Part 4

To constitute madness, the minds of ignorant people expect a display of continued violence, and they are not satisfied that the person can be pronounced in that state, without they see him exhibit the pranks of a baboon, or hear him roar and bellow like a beast. By these people the patient is stated only to be intemperate; they confess that he does very foolish things when intoxicated; but that he is not mad, and only requires to be restrained from drinking. Thus, a man is permitted slowly to poison and destroy himself; to produce a state of irritation, which disqualifies him for any of the useful purposes of life; to squander his property amongst the most worthless and abandoned; to communicate a loathsome and disgraceful disease to a virtuous wife, and leave an innocent and helpless family to the meager protection of the parish. If it be possible, the law ought to define the circumstances, under which it becomes justifiable, to restrain a human being from effecting his own destruction, and involving his family in misery and ruin. When a man suddenly bursts through the barriers of established opinions; if he attempt to strangle himself with a cord, to divide his larger blood-vessels with a knife, or swallow a vial full of laudanum, no one entertains any doubt of his being a proper subject for the superintendance of keepers, but he is allowed, without control, by a gradual process, to undermine the fabric of his own health, and destroy the prosperity of his family.

All patients have not the same degree of memory of what has passed during the time they were disordered: and I have frequently remarked, when they were unable to give any account of the peculiar opinions which they had indulged, during a raving paroxysm of long continuance, that they well remembered any coercion which had been used, or any kindness which had been shewn them.

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, 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 supposed free from any mental derangement, in many strange and ridiculous movements, particularly if their minds be intently occupied:[7]--this does not appear to be so much the effect of habit, as of a particular state of mind.

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 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 two hundred and sixty-five who were examined, two hundred and five were of a swarthy complexion, with dark, or black hair; the remaining sixty were of a fair skin, and light, brown, or redhaired. What connexion this proportion may have, with the complexion and colour of the hair of the people of this country in general, and what alterations may have been produced by age, or a 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 in the cold weather 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.

From the great degree of insensibility which prevails in some states of madness, a degree of cold would scarcely be felt by such persons, which would create uneasiness in those of sound mind; but experience has shewn that they suffer equally from severity of weather. When the mind is particularly engaged on any subject, external circumstances affect us less than when unoccupied. Every one must recollect that, in following up a favourite pursuit, his fire has burned out, without his being sensible of the alteration of temperature; but when the performance has been finished, or he has become indifferent to it from fatigue, he then becomes sensible to cold, which he had not experienced before.

Some maniacs refuse all covering, but these are not common occurrences; and it may be presumed, that by a continued exposure to the atmosphere, such persons might sustain, with impunity, a low temperature, which would be productive of serious injury to those who are clad according to the exigences of the season. Such endurance of cold is more probably the effect of habit, than of any condition peculiar to insanity.

Having thus given a general account of the symptoms, I shall now lay before my readers a history of the appearances which I have noticed on opening the heads of several maniacs who have died in Bethlem Hospital.

CHAP. III.

CASES, WITH THE APPEARANCES ON DISSECTION.

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.[8] 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 arachnoidea; in the ventricles about four ounces of water were contained--some large hyatids 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 previously to his admission, and that he 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 recal 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 arachnoidea 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 26th, 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 very seldom slept--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 arachnoidea 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 arachnoidea 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.

C. M. a man, forty years of age, was admitted into the hospital, December 26, 1795. It was stated, that he had been disordered two months previously to his having been received as a patient. His friends were unacquainted with any cause, which was likely to have induced the disease. During the time he was in the house he seemed sulky, or rather stupid. He never asked any questions, and if spoken to, either replied shortly, or turned away without giving any answer. He scarcely appeared to take notice of any thing which was going forward, and if told to do any little office generally forgot what he was going about, before he had advanced half a dozen steps. He remained in this state until the beginning of May, 1796, when his legs became oedematous, and his abdomen swollen. He grew very feeble and helpless, and died rather suddenly, May 19th. He was opened about forty-eight hours after death. The pericranium and dura mater adhered firmly to the scull; in many places there was an opake whiteness of the tunica arachnoidea. About four ounces of water were found in the ventricles. The plexus choroides were uncommonly pale. The medullary substance afforded hardly any bloody points when cut into. The consistence of the brain I cannot describe better than by saying, it was doughy.

CASE XI.

S. M. a man, thirty-six years of age, was admitted as an incurable patient in the year 1790. Of the former history of his complaint I have no information. As his habits, which frequently came under my observation, were of a singular nature, it may not here be improper to relate them.--Having at some period of his confinement been mischievously disposed, and, in consequence, put under coercion, he never afterwards found himself comfortable when at liberty. When he rose in the morning he went immediately to the room where he was usually confined, and placed himself in a particular corner, until the keeper came to secure him. If he found any other patient had pre-occupied his situation, he became very outrageous, and generally forced them to leave it. When he had been confined, for which he appeared anxious, as he bore any delay with little temper, he employed himself throughout the remainder of the day, by tramping or shuffling his feet. He was constantly muttering to himself, of which scarcely one word in a sentence was intelligible. When an audible expression escaped him it was commonly an imprecation. If a stranger visited him, he always asked for tobacco, but seldom repeated his solicitation. He devoured his food with avidity, and always muttered as he ate.

In the month of July, 1796, he was seized with a diarrhoea, which afterwards terminated in dysentery. This continued, notwithstanding the employment of every medicine usually given in such a case, until his death, which took place on September 23, of the same year. He was opened twelve hours after death. The scull was unusually thin; the glandulae Pacchioni were large and numerous: there was a very general determination of blood to the brain: the medullary substance, when cut, shewed an abundance of bloody points: the lateral ventricles contained about four ounces of water: the consistence of the brain was natural.

CASE XII.

E. R. was a woman, to all appearance about eighty years of age, but of whose history, before she came into the hospital, it has not been in my power to acquire any satisfactory intelligence. She was an incurable patient, and had been admitted on that establishment in February, 1782.