Chapter VI: Part 6

_Tetanus_, emprosthotonus, opisthotonus, locked jaw, trismus. This is not a frequent disease in this island, nor in Europe: it is far more universal and fatal in the tropical regions, and in the warmest seasons of those zones. In such climates tetanus, and all the train of spasmodick and convulsive diseases rage with more inveterate rancour and devastation: there the slightest wound or scratch will frequently occasion a locked jaw. It afflicts more adults than youth; and, as is reported, more males than females. The emprosthotonus, or head bent forward on the breast, is much less frequent than the reverse. Its assault is sometimes sudden and violent; but generally by slow approaches; and with stiffness of the muscles of the back, neck, and occiput; difficulty in rotating the head; sense of uneasiness about the root of the tongue; difficulty of swallowing, painful spasm at the lower part of the sternum darting to the back; spasm and rigidity of the muscles of the neck and occiput pulling the head backwards; and also of the muscles of the lower jaw, locking the teeth together, so that by the utmost force they cannot be separated: the muscles also of the face, eyes, and nose, are often violently distorted with a hideous grin. By degrees, this spasmodic conspiracy becomes more universal, communicating to the spine, abdomen, and extremities; and the contracted abdominal muscles feel as a hard-board. In the spasms there are repeated exacerbations, with excruciating pain; followed by remissions or transitory reprieves; but the latter seldom an hour in duration: and sometimes with these paroxisms, internal murmuring of the voice.

Seldom any fever accompanies this spasm, unless from cold; and in this case the disease commences a few days after such accident: but if from wounded nerves, frequently not until some days after the lesion, and even when the vulnerary pain and uneasiness was removed. The external and internal senses are seldom interrupted until the last and perilous stages, when the brain shares in the general disorder. But the natural functions and also those of respiration and circulation are unmolested. It may prove fatal in a few hours; generally, if not relieved, in a few days; and rarely is protracted beyond fourteen. Until of late years, and the discovery of more effectual remedies, few recovered. Its danger is increased by the sudden impetuosity of the assault; or from wounded nerves: the final tragedy is closed by convulsions.

Authors describe a spasm of the lower jaw and tetanus of infants, which they term Trismus: this is most frequent and dangerous early after birth: the aperture of the mouth and gums is contracted, and with difficulty separable: its lips and mouth remain nearly motionless, with contention or impracticability in suction: and sometimes the spasm becomes general amongst the muscles. I read in authors the diagnosticks of another species of tetanus, which they represent as not unfrequent in the European regions, and especially amongst infants; the symptoms agitation, trembling, convulsions, distortion of the lips, grinding of the teeth, difficulty of suction and deglutition, regurgitation of milk by the nose; the jaws locked together; spastic respiration, and with groans; the muscles of the neck rigid, with flushed face, tumid abdomen, vomiting, fetid stools. This, in some features, resembles what we term Inward Spasms. In fact, the history and accurate diagnosticks of infant diseases are as yet imperfect.

The predisposing and occasional _causes_ of tetanus and its species, are wounds, particularly of the fingers and toes; surgical operations, fractures, luxations, burns, injuries of a nervous tendinous and sensible part, bruised testicle; suppuration, abscess; cold and moisture applied to the body when heated; sudden suppression of perspiration; sudden vicissitudes of heat and cold; repletion, foul stomach and intestines in infants; dentition; bile in the stomach; worms; poisons; ebriety; excessive evacuations, hemorrhages; suppressed salutary evacuations, exanthemata and cutaneous eruptions; abortion; difficult parturition; violent mental emotion; angina; lurking gout; hemorrhoides; hypochondriasm, hystericks, melancholy. In many of these it is merely symptomatick.

_Spasms and cramps_ are idiopathick as well as symptomatick; fugacious, or more fixed and constant; and may affect various portions of the external and of the internal muscular fibres; of the head, neck, face, eye, lower jaw, lips, arms, hands, fingers, thighs, legs, feet, penis; the tongue, fauces, pharynx, œsophagus, lungs, stomach, intestines, kidneys, ureters, bladder. Fugitive cramps in the legs excite excruciating pain, tumor and rigidity of the muscle.

_St. Vitus’s Dance._ Chorea sancti Viti. This very uncommon disease may afflict either of the sexes about the period of adolescence and puberty; rarely afterwards. Its symptoms are lameness of one leg, which, when attempts are made to walk, is dragged as if paralytick; and is then, more or less, convulsed: at the same time, whenever the patient attempts to convey any food or drink to the mouth with the corresponding arm, it is incessantly convulsed, with a rapid succession of gesticulations. Some are even compelled to dance, leap, run, sing, or laugh. The paroxisms vary in duration and frequency: sometimes they are terminated in half an hour: sometimes they continue several days, rarely a week, without intermission: sometimes they recur several times daily, leaving behind debility and weakness. Delirium and a degree of fatuity are not unusual in the paroxisms. The predisposing and occasional _causes_ are mostly unknown: sometimes worms.

