Observations on insanity : with practical remarks on the disease, and an account of the morbid appearances on dissection

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OBSERVATIONS

ON

INSANITY.

OBSERVATIONS

QH

INSANITY

WITH

PRACTICAL REMARKS ON THE DISEASE,

AND AN

ACCOUNT OF THE MORBID APPEARANCES
. ON DISSECTION.

ia£^

^,.M»>»

By JOHN HASLAM,

LATE OF PEMBROKE-HALL, CAMBRIDGE,

MEM-BER OF THE CORPORATION OF SURGEONS,

AND APOTHECARY TO B ETHLE M -HOS PIT A L.

*' Of the uncertainties of our prefent ftate the moft dreadful and
alarming is the uncertain continuance of reafon."

Dr . J o H N s o N 's RaiTelas.

XontJon :

PRINTED FOR F. AND C. RIVINGTON, NO. 62,

8T. Paul's chvrch-yardj

AN3 SOLD BY J. HATCHARP, NO, 173, PICCATIltY,

1798.

TO THE

RIGHT WORSHIPFUL THE

PRESIDENT,

THE WORSHIPFUL THE

TREASURER, and GOVERNORS

OF

BETHLEM-HOSPITAL.

MV LORDS AND GENTLEMEN,

r»

THE foilowing Observations are refpe6Vfully
fubmitted to your notice, as the vigilant and
humane Guardians of an Inftitution which performs
much good to fociety, by diminiihing the severest
amongft human calamities.

By,

My Lords and Gentlemen,

Your very obedient and humble Servant,

The author.

A 3

PREFACE.

S the office I hold affords me
abundant means of acquiring
information on the fubjedl of mental
diforders, I fhould feel myfelf unworthy
of that fituation, were I to negledl any
opportunity of accumulating fuch know-
ledge, or of communicating to the pub-
lic any thing which might promife to
be of advantage to mankind. The
candid reader is therefore requefted to
accept this fentiment, as the beft apology
I can offer for the prefent produdlion-

It has been fomewhere obferved, that
in our own country more books on
Infanity have been publifhed than in

5 any

viii

any other ; and^ if the remark be juft,
it is certainly difcouraging to him who
propofes to add to their number. It
muft, however, be acknowledged, that
we are but httle indebted to thofe who
have been moil capable of affording us
inftf udion ; for, if we except the late
Dr. John Monro's Reply toDr.BATTiE's
Treatife on Madnefs, there is no work
on the fubje6l of mental alienation
which has been delivered on the au-
thority of extenlive obfervation and
pra6lice.

It is not intended to prefent the
following fiieets as a treatife, or com-
pleat difquilition on the fubje6l, but
merely as remarks, which have occur-
red during the treatment of feveral
hundred patients. As a knowledge of
the ftrufture^ and fundtions of the

body,

[ ix ]

body, have been held mdifpenfably
neceflary in order to become acquainted
with its difeafes, and to a fcientific
mode of treating them ; fo it would
appear, that he who propofes to write
on Madnefs Ihould be well informed -
concerning the powers and operations
of the human mind : but the various
and difcordant opinions, which have
prevailed in this department of know-
ledge, have led me to difentangle myfelf
as quickly as poffible from the per-
plexity of metaphylical mazes.

As fome very erroneous notions have
been entertained concerning the ftate of
the brain, and more efpecially refpedt-
ing its confiftence in maniacal diforders,
I have been induced to examine that
vifcus in thofe who have died infane,
and have endeavoured with accuracy to

report

[ X ]

report the appearances. It feemed
proper to give fome general hiftory of
thefe cafes; perhaps the account which
has been related of their erroneous
opinions might have been fpared, yet
fome friends v^hom I confulted expref-*
fed a wiih that they had been more
copioufly detailed.

Of the difficuliy of enumerating the
remote caufes of the difeafe I have been
fully aware, and have mentioned but
few, that I might be accufed of the
fewer miftakes. The prognofis con-
tains fome fa6ls which, as far as I ara
informed, have not hitherto been made
knovv^n, and appear to me of fufficient
importance to be communicated to the
public.

As

[ xi 3

As it is my intention at fome future
period .to attempt a more finifhed per-
formance on the fubjedt of Infanity, I
fliall feel grateful for any hints or
obfervations, with which the kindnefs

of profeffional gentlemen may fupply
me.

jBETHLEM-HOSPITALj
March 14, 1798,

OBSER,

OBSERVATIONS

ON

INSANITY.

T|3 EADERS in general require a definition
of the ilibjed, which an author propofes
to treat of; it is the duty therefore of every
writer, to define, as clearly as he is able, that
which he profelTes to elucidate.

A definition of a difeafe, fliould be a con-
centrated hiftory, a feledion of its prominent
features and difcriminative iymptoms*

B Of

[ ^ J

Of the definitions which have been given
of this difeafe, fome appear too contrafted ;
and others not fufEciently precife.

Dr. Mead, after having treated largely upon
the fubjed, concludes, '' That this difeafe con-
fifts entirely in the ftrength of imagination.'^
If the difeafe confifted entirely in the ftrength
of imagination, the imagination ought to be
equally ftrong upon all fubje6ls, which upon
accurate obfervation is not found to be the
cafe. Had Dr. Mead ftated, that, together
with this increafed ftrength of imagination^
there exifted an enfeebled ftate of the judg-
ment, his definition would have been more
*corre6t. The ftrength, or increafe of any
power of the mind, cannot conftitute a dif-
eafe of it ; ftrength of memory, has never
h^tn fulpeded to produce derangement of
intelieft ; neither is it conceived, that great
vigour of judgment can operate in any ftich
manner ; on the contrary it will readily be

granted

C 3 ]

granted, that imbecility of memory muft
create confufion, by obftruding the a6lion of
the other powers of the mind ; and that if
the judgment be impaired, a man muft ne-
ceflarily Ipeak, and generally a6l, in a very
incorre6l and ridiculous manner.

Dr. Ferriar, whom, to mention otherwife
than as a man of genius, of learning, and
of tafte, would be unjuft ; has adopted the
generally accepted divifion of Infanity, into
Mania and Melancholy. In Mania, he con-
ceives " falfe perception, and confequently
confufion of ideas, to be a leading circum-
ftance." The latter, he fuppofes to confift
" in intenfity of idea, which is a contrary
flate to falfe perception." From the obfcr-
vations I have been able to make relpe6ting
Mania, I have by no means been led to con-
clude, that falfe perception, is a leading cir-
cumftance in this diforder, and flill lefs, that

B 2 con-

[ 4 ]

confufion of ideas muft be the neceffary con-
fequence of falfe perception.

By perception, I underftand, v/ith Mr,
Locke, the appreheniion of fenfations ; and
arter a very diligent enquiry of patients who
have recovered from the difeafe, and from
an attentive obfervation of thofe labouring
under it, I have not frequently found, that
infane people perceive falfely, the obje6ls
v^hich have been prefented to them. It is
true, that they all have falfe ideas, but this by
no means infers, a defeft of the power by
M^hich fenfations are apprehended in the
mind.

We find madmen equally deranged upon
thofe ideas, which they have been long in
the poffeffion of, and on which the perception
has not been recently exercifed, as refpefting
thofe, which they have lately received : and
we frequently find thofe who become fud-

I denly

[ 5 ]

denly mad, talk incoherently upon every
fubjeft, and confequently, upon many, on
which the perception has not been exerciied
for a confiderable time.

It is well known, that maniacs often fup-
pofe they have feen, and heard thofe things,
which really did not exift at the time ; but
even this I fhould not explain by any dif-
ability, or error of the perception, fince it is
by no means the province of the perception
to reprefent unreal exiftences to the mind.
It muft therefore be fought elfewhere, pro-
bably in the fenfes, or in the imagination.

I have knov/n eight cafes of patients, who
infifted that they had feen the devil. It
might be urged, that in thefe inftances, the
perception was vitiated ; but it muft be ob -
ferved, that there could be no perception of
that, which was not prefent and exifting at
the time. Upon defiring thefe patients to

B 3 defcribe

[ 6 ]

defcribe what they had feen, they all repre-*
fented him as a big, black man, with a long
tail, cloven feet, and fharp talons, fuch as is
feen piftured in books. A proof that the
idea was revived in the mind from fome
former impreffions. One of thefe patients
however carried the matter a little farther,
as fhe folemnly declared, ihe heard him break
the iron chain with which God had confined
him, and faw him pafs fleetly by her win-
dow, with a trufs of ftraw upon his fhoulder.

It muft be acknowledged, that in the
foundeft ftate of our faculties we fometimes
perceive things which do not exift. If the
middle finger be croffed over the forefinger,
and a fingle pea be rolled under their extre-
mities, we have the perception of two. By
immerfing one hand into warm, the other
into cold water, and afterwards fuddenly
plunging them both into the fame fluid, of a
medium temperature, we Ihall derive the

fenfii^

[ 7 1

fenfations of heat^ and cold from the fame
water, at the fame time.

The power, by which the mind perceives
its own creations and combinations is perhaps
the fame, as that by which it perceives the
impreffions on the fenfes from external ob-
jefts. We polTefs the faculty of raifing up
of obje6ts in the mind which we had feen
before, and of profpefts, on which we had
formerly dwelt, with admiration and delight;
and in the cooleft ftate of our tinderftanding
we can even conceive that they lie before us.
If the power which awakens thefe remem-
brances in a healthy ftate of intelleft, fhould
ftir up diftorted combinations in difeafe, they
muft neceflarily be perceived ; but their ap-
prehenfion, by no means appears to imply a
vitiated ftate of the faculty by which they
are perceived. In fa61, that which is repre-
fented to the mind, either by a defe6l or de*
geption of the fenfes, or by the imagination,

B4 if

[ 8 J,

if it be fufficiently forcible and enduring,
muft neceffarily be perceived.

That '^ confufion of ideas" (lioiild be the
necelTary confequence of falfe perception, is
very difficult to admit. Perhaps much nlay
depend, in the difcuffion of this point, on the
various acceptations in M^hich confufion of
ideas may be underftood.

It has often been obferved that madmen,
will frequently reafon correftly from falfe
premifes, and the obfervation is certainly
true : we have indeed occafion to notice the
fame thing in thofe of the founded: minds.
It is very poffible 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 fre-.
quently occurred before. The reception of
this as a truth in the mind, if the power of
deducing from it the proper inferences ex-

ifted.

C 9 J

ifted, could neither create confufion, nor irre-
gularity of ideas.

Melancholy, the other form in which this
difeafe is fuppofed to exift, is made by Dr.
Ferriar to confift in " intenfity of idea." I
fhall fliortly have an opportunity, in the de-
finition I propofe to give, of attempting to
prove, that this divifion of Infanity, is neither
natural nor juft, upon the ground that the
derangement is equally complete in both
forms of the difeafe. V/e ought to attend
more to the ftate of the intellefl:, than to
the paffions which accompany the diforder.

By intenfity of idea, I prefume is meant,
that the mind is more ftrongly fixed on, or
more frequently recurs to, a certain fet of
ideas, than when it is in a healthy ftate.
But this definition applies equally to mania,
for we every day fee the moft furious maniacs
fuddenly fink into a profound melancholy ; and

the

[ ^o 1
the moft depreffed, and mlferable objeds, be-
come violent and raving. We have patients
in Bethlem Hofpital, whofe lives are divided
between furious, and melancholic paroxifms ;
and who, under both ftates, retain the fame
fet of ideas.

Infanity may, in my opinion, he defined
to be an incor're^l ajfoc'iat'ion of familiar ideas,
which is indejiendent of the jhejudices of edu-
cation^ and is always accompanied with im-
plicit beliefs and generally with either violent
or deprefftng pafjions. It appears to me ne-
ceflary, that the ideas incorre6lly affociated,
fhould be familiar^ becaufe we can hardly
be faid to have our ideas deranged upon fub-
jefts, concerning which we have little or no
information. A peafant, who had heard that
fuperior comforts of life, with fewer exer-
tions, were to be obtained by emigrating to
America, might faddle his beaft with an in-
tention of riding thither on horfe-back, with-
out

■ [ II 3

out any other imputation than that of igno-
rance; but if an old and experienced navi-
gator, were to propofe a limilar mode of
conveyance, I fhould have httle hefitatioii in
concluding him infane,

Refpefting the prejudices of education, it
may be obferved, that in our childhood, and
before we are able to form a true, and accu-
rate judgment of things, we have impreffed
upon our minds, a number of ideas which are
ridiculous ; but which were the received opi-
nions of the place in which we then lived,
and of the people who inculcated them; fuch
is the belief in the powers of witchcraft, and
in ghofts, and fuperftitions of every denomi-
nation, which grafp ftrongly upon the mind
and feduce its credulity. There are many
honeft men in this kino-dom who would not
fleep quietly, if a vefTel filled with quickfilver
were to be brought into their houfes ; they
would perhaps feel alarrned for the chaftitj

of

I 12 3

of their wives and daughters ; and this, be-
caufe they had been taught to confider that
many ftrange and unaccountable properties
' are attached to that metal. If a lefturer on
chemiftry were to exhibit the fame fears,
there could be no doubt that he laboured
under a diforder of intelleft, becaufe the
properties of mercury would be known to
him, and his alarms would arife from incor-
reftly affociating ideas of danger, with a fub-
fiance, which in that ftate is innoxious, and
whofe properties come within the fphere of
his knowledge,

^ As the terms Mania, and Melancholy, are
in general ufe, and ferve to diftinguifh the
forms under which Infanity is exhibited, there
can be no objedion to retain them ; but I
would ftrongly oppofe their being conlidered
as oppofite difeafes. In both, the aiTociation
of ideas is equally incorre6t, and they appear
to differ only, from the different paffions which

accom^

i ^3 ]

accompany them. On difledlon, the flate
of the brain does not fhew any appearances
peculiar to melancholy ; nor is the treatment
which I have obferved moft fuccefsful, dif-
ferent from that which is employed in
Mania.

CHAP,

[ H ]

CHAP. IL

SYMPTOMS OF THE DISEASE.

WITH moft authors, this part of the fub-
je6l has occupied the greateft fhare of their
labour and attention : they have generally
deicended to minute particularities and flu-
died difcriminations. DiftinSions have been
created, rather from the pecuHar turn of the
patients propenfities and difcourfe, than from
any marked difference, in the varieties, and-
Ipecies of the diforder : and it has been cuf-
tomary to ornament this part of the work
with copious citations from poetical writers.
As my plan extends only to a delcription of
that which I have obferved, I fhall nei-
ther amplify^ nor embelUlh my volume by
quotations* -

In

t >5 ]

In moft public hofpitals, the firft attack of
difeafes is feldom to be obferved; and it
might naturally be fuppofed,that there exifted
in Bethlem, fimilar impediments to an accu-
rate knowledge of madnels. It is true, that
all who are admitted into it have been a
greater, or lels time afflifted with the com-
plaint; yet from the occafional relapfes to
which infane perfons are fubjert, we have
frequent and fufficient opportunities of ob-
ferving the beginning, and tracing the pro-
®:refs of this difeafe.

