that which they have observed. By such persons,
a story is told with all the relations of time and place; connected with
the persons who were present, their situation, state of health, and a vast
variety of associated particulars; and these persons, however tedious,
generally afford the most correct account. On the other hand, those who
are men of business, and have much to communicate in a given space, are
obliged to subtract the more material circumstances from the gross
narrative, and exhibit these as the sum total. It is in this way, that
words, originally of considerable length, have been abbreviated for the
conveniency of dispatch, and from this necessity short hand writing has
been employed.

As the science of arithmetic consists in addition to, or subtraction from,
a given number; so does the human mind appear to be capable solely of
adding to, or separating from, its stock of ideas, as pleasure may prompt,
or necessity enforce.

Language, the representative of thought, bears the same construction; and
it is curious to remark in the investigation of its abbreviations, that
those words, which serve to connect ideas together, (_conjunctions_) and
which have been supposed to mark certain operations of intellect, postures
of mind, and turns of thought, have merely the force and meaning of to
add, or to subtract.

Insanity is now generally divided into Mania and Melancholia, but formerly
its distributions were more numerous. Paracelsus, speaking of this
disease, says, "Vesaniæ hujus genera quatuor existunt: primi _Lunatici_
vocantur: secundi _Insani_: tertii _Vesani_: quarti _Melancholici_,
Lunatici sunt qui omnem suum morbum ex Luna accipiunt, et juxta eam sese
gerunt ac moventur. Insani sunt, qui malum id ab utero materno hauserunt,
veluti hæreditarium, uno subindè insaniam in alterum transferente. Vesani
sunt, qui a cibis ac potibus ita inficiuntur ac taminantur, ut ratione
sensuque priventur. Melancholici sunt, qui ex intimæ naturæ vitio a
ratione deturbantur, et ad vesaniam precipitantur." Paracelsus, however,
thinks that a fifth genus may be added. "Ad quatuor hac genera genus
insuper aliud quodammodo annumerari potest, videlicet _obsessi_, qui a
diabolo variis modis occupari solent."--_Paracelsi Opera, folio, tom. i.
fol. 572._

The idea of being besieged, beset, or possessed by the devil was formerly
a very favourite notion, and is derived to us by an authority we are
taught to reverence: indeed it is still the opinion of many harmless and
believing persons, some of whom have bestowed considerable pains to
convince me that the violent and mischievous maniacs in Bedlam were under
the dominion of this insinuating spirit. They have employed one argument
which would seem to have considerable weight, namely, that the most
atrocious crimes are stated in our indictments (much to the credit of
human nature) to have been committed by the instigation of the devil: and
they have also endeavoured to explain, how a late and eminently successful
practitioner, by an union of the holy office with consummate medical
skill, was enabled to cure nine lunatics out of ten, which certainly has
not hitherto been accounted for.

Paracelsus, who contemplated this subject with uncommon gravity and
solicitude, is of opinion that the devil enters us much in the same manner
as a maggot gets into a filbert.--_Vide Fragmentum Libri Philosophiæ de
Dæmoniacis et Obsessis, tom. ii. p. 460._

To conclude this part of the subject, and to exhibit the state of belief
at that period, I shall take the liberty of extracting a portion from the
11th chapter of Dr. Andrewe Boord's Extravagantes, which "doth shewe of a
Demoniacke person, the which is possessed of or with the devyll or
devylls.

"Demoniacus or Demoniaci be the Latin wordes. In Greke it is named
Demonici. In Englyshe it is named he or they, the whiche be mad and
possessed of the devyll or devils, and their propertie is to hurt and kyll
them selfe, or els to hurt and kyll any other thynge, therfore let every
man beware of them, and kepe them in a sure custody.

_The cause of this Matter._

"This matter doth passe all maner sickenesses and diseases, and it is a
fearefull and terryble thyng to se a devyll or devylles shoulde have so
muche and so greate a power over man, as it is specified of such persons
dyvers tymes in the gospell, specyally in the IX. Chapitre of St. Marke.
Chryste sendynge his disciples to preache the worde of God, gevynge them
power to make sicke men whole, lame men to go, blynde to se, &c. Some of
them dyd go by a mans that was possessed of devils and they coud not make
him whole. Shortly to conclude, Chryst dyd make hym whole. The dysciples
of Chryste asked of him why that they coud not make the possessed man of
the devylls whole. And Jesus Chryste said to them: this kynde of devylls
can not be cast out without prayer and fastynge. Here it is to be noted,
that nowe a dayes fewe or els none doth set by prayer or fastynge,
regardyng not gods wordes; in this matter, I do feare that suche persons
be possessed of the devil, although they be not starke madde, and to shew
further of demoniacke persons the whiche be starke madde. The fyrste tyme
that I dyd dwell in Rome, there was a gentilwoman of Germani, the whych
was possessed of devyls, and she was brought to Rome to be made whole.
For within the precynct of St. Peters church, without St. Peters chapel,
standeth a pyller of whyte marble grated round about with iron, to the
which our Lorde Jesus Chryste dyd lye in hymselfe unto the Pylates hal, as
the Romaynes doth say, to the which pyller al those that be possessed of
the devyl, out of dyvers countreys and nacions be brought thyther, and as
they say of Rome, such persons be made there whole. Amonge al other this
woman of Germany, which is CCCC myles and odde from Rome, was brought to
the pyller, (I then there beyng presente,) with great strength and
violently with a XX or mo men, this woman was put into that pyller within
the yron grate, and after her dyd go in a preeste, and dyd examine the
woman under this maner in the Italian tonge. Thou devyl or devyls, I do
abjure thee by the potencial power of the father, and of the sonne our
Lorde Jesus Christe, and by the vertue of the Holy Ghoste, that thou do
shewe to me, for what cause that thou doeste possess this woman: what
wordes was aunswered I will not write, for men will not beleve it, but
wolde say it were a foule and great lye, but I dyd heare that I was afrayd
to tarry any longer, lest that the devyls shulde have come out of her, and
to have entred into me; remembrynge what is specified in the viii Chapitre
of St. Matthewe, when that Jesus Christ had made two men whole, the
whiche, was possessed with a legion of devils. A legion is IX M. IX C.
nynety and nyne: the sayd devyls dyd desyre Jesus, that when they were
expelled out of the aforesayde twoo men, that they might enter into a
herde of hogges, and so they did, and the hogges did runne into the sea
and were drowned. I consyderynge this, and weke of faith and afeard,
crossed myselfe and durste not heare and se such matters, for it was to
stupendious and above all reason yf I shulde wryte it; and in this matter
I dyd marvell of an other thynge; if the efficacitie of such makynge one
whole, dyd rest in the vertue that was in the pyller, or els in the wordes
that the preest dyd speake. I do judge it shulde be in the holy wordes
that the prest dyd speak, and not in the pyller; for and yf it were in the
pyller, the Byshops, and the Cardinalles that hathe ben many yeres past,
and those that were in my tyme, and they that hath bin sence, wolde have
had it in more reverence, and not to suffre rayne, hayle, snowe, and such
wether to fal on it, for it hath no coverynge, but at laste when that I
did consyder that the vernacle, the phisnomy of Christ, and scarse the
sacrament of the aulter was in maner uncovered and al St. Peters Churche
downe in ruyne, and utterly decayed, and nothing set by, consideringe in
olde chapels, beggers and baudes, hoores and theves dyd lye within them,
asses and moyles dyd defyle within the precincte of the Churche, and
byenge and sellynge there was used within the precinct of the sayde church
that it dyd pytie my harte and mynde to come and se any tyme more the
sayde place and churche."--_Andrewe Boorde,[2] the seconde Boke of the
Brevyary of health, 1557, fol. 4th._

To return from this digression. 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
melancholia. 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[3] 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.

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; most
probably in the senses.

We sometimes (more especially in the early stages of furious madness) find
patients from very slight resemblances, and sometimes, where none whatever
can be perceived by others of sound mind, confounding one person with
another. Even in this case it does not seem necessary to recur to false
perception for the explanation. It is equally probable that the organs of
vision are affected in consequence of the disease of the brain, and
therefore receive incorrect sensations: and still more likely, from the
_rapid succession_ in which objects are noticed, that a very slight trait
of countenance would recal the idea [or name] of some particular person.

I have known many 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 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, 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.

That "confusion of ideas" should be the necessary consequence of false
perception, is very difficult to admit. It has often been observed that
madmen will 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, if the person were capable of
deducing from it the proper inferences, could neither create confusion nor
irregularity of ideas.

Melancholia, the other form in which this disease is supposed to exist, is
made by Dr. Ferriar to consist in "intensity of idea." 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
melancholia, and the most depressed and miserable objects become violent
and raving. There are patients in Bethlem Hospital, whose lives are
divided between furious and melancholic paroxysms, and who, under both
forms, retain the same set of ideas. It must also have been observed, by
those who are conversant with this disorder, that there is an intermediate
state, which cannot be termed maniacal nor melancholic: a state of
complete insanity, yet unaccompanied by furious or depressing
passions.[4]

In speaking of the two forms of this disease, mania and melancholia, there
is a circumstance sufficiently obvious, which hitherto does not appear to
have been noticed: I mean the rapid or slow succession of the patient's
ideas. Probably sound and vigorous mind consists as much in the moderate
succession of our ideas, as in any other circumstance. It may be enquired,
how we are to ascertain this increased, proportionate, and deficient
activity of mind? From language, the medium by which thought is conveyed.
The connexion between thought and utterance is so strongly cemented by
habit, that the latter becomes the representative of the former.

The physiology of mind, I humbly conceive to be at present in its infancy,
but there seems good reason to imagine, that furious madness implies a
rapid succession of ideas; and the circumstance of rage, from whence its
origin has been deduced, points out the hurried consecution. In this state
of mind the utterance succeeds

  --------------------"sudden as the spark
  From smitten steel; from nitrous grain the blaze."

and it frequently happens, after the tumult has subsided, the person
remembers but little of that which had escaped him.

  "I then, all-smarting with my wounds, being cold,
  (To be so pestered with a popingay)
  Out of my greefe, and my Impatience,
  Answered (neglectingly) _I know not what_--
  _He should, or should not_: for he made me _mad_."

From this connexion between thought and utterance, we find many persons
(particularly those who are insane) talking to themselves; especially when
their minds are intently occupied; and taking the converse, we frequently
observe those who are desirous to acquire any subject by heart, repeating
it aloud.

From the same cause we have often occasion to remark, that strong, and
perhaps involuntary, propensity to repeat the emphatical words in a
sentence, and which are commonly the last, before we endeavour to reply
to, or confute them.

  "_King._ No: on the barren Mountaine let him sterve:
           For I shall never hold that man my friend
           Whose tongue shall aske me for one peny cost
           To ransome home revolted Mortimer.

  "_Hotsp._ Revolted Mortimer?
            He never did fall off, my Soveraigne Liege,
            But by the chance of warre:"

As the terms Mania and Melancholia, 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 there is an equal derangement. On
dissection, the state of the brain does not shew any appearances peculiar
to melancholia; nor is the treatment, which I have observed most
successful, different from that which is employed in mania.

As the practitioner's own mind must be the criterion, by which he infers
the insanity of any other person; and when we consider the various, and
frequently opposite, opinions of these intellectual arbitrators; the
reader will be aware that I have not abstained from giving a definition of
madness without some reason. There is indeed a double difficulty: the
definition ought to comprize the aberrations of the lunatic, and fix the
standard for the practitioner.

But it may be assumed that sound mind and insanity stand in the same
predicament, and are opposed to each other in the same manner, as right to
wrong, and as truth to the lie. In a general view no mistake can arise,
and where particular instances create embarrassment, those most conversant
with such persons will be best able to determine.

The terms sound mind and insanity are sufficiently plain. If to an
ordinary observer, a person were to talk in an incoherent manner, he would
think him mad; if his conduct were regular, and his observations
pertinent, he would pronounce him in his senses: the two opposite states,
well marked, are well understood; but there are many different shades,
which are not so likely to strike the common examiner.




CHAP. II.

SYMPTOMS OF THE DISEASE.


On this part of the subject, authors have commonly descended to minute
particularities, and studied discriminations. Distinctions have been
created, rather from the peculiar turn of the patient's propensities and
discourse, than from any marked difference in the varieties and species of
the disorder. Every person of sound mind, possesses something peculiar to
himself, which distinguishes him from others, and constitutes his
idiosyncrasy of body and individuality of character: in the same manner,
every lunatic discovers something singular in his aberrations from sanity
of intellect. It is not my intention to record these splintered
subdivisions, but to exhibit the prominent features, by which insanity may
be detected, as far as such appearances seem worthy of remark, and have
been the subject of my own observation.

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 incipient
madness. It is true, that all who are admitted into it, have been a
greater, or less time afflicted with the disorder; 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 establishment, a recurrence of the malady
very frequently takes place. Upon these occasions, there is an ample scope
for observing the first attack of the disease.

On the approach of mania, they first become uneasy,[5] 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 those who are 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;[6] the mind becomes crouded with thoughts, and confusion
ensues.

Those under the influence of the depressing passions, will exhibit a
different train of symptoms. The countenance wears an anxious and gloomy
aspect, and they are little disposed to speak. 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. Frequently they will keep their eyes fixed to some object for hours
together, or continue them an equal time "bent on vacuity." They next
become fearful, and conceive a thousand fancies: often recur to some
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.

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 melancholic patients. We have
in the hospital some unfortunate persons, who are obliged to be secured
the greater 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 admitted 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 persons 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. [The circumstances which probably
occasioned the employment of this term are pointed out in the chapter
which enumerates the causes of insanity.] 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.
As the law requires a precise developement of opinion, 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 short conversation, a person
under confinement shall bewray 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 its ramifications and
dependancies, 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 mad man'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 discovered 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 some years ago, and which is equally
apposite to the subject. A young man had become insane from habitual
intoxication; and, during the violence of his disorder, had attempted to
destroy himself. Under a supposed imputation of having unnatural
propensities, 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 he was not
well, although no incoherence 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: they have sometimes such a high degree of control 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.

Of this restraint, which madmen have sometimes the power of imposing on
their opinions, the remark has been so frequent, that those who are more
immediately about their persons, have termed it, in their rude phrase,
_stifling the disorder_.

Among the numerous instances of this cunning and dissimulation, which I
have witnessed in insane persons, the relation of one case will be
sufficient to exemplify the subject.

An Essex farmer, about the middle age, had on one occasion so completely
masked his disorder, that I was induced to suppose him well, when he was
quite otherwise. He had not been at home many hours, before his
derangement was discernable by all those, who came to congratulate him on
the recovery of his reason. His impetuosity, and mischievous disposition
daily increasing, he was sent to a private mad-house; there being, at that
time, no vacancy in the hospital. Almost from the moment of his
confinement he became tranquil, and orderly, but remonstrated on the
injustice of his seclusion.

Having once deceived me, he wished much, that my opinion should be taken
respecting the state of his intellects, and assured his friends that he
would submit to my determination. I had taken care to be well prepared for
this interview, by obtaining an accurate account of the manner in which he
had conducted himself. At this examination, he managed himself with
admirable address. He spoke of the treatment he had received, from the
persons under whose care he was then placed, as most kind and fatherly: he
also expressed himself as particularly fortunate in being under my care,
and bestowed many handsome compliments on my skill in treating this
disorder, and expatiated on my sagacity in perceiving the slightest tinges
of insanity. When I wished him to explain certain parts of his conduct,
and particularly some extravagant opinions, respecting certain persons and
circumstances, he disclaimed all knowledge of such circumstances, and felt
himself hurt, that my mind should have been poisoned so much to his
prejudice. He displayed equal subtilty on three other occasions when I
visited him; although by protracting the conversation, he let fall
sufficient to satisfy my mind that he was a mad-man. In a short time he
was removed to the hospital, where he expressed great satisfaction in
being under my inspection. The private mad-house, which he had formerly so
much commended, now became the subject of severe animadversion; he said
that he had there been treated with extreme cruelty; that he had been
nearly starved, and eaten up by vermin of various descriptions. On
enquiring of some convalescent patients, I found (as I had suspected) that
I was as much the subject of abuse, when absent, as any of his supposed
enemies; although to my face his behaviour was courteous and respectful.
More than a month had elapsed, since his admission into the hospital,
before he pressed me for my opinion; probably confiding in his address,
and hoping to deceive me. At length he appealed to my decision, and urged
the correctness of his conduct during confinement as an argument for his
liberation. But when I informed him of circumstances he supposed me
unacquainted with, and assured him, that he was a proper subject for the
asylum where he then inhabited; he suddenly poured forth a torrent of
abuse; talked in the most incoherent manner; insisted on the truth of what
he had formerly denied; breathed vengeance against his family and friends,
and became so outrageous that it was necessary to order him to be strictly
confined. He continued in a state of unceasing fury for more than fifteen
months.

