Part 2

Insane people are said to be generally worse in the morning; in some cases they certainly are so, but perhaps not so frequently as has been supposed. In many instances (and, as far as I have observed) in the beginning of the disease they are more violent in the evening, and continue so the greatest part of the night. It is however a certain fact, that the majority of patients of this description have their symptoms aggravated, by being placed in a recumbent posture.

They seem themselves to avoid the horizontal position as much as possible when they are in a raving state: and when so confined that they cannot be erect, they will keep themselves seated upon the breech.

Many of those who are violently disordered will continue particular actions for a considerable time: some are heard to gingle the chain, with which they are confined, for hours without intermission; others, who are secured in an erect posture, will beat the ground with their feet the greatest part of the day. Upon enquiry of such patients, after they have recovered, they have assured me, that these actions afforded them considerable relief. We often surprize persons who are free from intellectual disease in many strange and ridiculous movements, particularly if their minds be intently occupied:--this does not appear to be the effect of habit, but of a particular state of mind.

Madmen do not always continue in the same furious or depressed states: the maniacal paroxysm abates of its violence, and some beams of hope occasionally cheer the despondency of the melancholick patients. We have some unfortunate persons who are obliged to be secured the greatest part of their time, but who now and then become calm, and to a certain degree rational: upon such occasions, they are allowed a greater range, and are permitted to associate with the others. In some instances, the degree of rationality is more considerable; they conduct themselves with propriety, and in a short conversation will appear sensible and coherent. Such remission, has been generally termed a _lucid interval_.

When medical men are called upon to attend a commission of lunacy, they are always asked, whether the patient has had a _lucid interval_? A term of such latitude as _interval_ requires to be explained in the most perspicuous and accurate manner. In common language it is made to signify, both a moment and a number of years, consequently it does not comprize any stated time. The term _lucid interval_ is therefore relative. I should define a _lucid interval_ to be _a complete recovery of the patient's intellects, ascertained by repeated examinations of his conversation, and by constant observation of his conduct, for a time sufficient to enable the superintendant to form a correct judgment_. Unthinking people are frequently led to conclude that, if during a conversation of a few minutes, a person under confinement shall betray nothing absurd or incorrect, he is well, and often remonstrate on the injustice of secluding him from the world. Even in common society, there are many persons whom we never suspect from a few trifling topics of discourse to be shallow minded; but, if we start a subject, and wish to discuss it through all it's ramifications and dependances we find them incapable of pursuing a connected chain of reasoning. In the same manner, insane people will often, for a short time, conduct themselves, both in conversation and behaviour, with such propriety, that they appear to have the just exercise and direction of their faculties; but let the examiner protract the discourse, until the favourite subject shall have got afloat in the madman's brain, and he will be convinced of the hastiness of his decision. To those unaccustomed to insane people, a few coherent sentences, or rational answers would indicate a lucid interval, because they discover no madness; but he who is in possession of the peculiar turn of the patient's thoughts, might lead him to disclose them, or by a continuance of the conversation they would spontaneously break forth. A beautiful illustration of this is contained in the Rasselas of Dr. Johnson: where the astronomer is admired as a person of sound intellect and great acquirements by Imlac, who is himself a philosopher, and a man of the world. His intercourse with the astronomer is frequent; and he always finds in his society information and delight. At length he receives Imlac into the most unbounded confidence, and imparts to him the momentous secret. "Hear Imlac what thou wilt not without difficulty credit. I have possessed for five years the regulation of weather, and the distribution of the seasons. The sun has listened to my dictates, and passed from tropic to tropic by my direction. The clouds at my call have poured their waters, and the Nile has overflowed at my command. I have restrained the rage of the Dog-star, and mitigated the fervours of the Crab. The winds alone of all the elemental powers have hitherto refused my authority, and multitudes have perished by equinoctial tempests, which I found myself unable to prohibit or restrain. I have administered this great office with exact justice, and made to the different nations of the Earth an impartial dividend of rain and sunshine. What must have been the misery of half the globe, if I had limited the clouds to particular regions, or confined the sun to either side of the equator?"