Among the incurables, there are fome who
have intervals of perfqCt foundnefs of mind;
but who are fubjetfl to relapfes, which would
render it improper, and even dangerous, to
trufl: them at large in fociety: and with
thofe who are upon the curable lift, a recur-
rence of the malady very frequently takes
place. Upon thefe occafions, there is ample

fcope

[ i6 ]

fcope for obferving the firft attack of the
difeafe.

To enumerate every fymptom would be
defcending to ufelefs minutiae, I fhall there-
fore content myfelf with defcribing the more
general appearances.

They firft become uneafy, are incapable of
confining their attention, and neglefl: any
employment to which they have been accuf-
tomed ; they get but little fleep, they are lo-
quacious, and difpofed to harangue, and decide
promptly, and pofitively upon every fubje6l
that may be ftarted. Soon after, they are di-
vefted of all reftraint in the declaration of
their opinions of thofe, with whom they are
acquainted. Their friendfhips are exprefled
with fervency and extravagance ; their en-
mities with intolerance and difguft. They
now become impatient of contradiflion, and
fcorn reproof. For fuppofed injuries, they

are

[ ^7 ].

are inclined to quarrel, and fight with thofe
about them. They have all the appearance
of perfons inebriated, and people unacquainted
with the fymptoms of approaching mania,
generally fuppofc them to be in a ftate of
intoxication. At length fulpicion creeps in
upon the mind, they are aware of plots which
had never been contrived, and detedt motives
that were never entertained. At laft, the
fucceffion of ideas is too rapid to be examined;
the mind becomes crouded with thoughts, and
indifcriminately jumbles them together.

Thofe under the influence of the deprefling
paffions, will exhibit a different train of fymp-
toms. The countenance, wears an anxious
and gloomy afped. They retire from the
company of thofe with whom they had for-
merly aflbciated, feclude themfelves in ob-
fcure places, or lie in bed the greateft part
of their time. They next become fearful,
and, when irregular combinations of ideas

C hav^

[ i8 ]

V

have taken place, conceive a thoufand fan-
cies : often recur to fome former immoral
ad which they have committed, or imagine
themfelves guilty of crimes which they never
perpetrated ; believe that God has abandoned
them, and with trembling, await his punifh*
ment. Frequently they become delperate,,
and endeavour by their own hands to termi-
nate an exiftence, which appears to be aa
affli6ting and hateful incumbrance.

The found mind feems to confift in a har-
monized aflbciation of its different powers,
and is fo conftituted, that a defe6l, in any
one, produces irregularity, and, moft com-
monly, derangement of the whole. The
different forms therefore under which wc
fee this difeafe, might not, perhaps, be im-
properly arrranged according to the powers
which are chiefly affeded.

I have before remarked, that the increafed

vigor of any mental faculty cannot conftitute

4 iutel-

[ 19 ]

•ihteileftual difeafe. If the memory of a perfon
were fd retentive, that he could re-aflemble the
whole of what he had heard, read, and thought,
fuch a man, even with a moderate under-
ftanding^ would pafs through life with repu-
tation and utility. Suppofe another to poflefs
a judgment, fo difcrimirlating and corre6l,that
he could afcertain pfecifely, the juft weight of
every argument ; this man would be a fplendid
ornament to human fociety. Let the ima-
gination of a third, create images and fcenes,
which mankind fhould ever view with rap-
ture and aftonifhment, fiich a ph-^nomenon
would bring Shakefpear to our recolledion.

If in a chain of ideas, a number of the
links are broken, the mind cannot pofTefs
any accurate information. When patients
of this defcription are aiked a queftion, they
appear as if awakened from a found fleep ;
they are fearching, they know not where,
for the proper materials of an anfwer, and,

C 2 in

[ 20 ]

in the painful, and fruitlefs efforts of recol-
leflion, generally lofe fight of the queftlon
itfelf.

In perfons of found mind, as well as in
maniacs, the memory is the firft power which
decays, and there is fomething remarkable in
the manner of its decline. The tranfa6lions
of the latter part of life are feebly recol-
lefted, whilfl the fcenes of youth, and of
manhood, remain more ftrongly impreiffed.
To many converfations of the old incurable
patients to which I have liftened, the topic has
always turned upon the fcenes of early days.
In many cafes, where the faculties of the
mind have been injured by intemperance^
the fame withering of the recolledion may
be obferved. It may perhaps arife, from the
mind at an early period of life being moft
fufceptible and retentive of impreffions, and
from a greater difpofition to be pleafed with
the obje(?ls whigh are prefented: whereas, the

cold

[ 21 ]

cold caution, and faftidioufnefs with which age
furveys the profpeds of life, joined to the dul-
nefs of the fenfes, and the flight curiofity
which prevails, will, in fome degree, explain
the difficulty, or rather impoflibility, of re-
calling the hiflory of later tranfaftions.

Infane people who have been good fcholars,
after a long confinement lofe, in a v/onderful
degree, the correftnefs of orthography; when
they write, above half the words are gene-
rally mif-lpelt — they are written according to
the pronunciation. It fliews how treacherous
the memory is v/ithout reinforcement. The
fame neceffity of a conftant recruit and fre-
quent review of our ideas, fatlsfaftorily
explains, why a number of patients lapfe
nearly into a ftate of ideotifm* Thefe have,
for fome years, been the filent and gloomy
inhabitants of the Hofpital, who have avoided
converfation, and fought folitude; confe-
quently have acquired no new ideas^ and

C 3 time

time has efFaced the impreffion of thpfe for^
merly ftamped upon the mind, Mr. Locke
well obferves, " that there feems to be a con-
ftant decay of all our ideas, even of thofe
which are ftruck deepeft, and in minds the
moft retentive ; fo that if they be not fome-
times renewed, by repeated exercife of the
fenfes, or reflexion on thofe kind of objefts^
which at firft occafioned them ; the print
w^ears out, and at lafl: there remains nothing
to be feen."

As it has been attempted to explain, how
an imbecility or lofs of memory will obftruft
the operation of the other powers qf the
mind : the next objeft is to fliew, how ne^
ceflarily our ideas muft be difarranged where
the determination on their comparifon is
wrong, or where the mind determines, or
judg<;:S, with little previous examination or
comparifon. An example or two will illuf-
trate this more fatisfadorily than any length

of

' . t ^3 ]

of reafoning, I remember a patient who
^ronceived, that, although dead men told no
tales, yet their feeling was very acute.
This affumed principle he extended to infe-
rior animals, and refufed to eat meat, be-
caufe he could not endure to be nourished at
the expence of the cruel fufFerings, which
beef fteaks neceffarily underwent in their
cookery. Another madman, who pretended
to extraordinary fkill in furgery, contrived to
fteal the wooden leg of an infane patient, and
laid upon it for a confiderable time, with a
firm belief of hatching it into a limb of flefh
and blood.

If a man fliall form fiich ideas, and con-
ceiv^e them to be true, either from a defe£l
in the power of his judgment, or without
any comparifon or examination Ihall infer
them to be fo, fuch defe6l will afford a fuf»
ficient fource of derangement.
«

C 4 Some

I M ]

Some who have perfe^Iy recovered from
this difeafe, and who are perfons of good
underftanding and liberal education, defcribe
the ftate they were in as refembling a dream ;
and, when they have been told how long
they were difordered, have been aftoniflied
that the time pafTed fo rapidly away. Others
fpeak of their diforder as accompanied with
great hurry and confufion of mind, where
the fucceffion of ideas is fo rapid and eva-
nefcent, that when they have endeavoured
to arreft or contemplate any particular
thoughts, they have been carried away by
the tide, which was rolHng after thern.

All patients have not the fame degree of
memory of what has pafTed during the time
they were difordered : but for the moft part
they recoUeft thofe ideas which were tranf-
mitted through the medium of the fenfes,
better than the combinations of their own
minds. I have frequently remg^rk^d that,

wheu

- t ^5 ]

when they were unable to give any account
of the pecuHar opinions which they had
indulged during a raving paroxyfin of long
continuance, they well remembered any
coercion which had been ufed, or any kind-
nefs which had been ihewn them.

Infane people are faid to be generally
worfe in the morning ; in fome cafes they
certainly are fo^ but perhaps not fo frequently
as has been iuppofed. In many inftances
(and, as far as I have obferved) in the be-
ginning of the difeafe they are more violent
in the evening, and continue fo the greateft
part of the night. It is however a certain
fa6l, that the majority of patients of this
defcription have their fymptoms aggravated,
by being placed in a recumbent pofture.

They feem themfelves to avoid the hori-
zontal pofition as much as poffible when
they are in a raving ftate : and when fo

confined

2

[ 2^ 3 «

.confined that they cannot be ere£l, they will
keep themfelves feated upoii the breech.

Many of thofe who are violently difordered
will continue particular anions for a con«
fiderable time : forne are heard to gingle the
chain, with which they arc confined, for
hours without intermiffion ; others, who are
fecured in an ere<Sl pofture, will beat the
ground with their feet the greateft part of
the day. Upon enquiry of fuch patients^
after they have recovered, they have affured
me, that thefe aflions afforded them con«
fiderable relief. We often furprize perfons
who are free from intelle6lual difeafe in
many ftrange and ridiculous movements^
particularly if their minds be intently occu^
pied : — this does not appear to be the effe^l
of habit, but of a particular ftate of mind.

Madmen do not always continue in the
fame furious or deprefled ftates : the maniacal

paroxyfm

[ ^7 ]

paroxyfm abates of its violence, and fome
beams of hope occafionally cheer the defpon-
dency of the melanchohck patients. We
have fome unfortunate perfons who are
obliged to be fecured the greateft part of
their time, but who now and then become
calm, and to a certain degree rational : upon
fuch occafions, they are allowed a greater
range, and are permitted to aflbciate with
the others. In fome inftances, the degree
of rationality is more confiderable ; they con-
dud themfelves with propriety, and in a fhort
converfation will appear fenfible and cohe-
rent. Such remiffion, has been generally
termed a lucid interval.

When medical men are called upon to attend
a commiffion of lunacy, they are always afked,
whether the patient has had a lucid i?iterval?
A term of fuch latitude as /;^/^r'y^/ requires to
be explained in the moft perfpicr.oiis and accu-
rate manner. In common language it is made
to fignify, both a moment and a number of

years,

[ 28 ]

years, confequently it does not comprize any
ftated time. The term lucid interval is there-
fore relative. I fliould define a lucid interval
to be a complete recovery of the patient's in-
telle fis^ afcertained by repeated examinations
of his converfation^ and by conjiant obfervation
of his conduEly for a time fujfficient to eatable
the fuperintendant to form a correal judgment*
Unthinking people are frequently led to con-
clude, that, if during a converfation of a few
minutes, a perfon under confinement fliall
betray nothing abfurd or incorred, he is well,
and often remonftrate on the injuftice of
fecluding him from the world. Even in
common fociety, there are many perfons
whom we never fiifpeft from a few trifling
topics of difcourfe to be {hallow minded ;
but, if we ftart a fubje6l, and wifh to difcufs
it through all it's ramifications and depen-
dances, we find them incapable of purfuing
a connefted chain of reafoning. In the
fame manner, infane people will often, for

a ihort

[ ^9 ]

a ihort time, conduct themfelves, both ia
converfation and behaviour, with fuch pro-
priety, that they appear to have the juft
exercife and 'diredlion of their faculties; but
let the examiner protraft the difcourfe, until
the favourite fubjeft Ihall have got afloat in .
the madman's brain, and he will be con-
vinced of the haftinefs of his decifion. To
thofe unaccuftomed to infane people, a few
coherent fentences, or rational anfwers would
indicate a lucid interval, becaufe they dif-
cover no madnefs ; but he who is in pof-
feffion of the peculiar turn of the patient's
thoughts, might lead him to difclofe them,
or by a continuance of the converfation they
w^ould fpontaneoufly break forth. A beau-
tiful ilUiftration of this is contained in the
R^ffelas of Dr. Johnfon : where the aftro-
nomer is admired as a perfon of found in-
telle6l and great acquirements by Imlac, who
is himfelf a philofopher, and a man of the
world. His intercourfe with the aftronomer

is

t so 1

Is frequent * and he always finds in his fo-
ciety information and delight. At length
he receives Imlac into the moft tinbounded
confidence, and imparts to hirii the momentous
fecret. " Hear Imlac what thou wilt not
without difficulty credit. I have poffefTed for
five years the regulation of weather, and the
diftribution of the feafons. The fun has
liftened to my diftates, and pafTed from tropic
to tropic by my direftion. The clouds at my
call have poured their waters^ and the Nile
has overflowed at my command. I have re--
ftrained the rage of the Dog-ftar^ and miti-^
gated the fervours of the Crab* The winds
alone of all the elemental powers have
hitherto refufed miy authority, and multi^
tudes have periilied by equinodial tempefts^
which I found myfeif unable to prohibit or
reftrain. I have adminiftered this great
office with exa6l juftice, and made to the
different nations of the Earth an impartial
dividend of rain and funfhine. What mufi:

have

[ 3' ]

kave been the mifery of half the globe, if I
had limited the clouds to particular re-
gicfns, or confined the flui to either fide of the
equator?'*

A real cafe came under my obfervation a
few months ago, and which is equally ap-»
pofite to the fiibjeft. A young man had be-
come infane from habitual intoxication, and
during the violence of his complaint had at-
tempted to deftroy himfelf. Under a lup«
pofed imputation of having unnatural diipo-
fitions he had amputated his penis, with a
view of precluding any future infinuations
of that nature. For many months after he
was admitted into the hofpital, he continued
in a ftate which obliged him to be ftridly
confined, as he conftantly meditated his own
deftru6iion. On a fudden he became ap-
parently well, was highly fenfible of the
delufion under which he had laboured, and
converfed as any other perfon upon the or-
dinary

[ 32 ]
dinary topics of difcourfe. There was, how-
ever, fomething in the referve of his manner,
and pecuharity of his look, which perfuaded
me that he was not well, although no in-
coherence of ideas could be detefted in his
converfation. I had obferved him for fame
days to walk rather lame, and once or twice
had noticed him fitting with his flioes off,
rubbing his feet. On enquiring into the
motives of his doing fo, he replied, that his
feet were bliftered, and wiflied that fome
remedy might be applied to remove the veli-
cations. When I requefted to look at his
feet, he declined it and prevaricated, faying,
that they were only tender and uncomfort-
able. In a few days afterwards, Ije afTured
me they were perfedly well. The next
evening I obferved him, unperceived, ftill
rubbing his feet, and then peremptorily in-
lifted on examining them. They were quite
free from any diforder. He now told me
with fome embarraffment, that he wifhed

much

t 33 ]

tniich for a confidential friend, to whom he
might impart a fecret of importance. Upon
affuring him that he might truft me, he faid,
that the boards on which he walked, (the fe»
cond ftorj) were heated by fubterraneous fires,
under the direftion of invifible and malicious
agents, whofe intentions^ he was v/ell con-
vinced, were to confume him by degrees^

Fforii thefe confiderations I am Inclined to
think, that a lucid interval includes all thft
circumftances w^hich I have enumerated in
my definition of it« If the perfon who is to
examine the ftate of the patient's mind be
unacquainted with his peculiar opinions, he
may be eafily deceived, becaufe, wanting this
information, he will have no clue to direft
his enquiries, and madmen do not always,
nor immediately intrude their incoherent
notions into notice. They have fometimes
fuch a high de2:ree cf controul over their
minds, that when they have any particular

D purpofc

[ 34 ] >

purpofe to carry, they will affect to renounce
thofe opinions which fhall have been judged
inconfiftent : and it is well known that they
have often difTembled their refentment, until
a favourable opportunity has occurred of gra-
tifying their revenge.

