PREFACE. (continued 2)

Although patients, who have been affected with insanity more than a year, are not admissible into the hospital, to continue there for the usual time of trial for cure, namely, a twelvemonth, yet, at the discretion of the committee, they may be received into it from Lady-day to Michaelmas, at which latter period they are removed. In the course of the last ten years, fifty-six patients of this description have been received, of whom only one has been discharged cured. This patient, who was a woman, has since relapsed twice, and is, at present, in the hospital.

When the reader contrasts the preceding statement with the account recorded in the report of the committee, appointed to examine the physicians who have attended his majesty, &c. he will either be inclined to deplore the unskilfulness or mismanagement which has prevailed among those medical persons who have directed the treatment of mania in the largest public institution, in this kingdom, of its kind, compared with the success which has attended the private practice of an individual; or, to require some other evidence, than the bare assertions of the man pretending to have performed such cures[5]. It was deposed by that reverend and celebrated physician, that of patients placed under his care within three months after the attack of the disease, nine out of ten had recovered[6]; and also that the age was of no signification, unless the patient had been afflicted before with the same malady[7].

How little soever I might be disposed to doubt such a bold, unprecedented, and marvellous account, yet, I must acknowledge, that my mind would have been much more satisfied as to the truth of that assertion, had it been plausibly made out, or had the circumstances been otherwise than feebly recollected by that very successful practitioner. Medicine has generally been esteemed a progressive science, in which its professors have confessed themselves indebted to great preparatory study, and long subsequent experience, for the knowledge they have acquired; but in the case to which we are now alluding, the outset of the doctor’s practice was marked with such splendid success, that time and observation have been unable to increase it.

This astonishing number of cures has been effected by the vigorous agency of remedies, which others have not hitherto been so fortunate as to discover; by remedies which, when remote causes have been operating for twenty-seven years, such as weighty business, severe exercise, too great abstemiousness and little rest, are possessed of adequate power directly to meet and counteract such causes[8].

It will be seen by the table that a greater number of patients have been admitted between the age of thirty and forty, than during any other equal period of life. There may be some reasons assigned for the increased proportion of insane persons at this age.

Although I have made no exact calculation, yet, from a great number of cases, it appears to be the time, when the hereditary disposition is most frequently called into action; or, to speak more plainly, it is that stage of life when persons, whose families have been insane, are most liable to become mad. If it can be made to appear, that at this period people are more subject to be acted upon by the remote causes of the disease, or that a greater number of such causes are then applied, we may be enabled satisfactorily to explain it. At this age people are generally established in their different occupations, are married, and have families; their habits are more strongly formed, and the interruptions of them are, consequently, attended with greater anxiety and regret. Under these circumstances, they feel the misfortunes of life more exquisitely. Adversity does not depress the individual for himself alone, but as involving his partner and his offspring in wretchedness and ruin. In youth, we feel desirous only of present good; at the middle age, we become more provident and anxious for the future; the mind assumes a serious character, and religion, as it is justly or improperly impressed, imparts comfort, or excites apprehension and terror.

By misfortunes the habits of intoxication are readily formed. Those, who in their youth have shaken off calamity as a superficial incumbrance, at the middle age feel it corrode and penetrate: and when fermented liquors have once dispelled the gloom of despondency, and taught the mind either to excite a temporary assemblage of cheerful scenes, or to disdain the terror of impending misery, it is natural to recur to the same, though destructive cause, to reproduce the effect.

Patients, who are in a furious state, recover in a larger proportion than those who are depressed and melancholick. An hundred violent, and the same number of melancholick cases were selected. Of the former, sixty-two were discharged well; of the latter, only twenty-seven. When the furious state is succeeded by melancholy, and after this shall have continued a short time, the violent paroxysm returns, the hope of recovery is very slight. Indeed, whenever these states of the disease frequently change, such alternation may be considered as unfavourable.

Where the complaint has been induced from remote physical causes, the proportion of those who recover is considerably greater, than where it has arisen from causes of a moral nature. In those instances where insanity has been produced by a train of unavoidable misfortunes, as where the father of a large family, with the most laborious exertions, ineffectually struggles to maintain it, the number who recover is very small indeed.