As the memory, appears to be particularly defective in cases of insanity,
it is much to be wished, that we possessed a correct history, and
physiological account of this wonderful faculty. Unfortunately, this
knowledge is not to be sought for with much prospect of attainment, from
books which treat of the human mind and its philosophy; nor is the present
work, to be considered as the depository of such information. A deliberate
attention, to the precise order in which we acquire information on any
subject; a consideration of the effects of its repetition; an
investigation of the result (comparing it to a chain) whenever the links
are separated, together with a knowledge of the contrivance of abbreviated
signs, would perhaps render the matter sufficiently intelligible. But it
would be necessary, thoroughly to understand the nature of the thing, of
which the sign has been abbreviated: particularly, as the usual mode of
education is satisfied with possessing the convenience of the
abbreviation, without any inquiry into the nature of the thing, and the
cause of the abbreviation of its sign. This faulty mode of instruction,
has furnished us with a profusion of names, and left us ignorant of the
things they represent.

Ben Johnson has afforded us the shortest, and probably, the best account
of memory.

"_Memory_ of all the _powers_ of the mind, is the most _delicate_, and
frail: It is the first of our _faculties_ that age invades. Seneca, the
Father, the _Rhetorician_, confesseth of himself, he had a miraculous one,
not only to receive, but to hold. I myself could in my youth, have
repeated all that ever I had made, and so continued till I was past
forty: since it is much decayed in me. Yet I can repeat whole books that I
have read, and _Poems_ of some selected friends, which I have lik'd to
charge my memory with. It was wont to be faithful to me, but shaken with
_Age_ now, and _Sloth_ (which weakens the strongest abilities) it may
perform somewhat, but cannot promise much. By exercise it is to be made
better and serviceable. Whatsoever I pawn'd with it while I was young and
a boy, it offers me readily, and without stops: but what I trust to it
now, or have done of later years, it lays up more negligently, and
sometimes loses; so that I receive mine own (though frequently called for)
as if it were new and borrow'd. Nor do I always find presently from it
what I do seek; but while I am doing another thing, that I laboured for
will come: and what I sought with trouble, will offer itself when I am
quiet. Now in some men I have found it as happy as nature, who, whatsoever
they read or pen, they can say without book presently; as if they did then
write in their mind. And it is more a wonder in such as have a swift
stile, for their Memories are commonly slowest; such as torture their
writings, and go into council for every word, must needs fix somewhat, and
make it their own at last, though but through their own
vexation."--_Discoveries, vol. vi. p. 240, 1716._

If in a chain of ideas, a number of the links are broken, or leaving out
the metaphor, if there be an inability to recollect circumstances in the
order, in which they occurred, 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. Shakespeare, the highest authority in every thing
relating to the human mind and its affections, seems to be persuaded, that
some defect of memory is necessary to constitute madness.

                          "It is not madnesse
  That I have uttered: bring me to the test
  And I the matter will _re-word_, which madnesse
  Would gambol from."--_Hamlet, Act III. Scene 4._

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. When I have listened to the conversations of the old
incurable patients, the topic has generally turned upon the transactions
of early days; and, on the circumstances of that period of life, they have
frequently spoken with tolerable correctness. In many cases, where the
mind has 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 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 frequently 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 courted solitude; consequently have acquired no
new ideas, and time has effaced the impression of those, formerly stamped
on the mind. Mr. Locke, well observes, although he speaks figuratively,
"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."

Connected with loss of memory, there is a form of insanity which occurs in
young persons; and, as far as these cases have been the subject of my
observation, they have been more frequently noticed in females. Those whom
I have seen, have been distinguished by prompt capacity and lively
disposition: and in general have become the favourites of parents and
tutors, by their facility in acquiring knowledge, and by a prematurity of
attainment. This disorder commences, about, or shortly after, the period
of menstruation, and in many instances has been unconnected with
hereditary taint; as far as could be ascertained by minute enquiry. The
attack is almost imperceptible; some months usually elapse, before it
becomes the subject of particular notice; and fond relatives are
frequently deceived by the hope that it is only an abatement of excessive
vivacity, conducing to a prudent reserve, and steadiness of character. A
degree of apparent thoughtfulness and inactivity precede, together with a
diminution of the ordinary curiosity, concerning that which is passing
before them; and they therefore neglect those objects and pursuits which
formerly proved sources of delight and instruction. The sensibility
appears to be considerably blunted; they do not bear the same affection
towards their parents and relations; they become unfeeling to kindness,
and careless of reproof. To their companions they shew a cold civility,
but take no interest whatever in their concerns. If they read a book, they
are unable to give any account of its contents: sometimes, with steadfast
eyes, they will dwell for an hour on one page, and then turn over a number
in a few minutes. It is very difficult to persuade them to write, which
most readily develops their state of mind: much time is consumed and
little produced. The subject is repeatedly begun, but they seldom advance
beyond a sentence or two: the orthography becomes puzzling, and by
endeavouring to adjust the spelling, the subject vanishes. As their apathy
increases they are negligent of their dress, and inattentive to personal
cleanliness. Frequently they seem to experience transient impulses of
passion, but these have no source in sentiment; the tears, which trickle
down at one time, are as unmeaning as the loud laugh which succeeds them;
and it often happens that a momentary gust of anger, with its attendant
invectives, ceases before the threat can be concluded. As the disorder
increases, the urine and fæces are passed without restraint, and from the
indolence which accompanies it, they generally become corpulent. Thus in
the interval between puberty and manhood, I have painfully witnessed this
hopeless and degrading change, which in a short time has transformed the
most promising and vigorous intellect into a slavering and bloated ideot.

Of the organs of sense, which become affected in those labouring under
insanity, the ear, more particularly suffers. I scarcely recollect an
instance of a lunatic becoming blind, but numbers are deaf. It is also
certain that in these persons, more delusion is conveyed through the ear
than the eye, or any of the other senses. Those who are not actually deaf,
are troubled with difficulty of hearing, and tinnitus aurium. Thus an
insane person shall suppose that he has received a commission from the
Deity; that he has ordered him to make known his word, or to perform some
act, as a manifestation of his will and power. It is however much to be
regretted, that these divine commissions generally terminate in human
mischief and calamity, and instances are not unfrequent, where these holy
inspirations, have urged the unfortunate believer to strangle his wife,
and attempt the butchery of his children. From this source may be
explained, the numerous delusions of modern prophecies, which
circumstantially relate the gossipings of angels, and record the
hallucinations of feverish repose.

In consequence of some affection of the ear, the insane sometimes insist
that malicious agents contrive to blow streams of infected air into this
organ: others have conceived, by means of what they term hearkening wires
and whiz-pipes, that various obscenities and blasphemies are forced into
their minds; and it is not unusual for those who are in a desponding
condition, to assert, that they distinctly hear the devil tempting them
to self-destruction.

A considerable portion of the time of many lunatics, is passed in replies
to something supposed to be uttered. As this is an increasing habit, so it
may be considered as an unfavourable symptom, and at last the patient
becomes so abstracted from surrounding objects, that the greater part of
the day is consumed in giving answers to these supposed communications. It
sometimes happens that the intelligence conveyed, is of a nature to
provoke the mad-man, and on these occasions, he generally exercises his
wrath on the nearest bystander; whom he supposes, in the hurry of his
anger, to be the offending party.

In the soundest state of our faculties, we are more liable to be deceived
by the ear, than through the medium of the other senses: a partial
obstruction by wax, shall cause the person so affected, to hear the
bubbling of water, the ringing of bells, or the sounds of musical
instruments; and on some occasions, although the relation seems tinged
with superstition, men of undeviating veracity, and of the highest
attainments, have asserted, that they have heard themselves _called_. "He
[Dr. Johnson] mentioned a thing as not unfrequent, of which I [Mr.
Boswell] had never heard before--being _called_, that is, hearing one's
name pronounced by the voice of a known person at a great distance, far
beyond the possibility of being reached by any sound, uttered by human
organs. An acquaintance on whose veracity I can depend, told me, that
walking home one evening to Kilmarnock, he heard himself called from a
wood, by the voice of a brother who had gone to America; and the next
packet brought account of that brother's death. Macbean asserted that
this inexplicable _calling_ was a thing very well known. Dr. Johnson said,
that one day at Oxford, as he was turning the key of his chamber, he heard
his mother distinctly call _Sam_. She was then at Litchfield; but nothing
ensued. This phænomenon is, I think, as wonderful as any other mysterious
fact, which many people are very slow to believe, or rather, indeed,
reject with an obstinate contempt."--_Boswell's Life of Dr. Johnson,
4to. vol. ii. p. 384._

One of the most curious cases of this nature which has fallen under my
observation, I shall here venture to relate, for the amusement of the
reader. The patient was a well educated man, about the middle age; he
always stopped his ears closely with wool, and, in addition to a flannel
night-cap, usually slept with his head in a tin saucepan. Being asked the
reason why he so fortified his head, he replied, "To prevent the
intrusion of the _sprites_." After having made particular enquiry
concerning the nature of these beings, he gravely communicated the
following information:--"Sir, you must know that in the human seminal
fluid there are a number of vital particles, which being injected into the
female, impregnate her, and form a foetus of muscles and bones. But this
fluid has other properties, it is capable, by itself, of producing
vitality under certain circumstances, and experienced chemists and
hermetical philosophers have devised a method of employing it for other
purposes, and some, the most detrimental to the condition and happiness of
man. These philosophers, who are in league with princes, and their
convenient and prostituted agents, contrive to extract a portion of their
own semen, which they conserve in rum or brandy: these liquors having the
power of holding for a considerable time the seminal fluid, and keeping
its vitality uninjured. When these secret agents intend to perform any of
their devilish experiments on a person, who is an object of suspicion to
any of these potentates, they cunningly introduce themselves to his
acquaintance, lull him to sleep by artificial means, and during his
slumbers, infuse a portion of their seminal fluid (conserved in rum or
brandy) into his ears.

"As the semen in the natural commerce with the woman, produces a child,
so, having its vitality conserved by the spirit, it becomes capable of
forming a _sprite_; a term, obviously derived from the spirit in which it
had been infused. The ear is the most convenient nidus for hatching these
vital particles of the semen. The effects produced on the individual,
during the incubation of these seminal germs, are very disagreeable; they
cause the blood to mount into the head, and produce considerable giddiness
and confusion of thought. In a short time, they acquire the size of a
pin's head; and then they perforate the drum of the ear, which enables
them to traverse the interior of the brain, and become acquainted with the
hidden secrets of the person's mind. During the time they are thus
educated, they enlarge according to the natural laws of growth; they then
take wing, and become invisible beings, and, from the strong ties of
natural affection, assisted by the principle of attraction, they revert to
the parent who afforded the semen, and communicate to him their
surreptitious observations and intellectual gleanings. In this manner, I
have been defrauded of discoveries which would have entitled me to
opulence and distinction, and have lived to see others reap honours and
emoluments, for speculations which were the genuine offsprings of my own
brain."

By some persons, madness has been considered as a state of mind analogous
to dreaming: but an inference of this kind supposes us fully acquainted
with the actual state, or condition of the mind in dreaming, and in
madness. The whole question hinges on a knowledge of this _state of mind_,
which I fear is still involved in obscurity. As it is not the object of
the present work to discuss this curious question, the reader is referred
to the fifth section of the first part of Mr. Dugald Stewart's Elements of
the Philosophy of the Human Mind, and to the note, o, at the end; he will
also find the subject treated with considerable ingenuity in the eleventh
section of Mr. Brown's Observations on Zoonomia.

There is, however, a circumstance, which to my knowledge, has not been
noticed by those who have treated on this subject, and which appears to
establish a marked distinction between madness and dreaming. In madness,
the delusion we experience is most frequently conveyed through the ear; in
dreaming, the deception is commonly optical; we see much, and hear little;
indeed dreaming, at least with myself, seems to be a species of
intelligible pantomime, that does not require the aid of language to
explain it. It is true, that 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. But this only refers to that consciousness of
delusion, which is admitted by the patient on his return to reason; in the
same manner as the man awake, smiles at the incongruous images, and
abrupt transitions of the preceding night. In neither condition, does the
consciousness of delusion, establish any thing explanatory of the _state_
of the mind.

In a description of madness, it would be blameable to omit a form of this
disease which is commonly very intractable, and of the most alarming
consequences; I mean, the insanity which arises from the habit of
intoxication. All persons who have had any experience of this disease,
readily allow that fermented liquors, taken to excess, are capable of
producing mental derangement: but the medical practitioner has in such
cases, to contend, and generally without effect, with popular prejudice,
and sometimes, with the subordinate advisers of the law.

To constitute madness, the minds of ignorant people expect a display of
continued violence, and they are not satisfied that the person can be
pronounced in that state, without they see him exhibit the pranks of a
baboon, or hear him roar and bellow like a beast. By these people the
patient is stated only to be intemperate; they confess that he does very
foolish things when intoxicated; but that he is not mad, and only requires
to be restrained from drinking. Thus, a man is permitted slowly to poison
and destroy himself; to produce a state of irritation, which disqualifies
him for any of the useful purposes of life; to squander his property
amongst the most worthless and abandoned; to communicate a loathsome and
disgraceful disease to a virtuous wife, and leave an innocent and helpless
family to the meager protection of the parish. If it be possible, the law
ought to define the circumstances, under which it becomes justifiable, to
restrain a human being from effecting his own destruction, and involving
his family in misery and ruin. When a man suddenly bursts through the
barriers of established opinions; if he attempt to strangle himself with a
cord, to divide his larger blood-vessels with a knife, or swallow a vial
full of laudanum, no one entertains any doubt of his being a proper
subject for the superintendance of keepers, but he is allowed, without
control, by a gradual process, to undermine the fabric of his own health,
and destroy the prosperity of his family.

All patients have not the same degree of memory of what has passed during
the time they were disordered: and I have frequently remarked, when they
were unable to give any account of the peculiar opinions which they had
indulged, during a raving paroxysm of long continuance, that 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, 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 supposed free from
any mental derangement, in many strange and ridiculous movements,
particularly if their minds be intently occupied:[7]--this does not
appear to be so much the effect of habit, as of a particular state of
mind.

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 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
two hundred and sixty-five who were examined, two hundred and five were of
a swarthy complexion, with dark, or black hair; the remaining sixty were
of a fair skin, and light, brown, or redhaired. What connexion this
proportion may have, with the complexion and colour of the hair of the
people of this country in general, and what alterations may have been
produced by age, or a 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 in the cold weather 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.

From the great degree of insensibility which prevails in some states of
madness, a degree of cold would scarcely be felt by such persons, which
would create uneasiness in those of sound mind; but experience has shewn
that they suffer equally from severity of weather. When the mind is
particularly engaged on any subject, external circumstances affect us less
than when unoccupied. Every one must recollect that, in following up a
favourite pursuit, his fire has burned out, without his being sensible of
the alteration of temperature; but when the performance has been finished,
or he has become indifferent to it from fatigue, he then becomes sensible
to cold, which he had not experienced before.

