Part 1

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OBSERVATIONS ON INSANITY.

OBSERVATIONS ON INSANITY:

WITH PRACTICAL REMARKS ON THE DISEASE, AND AN ACCOUNT OF THE MORBID APPEARANCES ON DISSECTION.

BY JOHN HASLAM,

LATE OF PEMBROKE-HALL, CAMBRIDGE, MEMBER OF THE CORPORATION OF SURGEONS, AND APOTHECARY TO BETHLEM-HOSPITAL.

"Of the uncertainties of our present state the most dreadful and alarming is the uncertain continuance of reason." Dr. JOHNSON's Rasselas.

London:

PRINTED FOR F. AND C. RIVINGTON, NO. 62, ST. PAUL'S CHURCH-YARD; AND SOLD BY J. HATCHARD, NO. 173, PICCADILLY. 1798.

TO THE RIGHT WORSHIPFUL THE _PRESIDENT_, THE WORSHIPFUL THE _TREASURER, AND GOVERNORS_ OF BETHLEM-HOSPITAL.

MY LORDS AND GENTLEMEN,

The following OBSERVATIONS are respectfully submitted to YOUR notice, as the vigilant and humane Guardians of an _Institution_ which performs much good to society, by diminishing the SEVEREST amongst human calamities,

By, My LORDS and GENTLEMEN,

Your very obedient and humble Servant, THE AUTHOR.

PREFACE.

As the office I hold affords me abundant means of acquiring information on the subject of mental disorders, I should feel myself unworthy of that situation, were I to neglect any opportunity of accumulating such knowledge, or of communicating to the public any thing which might promise to be of advantage to mankind. The candid reader is therefore requested to accept this sentiment, as the best apology I can offer for the present production.

It has been somewhere observed, that in our own country more books on Insanity have been published than in any other; and, if the remark be just, it is certainly discouraging to him who proposes to add to their number. It must, however, be acknowledged, that we are but little indebted to those who have been most capable of affording us instruction; for, if we except the late Dr. JOHN MONRO'S Reply to Dr. BATTIE'S Treatise on Madness, there is no work on the subject of mental alienation which has been delivered on the authority of extensive observation and practice.

It is not intended to present the following sheets as a treatise, or compleat disquisition on the subject, but merely as remarks, which have occurred during the treatment of several hundred patients. As a knowledge of the structure, and functions of the body, have been held indispensably necessary in order to become acquainted with its diseases, and to a scientific mode of treating them; so it would appear, that he who proposes to write on Madness should be well informed concerning the powers and operations of the human mind: but the various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes.

As some very erroneous notions have been entertained concerning the state of the brain, and more especially respecting its consistence in maniacal disorders, I have been induced to examine that viscus in those who have died insane, and have endeavoured with accuracy to report the appearances. It seemed proper to give some general history of these cases; perhaps the account which has been related of their erroneous opinions might have been spared, yet some friends whom I consulted expressed a wish that they had been more copiously detailed.

Of the difficulty of enumerating the remote causes of the disease I have been fully aware, and have mentioned but few, that I might be accused of the fewer mistakes. The prognosis contains some facts which, as far as I am informed, have not hitherto been made known, and appear to me of sufficient importance to be communicated to the public.

As it is my intention at some future period to attempt a more finished performance on the subject of Insanity, I shall feel grateful for any hints or observations, with which the kindness of professional gentlemen may supply me.

BETHLEM-HOSPITAL, MARCH 14, 1798.

OBSERVATIONS ON INSANITY.

CHAP. I.

Readers in general require a definition of the subject, which an author proposes to treat of; it is the duty therefore of every writer, to define, as clearly as he is able, that which he professes to elucidate.

A definition of a disease, should be a concentrated history, a selection of its prominent features and discriminative symptoms.

Of the definitions which have been given of this disease, some appear too contracted; and others not sufficiently precise.

Dr. Mead, after having treated largely upon the subject, concludes, "That this disease consists entirely in the strength of imagination." If the disease consisted entirely in the strength of imagination, the imagination ought to be equally strong upon all subjects, which upon accurate observation is not found to be the case. Had Dr. Mead stated, that, together with this increased strength of imagination, there existed an enfeebled state of the judgment, his definition would have been more correct. The strength, or increase of any power of the mind, cannot constitute a disease of it; strength of memory, has never been suspected to produce derangement of intellect; neither is it conceived, that great vigour of judgment can operate in any such manner; on the contrary it will readily be granted, that imbecility of memory must create confusion, by obstructing the action of the other powers of the mind; and that if the judgment be impaired, a man must necessarily speak, and generally act, in a very incorrect and ridiculous manner.