Among the bodily particularities which
mark this difeafe, may be obferved the pro-
truded, and oftentimes gliftening eye, and a
peculiar caft of couatenance which, how-
ever, cannot be defcribed. In fome, an ap-
pearance takes place which has not hitherto
been noticed by Authors. This is a relaxa-
tion of the integuments of the cranium, by
means of which they may be wrinkled, or
rather gathered up by the hand to a confider-
able degree. It is generally mofl: remarkable
on the pofterior part of the fcalp ; as far as
my enquiries have reached, it does not take
place in the beginning of the difeafe, but
after a raving paroxyfm of fome coatinuance.

It

t 55 1

It }ia§ been frequently aGcompanied with Coli-
tra6lion of the iris*

On the fuggeftioii of a medical gentleman^
1 was induced to afcertain the prevailing
complexiori and colour of the hair in infane
patients. Out of 265 who were examined,
^05 were of a fwarthy completion, with
dark, or black hair ; the remaining 60 were
of a fair Ikin, and light, brown, or red haired*
What connexion this proportion may have
with the completion and colour of the hair
of the people of this country in general, and
what alterations may have been produced by
age or refidence in other climates, I am to-
tally uninformed.

Of the power which maniacs poflefs of
refifting cold the belief is general, and the
hiftories which are on record are truly won-
derful. It is not my wifh to difbelieve, nor
my intention to difpute them ; it is proper,

D z however,

[ 36 I
however, to ftate, that the patients in Beth-
lem hofpital poffefs no fuch exemption from
the «ffe6ls of levere cold. They are parti-
cularly fubje6l to mortifications of the feet ;
and this faft is fo well eftablifhed from former
accidents, that there is an exprefs order of
the houfe, that every patient, under fi:ri£l
confinement, fhall have his feet examined
morning and evening by the keeper, and alfb
have them conftantly wrapped in flannel;
and thofe who are permitted to go about
are always to be found as near to the fire
as they can get, during the winter feafon.

Having thus given a general account of
the fymptoms which I have obferved to
occur moft commonly in perfons afFeSed with
madnels, I fliall now lay before my readers
a hiftory of all the appearances which I have
noticed on opening the heads of feveral
' maniacs, who have died in BethleiH Hof-
pitaL

[ n ]

CASE L

J. H. a man twenty-eight years of age, was
admitted a patient in May 1795. He had
been difordered for about two months before
he came into the hofpital. No particular
caufc was ftated to have brought on the
complaint. It was moft probably an here-
ditary afFe£tion, as his father had been fever^l
times infane and confined in our holpital.
During the time he was in the houfe, he
was in a very low and melancholic ftate ;
fhewed an averfion to food, and faid he was
relblved to die. His obftinacy in refuling
all nourifliment was very great, and it was
with much difRculty forced upon him. He
continued in this ftate, but became daily
weaker and more emaciated until Auguft iftj
when he died. Upon opening the head, the
pericranium was found loofely adherent to

D 3 the

[ 38 J

the fculL* The bones of the cranium were
thick. The pia mater was loaded with
blood, and the medullary fubftance, when cut
into, was full of bloody points. The pineal
gland contained a large quantity of gritty
matter*. The confiftence of the brain was
natural ; he was opened twenty-four hours
lafter death,

CASE 11.

J. W. was a man of fixty-two years of age,
who had been many years in the houfe as an
incurable patient, but with the other parts of
whofe hiftory I am totally unacquainted. He
appeared to be a quiet and inofFenfive perfon,
who found amufement in his own thoughts,
and feldom joined in any converfation with

* This gntty. matter, fubjeded to chcmicaJ cxamina-
tion, was found to be phofphat of lime,

tbe

c 39 r

the other patients : for fome months he had
been troubled with a cough, attended with
copious expedoration, which very much re-
duced him ; dropfical lymptoms followed
thefe complaints. He became every day
weaker, and on July I oth 5 1795, died. Hewas
opened eighteen hours after death. The pe-
ricranium adhered loofely to the fcuU ; the
bones of the cranium were unufually thin*
There were flight opacities in many parts of
the tunica arachnoides ; in the ventricles
about four ounces of water were contained —
fome large hydatids were difcovered on the
plexus choroides of the right fide. The
confifteace of the brain was natural.

CASE IIL

G. H. a man twenty-fix years of age, was
received into the holpital July 1 8th, 1 795. It
was ftated that he had been difordered fix

D 4 weeks

[ 40 ]

weeks previous to his admiflion, and that ho
had never had anyTornaer attack. He had been
a drummer with a recruiting party, and had
been for fome time in the habit of conftant
intoxication, which was affigned as the caufe
of his infanity. He continued in a violent
and, raving ftate about a month, during the
whole of which time he got little or no fleep.
He had no knowledge of his fituation but
fuppofed himfelf with the regiment, and
was frequently under great anxiety and
alarm for the lofs of his drum, which he
inaagined had been ftolen and fold. The
medicines which were given to him he con-
ceived were fpirituous liquors, and fwallowed
them with avidity. At the expiration of a
month, he was very weak and reduced ; his
legs became oedematous — his pupils were
much diminifhed. He now believed himfelf
a child, called upon the people about him as
his playfellows, and appeared to recall the
fcenes of early life with facility and corre6l-

[ 41 ]

Befi. Within a few days of his deceafe he
-only muttered to himfelf. Augufl: 26th^ he
died. He was opened fix hours after death.
The pericranium was loofely adherent. The
tunica arachnoides had generally loft its
tranfparency, and was confiderably thickened^
The veins of the pia mater were loaded with
blood, and in many places leemed to contain
ain There was a confiderable quantity of
water between the membranes, and as nearly
as could be afcertained about four ounces
in the ventricles, in the cavity of which,
the veins appeared remarkably turgid. The
confiftcnce of the brain was more than
ufually firm-

CASE IV.

E. M. a woman, agedfixty, was admitted
into the houfe, Auguft 8th, 1795 ; flie had
been difordered five months ; the caufe

afJigned

C 42 j

afligned was extreine gnef, in confcquencc
of the lofs of her only daughter. She was
very miferable and reftlefs ; conceived fhc
had been aecufed of fome horrid crime, for
which fhe apprehended flie fhould be burned
ahve. When any perfons entered her room
ihe fuppofed them officers of juftice, who
were about to drag her to fome cruel puniih-
ment. She was frequently violent, and
would ftrike and bite thofe who came near
her. Upon the idea that fhe fhould fliortly
be put to death, fhe refufed all fuflenance ;
and it became necefTary to force her to take
it. In this ftate ihe continued, growing
daily weaker and more emaciated, until
O6lober 3d^ w^hen fhe died.

upon opening the head there was a copi-
ous determination of blood to the whole con-
tents of the cranium. The pia mater was
confiderably inflamed; there was not any
water either in the ventricles or between the

mem-

I 43 J

membranes. The brain was particularly
foft. She was opened thirty hours after
death.

CASEY.

W. P. a young man aged twenty-fivQ,
was admitted into the holpital September 265
1 795. He had been difordered five months,
and had experienced a fimllar attack fix years
before. The difeafe was brought on by
exceffive drinking. He was in a very furipus
ftate, in confequence of which he was con*
ftantly confined. He got little or no fleep
— during the greater part of the night he
was finging, or fwearing, or holding conver-
fations with perfons he imagined to be about
him: fometimes he would rattle the chain
with which he was confined for feveral hours
together, and tore every thing to pieces
within his reach. In the beginning of

Novem-

[ 44 ]

November the violence of his diforder fub*
fided for two or three days, but afterwards
returned ; and on the lothhe died compleatly
exhaufted by his exertions. — Upon opening
the head the pericranium was found firmly
attached; the pia mater was inflamed, though
not to any very confiderable degree ; the tunica
arachnoides in fome places was flightly (hot
with blood; the membranes of the brain, and
its convolutions when thefe were removed,
v^ere of a brown, or brownifh ftraw colour.
There was no water in any of the cavities of
the brain, nor any particular congeftion of
blood in its fubftance — the confiftence of
which was natural. He was opened twenty
hours after death.

CASE VL

B. H. was an incurable patient, who had
been confined in the houfe from the year

1788.

[ 45 ]

,1788, and for fome years before that time in
a private madhoufe. He was about fixty
years of age — had formerly been in the habit
of intoxicating himfelf. His chara6ler was
ftrohgly marked by pride, irafcibiHty, and
malevolence. During the four laft years of
his life he was confined for attempting to
commit fome violence on one of the officers
of the houfe. After this he was feldom
heard to ipeak ; yet he manifefted his evil
difpofition by every Ipecies of dumb infult.
Latterly he grew fulpicious, and would
fometimes tell the keeper that his vi6tuals
were poilbned. About the beginning of
December he was taken ill with a cousfh,
attended with copious expedloration. Being
then alked refpedling his complaints, he faid
he had a violent pain acrofs the ftomach,
which arofe from his navel ftring at his birth
having been tied too Ihort. He never fpoke
afterwards, though frequently importuned to

defcribc

[ 46 1

defcribe his complaints,. He died December

Upon dividing the integtfments of thc^
head, the pericranium was found fcarcely ta
adhere to the fculL On the right parietal
bone there was a large blotch, as if the bone
had been inflamed : there were others on dif-
ferent parts of the bone, but confiderably
Imaller. The glandulaer Pacchioni were un*
commonly large : the tunica arachnoides in
many places wanted the natural transparency
of that membrane ; there was a large deter-
mination of blood to the fubftance of the
brain : the ventricles contained about three
ounces of water ; the conliflence of the brain
was natural. He was opened two days after
death.

CASE

[ 47 ]

CASE VII.

A. M. a woman aged twenty-feven, was
admitted into the hoipital Auguft 15, 1795;
file had then been eleven weeks difordered*
Religious enthufiafm, and a too frequent
attendance on conventicles, were ftated to
have occafioned her complaint. She was in
a very miferable and unhappy condition, and
terrified by the mofl: alarming apprehen^ons
for the falvation of her foul. Towards the
latter end of September fhe appeared in a
convalefcent flate, and continued tolerably
well until the middle of November, when
fhe began to relapfe.

The return of her diforder commenced
with lofs of fleep. She alternately fang, and
cried the greatefl part of the night. She
conceived her infide full of the mofl loath-
fome vermin, and often felt the fenfation as

9 If

[ 48 ]

if they were crawling into her throat. She
was fuddenly feized with a ftrong and un-*
conquerable determination to deftroy herfelf j
liecamevery fenfible of her malady, a.nd faidy
that God had inflifled this punifhrnent on
her, from having (at fome former part of her
life) faid the Lord's Prayer backwards^ She
continued fome time in a reftfefs and forlora
ftate ; at one moment expeding the devil to
leize upon her and tear her to pieces ; in the
next, wondering that (he was not inftigated to
commit violence on the perfons about hen
On January 12, 1796, fhe died fuddenly.
She was opened twelve hours after death.
The thoracic and abdominal vifeera were
perfeftly healthy^

Upon examining the contents of the cra-
nium,the pia mater was confiderably inflamed,
and an extravafated blotch, about the lize af
a fhilling, was feen upon thst membrane,
near the middle of the right lobe of the

cere-

t 49 ]

cerebrum. There was no water between
the membranes, nor in the ventricles, but a
general determination of blood to the con-
tents of the cranium. The medullary fub-
ftance when cut into was full of bloody points*
The confiflence of the brain was natural*

CASE VIIL

M. W. a very tall and thin woman, forty-
four years of age, was admitted into the
hofpital September 19, 1795. Her diforder
was of fix months ftanding, and eight years
before ihe had alfo had an attack of this dif-
eafe. The caufe affio-ned to have brought it
on, the laft time, was the lofs of fome pro-
perty, the difeafe having fhortly followed that
circumftance. The conftant tenor of her
difcourfe was, that fhe fhould live but a Jfhort
time. She feemed anxioufly to wifh for her
diflfolution, but had no thoughts of accom-

E plifhing

\

plirtiing her own deftruftion. In the couric
of a few weeks fhe began to imagine, that
fome malevolent perfon had given her mer-
cury with an intention to deftroy her. She
was conftantly Ihewing her teeth, which had
decayed naturally, as if this efFect had been
produced by that medicine : at laft fhe infifted,
that mercurial preparations were mingled in
the food and medicines which were admini -
flered to her. Fler appetite w^as voracious
notwithftanding this belief. She had a con-
tinual thirft, and drank very large quantities
of, cold water.

On January 14., 1796, fhe had an apo-
pleiStic fit, well marked by flertor, lofs of
voluntary motion, and infenfibility to ftimuli.
On the following day fhe 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 fuh-
>^ance of the brain was loaded with blood.

When

[ 51 ]

When the medullary fubftance was cut into
blood oozed from it ; and upon fqueezing it a
greater quantity could be forced out. On the
pia mater covering the right lobe of the cere-
brum, were fome flight extravafations of
blood. The ventricles contained no water ;
on the plexus choroides were fome veficles of
the lize of coriander-feeds, filled with a yellow
fluid. The pericranium adhered firmly to
the fcull. The confiftence of the brain was
firmer than iifuaL

CASE IX.

E. D, a woman aged thirty -fix, was ad-
mitted into the hofpital February 20, 1795:
flie had then been difordered four months.
Her infanity came on a few days after havincr
been delivered. She had alfo laboured under
a.fimilar attack {even years before, which,

E 2 hke

[ 52 ]

like the prefent, fupervened upon the birth of
a child. Under the impreflion that
ought to be hanged, (he deftroyed her infant,
with the view of meeting with that punifh-
ment. When fhe came into the houfe, {he
was very fenfible of the crime (he had com-
mitted, and felt the moft poignant afBidion
for the aft. For about a month fhe conti-
nued to amend : after which time fhe be-
came more thoughtful, and frequently fpokc
about the child : great anxiety and reftlefs-
nefs fucceeded. In this ftate fhe remained
until April ^23, when her tongue became
thickly furred, the Ikin parched, her eyes
inflamed and glaffy, and her pulfe quick.
She now talked incoherently ; and, towards
the evening, merely muttered to herfelf.
She died on the following day comatofe.

