Part 9

It is painful to reflect on their former treatment; caged in iron-gratings and exhibited for money! Treated as wild beasts, they necessarily became like them, or worse! Devils in revenge and evil, Satans in deceit and delusion! Or if any portion of the man remained, think of the spirit writhing in agony, or sinking with despair within them! All this, and worse, in some despotic countries, even now exists; and in how many places are they not still made to drink the bitter cup of neglect and coldness, contempt and cruelty. Where do they receive, as they ought, judiciously and constantly, the cordial of sympathy and friendship? Where is every appearance of confinement and injurious association carefully avoided, and every thing studied to make them feel at home, and all this combined with medical attendance? Say not all this is unnecessary; for if life, under any circumstances, cannot be said to exist without some association of sympathy, it is certain there are among the insane, cases of misery and wretchedness which absolutely require for their cure, as well as their comfort, all the moral kindness and medical attention we can possibly give them.

It has been an universal complaint, that there is nothing certain or fixed in the treatment of Insanity, and that it is presumed it is not yet fully understood. I am of opinion that no medical treatment in any case can be fixed as certain or judicious unless we understood the origin and nature of disease; and I have therefore devoted a considerable portion of this Essay to the consideration of the correspondence which exists between the causes and effects produced; and this I only consider as preliminary to a more full and adequate investigation of causes than I am aware has hitherto been made; but still, as preliminary to this important subject, I shall, in my next Essay, first give a general explanation of the origin and cause of disease, and this in agreement with a principle which I conceive to be of universal application.

APPENDIX TO THE ESSAY ON CLASSIFICATION.

INTRODUCTORY OBSERVATIONS.

As in the foregoing Essay on Classification, I have several times stated my objections against writers on Insanity selecting only extreme cases, by which, I conceive, impressions of horror against the Insane are increased to their prejudice; I shall, therefore, for the _express purpose of exhibiting a fair specimen_ of the general character of the insane collectively, in their worst and most revolting state, add, in an Appendix to this Essay, about twenty of the oldest in age as well as in the duration of the disease, and of course of the most incurable cases, taken in regular rotation from the Register Book of the oldest Asylum in the kingdom, excepting Bedlam; containing, at the time the living characters were described, about one hundred of the same class. Now though these are taken from among those who had suffered all the brutalizing influence of the old and neglected system of treatment, yet they do not, as a whole, exhibit so shocking a picture as previous popular prejudice would imagine. Notwithstanding this truth, it is proper to state, that they are incomparably a worse picture, than the same number would make, taken with equal fidelity and correctness, from among my own patients, admitted within the period of my own exclusive superintendance,—this would, therefore, be much better calculated to correct this injurious prejudice than that which I _now_ give for this purpose: but they are too recent to be so introduced; yet as this would be a very striking contrast illustrating the effects of different treatment, I shall be prepared, should I live long enough for time to throw his dark veil over their memory, with the same number of cases, taken and described on the same principle.

I am the more anxious to do this at present, and fulfil this my future intention, because it may perhaps be laid to my charge, that in adducing cases illustrative of the principles contained in this Essay on Classification, as well as those which, from similar reasons, I may have hereafter to introduce, that I have been guilty, and may be guilty of the same error of selecting peculiar and extreme cases for my purpose; but I have been led into this, from the feeling that circumstances had forced upon me, however contrary to my previous intentions, something of a defensive attitude.

These are the reasons which have been my inducements in adding this Appendix; at the same time, to make the cases, in this naked form, as interesting and as useful as possible, I have not only drawn them with the most minute attention to truth, but to each I have appended some appropriate and useful observation.

Previous, then, to my entering upon the important subject mentioned at the end of this Essay, I shall now introduce these cases as a faithful portraiture of the Insane.

_No._ 1.—_Admitted_ 1782; _aged_ 76.

THERE is nothing recorded of this case, from which any correct information of the causes of the malady, or of its nature, when admitted, or of its progress since that period, can be drawn. Some of his relations are insane, and many of them exceedingly eccentric. His friends accuse some nurse of an improper application for the itch; yet, notwithstanding this accusation, the disease was gradual in its approach. He was gay when at Cambridge, and lost considerable sums at the gaming table. There is reason to believe that he had always been eccentric; and I have been told, that in his youth, he was proverbially called the proud and polite man. {114a} Whether this be correct or not, it is certain, that even now, though so little mind remains, he is soonest roused and offended, though otherwise very good-natured, by whatever questions his own importance.