Some maniacs refuse all covering, but these are not common occurrences;
and it may be presumed, that by a continued exposure to the atmosphere,
such persons might sustain, with impunity, a low temperature, which would
be productive of serious injury to those who are clad according to the
exigences of the season. Such endurance of cold is more probably the
effect of habit, than of any condition peculiar to insanity.

Having thus given a general account of the symptoms, I shall now lay
before my readers a history of the appearances which I have noticed on
opening the heads of several maniacs who have died in Bethlem Hospital.




CHAP. III.

CASES, WITH THE APPEARANCES ON DISSECTION.


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.[8] 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 arachnoidea; in the ventricles about four ounces of water were
contained--some large hyatids 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 previously
to his admission, and that he 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 recal 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 arachnoidea 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 26th, 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 very seldom slept--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 arachnoidea 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 glandulæ
Pacchioni were uncommonly large: the tunica arachnoidea 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, December
26, 1795. It was stated, that he had been disordered two months previously
to his having been received as a patient. His friends were unacquainted
with any cause, which was likely to have induced the disease. 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 scarcely appeared to take 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 arachnoidea. 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 glandulæ
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 glandulæ
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.[9] 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
tunica arachnoidea 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 re-admitted
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 forepart 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 slept but little, 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 tunica arachnoidea,
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 disorder. 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 spongy 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 to
the whole contents of the cranium: the consistence of the brain did not
differ from what is found in a 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 tunica arachnoidea
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 most 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 bewrayed 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 arachnoidea, 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 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 tunica 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.[10] 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 of animal
matter took place, 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 melancholic 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 mad
house 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
arachnoidea was slightly opake: the pia mater was inflamed; and in the
ventricles were found about two tea-spoons full of water tinged deeply
yellow, and the vesicles of the plexus choroides were of the same colour:
to 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 gall-bladder 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 had
little 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 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 securing 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 arachnoidea 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.


CASE XXX.

T. G. a man, about fifty-five years of age, was admitted into the
hospital, January 20, 1798. It was stated, that he had been disordered a
year and half, and that his madness arose from repeated intoxication.
Having set fire to several hay-stacks, and committed frequent depredations
on the neighbouring farmers, it had been found necessary to confine him in
the county goal. His behaviour in this situation marked the cunning and
malignity of his mind, so that he was always attempting some mischief
either by violence or stratagem.

When brought to the hospital he conducted himself with propriety and
order, and appeared to be in a state of recovery. On the second of May he
was attacked with a diarrhoea which daily encreased, notwithstanding the
medicines employed for its removal. His mind became violently agitated
from the commencement of the diarrhoea, and it was found proper to
secure him. On the 8th, dysenteric symptoms appeared, which continued to
the 13th, when he died.

_Appearances on Dissection._

The head was opened twenty-four hours after death. The pericranium was
loosely attached to the scull, and the dura mater adhered but slightly to
the internal surface of the cranium; there was a considerable quantity of
water between the dura mater and tunica arachnoidea, this latter membrane
(especially where the hemispheres meet) was of a milky whiteness, and
generally so in the course of the veins of the pia mater. The glandulæ
Pacchioni were very large and numerous. Between the tunica arachnoidea and
pia mater there was much water; and from the lateral ventricles, which
were uncommonly enlarged and distended, eight ounces of fluid were
collected: the infundibulum was remarkably large: the membrane lining the
cavity of the lateral ventricles had its veins very turgid: the
consistence of the brain was softer than natural.

The fluid obtained from the brain in this case being very pellucid and
abundant, it was submitted to some chemical tests in order to ascertain
its composition.

An attempt of this kind had been made before; (vide Case 23) the present
may be considered a small addition to our knowledge of this fluid, though
by no means a satisfactory developement of its materials, according to the
severity and precision of modern analysis.[11]

ANALYSIS OF THE FLUID.

  _Tincture of Galls_,  produced a white precipitate in
                        moderate quantity.

  _Lime Water_,         afforded a considerable quantity
                        of a white precipitate, which was
                        redissolved without effervescence
                        by muriatic acid.

  _Solution of Sulphat  A drop of this solution added to
    of Copper._         two drams of the brain fluid
                        tinged it with a pretty deep blue.

The presence of animal matter is inferred from the deposition produced by
infusion of galls.

The precipitation by lime-water indicates the phosphoric acid.

And it appears from the blue tinge given to the fluid by the sulphat of
copper, that ammonia or some of its combinations was contained.

As it occurred on many former trials, there was no coagulation by heat; a
slight sediment fell, after boiling some minutes.

As this patient remained in the hospital from the middle of January to the
beginning of May, in a state perfectly tranquil, and without the
appearance of disarrangement of mind, it is improbable that a so great
enlargement of the ventricles, and accumulation of water, could have taken
place within the short space of two weeks, it is therefore most likely
that the greatest part of this fluid had been previously collected.

It may be conjectured that a very gradual accumulation of water (although
the quantity be at last considerable) would not affect the sensorium so as
a sudden secretion of fluid; or, that a quantity, which at one time had
occasioned great disturbance, would by habit become less inconvenient.

We are not well informed, but there is reason to believe, that gradual
pressure on the brain, will not occasion those serious symptoms which a
sudden pressure would excite.


CASE XXXI.

H. K. a woman, aged thirty, was admitted into the hospital, October 15,
1796. She had then been mad about four months, and her disorder was stated
to have supervened on the birth of a child. From subsequent enquiry it was
ascertained that her mother had been insane, and that her elder sister
had been similarly affected; but from the best information it did not
appear that her brothers (she had two) had ever been visited with this
calamity.

Previously to her admission she had frequently attempted to destroy
herself, and had also endeavoured to take away the life of her husband. In
the hospital she was extremely violent; supposed her neighbours had
conspired to take away her liberty, and became jealous of her husband: she
was often naming some female of her acquaintance who had artfully ensnared
his affections, and whom he had decked out in her best apparel: she
breathed revenge when she should return home, and seemed much delighted
with the idea of destroying these favourites, when they were dressed for
some excursion with her husband.

She had understood that a year was the extent of time that persons were
detained in the hospital, and conceived she should be liberated when it
had elapsed, to put her menaces into execution. Her disorder being of a
dangerous tendency she was retained in the hospital after the period of
probation. When she found the hope of gratifying her revenge frustrated,
by being kept beyond the time of her expectation, she began to pine away,
her appetite diminished, and a cough, with copious expectoration and
hectic fever supervened. During the whole period of her bodily disease,
she would never acknowledge herself to be ill, and the violence of her
mental disorder was unabated. She died of Phthisis Pulmonalis, April 1st,
1798.

The head was opened twenty four hours after her decease. The tunica
arachnoidea was in many places opake; the pia mater was highly inflamed,
and loaded with blood, and a considerable quantity of water was contained
between it and the former membrane. The ventricles were enlarged, but
contained scarcely any fluid. The other parts of the brain were healthy,
and its consistence was natural.

It is a common opinion, that Phthisis Pulmonalis is frequently suspended
by the supervention of mania; medical books abound with such accounts, and
some persons have supposed it difficult, if not impossible, for these
diseases to co-exist. It is not my intention to dispute the accuracy of
such relations, nor to question the power which Mania may possess in
arresting the progress of Phthisis Pulmonalis, but, to state that the
converse does not obtain; and, that whatever obligations may be due from
Phthisis to Mania, the compliment has not been returned. From my own
experience I can affirm, that insane persons are as liable to Phthisis
Pulmonalis as others, that numbers of them die of that disease; and that I
never saw any abatement of the maniacal symptoms through the progress of
consumption.


CASE XXXII.

J. P. aged 57, was admitted into the hospital, January 19, 1799; he was
stated to have been insane about three weeks, and that his disorder came
on shortly after the death of his master, in whose service he had
continued many years, and to whom he was much attached. He had been in the
hospital three times before, and had each time been discharged well. His
disorder usually recurred every seven or eight years. His father also had
been maniacal about the middle period of life, but never recovered. When
admitted he was very talkative, although his natural character was
reserved. He endeavoured to explain his meaning with superior correctness,
and sought to define every subject, however trifling, with a tedious
minuteness; but, upon religion and politics, the Scylla and Charybdis of
human discussion, he was pertinacious and intollerant. This dictatorial
manner and stubbornness of opinion, not being capable of producing the
relations of peace and amity with other philosophers, equally obstinate,
and whose principles had been matured by long confinement, it became
necessary to shut him up in his cell. During the period of his seclusion,
nothing very incoherent escaped from him; every thing he said was within
the sphere of possibility. His fastidiousness rendered him unhappy: he
acknowledged the food which was brought him to be good, but he conceived
it might have been better. The cathartic medicine, which was administered
to him, he confessed had answered the purpose, but its taste was most
nauseous, and he had never before been so severely griped. He ornamented
his person and apartment in a very whimsical manner: latterly he tore his
clothes because he suspected the taylor had deceived him in the materials.
After this he continued naked until the beginning of March, when he
appeared more composed, and sensible of the state he had been in. On the
morning of the 12th, when the keeper opened his cell, he was speechless;
his mouth drawn to the right side, and so feeble that he could not support
himself. A cathartic medicine was given, and sinapisms were applied to the
feet and legs. In the evening he was much recovered, his speech had
returned, and he was able to move himself. He was visited again at
midnight, when he appeared still better. In the morning it was evident
that he had experienced another attack, his mouth was drawn aside; he was
stupid, and died within half an hour. The head was opened on the
following day. The tunica arachnoidea was in some places slightly opake.
The pia mater was inflamed, but not to any considerable degree. There was
no water between any of the membranes. The ventricles were of a natural
capacity, and did not contain any fluid. There was no extravasation in any
part of the substance of the cerebrum or cerebellum. Excepting the slight
inflammation of the pia mater, the brain had a very healthy appearance;
its consistence was firm; the scull was unusually thick. I regret, from a
promise which had been made to the friends, of inspecting the head only,
that the thoracic and abdominal viscera were not examined.

This history has been related to shew, that although the patient died with
those symptoms, which indicate pressure on the brain, as loss of speech,
the mouth being drawn aside, stupor and insensibility; yet the brain did
not afford the same appearances, on dissection, as have been usually
detected in such cases. The following relation is an additional example of
the same fact:


CASE XXXIII.

N. B. He had been many years in the hospital as an incurable patient; his
mother was known to have been maniacal; his two brothers and his sister
have been insane. His eldest son, on taking a very small quantity of
fermented liquor, becomes frantic, and its effects continue much longer
than on persons in general. During this patient's confinement, he was, as
far as could be ascertained, completely in his senses; this induced the
medical persons of the hospital, on two or three occasions, to give him
leave of absence, that he might return on trial to his wife and family;
but, in a few hours after he came home, he felt uneasy, and found himself
bewitched at all points: the devil and his imps had pre-occupied the best
places in the house; he became very turbulent, and also jealous of his
wife, and was obliged to be returned to the hospital. As he found his home
so beset with difficulties he resolved that he would never enter it again.
During eight years that I was acquainted with him I never discovered the
least insanity in his actions or conversation. He was perfectly sensible
that his intellects were disordered whenever he returned to his family.
His wife and children frequently visited him in Bethlem, and he always
conducted himself affectionately towards them. About 14 months before his
death he laboured under a severe dysentery, which continued six weeks, and
left him in a very reduced state, with oedematous legs, and incipient
dropsy of the abdomen. On his recovery from these symptoms he became
troubled with fits; they appeared to be such as a medical person would
have termed apoplectic. After the attack, no symptoms of paralysis
remained, nor did he experience the fatigue and exhaustion, or fall into a
profound sleep, which usually accompanies Epilepsy. On October 10th, 1802,
being then in a pretty good state of health, he fell down, and expired in
a few minutes. He was about sixty-five years of age. On examination of the
head after death, there was a considerable determination of blood to the
brain; but there was no extravasation of that fluid, nor any collection of
water: the brain and its membranes had a healthy appearance, and its
consistence was natural. The heart was sound, and the abdominal viscera
were not conspicuously diseased.


CASE XXXIV.

J. P. a man, aged thirty, was admitted into the hospital, October 18th,
1800. It was then deposed, by the persons who brought him, that he had
been for eight months in a melancholic state; but they were unable to
assign any circumstances, which preceded his disorder, as a cause of his
disease. He had a large tumor on the throat which extended backward to the
neck, principally on the left side; the increase of this swelling, they
alledged, had much alarmed him, at the commencement of his melancholic
attack. During the time he was the subject of my observation, he was in a
very mopish and stupid state; if spoken to, he would sometimes give a
short answer, but ordinarily he took no notice of those who addressed him.
Some days he would walk slowly in the less frequented part of the
building; frequently he sat down for some hours in a corner. His appetite
was good, he ate the food which was brought him, but never took the
trouble to go for it, when serving out. In this state he continued until
April 2d, when he became more stupid, and could not be made to rise from
his bed. He did not appear to be in any pain, nor was he at all convulsed.
His bowels were regular. On the 5th he became comatose, and on the 9th he
died.

_Appearances on Dissection._

There was an excessive determination of blood to the brain, and the pia
mater was highly inflamed. On the inferior part of the middle lobe of the
brain, there was a gangrene of considerable extent, together with a
quantity of very foetid purulent matter.

This is the only instance of a gangrenous state of the brain which has
fallen under my observation.


CASE XXXV.

T. C. This person had remained many years in the hospital on the incurable
establishment. He had been a schoolmaster at Warrington in Lancashire, and
was a man of acuteness and extensive mathematical learning. As he became
very furious on the attack of his maniacal disorder, he was placed in the
Lunatic Asylum at Manchester, where he killed the person who had the care
of him, by stabbing him in the back with a knife.

The following is the account he gave me of that transaction, and which I
immediately committed to paper; as it conveys a serious and important
lesson to those who are about the persons of the insane.

  "He that would govern others, first should be
  The master of himself, richly indu'd
  With depth of understanding, height of courage."
                _Massinger's Bondman, Act I. Scene 3._

It ought to be more generally understood that a madman seldom forgets the
coercion he has undergone, and that he never forgives an indignity.

"The man whom I stabbed richly deserved it. He behaved to me with great
violence and cruelty, he degraded my nature as a human being; he tied me
down, handcuffed me, and confined my hands much higher than my head, with
a leathern thong: he stretched me on a bed of torture. After some days he
released me. I gave him warning, for I told his wife I would have justice
of him. On her communicating this to him, he came to me in a furious
passion, threw me down, dragg'd me through the court-yard, thumped on my
breast, and confined me in a dark and damp cell. Not liking this
situation, I was induced to play the hypocrite. I pretended extreme sorrow
for having threatened him, and by an affectation of repentance, prevailed
on him to release me. For several days I paid him great attention, and
lent him every assistance. He seemed much pleased with the flattery, and
became very friendly in his behaviour towards me.--Going one day into the
kitchen, where his wife was busied, I saw a knife; (this was too great a
temptation to be resisted;) I concealed it, and carried it about me. For
some time afterwards the same friendly intercourse was maintained between
us; but, as he was one day unlocking his garden door, I seized the
opportunity, and plunged the knife up to the hilt in his back."--He
always mentioned this circumstance with peculiar triumph, and his
countenance (the most cunning and malignant I ever beheld) became highly
animated at the conclusion of the story.

During the time he was in Bethlem Hospital he most ingeniously formed a
stiletto out of a mop-nail; it was an elaborate contrivance, and had
probably been the work of several months. It was rendered extremely sharp
and polished, by whetting on a small pebble; it was fixed into a handle,
and had a wooden sheath made from the mop-stick. This instrument he
carried in his left breeches pocket, his right hand grasping the hilt. As
I always found him in that posture when I visited him, I suspected he had
some concealed implement of mischief, and therefore employed a
convalescent patient to watch him through the key-hole of his door. This
person saw him with the weapon, and also ascertaining the distance at
which he could use it.

