An essay on the prevention and cure of insanity; with observations on the rules for the detection of pretenders to madness

Front matter

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Chap II

Sect. I.

Insanity consists of one species under two forms, viz. Sthenic and Asthenic, or Mania and Melancfiolia 54

Sect. II.

History of the Sthenic or high form of Insanity.... 67

Sect. III.

On the terminations of Sthenic Insanity 85

Sect. IV.

History of the Asthenic or low form of Insanity .... 91

Sect. V.

On the terminations of Asthenic Insanity 107

Sect. VI.

On the predisposing causes of Insanity Ill

Sect. VII.

On the Proximate cause of Insanity 131

Sect. VIII.

On the Exciting causes of Insanity 186

Sect. IX.

On lucid interval and partial Insanity 158

CONTENTS.

Sect. X.

Of the Prognosis 174

Chap. III

■Insanity is not a hereditary disease in the vulgar sense of the word as commonly understood 189

Chap. IV

Sect. X Insanity is as generally curable as any of those vioient diseases most successfully treated by medicine 201 Sect. II.

On the causes of failure in the cure of Insanity .... 211 Sect. III.

Distinction of the Sthenic from the Asthenic form of Insanity '_ _ 229

Seet. IV. \ t

On the prevention of Insanity 236

Sect. V.

On the dure of Sthenic Insanity 271

Sect. VI.

On the cure of Asthenic Insanity 330

Sect. VII.

On the causes and prevention of Insane relapse 378

Sect. VIII.

On pretended Insanity 3 gj

Introduction

" There is reason to believe that the writer who should be happy enough to unfold sorne of its intricacies, xvould inspire a gieat interest among his countrymen, and that by a proper application of his principles, he might render them a most essential service."

Betldocs on Insanity, Essay x.

Publications upon the subject of Insanity have within these few* years become so numerous, that any additional one seems to require an apoloo-y, but with the exception of the "Observations of Dr. Cox," none of them are so directly practical as the importance of the subject certainly demands, not even the " Observations on the management of the Insane " by the veteran Dr. Arnold can be fairly exempt from this remark ; how greatly the public expectation has been gratified or disappointed by this long promised work I cannot presume to determine, but a very different performance was no doubt expected from a practitioner who says " I have had the experience in my awn house established for the reception of.

B i'l INTRODUCTION.

insane patients of two and forty years, and to this management together with the administration of such medicines as long use has proved to be efficacious, may, I think fairly, be attributed a very successful practice in which two- thirds of the insane patients committed to my care in that institution have been sent home again to their friends perfectly restored to soundness of mind and understanding." Arnolds Obs. on the management of the insane, p. 54.

But where, says the young medical artist, is the catalogue of " efficacious medicines'' and the accurate account of their doses, modes of exhibition and detail of their effects, which have been so successfully employed for near half a century in producing such a sum of general good? Alas! in vain will he search for " that candid and full exposition of his principles of treatment "which the able translator of the learned work of M. Pinel hopes he will favor the world ; great learning, indefatigable research and amusing descriptive talent cannot be denied to Dr. Arnold, but it is justly observed by M. Pinel, and Dr. Davis, when mentioning his original and largest work, *' it is more calculated to retard than to accelerate the progress of science" — " it is little more than a Nosography of insanity," Dr. Davis's Trans, p. 50 The ingenious Pinel has held out a similar promise to that made by Dr. Arnold at the termination of his histoiy of insanity published thirty years ago, " he hopes soon to have it in his power from more conclusive experiments, to establish a systematic

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INTRODUCTION. Ill

treatment of the disorder," Ibid. p. 237. Surely he will not let the present generation pass away before he gratifies the expectations he may have raised in a more satisfactory manner than his contemporary ; in the interim the author of the following essay indulges the hope, that his attempt to elucidate the moral and medical treatment of the most dreadful of human diseases will meet with a favorable reception, and supersede the necessity for the repetition of a too just remark made by the Editors of the London Medical Review. " If any one will take the trouble to read the most esteemed works on mental insanity, we have no doubt he will think with us, that the treatises on this subject are more than commonly uninstructive, and that when arrived at the conclusion of his task, he knew little more than when he began it." No 1. Art. Pincl on Insanity.