Though, like many old men, he is fond of dozing away his time in bed, he has, notwithstanding, seasons of greater animation, when he seems more busily occupied with his own thoughts, often talking to himself; repeating very correctly passages committed to memory, probably forty years ago. {114b}

At these periods, unless teased or vexed in the way already stated, he is very good-natured and polite; and from his general manners, and particularly in the modulation of his voice, he still appears, in spite of the coarseness of his dress, {114c} the remains of a perfect gentleman. At these times, he is, for the most part, very happy, laughing and playing like a little child; and his very mischievous tricks—throwing stones, writing on the walls, tearing his clothes in order to make some little fanciful change and decoration of his dress, seem to be done rather as resources for regular employment or amusement, than from any malicious design or delight to be mischievous.

OBSERVATION I.

The slight changes or states of excitement described in this case, are in my opinion, the mere fluctuation of his animal spirits. I shall hereafter make further remarks (see ob. 5) on this subject; and therefore, in the mean time, (to obviate the objections which may be brought against this view,) I shall only observe that when we consider the defective and uncontrolled state of mind, {115} in these old and incurable cases of insanity, any change or increase of their animal spirits must, though perhaps depending on causes which equally affect the sane, display itself in them, in a very different manner.

_No._ 2.—_Admitted_ 1785; _aged_ 67.

There is no statement of this case on record, from which any satisfactory information can be derived; nor have I been able to obtain any account of his former life, or the nature or treatment of his case. There has been nothing of late years to distinguish his case from many old ones, whose minds have sunk into the torpid state, except it be, which is scarcely worthy of notice, that he has sometimes stood on his head to say his prayers; sometimes spit in his pocket; and, when provoked, used indecent language; otherwise his state of mind has not, for many years, exhibited any observable alteration. {116} He will be best known when I say, that he is singled out from the rest, as a little, timid, old-looking man, uniformly sitting in a moping, creeping posture.

[Picture: No. 2 page 116]

OBSERVATION II.

This man is not more of an idiot than the one just described, yet there is much less appearance of mind about him; but his mental powers had not formerly been so much evolved and improved by education; and the mind, like the soil we tread on, once properly broken up and cultivated, will, in defiance of neglect, long retain traces of its former improved state. Besides his want of early culture, being one of the middle class of patients, he was wholly left without mental food or exercise. There was, under the old system, a complete sacrifice of the lowest, utter neglect of the middle, for the sake of the higher class of patients; so that there was, with the middle class, for the most part, no intellectual interest excited by social converse and attention; nor, on the other hand, were the malignant passions kept alive by brutal treatment: and hence we now find amongst this class, the greatest proportion {117} of those whose minds have sunk into torpid inactivity; and not so much because they are lost, but because, from their want of excitement, they have too long continued in this motionless state. It is true, that their minds may, by the first attack, have undergone some great shock, to derange or paralyse the more perfect performance of its functions; but it is certain, that afterwards, no means were used to resuscitate or feed the powers of the mind into renewed vigour and activity. Few, even in the perfect possession of their faculties, could bear to be excluded from the air and sunshine of social life, and mingle only with beings in this melancholy state, without feeling its effects upon them. We are not to wonder, then, that those whose spirits have thus been prematurely entombed within them, should have become almost as dead to themselves and the world, as if the soul had already left them. To prevent these consequences, I shall state all that I think ought to be done, in another number of this work; which I conceive is the most interesting part in the treatment of insanity.

_No._ 3.—_Admitted_ 1787.

There is nothing on record about this case, nor have I been able to obtain any information of his previous history.

His mind is not in so defective or deranged a state, as strangers and superficial observers are, from appearances, apt to imagine. It is true, he seems stupid and churlish, always silent unless spoken to, and then he answers with abruptness and impatience, in a murmuring, grumbling, and almost unintelligible manner, putting his words oddly together, like a child, or one unused, or too lazy, to articulate, and not that his answers are absolutely irrational.

[Picture: No. 3 page 118]

He plays well at draughts and whist, but his doing so appears to depend more on old habits, {119a} than on the present exercise of his faculties; which, though, as already observed, they are not wholly lost, yet, from his torpor, age, and the natural obstinacy of his disposition, he is disinclined to exert himself out of his usual course: and though his constant habits of employment and amusement in the house, make up for him a considerable stock of felicity, and aid in procuring the degree of health and spirits he enjoys, and the degree of mind he still possesses; yet he is so extremely obstinate and tenacious of his own mode of procedure, that any attempts to oppose him, will arouse his temper into fits of angry passion. {119b}

OBSERVATION III.