She was opened about twenty-four hours
after death. The fcull was thick, the peri-
cranium fcarcely adhered to. the bone, the

dura

[ 53 ]

dura mater was alio but fiightly attached to
its internal Hirface. 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
confiderable accumulation of water. Th$
veins of the pia mater were particularly
turp-id. About three ounces of water were
contained in the lateral ventricles : the veins
of the membrane lining thefe cavities
were remarkably large and turgid with blood.
When the medullary fubilance of the cere-
brum and cerebellum was cut into, there
appeared a great number of bloody points.
The brain was of its natural Confidence.

CASE X.

C. M. a man forty years of age, was
admitted into the hofpital Dec. 26, 1795.

E3 It

[ 54 ]

It was ftatedy that he had been difordered two
months previous to his having been received
as a patient. His friends were unacquainted
with any caufe, which was hkely to have in-
duced the complaint. During the time he
was in the houfe he feemed fulky, or rather
ftupid. He never alked any queftions, and
if fpoken to, either replied fhortly, or turned
away without giving any anfwer. He ap-
peared to take little 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 fteps. He remained in this ftate until
the beginning of May, 1796, when his legs
became ^Edematous, and his abdomen fwollen.
He grew very feeble and helplefs, and died
rather fuddenly May 19th. He was opened
about forty-eight hours after death. The peri-
cranium and dura mater adhered firmly to the
fcuU ; in many places there was an opake
whitenefs of the tunica arachooides. About

foui'

[ 55 ]
four ounces of water were found in the ven-
tricles. The plexus choroides were uncom-
monly pale. The medullary fubftance,
afforded hardly any bloody points when cut
into. The confiftence of the brain I cannot
defcribe better than by faying, it was doughy.

CASE XL

S. M. a man thirty-fix years of age, wa^
admitted as an incurable patient in the year
1790. Of the former hiftory of his com-
plaint I have no information. As his habits,
which frequently came under my obferva-
tion, were of a fingular nature, it may not
here be improper to relate them. Having
at fome period of his confinement been mif-
chievoufly difpofed, and, in confequence, put
under coercion, he never afterwards found
himfelf comfortable when at liberty. When
he rofe in the morning he went immediately

E 4 to

[ 56 ]

to the room where he was ufually confined,
and placed himfelf in a particular corner,
until the keeper came to fecure him. If he
found any other patient had pre-occupied his
fituation, 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 himfelf throughout the
remainder of the day, by tramping or fliuffiing
his feet. He v/as conftantly muttering to

himfelf, of which fcarcelv one w^ord in a

•J

fentence was intelligible. "When an audible
expreffion efcaped him it was commonly an
imprecation. If a ftranger vifited him, he
always afked for tobacco, but feldom re-
peated his folicitation. He devoured his
food with avidity, and always muttered as he
ate.

In the month of July, 1 796, he v^as feizcd
with a diarrhoea, which afterwards termi-

L 57 ]

nated in dyfentery. This continued, not-
withftanding the employment of every
medicine ufually given in fiich a cafe, until
his death, which took place on September
23, of the fame year. He v/as opened
twelve hours after death. The fcull was
unufaally thin; the glandulae Pacchioni were
large and numerous : there was a very
general determination of blood to the brain :
the medullary fubftance, when cut, fhewed
an abundance of bloody points ; the lateral
ventricles contained about four ounces of
w^ater : the confiftence of the brain was
natural*

CASE XII.

E. R. was a woman, to all appearance
about eighty years of age, but of whoie
hiftory, before fhe came into the hofpital,
it has not been in my power to acquire

any

I S8 ]

any fatlsfaftory intelligence. She was an
incurable patient, and had been admitted
on that eftablifhment in February 1782.

During the time I had an opportunity of
obferving her, llie continued in the fame
ftate : fhe appeared feeble and childifh.
During the courfe of the day, (he fat in a
particular part of the common-room, from
which fhe never ftirred. Her appetite was
tolerably good, but it was requifite to feed
her. Except Ihe was particularly urged to
ipeak fhe never talked. As the fummer
declined fhe grew weaker, and died Oftober
19, 1796, apparently worn out. She was
opened two days after death. The fcull
was particularly thin ; the pericranium
adhered firmly to the bone, and the fcull- cap
was with diifEculty feparated from the dura
mater. There was a very large quantity of
water between the membranes of the brain:
the glandulae. Pacchioni were uncommonly

lar^e ;

[ 59 ]

large : the tunica arachnoidea was in mauy
places blotched and ftreaked with opacities :
when the medullary fubftance of the brain
was cut into, it was every where bloody; and
blood could be preffed from it, as from a
fponge. There were fome large hydatids
on the plexus choroides : in the ventricles
about a tea fpoonful of water was obferved :
the conliftence of the brain was particularly
firm, but it could not be called elaftic. There
were no lymptoms of general dropfy.

CASE XIII.

J. D, a man thirty-five years of age, was
admitted into the hofpital in Oftober 1796.
He was a perfon of good education, and had
been regularly brought up to medicine,
which he had pradifed in this town for feveral
years. It was ftated by his friends, that,
^bout two years before, he had fufFered a

fimilar

[ 6o ]

fimllar attack, which continued fix months :
but it appears from the obfervations of fome
medical perfons, that he never perfeftly
recovered from it, although he returned to
the exercife of his profeffion. A laborious
attention to bufinefs, and great apprehenfions
of the want of fuccefe, were affigned as
caufes of his malady. In the beginning of
the year 1796 the difeafe recurred, and be-
came fo violent that it was neceflary to
confine him.

At the time he was received into Bethlem
hofpital, he was in an unquiet ilate, got little
or no fleep, and was conftantly fpeaking
loudly : in general he was worfe towards
evening. He appeared little fenfible of
external objects : his exclamations were of
the moft incoherent nature.

During the time he was a patient
he was thrice cupped on the fcalp. After

each

[ 6i ]

each operation, he became rational to a
certain degree ; but thefe intervals were of a
ihort continuance, as he relapfed in the courfe
of a few hours. The fcalp, particularly at
the pofterior part of the head, was fo loofe
that a conliderable quantity of it could be
gathered up by the hand *• The violence
of his exertions at lafr exhaufted him, and,
on December ii, he died. He was opened
about twentv-four hours after death. There
was a large quantity of water between the
dura mater and tunica aracfinoidea, and alfo
between this latter membrane and the pia
mater. The arachnoid micmbrane was
thickened and opake ; the velTels of the pia
mater were loaded with blood : when the

* This appearance I have found frequently to occur in
maniacs who have fuiFered a violent paroxyfm of conli-
derable duration : and in fuch cafes, vi^hen there has been
an opportunity of infpecSting the contents of the cranium
after death, v/ater has been found between the dura mater
and arachnoid membrane.

medul-

i

[ 6z ]

medullary fubftance was cut into, it was very
abundarxt in bloody points : about three
ounces of water were contained in the lateral
ventricles : the plexus choroides were re-
markably turgid with blood : a quantity of
water was found in the theca vertebralis :
the confidence of the brain was natural.

CASE XIV.

J. C. a man aged fixty-one, was admitted
into the hofpital September 17, 1796. It
was ftated that he had been difordered ten
months. He had for thirty years kept a
public houfe, and had for fome time been in
the habit of getting intoxicated. His me-
mory was confiderably impaired : circum-
ftances were fo feebly imprelTed on his mind,
that he was unable to give any account of
the preceding day. He appeared perfeflly
reconciled to his fituation, and conducted
6 himfelf

L 63 J

himfelf with order and propriety* As he
feldom fpoke but when interrogated, it was
not poffible to colled his opinions. In this
quiet ftate he continued about two .months,
when he became more thoughtful and ab-
ftraded, walked about with a quick flep, and
frequently ftarted, as if (liddenly interrupted.
He was next feized with trembling, ap-
peared anxious to be releafed from his con-
finement : conceived at one time that his
houfe was filled with company; at another
that different people had gone off without
paying him., and that he ihould be arrefted
for fums of money which he owed. Under
this conftant alarm and difquietude he con-
tinued about a week, when he became fullen
and refufed his food. When importuned to
take nourifhment, he faid it was ridiculous to
offer it to him, as he had no mouth to eat it:
though forced to take it, he continued in the
fam^ opinion ; and when food was put into
his mouth, inlifted that a wound had been

mads

[ 64 i

in^de ill his throat, in order to force it into
his ftomach. The next day he complained
of violent pain in his head, and in a few
minutes afterwards died. He was opened
twelve hours after death. There was a
large quantity of water between the tutiica
arachnoidea and pia mater ; the latter mem-
brane was much iuffufed with blood, and
many of its veffels were conliderably en-
larged : the lateral ventricles contained at
leafl: (ix ounces of water : the brain was very
firm.

CASE XV,

J. A. a man forty-two years of age, was
firft admitted into the houfe on June 27,
1795. His difeafe came on fuddenly Vvhilft
he was working in a garden, on a very hot
day, without any covering to his head. He
had fome years before travelled with a gentle-
man

■ C 65 ]

man over a great part of Europe : his ideas
ran particularly on what he had feen abroad ;
ibmetimes he conceived himfelf the kins: of
Denmark, at other times the king; of France.
Although naturally dull and wanting common
education, he profefled himfelf a mafter of
all the dead and living languages; but his
moil intimate acquaintance was with the old
French; and he was perfuaded he had fome
faint recolle£tion of coming over to this
country with William the Conqueror. His
temper was very irritable, and he was dif-
pofed to quarrel with every body about him.
After he had continued ten months in the
hofpital, he became tranquil, relinquifhed his
ablurdities, and was cjifcharged well in June
1796. He went into the country with his
wife to fettle fome domeftic affairs, and in
about fix weeks afterwards relapfed. He
was readmitted into the hofpital Auguft

He

I 66 3

He now evidently had a paralytic affeftion i
his :^eech was inarticulate, and his mouth
drawn afide* He fhortly became ftupid, his
legs fwelled and afterwards ulcerated : at
length his appetite failed him; he became
emaciated, and died December 27th, of the
fame year.. The head was opened twenty
hours after death. There was a greater
quantity of water between the different
meml3ranes pf the brain than has ever occur-
red to me. The tunica arachnoide^ wa^
generally opake and very much thickened ;
the pia mater was loaded with blood, and the
veins of that membrane were particularly
enlarged^ On the fore-part of the right
hemifphere of the brain, when ftripped of
its membranes, there was a blotch, of a brown
<^olour, feveral fhades darker than the reft of
the cortical flibftance: the ventricles Were
much enlarged, and contained, by eftiitiation,
at leaft lix ounces of water. The veiiis in
thefe cavities were particularly turgid.

The

[ 67 ]

The confiftence of the brain was firmer thaa
^fiiaL

CASE XVL

J. H. a man aged forty-two, was admitted
into the houfe on April 12, 1794. He had
then been difordered two months : it was a
family difeafe on his father's fide. Having
manifeflied a mifchievous dilpofition to fome
of his relations, he was continued in the hof-
pital upon the incurable efl:abliftiment.
His temper was naturally violent, and he
was eafily provoked. As long as he was kept
to any employment he conduced himfelf
tolerably well; but when unoccupied, would
walk about in a hurried and diftraSed
manner, throwing out the moft horrid threats
and imprecations* He would often appear
to be holding converfations : but thefe confer-
ences always terminated in a violent quarrel

F 2 between

[ 68 3

between the imaginary being and himfelf»
He conftantly fuppofed unfriendly people
were placed in different parts of the honfe to
torment and annoy him. However violently
he might be conteftijig any fubjeft with thefc
fuppofed enemies, if direfted by the keepers
to render them miy affiftance, he immediately
gave up thp dilput^ and went with alacrity,
As he got but little fleep, the greateft part of
the night was Ipent in a very noify and
riotous manner^ In this ftate he continued
until April 1 796, when he was attacked with
a paralytic affeftion, which deprived him of
the ufe of the left fide. His articulation was
now hardly intelligible ; he became childifh,
got gradually weaker, and died Deceipber
28, 1796. He was opened twenty-four
hours after death. There was a general
opacity of the arachnoid coat., and a imall
quantity of water between that merjibrane
and the pia mater 5 the ventricles were much
enlarged and contained a confiderable quantity

[69 ]

bf water, by eftimation four ounces : the
conlifience of the brain was natural.

CASE XVIL

JM; G. a woman about fifty years of age^
had been admitted on the incurable eftablifli-
ment in July 1785. She had for fome years
before been in a difordered ftate, and was
confidered as a dangerous patient. Her
temper was violent ; and if interrupted in her
ulual habits, flie became very furious. Like
many others among the incurables, fhe was
an infulated being : fhe never fpoke except
when difturbed. Her greateft delight ap-
peared to be in getting into fome corner to
fleep ; and the interval between breakfafl and
dinner^ was ufually paft in this manner. At
other times fhe was generally committing
fome petty mifchief, fiach as flyly breaking a
window^ dirtying the rooms of the o^her

F 3 patients.

^'

[ 7° ]

patients, or purloining their provifions. She
had been for feme months in a weak and
declining ftate, but would never give any
account ,of her complaints. On January 5,
1797, /he died, apparently worn out. The
head was opened three days after death.
The pericranium adhered but flightly to the
fcull, nor was the dura mater firmly attached.
There was water between the membranes of
the brain ; and the want of tranfparency of
the tunica arachnoidea, indicated marks of
former inflammation. The pofterior part
of the hemifpheres of the brain was of
a brownifh colour. In this cafe there
was a confiderable appearance of air in the
veins; the medullary fubftance, when cut,
^as full of bloody points : the lateral ventri-
cles were fmall, but filled with water ; the
plexus choroides were loaded with veficles of
a much larger fize than ufual : the confiftenee
of the bram was natural.

CASE

i 7^ 1

CASE XVIIL

S. Tr. a woman aged fifty-feven, was ad-
mitted into the houfe January 14, 1797- It
was jftated by her friends, that fhe had been
difordered eight months : they were tmac-
quainted with any caufe, which might have
induced the difeafe. She had evidently
fufFered a paralytic attack, which confider-
ably afFefted her fpeech, and occafioned her
to walk lame with the right leg. As fhe
avoided all converfation, it was not poffible to
colled any further account of her cafe.
Three days after her admiffion, Ihe had an-
other paralytic ftroke, which deprived her
entirely of the ufe of the right fide. Two
days afterwards fhe died. She was opened
forty-eight hours after death. There was a
fmall quantity of water between the tunica
arachnoidea and pia mater, and a number of

F 4 ^ opake

[ 72 3
©pake fpots on the former membrane.
On the pia mater covering the pofterior part
of the left hemilphere of the brain, there was
an extravafated blotch, about the fize of a
ihilling^: the medullary fubftancc was unu-
fually loaded with blood : the lateral ventricles
Were large, but did not contain much water:
the confiftence of the brain was very foft.