_Catalepsis, and extasis._ It falls to the lot of very few physicians, at least in this island, to see a single instance of this phenomenon, a living statue fixed in whatever situation and posture they happen to be in when seized: the legs and arms flexible, remain sometime in whatever posture they are placed by a spectator: the functions of internal and external sensation are suspended; the eyes are open; the countenance and colour are nearly natural; the pulse and respiration alone continue in motion, but obscure. The duration of the paroxism is from a minute to hours, very rarely days: and the recovery as if from a profound sleep: in some with confused ideas of surrounding objects during the chasm. In the extasis strange visions are seen: and of these trances there are extraordinary instances on record. It may be complicated with somnambulismus, and hystericks. The _causes_, deep meditation, fanaticism, mental passions, intense cold, worms, foul stomach, suppressed evacuations: it is feigned by impostors.

_Fainting and asphyxy:_ syncope, leipothymia, asphyxia, idiopathick, symptomatick. In syncope the action of the heart and of respiration become considerably weaker than usual, or for a short time suspended: the pulse and breathing are sometimes so weak as to be imperceptible; the countenance pale and cold, with a clammy sweat, especially on the forehead; the functions of external and internal sense, and of voluntary motion, during this vital chasm, are interrupted or suspended. It sometimes arrests suddenly, sometimes with preceding languor and anxiety about the heart, giddiness, and dimness of sight; objects are seen as through a mist, sounds are scarcely audible; and there is confused noise in the ears. In the gradation and duration of vital suspension, there are diversities: after the lapse of a few or more minutes they gradually revive, yawning, sighing; some with vomiting; and some without vestiges of reminiscence during the temporary interreign. This partial cessation of the vital functions distinguishes it, at the first glance, from apoplexy. Asphyxy is only a more violent degree of syncope in which the intire human machinery is stopped: the counterfeit of death; but in which there are embers capable of being fanned and vivified into vital renovation. The first exertions towards a restitution of the vital energy when suspended, are sometimes with symptoms of epilepsy and convulsions.

The predisposing and occasional _causes_ of syncope and asphyxy, idiopathick and symptomatick are, profuse evacuations and hemorrhages; venesection; tapping the abdomen in ascites; strong emeticks and purgatives; exhausted strength; violent exertions of strength, or muscular action; excessive fatigue; venery in excess; sudden terror or joy, or other mental emotions; intense anxiety; severe pain; offensive smells; foul air; close rooms and crowds, and the air contaminated with their breath, and effluvia; charcoal fumes; foul stagnant confined air, and gas of old damp pits, wells, subterranean caverns, mines; mephitick vapours from fermenting liquors in considerable quantity; lightening, thunder-shocks; excessive heat; excessive cold; sanguineous plethora; various diseases of the stomach; poisons, narcoticks; repelled cutaneous eruptions; hysterick, scorbutick, arthritick, febrile; wounds or blows on the head, spine, or stomach; severe labour and parturition, in which the infant’s head and brain is compressed, injured, or mouldshot, or the navel-string compressed, and the circulation interrupted; hydrocephalus; internal aneurism, polypi of the heart, or large arterial trunks; rupture of large blood vessels, or of internal abscess; palsy of the heart, dropsy of the pericardium; gangrene; drowning; hanging.

_Palpitation of the Heart._ Chronic is here meant, not transitory, which may occur on every sudden emotion of body or mind. In this the contraction of the heart is with preternatural outrageous rapidity and force, and often with audible strokes against the ribs, and intermittent pulse. It is generally periodical; and by continuance, it is evident that, from the convulsion of this important motory pendulum, the entire subordinate series of hydraulick offices, together with those of sense and motion, must share in the disorder. The predisposing and occasional _causes_ are, plethora; repletion, intemperance in food or drink; suppression of habitual evacuations; excessive evacuations; inanition; passions of mind; long continued grief, terror, venery, pain, anxiety, thirst, immoderate exercise; light cloathing; extreme irritability, peculiar irritability of the heart, and debility, spasm; pressure on the aorta; aneurism; ossification and straitness of the aorta; tumors about the great vessels; polypi; dropsy of the pericardium; impeded respiration and circulation through the lungs; broken ribs; weak disordered stomach, flatulence; diseases of the abdominal viscera; sweat of the feet, ulcers, scabs prematurely repressed; cachexy; hysterick, hypochondriack, melancholick, scorbutick, arthritick, atrabilarious, inflammatory.