There is nothing particular to observe here, unless it be the obvious remark, that from his age and confinement for such a number of years, among beings who, for the most part, have no commerce with right feelings and thoughts, it is wonderful that any thing like powers of mind should still remain; or that he should, excluded from the excitement and collision of the world, possess any inclination to exercise them; but this is most probably owing to the amusements and employments already stated; and for the sake of drawing attention to this fact, have I been induced to make any observation on this case.

_No._ 4.—_Admitted_ 1787.

There is no statement of this case on record; but I have been informed, it was the consequence of injury on the head. He is a hopeless, and the most striking, case of idiotcy, at present in the house: a poor, simple, innocent, dangling, pouting, starved-looking creature, with a bluish red nose, and his head hanging forwards, saliva running over his falling lip—generally moving about to gratify his childish curiosity. Yet, as little mind as there is about him, still even he has fluctuations of the animal spirits: sometimes he is depressed and miserable; at other times he is animated and happy. When depressed, he for the most part repeats, in a feeble, plaintive tone,—“poor creature.” When animated and happy, he will throw his arms about in a most laughable manner, to the great amusement of other patients; so much so, that it is impossible to convey any conception of it, unless it be by making an old person try to imitate the frisky movements of an infant’s arms. These exhibitions are of rare occurrence. He will mumble over a tune very correctly, {121a} but has seldom any words. He is pleased with striking objects, particularly such as have glaring colours about them; and women, or their dress, arrest his attention. {121b}

[Picture: No. 4 page 120]

_No._ 5.—_Admitted_ 1791.

There is likewise no statement of this case on record, from which any satisfactory information can be drawn.

His personal appearance, and moping manners, were so very like the case described, No. 2, that it was common for those in the house to mistake the one for the other. He, like many other old and incurable cases, sat in a solitary, half-dozing state, his head reclining against the fire-guard, and seemed, when roused, like one who wakened out of his sleep unrefreshed. He was most remarkable for his extreme good nature, and excellent disposition. {122a} When on his death-bed, his gratitude and affection to his attendant (who was certainly an excellent nurse) were very pleasing. He had been long sinking from disease of the lungs, constantly coughing and spitting; and, latterly, purulent matter, in a very great quantity. He died on the 13th April, 1822.

_No._ 6.—_Admitted_ 1791.

There is no statement of his case, and I have not been able to collect much information about him. It is said, he received a severe wound, and the mark remains on the upper back part of his head. {122b} Report says, that he fancied himself in love with a farmer’s daughter, and walked whole nights before her father’s door, without the slightest previous acquaintance with the object of his choice. This would seem rather the effect than the cause—a common mistake; they are constantly confounded together, or mistaken for each other. It is certain, that his neighbours were obliged to send him to a place of confinement, for this reason—whenever he saw any cattle in a poor pasture, he, from the impulse of his nature, invariably removed them into a better.

[Picture: No. 6 page 122]

He is well known through the house, and even through the town; and on this account, I feel some hesitation and difficulty in attempting to describe his case.

He is a general favourite, and every one meets him, and he meets every one, with a welcome, good-natured smile, and he appears so much pleased to entertain them with some extraordinary ridiculous tale, that a stranger would suppose he talked absurdly, on purpose to amuse him. {123} Notwithstanding all his talk, he is most industrious, and the most useful man in the house; does his work most correctly and systematically; delights in going upon errands amongst his acquaintances in town, always delivering the messages properly; and the moment he has done so, begins with his own strange nonsense, to the great delight of his hearers. His spirits are always even, he has regular exercise, and his good nature is proverbial; nothing vexes him, unless it be, threatening that another shall be employed instead of him, to do the work he has been in the habit of doing for his favourites in the house.—His delight is, night or day, to be of service to others, so that his energies are wholly and regularly expended in being useful, making himself happy, and pleasing all who come near him.

OBSERVATION IV.

Probably his astonishing correctness in delivering messages, &c., in the midst of so much apparent confusion of mind, may be thus explained:—From the pre-eminence of his good nature, the desire to please still retains some hold over the rest of his faculties, and, perhaps, also over the extreme extravagance of his conversation, which may arise from the same cause. We have only to imagine, that his erroneous tales were, in the first instance, listened to (a fact, this, of injudicious treatment, which is too common,) with seeming assent and delight, until he found, from daily experience, that to please others, he had only to encourage his foolish thoughts, and utter them, and then the habit would insensibly grow upon him, until it became inveterate; and hence is explained another singularity about him,—that in his present manner of talking, it appears as if he were talking absurdly for the very purpose of amusing others. It is now, however, certain, that it would be not only useless, but cruel, to try, by direct means, to prevent it. Yet, though we are not to tease and vex him, by contradiction, or by refusing to listen to his tales; it ought to be remembered, that in this and all other cases, we ought never, on any account, to violate the truth.

