A treatise on the nature, symptoms, causes, and treatment of insanity, with practical observations on lunatic asylums and a description of the Pauper Lunatic Asylum for the county of Middlesex, at Hanwell ..

Front matter

PRIVATE LIBRARY DR. S. K. LAWTON,

YALE MEDICAL LIBRARY

HISTORICAL LIBRARY

Preface

The fearful extent to which Insanity prevails, the severe bodily suffering usually attending its commencement and the painful change produced by it, in the powers and moral condition of man, render it a subject of intense interest to the philanthropist and the man of science. Recent parliamentary returns show, that there are in England 12,668 Pauper Lunatics and Idiots ; and the Insane alone, including the different classes of society, cannot be estimated at fewer than 10,000. From the habits and mode of education of the upper ranks, particularly of the females, the brain and nervous system are kept in a state of constant over-excitement, whilst the frame is debilitated, from the muscles being rarely called into proper and regular exercise.

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Hence arises a high degree of susceptibility of disease, with little constitutional stamina, to resist the over-anxiety and other effects of the sudden changes in circumstances, peculiarly incident to the present times. Amongst the poor, different, but no less pernicious causes are followed by similar consequences. Excess, especially in the use of ardent spirits, exposure to cold, the want of the common necessaries of life, and the other results of extreme poverty all create in them a liability to Insanity. Were men, habitually, to be temperate in all things, to take no anxious thought for the morrow, and " to set their affections on things above, and not on things below," but few, comparatively, would be afflicted with this disease. Under existing circumstances, however, I am afraid that it would be enthusiasm to hope that its prevalence will be greatly diminished. The objects of the following pages are to point out the symptoms by which an attack of this disease may be foreseen, and the means by which it may be warded off ; and in those cases where it has already supervened, to explain the mode of treatment most likely to restore the patient to reason and society ; and where this is impossible, to show how the sufferings may be

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alleviated, and life rendered, if not a state of happiness at least, one of moderate enjoyment. Should the attempt, undertaken amidst anxious and laborious professional engagements, prove unsuccessful, an earnest desire to promote the welfare of a large and much enduring class of my fellow-creatures, who cannot plead their own cause, must be my apology for having made it.

Though my attention, from early life, has been particularly directed to Insanity, and a residence in the Asylums at Wakefield and Hanwell, during nearly twenty years, has placed under my immediate care and observation upwards of 2,700 cases, I feel that I have still much to learn. Even if the general view taken in the present work be correct (as I fully believe it to be), patient subsequent investigation will be required to make the picture in all its parts complete. Should I succeed in exciting an interest on the subject at all adequate to its importance, it will soon be investigated by men of more leisure, deeper research, and greater anatomical skill, than myself. If the end be but answered, and the Insane benefited, I care not whether it be by the adoption of the plan mentioned in the following pages, or by any other means. Most thankfull

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shall I avail myself of any additional light that can be thrown on the nature of this obscure disease, and of any mode of treatment, however opposite to my present views, by which it may be palliated or removed.

NATURE, SYMPTOMS, CAUSES, AND TREATMENT

INSANITY.

Introduction

The more various the forms in which a disease exhibits itself, the more difficult it is to come to a correct conclusion as to its nature. In scarlet fever, small-pox, and many other acute diseases, we find, whatever be the constitution, similar general effects, only in a more aggravated form in some than in others. In these cases we can always identify the disease ; and if we cannot immediately discover its origin, we can at least find out the mode in which it shows itself. In dyspepsia, and some other disorders, the immediate effects seem to vary with the habits and idiosyncrasies of the individual attacked ; and there is consequently a difficulty in determining to what morbid affection the particular symptoms are to be traced. But in no disease do we find the same complicated and varying forms as in insanity.

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INTRODUCTION.

In some, it is attended with the highest degree of maniacal excitement, excessive muscular strength, and extraordinary vivacity of intellect ; in others, the greatest depression is found, not a word is uttered, and the patient remains like an automaton for weeks together. In some, the senses are quickened, and the sight and hearing are morbidly acute ; in others, they are excessively obtuse, and the whole nervous system becomes in a great measure insensible to feeling. Indeed, from our observing, that circumstances apparently similar produce results diametrically opposite in different individuals, we might be led to conclude, that, in this disease nature is at variance with herself, and that, although in all other cases she is uniform, insanity forms an exception to her rule. A further inquiry into its nature will show us that, when fully examined, these inconsistencies do not exist ; and that they are to be traced to our classing under the name of insanity a set of diseases, which really act in totally different ways, and most probably affect different parts. It will be seen, that an attempt has been made in the following pages, in the first place, to investigate the nature of insanity. The results of this investigation are offered with much diffidence. It is felt, that the theory is liable to many and plausible objections, and that it is incapable of demonstration ; and it is also felt that even if the view be correct, not more than the first step has been advanced in the inquiry. If it be true that insanity is really, in all cases, a disease affecting the brain and nervous system, and that it is highly probable that the parts of it which suffer vary according to the cause, and that the disease of each part is susceptible of great modification, it is obviously a work of patient anatomical research and careful previous inquiry to point out and to classify the different morbid appearances of the brain, according to the different modes in which the disease has exhibited itself. The general result is given as that which, in spite of all the difficulties, appears the most reasonable and satisfactory.