CASE XIX, .;!

W. C* a man aged fixty-three, was ad-
mitted into the hofpital January 21, 1797-
The perfons, who attended at his admiffion^
depofed, that he had been difordered five
months ; that he never had been infane
before, and that the difeafe came on fhortly
after the death of his fon. He was in a:
very anxious and miferable ftate. No per-
fuafion coiild induce him to take nouriih-
ment; and it was with extreme difficulty that

any

[ 73 3

any food could be forced upon hinn. lit
paced about with an hurried ftep ; was often
fuddenly ftruck \\'ith the idea of having im-
portant bufinefs to adjuft in fome diftant
place, and which would not admit of a mo-
ment's delay. Prefently after, he would
conceive his houfe to be on fire, and would
haftily endeavour to refcue his property from
the flames. Then he would fancy that his
fon was drowning, that he had twice fiink :
he was prepared to plunge into the river to
fave him, as he floated for the laft time:
every moment appeared an hour until he rofe.
In this miferable ftate he continued till the
27th, when, with great perturbation, he fud-
denly ran into his room, threw himfelf oa
the bed, and in a few minutes expired. The
headwas opened twenty-fourhours after death..
The pericranium was but flightly adherent
to the fcull: the tunica arachnoidea, particu-
larly where the hemifpheres meet, was of
a milky whitenefs. Between this membrane,

which

74 ]

#hicli was forrievvhat thickened, and the pil
mater^ there was" a very large colleftioit of
water : the pia mater was inflamed r the
veins of this membrane were enlarged htfbiid
what I had ever before obferved : there wai
a flriking appearance of air in the veilis : the
medullary fiibftance of the brain^ when cut
into, bled freely, and feemed fpungy from the
number and enlargement of it^ v^ffel^: hi
the ventricles^ which were of a natural capa-
city, there was about half an ounce of water ^
the brain was of a healthy donfiftence^

CASE XX.

M. L. a woman aged thirty-eight, was
admitted into the houfe June ii, 1796;
From the information of the people who had
attended her^ it appeared, that ihe had been
difordered fix weeks, and that the difeafe
took place fhortly after the death of her

hufband.'

[ 75 ]

hufband. At the firft attack fhe was violenf,
but (he foon became more calm. She conceived
that the overfeers of the parifh, to which flie
belonged, meditated her definition : after-
w^ards fhe fuppofed them deeply enamoured
of her, and that they were to decide their
claims by a battle. During the time fhe
continued in the hofjDital fhe was perfe6tly
quiet, although very much deranged* She
fancied that a young man, for whom fhe had
formerly entertained a partiality, but who
had been dead fome years, appeared fre-
quently at her bed-fide in a ftate of putrefac-
tion, which left an abominable ftench in her
room. Soon after fhe grew fulpicious, and
became apprehenfive of evil intentions in the
people about her. She would frequently
watch at her door, and, when afked the
reafon, replied, that fhe was fully aware of a
defign, which had been formed, to put her
fecretly to death. Under the influence of
thefe opinions fhe continued to her death,

which
9

i 76 ]

which took place on February 8, 1797^ id
confequence of a violent rheumatic fever*
She was opened twelve hours after death;
There were two opake fpots on the
tunica arachnoidea .' the pia mater was
{lightly inflamed : there was a general eon-
sreftion of blood in the who^le contents of
the cranium : the confiftence of the brain
did not differ from what is found in an healthy
ftate.

. CASE XXI. '

H. C, a woman of about lixty-five year^
of age, had been admitted on the incurable
eftablifliment in the year 1788^ I have not
been able to colle6l any particulars of her
former hiftory. During the time I had an
opportunity of feeitig her, Ihe continued in a
very violent and irritable ftate : it was her
cuftom to abufe every one who came near

her^

\

her. The greateft part of the day wa$
pafled in curfing the perfons fhe faw about
her ; and when no one was near, (he ufually
muttered fbme blafphemy to herfelf. She
died of a fever on February 19, 1797, on the
fourth day after the attack. She was opened
two days after death. The arachnoid
jnembrane was, in many parts, without its
natpral tranfparency : the pia mater was
generally fiifFufed with blood, and its velfels
were enlarged : the eonfiftence of the brain
was firm.

CASE XXIJ.

J. C. a man aged fifty, was admitted into
the hofpital Auguft 6, 1796. It was ftated
that he had been difordered about three
weeks, and that the difeafe had been induced
by too great attention to bufinefs, and the
want of fufficient reft. About four years

before

[ 78 ]
before^ he had been a patient, and was dif*
charged uncured. He was an artful and
deligning man, and with great ingenuity once
efFefted his eicape from the hofpital. His
time was rnoftly paiTed in childifh amufev
ixients, fuch as tearing pieces of paper and
flicking them on the walls of his room, col-
le6ling rubbifh and afforting it. However,

' when he conceived himfelf unobferved, he
was intriguing with other patients, and in^
ftru£ling them in the means, by which, they

'might efcape. Of his diforder he feemed
highly fenfible, and appeared to approve 'fo
much of his confinement, that when his
friends wifhed to have him releafed, he op-
pofed it, except it fhould meet with my
approbation; telUng them, in my prefence,
that although, he might appear well to them,
th€ medical people of the houfe, were alone
capable of judging of the aftual ftate of his
mind; yet I afterwards difcovered,that he had
inftigated them to propure his enlargement,

[ 79 3

by a relation of the groffeft falfhoods and un^
juflt complaints. In April 1797, he was
permitted to have a month's leave of abfence,
as he appeared tolerably well, and wifhed to
inain^ain his family by his induftry. For
above three weeks of this time, he conduced
Jiimfelf in a very rational and orderly manner.
The day preceding that, on which he was to
have returned thanks, he appeared gloomy
and fufpicious, and felt a difinclination for
work. The night was paffed in a reftlefs
manner, but in the morning he feemed better,
and propofed coming to the hoipital to obtain
jhis difcharge. His wife having been abfent
for a few minutes from the room, found him,
on her return, with his throat cut. He was
Te»admitted as a patient, and exprelTed great
forrow and penitence for what he had done ;
and faid that it was committed in a moment of
rafhnefs and defpair. After a long and
piinute examination, he betrayed nothing in-
coherent in his difcourfc. His wound, from

which

8o

which it was ftated, that he had loft a large
quantity of blood, was attended to by Mr.
Crowther, the furgeon to the holpital.
Every day he became more dilpirited, and
at laft refufed to Ipeak. He died May 29th,
about ten days after his re-admiffion. His
head was opened two days after death.
There were fome flight opacities of the
tunica arachnoides, and the pia mater was a
little inflamed : the other parts of the brain
were in an healthy ftate^ and its cpnliftence
nature}.

CASE XXIIL

E. L. was a man about feventy-eight
years of age ; had been admitted on the in-
curable eftablifliment January 3, 1767. By
report, I have underftood that he was for-
merly in the navy, and that his infanity was
caufed by a difappointment of fome promo-
tion

[ Bi ]

tion which he expected. It was alfo faid
that he was troublefome to fome perfonshigh
in office, which rendered it neceflary that he
fhould be confined. At one time he inia-
gined himfelf to be the king, and infifled on
his crown. During the time I had an op-
portunity of knowing him, he conduced him-
felf in a very gentlemanly manner. His
difpofition was remarkably placid, and I never
remember him to have uttered an unkind or
hafty expreffion. With the other patients he
feldom held any converfation. His chief
amufement was in reading, and writing let-
ters to the people of the houfe. Of his books
he was by no means choice ; he appeared to
derive as much amufement from an old
catalogue as from the moft entertaining per-
formance. His writings always contained
diredlons for his releafe from confinement ;
and he never omitted his high titles of
God^s King, Holy Ghoft, Admiral and Phy-
sician. He died June 13, 1797, worn out

G with

[ 82 ]

with age. He was opened two days after
death. The fcuU was thick and porous*
There was a large quantity of water between
the different membranes. The membrana
arachnoidea was particularly opake : the
veins feemed to contain air : in the medul-
lary fubflance the veffels were very copious
and much enlarged : the lateral ventricles
contained two ounces of pellucid water : the
confiftence of the brain was natural.

It has been ftated by a gentleman of great
accuracy, and whofe fituation affords him
abundant opportunity of acquiring a know-
ledge of difeafed appearances, that the fluid
of hydrocephalus appears to be of the iame
nature with the water which is found in
dropiy of the thorax and abdomen*. That
this is generally the cafe, there can be no
doubt, ffois^vthe refpeftable teftimony of the

* Morbid Anatomy, page ^04.

author

[ 83 3

author of the Morbid Anatomy. But in
three inftances, where I fubmitted this fluid
to experiment, it was incoagulable by acids
and by heat : in all of them its confiftence
was not altered even by boiling. There was,
however, a cloudinefs produced; and after
the liquor had flood fome time, a flight depo-
sition took place of animal matter, which,
prior to the application of heat or mineral
acids, had been difTolved in the fluid. This
liquor tinged green the vegetable blues : pro-
duced a copious depofition with nitrat of
filver, and on evaporation afforded cubic
cryftals (nitrat of foda). From this exami-
nation it was inferred, that the water of the
brain, collefted in maniacal cafes, contained
a quantity of uncombined alkali and fome
common fait. What other fubftances may
enter into its compofition, from want of fuf-
ficient opportunity, I have not been enabled
to determine.

G 2 CASE

I 84 ]

CASE XXIV.

S. W. a woman thirty-five years of age,
was admitted into the hofpital June 3, 1797?
It was ftated that ilie had been one month
difordered, and had never experienced any
prior afFedlion of the fame kind. The dif-
eafe was laid to have been produced by mif-
fortunes which had attended her family, and
from frequent quarrels with thofe who com-
pofed it. She was in a truly melancholy
ftate ; fhe was loft to all the comforts of this
life, and conceived herfelf abandoned for
ever by God. She refufed all food and
medicines. In this wretched condition ihe
continued until July 29th, when flie loft the
ufe of her right fide. On the 30th flie became
lethargic, and continued fo until her death,
which happened on Auguft the 3d, She was
opened two days after death. There was a

large

[ 85 1

large colledlion of water between the different
membranes of the brain, amounting at leaft
to four ounces : the pia mater was very much
inflamed, and was feparable from the convo-
lutions of the brain with unufual facility : the
medullary fubftance was abundantly loaded
with bloody points : the confiftence of the
brain was remarkably firm.

CASE XXV.

D. W. a man about fifty-eight years of
age, had been admitted upon the incurable
eftablifhment in 1789. He was of a violent
and mifchievous difpofition, and had nearly
killed one of the keepers at a private mad-
houfe, previoufly to his admiffion into the
holpital. At all times he was equally de-
ranged refpefting his opinions, although he
was occafionally more quiet and tradable :
thefe intervals were extremely irreo:ular as to

G 3 their

[ 86 ]

their duration and period of return. He was
of a very conftipated habit, and required large
dofes of cathartic medicines to procure ilools.
On Auguft 3, 1 797, he was in a very furious
ftate; complained of coftivenefs, for v/hich
he took his ordinary quantity of t)pening
phyfic, which operated as ufual. On the
fame day he ate his dinner with a good ap-
petite ; but about fix o'clock in the evening
he was ftruck with hemiplegia, which de^
prived him completely of the ufe of his left
fide. He lay infenlible of what palTed about
him, muttered conftantly to himfelf, and
appeared to be keeping up a kind of conver-
fation. The pulfe was feeble, but not op^
preflTed or intermitting. He never had any
ftertor. He continued in this ftate until the
I ^th, when he died. He was opened twelve
hours after death. There was fome water
between the tunica arachnoidea and pia
mater : the former membrane was opake in
many places ; bearing the marks pf former in-
flammation :

[ 8/ ]

flammation : in the veins of the membrane^
of the brain there was a confiderable appear-
ance of air, and they were likewife particu-
larly charged with blood : the veffels of the
medullary fubftance were numerous and
enlarged. On opening the right lateral
ventricle, which was much diftended, it was
found filled with dark and grumous blood ;
fome had alfo efcaped into the left, but in
quantity inconfiderable when compared with
what was contained in the other : the con«
fiftence of the brain was very foft.

CASE XXVI.

J. S. a man forty-four years of age, was
received into the hofpital June 24, 1797-
He had been difordered nine months previous
to his admifiion. His infanity was attributed
to a violent quarrel, which had taken place
with a young woman, to whom he was

G 4 attached^

[ 83 3

attached, as he fhortly afterwards became
fullen and melancholy.

During the time he remained in the honfe
he feldom Ipoke, and wandered about like a
forlorn perfon. Sometimes he would fud-
denly flop, and keep his eyes fixed on an
objeft, and continue to flare at it for more
than an hour together. Afterwards he be-
came ftupid, hung down his head, and dri-
velled like an ideot. At length he grew
feeble and emaciated, his legs were fwollen
and oedematous, and on September 13th,
after eating his dinner, he crawled to his
room, where he was found dead about an
hour afterwards. He was opened two days
after death. The tunica arachnoidea had a
milky whitenefs, and was thickened. Inhere
was a confiderable quantity of water between
that membrane and the pia mater, which
latter was loaded with blood : the lateral
^ventricles were very much enlarged, and

contained,

t 89 ']

contained, by eftimation, about fix ounces of
tranfparent fluid : the brain was of its uatu-
ral confiflence.

CASE XXVIL

T. W. a man thirty- eight years of age,
was admitted into the houfe May 16, 1795.
He had then been difordered a yean His
difeafe was ftated to have arifen, from his
having been defrauded, by two of his near
relations, of fome property, which he had
accumulated by fervitude. Having remained
in the hofpital the ufual time of trial for cure,
he was afterwards continued on the incurable
eftabliftiment, in confequence of a ftrong
determination he had always fhewn, to be
revenged on thofe people who had difpofed
of his property, and a declared intention of
deftroying himfelf. He was in a very mifer-
able flate, conceived that he had offended

God,

[ 9° ]

God, and that his foul was burning in Hell,
Notwithftanding he was haunted with thefe
dreadful imaginations, he afted with pro-
priety upon moft occafions. He took delight
in rendering any affiftance in his power to
the people about the houfe, and waited on
thofe who were fick, with a kindnefs that
made him generally efteemed. At fome
period of his life he had acquired an unfor-
tunate propenfity to gaming, and whenever
he had colle£led a few pence, he ventured
them at cards. His lofTes were borne with
very little philofophy, and the devil was
always accufed of fome unfair interpofition.