_Polypi of the Heart, internal Aneurism, and Ossification._ Polypi are solid coagulums of blood, of a firm or fleshy consistence: aneurism a distention and weakness in some portion of the arterial coats, and partial enlargement or bulge in the sanguineous canal; the usual seat of the first is in the auricles and ventricles; of the second, in the large trunks, and more about their origin: ossification of the valves, and of the aorta, or the smaller branches, is more frequent in old age. The symptoms of polypi and aneurism are often ambiguous; most of them are common to some other diseases; such as difficulty of breathing, violent palpitation of the heart, and anxiety aggravated by the least motion, with propensity to faint, intermittent pulse, pain under the sternum, torpor of the arm, pale face, edematous ancles, frightful dreams, timidity to walk alone without support. These, together with syncope and asphyxy, no doubt make a part of the sudden deaths, and some other casualties in the London bills.

I had nearly omitted the description of two diseases in which we are not personally interested; the Berbiers of Indostan, and the Raphania, once a European meteor. In the berbiers there is chronic tremulous motion of the hands and feet, sometimes of the whole body: at the same time pricking and formication, and some degree of insensibility; weakened voice; anhelation: it usually originates from suppressed perspiration. The raphania was once a transient epidemick, and principally noxious to infants; the symptoms stupor of the spine, sensation of pricking pain in the muscular fibres; the lower extremities rigid, sometimes convulsed; eyes rigid and distorted; pharynx constricted; tongue retracted.

_Hypochondriasm_, hips, spleen, and vapours, imaginary maladies. This chronic valetudinary infatuation is very frequent in our island: it occurs principally in the adult and middle age; seldom early in life; in the male more than in the female sex, especially in those of melancholick temperaments; and much more amongst persons of independent fortunes, and amongst literary and sedentary professions, than the exercised and industrious. Vapours are often complicated with diseases of the stomach, hystericks, melancholy. But in the true hypochondriasm, the valetudinary dyspepsy, and diseases of the digestive organs, seem rather a natural consequence and sequel of the lugubrious mental temperament: besides, in dyspepsy the mental perturbation is slight; it is also a far more universal disease than hypochondriasm, affecting equally both sexes; and the young as well as the old.

Hypochondriacks feel, or imagine they feel, all diseases; against these they combat with a thousand remedies, and exhaust the whole pharmaceutical rotine. They exaggerate with minute narrative these morbid phantoms, which no other person can perceive, nor account for; examining their pulse, fatiguing and harassing their physicians, visitors, and domesticks; on the slightest grounds haunted with apprehensive forebodings of misfortunes, misery, and death; and in the utmost anxiety about the event, at the time perhaps that the appetite is not much impaired: in most things, however, their judgment is correct; their health and diseases excepted, which are the constant objects of their fears.

By such anxious solicitude, and passive submission to fanciful and imperative chimeras, a luxuriant brood of symptoms, like irregular hysteria, are engendered: they at length convert, or at least aggravate, accelerate, and multiply imaginary into real evils, deranging the complicated offices of digestion and circulation: hence flatulence, eructation, indigestion, nausea, acid bilious vomiting, exspuition of watery fluid, irregular appetite; profuse, irregular excretions and secretions by urine, perspiration, saliva, mucus, diarrhœa, or its reverse costiveness; with palpitation of the heart, flushing of heat and cold, fugacious spasms, anhelation; obscure vision, vertigo, noise in the ears, headach, disturbed sleep, frightful dreams; slothfulness, pusillanimity, want of resolution and activity, disposition to seriousness and sadness, shyness, suspicion, peevishness, moroseness: the mind often dejected and in despair, so as not to be solaced with hopes of relief. It sometimes ceases, or at least abates weeks and months, recurring in periodical exacerbations on any exciting cause or mental distress, intemperance, or vicissitudes and irregularity of the seasons. Costiveness and hardened feces indicate the obstinacy of the disease. It is not immediately dangerous to life; but when of inveterate continuance, may terminate in insanity, cachexy, jaundice, dropsy, tympany, consumption.

The predisposing and occasional _causes_ are morbid extreme of sensibility; hereditary; various depressing passions of mind; studious sedentary life and abstruse meditation; retirement to an inactive after a bustling busy life; excess of venery, manustupration; wealth, indolence, transient, unsatisfactory amusements; revelling in pleasures, and cloyed with satiety; November fogs, easterly winds, sirocco winds; intemperance in food or drink, suppression of usual and solitary evacuations, as menses, hemorrhoids; repulsion of cutaneous eruptions; obstruction in the circulation through the vena porta and liver, and in the biliary secretion; obstruction in the abdominal viscera; debility in the stomach and intestines, and consequently vitiated chyle; pituita in excess; worms; irregular gout; hystericks; intermittent fever.

