by the community, by the medical profession, or, in truth, by the
greatest part of the authors on the subject, I shall rather trespass
beyond the limits of a concise systematic survey of diseases. I had
long since procured the printed annual reports of Bedlam during thirty
years, from 1750 to 1780, wherein it appeared, that out of 6000
lunaticks, the deaths amounted to 1200, or 1 of 5. This information, so
far as it went, was partly truth, but it was not the whole truth; and,
in confirmation of the general proverb, I was compelled to search for
it in a well. I was anxious to extend my inquiries to a vast variety
of particulars, not one of which could be learned from the crowd of
authors, good, bad, and indifferent, whom I perused for this purpose;
from the remote era of the Greek and Roman Catholicon, the Hellebore,
down to the present time.
Chagrined with this unprofitable research, I waited upon the learned
and venerable physician of Bedlam, Dr. Monro; who, with his accustomed
liberality and affability, recommended me to his son, upon whom the
principal medical department of Bedlam now devolves; and in whom the
hereditary virtue and exalted medical reputation of the father, are
not likely to suffer any diminution. Dr. Monro, junior, introduced me
to Mr. Gonza, the apothecary of Bedlam; whose curiosity and learning
induced him to keep a private register of all the patients; and with
all which Mr. Gonza most obligingly furnished me. It is from the
records of this respectable and well-informed gentleman, especially on
the subject of insanity, that I am enabled to form all the following
Tables and data respecting a disease, wherein, except to the few
high-priests of those temples, the rest of the Esculapian train are
nearly as ignorant as the ancients; and the unenlightened mass of the
community stare with superstitious amazement as the Israelites formerly
on the epilepsy.
In penetrating this untrodden wilderness, and reconnoitering an
unexplored host of morbid foes, I shall proceed with the cautious
investigation of astronomers and natural philosophers; first to
establish the facts and phenomena previous to any deduction or
inference. From Bedlam, the largest palace and congregation of insane
in any part of the globe; and from its valuable, but hitherto dormant
archives, I shall attempt to settle all the leading and important data,
by analyzing its internal history and transactions during fifteen
years, or half a generation; which is sufficient to decide every
ambiguity nearly as well as half a century. The materials are extracted
from many volumes; they are condensed, classed, and arranged into a
concise compendium, with no little trouble and fatigue to the author.
In number, and consequently in magnitude of information, they must be
as superior to any solitary individual observations on this subject,
as the swelling flood of the Thames is to one of the thousand smaller
rills which are swallowed up in its majestic stream. In this way we
shall not be confounded with contradictory affirmation and negation,
and the clash of oracles.
The following, therefore, are the general proportions which I shall
endeavour to demonstrate, and upon them to found a multitude of others:
the comparative proportion of insane males and females; their ages;
the cured; incurable, and dead; the length of time they were insane
before admission; the mischievous; those who attempted suicide; and
the harmless; the relapses; the periods when recovery may be despaired
of; the various remote causes. Mr. Gonza had distinguished the married
and single; but in a treatise of this nature, these, and many other
minutiæ, must be omitted.
The usual number, on a general average, of patients in Bedlam is 250;
of which 110 are stationary incurables, male and female; and who remain
there until they either die, or are discharged, for reasons hereafter
to be explained. The remainder are a moving body, upwards of 200 of
whom are annually admitted, and the same number annually discharged:
the difference of males and females is very inconsiderable; in general
the latter rather preponderate. During fifteen years, from 1772 to
1787, of 2829 insane males and females, their respective ages and
numbers in each interval of life, when classed, were as follows:—Under
10 years of age, 1; from 10 to 20, 132; from 20 to 30, 813; from 30 to
40, 908; from 40 to 50, 632; from 50 to 60, 266; from 60 and upwards,
78. Of these the cured were, 934; the incurable, 1694; the dead, 230.
Of these also, the mischievous were 743; attempted suicide, 323; not
mischievous, 886; committed shocking murders, upwards of 20; relapsed,
535.