The instrument was taken from him by surprise. When he found he was
prevented from executing his purpose, he roared out the most horrid
imprecations; he cursed the Almighty for creating him, and more especially
for having given him the form of a human being, and he wished to go to
Hell that he might not be disgraced by an association with the Deity.

He had an uniform and implacable aversion to the officers and servants of
the hospital; he said he courted their hatred for their curse was a
blessing. He seldom answered a question but some impiety was contained in
the reply. An indifferent person remarking that it was a bad day, he
immediately retorted, "Sir, did you ever know God make a good one?"
Although the whole of the day, and the greatest part of the night, were
consumed in pouring forth abuse and coining new blasphemies; yet there
were some few patients for whom he professed a friendship, and with whom
he conversed in a mild and civil way: this confidence had been obtained by
the compliments they had addressed to him on the score of his
understanding, of which he entertained a very high opinion. At one time he
conceived himself to be the Messiah, at another, that he was Mr. Adam, the
architect; and that he was shortly to go to America in order to build the
new Jerusalem in Philadelphia.

About six months before his death he complained of pain in his stomach,
and said he felt as if he had no intestines. His appetite diminished, and
he became melancholic.

The scene now began to alter; he had a presentiment that his time in this
world would be short, and he dreaded the change: no hope arose, no
consolation could cheer him; he became daily more emaciated and despairing
until he died, which took place August 27, 1801; he appeared to be about
seventy years of age.

On opening the head, the pericranium was scarcely adherent. This membrane
being removed, blood oozed freely from the parietal bones. There was a
large accumulation of water between the dura mater and tunica arachnoidea;
when this was let out the dura mater became flaccid, and seemed to hang
loose on the brain. On the left posterior lobe of the cerebrum there was a
large quantity of a milky fluid, between the tunica arachnoidea and pia
mater, giving the appearance of a vesication; and in that place there was
a depression or cavity formed in the convolutions of the brain. The
convolutions were so strongly and distinctly marked, that they resembled
the intestines of a child. The lateral ventricles were but little
distended, and did not contain much water. The head was not particularly
loaded with blood, nor were the bloody points, in the medullary substance,
very abundant. The brain was of a natural consistence. There was no
disease in the stomach, intestines, or liver. The body was opened about
six hours after his death.


CASE XXXVI.

B. S. a man, generally noticed by those who have visited Bethlem hospital
a few years ago. It was said, that an attachment to a young woman, who
slighted his addresses, was the cause of his becoming insane. He was
considered a very dangerous lunatic, and for many years was confined to
his cell. In this situation he employed himself in the manufacture of
straw baskets and table mats. The desire of money was the leading feature
of his mind, and the whole of his energies were devoted to its
acquisition; nor was he at all scrupulous as to the means, by which he
attained his object. Although repeatedly assured that he would never be
liberated, he disbelieved such information, and was persuaded, when he had
acquired a sum sufficient to purchase a horse and cart, filled with
higler's ware, that he should be released. The idea of becoming a trader,
on so large a scale, stimulated him to constant occupation. He employed
several lunatic journeymen to plat the straw for him, but they were poorly
rewarded. He generally chose for his workmen such as were chained, and
could not come personally to insist on the reward of their labour. He
commonly pretended that the platting was badly performed, and
consequently unsaleable; sometimes he would protest that he had settled
with them, but that they were too mad to recollect it; and if at any time
he did pay them, it was in bad coin. For many years he was unrivalled in
this trade, and, by every species of fraud, had amassed nearly sufficient
to set his plans afloat: when an unfortunate event took place, which
considerably reduced his capital. He had always a propensity to game,
which, from his skill and dexterity in cheating, was generally attended
with success; but in this science he was once over-matched. An insane
soldier, an ingenious man, became his intimate friend, and finding him
possessed of some money proposed a game at cards. The result was deeply
disastrous to the artificer in straw, who endeavoured to evade the
payment; but his friend stated it to be a debt of honor; and besides he
was a very powerful man, of a stern aspect, and not to be trifled with;
he was therefore compelled to tell down at once the slow accumulation of
several years. It was intended to make the soldier restore the property,
but he, conceiving that he had already derived sufficient benefit from the
hospital, went away in the night, without the formalities of a regular
discharge.

To fill up the measure of his misfortunes, when Hatfield, the maniac who
shot at his Majesty in the theatre, was brought to Bethlem, he, in
conjunction with a contriving cobbler, established a rival manufactory,
which shortly eclipsed the fabric of the old school, and by superior taste
rendered his further exertions unnecessary.

It is natural to suppose, that no great cordiality could exist between
persons, where the prosperity of one had been established on the ruin of
the other. Frequent altercations arose, and much offensive language was
exchanged. At length the patience of the original dealer was exhausted,
and, in collecting his force to give his opponent a blow, he fell down and
instantly expired.--He was about fifty-eight years of age.

Some of his habits and opinions were extremely singular; he believed that
all occurrences were regulated by witches: prosperity was to be attributed
to the good witches having obtained the mastery; and when bad witches
gained the ascendancy, misfortunes arose. When the latter were at work he
supposed himself in possession of a power to frighten and disperse them,
and this was effected by a peculiar noise he made. It is probable he might
have laboured under indigestion, for immediately after he had eaten his
dinner, he sent forth a dreadful howl, which he continued for about ten
minutes: but his great terror was a thunder storm; when this occurred, he
took a very active part, and brought the whole force of his lungs to bear
upon the enemy. A cat was supposed to have a natural antipathy to bad
witches, she could smell them at a distance; for which reason he always
domesticated an animal of that kind to sleep in his cell.

When his head was opened, the dura mater was very easily separable from
the scull; upon puncturing this membrane a considerable quantity of blood
flowed from the opening; and there was a copious extravasation of this
fluid between the membranes of the brain: but the most remarkable
circumstance was, that the tunica arachnoidea was so thickened, that it
exceeded the dura mater on an accurate comparison. The pia mater was
loaded with blood, and its vessels were enlarged. The brain and its
cavities were sound and natural.


CASE XXXVII.

R. B. This man had been many years an incurable patient, and it was
supposed that jealousy of his wife had been the cause of his madness,
although it appeared from very respectable testimony that he had no real
grounds for such suspicion. During eight years, (the period he was subject
to my observation,) he was mostly in a very furious state, and obliged to
be strictly confined. His mischeivous disposition was manifested on every
occasion; he would hurl the bowl, in which his food was served, against
those who passed his cell; and when his hands were secured he would kick,
bite, or throw his head into the stomachs of those who came near him. He
entertained a constant aversion to his keeper, whom he suspected to be
connected with his wife. His life was miserably divided between furious
paroxysms and melancholic languor, and there was great uncertainty in the
duration of these states. He has been known to continue ten months in the
highest degree of violence, and relapse into the same state after a few
days passed in tranquil depression. There was one circumstance which never
failed to produce a relapse, however quietly he might have conducted
himself, this was a visit from any of his family, and a very striking
instance occurred. From May, 1799, to September, 1800, he had every
appearance of being perfectly recovered: he was, in consequence, allowed
additional comforts, and treated as a convalescent. At this time he was
visited by his son, who, after many hours conversation with him, was
persuaded that he had perfectly recovered his intellects; and he expressed
himself astonished at his father's accurate recollection of particulars
which might be supposed to have been obliterated from his mind. This
dutiful visit and affectionate intercourse produced unpleasant
consequences. The numerous enquiries which the patient had made, furnished
him with materials for reflexion. On the departure of his son he began to
detect mismanagement in his affairs, and improprieties in the conduct of
his family: he was very talkative, and became impatient to return home.
The following day he had a wildness in his eyes, spoke fast, and appeared
busy: before the evening he was so irritable and disobedient that it
became necessary to confine him. From this time he continued in the most
furious condition, singing and vociferating the greatest part of the
night, until January 2d, 1801, when he became suddenly calm, complained of
extreme debility, and said he should die in a few hours. He gave very
proper answers to the questions which were asked him, but complained of
the fatigue which talking induced. On the next morning he expired. He was
sixty-eight years of age. The head was opened two days after his death.
The tunica arachnoidea was in many places opake, and considerably
thickened. There was a small quantity of limpid water between this
membrane and the pia mater. When the medullary substance was cut into,
there oozed from many points a quantity of dark blood, indeed the whole
head was loaded with venous blood. The lateral ventricles were
considerably enlarged and filled with water--four ounces were collected.
The internal carotid arteries were much enlarged, and when divided, did
not collapse, but remained open, as arteries in the other parts of the
body. The consistence of the brain was doughy.




CHAP. IV.

CASES OF INSANE CHILDREN.


In the month of March, 1799, a female child, three years and a quarter
old, was brought to the hospital for medical advice. She was in good
bodily health, and born of sane and undiseased parents. The mother, who
attended, stated that her husband's parents and her own had never been in
the slightest degree afflicted with mania, but that she had a brother who
was born an ideot. She related that her child, until the age of two years
and a half, was perfectly well, of ordinary vivacity, and of promising
talents; when she was inoculated for the small pox. Severe convulsions
ushered in the disease, and a delirium continued during its course. The
eruption was of the mild kind, and the child was not marked with the
pustules. From the termination of the small-pox to the above date, (nine
months) the child continued in an insane state. Previously to the
small-pox, she could articulate many words, and use them correctly for the
things they signified: but since that time she completely forgot her
former acquisitions, nor ever attempted to imitate a significant sound.
Whatever she wished to perform, she effected with promptitude and
facility. She appeared anxious to possess every thing she saw, and cried
if she experienced any disappointment; and on these occasions she would
bite, or express her anger by kicking or striking. Her appetite was
voracious, and she would devour any thing that was given to her, without
discrimination; as fat, raw animal food, or tainted meat. To rake out the
fire with her fingers was a favourite amusement, nor was she deterred from
having frequently burned them. She passed her urine and fæces in any place
without restraint; but she could retain a considerable quantity of the
former before she discharged it. Some cathartic remedies were ordered for
her, with an emetic occasionally, and she was brought to the hospital
every fortnight, but she did not appear in any degree amended. On June 22
she was admitted a patient, and continued in the hospital until the middle
of October, when she was attacked with an eruptive fever, and consequently
discharged. During this time little progress was made, although
considerable pains were bestowed. She became more cunning, and her taste
appeared improved. The cathartic medicine, which she drank at first
without reluctance, became afterwards highly disgusting, and when she saw
the basket which contained it, she endeavoured to escape and hide
herself. To particular persons she was friendly, and felt an aversion to
others. She was sensible of the authority of the nurse who attended her,
and understood by the tone of her voice whether she were pleased or
offended. The names of some things she appeared to comprehend, although
they were extremely few; when the words, dinner, cakes, orange, and some
more were mentioned, she smiled, and appeared in expectation of receiving
them. By great attention and perseverance on the part of the nurse, she
was brought to evacuate her fæces and urine in a night stool.

After the elapse of three years I was informed that the child had made no
intellectual progress.

W. H. a boy, nearly seven years of age, was admitted into the Hospital,
June 8th, 1799. His mother, who frequently visited him, related the
following particulars respecting his case.--She said that, within a month
of being delivered of this child, she was frightened by a man in the
street, who rudely put his hand on her abdomen. When the child was born it
was subject to startings, and became convulsed on any slight
indisposition. When a year old, he suffered much with the measles: and
afterwards had a mild kind of inoculated small-pox. At this age she
thought the child more lively than usual, and that he slept less than her
other children had done. At two years, the mother perceived he could not
be controled, and therefore frequently corrected him.

There was a tardiness in the developement of his physical powers. He was
fifteen months old before he had a tooth, and unable to go alone at two
years and a half: his mind was equally slow; he had arrived at his fourth
year before he began to speak; and, when in his fifth, he had not made a
greater proficiency in language than generally may be observed in children
between two and three years. When admitted into the hospital, he wept at
being separated from his mother, but his grief was of very short
continuance. He was placed on the female side, and seemed highly delighted
with the novelty of the scene: every object excited his curiosity, but he
did not pause or dwell on any. He was constantly in action, and rapidly
examined the different apartments of the building. To the patients in
general he behaved with great insolence--he kicked and spat at them, and
distorted his face in derision; but, on the appearance of the nurse, he
immediately desisted, and assured her he was a very good boy. Great, but
ineffectual, pains were taken, to make him understand the nature of
truth,--he could never be brought to confess any mischief he had
committed, and always took refuge in the convenient shelter of a lie. In a
short time he acquired a striking talent for mimickry, and imitated many
of the patients in their insane manners; he generally selected, for his
models, those who were confined, as he could practise from such with
impunity.

In about three months he had added considerably to his stock of language,
but, unluckily, he had selected his expressions from those patients who
were addicted to swearing and obscene conversation. To teach him the
letters of the alphabet had many times been endeavoured, but always
without success; the attempt uniformly disgusted him: he was not to be
stimulated by coaxing or coercion; his mind was too excursive, to submit
to the painful toil of recording elementary sounds; but it may rather be
inferred that he did not possess a sufficient power of attention to become
acquainted with arbitrary characters.

He was in good health, his pulse and bowels were regular, and his appetite
was keen, but not voracious. One circumstance struck me, as very peculiar,
in this boy,--he appeared to have very incorrect ideas of distance: he
would frequently stretch out his hand, to grasp objects considerably
beyond his reach, but this referred principally to height: he would
endeavour to pluck out a nail from the ceiling, or snatch at the moon. In
October he became unwell, and, at the mother's request, was discharged
from the hospital.

In September 1805, I again saw the boy: he was then thirteen years of age,
had grown very tall, and appeared to be in good health. He recollected me
immediately, and mentioned the words, school Moorfields, nasty physic. On
meeting with some of the female patients, he perfectly remembered them,
and seemed for the moment, much pleased at the renewal of the
acquaintance. By this time, he had made comparatively, a great progress in
language; he knew the names of ordinary things, and was able to tell
correctly the street in which he resided, and the number of his house. His
mother informed me that he was particularly fond of going to church,
although he was unable to comprehend the purpose for which he went: when
there, he conducted himself with great order and decorum, but was disposed
to remain after the congregation had dispersed. To shew how little he
understood, why he frequented a place of worship: his mother once took him
to church on Sacrament-sunday, and fearful of disturbing the persons
assembled, by compelling him to return home, allowed him to be a
spectator of those solemn administrations. The only reflexion he made on
the subject, but in disjointed expressions, was, that he thought it
extremely hard, that the ladies and gentlemen should eat rolls and drink
gin, and never ask him to partake. In his person he was clean, and dressed
himself with neatness. Having been taught when in the hospital to use a
bowl for his necessary occasions, he obstinately continued the same
practice when he returned home, and could never be persuaded to retire to
the closet of convenience; but the business did not terminate here, when
he had evacuated his intestines into the bowl he never failed to paint the
room with its contents. To watch other boys when they were playing, or to
observe the progress of mischief, gave him great satisfaction: but he
never joined them, nor did he ever become attached to any one of them. Of
his mother he appeared excessively fond, and he was constantly caressing
her: but in his paroxysms of fury he felt neither awe nor tenderness, and
on two occasions he threw a knife at her. Although equally ignorant of
letters, as when discharged from the hospital, he took great delight in
having gilt books; indeed every thing splendid attracted his attention,
but more especially soldiers and martial music. He retained several tunes,
and was able to whistle them very correctly. The day on which I last saw
him his mind was completely occupied with soldiers; when questions were
put to him, if he answered them it was little to the purpose, generally he
did not notice them, but turned round to his mother and enquired about the
soldiers.

The defect of this lad's mind, appeared to be a want of continued
attention to things, in order to become acquainted with their nature; and
he possessed less curiosity than other children, which serves to excite
such attention: and this will in some degree explain, why he had never
acquired any knowledge of things in a connected manner. His sentences were
short, and he employed no particles to join them together. Although he was
acquainted with the names of many things, and also with expressions which
characterize passion, he applied them in an insulated way. For instance,
if a shower fell, he would look up and say, "rains;" or when fine, "sun
shines." When in the street he would pull his mother, to arrest her
attention, and point to objects, as a fine horse, or a big dog; when he
returned home he would repeat what had attracted his notice, but always
speaking of himself in the third person. "Billy see fine horse, big dog,
&c."[12] Of circumstances boldly impressed, or reiterated by habit, his
memory was retentive, but as his attention was only roused by striking
appearances, or loud intonations, ordinary occurrences passed by
unobserved.

