Part 9

His friends and acquaintances now began to perceive a considerable alteration in his temper; though naturally diffident, he had assumed a high degree of literary importance, and plumed himself on the extent of his learning. Before this excessive, but ill-directed application, he was a strict relator of the truth, but he now found a convenience in supplying by fancy, that, which the indigence of his memory was unable to afford. Shortly he began to complain that he could not sleep, and that the long night was passed in shifting from side to side.

"Lasso, ch'n van te chiamo, et queste oscure, Et gelide ombre in van lusingo: o piume D'asprezza colme: o notti acerbe, et dure." _Gio: Della Casa._

Fever succeeded, accompanied with delirium in the evening. By quietness, and the ordinary remedies, these symptoms were removed; but he was left in a state of extreme weakness. As he recovered from this, his habits became materially altered: he would continue to lie in bed for several days, after which, he would suddenly rise and walk a number of miles. Personal cleanliness, and dress were entirely neglected: sometimes he would fast for two or three days, and then eat voraciously. Afterwards he became suspicious that poison had been mixed with his food. It was found necessary to confine him, from having attempted to castrate himself: this he afterwards effected in a very complete manner, and continues a maniac to the present time.

Few persons, I believe, will be disposed to consider the above case, as an instance of insanity succeeding to a laborious exercise of the intellectual faculties. It is true, he was busied with books: but this occupation could not have strained his mind, for he appears neither to have comprehended, nor retained any of the objects of his pursuit.

_Hereditary Disposition._

"Ut male posuimus initia sic cetera sequuntur."--_Cicero._

"Whatever was in the womb imperfect, as to her proper work, comes very rarely, or never at all, to perfection afterwards."--_Harrington's Works, p. 177._

Considerable diversity of opinion has prevailed, whether insanity be hereditary or not; and much has been said on both sides of this question. Great ingenuity has been exerted to prove that this disease is accidental, or that there are sufficient causes to account for its occurrence, without supposing it one of those calamities that "_flesh is heir to_." It has been argued, that, if the disease were hereditary, it ought uniformly to be so, and that the offspring of a mad parent should necessarily become insane.

All theories and reasonings appear to be good for as much as they prove; and if the term _hereditary_ be employed with a degree of strictness, so as to denote certain and infallible transmission, such inevitable descent cannot be defended. Several instances have come under my observation where the children of an insane parent have not hitherto been affected with madness, and some have died early in life, without having experienced any derangement of mind. More time is therefore required.

All observations concur in acknowledging that there are many circumstances in which children resemble their parents. It is very common to see them resemble one of their parents in countenance, and when there are several children, some shall bear the likeness of the father and others of the mother. Children often possess the make and fashion of the body, peculiar to one or other of their parents, together with their gait and voice; but that which has surprized me most is the resemblance of the hand-writing. If a parent had taught his son to write, it might be expected that a considerable similarity would be detected; but in general the fact appears to be otherwise, for it seldom happens that the scholars, though constantly imitating the copy of the master, write at all like him, or like each other. In a few instances I have noticed a correct resemblance between the hand-writing of the father and son, where the former died before the latter had been taught the use of the pen, and who probably never saw the hand-writing of his father. The transmission of personal deformities is equally curious. I am acquainted with a person in this town, whose middle and ring finger are united, and act as one; all the children of this man carry the same defect. A toenail, particularly twisted, has been traced through three generations, on the same foot and toe. Abundant instances might be adduced on this subject; there is scarcely a family which cannot produce something in confirmation; and if to these circumstances in the human species, were to be added the experiments which have been made on the breeding of cattle, perhaps little doubt would remain.

The reasoners against the transmission of madness urge, that, if the contrary were true, we should by this time have detected the rule or law by which nature acts, and that we should have been able to determine,--First, whether the disorder descended to the male or female children accordingly as the father or mother was affected.--Secondly, which of the parents is most capable of transmitting the disease?--Thirdly, what alternations in the succession take place, does it shift from the male to the female line, and, does it miss a generation, and afterwards return?

These, and a multitude of other queries, might be proposed; I believe much faster than they could be answered. Nature appears to delight in producing new varieties, perhaps less in man than in other animals, and still less in the animal than in the vegetable kingdom. Before these subtile reasoners expect, from those who maintain that madness generally descends from the parent to the offspring, a developement of the laws by which Nature acts, it would be convenient first to settle whether in this matter she be under the dominion of any law whatever.