It seems necessary to be first mentioned, that I made memorandums of
all the different periods, and time elapsed, from the invasion of the
disease, or insane paroxism, to their admission into Bedlam, from one
week to one year and upwards. I do not, however, think it important to
form a distinct class, or table, of these, but merely to observe in the
aggregate, that of the patients admitted into Bedlam, the majority were
not above six months unremittingly deprived of reason; and those, in
all the intervals, from one week to six months. The second great class
were, in the intervals, from six to twelve months. After one year, and
upwards, there are comparatively very few admissions, except on the
incurable list.
The ages at which insanity predominates are obvious, and require no
comment. During the first period under 20, the greatest part of this
small group were between 15 and 20. The ages of about 300, as also
of their cures, incurables, and deaths, are omitted in the records:
fractional exactness cannot be expected: but for gross calculation
there is abundant accuracy. With respect to the cured, incurable, and
dead, I shall make a few remarks: amongst the discharged I found a
considerable number reported as sick and weak; others, and amounting
to some hundreds, as troubled with fits, or with paralytick strokes,
and some with a complication of both the latter maladies; and also
a small fragment of pregnant females; and none of these liberated
from insanity. All these I threw into the incurable list, as I could
discover very few of them ever to return back again. Many of the sick
and weak may safely be added to the dead list; being on the confines
of the grave when dismissed. The incurables likewise contain those
admitted on the incurable list of Bedlam, as well as the great mass
discharged from thence incurable, after one year’s trial.
About one of every three are reported as cured; but from them we
must subtract for relapses, which probably would sink the cured,
radically, to one of 4. The cured are reported in all the intervals,
from one month to one year. Formerly the mortality in Bedlam was
swelled by adventitious diseases, particularly the small pox and
scurvy; both of which are now prevented. Melancholy and confinement
are known to predispose to scurvy, but by an increase of vegetable
diet, this disease is no longer in the mortal catalogue of Bedlam.
The mental derangement, no doubt, must add to the mortality: numbers
discharged, as troubled with epilepsy and palsy, must have fallen into
these afflictions posterior to their admission, as they are always
an exception: and it is observed, that few are cured without the
fits also. The insane generally die of epileptick, apoplectick, and
paralytick strokes, and convulsions, of frenzy, atrophy, or nervous
tabes. If we were to add the sick and weak, the fits and palsy, I
believe lunatick mortality would be doubled; and would then be about
one of five or six. More comparatively die of the insane patients
recently admitted, than of the stationary incurables.
The greatest proportion of patients in Bedlam, especially at the
beginning, have attempted some mischief against themselves, or their
relations and keepers: in the above list there are above a score of
atrocious murderers, exclusive of suicides. There are parricides, and
butchers of their own offspring. Their mischievous acts and attempts
were in various ways, by jumping out of windows, hanging, drowning,
stabbing, shooting, tearing off their cloaths, setting fire to houses,
and several other overt acts of malignity. Some were mischievous by
open acts of violence; others by threats only. Some not mischievous
at first, have become so, and “_vice versa_;” and several reported
as not mischievous, have afterwards hanged themselves. Females, as
well as males, are mischievous; but I do not observe so many dreadful
murders committed by the female sex. By far the greater majority of
patients in Bedlam, except at temporary intervals and exacerbations,
walk peaceably about the wards: separate confinement in their cells,
strait waistcoats, or in the ferocious maniac, handcuffs and chains,
soon render them tractable and obedient: a very small number, even of
incurables, are kept as wild beasts, constantly in fetters. Some, by
time and long confinement in the incurables, and who were extremely
vicious and dangerous, become harmless, and are then discharged. From
all the variety of causes, depressing or stimulating, I perceive
mischievous or harmless. This circumstance seems to make no material
difference in the curable or incurable. Numbers who had attempted
suicide, some who had committed murders, are in the list of cured.