It must be most painful to the anxious enquiring mind of a young medical practitioner, to explore leaf after leaf of Mr. Haslam's second edition of " Observations," without attaining the consolation of a firm resting place, after having been told that the book was to be considered as "an abbreviated relation and condensed display of many years observations and practice, in a situation affording constant opportunities and abundant supplies for such investigations." Pre/, p. 6.

It would be an unwarrantable waste of the

JV INTRODUCTION.

reader's tiVne to detain him with such an account of the great inattention the rational method of curing insanity has experienced from the medical world which might be candidly written, or to discuss with precision the history of the causes why this most serious branch of practice has been so often disgracefully consigned to the management of the ignorant and barbarous keepers of prisons, work-houses and asylums ; nor is it necessary to make a long pathetic appeal to the feelings of the medical faculty upon this important concern, for to the honor of human nature an immense majority of them have seconded the efforts of a Jenner with a liberality and zeal which has crowned them with an imperishable lustre ; to derive a portion of this honorable and enlightened ardor into a channel no less important is the grand object of the present attempt, for as a late and justly lamented writer observes, " Madness, while it hastens not the approach of death, destroys all that makes life valuable, and strikes at once at all the powers and privileges of man!! '.' Curries Med, Bep. v. 2 p. £2. append.

The endeavor to diffuse medical knowledge, howe\er obscure and humble may be the channel which conveys it to the general stock, is at all times the best apology for defect of style or prolixity of manner, and ought upon every well intended occasion to form an impenetrable shield against the shafts of severe criticism, to disarm their acerbity on the present occasion it may uiffice to observe, that next to the preservation

INTRODUCTION. V

of human life ranks the prevention and removal of disease, probably the exaltation of human reason is not of higher importance than its restoration when suspended.

Insanity has much too long been considered as a disease, affording a tremendous succession of the most discouraging obstacles to successful treatment, and too often been hastily ranked by ignorance, aversion or imbecility among the incurable maladies ; half a century past it was observed, that " Madness, though a terrible and at present a very frequent calamity, is perhaps as little understood as any that ever afflicted mankind." Dr. Bat tie on Madness, 1758. Cox on Insanity, Pre/. The want of certainty complained of in the practical treatment of Insanity is doubtless just, and is attributable to two general causes, the leading one disinclination to encounter the peculiar obstacles it always presents, the subordinate one to the having imbibed erroneous ideas as to its causes, symptoms, and rational management. Too assiduous an attention has hitherto been paid to the developement of moral metaphysical and exciting causes of the evil, in paths affording little hope of ultimate success, whilst those- strictly corporeal and predisponent indisputably more within the sphere of human reasoning have been greatly neglected, in fact the mental faculties have attracted diligent investi gation, whilst the sources from whence they are derived have been most injuriously and unac-

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countably overlooked. " Philosophy," says the learned Richerand, " has been in the wrong not to descend more deeply into physical man, there it is that the moral man lies concealed." Physiology, p. 529. It is no presumption to infer, that by adopting the idea of the learned Physiologist, the erroneous and often mischievous views which have been entertained of this disease, will cease to operate so prejudicially to future unhappy sufferers.

Several voluminous works have been written with great labor and minuteness of investigation on the nature and faculties of the human mind, its contfexion with the body, its extensive influence over it, their reciprocity and yet the independance of the mind on the body, but perhaps there would be no difficulty in proving that few, if any, of these productions (however otherwise valuable) have tended to establish a rational, and happy mode of treating insane disease, practical utility having given place to metaphysical enquiry, confusion, perplexity and error of judgment have assumed the situation of that clearness, precision and truth which ought to be the ultimate object of all Ideological investigation. " Perhaps no science has suffered so much as medicine by the neglect of its true end, it has indeed made the slowest progress of any of the useful and practical arts, not so much from any deficiency of genius as from a misapplication of it." Greg. Led. on the duties of a Phys. p. 160. It follows then, that, either from neglect or

INTRODUCTION. V)'i

impropriety, the most useful part of the business has been thrown into the back ground, and given place to the more specious and pleasing attempts to explain the intricate nature of the human mind, hitherto almost universally though erroneously deemed the fountain of insanity independant of corporeal influence, organic affection, or vital laesion, a doctrine as unfounded in truth as it is highly prejudicial to the best interests of the human race.