Having investigated the nature of the disease, its causes will form the next subject of inquiry. It will be seen that, in many cases, these can be ascertained with a reasonable degree of certainty- And when it is observed, that so many apparently trifling things, affecting either the body or the mind, will produce such a diseased action in the brain and nervous system as to cause insanity, somewhat of the difficulty felt on account of the various forms it assumes will be diminished. Its perusal will be attended with one cheering effect at least : it will be seen that, in many instances, the cause is capable of removal ; and that, in most, proper caution and attention to the natural constitution will enable those, who are even predisposed to the disease, to avoid an attack. It is hoped, too, that when it becomes known that mere disease of the viscera, in many cases, produces it, the painful feeling of con-

b2 cealment, which harasses the minds of the friends, and operates most prejudicially to the patient, will vanish ; and that the disease will not be suffered to be confirmed, from a false delicacy preventing- the timely application of proper remedies. It will be observed that it frequently is hereditary ; but there is stili no reason why, even in these cases, it may not be avoided. Of course, an individual knowing that he inherits a liability to a particular disease, ought most carefully to avoid those circumstances which will have a tendency to produce it. In these cases, the constitution should be supported by proper nutritious diet ; but the constant use of stimulants of any kind should, if possible, be avoided. And such a situation in life should be selected, as will place the individual in certain, though moderate, circumstances, and not expose him to any great vicissitudes either of good or adverse fortune. With these precautions, those who have an hereditary predisposition to insanity, may in general pass through life without being attacked. And the same high degree of nervous sensibility which renders this class susceptible of disease, is usually accompanied with that mental energy and activity, which make them the most accomplished and valuable members of society.

But little is known of connate idiocy, and dissection has hitherto scarcely thrown any light on the subject. In general the brain, especially the cerebrum, is very deficient in size ; but in some instances the head is well proportioned, and the contents, on post mortem examinations, exhibit no traces of disease. It was not thought right to pass over the subject of fatuity, without adding a warning against the pernicious habit, which appears to be a very frequent cause of it.

The Chapter on Symptoms will be found to embody a somewhat minute account of those mental and corporeal changes, which usually precede an attack of insanity. If the attention of friends were but sufficiently aroused to these premonitory symptoms, the disease could, in many instances, be checked in the onset ; and in others it would, in a comparatively short time, yield to simple and easy remedies. This chapter also contains a description of the most usual mental aberrations, and of the marks by which the existence of lesion of the brain is indicated. The symptoms .exhibited by suicidal patients are detailed at some length ; as the care of this class is obviously one of the most painful and anxious duties devolving upon a professional man.

Great improvements have taken place in the general condition and treatment of the insane, since the horrible and disgusting disclosures brought to light by the parliamentary investigation in the year 1814. But although they are, in a great measure, protected by the present system of inspection from gross acts of cruelty, much ignorance still prevails on the method of their treatment. Nor will this be a matter of surprise, when it is considered that the b INTRODUCTION.

subject of insanity forms but an inadequate part of medical education. In many instances, when a professional man is called in to attend a patient in a high state of mania, the disease is as new to him as it is to the friends, and he is as much terrified as any of those about him with the violence exhibited. The irritation of the patient is increased by the excitement into which all those around him are thrown ; and by the excessive confinement in which he is necessarily placed, from the want of proper and convenient means of restraint. Under these circumstances, the most vigorous means are adopted ; and as the pulse for a length of time appears to indicate excessive circulation, they are persevered in, until the physical powers are exhausted, and the constitution, in very many instances, irreparably injured. So many cases have fallen under my own observation, where well-meant, but injudicious treatment, the result of want of proper instruction, has rendered all attempts at subsequent cure hopeless, that some suggestions will be found to remedy this evil : it is hoped that they will not be considered out of place.

