The prediction of the event, in cases of insanity, must be the result of
accurate and extensive experience; and even then it will probably be a
matter of very great uncertainty. The practitioner can only be led to
suppose, that patients, of a particular description, will recover, from
knowing that, under the same circumstances, a certain number have been
actually restored to sanity of intellect.
The practice of an individual, however active and industrious he may be,
is insufficient to accumulate a stock of facts, necessary to form the
ground of a regular and correct prognosis: it is therefore to be wished,
that those, who exclusively confine themselves to this department of the
profession, would occasionally communicate to the world the result of
their observations.
Physicians, attending generally to diseases, have not been reserved, in
imparting to the public the amount of their labours and success: but, with
regard to this disorder, those, who have devoted their whole attention to
its treatment, have either been negligent, or cautious of giving
information respecting it. Whenever the powers of the mind are
concentrated to one object, we may naturally expect a more rapid progress
in the attainment of knowledge: we have therefore only to lament the want
of observations upon this subject, and endeavour to repair it.
The records of Bethlem Hospital have afforded me some satisfactory
information, though far from the whole of what I wished to obtain. From
them, and my own observations, the prognosis of this disease is, with
great diffidence, submitted to the reader.
In our own climate, women are more frequently afflicted with insanity than
men. Several persons, who superintend private mad-houses, have assured me,
that the number of females brought in annually, considerably exceeds that
of the males. From the year 1748 to 1794, comprizing a period of forty-six
years, there have been admitted into Bethlem Hospital, 4832 women, and
4042 men.
The natural processes, which women undergo, of menstruation, parturition,
and of preparing nutriment for the infant, together with the diseases, to
which they are subject at these periods, and which are frequently remote
causes of insanity, may, perhaps, serve to explain their greater
disposition to this malady. As to the proportion in which they recover,
compared with males, it may be stated, that of 4832 women affected, 1402
were discharged cured; and that, of the 4042 men, 1155 recovered. It is
proper here to mention, that, in general, we know but little of what
becomes of those who are discharged; a certain number of those cured,
occasionally relapse, and some of those, who are discharged uncured,
afterwards recover: perhaps in the majority of instances where they
relapse, they are sent back to Bethlem. To give some idea of the number,
so re-admitted, it may be mentioned, that, during the last two years,[18]
there have been admitted 389 patients, 53 of whom had at some former time
been in the house. There are so many circumstances, which, supposing they
did relapse, might prevent them from returning, that it can only be stated
with certainty, that within twelve months, the time allowed as a trial of
cure, so many have been discharged perfectly well.
To shew how frequently insanity supervenes on parturition, it may be
remarked, that from the year 1784 to 1794 inclusive, 80 patients have been
admitted, whose disorder shortly followed the puerperal state. Women
affected from this cause, recover in a larger proportion than patients of
any other description of the same age. Of these 80, 50 have perfectly
recovered. The first symptoms of the approach of this disease after
delivery, are want of sleep; the countenance becomes flushed; a
constrictive pain is often felt in the head; the eyes assume a morbid
lustre, and wildly glance at objects in rapid succession; the milk is
afterwards secreted in less quantity; and when the mind becomes more
violently disordered, it is totally suppressed. Where the disease is
hereditary, parturition very frequently becomes an exciting cause.
From whatever cause this disease may be produced in women, it is
considered as very unfavourable to recovery, if they should be worse at
the period of menstruation, or have their catamenia in very small or
immoderate quantities.
A few cases have occurred where the disease, being connected with
menstruation, and having continued many years, has completely disappeared
on the cessation of the uterine discharge.
At the first attack of this disease, and for some months afterwards,
during its continuance, females most commonly labour under amenorrhoea.
The natural and healthy return of this discharge generally precedes
convalescence.
From the following statement it will be seen, that insane persons recover
in proportion to their youth, and that as they advance in years, the
disease is less frequently cured. It comprizes a period of about ten
years, viz. from 1784 to 1794. In the first column the age is noticed; in
the second, the number of patients admitted; the third contains the number
cured; the fourth, those who were discharged not cured.
_Number _Number _Number
_Age between_ admitted._ discharged discharged
cured._ uncured._
10 and 20 113 78 35
20 and 30 488 200 288
30 and 40 527 180 347
40 and 50 362 87 275
50 and 60 143 25 118
60 and 70 31 4 27
------- ------- -------
Total 1664 Total 574 Total 1090
------- ------- -------
From this table it will be seen, that when the disease attacks persons
advanced in life, the prospect of recovery is but small.