In the month of July 1803, my opinion was requested respecting a young
gentleman, ten years of age, who was sent here, accompanied by a kind and
decent young man, to take care of him. Previously to his arrival I had
corresponded respecting his case with a very learned and respectable
physician in the country, under whose care the boy had been placed. From
the information furnished by this gentleman, and that which was collected
from the keeper, I believe the former history of his case is correctly
given.

The parents are persons of sound mind, and they do not remember any
branches of their respective families to have been (in any manner)
disordered in their intellects. The subject of the present relation was
their eldest son; the second child was of a disposition remarkably mild;
and the youngest, a boy, about two years and a half, was distinguished by
the irritability and impatience of his temper. At the age of two years,
the subject of the present relation, became so mischievous and
uncontroulable, that he was sent from home to be nursed by his aunt. In
this situation, at the request of his parents, and with the concurrence of
his relation, he was indulged in every wish, and never corrected for any
perverseness or impropriety of conduct. Thus he continued until he was
nearly nine years old, the creature of volition and the terror of the
family. At the suggestion of the physician, whom I have before mentioned,
and who was the friend of his parents: a person was appointed to watch
over him. It being the opinion of the doctor that the case originated in
over indulgence and perverseness; a different system of management was
adopted. The superintendant was ordered to correct him for each individual
impropriety. At this time the boy would neither dress nor undress himself,
though capable of doing both; when his hands were at liberty, he tore his
clothes: he broke every thing that was presented to him, or which came
within his reach, and frequently refused to take food. He gave answers
only to such questions as pleased him, and acted in opposition to every
direction. The superintendant exercised this plan for several months, but
perhaps not to the extent laid down; for it may be presumed, that after a
a few flagellations his humanity prevailed over the medical hypothesis.
When he became the subject of my own observation, he was of a very healthy
appearance, and his head was well formed; this was also the opinion of
several gentlemen, distinguished for their anatomical knowledge, to whom
the boy was presented. His tongue was unusually thick, though his
articulation was perfectly distinct. His countenance was decidedly
maniacal.[13] His stature, for his age, was short, but he was well
compacted, and possessed great bodily strength. Although his skin was
smooth and clear, it was deficient in its usual sensibility; he bore the
whip and the cane with less evidence of pain than other boys. Another
circumstance convinced me of this fact. During the time he resided in
London he was troubled with a boil on his leg; various irritating
applications were made to the tumor, and the dressings were purposely
taken off with less nicety than usual, yet he never complained. His pulse
was natural, and his bowels were regular. His appetite was good, but not
inordinate, and he bore the privation of food for a considerable time
without uneasiness. Although he slept soundly, he often awoke as if
suddenly alarmed, and he seemed to require a considerable duration of
sleep.

He had a very retentive memory, and had made as great proficiency in
speech as the generality of boys of his own age. Few circumstances
appeared to give him pleasure, but he would describe very correctly any
thing which had delighted him. As he wanted the power of continued
attention, and was only attracted by fits and starts, it may be naturally
supposed he was not taught letters, and still less that he would copy
them. He had been several times to school, and was the hopeless pupil of
many masters, distinguished for their patience and rigid discipline; it
may therefore be concluded, that from these gentlemen, he had derived all
the benefits which could result from privations to his stomach, and from
the application of the rod to the more delicate parts of his skin.

On the first interview I had with him, he contrived, after two or three
minutes acquaintance, to break a window and tear the frill of my shirt. He
was an unrelenting foe to all china, glass, and crockery ware, whenever
they came within his reach he shivered them instantly. In walking the
street, the keeper was compelled to take the wall, as he uniformly broke
the windows if he could get near them, and this operation he performed so
dextrously, and with such safety to himself, that he never cut his
fingers. To tear lace and destroy the finer textures of female ornament,
seemed to gratify him exceedingly, and he seldom walked out without
finding an occasion of indulging this propensity. He never became attached
to any inferior animal, a benevolence so common to the generality of
children: to these creatures his conduct was that of the brute: he
oppressed the feeble, and avoided the society of those more powerful than
himself. Considerable practice had taught him that he was the cat's
master, and whenever this luckless animal approached him he plucked out
its whiskers with wonderful rapidity; to use his own language, "_I must
have her beard off_." After this operation, he commonly threw the creature
on the fire, or through the window. If a little dog came near him he
kicked it, if a large one he would not notice it. When he was spoken to,
he usually said, "I do not choose to answer." When he perceived any one
who appeared to observe him attentively, he always said, "Now I will look
unpleasant." The usual games of children afforded him no amusement;
whenever boys were at play he never joined them: indeed, the most singular
part of his character was, that he appeared incapable of forming a
friendship with any one: he felt no considerations for sex, and would as
readily kick or bite a girl as a boy. Of any kindness shewn him, he was
equally insensible; he would receive an orange as a present, and
afterwards throw it in the face of the donor.

To the man who looked after him, he appeared to entertain something like
an attachment: when this person went out of the room, and pretended that
he would go away, he raised a loud outcry, and said, "what will become of
me, if he goes away; I like him, for he carries the cane which makes me a
good boy:" but it is much to be doubted, whether he really bore an
affection for his keeper; the man seemed to be of a different opinion, and
said, when he grew older he should be afraid to continue with him, as he
was persuaded the boy would destroy him, whenever he found the means and
opportunity.

Of his own disorder he was sometimes sensible: he would often express a
wish to die, for he said, "God had not made him like other children;" and
when provoked, he would threaten to destroy himself.

During the time he remained here, I conducted him through the hospital,
and pointed out to him several patients who were chained in their cells;
he discovered no fear or alarm; and when I shewed him a mischievous maniac
who was more strictly confined than the rest, he said, with great
exultation, "this would be the right place for me." Considering the
duration of his insanity, and being ignorant of any means by which he was
likely to recover, he returned to his friends, after continuing a few
weeks in London.




CHAP. V.

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 be readily 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 concerning this point, and cautious of exposing their
frailties or immoral habits: and when the disease is connected with the
family, 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.[14]

Under the first, are comprehended repeated intoxication: blows received
upon the head; fever, particularly when attended with delirium; mercury,
largely and injudiciously administered; cutaneous eruptions repelled, and
the suppression of periodical or occasional discharges and secretions;
hereditary disposition, and paralytic affections.

By the second class of causes, which have been termed _moral_, are meant
those which are supposed to originate in the mind, or which are more
immediately applied to it. 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:[15] in
short, the frequent and uncurbed indulgence of any passion or emotion, and
any sudden or violent affection of the mind.

There are, doubtless, many other causes of both classes, which may tend to
produce this 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.

It is an old opinion, and continues still to prevail, that maniacs are
influenced by the changes of the moon. In the fourth chapter of St.
Matthew's Gospel, verse 24, we find the word "[Greek: Selêniaxomenous]"
which is rendered in the English version, "those which were lunatic."
Notwithstanding the notion of being moon-struck might prevail among the
ignorant people of Galilee, yet Hippocrates, a philosopher, and correct
observer of natural phænomena, does not appear to have placed any faith in
this planetary influence. Although the Romans were infected with this
popular tradition, as may be seen in the following passage of the Art of
Poetry,

  "Ut mala quem scabies aut morbus regius urget,
  Aut fanaticus error, et IRACUNDA DIANA
  Vesanum tetigisse timent fugiuntque poetam,
  Qui sapiunt:"--

yet Celsus did not consider the operation of the moon on the human
intellect sufficiently well founded to admit it into his medical work.
Not a word on this subject is mentioned in the eighteenth chapter of his
third book, which particularly treats of Insanity, "_De tribus insaniæ
generibus_;" it is true that, in the fourth chapter of the first book,
which speaks "_De his quibus caput infirmum est_," he says "Cui caput
infirmum est, is si bene concoxit, leniter perfricare id mane manibus suis
debet; nunquam id, si fieri potest, veste velare; aut ad cutem tondere:
utileque lunam vitare, maximeque ante ipsum lunæ solisque concursum." By
the _infirmum caput_, Celsus does not mean madness, as may be clearly seen
by perusing the chapter: the weakness of intellect, which frequently
continues after fever, or other violent diseases, is evidently his
meaning; but Dr. Cox has quoted the above passage, to prove that Celsus
was impressed with the truth of this vulgar opinion. He says, "This idea
of lunar influence, in _maniacal complaints_, was handed down to us by
our medical forefathers, and is still very generally adopted."

It is most probable that this idea of planetary regency, however it might
have arisen, or to whatever extent it may have been credited, received in
the Arabian school, the stamp by which its currency has been subsequently
maintained. For the revival and dispersion of ancient medical knowledge,
we are confessedly under considerable obligations to the Arabians;[16] and
more especially for the incorporation of astrology, magic and alchymy,
with medicine.

Popular superstitions and national proverbs, are seldom without some
foundation; and with respect to the present, it may be observed, that if
it were not in some degree rooted in fact, and trained up by observation,
it would become difficult to ascertain how such an opinion came to be
adopted; and this investigation is rendered still more important from the
consideration, that the existing law in this country, respecting insane
persons, has been established on the supposed prevalence of this lunar
regulation. A commission is issued, de _lunatico_ inquirendo, and the
commissioners sitting for that purpose, are particular in their enquiries,
whether the patient enjoys lucid intervals. The term _lucid interval_ has
been properly connected with the word _lunacy_; for, if the patient, as
they supposed, became insane at particular changes of the moon, the
inference was natural, that in the intervening spaces of time he would
become rational.

It is more than probable, that the origin of this supposition of the lunar
influence may be traced to the following circumstances. The period of the
return of the moon, and of regular menstruation in women, is four weeks;
and the terms which designate them, have been imposed from the period of
time in which both are compleated. Insanity and epilepsy are often
connected with menstruation, and suffer an exacerbation of their paroxysms
at the period when this discharge happens, or ought to take place. If,
therefore, the period of menstruation in an insane woman should occur at
the full of the moon, and her mind should then be more violently
disturbed, the recurrence of the same state may be naturally expected at
the next full moon. This is a necessary coincidence, and should be
discriminated from effect. But such has been the prevalence of this
opinion, that when patients have been brought to Bethlem hospital,
especially those from the country, their friends have generally stated
them to be worse at some particular change of the moon, and of the
necessity they were under, at those times, to have recourse to a severer
coercion. Indeed, I have understood from some of these _lunatics_, who
have recovered, that the overseer or master of the work-house himself has
frequently been so much under the dominion of this planet, and keeping
steadily in mind the old maxim, _venienti occurrite morbo_, that, without
waiting for any display of increased turbulence on the part of the
patient, he has bound, chained, flogged, and deprived these miserable
people of food, according as he discovered the moon's age by the almanack.

To ascertain how far this opinion was founded in fact, I kept, during more
than two years, an exact register, but without finding, in any instance,
that the aberrations of the human intellect corresponded with, or were
influenced by, the vicissitudes of this luminary.

As insane persons, especially those in a furious state, are but little
disposed to sleep, even under the most favourable circumstances, they will
be still less so, when the moon shines brightly into their apartments.

It has also been considered, that intellectual labour frequently becomes a
cause of insanity; that those, who are in the habit of exercising the
faculty of thought, for the perfection and preservation of the reason of
others, are thereby in danger of losing their own. We hear much of this,
from those who have copiously treated of this disease, without the toil of
practical remark; whose heads become bewildered by the gentlest exercise,
and to whom the recreation of thinking becomes the exciting cause of
stupidity or delirium. These persons enumerate, among the exciting causes
of delirium, "Too great, or too long continued exertion of the mental
faculties, as in the delirium which often succeeds long continued and
abstract calculation; and the deliria to which men of genius are
peculiarly subject."

The mind of every man is capable of a definite quantity of exertion to
good effect; all endeavours, beyond that point, are impotent and
perplexing. The attention is capable of being fixed to a certain extent,
and, when that begins to deviate, all continuance is time lost. It is
certain that, by habit, this power may be much increased; and, by frequent
exercise, that, which at first excited fatigue, may be continued with
facility and pleasure. What species of delirium is that, which succeeds
long continued and abstract calculation? Newton lived to the age of 85
years, Leibnitz to 70, and Euler to a more advanced period, yet their
several biographers have neglected to inform us, that their studies were
checquered with delirious fermentations. The mathematicians of the present
day (and there are many of distinguished eminence) would conceive it no
compliment to suppose that they retired from their labours with addled
brains, and that writers of books on insanity should impute to them
miseries which they never experienced.

It is curious to remark, in looking over a biographical chart, that
mathematicians and natural philosophers have in general attained a
considerable age; so that long continued and abstract calculation, or
correct thinking upon any subject does not appear, with all these
delirious visitations, to shorten the duration of human life. What is
meant by the deliria, to which men of genius are peculiarly subject, I am
unable, from a want of sufficient genius and delirium, to comprehend.

It is well understood, that a want of rational employment is a very
successful mode of courting delirium; that an indulgence in those reveries
which keep the imagination on the wing, and imprison the understanding, is
likely to promote it: and it must be owned, that the same effect has often
been produced, where vanity or ambition has urged minds, puny by nature,
and undrilled in intellectual exercises, to attempt to grasp that which
they were unable to embrace. This may be illustrated by the following
case.

A young gentleman of slender capacity, and very moderate education, at the
age of nineteen, was placed in a merchant's counting house, where he
continued for two years diligently, though slowly, to perform the duties
of the office. Coming at this time into the possession of considerable
property, and perhaps, aware of the uncultivated state of his own mind, he
very laudably determined to improve it. He frequented the society of
persons esteemed learned and eminent in their different professions, and
became much delighted with their conversation; but at the same time
sensible that he was unable to contribute to the discourse. He resolved to
become a severe student, and for this purpose purchased an immense
quantity of books on most subjects of literature and science. History
commenced the career of his enquiries: Rollin, Gibbon, Hume and Robertson
were anxiously and rapidly perused; but he never paused to consider, or to
connect dates and circumstances, so that these excellent authors, after he
had waded through them, left scarcely an impression on his mind. Chemistry
next engaged his attention, and on this subject, he pored over many
volumes with little advantage: the terms proved a source of embarrassment,
and he made no experiments. In a hasty succession, the ancient languages,
antiquities, etymology, agriculture, and moral philosophy, occupied his
mind. About eight hours were daily devoted to reading. Somewhat more than
two years were consumed in this employment, which had distracted his mind,
without conferring any positive knowledge.

His friends and acquaintances now began to perceive a considerable
alteration in his temper; though naturally diffident, he had assumed a
high degree of literary importance, and plumed himself on the extent of
his learning. Before this excessive, but ill-directed application, he was
a strict relator of the truth, but he now found a convenience in supplying
by fancy, that, which the indigence of his memory was unable to afford.
Shortly he began to complain that he could not sleep, and that the long
night was passed in shifting from side to side.

  "Lasso, ch'n van te chiamo, et queste oscure,
  Et gelide ombre in van lusingo: o piume
  D'asprezza colme: o notti acerbe, et dure."
                                      _Gio: Della Casa._

Fever succeeded, accompanied with delirium in the evening. By quietness,
and the ordinary remedies, these symptoms were removed; but he was left in
a state of extreme weakness. As he recovered from this, his habits became
materially altered: he would continue to lie in bed for several days,
after which, he would suddenly rise and walk a number of miles. Personal
cleanliness, and dress were entirely neglected: sometimes he would fast
for two or three days, and then eat voraciously. Afterwards he became
suspicious that poison had been mixed with his food. It was found
necessary to confine him, from having attempted to castrate himself: this
he afterwards effected in a very complete manner, and continues a maniac
to the present time.