Insanity has long been the most neglected and despised of human disorders. " It was not until very lately that lunatics were considered as being worthy of the public care, they were permitted to wander about the city to the terror of the weak and to the horror of the humane." Month. Mag. vol. 12. Even in the time of Locke, madness was spoken of as "a taint," " a harsh name," "an ungrateful imputation." Essay on Hum Und. p. 279-80. Too many very intelligent and extensively useful medical practitioners even in this day of enlightened humanity, either wholly neglect the victims of insane disease, or hastily consign them as loathsome terrific objects to chains, painful coercion, starving and darkness. The author of a great work which has had more influence over general medical practice than the Boerhaavian, Stahlian, or any other system ever obtained, when treating of insanity frequently and candidly owns his deficiency, in the following emphatic acknowledgments; " In my limited views of the

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different states of insanity," " but 1 have not had experience enough to ascertain these points with sufficient confidence;'''' speaking of vomiting one of the most useful of curative agents, he says, " / have not had experience enough to determine. " Of pediluvia whilst cold is applied to the head. " Of this practice however I have had no experience." Of Opium " / have never indeed carried the trial so far as seems to be requisite to a compleat cure.'" Cidlens First Lines, v. 4. on Mania. Although an immense load of the lumber of the schools has been cleared away by the* honorable labors of the medical lecturers of the latter end of the last and the commencement of the present century, still the subject of insanity has not received that share of attention it merits, or the following remarks had never been made : " The Physician will find that he has a new region of medical science to explore, for it is a circumstance to be regretted both by the faculty and the public, that the various diseases which are classed under the title of insanity, remain less understood than any other with which mankind are visited." Percwafs Med. Eth. p. 28.

Habitual neglect like habitual error is not easily removed, he who has failed whilst a student to consider tire subject with the attention it demands, comes very ill qualified to administer that radical relief to the wretched object placed under his care, which almost every case in its commencement is capable of receiving, it is painful to remark that there has long existed too much

INTRODUCTION. IX

of this in medical schools and practice, too much of the " Idola Theatbi."* For verification of these assertions appeal may be justly made to the innumerable melancholy proofs contained in our crowded houses of reception, hospitals and asylums, from the elegant and sequestered apartments in the country where " a carriage is kept for the use of convalescents " down to the miserable cells of the vilest receptacle in the precincts of the overgrown metropolis." Vide Reports of the Select Committee on the State of Pauper Lunatics, 1807. There were 1800 insane subjects in poorhouses, and near 500 in private custody. There were 300 patients then in St. Luke's Hospital, and no less a number than 640 waiting for admission to that institution, according to the evidence of Mr. Dunster the master of the house.

Whatever truth there may be in the remark of the acute writer of the " Essays on Health," that insanity is more common in England than in other countries, it is certainly not to be ranked among our declining diseases, it is the more incumbent therefore on those who enjoy the greatest opportunities, to exert their abilities in exploring the causes of this increase, and strike a bold stroke at the root of so dreadful an evil. Let then these considerations operate strongly upon the minds of all concerned in the practice of medicine, let the increasing activity of the disease, the best interests of suffering humanity,

X INTRODUCTION.

and a due regard to the honor of the first of human attainments, all which press forcibly on the feelings of benevolence henceforth influence every medical man to pay due regard to this branch of practice.