I am led to conclude, from the very rare instances of complete cure, or
durable amendment, among the class of patients deemed incurable, as well
as from the infrequent recovery of those who have been admitted, after the
disorder has been of more than twelve months standing, that the chance of
cure is less, in proportion to the length of time which the disorder shall
have continued.
Although patients, who have been affected with insanity more than a year,
are not admissible into the hospital, to continue there for the usual time
of trial for cure, namely, a twelvemonth, yet, at the discretion of the
committee, they may be received into it, from Lady-day to Michaelmas, at
which latter period they are removed. In the course of the last twenty
years seventy-eight patients of this description have been received, of
whom only one has been discharged cured: this patient, who was a woman,
has since relapsed twice, and was ultimately sent from the hospital
uncured.
When the reader contrasts the preceding statement with the account
recorded in the report of the Committee, appointed to examine the
Physicians who have attended His Majesty, &c. he will either be inclined
to deplore the unskilfulness or mismanagement which has prevailed among
those medical persons who have directed the treatment of mania in the
largest public institution in this kingdom, of its kind, compared with the
success which has attended the private practice of an individual; _or to
require some other evidence, than the bare assertion of the man
pretending to have performed such cures_.[19]
It was deposed by that reverend and celebrated physician, that of patients
placed under his care, within three months after the attack of the
disease, nine out of ten had recovered;[20] and also that the age was of
no signification, unless the patient had been afflicted before with the
same malady.[21]
How little soever I might be disposed to doubt such a bold, unprecedented,
and marvellous account, yet, I must acknowledge, that my mind would have
been much more satisfied, as to the truth of that assertion, had it been
plausibly made out, or had the circumstances been otherwise than feebly
recollected by that very successful practitioner. Medicine has generally
been esteemed a progressive science, in which its professors have
confessed themselves indebted to great preparatory study and long
subsequent experience for the knowledge they have acquired; but, in the
case to which we are now alluding, the outset of the Doctor's practice was
marked with such splendid success, that time and observation have been
unable to increase it.
This astonishing number of cures has been effected by the vigorous agency
of remedies, which others have not hitherto been so fortunate as to
discover; by remedies, which, when remote causes have been operating for
twenty-seven years, such as weighty business, severe exercise, too great
abstemiousness and little rest, are possessed of adequate power directly
to _meet and counteract_ such causes.[22]
It will be seen by the preceding table, that a greater number of patients
have been admitted, between the age of 30 and 40, than during any other
equal period of life. The same fact also obtains in France, as may be seen
from the statement of Dr. Pinel, (_Traite Medico-Philosophique sur la
Manie, p. 109_,) and which, from its agreement with that of Bethlem
Hospital, is here introduced to the notice of the reader.
+--------------------------------------------------------------+
|Manical | | |
|Patients | AGE BETWEEN | |
|admitted into |-----------------------------------------|Total|
|the Bicetre, | 15 & | 20 & | 30 & | 40 & | 50 & | 60 & | |
|in the Years | 20 | 30 | 40 | 50 | 60 | 70 | |
+--------------|------|------|------|------|------|------|-----|
| 1784 | 5 | 33 | 31 | 24 | 11 | 6 | 110 |
| 1785 | 4 | 39 | 49 | 25 | 14 | 3 | 134 |
| 1786 | 4 | 31 | 40 | 32 | 15 | 5 | 127 |
| 1787 | 12 | 39 | 41 | 26 | 17 | 7 | 142 |
| 1788 | 9 | 43 | 53 | 21 | 18 | 7 | 151 |
| 1789 | 6 | 38 | 39 | 33 | 14 | 2 | 132 |
| 1790 | 6 | 28 | 34 | 19 | 9 | 7 | 103 |
| 1791 | 9 | 26 | 32 | 16 | 7 | 3 | 93 |
| 1792 | 6 | 26 | 33 | 18 | 12 | 3 | 98 |
| 1793 | 1 | 13 | 13 | 7 | 4 | 2 | 40 |
| 1794 | 3 | 23 | 15 | 15 | 9 | 6 | 71 |
+--------------------------------------------------------------+
There may be some reasons assigned for the increased proportion of insane
persons at this age. Although I have made no exact calculation, yet from a
great number of cases, it appears to be the time when the hereditary
disposition is most frequently called into action; or, to speak more
plainly, it is that stage of life, when persons, whose families have been
insane, are most liable to become mad. If it can be made to appear, that
at this period persons are more subject to be acted upon by the remote
causes of the disease, or that a greater number of such causes are then
applied, we may be able satisfactorily to explain it.