The investigation of the hereditary tendency of madness is an object of the utmost importance, both in a legal and moral point of view. Parents and guardians, in the disposal, or direction of the choice of their children in marriage, should be informed, that an alliance with a family, where insanity has prevailed, ought to be prohibited.

Having directed some attention to enquiries of this nature, I am enabled truly to state, that, where one of the parents have been insane, it is more than probable that the offsprings will be similarly affected.

Madness has many colours, and colours have many hues; actual madness is a severe calamity, yet experience has pointed out the treatment, and the law has permitted the imposition of the necessary restraint: but it very frequently occurs that the descendants from an insane stock, although they do not exhibit the broad features of madness, shall yet discover propensities, equally disqualifying for the purposes of life, and destructive of social happiness.

The slighter shades of this disease include eccentricity, low spirits, and oftentimes a fatal tendency to immoral habits, notwithstanding the inculcation of the most correct precepts, and the force of virtuous example.

In illustration of the fact, that the offsprings of insane persons are, _ceteris paribus_, more liable to be affected with madness than those whose parents have been of sound minds; it was my intention to have constructed a table, whereon might be seen the probably direct course of this disease, and also its collateral bearings: but difficulties have arisen. It appeared, on consideration, improper to attempt precision with that which was variable, and as yet unsettled; I have therefore been content to select a few histories from my book of notes, and to exhibit them in the rude state in which they were set down.

_1st._--R. G. His grandfather was mad, but there was no insanity in his grandmother's family. His father was occasionally melancholic, and once had a raving paroxysm. His mother's family was sane. His father's brother died insane. R. G. has a brother and five sisters; his brother has been confined in St. Luke's, and is occasionally in a low spirited state. All his sisters have been insane; with the three youngest the disease came on after delivery.

_2d._--M. M. Her grandmother was insane and destroyed herself. Her father was mad for many years, but after the birth of all his children. M. M. has two brothers and a sister; both her brothers have been insane; the sister has never been so affected, but was a person of loose character. The insanity of M. M. was connected with her menstruation; after its cessation she recovered, although she had been confined more than sixteen years.

_3d._--M. H. Her father had been several times insane; her mother was likewise so affected a few months before her death. Afterwards her father married a woman perfectly sane, by whom he had three children, two female and a male; both the females are melancholic, the male was a vicious character, and has been transported. M. H. has had ten children, three have died with convulsions, the eldest, a girl, is epileptic.

_4th._--T. B. His mother became insane soon after being delivered of him, and at intervals has continued so ever since. He has a brother who became furiously mad at the age of twenty, and afterwards recovered. T. B.'s disorder came on at the age of twenty-six.

_5th._--S. F. Her father's mother was insane, and confined in the hospital. Her father never discovered any symptoms of insanity, and her mother was perfectly sane. Her only sister (she had no brothers) was mad about five years ago, and recovered. S. F. has been twice in the hospital.

_6th._--P. W. After the best enquiries it does not appear that her father or mother ever experienced any attack of madness or melancholy. P. W.'s disorder commenced shortly after the delivery of a child. She has three sisters, the eldest has never been married, and has hitherto continued of sound mind. The two younger have been mothers, and in both insanity has supervened on childbearing.

_7th._--J. A. H. His father's father was insane, and his father was also disordered, and destroyed himself. His mother was of sound mind. J. A. H. became insane at the age of twenty-three. He has two sisters, the elder has once been confined for insanity, the younger is of weak intellects, nearly approaching to ideotism.

_8th._--M. D. Her mother was insane and died so. M. D. continued of sane mind until she had attained the age of fifty-seven, when she became furiously maniacal; her only daughter, eighteen years of age, was attacked with mania during the time her mother was confined.

_9th._--G. F. His mother was melancholic during the time she was pregnant with him, and never afterwards completely recovered. She had five children previously to this melancholic attack, who have hitherto continued of sound mind. She bore another son after G. F. who is extremely flighty and unmanageable. G. F. was attacked with madness at the age of nineteen, and died apoplectic, from the violence and continued fury of his disorder.

_10th._--M. T. Her mother was of sound mind. Her father was in a melancholic state for two years, before she was born, but this was afterwards dissipated by active employment. M. T. has two brothers, younger than herself, who have been attacked with insanity, neither of whom have recovered. She has two sisters, some years older than herself, these have never been deranged. M. T. has had nine children. The three first have been melancholic. The youngest, at the age of five years, used to imagine she saw persons in the room covered with blood, and other horrible objects, she afterwards became epileptic and died. The youngest of her three first children has been married and had three children, one of whom is afflicted with chorea Sancti Viti, and another is nearly an ideot.