Dr. Ferriar, whom, to mention otherwise than as a man of genius, of learning, and of taste, would be unjust; has adopted the generally accepted division of Insanity, into Mania and Melancholy. In Mania, he conceives "false perception, and consequently confusion of ideas, to be a leading circumstance." The latter, he supposes to consist "in intensity of idea, which is a contrary state to false perception." From the observations I have been able to make respecting Mania, I have by no means been led to conclude, that false perception, is a leading circumstance in this disorder, and still less, that confusion of ideas must be the necessary consequence of false perception.

By perception, I understand, with Mr. Locke, the apprehension of sensations; and after a very diligent enquiry of patients who have recovered from the disease, and from an attentive observation of those labouring under it, I have not frequently found, that insane people perceive falsely, the objects which have been presented to them. It is true, that they all have false ideas, but this by no means infers, a defect of the power by which sensations are apprehended in the mind.

We find madmen equally deranged upon those ideas, which they have been long in the possession of, and on which the perception has not been recently exercised, as respecting those, which they have lately received: and we frequently find those who become suddenly mad, talk incoherently upon every subject, and consequently, upon many, on which the perception has not been exercised for a considerable time.

It is well known, that maniacs often suppose they have seen, and heard those things, which really did not exist at the time; but even this I should not explain by any disability, or error of the perception, since it is by no means the province of the perception to represent unreal existences to the mind. It must therefore be sought elsewhere, probably in the senses, or in the imagination.

I have known eight cases of patients, who insisted that they had seen the devil. It might be urged, that in these instances, the perception was vitiated; but it must be observed, that there could be no perception of that, which was not present and existing at the time. Upon desiring these patients to describe what they had seen, they all represented him as a big, black man, with a long tail, cloven feet, and sharp talons, such as is seen pictured in books. A proof that the idea was revived in the mind from some former impressions. One of these patients however carried the matter a little further, as she solemnly declared, she heard him break the iron chain with which God had confined him, and saw him pass fleetly by her window, with a truss of straw upon his shoulder.

It must be acknowledged, that in the soundest state of our faculties we sometimes perceive things which do not exist. If the middle finger be crossed over the forefinger, and a single pea be rolled under their extremities, we have the perception of _two_. By immersing one hand into warm, the other into cold water, and afterwards suddenly plunging them both into the same fluid, of a medium temperature, we shall derive the sensations of heat, and cold from the same water, at the same time.

The power, by which the mind perceives its own creations and combinations is perhaps the same, as that by which it perceives the impressions on the senses from external objects. We possess the faculty of raising up of objects in the mind which we had seen before, and of prospects, on which we had formerly dwelt, with admiration and delight; and in the coolest state of our understanding we can even conceive that they lie before us. If the power which awakens these remembrances in a healthy state of intellect, should stir up distorted combinations in disease, they must necessarily be perceived; but their apprehension, by no means appears to imply a vitiated state of the faculty by which they are perceived. In fact, that which is represented to the mind, either by a defect or deception of the senses, or by the imagination, if it be sufficiently forcible and enduring, must necessarily be perceived.

That "confusion of ideas" should be the necessary consequence of false perception, is very difficult to admit. Perhaps much may depend, in the discussion of this point, on the various acceptations in which confusion of ideas may be understood.

It has often been observed that madmen, will frequently reason correctly from false premises, and the observation is certainly true: we have indeed occasion to notice the same thing in those of the soundest minds. It is very possible for the perception to be deceived in the occurrence of a thing, which, although it did not actually happen, yet was likely to take place; and which had frequently occurred before. The reception of this as a truth in the mind, if the power of deducing from it the proper inferences existed, could neither create confusion, nor irregularity of ideas.

Melancholy, the other form in which this disease is supposed to exist, is made by Dr. Ferriar to consist in "intensity of idea." I shall shortly have an opportunity, in the definition I propose to give, of attempting to prove, that this division of Insanity, is neither natural nor just, upon the ground that the derangement is equally complete in both forms of the disease. We ought to attend more to the state of the intellect, than to the passions which accompany the disorder.

By intensity of idea, I presume is meant, that the mind is more strongly fixed on, or more frequently recurs to, a certain set of ideas, than when it is in a healthy state. But this definition applies equally to mania, for we every day see the most furious maniacs suddenly sink into a profound melancholy; and the most depressed, and miserable objects, become violent and raving. We have patients in Bethlem Hospital, whose lives are divided between furious, and melancholic paroxisms; and who, under both states, retain the same set of ideas.