At this age people are generally established in their different
occupations, are married, and have families; their habits are more
strongly formed, and the interruptions of them are consequently attended
with greater anxiety and regret. Under these circumstances, they feel the
misfortunes of life more exquisitely. Adversity does not depress the
individual for himself alone, but as involving his partner and his
offspring in wretchedness and ruin. In youth we feel desirous only of
present good; at the middle age, we become more provident and anxious for
the future; the mind assumes a serious character; and religion, as it is
justly or improperly impressed, imparts comfort, or excites apprehension
and terror.
By misfortunes the habit of intoxication is readily formed. Those who in
their youth have shaken off calamity as a slight incumbrance, at the
middle age feel it corrode and penetrate; and when fermented liquors have
once dispelled the gloom of despondency, and taught the mind to provoke a
temporary assemblage of cheerful scenes, or to despise the terror of
impending misery, it is natural to recur to the same, though destructive
cause, to re-produce the effect.
Patients, who are in a furious state, recover in a larger proportion than
those who are depressed and melancholic. An hundred violent, and the same
number of melancholic cases were selected: of the former, sixty-two were
discharged well; of the latter, only twenty-seven: subsequent experience
has confirmed this fact. The same investigation, on the same number of
persons has been twice instituted, and with results little varying from
the originally stated proportions. When the furious state is succeeded by
melancholy, and after this shall have continued a short time, the violent
paroxysm returns, the chance of recovery is very slight. Indeed, whenever
these states of the disease frequently change, such alteration may be
considered as very unfavourable.
After a raving paroxysm of considerable duration, it is a hopeful symptom,
if the patient become dull, and in a stupid state; inclined to sleep much,
and feeling a desire of quietude. This appears to be the natural effect of
that exhaustion, and, if the language be allowable, of that expenditure of
the sensorial energy, which the continued blaze of furious madness would
necessarily consume. When they gradually recover from this state there is
a prospect that the cure will be permanent.
In forming a prognosis of this disease, it is highly important to
establish a distinction between derangement and decline of intellect: the
former may frequently be remedied; the latter admits of no assistance from
our art. Where insanity commences with a loss of mental faculty, and
gradually proceeds with increasing imbecility, the case may be considered
hopeless.
When the disorder has been induced from remote physical causes, the
proportion of those who recover is considerably greater, than where it has
arisen from causes of a moral nature. In those instances where insanity
has been produced by a train of unavoidable misfortunes, as where the
father of a large family, with the most laborious exertions, ineffectually
struggles to maintain it, the number who recover is very small indeed.
Paralytic affections are a much more frequent cause of insanity than has
been commonly supposed, and they are also a very common effect of madness;
more maniacs die of hemiplegia and apoplexy than from any other disease.
In those affected from this cause, we are, on enquiry, enabled to trace a
sudden affection, or fit, to have preceded the disease. These patients
usually bear marks of such affection, independently of their insanity: the
speech is impeded, and the mouth drawn aside; an arm, or leg, is more or
less deprived of its capability of being moved by the will: and in most of
them the memory is particularly impaired. Persons thus disordered are in
general not at all sensible of being so affected. When so feeble, as
scarcely to be able to stand, they commonly say that they feel perfectly
strong, and capable of great exertions. However pitiable these objects may
be to the feeling spectator, yet it is fortunate for the condition of the
sufferer, that his pride and pretensions are usually exalted in proportion
to the degradation of the calamity which afflicts him. None of these
patients have received any benefit in the hospital; and from the
enquiries I have been able to make at the private mad-houses, where they
have been afterwards confined, it has appeared, that they have either died
suddenly, from apoplexy, or have had repeated fits, from the effects of
which they have sunk into a stupid state, and gradually dwindled away.
The paralytic require to be kept warm, and to be allowed a more nutritious
diet and cheering beverage than insane patients of any other description.
In the winter months they suffer extremely, and ought to be treated as
hot-house plants. The fare of the workhouse is ungenial to this wretched
state of existence, and therefore they seldom long continue a burden to
the parish.
When insanity supervenes on epilepsy, or where the latter disease is
induced by insanity, a cure is very seldom effected. In two instances I
have known madness alternate with epilepsy: one, a man about forty-eight
years of age, was a pauper in the Cripplegate workhouse, where he had been
kept about three years on account of his epileptic fits, but, becoming
insane, was admitted into Bethlem Hospital, therein he continued a year,
without being at all benefited; during that time he had no epileptic fit.
Being returned to the workhouse, he there recovered his senses in a few
months, when his epileptic attacks returned, and continued with their
usual frequency. About two years afterwards he was re-admitted into the
hospital, his insanity having recurred, and continued there another year
without experiencing any attack of epilepsy. The other was a young woman,
who had been epileptic for many years until she became insane, when she
lost her epileptic fits; these, however, were said to have returned in a
short time after she had recovered from her insanity.