It will be seen that the medical remedies, on which much reliance is to be placed, are but few, and that they are principally of use in the early stages of the disease. The moral treatment is by far the most difficult part of the subject. In this the most essential ingredient is constant, never-tiring, watchful kindness : there are but few, even amongst the insane, who, if a particle of mind be left, are not

INTRODUCTION.

to be won by affectionate attention. The attempt must be made day by day, and for weeks together ; and no discouragement must be felt, if even then the end is not accomplished. Persevere, and the reward will follow. In many cases, there will be the delight of witnessing the gradual return to reason and happiness ; in all the peace and satisfaction arising from a consciousness of having done what is right to the uttermost. The various modes subsequently pointed out, in which the patients have been acted upon by moral means, are not given as an enumeration of all which may be used with advantage, but merely as specimens, and for the purpose of exciting benevolent ingenuity.

In the Chapter on Asylums, several minutiae are gone into, which, it is feared, will be uninteresting to the professional reader. It is, however, hoped, that it will afford useful practical information to those, under whose direction similar institutions are about to be built. Indeed, many things, which appear trifling to a superficial observer, materially affect both the comfort and the cost of the patients. It is hoped, too, that, whilst the hints it contains will have a tendency to diminish the expense of executing such buildings, an enumeration of the various requisites for lunatic asylums will remove the too general impression, that, because they are to be occupied by paupers, they ought, therefore, with proper economy, to be erected at as cheap a rate as poor-houses.

In the account of the mode in which the Asylum at Hanwell is managed, the various steps will be traced, by which the system of employing the patients has gradually increased, until, at the present, 454 out of 610 are regularly at work; and many of them at trades, with which they were totally unacquainted until they were taught them in the institution. When the system was commenced by myself and my wife, on the opening of the Asylum for the West Riding of Yorkshire, at Wakefield, so great was the prejudice against it, that it was seriously proposed, that no patient should be allowed to work in the grounds outside the walls without being chained to a keeper. Another suggestion was, that a corner of the garden should be allotted for their labour, and that they should dig it over and over again all the year round. The kind feeling and good sense of the people in the neighbourhood soon overcame these prejudices ; and not only did they witness with pleasure the unfortunate patients happily engaged in their works in the grounds of the institution, but they were delighted to meet them emerging from its bounds, and, by a walk in the country, and a little intercourse with their fellow-men, preparing to enter again into society. They felt too, when bowed before that God, in whose sight all men are equal, that no spectacle could be more cheering and appropriate than to witness the poor lunatic listening with them to those offers of mercy, which are peculiarly addressed to the weary and the heavy laden. Most sincerely do I hope that similar feelings will soon operate in favour of the patients at Hanwell, and that an unfounded prejudice will not long continue to confine them entirely within the pales which surround the building.

An account is also given of the measures actually adopted for the punctual and orderly arrangement of the duties necessary to the management of so large a family. It is hoped, that those who are about to undertake the conduct of similar institutions may derive from it some assistance in the formation of their plans. A copy of the written rules given to each of the domestics is added in the Appendix. These have been gradually framed as experience has pointed out the advantage of the various observances which they are intended to secure. But, notwithstanding all the rules that can be laid down, much of the comfort of the patients, and of the probability of their cure, will depend upon an unceasing watchfulness, that those, under whose care they are placed, constantly treat them with the greatest kindness and forbearance. And, indeed, unless proper persons be selected, it is impossible to prevent acts of oppression occasionally taking place. When the harassing and irksome nature of the duties of the attendants on the insane, and the importance of those duties being properly fulfilled, are considered, it is obvious, that such an amount of remuneration should be proposed as should induce persons of character and respectability to offer themselves as keepers and nurses. And, in estimating what is a fair reward for their labour, it ought to be remembered, that their lives are constantly exposed to be attacked by those whose insanity has not diminished the influence of their evil passions, but who have sense enough to know that however violent or fatal the outrage they may commit, their disease exempts them from all liability to punishment.

A conviction that the insane of the middle and higher classes do not possess half the advantages afforded by public asylums to the poor, has induced me to add a short sketch of a system, which, I hope, will secure to them every facility of cure, with but little risk of improper detention. I know that objections may be raised against the system of proprietary asylums, by which I hope that these important ends may be attained. But I think if the medical superintendent is not allowed to have any share in the concern, or to derive any pecuniary benefit from the patients remaining under his care, it will be so obviously important to his professional reputation to use every possible means for their cure, and to discharge them as soon as they can be safely restored to society, that there will be no doubt but, under this system, the rich will, at least, be put upon an equal footing with the poor. If such a refuge were but established, to which the friends of the patients could at once entrust them

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with confidence, the disease would be stripped of half its terrors, and the constant succession of patients to such an institution would abundantly repay the proprietors.

