Chapter IV: Part 4

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: Seleniaxomenous]" 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 phaenomena, 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 insaniae 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 lunae 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, (_Traite Medico-Philosophique sur la Manie, p. 109_,) and which, from its agreement with that of Bethlem Hospital, is here introduced to the notice of the reader.

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

There may be some reasons 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.