A real case came under my observation a few months ago, and which is equally apposite to the subject. A young man had become insane from habitual intoxication, and during the violence of his complaint had attempted to destroy himself. Under a supposed imputation of having unnatural dispositions he had amputated his penis, with a view of precluding any future insinuations of that nature. For many months after he was admitted into the hospital, he continued in a state which obliged him to be strictly confined, as he constantly meditated his own destruction. On a sudden he became apparently well, was highly sensible of the delusion under which he had laboured, and conversed as any other person upon the ordinary topics of discourse. There was, however, something in the reserve of his manner, and peculiarity of his look, which persuaded me that he was not well, although no incoherence of ideas could be detected in his conversation. I had observed him for some days to walk rather lame, and once or twice had noticed him sitting with his shoes off, rubbing his feet. On enquiring into the motives of his doing so, he replied, that his feet were blistered, and wished that some remedy might be applied to remove the vesications. When I requested to look at his feet, he declined it and prevaricated, saying, that they were only tender and uncomfortable. In a few days afterwards, he assured me they were perfectly well. The next evening I observed him, unperceived, still rubbing his feet, and then peremptorily insisted on examining them. They were quite free from any disorder. He now told me with some embarrassment, that he wished much for a confidential friend, to whom he might impart a secret of importance. Upon assuring him that he might trust me, he said, that the boards on which he walked, (the second story) were heated by subterraneous fires, under the direction of invisible and malicious agents, whose intentions, he was well convinced, were to consume him by degrees.

From these considerations I am inclined to think, that a _lucid interval_ includes all the circumstances which I have enumerated in my definition of it. If the person who is to examine the state of the patient's mind be unacquainted with his peculiar opinions, he may be easily deceived, because, wanting this information, he will have no clue to direct his enquiries, and madmen do not always, nor immediately intrude their incoherent notions into notice. They have sometimes such a high degree of controul over their minds, that when they have any particular purpose to carry, they will affect to renounce those opinions which shall have been judged inconsistent: and it is well known that they have often dissembled their resentment, until a favourable opportunity has occurred of gratifying their revenge.

Among the bodily particularities which mark this disease, may be observed the protruded, and oftentimes glistening eye, and a peculiar cast of countenance which, however, cannot be described. In some, an appearance takes place which has not hitherto been noticed by Authors. This is a relaxation of the integuments of the cranium, by means of which they may be wrinkled, or rather gathered up by the hand to a considerable degree. It is generally most remarkable on the posterior part of the scalp; as far as my enquiries have reached, it does not take place in the beginning of the disease, but after a raving paroxysm of some continuance. It has been frequently accompanied with contraction of the iris.

On the suggestion of a medical gentleman, I was induced to ascertain the prevailing complexion and colour of the hair in insane patients. Out of 265 who were examined, 205 were of a swarthy complection, with dark, or black hair; the remaining 60 were of a fair skin, and light, brown, or red haired. What connection this proportion may have with the complection and colour of the hair of the people of this country in general, and what alterations may have been produced by age or residence in other climates, I am totally uninformed.

Of the power which maniacs possess of resisting cold the belief is general, and the histories which are on record are truly wonderful. It is not my wish to disbelieve, nor my intention to dispute them; it is proper, however, to state, that the patients in Bethlem hospital possess no such exemption from the effects of severe cold. They are particularly subject to mortifications of the feet; and this fact is so well established from former accidents, that there is an express order of the house, that every patient, under strict confinement, shall have his feet examined morning and evening by the keeper, and also have them constantly wrapped in flannel; and those who are permitted to go about are always to be found as near to the fire as they can get, during the winter season.

Having thus given a general account of the symptoms which I have observed to occur most commonly in persons affected with madness, I shall now lay before my readers a history of all the appearances which I have noticed on opening the heads of several maniacs, who have died in Bethlem Hospital.

CASE I.

J. H. a man twenty-eight years of age, was admitted a patient in May 1795. He had been disordered for about two months before he came into the hospital. No particular cause was stated to have brought on the complaint. It was most probably an hereditary affection, as his father had been several times insane and confined in our hospital. During the time he was in the house, he was in a very low and melancholic state; shewed an aversion to food, and said he was resolved to die. His obstinacy in refusing all nourishment was very great, and it was with much difficulty forced upon him. He continued in this state, but became daily weaker and more emaciated until August 1st when he died. Upon opening the head, the pericranium was found loosely adherent to the scull. The bones of the cranium were thick. The pia mater was loaded with blood, and the medullary substance, when cut into, was full of bloody points. The pineal gland contained a large quantity of gritty matter[1]. The consistence of the brain was natural; he was opened twenty-four hours after death.

CASE II.

J. W. was a man of sixty-two years of age, who had been many years in the house as an incurable patient, but with the other parts of whose history I am totally unacquainted. He appeared to be a quiet and inoffensive person, who found amusement in his own thoughts, and seldom joined in any conversation with the other patients: for some months he had been troubled with a cough, attended with copious expectoration, which very much reduced him; dropsical symptoms followed these complaints. He became every day weaker, and on July 10th, 1795, died. He was opened eighteen hours after death. The pericranium adhered loosely to the scull; the bones of the cranium were unusually thin. There were slight opacities in many parts of the tunica arachnoides; in the ventricles about four ounces of water were contained--some large hydatids were discovered on the plexus choroides of the right side. The consistence of the brain was natural.