Of the causes termed moral, the greatest number may, perhaps, be traced to the errors of education, which often plant in the youthful mind those seeds of madness which the slightest circumstances readily awaken into growth.

It should be as much the object of the teachers of youth, to subjugate the passions, as to discipline the intellect. The tender mind should be prepared to expect the natural and certain effects of causes: its propensity to indulge an avaricious thirst for that which is unattainable, should be quenched: nor should it be suffered to acquire a fixed and invincible attachment to that which is fleeting and perishable.

Of the more immediate, or, as it is generally termed, the proximate cause of this disease, I profess to know nothing. Whenever the functions of the brain shall be fully understood, and the use of its different parts ascertained, we may then be enabled to judge, how far disease, attacking any of these parts, may increase, diminish, or otherwise alter its functions. But this is a degree of knowledge, which we are not likely soon to attain. It seems, however, not improbable, that the only source, from whence the most copious and certain information can be drawn, is a strict attention to the particular appearances which morbid states of this organ may present.

From the preceding dissections of insane persons, it may be inferred, that madness has always been connected with disease of the brain and of its membranes. Having no particular theory to build up, they have been related purely for the advancement of science and of truth.

It may be a matter, affording much diversity of opinion, whether these morbid appearances of the brain be the cause or the effect of madness: it may be observed that they have been found in all states of the disease. When the brain has been injured from external violence, its functions have been generally impaired, if inflammation of its substance, or more delicate membranes has ensued. The same appearances have for the most part been detected, when patients have died of phrenitis, or in the delirium of fever: in these instances, the derangement of the intellectual functions appears evidently to have been caused by the inflammation. If in mania the same appearances be found, there will be no necessity of calling in the aid of other causes, to account for the effect: indeed, it would be difficult to discover them.

Those who entertain an opposite opinion are obliged to suppose, _a disease of the mind_. Such a morbid affection, from the limited nature of my powers, perhaps I have never been able to conceive. Possessing, however, little knowledge of metaphysical controversy, I shall only offer a few remarks upon this part of the subject, and beg pardon for having at all touched it.

Perhaps it is not more difficult to suppose, that matter, peculiarly arranged, may _think_,[17] than to conceive the union of an immaterial being with a corporeal substance. It is questioning the infinite wisdom and power of the Deity to say, that he does not, or cannot, arrange matter so that it shall think. When we find insanity, as far as has been hitherto observed, uniformly accompanied with disease of the brain, is it not more just to conclude, that such organic affection has produced this incorrect association of ideas, than that a being, which is immaterial, incorruptible, and immortal, should be subject to the gross and subordinate changes which matter necessarily undergoes?

But let us imagine _a disease of ideas_. In what manner are we to effect a cure? To this subtle spirit the doctor can apply no medicines. Though so refined as to elude the force of material remedies, some may however think that it may be reasoned with. The good effects which have resulted from exhibiting logic as a remedy for madness, must be sufficiently known to every one who has conversed with insane persons, and must be considered as time very judiciously employed: speaking more gravely, it will readily be acknowledged, by persons acquainted with this disease, that, if insanity be a disease of ideas, we can possess no corporeal remedies for it: and that an endeavour to convince madmen of their errors, by reasoning, is folly in those who attempt it, since there is always in madness the firmest conviction of the truth of what is false, and which the clearest and most circumstantial evidence cannot remove.

CHAP. VI.

ON THE PROBABLE EVENT OF THE DISEASE.

The prediction of the event, in cases of insanity, must be the result of accurate and extensive experience; and even then it will probably be a matter of very great uncertainty. The practitioner can only be led to suppose, that patients, of a particular description, will recover, from knowing that, under the same circumstances, a certain number have been actually restored to sanity of intellect.

The practice of an individual, however active and industrious he may be, is insufficient to accumulate a stock of facts, necessary to form the ground of a regular and correct prognosis: it is therefore to be wished, that those, who exclusively confine themselves to this department of the profession, would occasionally communicate to the world the result of their observations.

