Observations on Insanity / With Practical Remarks on the Disease and an Account of the Morbid Appearances on Dissection

by John Haslam

Of the more immediate, or, as it is generally termed, the proximate cause of this disease, I profess to know nothing. Whenever the functions of the brain shall be fully understood, and the use of its different parts ascertained, we may then be enabled to judge, how far disease, attacking any of these parts, may increase, diminish, or otherwise alter its functions. But this appears a degree of knowledge which we are not likely soon to attain. It seems, however, not improbable that the only source from whence the most copious and certain information can be drawn, is a laborious attention to the particular appearances which morbid states of this organ may present.

From the preceding dissections of insane persons, it may be inferred, that madness has always been connected with disease of the brain, and of its membranes. These cases have not been selected from a variety of others, but comprize the entire number which have fallen under my observation. Having no particular theory to build up, they have been related purely for the advancement of science and of truth.

It may be a matter affording much diversity of opinion, whether these morbid appearances of the brain be the cause or the effect of madness: it may be observed, that they have been found in all states of the disease. When the brain has been injured from external violence, its functions have been generally impaired if inflammation of its substance, or more delicate membranes has ensued. The same appearances have for the most part been detected when patients have died of phrenitis, or in the delirium of fever: in these instances the derangement of the intellectual functions appears evidently to have been caused by the inflammation. If in mania the same appearances be found, there will be no necessity of calling in the aid of other causes to account for the effect; indeed it would be difficult to discover them. Those who entertain an opposite opinion, are obliged to suppose, a disease of the mind. Such a morbid affection, from the limited nature of my powers, perhaps I have never been able to conceive. Possessing, however, little knowledge of metaphysical controversy, I shall only offer a few remarks upon this part of the subject, and beg pardon for having at all touched it.

Perhaps it is not more difficult to suppose that matter peculiarly arranged may think, than to conceive the union of an immaterial being with a corporeal substance. It is questioning the infinite wisdom and power of the Deity to say, that he does not, or cannot arrange and organize matter so that it shall think. When we find insanity, as far as has hitherto been observed, uniformly accompanied with disease of the brain, is it not more just to conclude, that such organic affection has produced this incorrect association of ideas, than that a being, which is immaterial, incorruptible and immortal, should be subject to the gross and subordinate changes which matter necessarily undergoes?

But let us imagine a disease of ideas. In what manner are we to effect a cure? To this subtle spirit the doctor can apply no medicines. But though so refined as to elude the force of material remedies, some may however think that it may be reasoned with. The good effects which have resulted from exhibiting logic as a remedy for madness, must be sufficiently known to every one who has conversed with insane persons, and must be considered as time very judiciously employed: speaking more gravely, it will readily be acknowledged, by persons acquainted with this disease, that if insanity be a disease of ideas, we possess no corporeal remedies for it: and that to endeavour to convince madmen of their errors, by reasoning, is folly in those who attempt it, since there is always in madness the firmest conviction of the truth of what is false, and which the clearest and most circumstantial evidence cannot remove.

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 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 health.

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 affected 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 readmitted, it may be mentioned, that, during the last two years, there have been admitted 389 patients, 53 of whom had at some former time been in the house. There are such a variety of circumstances, which, supposing they did relapse, might prevent them from returning, that it can only be stated, with confidence, 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 symptom of the approach of this disease, after delivery, is want of sleep; the milk is afterwards secreted in less quantity, and, when the mind becomes more violently disordered, it is totally suppressed.