CASE III.

G. H. a man twenty-six years of age, was received into the hospital July 18th, 1795. It was stated that he had been disordered six weeks previous to his admission, and that he had never had any former attack. He had been a drummer with a recruiting party, and had been for some time in the habit of constant intoxication, which was assigned as the cause of his insanity. He continued in a violent and raving state about a month, during the whole of which time he got little or no sleep. He had no knowledge of his situation but supposed himself with the regiment, and was frequently under great anxiety and alarm for the loss of his drum, which he imagined had been stolen and sold. The medicines which were given to him he conceived were spirituous liquors, and swallowed them with avidity. At the expiration of a month, he was very weak and reduced; his legs became oedematous--his pupils were much diminished. He now believed himself a child, called upon the people about him as his playfellows, and appeared to recall the scenes of early life with facility and correctness. Within a few days of his decease he only muttered to himself. August 26th, he died. He was opened six hours after death. The pericranium was loosely adherent. The tunica arachnoides had generally lost its transparency, and was considerably thickened. The veins of the pia mater were loaded with blood, and in many places seemed to contain air. There was a considerable quantity of water between the membranes, and as nearly as could be ascertained about four ounces in the ventricles, in the cavity of which, the veins appeared remarkably turgid. The consistence of the brain was more than usually firm.

CASE IV.

E. M. a woman, aged sixty, was admitted into the house, August 8th, 1795; she had been disordered five months; the cause assigned was extreme grief, in consequence of the loss of her only daughter. She was very miserable and restless; conceived she had been accused of some horrid crime, for which she apprehended she should be burned alive. When any persons entered her room she supposed them officers of justice, who were about to drag her to some cruel punishment. She was frequently violent, and would strike and bite those who came near her. Upon the idea that she should shortly be put to death, she refused all sustenance; and it became necessary to force her to take it. In this state she continued, growing daily weaker and more emaciated, until October 3d, when she died.

Upon opening the head there was a copious determination of blood to the whole contents of the cranium. The pia mater was considerably inflamed; there was not any water either in the ventricles or between the membranes. The brain was particularly soft. She was opened thirty hours after death.

CASE V.

W. P. a young man aged twenty-five, was admitted into the hospital September 26, 1795. He had been disordered five months, and had experienced a similar attack six years before. The disease was brought on by excessive drinking. He was in a very furious state, in consequence of which he was constantly confined. He got little or no sleep--during the greater part of the night he was singing, or swearing, or holding conversations with persons he imagined to be about him: sometimes he would rattle the chain with which he was confined for several hours together, and tore every thing to pieces within his reach. In the beginning of November the violence of his disorder subsided for two or three days, but afterwards returned; and on the 10th he died compleatly exhausted by his exertions.--Upon opening the head the pericranium was found firmly attached; the pia mater was inflamed, though not to any very considerable degree; the tunica arachnoides in some places was slightly shot with blood; the membranes of the brain, and its convolutions when these were removed, were of a brown, or brownish straw colour. There was no water in any of the cavities of the brain, nor any particular congestion of blood in its substance--the consistence of which was natural. He was opened twenty hours after death.

CASE VI.

B. H. was an incurable patient, who had been confined in the house from the year 1788, and for some years before that time in a private madhouse. He was about sixty years of age--had formerly been in the habit of intoxicating himself. His character was strongly marked by pride, irascibility, and malevolence. During the four last years of his life he was confined for attempting to commit some violence on one of the officers of the house. After this he was seldom heard to speak; yet he manifested his evil disposition by every species of dumb insult. Latterly he grew suspicious, and would sometimes tell the keeper that his victuals were poisoned. About the beginning of December he was taken ill with a cough, attended with copious expectoration. Being then asked respecting his complaints, he said he had a violent pain across the stomach, which arose from his navel string at his birth having been tied too short. He never spoke afterwards, though frequently importuned to describe his complaints. He died December 24, 1795.

Upon dividing the integuments of the head, the pericranium was found scarcely to adhere to the scull. On the right parietal bone there was a large blotch, as if the bone had been inflamed: there were others on different parts of the bone, but considerably smaller. The glandulae Pacchioni were uncommonly large: the tunica arachnoides in many places wanted the natural transparency of that membrane: there was a large determination of blood to the substance of the brain: the ventricles contained about three ounces of water; the consistence of the brain was natural. He was opened two days after death.