I also perceive recoveries after reiterated relapses; and the
prognosticks are then nearly as favourable as though it had been
the first attack. No disease is more prone to relapse: these are,
at various intervals, in different persons, from one to upwards of
twenty years, and during this period, either one or many relapses.
Multitudes of the relapses are either after being discharged cured
from Bedlam, or before they were brought there for admission. There
are some few instances, wherein the sagacious physician of Bedlam has
been deceived; and when, after apparent recovery, and the subsequent
lunatick quarantine, patients have been discharged with sound bills of
health, but on the same day have relapsed; and even before departure
from the house. They are in danger of relapses from all the causes
which give birth to insanity. From the proportion of cured and
incurable, and successive relapses, many of which at length become
incurable, we see how difficult it is, as yet, to expel this mental
usurper, and to restore chaos into order.
I do not observe so great a difference in the recovery, from either
age or cause, as might be expected: there are cured and incurable,
promiscuously at all ages; and from all the different causes, whether
adventitious or hereditary. Even from hereditary insanity, they seem
to recover nearly as well as from the less inherent causes: there are
several instances of recovery when hereditary from the parents on both
sides. In some, where the disease was entailed, it has made its first
appearance in all the intervals from puberty to fifty years of age.
I was struck with one curious instance of hereditary insanity from
both parents, in a brother and sister, and nearly about the same time;
the one twenty, the other twenty-three years of age; one of whom was
melancholic, the other maniac. There are some few instances of recovery
after one, two, or even three years pertinacious privation of reason:
some few of the incurable in Bedlam have recovered; but all these are
very rare. After only one year’s uninterrupted perseverance of the
disease, they are generally refused admission into Bedlam, except as
incurables; and of such I cannot perceive the cured above one or two
_per cent._
Many features and particulars of the insane character and history have
now been developed. But I have not yet, as in other diseases, ventured
to affix a nosological signature, or definition, and to circumscribe
the limits between the insane and the multitude of others reputed
as rational beings. In such an attempt I might probably appear as
ridiculous as the Greek philosopher in his concise definition of man.
It is not confined within the porticoes of Bedlam and madhouses: we
might find it sprinkled over the earth; not only amongst the fanaticks
of Asia, the Bonzes and Faquirs, and some of the austere cloistered
devotees of Europe; but thro’ every rank and station of civilized
communities.
Insanity has been usually described in the two extremes of mania,
and melancholia: but it is frequently of a complex nature, with
alternating exacerbations of frenzy, and of melancholy. It is termed a
delirium without fever; of which mental anarchy there are innumerable
symptoms, gradations, shades, species, and varieties: the enumeration
of which would be as infinite as the diversity of their faces and
ideas. Sometimes insanity bursts out unexpectedly, like a squall of
wind or thunder-storm: but in general the paroxism is preceded days,
weeks, or even months, by few or many of the following symptoms, which
vary in different persons; quick motion of the eyelids, redness or
wildness in the eyes and looks, restlessness, headach, vertigo, by
something unusual and different from their ordinary conduct in the
speech, gestures, actions, looks; by high or low spirits, loquacity,
or taciturnity: in some, the appetite is voracious; in others, there is
aversion to food.
On the first ebullition of frantick mania, the looks, voice, and
gestures are wild and impetuous; in many audacious and ferocious:
they are irascible, impatient, and violent on any contradiction or
restraint: they ramble with wonderful rapidity of ideas, and garrulity
of speech, from one object to another; shouting, singing, laughing:
some, transported with extacy, roam in incoherent rhapsody through
all the fairy regions of enchantment and romance: we observe maniacks
in idea personating every being and object celestial and terrestrial,
animate and inanimate. But by such numbers either attempting or
committing mischief upon themselves or others, it is evident that
the disagreeable, turbulent, malevolent, and desponding passions
do often predominate; there is more of the jarring and discordant
than of the harmonick notes and keys: some maniacks are distracted
with malevolence, antipathy, animosity, rancour, and revenge. In the
melancholia, the mind is generally rivetted upon one object and train
of thought, about which they incessantly rave or ponder: many are
cogitative, taciturn, morose, or fixed like statues: and more of this
character are said to commit suicide. Some, plunged into despair, are
haunted with all the horrors of tartarus; or even chained within the
gloomy dungeons and inexorable bars of Cerberus.