_Insanity_, lunacy, mania, melancholia, and complex insanity. During the preceding century, distracted and lunatick was the term in the London registers; and in the last thirty years of that century, amounted in the funerals to 544; but in the present century, are quadruple. We must reflect, that two of the largest lunatick hospitals in Europe are erected in this metropolis, exclusive of several large private madhouses; all of which are of late years enlarged and multiplied in London and its suburbs. Into these publick and private receptacles many lunaticks, from sundry parts of the kingdom, are congregated; amounting in all, by the nearest calculation which I can form, to upwards of one thousand. Perhaps those whom nature originally, or disease branded as idiots, are also included in the lunatick catalogue of mortality. The coroner’s inquest generally returns suicides as lunaticks, after reciting the mode of their death; but the searcher’s reports in the bills of mortality, have invariably ranged lunatick and self-murder under two distinct heads. I have reason to believe that many lunatick deaths in London are not reported, from their being interred in dissenting and unregistered burying grounds, or in other places of interment without the verge of the bills; others intentionally suppressed, and a considerable remnant sunk amongst the suicides and drowned. It is probable, that in lunaticks and suicides, this island may challenge any other in Europe, whether in modern or in ancient times.

In illustrating this disease, above all others so little understood by the community, by the medical profession, or, in truth, by the greatest part of the authors on the subject, I shall rather trespass beyond the limits of a concise systematic survey of diseases. I had long since procured the printed annual reports of Bedlam during thirty years, from 1750 to 1780, wherein it appeared, that out of 6000 lunaticks, the deaths amounted to 1200, or 1 of 5. This information, so far as it went, was partly truth, but it was not the whole truth; and, in confirmation of the general proverb, I was compelled to search for it in a well. I was anxious to extend my inquiries to a vast variety of particulars, not one of which could be learned from the crowd of authors, good, bad, and indifferent, whom I perused for this purpose; from the remote era of the Greek and Roman Catholicon, the Hellebore, down to the present time.

Chagrined with this unprofitable research, I waited upon the learned and venerable physician of Bedlam, Dr. Monro; who, with his accustomed liberality and affability, recommended me to his son, upon whom the principal medical department of Bedlam now devolves; and in whom the hereditary virtue and exalted medical reputation of the father, are not likely to suffer any diminution. Dr. Monro, junior, introduced me to Mr. Gonza, the apothecary of Bedlam; whose curiosity and learning induced him to keep a private register of all the patients; and with all which Mr. Gonza most obligingly furnished me. It is from the records of this respectable and well-informed gentleman, especially on the subject of insanity, that I am enabled to form all the following Tables and data respecting a disease, wherein, except to the few high-priests of those temples, the rest of the Esculapian train are nearly as ignorant as the ancients; and the unenlightened mass of the community stare with superstitious amazement as the Israelites formerly on the epilepsy.

In penetrating this untrodden wilderness, and reconnoitering an unexplored host of morbid foes, I shall proceed with the cautious investigation of astronomers and natural philosophers; first to establish the facts and phenomena previous to any deduction or inference. From Bedlam, the largest palace and congregation of insane in any part of the globe; and from its valuable, but hitherto dormant archives, I shall attempt to settle all the leading and important data, by analyzing its internal history and transactions during fifteen years, or half a generation; which is sufficient to decide every ambiguity nearly as well as half a century. The materials are extracted from many volumes; they are condensed, classed, and arranged into a concise compendium, with no little trouble and fatigue to the author. In number, and consequently in magnitude of information, they must be as superior to any solitary individual observations on this subject, as the swelling flood of the Thames is to one of the thousand smaller rills which are swallowed up in its majestic stream. In this way we shall not be confounded with contradictory affirmation and negation, and the clash of oracles.

The following, therefore, are the general proportions which I shall endeavour to demonstrate, and upon them to found a multitude of others: the comparative proportion of insane males and females; their ages; the cured; incurable, and dead; the length of time they were insane before admission; the mischievous; those who attempted suicide; and the harmless; the relapses; the periods when recovery may be despaired of; the various remote causes. Mr. Gonza had distinguished the married and single; but in a treatise of this nature, these, and many other minutiæ, must be omitted.

The usual number, on a general average, of patients in Bedlam is 250; of which 110 are stationary incurables, male and female; and who remain there until they either die, or are discharged, for reasons hereafter to be explained. The remainder are a moving body, upwards of 200 of whom are annually admitted, and the same number annually discharged: the difference of males and females is very inconsiderable; in general the latter rather preponderate. During fifteen years, from 1772 to 1787, of 2829 insane males and females, their respective ages and numbers in each interval of life, when classed, were as follows:—Under 10 years of age, 1; from 10 to 20, 132; from 20 to 30, 813; from 30 to 40, 908; from 40 to 50, 632; from 50 to 60, 266; from 60 and upwards, 78. Of these the cured were, 934; the incurable, 1694; the dead, 230. Of these also, the mischievous were 743; attempted suicide, 323; not mischievous, 886; committed shocking murders, upwards of 20; relapsed, 535.