On September 14, 1797, he appeared
jaundiced, the yellownefs daily increafed, and
his depreffion of mind was more tormenting
than ever. From the time be was firll: at-
tacked by the jaundice he had a ftrong pre-*
fentiment that he fhould die. Although he
took the medicines which were ordered, as a

mark

[ 91 3

mark of attention to thofe who prelcrib^d
them, he was firmly perfaaded they could be
of no fervice. The horror and anxiety h^
felt was, he faid, fufficient to kill him inde-
pendantly of the jaundice.

On the 20th he was drowfy, and on the
following day died comatofe. He was
opened twenty-fout hours after death. la
fome places the tunica arachnoides was
{lightly opake : the pia mater was inflamed;
and in the ventricles were found about two
tea-fpoonsful of water tinged deeply yellow,
and the velicles of the plexus choroides were
of the fame colour : in the whole contents of
the cranium there was a confiderable con-
geftion of blood : the confiftence of the brain
was natural : the liver was found : the gall-
bladder very much thickened, and contained
^ ftone of the mulberry appearance, of a
white colour. Another ftone was alfo found
in the dugdeuum.

CASE

[ 9^ ]

- CASE XXVIII.

R. B. a man fixty-four years of age, was
admitted into the hofpital September 2, 1 797.
He ha4 then been difordered three months. It
was allb ftated, that he had fufFered an attack
of this difeafe feven years before, which then
continued about two months. His diforder
had, both times, been occafioned by drinking
fpirituous liquors to excels. He was a per-
son of Hberal education, and had been occa-
fionally employed as uiher in a fchool, and at
other times as a librarian and amanuenfis.
When admitted he was very noify, and im-
portunately talkative. During the greateft
part of the day he was reciting paflages from
the Greek and Roman poets, or talking of
his own literary importance. He became fb
troublefome to the other madmen, who were
fufficiently occupied with their own fpecula-

tions,

[ 93 ]

fpeculatlons, that they avoided, and excluded
him from the common room ; fo that he was,
at laft, reduced to the mortifying fituation,
of being the fole auditor of his own compo*
fitions.

He conceived himfelf very nearly related
to Anacreon, and pofTefTed of the peculiar
vein of that poet. He alfo fancied that he
had difcovered the longitude, and was very
urgent for his liberation from the hofpital,
that he might claim the reward, to which
his difcovery was intitled. At length he
formed fchemes to pay off the national debt :
thefe, however, fo much bewildered him that
his diforder became more violent than ever,
and he was in confequence obliged to be con-
fined to his room. He now, after he had
remained two months in the houfe, was more
noily than before, and got hardly any fleep.
Theft exertions very much reduced him.

In

[ 94 ]

In the beginning of January 1798, hi^
conceptions were lefs diftinft, and although
his talkativenefs continued, he was unable to
conclude a iingle fentence. When he began
to fpeakjhis attention was diverted by the firft
objed which caught his eye, or by any found
that ftruck him. On the 5th he merely
muttered ; on the 7th he loft the ufe of his
right fide, and became ftupid and taci-
turn. In this ftate he continued until the
1 4th, when he had another fit ; after which,
he remained comatofe and infenfible. On
the following day he died. He was opened
thirty-fix hours after death. The pericra-
nium adhered very loofely to the fcuU : the
tunica arachnoldea was generally opake, and
fufFufed with a brownifii hue : a large
quantity of water was contained between it
and the pia mater : the contents of the era*
nium were unufually deftitute of blood : there
was a confiderable quantity of water (perhaps
four ounces) in the lateral ventricles, which

were

C 95 ]

were very much enlarged : the confiftencc of
the train was very foft.

CASE XXIX.

E. T. a man aged thirty years, was admit-
ted a patient July 23, 1796. The perfons
who attended related, that he had been dil^
ordered eleven months, and that his infanity
fhortly fupervened to a violent fever. It
alfo appeared, from fubfequent enquiries,
that his mother had been affefted with
madnefs.

He was a very violent and mifchievous^
patient, and pollefled of great bodily ftrength
and a6Uvity. Although confined, he con-
trived feveral times during the night to tear
up the flooring of his cell ; and had alio de-
tached the wainfcot to a confiderable extent,
and loofened a number of bricks in the wall.

When

[ 96 ]

When a new patient was admitted, he gene-
rally enticed him into his room, on pretence
of being an old acquaintance, and, as foon as
he came within his reach, immediately tore
his clothes to pieces. He was extremely
dexterous with his feet, and frequently took
off the hats of thofe who were near him with
his toes, and deftroyed them with his teeth.
After he had dined he generally bit to pieces
a thick wooden bowl, in which his food was
ferved, on the principle of fharpening his
teeth againft the next meal. He once bit
out the tefticles of a living cat, becaufe the
animal was attached to fome perfon who had
offended him. Of his diforder he appeared
to be very fenfible ; and after he had done
any mifchief, always blamed the keepers for
not having fecured him fo, as to have pre-
vented it. After he had continued a year in
the hofpital he was retained as an incurable
patient- He died February 17, 1798,
in confequence of a tumor of the neck.

He

[ 97 ]
He was opened two days after death. The
tunica arachnoides was generally opake, and
of a milky whitenefs : the velTels of the pia
mater were turgid, and its veins contained a
quantity of air ; about an ounce of water was
contained in the lateral ventricles : the con-
fiftence of the brain was unufually firm and
poffeired of coniiderable elafticity : it is the
only inftance of this nature which has fallen
mider my obfervation.

JH CHAP.

E 9S 1

CHAP, III.

ON THE CAUSES OF INSANITY, ^

WHEN patients are admitted into Beth-
lem Hofpital, an enquiry is always made of
the friends who accompany them, refpe6ling
the canfe fuppofed to have occafioned their
infanity, ,

It will readily be conceived that tKerq
mufl: be great "uncertainty attending the in-
formation we are able to procure upon this
head : and even fr*om the moft accurate
accounts, it would be difficult to pronounce,
that the circumftances which are related to
us have adually produced the efFe£t, The
friends and relatives of patients are, upon
many occafionsj ver^ delicate upon this

pointj

^

I 99 ]
point, and cautious of expoling their frailties
or immoral habits : and when the difeafe is a
family one, they are oftentimes ftill niore
jefcrved in difclofing the truth.

Fully aware -of the incorre£l ftatement
frequently made concerning thefe caufes, I
Jbave been at no inconliderable pains to correft
or confirm the firil information , by fubfequent
enquiries^

The caufes which I have been enabled
moft certainly to afcertain, may be divided
into phyjical and moral.

Under the firft are comprehended rejieated ^
intoxication ; blows received upon the head ;
fever, particularly when accompanied with
delirium ; mercury largely or injudicioufly
adminiftered ; the fuppreffion of periodical
^r occafional difcharges and fecretions ; here*
iltary dilpofition, and paralytic affedions,

H2 By

[ lOO ]

By the fecond clafs of caufes, which I
have termed morale are meant thofe which
are appHed djreftly to the mind. Such are
the long endurance of grief, ardent and un-
gratified defires, rehgious terror, the difap-
pointment of pride, fudden fright, fits of
anger^ profperity l^umbled by misfortunes ^ :
in fhort, the frequent and uncurbed indul-
gence of any paffion or emotion, and any
fudden and violent afFe£lion of the mind.

There are, doubtlefs, many other caufes of
both claffes which may tend to produce the
difeafe, Thofe which have been ftated arc
fuch as I am moft familiar with ; or, to fpeak
more accurately, fuch are the circumftances
jfnoil: generally found to have preceded this
affeSion.

•* u

Neflun maggior dolpre.

" Che ricordarfi del tempo felice

f^ Nella miferia." Dante.

Th(

i loi ]

The greatefl: number of thefe moral caufes
may, perhaps, be traced to the errors of
education, which often plant in the youthful
niind thofe feeds of madnefs, which the
llighteft cireumftanees readily awaken into
growth.

It fhould be as much the obje6l of teacher^
cf youth, to fubjugate the paffions, as to dif-
ciphne the intelle6t. The tender mind
fhould be prepared to expe6l the natural and
certain efFefts of caufes : its propenfity to
indulge an avaricious thirft for that which is
unattainable fhould be quenched : nor fhould
it be fuffered to acquire a fixed and invin-
cible attachment to that which is fleetins: and
perifhable.

Of the more immediate, or, as it is gene-
rally termed, the proximate caufe of this
difeafe, I profefs to know nothing. When-
ever the funftions of the braui fhall be fully

H 3 under-

tinderftcod, and the ufe of its different parts
afcertained, we may then be enabled to-
judge, how far difeale, attacking any of thefe
parts, may increafe, diminifli, or otherwife
alter its furiflions. But this appears a degree
of knowledge which we are not likely fooii:
to attain. It feems, however, not improba-
ble that the only fource from whence the
moft copious and certain information can be
draiwn, is a laborious attention to the parti*
cular appearances which morbid ftates of this^
organ may prefent.

From the preceding diiTeSions of infane
perfons, it may be inferred, that madnefs has
always been conne&d with difeafe of the
brain, and of its membranes, Thefe cafes
have not been fele6l!ed from a variety of
jrthers, but comprize the entire number
which have fallen under my obfervation^
Having no particular theory to build up>

thej

9

I 1^3 3

tKey have been related purely for the advanc€»
merit of fcience and of truth.

It may be a matter affording much diver-
fity of opinion, whether thefe morbid ap-
pearances of the brain be the caufe or the
effe6l of madnefs : it may be obferved, that
they have been found in all ftates of the
difeafe. When the brain has been injured
from externa:l violence, its fun6lions have
been generally impaired if inflammation of
its fubftance, or more delicate membranes has
enliied. The fame appearances have for the
moft part been dete6ied when patients have
died of phrenitis, or in the delirium of fever :
in thefe inftances the derano-emerit of the
intelle6iual funftions appears evidently to
have been caufed by the inflammation, if
in mania the fame appearances be found,
there will be no' neceffity of calling in the aid
of other caufes to account for the effeft ;
indeed it would be difficult to dtfcover them.

H 4 Thofe

[ i^4 ]

Thofe who entertain an oppofite opinioit,
are obliged to fuppofe, a difeafe of the fnind.
Such a morbid afFeftion, from the hmited
nature of my powers, perhaps I have never
been able to conceive. Pofleffing, however,
little knowledge of metaphyfical contrcverfy,
I fhall only offer a few remarks upon this
part of the fubjeft, and beg pardon for having
at all touched it.

Perhaps It is not more difficult to fuppofe
that matter peculiarly arranged may tkinkj
than to conceive the union of an immaterial
being with a corporeal fubftance. It is
queftioning the infinite wifdom and power of
the Deity to fay, that he does not, or cannot
arrange and organize matter fo that it Ihall
think. When we find infanity, as far as has
hitherto been obferved, uniformly accompa-
nied with difeafe of the brain, is it not more
juft to conclude, that fuch organic affe61ion
, has produced this incorreft affociation of
^ - ideas.

[ 105 ]

ideas, than that a being, which is immaterial,
incorruptible and immortal, fliould be fubjedl
to the grofs and fubordinate changes which
matjpr necefTarily undergoes ?

But let us imagine a dlfeafe of ideas. In
what manner are we to efFe6l a cure ? To
this fubtle Ipirit the do6tor can apply no
medicines. But though fo refined as to elude
the force of material remedies, fome may
however think that it may be reafoned with.
The eood efFe6ts which have refulted from
exhibiting logic as a remedy for madnefs,
muft be lufficiently known to every one who
has converfed with infane perfons, and mufl
be confidered as time very judicioufly em-
ployed : fpeaking more gravely, it will
readily be acknowledged, by perfons acquaint-
ed with this difeafe, that if infanity be a
difeafe of ideas, we pclfefs no corporeal
remedies for it : and that to endeavour to
convince madmen of their errors, by reafon-

i io6 ]

irig, is folly in thofe wKo attempt it, fincfi
there is always in madnefs the firmeft con'^
iiftion of the truth of what is faffe, and
which the clearefl: and moll eircumflantial
evidence cannot remove,;

dN THE PioBABLE EVEJSfT OF THE
DISEASE*

THE prediftion of the event in cafes of
inlani ty mull be the reliilt of accurate and
exteniive experience ; and even then it will
be a matter of very great uncertainty. The
praftitioner can only be led to fuppofe that
patients of a particular defcription will
recover j- from knowings that under the fame
circumllances, a certain number have been
aftually rellored to health.

The praffice of an individual, however
adive and indultrious he may bc;^ is inlliffi-

cient

t ^^1 ]

eient to accum-ulate a frock of fads, neceflary
to form the ground of a regular and correft
prognofis : it is therefore to be wiflied, that
thofe who exclufively confine themfelves to
this department of the profeffion, woijd oc-
cafionally communicate to the world the
refult of their obfervations. Phyficians at-
tending generally to difeafes, have not been
referved in imparting to the public the
amount of their labours and fuccefs ; but
with regard to this diforder^ thofe who have
devoted their whole attention to its treat-
ment have either been negligent of cautious
of giving information refpeding it. When-
ever the powers of the mind are concentrated
to one objed, we may naturally expeft a
more rapid progrefs in the attainment of
knowledge ; we have therefore only to
lament the want of obfervations upon this
ilibjeft, and endeavour to repair it. The
records of Bethlem Hofpital have afforded
xne fame f^itisfadory information; though far

from

from file whole of what I wiihcd to obtain*
Prom them and my own obfervation$ the
prognofis of this difeafe is, with great diffi-
<Jence, fubmitted to the reader.

In our own climate Womefi are more fre-
quently afFeded wtth infanity thart men.
Several perfons who iiiperintend private
mad-houfes have aflured me, that the number
of females brought in annually confidefably
exceeds that of the males. From the year
1748^ to 1794, comprizing a period of
forty-fix years, there have been admitted into
Bethlem Hofpital 4832 women, and 4042
men. The natural proceffes which women
undergo, of menftruation, parturition, and of
preparing nutriment for the infant, togethef
with the difeafes to which they are fubje6l at
thefe periods, and which are frequently
remote caufes of infanity, may, perhaps, ferve
to explain their greater difpofition to this
malady. As to the proportion in which

they

[ 109 ]

they recover, compared with males, it may
J)e ftated, that of 4832 women afFefted,
1402 were difcharged 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 thofe who are dif-
.charged, a certain number of thofe cured
occafionally relapfe; and fome of thofe who
iare difcharged uncured afterwards recover:
perhaps in the majority of inftances, where
they relapfe, they are fent back to Bethlem.
To give fome idea of the number fo read-
piitted^ it may be mentioned, that, during the
laft two years, there have been admitted
389 patients, ^^ of whom had at fome for-
mer time been ir) the houfe. There are fuch
a variety of circumftances, which, fuppofing
they did relapfe, might prevent them
from returning, that it can only be ftated,
with confidence, that within twelve months
(the time allowed as a trial of cure) fo many
,J>ave been difcharged perfedly well.