A few observations are added on epilepsy and the diseases of the insane. On the former very little is yet known.

An attempt has been made to draw a distinction between moral evil and insanity. A marked difference between the two really exists, although this difference is often difficult to be determined in individual cases. I greatly fear that, in every large public asylum, many will be found morally responsible before God, as rational beings, for that vicious conduct, which is by society mercifully attributed to insanity.

Chapter II. On The Nature Of Insanity

The first question which naturally suggests itself to the mind, on entering on the consideration of this subject, is, What is insanity ? Is it a mental, or is it a bodily disease ? or are both the mind and the body simultaneously affected ? As it is obviously of great importance to have a definite notion of the nature of insanity, we shall attempt to answer these questions in the present chapter.

Our total ignorance of the nature of the mind itself, and the little knowledge of the brain and nervous system, by which it acts and is acted upon, that has hitherto been derived from the minutest anatomical research, and the most patient investigation, will easily explain why so many contradictory opinions on this subject have existed amongst mankind. In the earliest periods, the insane were supposed to be possessed by demons ; and superstition assigned to the priests the task of curing them by exorcism. Hippocrates, and other ancient writers, treated insanity solely as a bodily disease, although they differed as to its immediate cause; he- attributing it to a mixture of bile with the blood ; others, to a too great determination of blood to the head. Amongst the moderns it has more frequently been considered purely a mental disease, and requiring only moral remedies ; though, within the last few years, the doctrine of its being a bodily disease seems again to prevail. But as a mere enumeration of the contradictory opinions of the various writers would evidently not tend to increase the distinctness of our notions ; and as the proposed limits of the present work will not allow us fully to state the modes by which they severally arrive at their conclusions ; we will investigate for ourselves the nature of this obscure and mysterious disease. Before we proceed, it is necessary to observe, that, we shall at present confine our attention entirely to Insanity. The different manifestations of mind arising from Idiocy, Eccentricity, and Moral Evil, often confounded with it, will be taken into consideration hereafter.

We have every reason to believe, that all living beings, from the smallest insects to the largest animals, possess such a portion of mind, or instinct, as mind in animals is usually called, as is adapted to their several conditions. Some require no more than is sufficient to direct them in the choice of food, to warn them of danger, and to induce them to procreate their species. In these the corporeal machinery is exceedingly simple. They are furnished with ganglia and plexus of nerves, but are without brain. When the powers of instinct are more extended, we find, in addition to a more elaborate development of the nervous system, a cerebral organization. Ascending in the scale of creation, we arrive at man. He possesses a bodily organization and mental faculties, of a nature similar to those observed in animals, although much more perfect in their kind. But, in addition to these, he is endowed with higher and nobler faculties. He has, and ever has had, the capability of knowing, worshipping, and loving God, and receiving the influences of the Holy Spirit. And this distinction exists wherever man is found : at the poles, or at the equator ; in the white-skinned European, the sable African, or the American savage : and it is a distinction that can never be obliterated. What then do we observe in the formation of man, uniformly distinct from that which exists in all other animals? A more elaborate cerebral organization, and a great multiplication of its parts, many of which are not found in any other animals whatever, although there is no other part of the human body which is not, more or less, developed in one species or another. Now, in each class of animals, there appears to be a certain limit to the manifestations of mental power ; and it is exceedingly probable, that, in the individuals composing each class, there exists a great difference in their capabilities. We know that in various quadrupeds, and the higher class of animals, such a difference does exist, and in man, more particularly, to a very great degree.

