ON THE PROBABLE EVENT OF THE DISEASE.

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

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

Physicians, attending generally to diseases, have not been reserved, in imparting to the public the amount of their labours and success: but, with regard to this disorder, those, who have devoted their whole attention to its treatment, have either been negligent, or cautious of giving information respecting it. Whenever the powers of the mind are concentrated to one object, we may naturally expect a more rapid progress in the attainment of knowledge: we have therefore only to lament the want of observations upon this subject, and endeavour to repair it.The records of Bethlem Hospital have afforded me some satisfactory information, though far from the whole of what I wished to obtain. From them, and my own observations, the prognosis of this disease is, with great diffidence, submitted to the reader.

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

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

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

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

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

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

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

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, (TraitÉ 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.

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.