Paralytic affections are a much more frequent cause of insanity than has been commonly supposed. In those affected from this cause, we are, on enquiry, enabled to trace a sudden affection, or fit, to have preceded the disease. These patients usually bear marks of such affection, independent of their insanity: the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capacity of being moved by the will: and in by far the greatest number of these cases the memory is particularly affected. Very few of these cases have received any benefit in the hospital; and from the enquiries I have been able to make at the private houses, where they have been afterwards confined, it has appeared, that they have either died suddenly from apoplexy, or have had repeated fits, from the effects of which they have sunk into a stupid state, and have gradually dwindled away.

When the natural small-pox attacks insane persons, it most commonly proves fatal.

When insanity supervenes on epilepsy, of where the latter disease is induced by insanity, a cure is very seldom effected: from my own observation, I do not recollect a single case of recovery.

When patients during their convalescence become more corpulent than they were before, it is a favourable symptom; and, as far as I have remarked, such persons have very seldom relapsed.

METHOD OF CURE.

This part of the subject may be divided into management, and treatment by medicine.

As most men perceive the faults of others without being aware of their own, so insane people easily detect the nonsense of other madmen without being able to discover, or even to be made sensible of the incorrect associations of their own ideas. For this reason it is highly important, that he who pretends to regulate the conduct of such patients, should first have learned the management of himself. It should be the great object of the superintendant to gain the confidence of the patient, and to awaken in him respect and obedience: but it will readily be seen, that such confidence, obedience, and respect, can only be procured by superiority of talents, discipline of temper, and dignity of manners. Imbecility, misconduct, and empty consequence, although enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt.

In speaking of the management of insane persons, it is to be understood that the superintendant must first obtain an ascendency over them. When this is once effected, he will be enabled, on future occasions, to direct and regulate their conduct, according as his better judgment may suggest. He should possess firmness; and, when occasion may require, should exercise his authority in a peremptory manner. He should never threaten, but execute: and when the patient has misbehaved, should confine him immediately. As example operates more forcibly than precept, I have found it useful, to order the delinquent to be confined in the presence of the other patients. It displays authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. It also prevents the wanton exercise of force, and those cruel and unmanly advantages which might be taken when the patient and keeper are shut up in a private room. When the patient is vigorous and powerful, two, or more should assist in securing him; by these means it will be easily effected; for, where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger.

As management is employed to produce a salutary change upon the patient, and to restrain him from committing violence on others and himself, it may be proper here to enquire, upon what occasions, and to what extent, coercion may be used. The term coercion has generally been understood in a very formidable sense, and not without reason. It has been recommended, by very high medical authority, to inflict corporal punishment upon maniacs, with a view of rendering them rational by impressing terror[9]. What success may have followed such disgraceful and inhuman treatment I have not yet learned, nor should I be desirous of meeting with any one who could give me the information. If the patient be so far deprived of understanding, as to be insensible why he is punished, such correction, setting aside its cruelty, is manifestly absurd. And if his state be such, as to be conscious of the impropriety of his conduct, there are other methods more mild and effectual.

Would any rational practitioner, in a case of phrenitis, or in the delirium of fever, order his patient to be scourged? He would rather suppose that the brain or its membranes were inflamed, and that the incoherence of discourse, and violence of action, were produced by such local disease. We have seen, by the preceding dissections, that the contents of the cranium, in all the instances that have occurred to me, have been in a morbid state. It should therefore be the object of the practitioner to remove such disease, rather than irritate and torment the sufferer. Coercion should only be considered as a protesting and salutary restraint.

In the most violent state of the disease, the patient should be kept alone in a dark and quiet room, so that he may not be affected by the stimuli of light or sound, such abstraction more readily disposing to sleep. As in this violent state there is a strong propensity to associate ideas, it is particularly important to prevent the accession of such as might be transmitted through the medium of the senses. The hands should be properly secured, and the patient should also be confined by one leg: this will prevent him from committing any violence. The straight waistcoat is admirably calculated to prevent patients from doing mischief to themselves; but in the furious state, and particularly in warm weather, it irritates and increases that restlessness, which patients of this description usually labour under. They then scorn the incumbrance of cloathing, and seem to delight in exposing their bodies to the atmosphere. Where the patient is in a condition to be sensible of restraint, he may be punished for improper behaviour by confining him to his room, by degrading him, and not allowing him to associate with the convalescents, and by withholding certain indulgences he had been accustomed to enjoy.