To

To fliew how frequently infanity fuper-
^enes on parturitiGn, it may be remarkedj
fhat, from the year 1784 to 1794 inclufive.
So patients have been admitted, whofe dif-
prder iKortly follo¥/ed the puerperal ftate«
Women afFeSed from this caufe recover in a
larger proportion than patients of any other
defcription of the fame age. Of thefe 80,
50 have perfe6Hy recovered. The firft
iymptom of the approach of this difeafe, after
delivery, is vv^ant of fieep ; the milk is after-
wards fecreted in lefs quantity, and, when
the mind becomes more violently diforderedj
it is totally fuppreffedo

From whatever caufe this difeafe may be
produced in women, it is conlidered as very
unfavourable to recovery, if they are worft
at the period of menftruation, or have their
catamenia in very fmall or immoderate
quantities.

At

[ "I ]

At the firft attack of the difeafe, and for
fome months afterwards, during its continu-
ance, females moft commonly labour under
amenorrhoea. The natural and healthy re-
turn of this difcharge generally precedes
convalefcence.

From the following ftatement it will be
ieen, that infane perfons recover in propor-
tion to their youth, and that as they advance
in years, the difeafe is lefs frequently cured.
It comprizes a period of about ten years, viz.
from 1 784 to 1 794. In the firft column the
age is noticed, in the fecond the number of
patients admitted ; the third contains the
number cured ; the fourth thofe who were
difchar^ed not cured.

Ag<?

112

V

hO

*— ' flj

• T-( if

-^ a
u o

Si =5

3

Z

*o oo t^ ^ CO r^

en oo ^ r^ *-" c^

I I I I I I

n3 n

B

3

o o

t3

at

Li

1

:3

<>. O oo oo

I I I I I I

rrj oo r^ N crj 1-1
M CO c^ vo '^ CTi
HH -^ vr> ro •-«

On O
O C!

T3

1)

*^

r— «

a

4-i

o

^

•

TS

(D

-t

4-i

■4-i

vo

• 1-H

so

a

w

n3

cJ

1— t

d

4->

O

4-*

bO

o o o o o o

c^ CO rt- >-n vo t^

^ T3 T^ "^ T3 T3

d c: d G fl d

C^ Cj C^ C^ C^ CsS

O O O O O O

ti c^ CO ^ >^ vo

From this table it will be feen, that when
the difeafe attacks perfonS advanced in life,
the profpeft of recovery is but fmalh

From

1^3 J

Ffom the very rare inftances of complete
cure, or durable amendment, among the clafi
of patients deemed incurable, as well as from
the infrequent recovery of thofe v/ho have
been admitted, after the complaint has beea
of more than twelve months ftandino*. I am
led to conclude, that the chance of cure is
lefs, in proportion to the length of tim0
which the diforder ihall have continued.

Although patients, who have been afFefled
with infaiiity more than a year, are not ad-
miffible into the hofpital, to continue there
for the lifual time of trial for cure, namely,
a twelvemonth, yet, at the difcretion of the
committee, they may be received into it from
Lady-day to Michaelmas, at v/hich latter
|)eriod they are removed. In the courfe of
.the laft ten years, fifty-iix patients of this
defcription have been received, of whom
only one has been difcharged cured. This
patient, who was a woman, has fince

I rclapfed

[ ri4 I

relapfed twice, and is,, at prefent, in tE#
hofpital.-

When the reader contraffs the preceding^
ftatement with the account recorded in the
report of the committee, appointed to exa-
mine the phyiicians who have attended his
majefty, &c. he will either be inclined to
deplore the unfkilfulnels or mifmanagement
which has prevailed among thofe medical
perfons \vho have direcled the treatment of
mania in the largeft public iiiftitution, in
this kingdom, of its kind, compared with the
fuccefs which has attended the private prac-
tice of an individual ; or,> fo require fome
other evidence^ than^ the bare ajfertions of
the man Jiretending to have performed fuck
cures *. It was depofed by that reverend
and celebrated phylician, that of patients
placed under his care within three months
after the attack of the difeafe, nine out of

* Vide Report, Part ad, p. 25.

gt tea

[ "5 1

teii had recovered ^ ; and alio that the age
was of no lignlfication, unlefs the patient had
been afflifted before v/lth the fame malady "f*

How little foever I might be difpofed to
doubt fiich a bold, unprecedented, and mar->
Vellous account, yet, I mufi: acknowledge^
that my mind would have been much more
fatisfied as to the truth of that alTertion, had
it been plaufibly made out, or had the circum-
ftances been otherwife than feebly recolle6led
by that very fuccefsftil praftitioneri Medi-
cine has generally been efteemed a progref-
five fcience, in which its profeffors have con-
fefled themfelves indebted to great prepara-
tory ftudy, and long fubfequent experience^
for the knowledge they have acquired; but^
in the cafe to which we are now alluding,
the outfet of the doftor's practice was marked
^ with fuch fplendid faccefs, that time and
obfervation have been unable to increafe it.

* Report) p. 59. t Ibid. ^j.

I 2 This

[ ii6 ] .^

This aftoiiifhing number of cures has beea
efFefted by the vigorous agency of remedies,
which others have not hitherto been fo for-
tunate as to difcover; by remedies which,
when remote caufes have been operating for
twenty-feven years, fuch as weighty bulinefs^
fevere exercife, too great abftemioufnefs and
little reft, are poffeffed of adequate power
direftly to fueet a?id counter a£l iuch caufes*^

It will be feen by the table that a greater
number of patients have been admitted
between the age of thirty and forty, than
during any other equal period of life. There
may be Ibme reafons afiigned for the in-
creafed proportion of infane perfons at this
age.

Although I have made no exa6l calcula-
tion, yet, from a great number of cafes, it

* Report, p, 54e

appears

[ 1^7 ]
appears to be the time, when the hereditary
difpofition is moft frequently called into
a6lIon ; or, to fpeak more plainly, it is that
rtage of life when perfons, whofe families
have been infane, are moft liable to become
mad. If it can be made to appear, that at
this period people are more fiibjeft to be
a£ted upon by the remote caufes of the dif-
eafe, or that a greater number of fuch caufes
are then applied, we may be enabled fatif-
faftorily to explain it. At this age people
are generally eftablifhed in their different
occupations, are married, and have families;
their habits are more ftrongly formed, and
the interruptions of them are, conlequcntly,
attended with greater anxiety and regret*
Under thefe circumftances, they feel the
misfortunes of life more e^quiiitely. Adver-
iity does not deprefs the individual for him-
felf alone, but as involving his partner and
bis offspring in wretchednefs and ruin. In
youthj we feel defirous only of prefent good ;

I 3 at

[ "8 ]

at the middle age, we become more provi*
dent and anxious for the future ; the mind
affumes a ferious chara6ler, and religion, as
it is juftly or improperly imprefled, imparts
comfort, or excites apprehenfion and terror^

By misfortunes the habits of intoxication
are readily formed. Thofe, who in their
youth have fhaken off calamity as a fuperfi-
cial incumbrance, at the middle age feel it
corrode and penetrate : and when fermented
liquors have once difpelled the gloom of de-
Ipondency, and taught the mind either to
excite a temporary afTemblage of cheerful
fcenes, or to difdain the terror of impending
mifery, it is natural to recur to the fame, though
defl:ru6live caufe, to reproduce the effeft.

Patients, who are in a furious ftate, recover
in a larger proportion than thofe who are
depreiTed and melancholick. An hundred
violent, and the fame number of melancho-
lick

r ^'9 ]

Tick cafes were felefted. Of the former,
fety-two were difcharged well ; of the latter,
only twenty-feven. When the furious ftate
is fucceeded by melancholy, and after this
/(hall have continued a fhort time, the violent
paroxyfm returns, the hope of recovery i^
very flight. Indeed, wh:enever thefe ftates
of the difeafe frequently change, fuch alter-
nation may be confidered as unfavourable..

Where the complaint has been induced
from remote phyfical caufes, the proportion
of thofe who recover is confiderably greater,
than where it has arifen from caufes of a
moral nature. In thofe inftances where in-
fanity has been produced by a train of una-
voidable misfortunes, as where the father of
a large family, with the moft laborious ex-
ertions, ineffeftually ftruggles to maintain it,
the number who recover is very litiall
indeed.

1 4 Paralytic

' [ IZO ]

J

Paralytic afFeftions are a much more fre*
quent caufe of infanity than has been com^
monly fuppofed. In thofe affefted from
this caufcj we are, on enquiry, enabled to
trace a fudden affeflion, or ifit, to have pre-'-
ceded the difeafe. Thefe patients ufually
bear marks of fuch affeftion, independent of
their infanity : the fpeech is impeded, and
the mouth drawn afide ; an arm, pr leg, is
miore or lefs deprived of its capacity of being
moved by the will : and in by far the greatefl:
number of thefe cafes the memory is parti-
cularly afFefied. Very few of thefe cafeS
have received any benefit in the hofpital ; and
from the enquiries I have been able to make
at the private houfes, where they have beeii
afterwards confined, it has appeared, that
they have either died fuddenly from apoplexj,
or have had repeated fits, from the efFe6ls of
which they have funk into a ftupid ft^te, and
have gradually dwindled away.

Whea

[ 121 ]

When the natural fmall-pox attacks iniane
perfons, it moft commonly proves fatal.

When Infanity flipervenes on epilepfy, of
where the latter difeafe is induced by
infanity, a cure is very feldom effefted : from
my own obfervation, I do not recollect ^
{ingle cafe of recovery.

When patients during their convalefcenc^
become more corpulent than they were be^
fore, it is a favourable fymptom ; and, as far
as I have remarked, fuch perfoas have vciy
feldom relapfed^

METHOD

I 1 22 3

METHOD OF CURE.

THIS part of the fubjeft may be dmded
into management, and treatment by medi«
cine.

As moft men perceive the faults of others
without being aware of their own, fo infane
people eafily dete6l the nonfenfe of other
madmen without being able to difcover, or
even to be made fenfible of the incorreft
S^fiTociations of their own ideas. For this
reafon it is highly important, that he whq
pretends to regulate the conduct of fuch
patients, ihould firft have learned the ma-
nao:ement of himfelf. It fhould be the orreat
objeft of the fuperintendant to gain the con-
fidence of the patient, and to awaken in him
refpedt and obedience : but it will readily be
feen, that fach confidence, obedience, and

relpeft,

[ ^^3 ]

refpeft, can only be procured by luperiority
of talents, difcipline of temper, and dignity
of manners. Imbecility, mifconduft, and
empty confequence, although enforced with
the mofl tyrannical feverity, may excite fear,
but this will always be mingled with con-
tempt.

In fpeaking of the management of infanc
perfons, it is to be underftood that the fliper-
intendant muft firft obtain an afcendency
over them. When this is once efFe6led, he
will be enabled, on future occafions, to direct
and regulate their conduft, according as his
better judgment may fuggeft. He fhould
poifefs iirmnefs ; and, when occafion may-
require, fhould exercife his authority in a
peremptory manner. He fhould never
threaten, but execute : and when the patient
has miibehaved, fhould confine him immedi-*
ately. As example operates more forcibly
th^n precept, I have found it ufeful, to

order

[ 124 3

order the delinquent to be confined in the
prefence of the other patients. It difplays
authority; and the perfon who has miibe-
haved becomes awed by the fpeciators, and
jnore readily fubrnits. It alio prevents the
wanton exercife of force, and thofe cruel and
iinmanly advantages which might be taken
when the patient and keeper are ihut up in a
private room. When the patient is vigorous
and powerful, two, or more fhould affift in
fecunng him ; by thefe means it will be eafily
effefted ; for, where the force of the con-
tending perfons is nearly equal, the maftery
cannot be obtained without difficulty and
danger.

As management is employed to produce
a falutary change upon the patient, and to
reftrain him from committing violence on
others and himfelf, it may be proper here to
enquire, upon what occafions, and to what
extent, coercion may be ufed. The term

coercion

[ 125 ]

coercion has generally been underftocd in S
very formidable fenfe, and not without reafon^
It has been recommended, by very high
raiedical authority, to inflidl corporal pimiih-
ment upon maniacs, with a view of render-
ing them rational by impreffing terror*.
What fuccefs may have followed fuch dif^
eraceful and inhuman treatment I have not
yet learned, nor fhould I be deiirous of meet-
ing with any one who could give me the
information. If the patient be fo far de-
prived of underftanding, as to be infenfible
why he is punifhed, fuch corre6lion, fetting
afide its cruelty, is manifeftly abfurd. And if
his ftate be fuch, as to be confcious of the
impropriety of his conduft, there are other
methods more mild and efteclual.

Would any rational praditioner, in a cafe
of phrenitis, or in the delirium of fever,

* Vide Cullen, firft lines, voli iv. p. 154.

ordef

t t2^ ]

order his patient to be fcourged ? He wottldi
leather fuppofe that the brain or its mem*
branes were inflamed, and that the incohe-
rence of difcourie, and violence of artion^
M^ere produced by fuch local difeafe^ We
have feen^ by the preceding difleifiiohs,
that the contents of the cranium , in all the
inftances that have occurred to me, have
been in a morbid liate* It Ihoiild therefore
be the obje6i of the practitioner to remove
liich difeale, rather than irritate and torment
the fufFeren Coercion fhould only be con-*
fidered as a protefting and falutary reflraint*

In the moft violent Irate of the difeafe, the
patient Hiould be kept alone in a dark and
quiet room, fo that he may not be afFeded by
the ftimuli of light or found, fuch abftrac-
tion more readily difpofing to fleep. As in
this violent flate there is a ftrong propenfity
to afibciate ideas, it is particularly important
to prevent the acceffion of fuch as might be

tranf««

t 127 J

tranimitted through the medium of the fenfes*
The hands fhould be properly fecured, and
the patient fhould alfo be confined by one
leg : this will prevent him from committing
any violence. The ftraight waiftcoat is
adm.irably calculated to prevent patients from
doing mifchief to themfelves ; but in the
furious ftate, and particularly in warm
w^eather, it irritates and increafes that reft-
leflnefs, w^hich patients of this defcriptioii
ufually labour under. They then fcorn the
incumbrance of cloathing, and feem to de-
light in expolTng their bodies to the atmos-
phere. Where the patient is in a condition
to be fenfible of reftraint, he may be punifhed
for improper behaviour by confining him ta
his room, by degrading him, and not allow-
ing him to aflbciate with the convalefcents,
and by withholding certain indulgences he
had been accuftomed to enjoy.

As

i 128 ]

As madmen freqiiently entertain very higB,^
and even romantic notions of honour, thej
are rendered much more tradable bj
wounding their pride^ than by feverity of
difcipline^

Speaking of the efFe6ls of management ori
a very extenfive feale, I can truly declare^
that by gentlenefs of manner^ and kindnefs
of treatment, I have never failed to obtaiii
the confidence, and conciliate the efteem of
infane perfons, and have fncceeded by thefe
means in procuring from them relpe£t and
obedience. There are certainly fome pa-
tients v^ho are not to be trufted, and in whom
malevolence forms the prominent feature of
their chara6ter : fuch perfons fhould always
be kept under a certain reftraint, but this is
not incompatible with kindnefs and huma-^

nity.