Insanity may, in my opinion, be defined to be _an incorrect association of familiar ideas, which is independent of the prejudices of education, and is always accompanied with implicit belief, and generally with either violent or depressing passions_. It appears to me necessary, that the ideas incorrectly associated, should be _familiar_, because we can hardly be said to have our ideas deranged upon subjects, concerning which we have little or no information. A peasant, who had heard that superior comforts of life, with fewer exertions, were to be obtained by emigrating to America, might saddle his beast with an intention of riding thither on horse-back, without any other imputation than that of ignorance; but if an old and experienced navigator, were to propose a similar mode of conveyance, I should have little hesitation in concluding him insane.

Respecting the prejudices of education, it may be observed, that in our childhood, and before we are able to form a true, and accurate judgment of things, we have impressed upon our minds, a number of ideas which are ridiculous; but which were the received opinions of the place in which we then lived, and of the people who inculcated them; such is the belief in the powers of witchcraft, and in ghosts, and superstitions of every denomination, which grasp strongly upon the mind and seduce its credulity. There are many honest men in this kingdom who would not sleep quietly, if a vessel filled with quicksilver were to be brought into their houses; they would perhaps feel alarmed for the chastity of their wives and daughters; and this, because they had been taught to consider that many strange and unaccountable properties are attached to that metal. If a lecturer on chemistry were to exhibit the same fears, there could be no doubt that he laboured under a disorder of intellect, because the properties of mercury would be known to him, and his alarms would arise from incorrectly associating ideas of danger, with a substance, which in that state is innoxious, and whose properties come within the sphere of his knowledge.

As the terms Mania, and Melancholy, are in general use, and serve to distinguish the forms under which insanity is exhibited, there can be no objection to retain them; but I would strongly oppose their being considered as opposite diseases. In both, the association of ideas is equally incorrect, and they appear to differ only, from the different passions which accompany them. On dissection, the state of the brain does not shew any appearances peculiar to melancholy; nor is the treatment which I have observed most successful, different from that which is employed in Mania.

CHAP. II.

SYMPTOMS OF THE DISEASE.

With most authors, this part of the subject has occupied the greatest share of their labour and attention: they have generally descended to minute particularities and studied discriminations. Distinctions have been created, rather from the peculiar turn of the patients propensities and discourse, than from any marked difference, in the varieties, and species of the disorder: and it has been customary to ornament this part of the work with copious citations from poetical writers. As my plan extends only to a description of that which I have observed, I shall neither amplify, nor embellish my volume by quotations.

In most public hospitals, the first attack of diseases is seldom to be observed; and it might naturally be supposed, that there existed in Bethlem, similar impediments to an accurate knowledge of madness. It is true, that all who are admitted into it have been a greater, or less time afflicted with the complaint; yet from the occasional relapses to which insane persons are subject, we have frequent and sufficient opportunities of observing the beginning, and tracing the progress of this disease.

Among the incurables, there are some who have intervals of perfect soundness of mind; but who are subject to relapses, which would render it improper, and even dangerous, to trust them at large in society: and with those who are upon the curable list, a recurrence of the malady very frequently takes place. Upon these occasions, there is ample scope for observing the first attack of the disease.

To enumerate every symptom would be descending to useless minutiae, I shall therefore content myself with describing the more general appearances.

They first become uneasy, are incapable of confining their attention, and neglect any employment to which they have been accustomed; they get but little sleep, they are loquacious, and disposed to harangue, and decide promptly, and positively upon every subject that may be started. Soon after, they are divested of all restraint in the declaration of their opinions of those, with whom they are acquainted. Their friendships are expressed with fervency and extravagance; their enmities with intolerance and disgust. They now become impatient of contradiction, and scorn reproof. For supposed injuries, they are inclined to quarrel, and fight with those about them. They have all the appearance of persons inebriated, and people unacquainted with the symptoms of approaching mania, generally suppose them to be in a state of intoxication. At length suspicion creeps in upon the mind, they are aware of plots which had never been contrived, and detect motives that were never entertained. At last, the succession of ideas is too rapid to be examined; the mind becomes crouded with thoughts, and indiscriminately jumbles them together.

Those under the influence of the depressing passions, will exhibit a different train of symptoms. The countenance, wears an anxious and gloomy aspect. They retire from the company of those with whom they had formerly associated, seclude themselves in obscure places, or lie in bed the greatest part of their time. They next become fearful, and, when irregular combinations of ideas have taken place, conceive a thousand fancies: often recur to some former immoral act which they have committed, or imagine themselves guilty of crimes which they never perpetrated; believe that God has abandoned them, and with trembling, await his punishment. Frequently they become desperate, and endeavour by their own hands to terminate an existence, which appears to be an afflicting and hateful incumbrance.

