Practical observations on insanity
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Introduction:
Practical observations on insanity, Joseph Mason Cox, 1811 AD
SWINGING.
This is both a moral and medical mean in the treatment of maniacs
. It may be employed in either the oscillatory or common, or the circulating form. The first, or oscillatory, is too generally known to require a description- the second, or circulating, is easily constructed by suspending a common Windsor chair to a hook in the ceiling, by two parallel ropes attached to the hind legs, and by two others passing round the front ones joined by a sliding knot, that may regulate the elevation of the patient when seated, who, besides being secured in a strait waistcoat, should be prevented from falling out of the chair by a broad leather strap, passed round the waist and buckled behind to the spars, while another strap to each leg may fasten it to the front ones of the chair. The patient thus secured, and suspended a few inches from the ground; the motion may be communicated by an attendant turning him round according to the degree of velocity required. But a more complete rotatory swing may be very easily contrived, of which I cannot convey a rate idea than in the words of Dr. Darwin, with whom I believe the idea first originated. "Let one end of a perpendicular shaft, armed with iron gudgeons, pass into the floor, and the other into a beam in the ceiling, with an horizontal arm, to which a small bed might be readily suspended." To this perpendicular shaft a chair may be fixed, and the patient secured in it as above described. A considerable improvement to this swing is a strong rod of iron, fixed to the upper extremity of the perpendicular shaft, and to that of the horizontal arm at the foot of the bed, which may be easily so contrived as to be shortened or lengthened, and thus to regulate the elevation of the bed. The necessary motion may be given by the hand of the attendant pushing or pulling the extremity of the projecting arm, with greater or less force, each time it circulates, but by a little very simple additional machinery any degree of velocity might be given, and the motion communicated with the utmost facility. Thus by means of the chair or the bed, the patient may be circulated in either the horizontal or perpendicular position.On persons in health these swings produce only the common, effects; but in proportion to the degree of motion communicated, and sooner by the circulating than by the oscillatory, and in the horizontal than in the perpendicular position. Independent of these more obvious effects in some maniacal cases, swinging, often repeated, has had the singular property of rendering the system sensible to the action of agents, whose powers it before resisted. One of its most valuable properties is its acting as a mechanical anodyne. After a very few circumvolutions, I have witnessed its soothing lulling effects, tranquillizing the mind and rendering the body quiescent; a degree of vertigo has often followed, which has been succeeded by the most refreshing slumbers of an object this the most desirable in every case of madness, and with the utmost difficulty procured. Maniacs in general are not sensible to the action of the common oscillatory swing, though it affords an excellent mode of secure confinement, and of harmless punishment; and I have met with a few instances where the circulating, in both the horizontal and perpendicular positions, produced no effect. The valuable properties of this remedy are not confined to the body, its powers extend to the mind. Conjoined with the passion of fear, the extent of its action has never been accurately ascertained; but I have no doubt it would afford relief in some very hopeless cases, if employed in the dark, where, from unusual noises, smells, or other powerful agents, acting forcibly on the senses, its efficacy might be amazingly increased. The employment of such Herculean remedies requires the greatest caution and judgment, and should never be had recourse to but in the immediate presence of the physician. The debility arising from swinging is never to be dreaded, it is generally accompanied by sleep and the sense of fatigue, while the slumbers thus procured surpass those induced by opiates, as much as the rest of the hardy sons of labour surpasses that of the pampered intemperate debauchee. Where insanity attacks patients of delicate habits, with previous consumptive or pulmonic symptoms, swinging has been found particularly beneficial. I have sometimes seen a patient almost deprived of his locomotive powers, by the protracted action of this remedy, who required the combined strength and address of several experienced attendants to place him in the swing, from whence he has been easily carried by a single person; the most profound sleep has followed, and this has been succeeded by convalescence and perfect recovery, without the assistance of any other mean. One of the most constant effects of swinging is a greater or less degree of vertigo, attended by pallor, nausea, vomiting, and frequently by the evacuation of the contents of the bladder. As in some maniacal cases, the mental alienation seems dependent upon, or regulated by the action of the heart, when rationality returns, if the pulse be reduced below the usual standard, and departs again, as it advances above this standard, the swing, from the powers it possesses over the circulation, has been known to produce the most beneficial effects. Though we cannot accurately explain in what way the best remedies promote relief in madness, yet we have the most unequivocal proofs that those which occasion a degree of vertigo, often contribute to correct the morbid state of the intellect, and no one of them is so well calculated to produce this effect as the swing. Madmen are never so easily made giddy as people in their senses; yet scarcely any, even of them, can resist the action of a continued whirling with increased velocity. The vertigo, as was observed above, may be produced by means of the swing, from its effects on the sense of sight, though it may be attributed with greater probability to feeling or consciousness, even in maniacs, when they are not insensible to the impression of the process; and this opinion seems confirmed from the circumstance that vertigo is produced by the circular motion even in the dark. Perhaps the appearances which usually accompany vertigo may contribute to explain its nature. The singular and unusual motion of swinging, when continued with increased velocity, induces first paleness, then nausea, and then alternately an obvious change in the circulation, and giddiness: these changes necessarily result from an impression made on those organs of sensibility, the brain and nervous system, and prove that the remedy acts on the seat of the disease; though the proximate cause cannot be satisfactorily ascertained.