Though we should never forget to exercise prudence, we must be careful that truth still presides at the helm, otherwise it may degenerate into cunning; then what we call prudence, is vicious and mischievous; and yet, men persuade themselves while doing so, that some evil is avoided, or some good is secured. No power of the mind should ever be so exercised, as to require the suspension or sacrifice of another. To exercise every virtue in its place, and to give to each “its relative and appropriate share,” is the perfection at which we should ever aim. This principle, as it is the best prevention, so also it is the best remedy in the cure, of insanity.

_No._ 7.—_Admitted_ 1792.

No statement of this case, from which any information can be drawn: it is, however, certain, that insanity is in the family.

Among the old cases, we have none that arrests the attention of strangers so much as this, and he never fails to attract the gaze of idle curiosity. His habits of circumgyration, with sudden stops and starts,—his strange air of abstractedness, a sort of excogitative look, apparently puzzled to find something out,—odd way of talking to himself, as if he himself were some other person, saying, “what a noise the fellow makes,” “I think the fellow’s a fool,” and striking his face in apparent anger,—strange mode of mentioning names once familiar to him,—putting a question,—seeming to listen, and giving an answer quite foreign to it, are most striking, and such as no descriptive powers can enable another to conceive, without seeing him. When noticed or teased, and sometimes without, he strikes and scratches, in a way that would seem either like a bad habit that had been taught him; or half frolic and half mischief, and which, by provocation, becomes more serious; otherwise, he is sensible of kind treatment; and now, from increasing age, and perhaps from being, on the whole, less teased, he exhibits less of this disposition. This state of continued exertion and restlessness, is followed by a proportional degree of depression, and, after being recruited by sleep, returns. These regular alternate states of excitement and restlessness, of depression and sleep, last each for several days, and this for many years’ duration. When most excited, he makes a strange loud singing noise, stamps with his feet, strikes his head and face, and exhibits various incommunicable indications of surprise, pleasure, or anger, just as his mind happens to be agitated, like one in a dream, with the floating and shattered images of times gone by, passing confusedly through his mind.

OBSERVATION V.

I am unable to ascertain, from any traditionary treatment of this case, whether the habit of gyration originated in some diseased imagination; or was merely, as I believe is more frequently the case, a habit which he had acquired from long confinement in a small space. This habit was common in former times, when they were confined in cells, and had no airing grounds; and yet some writers, without attending to this circumstance, have called it a symptom common to insanity! in this way, many things have been called symptoms, which have been, in fact, indications of improper treatment. The peculiar states of excitement and depression, so striking in this case, and which is so common with the old insane, as to have been called the chronic type of the incurable, I shall endeavour to show, how, in many instances, it may be explained on a different principle.

Dr. Halloran, in his practical observations on Insanity, says,—“Chronic insanity is that form of the disease, which, having passed through the acute and convalescent stages, has assumed the more permanent character, and is known by the frequent exacerbation of the original accession; also, finally, under circumstances of less violence, and with symptoms subacute in relation to the primary affection.” He adds,—“There are few Practioners of the most ordinary discernment, who will not feel themselves disposed to acknowledge that cases of insanity, precisely of this form, compose the greater majority of those committed to their care.” He further says,—“That these paroxysms are for the most part periodical in their approach; for though of shorter duration, they continue pertinaciously unyielding.”

From the observations which I have to suggest, it will be seen, that I conceive in some instances, in opposition to Dr. Halloran, and some others, that the chronic type, or the paroxysms of some of the permanently insane, are merely an exhibition of the irregular increase in the stock of their animal spirits, and not an exacerbation or new accession of the disease: and that even, in many cases, where the alternating changes of excitement and depression are most striking, I believe they first originated in those fluctuations of the animal spirits, common to all of us; in some instances, it is true, (and the case last described is one,) singularly modified, not merely by the state of mental alienation, but by circumstances connected with their confinement. Before, however, I endeavour to explain these singular modifications, it appears necessary to premise some observations on one of the causes which conspires to produce them, which cause is connected with the atmosphere.