In mania the strength is prodigiously increased. In general, insane
persons endure hunger, cold, nakedness, want of sleep, with astonishing
perseverance and impunity. During the exacerbation, most are restless;
and most are costive. Some obstinately refuse all food and medicine,
and are drenched by compulsion, as horses taking physick; which at
length renders them more docile. Some, if indulged, are ravenous and
insatiable as wolves. Some melancholick, on relapses, have only a
periodical invasion of profound grief, want of sleep and appetite,
restlessness and anxiety. Many persons, universally considered as
insane, will however, at times, act, speak, converse, and reason
acutely on various subjects, until some particular mental string or
chord is touched. With respect to general prognosticks in insanity, we
have been already copious and diffuse; and shall only add, that in some
degree of mania, more favourable hopes are entertained than in gloomy
melancholy: indecency, no intermissions or remissions, epilepsy, palsy,
tabes, frenzy, are all inauspicious. The piercing and intuitive eye of
the experienced physiognomist, will also discern presages which are
concealed from ordinary comprehension and observation.
Of the predisposing and occasional _causes_ of insanity. We all know
by demonstration and reading, that one eighth part of the blood is
circulated through the head: we know the origin and distribution of its
spinal elongation, and forty pairs of nerves; its internal structure
to the most minute discernible filaments; its division into cavities
and prominences, many of them with uncouth names, and swelling the
nauseous vocabulary of anatomy. But still the latent predisposition
or frailty in the recesses of the brain, which render some more than
others liable to this mutiny of reason, on the application of remote
and obvious causes, are totally unknown. Most of the proximate causes
assigned in authors for madness, are mere hypotheses; and of no active
use to the community, or to medicine. The pretended discoveries of
the anatomical knife; and the specific gravity or levity of the brain
in scales, are equally conjectural. The great master, decypherer, and
physiologist of the intellectual functions, Mr. Locke, has here taught
us to despair, and to be convinced of the imperfection of our senses
and faculties. Literature, however, ancient and modern, abounds with
madmen and authors, especially on the intellectual operations, and
springs of sense and motion. Many other subjects yet remain to engage
our attention, and to prevent our digressing into the jaded topick of
temperaments; of original organization; or the progressive revolutions,
corporeal and mental, by age and time. This is an inexhaustible theme
for observation and lucubration.
The late Dr. Mead broached a proposition, which has been transfused
through most succeeding authors: that from sudden transports of joy,
and the exhilirating passions, more were insane than from contrary
causes: and he quotes Bedlam as an instance during the year of the
South-Sea scheme, when great fortunes were suddenly acquired and
lost. I took the trouble, so far as they are recorded, to class the
different causes of insanity; which contain nearly one third of the
whole patients during the fifteen years of our scrutiny; wherein I
do not find a single example in proof of Dr. Mead’s aphorism, but
hundreds in direct contradiction to it; as appears in the following
table of causes:—Misfortunes, troubles, disappointments, grief, 206;
religion and Methodism, 90; love, 74; jealousy, 6; fright, 51; study,
15; pride, 8; drink and intoxication, 58; fever, 110; parturition, 79;
obstruction, 10; family and hereditary, 115; contusion and fracture,
12; venereal, 14; small pox, 7; ulcers and scab dried up, 5.—I have
not time to comment upon these causes: to them may be added all the
train of exasperating passions; long attention of mind rivetted upon
one object; faults of the blood or bile, and circulation in the vena
porta; plethora in the vessels of the head; _furor uterin_; in some of
the Asiatic nations, opium; also intoxicating poisons snuffed by the
nose; “_cum multis aliis_.” The revolution of the seasons seem to have
no effect on insanity; nor are the effect of the moon conspicuous in
Bedlam.