The regular leading phenomena attendant upon insanity, which by the anxious observer, may from the application of judicious methods be rendered subservient to its complete cure, are by no means so few, so complex, or so obscure as has commonly been apprehended ; another encouraging circumstance consequent on the rational investigation of this subject, if pursued conformable to the Baconian method, or the true spirit of all legitimate enquiry, will be the acquisition of clearer notions respecting the constitution and operations of the human mind in health, than can by any other channel be obtained ; in the same manner as a scientific knowledge of the integral composition of many parts of the body in their ordinary state, can only be acquired when their functions are impeded by disease ; the ancients denied the existence of nerves in the bones and tendons from their texture and seeming insensibility during health, but disease has discovered these parts to be possessed of a portion sufficient to admit of the most exquisite pain ; thus many of the intellectual operations will be better understood by the accurate study of insane malady than by any other means. See Richeran(Cs Physiology, p. 36 1.

INTRODUCTION. XI

To all who are possessed of sufficient leisure, opportunity, and a philosophical spirit of enquiry, some practical remarks are in the following essay suggested, for such alone will examine with cautious patience and strict impartiality the facts which elucidate and prove the general conclusions drawn from long experience and some industry of observation ; and to write on a disease so little understood as insanity confessedly is, can only be considered as a mere essay or attempt to advance a step in the path of improvement. Montesquieu remarks in the " Esprit des loLv" — " It is permitted to every citizen to wish to be useful to his country," such a wish has for many years occupied the first place in the mind of the author of the following work, to merit the appellation of friend to the human race, " nor steal inglorious to the silent grave," is the limit of his ambition, if therefore his anxiety be great and his zeal warm, these impelling motives must plead his excuse for defects incident to every thing human.

The reader is particularly intreated to observe, that the two following axioms contain the principles which form the basis of the essay ;

First. That Insanity is always a symptomatic disease.

Secondly. That it is never a purely mental disease.

xii INTRODUCTION.

"There are some truths," says the late learned Bishop of Cloyne, " so near and obvious to the mind, that a man need only open his eyes to see them," the foregoing axioms are two of this description, how far their justness of assumption will be supported by incontestible evidence remains to be seen during the investigation of the subject ; for the present they must be admitted as probable truths, ultimate conviction may be obtained by faithfully subjecting the plan hereafter proposed to the test of experience that dernier court from whence there is no appeal ; at the same time it must not be forgotten, that the grand aim is an endeavor to illustrate practical truths that rely principally upon experience, and that " it is not a thing so easy as is conceived to convey the conceit of one man's mind into the mind of another without loss or mistaking, especially in notions new and differing from those that are received." Bacon, v. I. p. 392.

Whilst detailing my opinions and practice with considerable hesitation to the world, I have presumed to appreciate the generous indulgence of all who will give attention to the subject proportioned to its desert, thus will they meet a fair examination finally to receive approval or condemnation from the most impartial tribunal. .

The scope of this essay will be learnt from what has been already advanced, and the following deductions which the success of the mode of treatment recommended have fully established, viz.

I. That

Insanity II

IV

INTRODUCTION. X1U

has always corporeal disease for its foundation.

consists of but one species under two forms, viz. the Sthenic and the Asthenic, or Mania and y Melancholia. is not a hereditary disease in the vulgar sense of the word as commonly understood. § is as generally curable as any of those violent diseases most successfully treated by medicine.

§ Mr. Haslam in attempting to form a table " wherein might be seen the probable direct course of this disease, and also its collateral bearings" tells us ** difficulties have arisen," truly they will ever arise, for such a table, neither can or ought to be formed, for the very reason he has given, viz. " It appeared, on consideration, improper to attempt precision with that which was variable and as yet unsettled," and happily for mankind will ever so remain. The few instances which Mr. H. with all his undoubted industry, zeal, and experience, in the most extensive field of observation has been able to select amount to nothing in proof of necessary hereditary insanity. The instance of M. M. was a case connected with menstruation ; after the final secession of this evacuation she recovered although she had been confined 16 years. Haslam on Insanity, 2nd. Edit.

AN

ESSAY

ON THE PREVENTION AND CURE

OF

INSANITY.