It seems necessary to be first mentioned, that I made memorandums of all the different periods, and time elapsed, from the invasion of the disease, or insane paroxism, to their admission into Bedlam, from one week to one year and upwards. I do not, however, think it important to form a distinct class, or table, of these, but merely to observe in the aggregate, that of the patients admitted into Bedlam, the majority were not above six months unremittingly deprived of reason; and those, in all the intervals, from one week to six months. The second great class were, in the intervals, from six to twelve months. After one year, and upwards, there are comparatively very few admissions, except on the incurable list.

The ages at which insanity predominates are obvious, and require no comment. During the first period under 20, the greatest part of this small group were between 15 and 20. The ages of about 300, as also of their cures, incurables, and deaths, are omitted in the records: fractional exactness cannot be expected: but for gross calculation there is abundant accuracy. With respect to the cured, incurable, and dead, I shall make a few remarks: amongst the discharged I found a considerable number reported as sick and weak; others, and amounting to some hundreds, as troubled with fits, or with paralytick strokes, and some with a complication of both the latter maladies; and also a small fragment of pregnant females; and none of these liberated from insanity. All these I threw into the incurable list, as I could discover very few of them ever to return back again. Many of the sick and weak may safely be added to the dead list; being on the confines of the grave when dismissed. The incurables likewise contain those admitted on the incurable list of Bedlam, as well as the great mass discharged from thence incurable, after one year’s trial.

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.

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_Diseases of the External Senses;_ including vision, hearing, smell, taste; to these we shall add the diseases of the voice and speech; obstructed deglutition; sterility, and morbid irritability of the generative organs. The derangement of those delicate and precious senses through which we derive such supreme delight; through whose avenues are conveyed into man the first rudiments of all his variegated ideas and knowledge, are important objects of medical scrutiny; notwithstanding very few from these causes are precipitated into the crater of mortality. I could, however, have wished to ascertain from registers, in conformity with my general plan, the proportion of cured and incurable; and especially the average of blind in a community.

_Vision._ The principal diseases may be comprehended under opthalmia, fistula-lachrymalis, gutta-serena, cataract, specks on the cornea. I exclude some other natural defects, rather than diseases, such as myops, presbyops; for the cure of which the optician is the best physician.

Opthalmy, or inflammation of the eyes is a frequent complaint: it may be in the exterior membranes of the globe, or in the edges of the eye-lids; or may be a complication of both; it may be in one, or in both eyes; it may be general, partial, external, internal, temporary, chronic, idiopathick, symptomatick: of all which species there are various gradations. In this local malady there is commonly little or no fever; but heat, pain, redness, and inflammation; the vessels of the eyes seem gorged with blood; the anterior portion of the tunica sclerotica, and the conjunctiva, resemble a scarlet cloth, with impediment in vision, intolerance of light, lachrymation. In the inflammation of the cartilaginous ring of the eye-lids or tarsus, there is frequently some remains of small ulcerations in the sebaceous glands. The external is by far the most frequent form of opthalmy; and, under discreet management, is attended with trifling danger: sometimes, however, it is followed by specks on the cornea, or callosity, and blindness; and violent inflammation has extended to the interior parts of the eyes and retina. In the internal inflammation of the choroid and retina, no redness is perceptible externally; but there is excruciating pain, headach, intolerance of light, restlessness, often delirium, in a few instances, insanity: and if not relieved in the course of fourteen days, there is danger of incurable blindness.

Fistula lachrymalis. In this partial inflammation affecting the lachrymal sac and ducts, and obstructing the descent of the tears, or superfluous moisture of the eyes into the nose, this fluid necessarily trickles down the cheeks, and the eye is overflowed with water: on pressure of the internal angle and puncta lachrymalia, there is a discharge of glareous serum, by which the eye-lids, during sleep, are glewed together. The degrees of inflammation and obstruction are various. In the inveterate stages it may terminate in abscess, ulcers, and caries of the contiguous nasal bone.

Gutta-serena, amaurosis; in one or in both eyes, and in various gradations, from obscure vision to cheerless tenebrosity. To a spectator the eyes appear nearly as in health, only that the pupil is dilated and inanimate; the retina insensible to the rays of light, and the iris mute, without corresponding contraction or enlargement: a physiognomist might say, there are no sensitive emanations or magnetick rays emitted through this mental mirror. It attacks suddenly or gradually, and sometimes intermits; but in general it is chronic, and always dangerous; often irremediable: sometimes it is accompanied with headach in the anterior part over the eye-brows.

Cataract may affect one eye, but in general both: it arises from disease or opacity of the crystalline lens obstructing the visual rays in their course to the retina: the consistence and colour of the lens is various, white, pearl, green, yellow; and from these the oculist forms his prognostick: in couching the eye the pearl-coloured is preferred: the white is too soft; the green and yellow incurable; as is also that species wherein the strongest rays of light excite no contraction of the pupil. Cataracts in general are gradual in their formation; weeks, months.