CASE VII.

A. M. a woman aged twenty-seven, was admitted into the hospital August 15, 1795; she had then been eleven weeks disordered. Religious enthusiasm, and a too frequent attendance on conventicles, were stated to have occasioned her complaint. She was in a very miserable and unhappy condition, and terrified by the most alarming apprehensions for the salvation of her soul. Towards the latter end of September she appeared in a convalescent state, and continued tolerably well until the middle of November, when she began to relapse.

The return of her disorder commenced with loss of sleep. She alternately sang, and cried the greatest part of the night. She conceived her inside full of the most loathsome vermin, and often felt the sensation as if they were crawling into her throat. She was suddenly seized with a strong and unconquerable determination to destroy herself; became very sensible of her malady, and said, that God had inflicted this punishment on her, from having (at some former part of her life) said the Lord's Prayer backwards. She continued some time in a restless and forlorn state; at one moment expecting the devil to seize upon her and tear her to pieces; in the next, wondering that she was not instigated to commit violence on the persons about her. On January 12, 1796, she died suddenly. She was opened twelve hours after death. The thoracic and abdominal viscera were perfectly healthy.

Upon examining the contents of the cranium, the pia mater was considerably inflamed, and an extravasated blotch, about the size of a shilling, was seen upon that membrane, near the middle of the right lobe of the cerebrum. There was no water between the membranes, nor in the ventricles, but a general determination of blood to the contents of the cranium. The medullary substance when cut into was full of bloody points. The consistence of the brain was natural.

CASE VIII.

M. W. a very tall and thin woman, forty-four years of age, was admitted into the hospital September 19, 1795. Her disorder was of six months standing, and eight years before she had also had an attack of this disease. The cause assigned to have brought it on, the last time, was the loss of some property, the disease having shortly followed that circumstance. The constant tenor of her discourse was, that she should live but a short time. She seemed anxiously to wish for her dissolution, but had no thoughts of accomplishing her own destruction. In the course of a few weeks she began to imagine, that some malevolent person had given her mercury with an intention to destroy her. She was constantly shewing her teeth, which had decayed naturally, as if this effect had been produced by that medicine: at last she insisted, that mercurial preparations were mingled in the food and medicines which were administered to her. Her appetite was voracious notwithstanding this belief. She had a continual thirst, and drank very large quantities of cold water.

On January 14, 1796, she had an apoplectic fit, well marked by stertor, loss of voluntary motion, and insensibility to stimuli. On the following day she died. She was opened two days after death. There was a remarkable accumulation of blood in the veins of the dura and pia mater; the substance of the brain was loaded with blood. When the medullary substance was cut into blood oozed from it; and upon squeezing it a greater quantity could be forced out. On the pia mater covering the right lobe of the cerebrum, were some slight extravasations of blood. The ventricles contained no water; on the plexus choroides were some vesicles of the size of coriander-seeds, filled with a yellow fluid. The pericranium adhered firmly to the scull. The consistence of the brain was firmer than usual.

CASE IX.

E. D. a woman aged thirty-six, was admitted into the hospital February 20, 1795: she had then been disordered four months. Her insanity came on a few days after having been delivered. She had also laboured under a similar attack seven years before, which, like the present, supervened upon the birth of a child. Under the impression that she ought to be hanged, she destroyed her infant, with the view of meeting with that punishment. When she came into the house, she was very sensible of the crime she had committed, and felt the most poignant affliction for the act. For about a month she continued to amend: after which time she became more thoughtful, and frequently spoke about the child: great anxiety and restlessness succeeded. In this state she remained until April 23, when her tongue became thickly furred, the skin parched, her eyes inflamed and glassy, and her pulse quick. She now talked incoherently; and, towards the evening, merely muttered to herself. She died on the following day comatose.

She was opened about twenty-four hours after death. The scull was thick, the pericranium scarcely adhered to the bone, the dura mater was also but slightly attached to its internal surface. There was a large quantity of water between the dura mater and tunica arachnoidea; this latter membrane was much thickened, and was of a milky white appearance. Between the tunica arachnoidea and pia mater, there was a considerable accumulation of water. The veins of the pia mater were particularly turgid. About three ounces of water were contained in the lateral ventricles: the veins of the membrane lining these cavities were remarkably large and turgid with blood. When the medullary substance of the cerebrum and cerebellum was cut into, there appeared a great number of bloody points. The brain was of its natural consistence.

CASE X.