AN

ESSAY

ON THE PREVENTION AND CURE OF INSANITY.

Chap. I. Insanity Has Always Corporeal Disease For Its Found Atiom

JVEFLECTING minds unfettered by the trammels of any system upon attentively scrutinizing the multifarious phenomena attending insanity, must consider the human body as forming together with the mind, one homogeneous mass no part of which can be injured without causing a painful impression on the brain. This machine is endowed with a greater or less degree of what has been very appositely termed excitability, which insanity more evidently than many other diseases proves to be one undivided property

c existing in every part variously, modified ifi individual systems, subjected every instant during life to the influence of exciting powers extending over all its parts. The nerves are the great instruments by which these effects are produced, and although some parts of this homogeneous mass as the brain, organs of sense, stomach and intestinal tube possess a greater readiness to be acted upon than many other parts, (as illustrated by the ingenious Ev. Home) and so comparatively some more than others throughout the whole, still the result differs not essentially, viz. that the whole is affected. All the parts of the human machine are so nicely balanced and fitted to their own duration, that no one can be materially injured without the rest suffering, assuming appearances according to their function and situation, but those parts which have the most ready communication with the sensorium are the most quickly and sensibly affected, as the stomach in Dyspepsia, the intestines in Enteritis, &c. These observations apply equally to the opposite states of health and of disease, no morbid change or material deviation from health can take place however apparently slight without the whole being more or less subjected (with some varieties) to synchronous action; because " Life properly so called is the result of a series of concurring and harmonic actions." Richerand's Phys. Prelim. Diss. p. 5. Whatever similar impressions then are made upon this uniform organized mass acting as apparent causes, the effects or apparent changes produced must of consequence in subjects of similar constitution or conformation be similar, making due allowance for the degree of excitability possessed by each individual. "As there is a general sympathy which prevails throughout the whole system, so there is a particular and very remarkable consent between various parts of the body" — "Every sensible part of the body has a sympathy with the ivhole which will sufficiently appear," &c. Why It's Pref. to Nervous diseases, p. 493, seq. This was the language of a very acute observer, and corresponds with what might be selected from the works of his predecessors and successors down to the time of Brown.

Excessive action or energy of the brain as it is sometimes termed cannot take place without a correspondent state supervening over the whole body, although from difference of conformation and various causes of an accidental nature, a difference of degree in form and force of derangement will be manifest, the same law is applicable to defective action or energy. Organic laesion on some occasions affords symptoms which tend to lead superficial observers to adopt very erroneous conclusions as to the sthenic or asthenic state of the subject whose case they are considering, for the organic lassion in every case present in a greater or less degree, may seem to indicate all the evidences of the prevalence of morbid augmented energy whilst the system at large~is manifestly labouring under the opposite state, as in obstructions and certain irritations existing in the stomach, bowels, &c. Local affection will often exhibit the marks of very energetic action in a frame of body truly labouring under actual debility, still philosophically speaking opposite states of the same system do not actually exist at one and the same time, but want of attention to this view of the subject has led to irreparable mischief in the treatment of insanity, for morbid increased energy in a part is generally at the expence of the whole, it is mere irregular excitement.

The wonderful and inexplicable property termed excitability known only by its curious and often astonishing effects has " alternately excited the wonder and provoked the doubts of mankind, who from the earliest times have considered it as the prerogative of human reason to deny what cannot be perfectly explained." "Yet philosophy is not without its prejudices and often rejects as impossible that which afterwards proves to be fact."

This property is subject to considerable inequalities, in diseases sudden and opposite changes take place which art is capable of rectifying, hence the irregularities exhibited in the torpid stomach and highly excited brain of lunatics, in the flushed and burning cheek with feet of marble coldness and insensibility. The following positions appear then to be founded in truth.

First. That local diseases cannot exist independant of general affection more or less violent according to predisposition, exciting causes and the nature and offices of the parts primarily deranged.