As madmen frequently entertain very high, and even romantic notions of honour, they are rendered much more tractable by wounding their pride, than by severity of discipline.

Speaking of the effects of management on a very extensive scale, I can truly declare, that by gentleness of manner, and kindness of treatment, I have never failed to obtain the confidence, and conciliate the esteem of insane persons, and have succeeded by these means in procuring from them respect and obedience. There are certainly some patients who are not to be trusted, and in whom malevolence forms the prominent feature of their character: such persons should always be kept under a certain restraint, but this is not incompatible with kindness and humanity.

Considering how much we are the creatures of habit, it might naturally be hoped, and experience justifies the expectation, that madmen might be benefited by bringing their actions into a system of regularity. It might be supposed, that as thought precedes action, that whenever the ideas are incoherent, the actions will also be irregular. Most probably they would be so if uncontrouled; but custom, confirmed into habit, destroys this natural propensity, and renders them correct in their behaviour, though they still remain equally depraved in their intellects.

We have a number of patients in Bethlem Hospital whose ideas are in the most disordered state, who yet act, upon ordinary occasions, with great steadiness and propriety, and are capable of being trusted to a considerable extent. A fact of such importance in the history of the human mind, might lead us to hope, that by superinducing different habits of thinking, the irregular associations may be corrected.

It is impossible to effect this suddenly, or by reasoning, for madmen can never be convinced of the folly of their opinions. Their belief in them is firmly fixed, and cannot be shaken. The more frequently these opinions are recurred to under a conviction of their truth, the deeper they subside in the mind and become more obstinately entangled: the object should therefore be to prevent such recurrence by occupying the mind on different subjects, and thus diverting it from the favorite and accustomed train of ideas. As I have been induced to suppose, from the appearances on dissection, that the immediate cause of this disease probably consists in a morbid affection of the brain, all modes of cure by reasoning, or conducting the current of thought into different channels, must be ineffectual, so long as such local disease shall continue. It is, however, likely that insanity is often continued by habit; that incoherent associations, frequently recurred to, become received as truths, in the same manner as a tale, which, although untrue, by being repeatedly told, shall be credited at last by the narrator, as if it had certainly happened. It should likewise be observed, that these incorrect associations of ideas are acquired in the same way as just ones are formed, and that such are as likely to remain, as the most accurate opinions. The generality of minds are very little capable of tracing the origin of their ideas; there are many opinions we are in possession of, with the history and acquisition of which, we are totally unacquainted. We see this in a remarkable manner in patients who are recovering: they will often say such appearances have been presented to my mind with all the force and reality of truth: I saw them as plainly as I now behold any other object, and can hardly be persuaded that they did not occur. It also does not unfrequently happen, that patients will declare, that certain notions are forced into their minds, of which they see the folly and incongruity, and complain that they cannot prevent their intrusion.

It is of great service to establish a system of regularity in the actions of insane people. They should be made to rise, take exercise, and food, at stated times. Independently of such regularity contributing to health, it also renders them much more easily manageable.

As the patient should be taught to view the superintendant as a superior person, the latter should be particularly cautious never to deceive him. Madmen are generally more hurt at deception than punishment; and whenever they detect the imposition, never fail to lose that confidence and respect, which they ought to entertain for the person who governs them.

Confinement is always necessary in cases of insanity, and should be enforced as early in the complaint as possible. By confinement, it is to be understood that the patient should be removed from home. During his continuance at his own house he can never be kept in a tranquil state. The interruptions of his family, the loss of the accustomed obedience of his servants, and the idea of being under restraint in a place where he considers himself the master, will be constant sources of irritation to his mind. It is also known, from considerable experience, that of those patients who have remained under the immediate care of their relatives and friends, very few have recovered. Even the visits of their friends, when they are violently disordered, are productive of great inconvenience, as they are always more unquiet and ungovernable for some time afterwards. It is a well-known fact, that they are less disposed to acquire a dislike to those who are strangers, than to those with whom they have been intimately acquainted; they become therefore less dangerous, and are more easily restrained.

