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.