Few persons, I believe, will be disposed to consider the above case, as an
instance of insanity succeeding to a laborious exercise of the
intellectual faculties. It is true, he was busied with books: but this
occupation could not have strained his mind, for he appears neither to
have comprehended, nor retained any of the objects of his pursuit.


_Hereditary Disposition._

    "Ut male posuimus initia sic cetera sequuntur."--_Cicero._

    "Whatever was in the womb imperfect, as to her proper work, comes very
    rarely, or never at all, to perfection afterwards."--_Harrington's
    Works, p. 177._

Considerable diversity of opinion has prevailed, whether insanity be
hereditary or not; and much has been said on both sides of this question.
Great ingenuity has been exerted to prove that this disease is accidental,
or that there are sufficient causes to account for its occurrence, without
supposing it one of those calamities that "_flesh is heir to_." It has
been argued, that, if the disease were hereditary, it ought uniformly to
be so, and that the offspring of a mad parent should necessarily become
insane.

All theories and reasonings appear to be good for as much as they prove;
and if the term _hereditary_ be employed with a degree of strictness, so
as to denote certain and infallible transmission, such inevitable descent
cannot be defended. Several instances have come under my observation where
the children of an insane parent have not hitherto been affected with
madness, and some have died early in life, without having experienced any
derangement of mind. More time is therefore required.

All observations concur in acknowledging that there are many circumstances
in which children resemble their parents. It is very common to see them
resemble one of their parents in countenance, and when there are several
children, some shall bear the likeness of the father and others of the
mother. Children often possess the make and fashion of the body, peculiar
to one or other of their parents, together with their gait and voice; but
that which has surprized me most is the resemblance of the hand-writing.
If a parent had taught his son to write, it might be expected that a
considerable similarity would be detected; but in general the fact appears
to be otherwise, for it seldom happens that the scholars, though
constantly imitating the copy of the master, write at all like him, or
like each other. In a few instances I have noticed a correct resemblance
between the hand-writing of the father and son, where the former died
before the latter had been taught the use of the pen, and who probably
never saw the hand-writing of his father. The transmission of personal
deformities is equally curious. I am acquainted with a person in this
town, whose middle and ring finger are united, and act as one; all the
children of this man carry the same defect. A toenail, particularly
twisted, has been traced through three generations, on the same foot and
toe. Abundant instances might be adduced on this subject; there is
scarcely a family which cannot produce something in confirmation; and if
to these circumstances in the human species, were to be added the
experiments which have been made on the breeding of cattle, perhaps
little doubt would remain.

The reasoners against the transmission of madness urge, that, if the
contrary were true, we should by this time have detected the rule or law
by which nature acts, and that we should have been able to
determine,--First, whether the disorder descended to the male or female
children accordingly as the father or mother was affected.--Secondly,
which of the parents is most capable of transmitting the
disease?--Thirdly, what alternations in the succession take place, does it
shift from the male to the female line, and, does it miss a generation,
and afterwards return?

These, and a multitude of other queries, might be proposed; I believe much
faster than they could be answered. Nature appears to delight in producing
new varieties, perhaps less in man than in other animals, and still less
in the animal than in the vegetable kingdom. Before these subtile
reasoners expect, from those who maintain that madness generally descends
from the parent to the offspring, a developement of the laws by which
Nature acts, it would be convenient first to settle whether in this matter
she be under the dominion of any law whatever.

The investigation of the hereditary tendency of madness is an object of
the utmost importance, both in a legal and moral point of view. Parents
and guardians, in the disposal, or direction of the choice of their
children in marriage, should be informed, that an alliance with a family,
where insanity has prevailed, ought to be prohibited.

Having directed some attention to enquiries of this nature, I am enabled
truly to state, that, where one of the parents have been insane, it is
more than probable that the offsprings will be similarly affected.

Madness has many colours, and colours have many hues; actual madness is a
severe calamity, yet experience has pointed out the treatment, and the law
has permitted the imposition of the necessary restraint: but it very
frequently occurs that the descendants from an insane stock, although they
do not exhibit the broad features of madness, shall yet discover
propensities, equally disqualifying for the purposes of life, and
destructive of social happiness.

The slighter shades of this disease include eccentricity, low spirits, and
oftentimes a fatal tendency to immoral habits, notwithstanding the
inculcation of the most correct precepts, and the force of virtuous
example.

In illustration of the fact, that the offsprings of insane persons are,
_ceteris paribus_, more liable to be affected with madness than those
whose parents have been of sound minds; it was my intention to have
constructed a table, whereon might be seen the probably direct course of
this disease, and also its collateral bearings: but difficulties have
arisen. It appeared, on consideration, improper to attempt precision with
that which was variable, and as yet unsettled; I have therefore been
content to select a few histories from my book of notes, and to exhibit
them in the rude state in which they were set down.

_1st._--R. G. His grandfather was mad, but there was no insanity in his
grandmother's family. His father was occasionally melancholic, and once
had a raving paroxysm. His mother's family was sane. His father's brother
died insane. R. G. has a brother and five sisters; his brother has been
confined in St. Luke's, and is occasionally in a low spirited state. All
his sisters have been insane; with the three youngest the disease came on
after delivery.

_2d._--M. M. Her grandmother was insane and destroyed herself. Her father
was mad for many years, but after the birth of all his children. M. M. has
two brothers and a sister; both her brothers have been insane; the sister
has never been so affected, but was a person of loose character. The
insanity of M. M. was connected with her menstruation; after its cessation
she recovered, although she had been confined more than sixteen years.

_3d._--M. H. Her father had been several times insane; her mother was
likewise so affected a few months before her death. Afterwards her father
married a woman perfectly sane, by whom he had three children, two female
and a male; both the females are melancholic, the male was a vicious
character, and has been transported. M. H. has had ten children, three
have died with convulsions, the eldest, a girl, is epileptic.

_4th._--T. B. His mother became insane soon after being delivered of him,
and at intervals has continued so ever since. He has a brother who became
furiously mad at the age of twenty, and afterwards recovered. T. B.'s
disorder came on at the age of twenty-six.

_5th._--S. F. Her father's mother was insane, and confined in the
hospital. Her father never discovered any symptoms of insanity, and her
mother was perfectly sane. Her only sister (she had no brothers) was mad
about five years ago, and recovered. S. F. has been twice in the hospital.

_6th._--P. W. After the best enquiries it does not appear that her father
or mother ever experienced any attack of madness or melancholy. P. W.'s
disorder commenced shortly after the delivery of a child. She has three
sisters, the eldest has never been married, and has hitherto continued of
sound mind. The two younger have been mothers, and in both insanity has
supervened on childbearing.

_7th._--J. A. H. His father's father was insane, and his father was also
disordered, and destroyed himself. His mother was of sound mind. J. A. H.
became insane at the age of twenty-three. He has two sisters, the elder
has once been confined for insanity, the younger is of weak intellects,
nearly approaching to ideotism.

_8th._--M. D. Her mother was insane and died so. M. D. continued of sane
mind until she had attained the age of fifty-seven, when she became
furiously maniacal; her only daughter, eighteen years of age, was attacked
with mania during the time her mother was confined.

_9th._--G. F. His mother was melancholic during the time she was pregnant
with him, and never afterwards completely recovered. She had five children
previously to this melancholic attack, who have hitherto continued of
sound mind. She bore another son after G. F. who is extremely flighty and
unmanageable. G. F. was attacked with madness at the age of nineteen, and
died apoplectic, from the violence and continued fury of his disorder.

_10th._--M. T. Her mother was of sound mind. Her father was in a
melancholic state for two years, before she was born, but this was
afterwards dissipated by active employment. M. T. has two brothers,
younger than herself, who have been attacked with insanity, neither of
whom have recovered. She has two sisters, some years older than herself,
these have never been deranged. M. T. has had nine children. The three
first have been melancholic. The youngest, at the age of five years, used
to imagine she saw persons in the room covered with blood, and other
horrible objects, she afterwards became epileptic and died. The youngest
of her three first children has been married and had three children, one
of whom is afflicted with chorea Sancti Viti, and another is nearly an
ideot.

Of the causes termed moral, the greatest number 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 the 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 is 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 strict
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. 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_,[17] 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 matter
so that it shall think. When we find insanity, as far as has been hitherto
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. 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 can possess no corporeal remedies for it: and
that an 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.




CHAP. VI.

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 probably 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 sanity of intellect.

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 afflicted 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 re-admitted, it may be mentioned, that, during the last two years,[18]
there have been admitted 389 patients, 53 of whom had at some former time
been in the house. There are so many circumstances, which, supposing they
did relapse, might prevent them from returning, that it can only be stated
with certainty, 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 symptoms of the approach of this disease after
delivery, are want of sleep; the countenance becomes flushed; a
constrictive pain is often felt in the head; the eyes assume a morbid
lustre, and wildly glance at objects in rapid succession; the milk is
afterwards secreted in less quantity; and when the mind becomes more
violently disordered, it is totally suppressed. Where the disease is
hereditary, parturition very frequently becomes an exciting cause.

From whatever cause this disease may be produced in women, it is
considered as very unfavourable to recovery, if they should be worse at
the period of menstruation, or have their catamenia in very small or
immoderate quantities.

A few cases have occurred where the disease, being connected with
menstruation, and having continued many years, has completely disappeared
on the cessation of the uterine discharge.

At the first attack of this 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.

                   _Number         _Number         _Number
  _Age between_    admitted._     discharged      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
                  -------        -------         -------
               Total 1664      Total 574      Total 1090
                  -------        -------         -------

From this table it will be seen, that when the disease attacks persons
advanced in life, the prospect of recovery is but small.

I am led to conclude, 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
disorder has been of more than twelve months standing, 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 twenty
years seventy-eight 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 was ultimately sent from the hospital
uncured.

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 assertion of the man
pretending to have performed such cures_.[19]

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;[20] and also that the age was of
no signification, unless the patient had been afflicted before with the
same malady.[21]

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.[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, (_Traité 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 Bicêtre,  | 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 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 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 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 habit of intoxication is readily formed. Those who in
their youth have shaken off calamity as a slight 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 to provoke a
temporary assemblage 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 instituted, 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 assistance 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 practitioner; and,
that restoration to reason in all cases is more the effect of accident, or
of circumstances 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 God
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 God of universal aid,
        The God, the Father of us all.

  "First shewn by Thee, thus glow'd the gracious scene,
      'Til Superstition, 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.

Instituting 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
multitude; when the dregs of society shall assume the garb of sanctity 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 constituted 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 assumed 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, circumstances 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 institutions 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
circumstances? 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 assume 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 principal 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 retard 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 passions. Finally, can a mere advertisement 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 practitioners 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 deperditæ_. 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 tetè a
tetè 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 assumed 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
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 a powerful man, 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.

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 chastisement 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]

"_Of a place called Timarahane for the Correction of the Insane._

"The sultan Bajazet caused a building to be erected for the reception of
insane persons, in order, that they might not wander about the city, and
there exhibit their mad pranks. This building is constructed in the manner
of an hospital: there are about an hundred and fifty keepers appointed to
look after them; they are likewise furnished with medicines and other
necessary articles. These keepers, armed with cudgels, patrole the city in
search of the insane; and when they discover such, they secure them by the
neck and hands with an iron chain, and, by dint of the cudgel, convey them
to Timarahane. On entering this place, they are confined by the neck, with
a much larger chain, which is fixed into the wall, and comes over their
bed place, so that they are kept chained in their beds. In general, about
forty are confined there, at some distance from each other.

"They are frequently visited by the people of the city, as a species of
amusement. The keepers constantly stand over them with cudgels; for, if
left to themselves, they would spoil and destroy their beds and hurl the
tables at each other. At the times of giving them food, the keepers
examine them, and, if they notice any, who are disorderly, they beat them
severely; but, if they should by accident, find any, who no longer exhibit
symptoms of insanity, they treat them with greater regard."

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. It has been shewn 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 protecting 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 more effectual and
convenient mode of confining the hands is by metallic manacles; for,
should the patient, as frequently occurs, be constantly endeavouring to
liberate himself, the friction of the skin against a polished metallic
body may be long sustained without injury; whereas excoriation shortly
takes place when the surface is rubbed with linen or cotton. Ligatures
should on all occasions be avoided. 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 disdain the incumbrance of clothing, 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.

In speaking of coercion, I cannot avoid reprobating a practice, which has
prevailed in some private receptacles for the insane, but which, it is
presumed, will henceforward be discontinued. I mean, the practice of
half-stifling a noisy patient, by placing a pillow before the mouth, and
forcibly pressing upon it, so as to stop respiration. It is unnecessary to
enquire, how such wanton cruelty came to be introduced; it must have been
the suggestion of ignorance, and the perpetration of savageness and
brutality. Sighs, tears, sobs, and exclamations, are the unaffected
language of passion, and come kindly to our relief, in states of sorrow
and alarm. Indeed, they appear to be the natural remedies, to

  "Cleanse the stufft bosom of that perillous stuffe,
  Which weighs upon the heart."

The mild and rational practice of Bethlem Hospital, tolerates these
involuntary ejaculations. It is there considered, that a noisy and
loquacious maniac, has not the power to control his utterance of sounds,
which, from the habitual connexion between ideas and speech, must
necessarily follow. It is there only viewed as a symptom, or part of the
disorder; and that, if the cause cannot be suppressed, the effect should
not be punished.

As madmen frequently entertain very high, and even romantic notions of
honour, they are often 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 seldom 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.

It would, in this part of the work, be particularly gratifying to my
feelings if I could develope this _English secret_ for the moral
management of the insane, which has been so ardently, yet unsuccessfully
sought after by Dr. Pinel. For fourteen years I have been daily in the
habit of visiting a very considerable number of madmen, and of mixing
indiscriminately among them, without ever having received a blow or
personal insult. During this time I have always gone alone, and have never
found the necessity for the assistance or protection of a keeper. The
superintendant of the Bicêtre, according to Dr. Pinel's account, is
usually attended by his keepers, [gens de service] though he is said to
possess[29] "une fermeté inébranlable, un courage raisonné et soutenu par
des qualités physiques les plus propres á imposer, une stature de corps
bien proportionnée, des membres pleins de force et de vigeur, et dans des
momens orageux le ton de voix le plus foudroyant, la contenance la plus
fiére et la plus intrepide." Not being myself endowed with any of these
rare qualities; carrying no thunder in my voice, nor lightning in my eye,
it has been requisite for me to have recourse to other expedients. In the
first place, it has been thought proper to devote some time and attention
to discover the character of the patient, and to ascertain wherein, and on
what points, his insanity consists: it is also important to learn the
history of his disorder, from his relatives and friends, and to enquire
particularly respecting any violence he may have attempted towards himself
or others.

In holding conferences with patients in order to discover their insanity,
no advantage has ever been derived from assuming a magisterial importance,
or by endeavouring to stare them out of countenance: a mildness of manner
and expression, an attention to their narrative, and seeming acquiescence
in its truth, succeed much better. By such conduct they acquire confidence
in the practitioner; and if he will have patience, and not too frequently
interrupt them, they will soon satisfy his mind as to the derangement of
their intellects.

When a patient is admitted into Bethlem Hospital, if he be sufficiently
rational to profit by such tuition, it is explained to him, by the keepers
and convalescents, that he is to be obedient to the officers of the
house, and especially to myself, with whom he will have daily intercourse;
they point out to him, that all proper indulgences will be allowed to good
behaviour, and that seclusion and coercion instantly succeed to
disobedience and revolt. As _nemo repente turpissimus_, so no one in an
instant, from a state of tranquillity, becomes furiously mad: the
precursory symptoms are manifold and successive, and allow of sufficient
time to secure the patient before mischief ensues; it is principally by
taking these precautions that our patients are observed to be so orderly
and obedient. The examples of those who are under strict coercion, being
constantly in view, operate more forcibly on their minds than any precepts
which the most consummate wisdom could suggest. In this moral management,
the co-operation of the convalescents is particularly serviceable; they
consider themselves in a state of probation, and, in order to be
liberated, are anxious, by every attention and assistance, to convince the
superintendants of their restoration to sanity of mind. From mildness of
treatment, and confidence reposed in them, they become attached, and are
always disposed to give information concerning any projected mischief.