* * * * *
_Diseases of the External Senses;_ including vision, hearing, smell,
taste; to these we shall add the diseases of the voice and speech;
obstructed deglutition; sterility, and morbid irritability of the
generative organs. The derangement of those delicate and precious
senses through which we derive such supreme delight; through whose
avenues are conveyed into man the first rudiments of all his variegated
ideas and knowledge, are important objects of medical scrutiny;
notwithstanding very few from these causes are precipitated into the
crater of mortality. I could, however, have wished to ascertain from
registers, in conformity with my general plan, the proportion of cured
and incurable; and especially the average of blind in a community.
_Vision._ The principal diseases may be comprehended under opthalmia,
fistula-lachrymalis, gutta-serena, cataract, specks on the cornea.
I exclude some other natural defects, rather than diseases, such as
myops, presbyops; for the cure of which the optician is the best
physician.
Opthalmy, or inflammation of the eyes is a frequent complaint: it
may be in the exterior membranes of the globe, or in the edges of
the eye-lids; or may be a complication of both; it may be in one,
or in both eyes; it may be general, partial, external, internal,
temporary, chronic, idiopathick, symptomatick: of all which species
there are various gradations. In this local malady there is commonly
little or no fever; but heat, pain, redness, and inflammation; the
vessels of the eyes seem gorged with blood; the anterior portion of
the tunica sclerotica, and the conjunctiva, resemble a scarlet cloth,
with impediment in vision, intolerance of light, lachrymation. In the
inflammation of the cartilaginous ring of the eye-lids or tarsus,
there is frequently some remains of small ulcerations in the sebaceous
glands. The external is by far the most frequent form of opthalmy; and,
under discreet management, is attended with trifling danger: sometimes,
however, it is followed by specks on the cornea, or callosity, and
blindness; and violent inflammation has extended to the interior parts
of the eyes and retina. In the internal inflammation of the choroid and
retina, no redness is perceptible externally; but there is excruciating
pain, headach, intolerance of light, restlessness, often delirium, in a
few instances, insanity: and if not relieved in the course of fourteen
days, there is danger of incurable blindness.
Fistula lachrymalis. In this partial inflammation affecting the
lachrymal sac and ducts, and obstructing the descent of the tears, or
superfluous moisture of the eyes into the nose, this fluid necessarily
trickles down the cheeks, and the eye is overflowed with water: on
pressure of the internal angle and puncta lachrymalia, there is a
discharge of glareous serum, by which the eye-lids, during sleep,
are glewed together. The degrees of inflammation and obstruction are
various. In the inveterate stages it may terminate in abscess, ulcers,
and caries of the contiguous nasal bone.
Gutta-serena, amaurosis; in one or in both eyes, and in various
gradations, from obscure vision to cheerless tenebrosity. To a
spectator the eyes appear nearly as in health, only that the pupil is
dilated and inanimate; the retina insensible to the rays of light, and
the iris mute, without corresponding contraction or enlargement: a
physiognomist might say, there are no sensitive emanations or magnetick
rays emitted through this mental mirror. It attacks suddenly or
gradually, and sometimes intermits; but in general it is chronic, and
always dangerous; often irremediable: sometimes it is accompanied with
headach in the anterior part over the eye-brows.
Cataract may affect one eye, but in general both: it arises from
disease or opacity of the crystalline lens obstructing the visual
rays in their course to the retina: the consistence and colour of the
lens is various, white, pearl, green, yellow; and from these the
oculist forms his prognostick: in couching the eye the pearl-coloured
is preferred: the white is too soft; the green and yellow incurable;
as is also that species wherein the strongest rays of light excite no
contraction of the pupil. Cataracts in general are gradual in their
formation; weeks, months.