The predisposing and occasional _causes_ of injured vision and of opthalmy, external violence and blows; sudden suppression of perspiration; extraneous bodies or acrids admitted within the eye-lids; acrid metallic fumes, and noxious exhalations; long exposure to confined smoke, especially from wood fires; smoky houses and cottages; acrid collyria; epidemick state of the air, and infection; long continuance of wet weather; long exposure of the eyes to the rays of strong light, to snow, or luminous objects; cold streams of air; suppression of salutary evacuations, or cutaneous eruptions, and of chronic ulcers; acrimony of the blood; interruption to the free return of blood from the head; frequent intoxication: nocturnal studies; long want of sleep, grief, tears; small tubercles within the eye-lids; ulcerated eye-lids; variolous: morbillous; scrophulous; venereal; erysipelatous; rheumatick; catarrhal; intermittent; herpes; cancerous. Of fistula-lachrymalis, inflammation of the lachrymal sac, or ducts. Of gutta-serena, plethora, distention of the vessels of the retina; palsy of the optick nerves, general or partial; diseases of the brain, or of the retina; profuse and suppressed evacuations; excess of venery; chronic headach; ebriety; cachexy; venereal; intermittent; symptomatick in the irregular gout, apoplexy, &c. Of the cataract, opacity of the crystalline lens. The general causes of injured vision, exclusive of opthalmy, may be briefly enumerated; and are long attention to minute objects; weakness of the power to contract the pupil; faults of the globe; defect of the aqueous humour, its impurity or density; opacity of the lens, or of the vitreous humour; the retina callous or too sensible; faults of the optic nerves; contraction, concretion, flaccidity of the pupil; gibbous or convex lens, or too near and flat; dropsical eye; spasm, or palsy of the ocular muscles; diseases and ulcerations of the eye-lids and ciliary glands; ulcers and fistula, specks and scars, in the cornea; films growing from the angle of the eye; the eye-lids inverted, elongated, concreted; various diseases of the brain from internal or external causes.

_Hearing_, injured by deafness; noise in the ears, inflammation. The first is a frequent infirmity in old age. The _causes_, faults in the original structure of this curious and complex organ; defect of the auricle, straitness of the external auditory tube, its obstruction or concretion: the tympanum relaxed, callous, obstructed with hardened wax, mucus, serum, ulcers, luxuriant flesh; caries, luxation of the small auditory bones; obstruction of the vestibule, cochlea, labrynth: the membranes lax, dry, indurated; palsy, and spasm of the internal auditory muscles; constriction and obstruction of the eustachian tube; colds, catarrh, obstructed perspiration, rheumatism, plethora, suppressed evacuations; disorders of the stomach, costiveness; nervous, loud explosions, age, fever, soporous diseases, and diseases of the auditory nerves, and of the brain; symptomatick in several diseases. Inflammation of the ear excites excruciating pain, sometimes delirium.

_Smelling_ too acute, or blunt, or unnatural. The _causes_, the membrane lining the nose rigid, dry, deficiency or excess of its mucus tense, irritable, obstructed, scirrhous, callous, carious, stifled with polypus, snuff; palsy of the olfactory nerves; diseases of the brain; sordes and pus in the olfactory sinusses; and also in the mouth, gums, teeth, tongue, larynx, fauces; foul effluvia from the stomach.

Sternutation is symptomatick in several diseases; but sometimes, is a primary malady, it has been known to infest hours, days, or even weeks. The _causes_, epidemick influence of the air; suppressed nasal hemorrhage, or cutaneous eruptions; venereal; worms, or abscess in the sinusses; disease of the brain.

_Taste._ The _causes_ affecting the principal gustatory organ, the tongue: sordes of the tongue and mouth in various diseases; the saliva in quantity or quality diseased, and either depraved from the blood, or from washing over diseased parts of the mouth or palate; tension or laxity of the gustatory organ, or papillæ; faults of the lingual nerves; diseases of the stomach, fauces, nose, tongue, lips, &c.

_Voice and Speech._ The immense multiplicity of objects, and the distance to the end of our literary journey, check us from expatiating upon this prolifick topick. Under it may be included hoarse, guttural, stridulous, deadened, stifled voice, or sound at the glottis; stammering, lisping, defect and impediments in articulation, muteness. The _causes_, defect or waste of mucus by exertion of the voice; destruction of the mucus ducts of the larynx; its cartilages ossified; injury of the recurrent nerves; laxity and palsy of the muscles of the glottis and contiguous cartilages; venereal; changes of weather; symptomatic in several diseases. Voice and speech may be injured in all the various parts of their complicated organization; the larynx, the pharynx, the tongue, uvula, fauces, nose, palate, gums, teeth, lips.