* See Case XIV. \ See Case XV.
* See Cases XVI, and XVII. t See Case XVIII.
* See Case XV.
In some cases, where the animal frame is easily influenced by the vertiginous motion, both the vital and animal functions are considerably affected, as well as the internal and external senses.
When vertigo is either symptomatic or idiopathic it is usually accompanied by nausea; and as the swing generally produces this effect, and as vomiting is often indicated, and the patient refuses to take any remedy, our mechanical apparatus is of the highest importance in such cases: indeed it often possesses superior advantages, as we can regulate the action on the stomach, producing either temporary or continued nausea, partial or full vomiting. The sickness produced resembles that occasioned by sailing, than which perhaps none is more severe: and though in long voyages the most delicate systems have borne it for weeks together, no ill consequences have accrued, as was observed before. When full vomiting has followed the use of this remedy it has often succeeded in bringing away viscid accumulated sordes and tenacious phlegm, with which the first passages of maniacs so frequently abound, and indigested matters, which appear to have been long pent up, though the most active drastic evacuating remedies have been employed, and apparently with considerable effect. As vomiting has been long esteemed among the most successful remedies in madness, if the swing produced only this effect, its properties would be valuable; but though it can be employed so as to occasion the mildest and most gentle effects, yet its action can be so regulated as to excite the most violent convulsions of the stomach, with the agitation and concussion of every part of the animal frame; thus rendering the finest system of vessels pervious, or, in other words, removing obstructions, and altering the very nature and quality of the secretions. The impressions made on the mind by the recollection of its action on the body is another very important property of the swing, and the physician will often only have to threaten its employment to secure compliance with his wishes, while no species of punishment is more harmless or efficacious.
* See Case XIV.
Though much of the beneficial effect of the swing may be justly ascribed to its action on the stomach, yet more of it may arise from its power over the circulation.
. . . I now find that the perpendicular position is best calculated for violent cases, and the horizontal for opposite ones, and that in both the motion should be communicated in the most gradual way, and be progressively increased to the degree of velocity required . . . Perhaps it would be too much to say that every mean employed for the removal of mental diseases, whether moral or medical, when successful, relieves by introducing some important change into the general system; but certain it is, that if any considerable commotion, any violent, new, action can be excited in maniacal complaints, by whatever means, the mental derangement is often considerably relieved if not permanently removed; thus small-pox has dissipated the most obstinate melancholia . . . Itch, too, has been known to bring about the same happy effect . . .
As diseases of the intellectual faculties often follow repelled eruptions drying up of old sores, habitual drains, &c. it is reasonable to expect advantage from the re-establishment of these, and perhaps there is no more manageable or efficacious mode of exciting new eruptions than . . . chrystalized emetic tartar, reduced to an impalpable powder and applied to any part of the surface, though it has succeeded best when rubbed on the newly shaved scalp, where a smaller or larger crop of eruptions, very similar to those of small-pox, may be speedily excited. Blisters, issues, setons, &c. will be proper substitutes for the old drains. Independent of the other valuable properties of fox-glove, tobacco, and similar medicines, may we not reasonably impute much of their antimaniacal power to the distressing affections they occasion in the stomach ? in fact, to their excitement of a species of new disease in the system.
CASE XIV.