In judging whether, in any species of animals, the functions are healthily performed, we naturally look at the previous habits and capabilities of the species ; and we do not consider the absence of that which is not usually found to exist in such a species, as any indication of disordered function ; nor should we think the existence of a capability much superior to that which is found amongst other species, of itself to constitute any evidence of soundness, because of the difference of their natural powers and habits. Is not the same rule applicable to different individuals of the same species, and particularly in man? We know, from experience, that an immense difference, both in physical and mental powers and habits, from some cause or other, exists among men. Whether this would, or could not have been obviated, by previous education, is foreign to our present consideration ; although I think there is very little doubt that differences do exist, which no external circumstances could remove. We should be unable to form any opinion of the soundness of a limb or muscle, merely from knowing its absolute power. The arm of a powerful man, though in a state of disease, may be able to lift a much greater weight than the perfectly healthy arm of a weak and delicate one. Before the present absolute power then can be the test, we must know the previous capabilities. Ought it not then to be the first object of our inquiries, in estimating the sanity of an individual, carefully to investigate what have been the previous habits and powers of his mind ; what has been the state of his sentiments and passions ; and what has been his general conduct ? And would it not be irrational to conclude that a man, possessing great mental powers, is necessarily sane, because he is capable of performing with accuracy certain mental operations? and equally irrational to conclude that an individual, of weak mental powers, is not sane, merely because he is incapable of performing similar operations? But should we not, in either case, be justified in pronouncing the individual sane, when the manifestations of his mind, his sentiments, passions, and general conduct, continue in accordance with the exhibition of his previous powers and habits ? These may have been such, that the individual has been incapable of performing the relative duties of life, and he may have been idiotic or imbecile : but such cases do not come within our present consideration.

We arrive then at the general conclusion, that, independently of cases of idiocy, imbecility, eccentricity, and moral evil, which will be the subject of future consideration, man is sane, when, as we have stated above, the manifestations of his mind, his sentiments, passions, aad general conduct, continue either to improve or to keep in accordance with the exhibitions of his previous powers and habits. And this too whether the mental powers are great or small ; and whatever may have been the degree of cultivation ; and however great the difference between the individual and others. The object of our introducing the analogy between the mental powers of animals and their cerebral development, will be seen as we proceed. Let us now go on with our investigation as to the nature of insanity.

The first step in ascertaining the nature of any disease, is to find out what, if any, are its invariable symptoms, distinguishing these from all others which only occur under particular circumstances. What then do we find constantly attendant upon insanity ? That which is first, and invariably noticed, is some injurious alteration, either in the intellectual manifestations, or in the conduct, or in both.

It is quite clear, that if we can show that there is an intimate connexion between the action of any part of the human body, and the intellectual manifestations and the conduct, which are the subjects of the alteration uniformly found to exist in insanity ; and can also show, that where this injurious alteration exists, there is at the same time diseased organization, or diseased action, in such parts ; we shall have done much to enable us to come to a right conclusion on the nature of insanity. Now, can we not trace such a connexion between our intellectual manifestations and the brain and nervous system ? We have seen that in animals, where little mental power exists, there is a proportionate absence of

c cerebral organization ; and that in man, where such mental powers are found in the highest degree, the cerebral organization is the most elaborate. Again, when in man the whole brain has become torpid, either from the effects of chronic inflammation, or pressure gradually taking place from the morbid secretion of serum, slowly distending the ventricles and membranes, an alteration takes place, and he is reduced in point of intellect to the level of the lowest animals : he is capable of taking his food, but all other voluntary action is lost, in proportion as the pressure and diseased organization increase. Now, what is the case when the brain is excited to an unusual state of activity ? We find a corresponding alteration, that is, an increased activity, in the mental manifestations. In the ordinary use of fermented liquors, until, from their being taken to excess, torpor is superinduced, by a quasi apoplexy, the operation of the mind, the sentiments, and the passions, are quickened in the same ratio in which the stimulus increases the action of the brain. In phrenitis, where this increased action of the brain amounts to acute inflammation, the violence of the mental manifestations corresponds with the activity of the disease ; and when, by cold applications and proper medical treatment, the inflammatory action is removed, the mind recovers its tone ; but the intellectual powers and feelings are never completely restored, if the inflammatory action has remained unsubdued, until the organization of the brain and its membranes has become permanently injured. This is found, on dissection, to be the case in all instances where the insanity has been the result of phrenitis. Now it is quite clear, that every other part of the body may be diseased or even totally destroyed, and still, if the brain continue to be healthy, the mental manifestations will remain unaffected.

May we not then, from these instances, fairly conclude that there is a necessary connexion between the mental manifestations and the state of the brain ; and that, at all events, in these extreme cases of complete torpor and excited action, the injurious alteration which results in the intellectual manifestations and the conduct, is to be traced to the state of the brain ? And as we know that the assistance of the brain is necessary to our intellectual manifestations, to our sentiments, and to our passions, may we not reasonably infer that the injurious alteration which we have previously described as the invariable attendant upon insanity, may, in like manner, in less extreme cases, be traced to the state of the brain ? This inference receives material support from the result of anatomical investigation. In old cases, diseased organization of the brain is almost invariably found ; whilst in the recent cases there is rarely diseased organization, but the vessels on the whole surface of the brain are surcharged with blood, and clearly indicate the existence of increased cerebral action.