_Sterility_ of the sexes: no inconsiderable number of both sexes are incapacitated from exercising that important and divine function of giving creation to their own species. The _causes_ in the male sex are, palsy, or torpidity of the penis, or its nerves, or generative organs; the penis short, monstrous in size, its prepuce straitned; impediments in the urethra and seminal ducts; testicles, epididymidis, vasa deferentia; the semen inert, vapid, aqueous, scanty; weakness of the ejecting or accelerator muscles; corpulency; too tense erection; old age; castration, manustupration, too frequent coition, extreme chastity, venereal disease, inebriety, broken constitution, tabes-dorsalis. In the female sex, original structure of some part of the generative machinery of the ovarium, fallopian tubes, womb, vagina, labia, clitoris; straitness, concretion, obstruction of the vagina or womb from inflammation, scirrhus, polypus; cold frigid temperament; promiscuous coition; excess of venery, irritability; fluor albus, obstructed menses, irregular menstruation, cachexy.

_Morbid irritability of the genitals_, including priapism, pollution, furor uterinus. Of involuntary pollution we have treated under dorsal tabes. In our climate the uterine mania rarely occurs in that extreme of indecency described by authors. The woman at first is bashful and silent; the pulse and circulation are agitated on mentioning a venereal topick; by significant looks and gestures she betrays her passion; and if disappointed, becomes low-spirited, anxious, and wastes in flesh. The same has happened to some women who had the mortification to be linked with impotent husbands. Sometimes, however, this universal passion has burst into a flame; the woman losing all sense of shame, soliciting, with obscenity in speech and gestures, the embraces of the other sex; and raving on this theme with maniacal insanity. The _causes_, acrid serum, spasm, inflammation of the urethra, vagina, or other generative organs; irritation of the bladder, womb, rectum; obstructed menses; fluor albus, heat, excoriation of the vagina, venereal; stimulating, acrid, diureticks, and emmenagogues; stimulating diet and drink, excess of venery, manustupration, libidinous books, prints; protrusion of the vagina.

_Deglutition_ interrupted: we very rarely meet with this similitude of tantalus, wherein food or drink is either swallowed with difficulty and pain, or totally interrupted in its descent to the stomach, and regurgitated by the mouth or nose. The causes spasmodick constriction of the œsophagus, and in various parts of the tube; palsy of the muscles of deglutition; tumors or scirrhus in the pharynx, œsophagus, pylorus, trachea, thyroid or dorsal glands; aneurism and enlargement of the aorta, ulcers in the œsophagus; luxation of the os hyoides; compression of the pharyngeal nerves; cachexy, worms, crudity, passions, extraneous substances stuck in the throat. The spasmodick is periodical and painful; and also affects the voice: in the lower part of the œsophagus it excites pain between the shoulders; sometimes eructation and vomiting.

_Manducation._ Diseases of the teeth are the principal impediments to the exercise of this function. There are few adults who cannot describe the pangs of tooth-ach from their own feelings. It is generally intermittent, seldom dangerous to life, except during the first dentition of infancy. Its constant symptoms, pain, flow of saliva, restlessness: its variable symptoms, swelled face, carious loosened teeth; fistula, exostoses of the gums and jaws. The _causes_, inflammation of the periosteum of the teeth, gums, or jaw; suppressed perspiration; moist air; catarrhal defluxion; suppressed habitual evacuations, nasal hemorrhage and venesection; plethora; intermittent, scorbutick, arthritick; rheumatick; caries of the teeth; sugar eat; beetle and tobacco chewed, acrimony of blood or saliva; spirituous liquors; mercury; suppuration in the maxillary sinusses and gums; spunginess and flaccidity of the gums and periosteum; irritation and disorder of the fifth pair of nerves.

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_Diseases of the Stomach and Intestinal Tube_, are very universal and frequent maladies in both sexes, and throughout all orders and ages. The stomach and alimentary canal are furnished with numerous nerves; and the sensibility of the former very acute, especially at its upper extremity. The length of the human alimentary tube, from the mouth to the anus, is five or six times the length of the whole body: it is folded into many convolutions, as may be daily seen at shambles, on the opening of animals. Into this alimentary muscular and contractile sewer are incessantly heaped food and drink, besides a variety of copious secretions from the body, requisite in the process of digestion and assimilation of chyle, as saliva, pancreatick fluid, bile, mucus, and arterial exhalation from the whole of its internal surface.