Secondly. That general diseases are productive of internal or external local affection which may remain after the general or primary disease is changed, or in a considerable degree passed away, inducing a new set of symptoms. In the brainular organs of insane persons, certain changes having taken place from general affection, which general affection yielding to the influence of suitable remedies, still occasionally leaves the local disease in such a state as to induce new symptoms, chronic insanity for example, thus also a disease originally of one form may become changed into another e. g. Phrenitis or inflammation of a milder description may be successfully removed, yet if the subject be predisposed to insanity, sudden deposition of coagulable lymph, formation of osseous excrescence, hydatids, membraneous induration, vascular ossification &c. may induce the maniacal form terminating in sudden death, but commonly the change is gradual and mild, partial or unintermitting chronic insanity from its nature incurable, always accompanied with more or less febrile irritative action, especially if the patient, as is too frequently the case, be suffered to wander at large subjected to all the irritating incidents of common life.

Now the brain comparatively possessing from its peculiar texture and functions, by much the larger portion of excitability, though perhaps not a greater facility to action than the stomach, whenever these stimuli are suddenly applied, in superabundance or vice versa, the whole system with all " those organic functions which conspire to produce thought and volition" must be generally affected and according to the then

C 3 existing state, health or disease must follow. Whenever excessive or defective action exists, or when general or local disease actually prevails, the organ whose facility of change or readiness to action at the time is greatest, will be the quickest and most powerfully affected, but precisely as to nature, or in what degree will always be determined by the state of the whole system at the period of attack. See Dumas's Phys. v. 2. p. 275.

The labored disquisitions concerning the distinctions between external and internal impressions, between moral and physical causes, the once much famed and not yet exploded STAH- LIAN doctrine, founded on the power termed Vis Medicalrix Naiura, are all nothing more than the result of certain organization, and the action of stimuli upon the excitability, all must finally be referred to this more simple view of the subject. The universal governing law of animal life is undeniably exemplified in the two forms of insanity viz, that health is the result of equable, and disease of excessive or defective stimulation, always in a greater or less degree combined with evident and demonstrable, or obscure and unknown organic lsesion. " The great attribute of organized nature seems to be susceptibility of impression from without, and the nervous system appears to be the prime distinction of animals of the higher order ; now on the habitual state of this system, two leading distinctive characters or temperaments may be found, one where the susceptibility is deficient, ajiolhcr where it is excessive, these are the two leading divisions to one or the other of which the various modifications of temperament are referable." Stock's Life of Beddoes. That everything relating to animal organization and intellectual faculty may be clearly illustrated by this fundamental law or unrefutable principle, a full and close examination of what is erroneously called Mental disease is alone sufficient to establish the indubitable truth ; that truth which is the emanation of just reasoning, corroborated by legitimate and successful experience, which will ever diffuse confidence through the independant mind, for " Truth has more than human strength, she is naturally invincible, and the more we put her to the test the more we promote her glory and success." Month. Rev. April 1807, p. 370. How much then is it to be regretted that so many absurd and fanciful distinctions have crept into the history of insanity, the love of mystery and an eager haste to explore abstract causes seem to have afforded their origin.

Whoever would comprehend the just nature and faculties of the human mind, so far as relates to mental aberration, must first well consider the animal ceconomy in the view here attempted to be given. The degree of excitability originally possessed by every human body is homogeneous with the principle of life, and mental faculty is the result and not any thingdistinct therefrom, as the illustrious Bacon says of the king's prerogative. " It is the Pars Prima of the body, but it still is the law, for in con-

C 4 serving and maintaining that we conserve and maintain the law, there is not in the body of man one law of the head," (or mind) " and another of the body, but all is ONE entire law." Medical practitioners as their conduct regards insanity, cannot be said to have adopted the principle of the immortal Verulam ; hence has increase of practical information in this department been so greatly impeded by the undisciplined vigor of vivid imaginations easily seduced from the paths of truth by some plausible metaphysical hypothesis, or luminous theory, presenting in meretricious form a readier road to fame than can be obtained by patient enquiry and slow investigation.