Confider

[ 129 ]

Gonfiderins; how much wc are the crea-
tures of habit, it might naturally be hoped,
and experience juftifies the expectation, that
madmen might be benefited by bringing their
aSions into a fyftem of regularity. It might
be fuppofed, that as thought precedes aSion,
that whenever the ideas are incoherent, the
aftions will alfo be irregular. Moft proba-
bly they would be fo if uncontrouled ; but
cuftom, coniirmed into habit, deftroys this
natural propeufity, and renders them correft
in their behaviour, though they ftill remain
equally depraved in their intelleds.

We have a number of patients in Bethlem
Hofpital vvhofe ideas are in the moft difor-
dered ftatCj who yet aft, upon ordinary
occafions, with great fteadinefs and propriety,
and are capable of being trufted to a confi-
derable extent. A faft of fuch iniportance
in the hiftory of the human mind, might
lead us to hope, that by fuperinducing

K differ-

[ ISO ]

diiFerent habits of thinking, the irregular
aflbciations may be correded.

It is impoffible to cfFeft this fuddenly, or
by reafbning, for madmen can never be con-
\dnced of the folly of their opinions. Their
belief in them is firmly fixed, and cannot be
Ihaken. The more frequently thefe opinions
are recurred to under a conviction of their
truth, the deeper they fubfide in the mind
and become more obftinately entangled : th«
obje6l fhould therefore be to prevent fiach
recurrence by occupying the mind on dif-
ferent fubje6ts, and thus diverting it from the
favorite and accuftomed train of ideas. As
I have been induced to fuppofe, from the
appearances on difTeftion, that the immediate
caufe of this difeafe probably confifts in a
morbid affedion of the brain, all modes of
cure by reafoning, or conduding the current
of thought into different channels, mufl: be
ineffeftual, fo long as fuch local difeafe fhall

continuei^.

continue. It is, however, likely that infanlty
is often continued by habit ; that incoherent
affociations, frequently recurred to, become
received as truths, in the fame manner as a
tale, which, although untrue, by being re-
peatedly told, ihali be credited at laft by the
narrator, as if it had certainly happened.
It fhould likewife be obferved, that thefe in-
corre6t afTociations of ideas are acquired in
the fame way as juft ones are formed, and
that fuch are as likely to remain, as the moft
accurate opinions. The generality of minds
are very little capable of tracing the origin of
their ideas ; there are many opinions w^e are
in pofieffion of, with the hiftory and ac-
qulfition of which,we are totally unacquainted.
We fee this in a remarkable manner in
patients who are recovering : they will often
fay fuch appearances have been prefented to
rny mind with all the force and reality of
truth : I faw thetn as plainly as I now behold
any other objed, ^ud can hardly be perfuaded

K 2 that

[ 13^ 3

that they did not occur. It alfo does not
unfrequently happen, that patients will de-
clare, that certain notions are forced into
their minds, of which they fee the folly and
iiicongruity, and complain that they cannot
prevent their intrufion.

It IS of great fervice to eflabliih a fyftem
of regularity in the actions of infane people.
They fliould be made to rife, take exercife,
and food, at ftated times. Independently of
fuch regularity contributing to health, it alfo
renders them much more eafily manageable.

As the patient fhould be taught to view the
fuperintendant as a fuperior perfon, the latter
fliould be particularly cautious never to de-
ceive him. Madmen are generally more
hurt at deception than punifhment; and
whenever they dete6l the impofition, never
fail to lofe that confidence and refpeft, which

they

[' ^33 ]

they ought to entertain for the perfon who

governs them.

, " Confinement is always neceflary in cafes
of infanity, and fhould be enforced as early
in the complaint as poffible. By confine-
ment, it is to be underftood that the patient
fhould be removed from home. During his
continuance at his own houfe he can never
be kept in a tranquil ftate. The interrup-
tions of his family, the lofs of the accuftomed
obedience of his fervants, and the idea of be-
ing under reftraint in a place where he con-
fiders himfelf the mafter, will be conftant
fources of irritation to his mind. It is alfo
known, from confiderable experience, that of
thofe patients who have remained under the
immediate care of their relatives and friends,
very few have recovered. Even the vifits of
their friends, when they are violently dif-
ordered, are produftive of great inconveni-
ence, as they arc always more unquiet and

K 3 ungo-

[ ^34 ]
tmgovcrnable for fome time afterwards. It
is a well-known fa6l, that they are lefs dif-.
pofed to acquire a diflike to thofe who arc
ftrangers, than to thofe with Avhom they
have been intimately acquainted ; they be-,
come therefore lefs dangerous, and are rnore
ealily reftraiqed.

It frequently happens, that patients who
have been brought immediately from their
families, and who have been faid to be in a
violent ar^d ferocious ftate, become fuddenly
' calm and tradable, when placed in the hof*
pitaL On the other hand, it is equally
certain, that there are many patients, who
have for a length of tirne conducted them-
felves in a very orderly manner under con-
finement, whofe diforder fpeedily recurs after
being fufFered tp return to their families.
When they are in a ponvalefcent ftate, the
occafional vifits of their friends are attended
with manifeft advantage. Such an intercourfe

imparts

[ ^35 3

imparts confolation, and prefents views of
future happinefs and comfort.

Many patients have received confiderable
benefit by change of fituation, and this fbme-
times takes place very fhortly after the
removal. In what particular cafes, or ftages
of the difeafe, this may be recommended, I
atn not enabled by fufEcierjt experience to
determine.

|C 4 MS:X)ICXN£v

136

MEDIC^^NE.

IT is Only intended, in this part of the
flibjeS, to fpeak of thofe medicines which 1
haye adminiftered, by the dire6i:ion of Dr;
Monro, the prefent celebrated and judicious
phyfician to Bethlem Hofpital, (to whom I
gratefully acknowledge many and ferious
obligations) without defcending to a minute
detail of the hofpital praftice, or of the order
in which they are commonly exhibited.
Of the efFefts of fuch remedies, I am able to
fpeak with coniiderable confidence, as they
have come immediately under my own
obfervation.

Bleeding. — Where- the patient is ftrong
and of a plethoric habit, and where the dif-
order has not been of any long continuance,
bleeding ^has been found of confiderable ad-
vantage,

[ ^31 ]
vantage, and, as far as I Have yet obferved, i^
the moft beneficial remedy that has been
employed. The melancholic cafes have been
equally relieved with the. maniacal by this
mode of treatment. Venefeftion by the
arm is, however, inferior in its goods efFe£ls
to blood taken from the head by cupping.
This operation, performed in the manner to
which I have been accuftomed, confifts in
having the head previoufly fhaven, and fix or
eight cupping glaffes applied on the fcalp;
By thefe means any quantity of blood may
be taken, and in as Ihort a time, as by aa
orifice rnade in a vein by the lancet. When
the raving paroxyfnl has continued for a
confiderable time, and the fcalp has become
unufually flaccid ; or where a ftupid ftate has
fucceeded to violence of confiderable dura-
tion, no benefit has been derived from bleed-
ing; indeed thefe ftates are generally attended
by a degree of bodily weaknefs, fufficient to

prohibit

[ 138 ] „

prohibit fuch praciice independently of other

confiderations*

s

The quantity of blood to be taken, muft
be left to the difcretion of the praftitioner :
from eight to fixteen ounces may be drawn,
and the operation occafionally repeated, as
circumftances niay require.

In the few cafes where blood was drawn
at the commencement of the difeafe from
the arm, and from patients who were
extremely furious and ungovernable, it was
covered with a buffy coat ; but in other cafes
it has feldom or never ilieh an appearance.
In more than two hundred patients, male
and femaley who were let blood by venefec*^
tion, there were only fix, whofe blood could
be termed fizy.

In fome few inftances hemoptyfis ha§
pfcceded convalefcence, as has alfo a

bleeding

I ^39 3
bleeding from the hemorrhoidal veins.
Epiftaxis has iiot, to my knowledge, ever
occurredt

Purging* — An opinion has long pre-
vailed, that mad people are particularly con*
ftipated, and likewife extremely difficult to
be purged. From all the obfervations I have
been able to make, infane patients, on the
contrary, are of very delicate and irritable
bowels, and are well and copioufly purged by
a common cathartic draught. That which
is commonly employed in the holpital is
prepared agreeably to the following formula..

Ijl. Infuli fenn^ gifs ad ^ij.
Tinfturae fennae ^i ad jij.
Syrupi fpin^e cervinae 5 i ad 3 ij.

This feldom fails of procuring four or fiv^
ftools, and frequently a greater number.

In

[ HO ]

Til confirmation of what I have advanced,
l^efpeding the irritable ftate of inteftines in
mad people, It may be mentioned, that the
ordinary complaints with which they are
afFeded, are diarrhoea and dyfentery : thefe
are fometimes very violent and obftinate.

Diarrhoea very often proves a natural cure
of infanity ; at leaft there is every reafon to
foppofe that fuch evacuation has frequently
very much contributed to it. The number
of cafes which might be adduced in confir-
fnation of this obfervation is confiderable,
and the fpeedy convalefcence after fuch eva-
cuation is ftill more remarkable.

In many cafes of infanity there prevails a
great degree of infenfibility, fo that patients
have appeared hardly to feel the pafRng of
fetons, the application of blifters, or the
operation of cupping. On many occafions I
have known the urine retained for a confi-
I durable

[ HI ]

derable time, without the patient complaining
of any pain, though it is well known that
there is no afFe6tion more diftreffing than
diftention of the bladder. Of this general
infenfibility the inteftinal canal may be
Rippofed to partake : but this is not com-
monly the cafe, and if it fhould, would be
widely different from a particular and ex-
clulive torpor of the primae viae.

There are fome circumftances uncon^
nefted with difeale of mind, which mio:ht
dilpofe infane perfons to coftivenefs. I now
Ipeak of fuch as are confined, and who come
more dire6ily under our obfervation. When
they are mifchievoufly difpofed, they re-
quire a greater degree of reftraint, and arc
confequently deprived of that air and exer-
cife, which fo much contributes to regularity
of bowels. It is well known, that thofe who
have been in the habits of free living, ^nd
who come fuddenly to a qiore fpare diet, are

very

[ 142 ]

very much difpofed to coftivcnefs. But to
adduce the faireft proof of what has been
advanced, I can truly ftate, that incufabk
patients, who have for many years been con-
fined in the houfe, are fubjed to no incon-
veniences from conftipation. Many patients
are averfe to food, and where httle is taken
in, the egefta muft be inconfiderable*

To return from this degreflion : it is con-
cluded, from very ample experience, that
cathartic medicines are of the greateft fervice,
and ought to be confidered as an indilpenfable
remedy in cafes of infanity. The good fenfe
and experience of every praditioner muil
direft him as to the dofe, and frequency, with
which thefe remedies are to be employed, and
of the occafions where they would be pre-
judicial.

Vomiting. — However ftrongly this
praftice may have been recommended, ai^d

how

[ H3 ]

how much foever it may at prefent prevail,
I ani forry that it is not in my power to fpeak
of it favourably. In many inftances, and in
fome where blood-letting has been previouflj
employed, paralytic afFeftions have within a
few hours fupervened on the exhibition of aa
emetic, more efpecially where the patient
has been of a full habit, and has had the ap-
pearance of an increafed determination to the
head.

It has been for many years the pra6iice of
Bethlem Hofpital, to adminifter to the cur-
able patients four or five emetics in the fpring
of the y^ar ; but, on confulting my book of
cafes, I have not found that patients have
been particularly benefited by the ufe of this
remedy. From one grain and half to two
grains of tartarized antimony has been the
ufual dofe, which has hardly ever failed of
procuring full vomithig. In the few in-
ilances where the plan of exhibiting this

medicine

[ ^44 ]

medicine in naufeating dofes was purfued for
a coufiderable time, it by no means anfwered
the expedations, which, by very high autho-
rity, had been raifed in its favour. Where
the tartarized antimony, given with this
intention, operated as a purgative, it gene-
rally produced beneficial efFecls.

Camphor.— This remedy has been highly
extolled, and doubtlefs with reafon, by'thofe
who have recommended it. My own expe-
rience nnerely extends to ten cafes, a number
from which no decifive inference of its utility
ought to be drawn. The dofe was gradually
increafed from five grains to two drams twice
a day ; and in nine cafes the ufe of this remedy
was continued for the Ipace of two months.
Of the patients, to whom the camphor
was given, only two recovered : one of thefe
had no fymptoms of convalefcence for feveral
months after the ufe of this remedy had been
abandoned ; the other, a meJancholick patient,

certainly

[ H5 3

certainly mended during the time he was
taking it ; but he was never able to bear more
than ten grains thrice a day. He complained
that it made him feel as if he was intoxicated.

Cold Bathing.-— This reinedy having
for the moft part been employed in con-
jun6tion with others, it becomes difficult to
afcertain how far it may be exclufively bene-
ficial in this difeafe. The inftances where
it has been feparately ufed for the cure of
infanity, are too few to enable me to draw
any fatisfa6lory conclufions. I may, how-
ever, fafely relate, that, in many inftances,
paralytic afFefl:ions have in a few hours
fupervened on cold bathing, efpecially where
the patient has been in a furious ftate, and of
a plethoric habit : in fome of thefe cafes
vertigo has been induced, and in others a
confiderable degree of fever. If I might be
permitted to give an opinion on this fubje6t,
the benefit principally derived from this

L remedy

[ 146 ]

remedy has been in the latter ftages of the
difeafe, and when the fyftem had been previ-
oufly lowered by evacuations.

Blifters have in feveral cafes been applied
to the head, and a very copious difcharge
maintained for many days, but without any
manifeft advanta2:e. The late Dr. John
Monro, who had, perhaps, feQii more cafes
of this difeafe than any other praditioner,
and who, joined to his exteniive experience,
pofleffed the talent of accurate obfervation,
mentions, that he '^ never faw the leaft
good effeft of blifters in madnefs, unlefs it
was at the befrinnins; while there was fome
degree of fever, or when they have been ap-
plied to particular fymptoms accompanying
this complaint ^."

In a few cafes fetons have been employed,
but no benefit has been derived from their

* V ide Remarks on Dr. B a t t i e's Treatife on Madnefs. '

ufe,
9

[ H7 ]
life, although the difcharge was continued
above two months.

Refpefting opium, It may be obferved,
that whenever it has been exhibited during a
violent paroxyfm, it has hardly ever procured
fleep; but, on the contrary, has rendered
thofe who have taken it much more furious :
and, where it has for a fliort time produced
reft, the patient has, after its operation,
awoke in a ftate of increafed violence.

FINIS.

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COUNT WAY UHRARY OF MEDICINE

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