The sound mind seems to consist in a harmonized association of its different powers, and is so constituted, that a defect, in any one, produces irregularity, and, most commonly, derangement of the whole. The different forms therefore under which we see this disease, might not, perhaps, be improperly arranged according to the powers which are chiefly affected.

I have before remarked, that the increased vigor of any mental faculty cannot constitute intellectual disease. If the memory of a person were so retentive, that he could re-assemble the whole of what he had heard, read, and thought, such a man, even with a moderate understanding, would pass through life with reputation and utility. Suppose another to possess a judgment, so discriminating and correct, that he could ascertain precisely, the just weight of every argument; this man would be a splendid ornament to human society. Let the imagination of a third, create images and scenes, which mankind should ever view with rapture and astonishment, such a phaenomenon would bring Shakespear to our recollection.

If in a chain of ideas, a number of the links are broken, the mind cannot possess any accurate information. When patients of this description are asked a question, they appear as if awakened from a sound sleep; they are searching, they know not where, for the proper materials of an answer, and, in the painful, and fruitless efforts of recollection, generally lose sight of the question itself.

In persons of sound mind, as well as in maniacs, the memory is the first power which decays, and there is something remarkable in the manner of its decline. The transactions of the latter part of life are feebly recollected, whilst the scenes of youth, and of manhood, remain more strongly impressed. To many conversations of the old incurable patients to which I have listened, the topic has always turned upon the scenes of early days. In many cases, where the faculties of the mind have been injured by intemperance, the same withering of the recollection may be observed. It may perhaps arise, from the mind at an early period of life being most susceptible and retentive of impressions, and from a greater disposition to be pleased with the objects which are presented: whereas, the cold caution, and fastidiousness with which age surveys the prospects of life, joined to the dulness of the senses, and the slight curiosity which prevails, will, in some degree, explain the difficulty, or rather impossibility, of recalling the history of later transactions.

Insane people who have been good scholars, after a long confinement lose, in a wonderful degree, the correctness of orthography; when they write, above half the words are generally mis-spelt--they are written according to the pronunciation. It shews how treacherous the memory is without reinforcement. The same necessity of a constant recruit and frequent review of our ideas, satisfactorily explains, why a number of patients lapse nearly into a state of ideotism. These have, for some years, been the silent and gloomy inhabitants of the Hospital, who have avoided conversation, and sought solitude; consequently have acquired no new ideas, and time has effaced the impression of those formerly stamped upon the mind. Mr. Locke well observes, "that there seems to be a constant decay of all our ideas, even of those which are struck deepest, and in minds the most retentive; so that if they be not sometimes renewed, by repeated exercise of the senses, or reflection on those kind of objects, which at first occasioned them; the print wears out, and at last there remains nothing to be seen."

As it has been attempted to explain, how an imbecility or loss of memory will obstruct the operation of the other powers of the mind: the next object is to shew, how necessarily our ideas must be disarranged where the determination on their comparison is wrong, or where the mind determines, or judges, with little previous examination or comparison. An example or two will illustrate this more satisfactorily than any length of reasoning. I remember a patient who conceived, that, although dead men told no tales, yet their feeling was very acute. This assumed principle he extended to inferior animals, and refused to eat meat, because he could not endure to be nourished at the expence of the cruel sufferings, which beef steaks necessarily underwent in their cookery. Another madman, who pretended to extraordinary skill in surgery, contrived to steal the wooden leg of an insane patient, and laid upon it for a considerable time, with a firm belief of hatching it into a limb of flesh and blood.

If a man shall form such ideas, and conceive them to be true, either from a defect in the power of his judgment, or without any comparison or examination shall infer them to be so, such defect will afford a sufficient source of derangement.

Some who have perfectly recovered from this disease, and who are persons of good understanding and liberal education, describe the state they were in as resembling a dream; and, when they have been told how long they were disordered, have been astonished that the time passed so rapidly away. Others speak of their disorder as accompanied with great hurry and confusion of mind, where the succession of ideas is so rapid and evanescent, that when they have endeavoured to arrest or contemplate any particular thoughts, they have been carried away by the tide, which was rolling after them.

All patients have not the same degree of memory of what has passed during the time they were disordered: but for the most part they recollect those ideas which were transmitted through the medium of the senses, better than the combinations of their own minds. I have frequently remarked that, when they were unable to give any account of the peculiar opinions which they had indulged during a raving paroxysm of long continuance, they well remembered any coercion which had been used, or any kindness which had been shewn them.