Within the short space of a few weeks, the generality of mankind consume more food and drink than amounts to the whole weight of their bodies. This diurnal superfluity and load, together with the corrupted and abraded animal parts of the body, and the different secreted fluids, must again, in a few hours, be expelled through the principal human excretories; the fecal, urinary, perspiratory. In the healthy state, by far the smallest proportion of this diurnal superfluity is through the intestinal excretion: the greatest part is absorbed by the lacteals and lymphaticks, intermixed with the blood, and afterwards filtered by urine, perspiration, and in the puerperal state, milk. In cold climates and winters, especially if moist, the urine; in warm climates, the perspiration preponderates. But in these prodigious diversities ensue from exercise or rest, sleep and waking, passions of mind, the quantity or quality of food, cleanness of the skin, constitution, atmosphere, and the alternation with each other of these excretions. Again, when we reflect that from the small parotid glands, between a pint and a quart of saliva is secerned during the twenty-four hours; and on the prodigious secretion through the kidneys, we may easily conceive in the natural and morbid state, what a considerable quantity may be secerned from the liver, the largest of the abdominal viscera: making, however, some deduction for the slower circulation through the vena porta.

The chart of London diseases demand some criticism on that inextricable miscellany surfeits, stoppage of the stomach, vomiting, cholick and gripes, bloody flux. In the last century, surfeits make a monstrous article in the chronicle of deaths, amounting in some years to four hundred; whereas, during fifteen years of the present century, they sink down to only fifteen. Yet all are witnesses that good eating and gormandizing are not worn out of fashion in this metropolis. Medical men know that surfeits and intemperance are often merely predisposing or occasional causes of diseases: they may rouse latent disorders, or dispose the body to receive noxious impressions externally. The searches therefore formerly, as I suspect, made many of these reports from the ostensible cause which they imagined gave birth to the disease and mortality. At the same time, I am not contending for the delicacy and moderation of our forefathers appetites. They were unquestionably in the last century, and partly indeed from the cheapness of flesh-meat, and scarcity of vegetable nutriment, more carnivorous in their diet than the present generation.

Stoppage of the stomach also, is a morbid centaur in the last century. It would baffle the ingenuity of an antiquarian to decypher the true import of this term: severe sickness, or the word Abracadabra, would be full as intelligible. It is a vulgar name for rejection of food; and there are few diseases in which the stomach does not sympathize. What proportion of the mortality of infants, adults, or the sexes, are crammed into this absurd article, I submit to the reader’s criticism.

An important circumstance, and overlooked so far as I know, by all the calculators and criticks on the rise and fall of infant diseases in London, and especially of convulsions, is this. In the first column of 15 years, at the beginning of the present century, colick and gripes of the guts amount to 13668, but continue through every succeeding column to diminish; and in the last or fifth, dwindle to 769 only. What is meant by this complaint, colick and gripes? was it dysentery? We observe that bloody flux makes a separate, though small group, through all the five columns. Were these two diseases confounded in the annual reports? or may it not be alledged, that many infant diseases and deaths, which were formerly crowded into colick and gripes, are in modern times transferred to the vortex of convulsions? I am aware that, in reply, it may be suggested that drains, sewers, drier lodgings, less damp, alteration in diet, and the more plentiful use of vegetable and fermented liquors, have decreased dysenteric complaints in this city; and also, that Dr. Sydenham, in 1670 and 71, describes an autumnal dysentery as annually prevailing in London, and about two months in duration. Turning the subject into every possible view, I continue to suspect that numbers of infant diseases, and commonly terminating fatally in convulsions, were formerly heaped into gripes and colick; for during the last thirty years of the preceding century, they amount to the enormous number of 69,799.

_Diseases of the Stomach_ are idiopathick and symptomatick. Under the present head we shall include inappetency, indigestion, nausea, vomiting, eructation, acidity, cardialgy, heartburn, regurgitation of bile, pica, soda, pyrosis, hiccup, rumination. Several of these are obvious symptoms, and are often complicated. Inappetency is generally accompanied with nausea. Foulness or feculence in the stomach, is indicated by weight and load in that region, anxiety, nausea, eructation, disagreeable taste in the mouth, foul tongue: the state of the gustatory organ is some index to that of the stomach. Acidity in excess will excite eructation, flatulence, heartburn, gnawing pain in that part, irregular appetite and craving, colicks, gripes, diarrhœa, vomiting. In infants, acidity is very frequently predominant; hence acid eructation, restlessness, gripes, green curdled feces, tumor of the abdomen, dyspnœa, sometimes costiveness, or diarrhœa, and sometimes dry cough, and muscular paleness and flaccidity. Of bilious regurgitation there are various gradations: with severe sickness at the stomach, nausea, bilious vomiting, bitter taste on the tongue, and its surface furred; inappetency, frequently colick; sometimes temporary jaundice. The cardialgy is a severe pain, threatening syncope. The pica an aversion to natural aliment, and craving for unusual. The bulimy is a monstrous appetency for food. The heartburn denotes a sensation of uneasiness, heat, and acrimony: the soda, or water-brash, a burning heat in the stomach and fauces, anxiety, acid eructation, exspuition of lymph, and fretting the edge of the teeth.