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 uncontroled; 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 would 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:[30] 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, it may be inferred, that 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 from their
insanity: 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 yet complain that they cannot prevent their
intrusion.

As the patient should be taught to view the medical 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.

In the moral management of the insane, this circumstance cannot be too
strongly impressed on the mind of the practitioner: and those persons, who
have had the greatest experience in this department of medical science,
concur in this opinion. The late Dr. John Monro expressly says, "The
physician should never deceive them in _any_ thing, but more especially
with regard to their distemper; for as they are generally conscious of it
themselves, they acquire a kind of reverence for those who know it; and by
letting them see, that he is thoroughly acquainted with their complaint,
he may very often gain such an ascendant over them, that they will readily
follow his directions."[31]

Very different directions are, however, issued by a late writer,[32] and
which, on account of their novelty, contrivance, and singular morality,
deserve the consideration of the reader.

"The _conscientious physician_, in the execution of his duty, attempting
the removal of these deplorable maladies, is under the necessity of
occasionally deviating from the accustomed routine of practice, of
stepping out of the beaten track, and, in some cases, that have resisted
the usual methods, is warranted in adopting any others, that have _only_
the slightest _plausibility_, or that promise the smallest hope of
success. Thus, the employment of what may be termed _pious frauds_: as
when _one_ simple erroneous idea stamps the character of the disease,
depriving the affected party of the common enjoyments of society, though
capable of reasoning with propriety, perhaps, with ingenuity, on every
subject, not connected with that of his hallucination, the correction of
which has resisted our very best exertions, and, where there is no obvious
corporeal indisposition, it certainly is allowable to try the effect of
certain deceptions, contrived to make strong impressions on the senses,
by means of _unexpected_, _unusual_, _striking_, or apparently
_supernatural_ agents; such as after waking the party from sleep, either
suddenly or by a gradual process, by _imitated thunder_, or soft music,
according to the peculiarity of the case; _combating_ the erroneous
deranged notion, either by some _pointed sentence_, or signs _executed in
phosphorus_ upon the wall of the bed chamber; or by some _tale_,
_assertion_, or _reasoning_; by one in the character of an _angel_,
_prophet_, or _devil_: but the actor in this drama must possess much
_skill, and be very perfect in his part_."

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.

Concerning their diet, it is merely necessary to observe, that it should
be light, and easy of digestion. The proper quantity must be directed by
the good sense of the superintendant, according to the age and vigour of
the patient, and proportioned to the degree of bodily exercise he may be
in the habit of using; "but they should never be suffered to live too low,
especially while they are under a course of physic."[33] To my knowledge,
no experiments have yet been instituted respecting the diet of insane
persons: they have never been compelled to live entirely on farinaceous
substances. The diet of Bethlem Hospital allows animal food three times a
week, and on the other days bread with cheese, or occasionally butter,
together with milk pottage, rice milk, &c. Those who are regarded as
incurable patients ought certainly to be indulged in a greater latitude
of diet, but this should never be permitted to border on intemperance. To
those who are in circumstances to afford such comforts, wine may be
allowed in moderation, and the criterion of the proper quantity, will be
that which does not affect the temper of the lunatic, that which does not
exasperate his aversions, or render his philosophy obtrusive. Although it
seems rational in all states of madness, that temperance should be
strictly enjoined, yet an author of the present day[34] steps out of the
trodden path, and seriously advises us, in difficult cases, to drown
lunacy in intoxication; and, strange as it may appear, has taught us to
await the feast of Reason from the orgies of Bacchus. "The conversion of
religious melancholy into furious madness is a frequent occurrence, and is
generally followed by recovery. This has suggested the _propriety_, in
some cases that have resisted more common means, of producing a degree of
excitement by means of stimuli, in fact, _keeping the patient for days in
succession in a state of intoxication_, which has often occasioned an
alleviation of symptoms, and sometimes _restored the sufferers to
reason_."

Confinement is always necessary in cases of insanity, and should be
enforced as early in the disease 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 ought to be understood that no interruption to this
discipline should defeat its salutary operation. On this account more
patients recover in a public hospital, than in a private house,
appropriated for the reception of lunatics. In the former, the
superintendants persist in a plan laid down, and seldom deviate from
their established rules: such asylum being a place of charitable relief,
they are indifferent about pleasing the friends and relatives of the
patient, who cannot there intrude to visit them at their option. In a
private receptacle emolument is the first object, and however wisely they
may have formed their regulations, they soon feel themselves subordinate
to the caprice and authority of those by whom they are paid.

It frequently happens, that patients who have been brought immediately
from their families, and who were said to be in a violent and ferocious
state at home, become suddenly calm and tractable when placed in the
hospital. On the other hand it is equally certain, that there are many
patients whose disorder speedily recurs after having been suffered to
return to their families, although they have for a length of time
conducted themselves, under confinement, in a very orderly manner. 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. But
certain restrictions should be imposed on the visits of these friends;
ignorant people often, after a few minutes conversation with the patient,
will suppose him perfectly recovered, and acquaint him with their opinion:
this induces him to suppose that he is well, and he frequently becomes
impatient of confinement and restraint. From such improper intercourse I
have known many patients relapse, and in two instances I have a
well-founded suspicion that it excited attempts at suicide.

Many patients have received considerable benefit by change of situation,
which occupies the mind with new objects, and this sometimes takes place
very shortly after the removal.

  "Haply the Seas and Countries different
  With variable objects, shall expell
  This something setled matter in his heart:
  Whereon his Braines still beating, puts him thus
  From fashion of himselfe."

In what particular cases, or stages of the disease, this may be
recommended, I am not enabled, by sufficient experience, to determine.




CHAP. VIII.

REMEDIES FOR INSANITY.


_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 good 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 some 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.

Before particular remedies, to be employed for the cure of mania and
melancholia, are recommended, it may be necessary to give some directions
concerning the means to be used for their certain administration.

Maniacs in general feel a great aversion to become benefited from those
medicinal preparations which practitioners employ for their relief; and on
many occasions they refuse them altogether. Presuming that some good is to
be procured by the operation of medicines on persons so affected, and
aware of their propensity to reject them, it becomes a proper object of
enquiry how such salutary agents may most securely, and with the least
disadvantage, be conveyed into the stomachs of these refractory subjects.
For the attainment of this end various instruments have been contrived,
but that which has been more frequently employed, and is the most
destructive and devilish engine of this set of apparatus, is termed a
_spouting_ boat. It will not be necessary to fatigue the reader with a
particular description of this coarse tool, except to remark, that it is
constructed somewhat like a child's pap boat; and is intended to force an
entrance into the mouth through the barriers of the teeth.[35]

In those cases, where patients have been obstinately bent on starving
themselves, or where they have become determined to resist the
introduction of remedies calculated for their relief, I have always been
enabled to convey both into their stomachs, at any time, and in any
quantity that might be necessary, by the employment of an instrument, of
which the figure and dimensions are here given.

[Illustration]

Since the use of this very simple and efficient instrument, which I
constructed about twelve years ago, I can truly affirm, that no patient
has ever been deprived of a tooth, and that the food or remedy has always
been conveyed into the stomach of the patient.

The manner in which this compulsory operation is performed, consists in
placing the head of the patient between the knees of the person who is to
use the instrument: a second assistant secures the hands, (if the
straight-waistcoat be not employed) and a third keeps down the legs. As
soon as the mouth is opened, the instrument may be introduced; it presses
down the tongue, and keeps the jaws sufficiently asunder to admit of the
introduction of the medicine, which should be contained in a vial, or tin
pot with a spout, to allow it to run in a small stream. The nose of the
patient being held by the left hand of the person who uses the
instrument, a small quantity of the medicine is to be poured into the
mouth, and when deglutition has commenced, is to be repeated, so as to
continue the act of swallowing until the whole be taken.

A little address will obviate the determination of the patient to keep his
teeth closed: he may be blindfolded at the commencement, which never fails
to alarm him, and urges him to enquire what the persons around him are
about: causing him to sneeze, by a pinch of snuff, always opens the mouth
previously to that convulsion, or tickling the nose with a feather
commonly produces the same effect.

With delicate females, where one or more of the grinder-teeth are wanting,
the finger may be introduced on the inside of the cheek, which being
strongly pressed outwards will prevent the patient from biting, and form
a sufficient cavity to pour in the liquid. With a wish of speaking
confidently on this subject, I have usually performed the business of
forcing, more especially amongst the females, and it has, in some degree,
rewarded my trouble; it has ascertained the practicability of
administering remedies; and it has also afforded the consolation, that,
where the means employed have produced no good, the patient has sustained
no injury.


_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 has been commonly
employed at the hospital, was prepared agreeably to the following formula:

  [Precsription] Infusi sennæ [ounce] iss ad [ounce] ij
                 Tincturæ sennæ [dram] i ad [dram] ij
                 Syrupi spinæ cervinæ, [dram] i ad [dram] ij.

but, within the last seven years, the tinctura jalapij has been
substituted for the tinctura sennæ. It is so far an improvement, that it
operates more speedily, and produces less griping.

This medicine 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
the intestines in mad people, it may be mentioned, that the ordinary
complaints, with which they are affected, are diarrhoea and dysentery:
these have heretofore been very violent and obstinate.

Perhaps it may be attributed to superior care that the occurrence of these
complaints has, of late years, been comparatively rare, contrasted with
the numbers who were formerly attacked with such diseases; and, when they
do happen, an improved method of treatment has rendered these intestinal
affections no longer formidable or fatal.

In those very violent diarrhoeas, which ordinarily terminate in
dysentery, from five to ten grains of the pilula hydrargyri have been
given according to the sex, constitution, and nature of the complaint,
once or twice a day, and with general success.

It may be necessary to add, that it is proper, during the course of this
mercurial remedy, which shortly arrests the disease, to keep the bowels
in an open state, by some of the milder purgatives employed every third or
fourth day.

Diarrhoea very often proves a natural cure of insanity; at least, there
is sufficient reason to suppose, that such evacuation has very much
contributed to it. The number of cases, which might be adduced in
confirmation of this remark, 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 scarcely appeared to feel the passing of setons, the
drawing of blisters, or the punctures of cupping. On many occasions, I
have known the urine retained for a considerable time, without complaint
from the patient, although it is well ascertained, that there is no
affection more painful and distressing than distension 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 frequently
prevail, would be widely different from a particular and exclusive torpor
of the primæ viæ.

But, sometimes, there arises a state of disease in maniacs, where the
stomach and intestines are particularly inert. The patient refuses to take
food, and is obstinately constipated: the tongue is foul, and the skin is
tinged with a yellowish hue: the eyes assume a glossy lustre, and exhibit
a peculiar wildness. In this state, I have given two drachms of the pulvis
jalapij for a dose, and which, on some occasions, has procured but one
stool, so that it has been necessary several times to repeat the same
quantity. After the bowels have been sufficiently evacuated, the appetite
commonly returns, and the patient takes food as usual.

Much mischief may be produced, if it be attempted to force food into the
stomach in such a case, which the ignorance of keepers may attempt,
supposing it to originate in the obstinacy of the patient. In order to
continue the bowels in a relaxed state, after they have been sufficiently
emptied of their contents, the following formula has been employed with
advantage:

  [Precsription] Infusi sennæ, [ounce] vijss
                 Kali Tartarizati, [ounce] ss
                 Antimonij Tartarizati, gr 1ss
                 Tincturæ jalapij, [dram] ij

From two to three table spoonsful may be given once or twice a day, as
occasion may require.

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 contribute 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 temperate 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 Hospital, 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 digression: 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 means 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
had 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 such 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 had been raised in its favour by very high authority.
Where the tartarized antimony, given with this intention, operated as a
purgative, it generally produced beneficial effects.

Ten years have elapsed since the former edition of this work appeared; but
this length of time, and subsequent observation, have not enabled me to
place any greater confidence in the operation of emetics, as a cure for
insanity.

An author[36] who has lately published a work, entitled "_Practical
Observations on Insanity_," is however a determined fautor of emetics in
maniacal cases. In his skilful hands they have worked marvellous cures;
nor have any prejudicial effects ever resulted from their employment.
Perhaps no one has enjoyed a fairer opportunity of witnessing the effects
of remedies for insane persons than myself; and when emetics are employed
in Bethlem Hospital they have the best chance of effecting all the relief
they are competent to afford, as they are given by themselves, without the
intervention of other medicines; and this course of emetics usually
continues six weeks. Had Dr. Cox confined himself to the relation of his
own victories in combating madness with vomits, it would have been
sufficient; but he endeavours to raise the leveé en masse of medical
opinion to co-operate with his sentiments. He says, page 78, "Yet _every_
physician, who has devoted his attention to this branch of the profession,
_must_ differ from him when he treats of vomiting." It was never my
intention to deny, in a disordered state of the stomach, that the madman
would be equally benefited with one in his senses by the operation of a
vomit: but I have asserted, that after the administration of many thousand
emetics to persons who were insane, but otherwise in good health, that I
never saw any benefit derived from their use. It will also be granted,
that some ascendancy may be gained over a furious maniac by forcing him to
take a vomit, or any other medicine, but this is widely different from any
positive advantage resulting from the act of vomiting. Sir John Colebatch,
in his "_Dissertation concerning Misletoe_," says, _p._ 35, "But I have
been for some years afraid of giving vomits, even of the gentlest sort, in
convulsive distempers, from some terrible accidents, that have been likely
to ensue, from moderate doses of Ipecacuanha itself."

In St. Luke's hospital, the largest public receptacle for insane persons,
where the medical treatment is directed by a physician of the highest
character and eminence, and whose experience is, at least, equal to that
of any professional man in this country, vomits are by no means considered
as the order of the day; they may be employed to remove symptoms
concomitant with madness, but are not held as specifics for this disease.

In reading over the cases related by Dr. Cox, there is no one, where
emetics have been solely employed as agents of cure; they have been always
linked with other remedies; and it requires more sagacity than even the
doctor can exact, to pronounce, when different means of cure are combined,
to which the palm should be adjudged. In the relation of my own experience
concerning vomiting, as a remedy for insanity, I have had only in view the
communication of facts, for I entertain neither partiality nor aversion to
any remedies, beyond the fair claim which their operations possess. Had I
modestly ventured to state, after the example of the Doctor, "that I had
_devoted_ myself _exclusively_ and _assiduously_ for a _series of years_,
to the care of insane patients in an _establishment_, where persons of
_both sexes_ are received,"[37] it might be suspected, that the
superstructure of my philosophy had been reared on the basis of private
emolument.


_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 drachms, 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
melancholic 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 were intoxicated. Considering
the insoluble nature of camphor, and the impracticability of compelling a
lunatic to swallow a pill or bolus, it has been found convenient (when a
large quantity was required) to give this medicine in the form of an
emulsion, by dissolving the camphor in hot olive oil, and afterwards
adding a sufficient quantity of warm water and aqua ammoniæ puræ.


_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. That this is not unlikely to happen may be supposed
from the difficulty of compelling the patient to go head-foremost into the
bath. In some cases vertigo, and in others a considerable degree of fever
ensued after immersion. The shower-bath was employed some years ago in the
hospital, and many cases were selected in order to give a fair trial to
this remedy, but I am unable to say, that any considerable advantage was
derived to the patients from its use. If I might be permitted to give an
opinion on this subject, the principal benefit resulting from this remedy,
has been in the latter stages of the disease, and when the system had been
previously lowered by evacuations. As a remedy for insanity cold bathing
has been disregarded by a celebrated practitioner. To a question from a
select committee of the House of Commons to Doctor Willis, 9th March,
1807, the following answer was given.

_Question._ Are you of opinion that warm and cold baths are necessary for
lunatic patients?