It frequently happens, that patients who have been brought immediately from their families, and who have been said to be in a violent and ferocious state, become suddenly calm and tractable, when placed in the hospital. On the other hand, it is equally certain, that there are many patients, who have for a length of time conducted themselves in a very orderly manner under confinement, whose disorder speedily recurs after being suffered to return to their families. When they are in a convalescent state, the occasional visits of their friends are attended with manifest advantage. Such an intercourse imparts consolation, and presents views of future happiness and comfort.

Many patients have received considerable benefit by change of situation, and this sometimes takes place very shortly after the removal. In what particular cases, or stages of the disease, this may be recommended, I am not enabled by sufficient experience to determine.

MEDICINE.

It is only intended, in this part of the subject, to speak of those medicines which I have administered, by the direction of Dr. Monro, the present celebrated and judicious physician to Bethlem Hospital, (to whom I gratefully acknowledge many and serious obligations) without descending to a minute detail of the hospital practice, or of the order in which they are commonly exhibited. Of the effects of such remedies, I am able to speak with considerable confidence, as they have come immediately under my own observation.

Bleeding.—Where the patient is strong and of a plethoric habit, and where the disorder has not been of any long continuance, bleeding has been found of considerable advantage, and, as far as I have yet observed, is the most beneficial remedy that has been employed. The melancholic cases have been equally relieved with the maniacal by this mode of treatment. Venesection by the arm is, however, inferior in its goods effects to blood taken from the head by cupping. This operation, performed in the manner to which I have been accustomed, consists in having the head previously shaven, and six or eight cupping glasses applied on the scalp; By these means any quantity of blood may be taken, and in as short a time, as by an orifice made in a vein by the lancet. When the raving paroxysm has continued for a considerable time, and the scalp has become unusually flaccid; or where a stupid state has succeeded to violence of considerable duration, no benefit has been derived from bleeding; indeed these states are generally attended by a degree of bodily weakness, sufficient to prohibit such practice independently of other considerations.

The quantity of blood to be taken, must be left to the discretion of the practitioner: from eight to sixteen ounces may be drawn, and the operation occasionally repeated, as circumstances may require.

In the few cases where blood was drawn at the commencement of the disease from the arm, and from patients who were extremely furious and ungovernable, it was covered with a buffy coat; but in other cases it has seldom or never such an appearance. In more than two hundred patients, male and female, who were let blood by venesection, there were only six, whose blood could be termed sizy.

In some few instances hemoptysis has preceded convalescence, as has also a bleeding from, the hemorrhoidal veins. Epistaxis has not, to my knowledge, ever occurred.

Purging.—An opinion has long prevailed, that mad people are particularly constipated, and likewise extremely difficult to be purged. From all the observations I have been able to make, insane patients, on the contrary, are of very delicate and irritable bowels, and are well and copiously purged by a common cathartic draught. That which is commonly employed in the hospital is prepared agreeably to the following formula.

℞.Infusi sennæ ℥iss ad ℥ij.

Tincturæ sennæ ℨi ad ℨij.

Syrupi spinæ cervinæ ℨi ad ℨij.

This seldom fails of procuring four or five stools, and frequently a greater number.

In confirmation of what I have advanced respecting the irritable state of intestines in mad people, it may be mentioned, that the ordinary complaints with which they are affected, are diarrhœa and dysentery: these are sometimes very violent and obstinate.

Diarrhœa very often proves a natural cure of insanity; at least there is every reason to suppose that such evacuation has frequently very much contributed to it. The number of cases which might be adduced in confirmation of this observation is considerable, and the speedy convalescence after such evacuation is still more remarkable.

In many cases of insanity there prevails a great degree of insensibility, so that patients have appeared hardly to feel the passing of setons, the application of blisters, or the operation of cupping. On many occasions I have known the urine retained for a considerable time, without the patient complaining of any pain, though it is well known that there is no affection more distressing than distention of the bladder. Of this general insensibility the intestinal canal may be supposed to partake: but this is not commonly the case, and if it should, would be widely different from a particular and exclusive torpor of the primæ viæ.