All authors who have treated this subject appear to agree respecting the
difficulty of curing religious madness. The infrequent recoveries in this
species of insanity, have caused thinking persons to suppose, that this
disorder is little under the dominion of the medical practitioner; and,
that restoration to reason in all cases is more the effect of accident, or
of circumstances not "dreamt of in our philosophy," than the result of
observation, skill, and experience. The idea that RELIGION; that which
fastens us to the duties of this life; that which expounds the laws of God
and of his creation to the ignorant; that which administers consolation to
the afflicted; that which regulates man's conduct towards his fellow
creatures, to exercise charity among them, and, from such benevolence, to
purchase happiness to himself: to believe, that the cultivation of such
exalted sentiments would decoy a human being into madness, is a foolish
and impious supposition.
"Thou, fair Religion, wast design'd,
Duteous daughter of the skies,
To warm and chear the human mind,
To make men happy, good, and wise;
To point, where sits in love array'd,
Attentive to each suppliant call,
The God of universal aid,
The God, the Father of us all.
"First shewn by Thee, thus glow'd the gracious scene,
'Til Superstition, fiend of woe,
Bad doubts to rise and tears to flow,
And spread deep shades our view and heaven between."
_Penrose._
It is therefore sinful to accuse RELIGION, which preserves the dignity and
integrity of our intellectual faculty, with being the cause of its
derangement. The mind becomes refreshed and corroborated by a fair and
active exercise of its powers directed to proper objects; but when an
anxious curiosity leads us to unveil that which must ever be shrouded from
our view, the despair, which always attends those impotent researches,
will necessarily reduce us to the most calamitous state.
Instituting a generous and tolerant survey of religious opinions, we see
nothing in the solemn pomp of catholic worship which could disorganize the
mind; as human beings, they have employed human art to render the
impression more vivid and durable. The decorous piety, and exemplary life
of the quaker has signally exempted him from this most severe of human
infirmities. The established church of this country, of which I am an
unworthy member, will delude no one, by its terrors, to the brink of
fatuity: the solid wisdom, rational exposition, and pure charity, which
flow through the works of Taylor, Barrow, Secker, and Tillotson, will
inspire their readers with a manly confidence: the most enlightened of our
species will advance in wisdom and in happiness from their perusal; and
the simplicity and truth of their comments will be evident to those of
less cultivated understanding. The pastors of this church are all men of
liberal education, and many have attained the highest literary character;
they are therefore eminently qualified to afford instruction. But what can
be expected, when the most ignorant of our race attempt to inform the
multitude; when the dregs of society shall assume the garb of sanctity and
the holy office; and pretend to point out a privy path to heaven, or cozen
their feeble followers into the belief that they possess a picklock for
its gates? The difficulty of curing this species of madness will be
readily explained from the consideration, that the whole of their doctrine
is a base system of delusion, rivetted on the mind by terror and despair;
and there is also good reason to suppose, that they frequently contrive,
by the grace of cordials, to fix the waverings of belief, and thus
endeavour to dispel the gloom and dejection which these hallucinations
infallibly excite.
Although the faction of faith will owe me no kindness for the disclosure
of these opinions, yet it would be ungrateful were I to shrink from the
avowal of my obligations to methodism[23] for the supply of those numerous
cases which has constituted my experience of this wretched calamity.
When the natural small-pox attacks insane persons it most commonly proves
fatal. I was induced to draw this conclusion from consulting the records
of Bethlem, where I found that few of those who had been sent to the
Small-pox Hospital recovered; but subsequent experience has enabled me to
point out this distinction: that those who have been in a furious state
have generally experienced a fatal termination, and that those who
recovered had the small-pox when they were in a state of convalescence
from their insanity.
When patients, during their convalescence, become more corpulent than they
were before, it is a favourable symptom; and, as far as I have remarked,
such persons have very seldom relapsed. But it should also be observed,
that many, who become stupid, and in a state, verging on ideotism, are
very much disposed to obesity: these cases are not to be remedied.
In proportion as insanity has assumed a systematic character, it become
more difficult of cure. It ought to be noticed, that this state of
methodical madness implies, that the disease has been of some continuance;
and, to use a figurative expression, has been more extensively rooted in
the mind. Every occurrence is blended with the ruling persuasion, and the
delusion becomes daily corroborated. As
--------------"Trifles, light as air,
Are to the jealous, confirmations strong
As proofs of holy writ;"
so in madness, circumstances wholly unconnected readily support the
favourite system, and persons the most disinterested are supposed to form
a part of the conspiracy.