Physicians, attending generally to diseases, have not been reserved, in imparting to the public the amount of their labours and success: but, with regard to this disorder, those, who have devoted their whole attention to its treatment, have either been negligent, or cautious of giving information respecting it. Whenever the powers of the mind are concentrated to one object, we may naturally expect a more rapid progress in the attainment of knowledge: we have therefore only to lament the want of observations upon this subject, and endeavour to repair it.

The records of Bethlem Hospital have afforded me some satisfactory information, though far from the whole of what I wished to obtain. From them, and my own observations, the prognosis of this disease is, with great diffidence, submitted to the reader.

In our own climate, women are more frequently afflicted with insanity than men. Several persons, who superintend private mad-houses, have assured me, that the number of females brought in annually, considerably exceeds that of the males. From the year 1748 to 1794, comprizing a period of forty-six years, there have been admitted into Bethlem Hospital, 4832 women, and 4042 men.

The natural processes, which women undergo, of menstruation, parturition, and of preparing nutriment for the infant, together with the diseases, to which they are subject at these periods, and which are frequently remote causes of insanity, may, perhaps, serve to explain their greater disposition to this malady. As to the proportion in which they recover, compared with males, it may be stated, that of 4832 women affected, 1402 were discharged cured; and that, of the 4042 men, 1155 recovered. It is proper here to mention, that, in general, we know but little of what becomes of those who are discharged; a certain number of those cured, occasionally relapse, and some of those, who are discharged uncured, afterwards recover: perhaps in the majority of instances where they relapse, they are sent back to Bethlem. To give some idea of the number, so re-admitted, it may be mentioned, that, during the last two years,[18] there have been admitted 389 patients, 53 of whom had at some former time been in the house. There are so many circumstances, which, supposing they did relapse, might prevent them from returning, that it can only be stated with certainty, that within twelve months, the time allowed as a trial of cure, so many have been discharged perfectly well.

To shew how frequently insanity supervenes on parturition, it may be remarked, that from the year 1784 to 1794 inclusive, 80 patients have been admitted, whose disorder shortly followed the puerperal state. Women affected from this cause, recover in a larger proportion than patients of any other description of the same age. Of these 80, 50 have perfectly recovered. The first symptoms of the approach of this disease after delivery, are want of sleep; the countenance becomes flushed; a constrictive pain is often felt in the head; the eyes assume a morbid lustre, and wildly glance at objects in rapid succession; the milk is afterwards secreted in less quantity; and when the mind becomes more violently disordered, it is totally suppressed. Where the disease is hereditary, parturition very frequently becomes an exciting cause.

From whatever cause this disease may be produced in women, it is considered as very unfavourable to recovery, if they should be worse at the period of menstruation, or have their catamenia in very small or immoderate quantities.

A few cases have occurred where the disease, being connected with menstruation, and having continued many years, has completely disappeared on the cessation of the uterine discharge.

At the first attack of this disease, and for some months afterwards, during its continuance, females most commonly labour under amenorrhoea. The natural and healthy return of this discharge generally precedes convalescence.

From the following statement it will be seen, that insane persons recover in proportion to their youth, and that as they advance in years, the disease is less frequently cured. It comprizes a period of about ten years, viz. from 1784 to 1794. In the first column the age is noticed; in the second, the number of patients admitted; the third contains the number cured; the fourth, those who were discharged not cured.

_Number _Number _Number _Age between_ admitted._ discharged discharged cured._ uncured._

10 and 20 113 78 35 20 and 30 488 200 288 30 and 40 527 180 347 40 and 50 362 87 275 50 and 60 143 25 118 60 and 70 31 4 27 ------- ------- ------- Total 1664 Total 574 Total 1090 ------- ------- -------

From this table it will be seen, that when the disease attacks persons advanced in life, the prospect of recovery is but small.

I am led to conclude, from the very rare instances of complete cure, or durable amendment, among the class of patients deemed incurable, as well as from the infrequent recovery of those who have been admitted, after the disorder has been of more than twelve months standing, that the chance of cure is less, in proportion to the length of time which the disorder shall have continued.

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

When the reader contrasts the preceding statement with the account recorded in the report of the Committee, appointed to examine the Physicians who have attended His Majesty, &c. he will either be inclined to deplore the unskilfulness or mismanagement which has prevailed among those medical persons who have directed the treatment of mania in the largest public institution in this kingdom, of its kind, compared with the success which has attended the private practice of an individual; _or to require some other evidence, than the bare assertion of the man pretending to have performed such cures_.[19]