There are some circumstances unconnected with disease of mind, which might dispose insane persons to costiveness. I now speak of such as are confined, and who come more directly under our observation. When they are mischievously disposed, they require a greater degree of restraint, and are consequently deprived of that air and exercise, which so much contributes to regularity of bowels. It is well known, that those who have been in the habits of free living, and who come suddenly to a more spare diet, are very much disposed to costiveness. But to adduce the fairest proof of what has been advanced, I can truly state, that incurable patients, who have for many years been confined in the house, are subject to no inconveniences from constipation. Many patients are averse to food, and where little is taken in, the egesta must be inconsiderable.

To return from this degression: it is concluded, from very ample experience, that cathartic medicines are of the greatest service, and ought to be considered as an indispensable remedy in cases of insanity. The good sense and experience of every practitioner must direct him as to the dose, and frequency, with which these remedies are to be employed, and of the occasions where they would be prejudicial.

Vomiting.—However strongly this practice may have been recommended, and how much soever it may at present prevail, I am sorry that it is not in my power to speak of it favourably. In many instances, and in some where blood-letting has been previously employed, paralytic affections have within a few hours supervened on the exhibition of an emetic, more especially where the patient has been of a full habit, and has had the appearance of an increased determination to the head.

It has been for many years the practice of Bethlem Hospital, to administer to the curable patients four or five emetics in the spring of the year; but, on consulting my book of cases, I have not found that patients have been particularly benefited by the use of this remedy. From one grain and half to two grains of tartarized antimony has been the usual dose, which has hardly ever failed of procuring full vomiting. In the few instances where the plan of exhibiting this medicine in nauseating doses was pursued for a considerable time, it by no means answered the expectations, which, by very high authority, had been raised in its favour. Where the tartarized antimony, given with this intention, operated as a purgative, it generally produced beneficial effects.

Camphor.—This remedy has been highly extolled, and doubtless with reason, by those who have recommended it. My own experience merely extends to ten cases, a number from which no decisive inference of its utility ought to be drawn. The dose was gradually increased from five grains to two drams twice a day; and in nine cases the use of this remedy was continued for the space of two months. Of the patients, to whom the camphor was given, only two recovered: one of these had no symptoms of convalescence for several months after the use of this remedy had been abandoned; the other, a melancholick patient, certainly mended during the time he was taking it; but he was never able to bear more than ten grains thrice a day. He complained that it made him feel as if he was intoxicated.

Cold Bathing.—This remedy having for the most part been employed in conjunction with others, it becomes difficult to ascertain how far it may be exclusively beneficial in this disease. The instances where it has been separately used for the cure of insanity, are too few to enable me to draw any satisfactory conclusions. I may, however, safely relate, that, in many instances, paralytic affections have in a few hours supervened on cold bathing, especially where the patient has been in a furious state, and of a plethoric habit: in some of these cases vertigo has been induced, and in others a considerable degree of fever. If I might be permitted to give an opinion on this subject, the benefit principally derived from this remedy has been in the latter stages of the disease, and when the system had been previously lowered by evacuations.

Blisters have in several cases been applied to the head, and a very copious discharge maintained for many days, but without any manifest advantage. The late Dr. John Monro, who had, perhaps, seen more cases of this disease than any other practitioner, and who, joined to his extensive experience, possessed the talent of accurate observation, mentions, that he “never saw the least good effect of blisters in madness, unless it was at the beginning while there was some degree of fever, or when they have been applied to particular symptoms accompanying this complaint[10].”

In a few cases setons have been employed, but no benefit has been derived from their use, although the discharge was continued above two months.

Respecting opium, it may be observed, that whenever it has been exhibited during a violent paroxysm, it has hardly ever procured sleep; but, on the contrary, has rendered those who have taken it much more furious: and, where it has for a short time produced rest, the patient has, after its operation, awoke in a state of increased violence.

FINIS.

Footnotes:

[1] This gritty matter, subjected to chemical examination, was found to be phosphat of lime.

[2] This appearance I have found frequently to occur in maniacs who have suffered a violent paroxysm of considerable duration: and in such cases, when there has been an opportunity of inspecting the contents of the cranium after death, water has been found between the dura mater and arachnoid membrane.

[3] Morbid Anatomy, page 304.

[4]

[5] Vide Report, Part 2d, p. 25.

[6] Report, p. 59.

[7] Ibid. 57.

[8] Report, p. 54.

[9] Vide Cullen, first lines, vol. iv. p. 154.

[10] Vide Remarks on Dr. Battie’s Treatise on Madness.