_Answer._ I think warm baths may be very useful, but it _can seldom
happen_ that a cold bath will be required.[38]


_Blisters._

These have been in several cases 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."[39] Dr. Mead
also concurs in this opinion. "Blistering plasters applied to the head
will possibly be thought to deserve a place among the remedies of this
disease, but I have often found them do more harm than good by their over
great irritation."--_Medical Precepts, page 94._ Although blisters
appear to be of little service, when put on the head, yet I have, in many
cases, seen much good result from applying them to the legs. In patients
who have continued for some time in a very furious state, and where
evacuations have been sufficiently employed, large blisters applied to the
inside of the legs, have often, and within a short time, mitigated the
violence of the disorder.

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, awaked in a state of increased violence.

Many of the tribe of narcotic poisons have been recommended for the cure
of madness; but, my own experience of those remedies is very limited, nor
is it my intention to make further trials. Other, and perhaps whimsical
modes of treating this disorder, have been mentioned: whirling,[40] or
spinning a madman round, on a pivot, has been gravely proposed; and, music
has been extolled, with a considerable glow of imagination, by the same
gentleman.--That the medical student may be fully aware of the manifold
agents which _practical physicians_ have suggested for the restoration of
reason, I shall conclude my volume with the following extract.[41]

"The medical philosopher, in his study of human nature, must have
observed, that _sympathetic correspondence of action_ between the mind and
body, which is _uniformly_ present in health and disease, though _varying_
with circumstances. The different passions, according to their nature, the
degree or intensity of application, and the sensibility of the party,
exhibit certain characteristic expressions of countenance, and produce
obvious _changes_, actions, or motions, in the animal economy. MUSIC has
been found to occasion _all_ these actions, changes, and movements, in
some sensible systems; and where one passion morbidly predominates, as
frequently happens in mania, those species of simple or combined sounds,
_capable of exciting an opposite passion_, may be _very usefully_
employed. _If_ then such effects _can_ be produced by such a power, acting
on a mind only endued with its healthy proportion of susceptibility, what
may we _not_ expect where the sensibility is morbidly increased, and where
the patient is alive to the most minute impressions? Cases frequently
occur where such acuteness of sensibility, and _extreme_ delicacy of
system exist, that most of the more common, _moral_, and medical means are
contra-indicated; _here_ relief may be often administered through the
medium of the _senses_; the _varied modulations, the lulling, soothing_
cords of even an Eölian harp have _appeased_ contending passions,
_allayed_ miserable feeling, and afforded ease and tranquillity to the
bosom _tortured_ with real or fancied woe: and I can easily _imagine_,
that _jarring discord_, _grating harsh rending_ sounds, applied to an ear
_naturally_ musical, would uniformly excite great commotion. Under
circumstances calculated to assist this action, by producing unpleasant
impressions through the medium of the other senses, as when SCREECHES and
YELLS are made in an apartment painted _black_ and _red_, or _glaring
white_, every man must be painfully affected: the maniacal patient,
_however torpid_, _must_ be roused: or, on the contrary, where an opposite
state obtains, extreme sensibility and impatience of powerful impression,
there _much may be expected_ from placing the patient in an _airy room_,
surrounded with _flowers breathing odours_, the walls and furniture
_coloured green_, and the air agitated by undulations of the softest
harmony. _Much_ of this may appear FANCIFUL and RIDICULOUS, but the
_enquiring_ practitioner _will_ find, on making the experiment, it
deserves his _serious_ attention; and no mean is to be despised that is
capable of arresting the attention, changing the trains of thought,
interesting the affections, removing or diminishing painful sensations,
and ultimately rendering both mind and body sensible to impressions, and
_all this has been effected by music_. Every individual is not capable of
accurately estimating the _extensive powers_ of this agent; but I would
ask the _musical amateur_, or the _experienced professor_, if he have not
frequently felt sensations the most _exquisite_ and _indescribable_; if he
have not experienced the whole frame _trilling_ with _inexpressible
delight_, when the _tide_ of full harmony has FLOWN on his ear, and the
most _wretched miserable_ feeling, UNIVERSAL HORRIPILATIO and CUTIS
ANSERINA from the _grating crash_ of discord? All the varied sensations
from transport to disgust, have been occasioned by the different movements
in one piece of music. I might _amuse_ my readers with a great variety of
instances where persons have been very singularly affected by means of
music, and where its powers have extended to the _brute creation_, but
this I purposely avoid."


FINIS.


  Printed by G. HAYDEN,}
  Brydges Street, Covent Garden.}




FOOTNOTES:

[1] The choice of these words must be left to the taste of the reader, Dr.
Johnson not having thought proper to admit them into his dictionary.

[2] Some doubts are entertained whether Dr. Boord was physician to King
Henry the eighth, but he was certainly a fellow of the College.

[3] Apprehension of sensations. This is perhaps only an endeavour to
explain the thing, _by_ the thing, or producing words of similar import
with different sounds. Junius, speaking of the word hand (as derived from
the gothic Handus) says, "Quidam olim deduxerunt vocabulum ab antiquo
verbo HENDO, _Capio_: unde PREHENDO, APPREHENDO, &c."--_Gothicum
Glossarium_, p. 188. Professor Ihre conceives it equally probable that the
old latin word _hendo_ may have had a northern origin. "Id vero non
possum, quin addam, oppidó mihi probabile fieri, ipsammet hanc vocem latio
olim peregrinam non fuisse, quod quippe augurar ex derivato HENDO, capio,
unde prehendo cum derivatis pullularunt."--_Glossarium Sviogothicum. tom.
i. p. 778._

[4] Quere. Why should the most _active_ characteristics of our nature be
termed _Passions_? The word seems properly employed in _Passion week_, the
period commemorative of Christ's suffering or _Passion_. But we are said
to _fly_, or _fall_ into a passion, and then passion _gets the better of
us_. For the softer sex we conceive the most delicate, refined, and
honorable _passion_, yet every one allows the dreadful consequences which
ensue from an indulgence of our _passions_, and most persons agree that
_passion_, carried to excess, constitutes madness--we live in a world of
metaphor.

[5] In many instances, although it is far from being general, pain of the
head, and throbbing of its arteries precede an attack of insanity;
sometimes giddiness is complained of as a precursory symptom. Those who
have been several times disordered, are now and then sensible of the
approaching return of their malady. Some have stated, a sense of working
in the head, and also in the intestines, as if they were in a state of
fermentation. Others observe that they do not seem to possess their
natural feelings, but they all agree that they feel confused from the
sudden and rapid intrusion of unconnected thoughts.

[6] To illustrate how necessarily our sensations, or ideas must become
confused, when their succession is too rapid, the relation of some
experiments on that subject will sufficiently conduce.

"But by the able assistance of Mr. Herschel, I am in a condition to give
some approximation, at least, towards ascertaining the velocity of our
audible sensations. For having, by means of a clock, produced sounds,
which succeeded each other with such rapidity, that the intervals between
each of them were (as far as could be judged) the smallest posible; he
found he could evidently distinguish one hundred and sixty of them to flow
in a second of time. Now as each interval must in this case be reckoned as
a sensation likewise, as it might be filled up with a sound thereby making
it a continued one; it follows, that we are capable of entertaining at
least three hundred and twenty audible sensations in that period of
time."--_Vide a Treatise on Time, by W. Watson, Jun. M. D. F. R. S. 8vo,
1785, page 32._

[7] The late Dr. Johnson was remarkably distinguished by certain
peculiarities of action when his mind was deeply engaged. Sir Joshua
Reynolds was of opinion "that it proceeded from a habit he had indulged
himself in, of accompanying his thoughts with certain untoward actions."
"One instance of his absence, and particularity as it is characteristic of
the man, may be worth relating. When he and I took a journey into the
West, we visited the late Mr. Banks, of Dorsetshire; the conversation
turning upon pictures, which Johnson could not well see, he retired to a
corner of the room, stretching out his right leg as far as he could reach
before him, then bringing up his left leg, and stretching his right still
further on. The old gentleman observing him, went up to him, and in a very
courteous manner assured him, that though it was not a new house, the
flooring was perfectly safe. The Doctor started from his reverie like a
person waked out of his sleep, but spoke not a word."--_Boswell's Life of
Dr. Johnson, vol. i. p. 76._ In the same work other of his tricks are
recorded, as talking to himself, measuring his steps in a mysterious
manner, half whistling, clucking like a hen, rubbing his left knee, &c.
Many sensible persons, with whom I am now acquainted, when particularly
thoughtful, discover strange bodily motions, of which they are by no means
conscious at the time.

[8] This gritty matter, subjected to chemical examination, was found to be
_phosphat of lime_.

[9] 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
tunica arachnoidea.

[10] Morbid Anatomy, page 304.

[11] Mr. Fourcroy does not appear to have given any particular attention
to this fluid. He says, "Cette humeur ne paraît pas différer de celle qui
mouille toutes les parois membraneuses du corps humain en general, et dont
j'ai déja parlé. C'est un liquide mucoso gelatineux, plus ou moins
albumineux, et contenant _quelques matiéres salines_."--_Systéme des
Connoisances Chimiques, 8vo. tom. ix. p. 303._

[12] It may be remarked, that all children in the early attempts at
language, speak of themselves and others in the third person, and never
employ the pronoun; they likewise never use connectives, or the
inflections of verbs, until they begin to acquire some knowledge of
numbers. Beyond this rude state our patient never advanced.

[13] For this term the indulgent reader must give the author credit,
because he finds himself unable adequately to explain it.--It is a complex
_term_ for many ideas, on which language has not as yet, and perhaps will
never be imposed. Very unfortunately there are many terms of this nature,
equally incapable of description--a smile, for instance, is not very easy
to be defined. Dr. Johnson calls it "a slight contraction of the face"
which applies as properly to a paralytic affection. He also states it to
be "opposed to frown." If curiosity should prompt the inquisitive reader
to seek in the same author for the verb, to frown, he will find it "to
express displeasure _by contracting the face_ to wrinkles." He who would

  "Finde the minde's construction in the face"

must not expect to be able to communicate to others, in a few words, that
knowledge which has been the slow and progressive accumulation of years.

[14] These are the usual terms employed by writers on this subject, but
the propriety of their use must be left to the judgment of the reader.
Every person will occasionally hesitate whether certain occurrences, said
to be causes, ought to be referred to one class, in preference to the
other. They are loose and vague names: for instance, a course of
debauchery long persisted in, would probably terminate in paralysis;
excessive grief we know to be capable of the same effect. Paralysis
frequently induces derangement of mind, and in such case it would be said,
that the madness was induced by the paralysis as a physical cause. But it
often happens that debauchery and excessive grief are followed by madness,
without the intervention paralysis. Moral, in this sense, means merely
habitudes or customs, reiteration of circumstances confirmed into usage;
and these may be indifferently accounted physical or moral.

[15]

  "----nessun maggior dolore,
  Che ricordarsi del tempo felice
  Nella miseria."--_Dante._

[16] The Jews also were particularly instrumental in the practice and
propagation of medical knowledge at that period.

[17] Cogitatio, (hîc minimè prætereunda) est motus peculiaris Cerebri,
quod hujus facultatis est proprium organum: vel potiùs Cerebri pars
quædam, in medulla spinali et nervis cum suis meningibus continuata, tenet
animi principatum, motumque perficit tam cogitationis quam sensationis;
quæ secundùm Cerebri diversam in omnium animalium structuram, mirè
variantur.--_Tolandi Pantheisticon, p. 12._

[18] 1796, 1797.

[19] Vide Report, Part II. p. 25.

[20] Report, p. 59.

[21] Ibid, 57.

[22] Report 54.

[23] "We shall use the general term of methodism, to designate these three
classes of fanatics, [Arminian and Calvinistic methodists, and the
_evangelical_ clergymen of the church of England] not troubling ourselves
to point out the finer shades, and nicer discriminations of lunacy, but
treating them all as in one general conspiracy against common sense, and
rational orthodox christianity."--_Edinburgh Review, Jan. 1808, p. 342._

[24] Traité Medico-Philosophique sur l'Alienation Mentale, 8vo. Paris, an.
9, p. 47.

[25] The late Reverend Dr. Willis.

[26] With respect to the persons, called Keepers, who are placed over the
insane, public hospitals have generally very much the advantage. They are
there better paid, which makes them more anxious to preserve their
situations by attention and good behaviour: and thus they acquire some
experience of the disease. But it is very different in the private
receptacles for maniacs. They there procure them at a cheaper rate; they
are taken from the plough, the loom, or the stable; and sometimes this
tribe consists of decayed smugglers, broken excisemen, or discharged
sheriffs' officers:

  "All that at home no more can beg or steal."

How well such a description of persons is calculated to regulate and
direct the conduct of an insane gentleman may be easily conjectured. If
any thing could add to the calamity of mental derangement, it would be the
mode which is generally adopted for its cure. Although an office of some
importance and great responsibility, it is held as a degrading and odious
employment, and seldom accepted but by idle and disorderly persons.

[27] Vide Cullen, First Lines, vol. iv. p. 154.

[28] "_D'uno luogo chiamato Timarahane, dove si castigano i matti._

"In Costantinopoli fece fare un luogo Sultan Paiaxit dove si dovessero
menare i pazzi, accioche non andassero per la citta, facendo pazzie, et è
fatto à modo d'uno Spedale, dove sono circa cento cinquanta guardiani in
loro custodia, et sonvi medicine, et altre cose per loro bisogni, e i
detti guardiani vanno per la citta con bastoni cercando i matti, et quando
ne truovano alcuno, lo'ncatenano per il collo con cathene di ferro, et per
le mani, et à suon di bastoni lo menano al detto luogo, et quivi gli
mettono una catena al collo assai maggiore, che è posta nel muro, et viene
sopra del letto, tal mente che nel letto per il collo tutti gli tengono
incatenati, et vene saranno per ordine, lontano l'uno dall'altro numero di
quaranta, i quali per piacere di quelli della citta molte volte sono
visitati, et di continovo col bastone i guardiani gli stanno appresso:
Percio che non essendovi guastano i letti, et tiransi le tavole l'uno à
l'altro: et venuta l'hora del mangiare, i guardiani gli vanno esaminando
tutti per ordine, et trovando alcuno, che non istia in buon proposito,
crudelmente lo battono, et se à caso truovano alcuno, che non faccia piu
pazzie, gli banno miglior cura, che à gli altri." _J. Costumi et la vita
de Turchi di Gio. Antonio Menavino Genovese da Vultri, 12mo, in Fiorenza,
1551._

[29] Traité sur la Mania, page 103.

[30] The frequent recurrence of any propensity leads, by sure steps, to
the final adjustment of the character; and even when the propensity is
ideal, the repetition of the fits will, in the end, invest fancy with the
habitudes of nature.--_Criticism on the Elegy written in a Country Church
Yard, p. 3._

[31] Remarks on Dr. Batties' Treatise on Madness, p. 38.

[32] Dr. Cox, Practical Observations on Insanity, p. 28.

[33] Dr. John Monro's Remarks on Dr. Battie, p. 39.

[34] Vide Dr. Cox's _Practical_ Obs. on Insanity, p. 42.

[35] It is a painful recollection to recur to the number of interesting
females I have seen, who, after having suffered a temporary disarrangement
of mind, and undergone the brutal operation of _spouting_, in private
receptacles for the insane, have been restored to their friends without a
front tooth in either jaw. Unfortunately the task of forcing patients to
take food or medicines is consigned to the rude hand of an ignorant and
unfeeling servant: it should always be performed by the master or mistress
of the mad-house, whose reputations ought to be responsible for the
personal integrity of the unhappy beings committed to their care.

[36] Dr. Cox.

[37] See Dr. Cox's Advertisement prefixed to his book.

[38] Vide Report from the select committee appointed to enquire into the
state of lunatics, page 25.

[39] Remarks on Dr. Batties' Treatise on Madness.

[40] See Dr. Cox, page 102.

[41] Dr. Cox, p. 61.




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