Mr. , aged 34, naturally of a gloomy, morose, reserved disposition, had been indulged in every wish of his heart from his infancy, became suspicious, revengeful, and impatient of control; had been engaged in a business which occupied his thoughts, with scarcely any bodily exercise: a series of disappointments and losses at length deprived him of reason: after being treated in the most judicious manner, without success, he was consigned to my care. I found all the peculiarities of his temperament increased by his indisposition, the countenance approached to saturnine blackness, the eyes, suffused with bile, were immovably fixed on the ground, the limbs seemed deprived of their locomotive powers, the action of the lungs, and the circulation retarded, the tongue parched, and the whole man resembled an automaton, seldom exhibiting any marks of existence but from the deepest sighs. His whole system was steeled against impressions, and he must have sunk to the grave but for the address of his attendants. All the more common means had failed, and he obstinately resisted medicine; I therefore adjudged him a fair case for the swing, into which he was placed two hours after he had taken a pint of thick water gruel and new milk, pulse 80, breathing twenty inspirations in sixty seconds, had had no alvine evacuation for six days, nor made any water for the last 24 hours, skin dry but cool, eye-lids half closed, the face vacant and of a murky hue: he made some resistance to being placed in the chair, but when properly seated and secured, he was at first turned round very gently, and after a few revolutions, he appeared to experience some unpleasant sensations, his attention was roused, and he made some violent but unavailing struggles; the motion being increased he became pale, and begged the operation might be discontinued, promising compliance with my wishes as to food, medicine, &c. I therefore directed his immediate liberation; he complained of giddiness, nausea, seemed exhausted, and had nearly fainted; being laid on a bed, I found his pulse 60, the inspirations fifteen, the expression of features changed, the extremities and superficies cold; he soon fell into a profound sleep, which continued three hours; but on waking I found him in mind and body just as before the swing was employed, all his promises were forgotten, and he refused both food and physic; next day the swing was repeated as before, when similar effects were soon excited, and by increasing the velocity the nausea advanced to vomiting, when the swing was suddenly stopt very unexpectedly to the patient, who appeared roused and alarmed, entreated to be relieved, and repeated his former promise. I again complied, and he was taken out of the swing in the most helpless state imaginable, was put to bed, where he soon fell asleep, and did not awake for six hours, when he reluctantly acquiesced in my proposal to take a mercurial purgative, a very small dose of which procured some copious alvine evacuations, though lie had before taken three times the quantity in disguise without effect, and he now began on a light nutritious regimen, with gentle exercise m the open air; but his former mental peculiarities soon after returning, the swing was prepared, and the necessary steps taken for its employment, but rather than repeat the ride in the whirligig, as he termed it, he submitted entirely to my wishes, and, with some occasional returns of obstinacy and disinclination to persist in the remedies I prescribed, I had the pleasure to see him gradually improve till he advanced to perfect reason.
CASE XIX.
Mr. , aged 22, of the choleric temperament, partaking of both the sanguine and melancholic, but the usual marks of the latter predominating; naturally grave, silent, and partial to solitude, gloomy and reserved; had passed the usual routine of a classical education, with the character of plodding industry, but exhibiting no coruscations of genius. His life was a model of probity and virtue, being rigidly regular in the performance of all his duties, but more particularly his moral and religious ones, tremblingly alive to the slightest dereliction. He professed some peculiar religious tenets, but believed every word of the scripture to be dictated and written by Divine inspiration, and these were the subjects of his daily study. After having been for some time considerably affected by an unguarded expression, uttered by a rash conceited teacher, who possessed more zeal than prudence, he became gloomy and depressed, till his life was such a burden to him that he seemed bent on destroying himself, and was only deterred by a sense of the criminality and sinfulness of suicide. After reading that part of the New Testament which mentions the cutting oft'a hand, or plucking out an eye, the idea of castrating himself rushed into his mind, and with a pair of small scissors he very completely performed the operation; the surgeon when called in found him in a state of syncope from the hemorrhage, and by the most judicious treatment healed the wounds in a few weeks, but the mind continued impressed with the most miserable ideas, and nothing but eternal perdition was ever in his view; in this state he was consigned to my care. He was perfectly silent, his eyes shut, averse to motion, and inattentive to the common calls of nature. No solicitations could induce him to utter a word, to move, to eat, or drink, and his design was to deprive himself of life by starving, every other mode being denied him: with the assistance of some experienced attendants, his amazing resistance was overcome, and he was forced to take a sufficient quantity of nutritious fluid; this process was continued with very little variety, and with constant resistance for six weeks; the trouble and anxiety his obstinacy occasioned is not to be described, all our efforts appeared unavailing, and I was, at times, afraid that we must abandon him to his fate: our exertions however were unceasingly continued, and with the food some evacuating medicine was occasionally introduced; and, at the expiration of two months of struggle, the eyes were sometimes observed half open, and a degree of new expression appeared in the countenance, which was one of the most incurious and vacant that can be imagined: soon after, the resistance to food was not so great, and we sometimes gained a word or a single syllable by way of answer to questions. Being so averse to speech, pen and ink were furnished, and when unobserved he wrote detached parts of scripture and sentences expressive of miserable apprehensions, from, having incurred the displeasure of the Deity, being excluded from hope and mercy, and numbered with the reprobate; and yet he retained such a reverence for the Deity, that he never used the letter, because it made a part of one of his titles, the Great I Am: his mind was overwhelmed with gloom and despair, and it was too obvious that opportunity alone was wanting to terminate his wretched existence. The system of forced feeding continued: when being furnished with the bible, his reading was constantly confined to the Leviticus, and though he refused to reason on what so occupied his attention, he made me sensible, by writing, that he wished to comply with some of the ceremonies prescribed by the Levitical law, particularly to make sin offerings; I paid little attention to so useless and impracticable a proposal, but his determined obstinacy was insurmountable, and I began again to fear that he would fall a victim to it, when he proposed complying with some of my earnest solicitations if I would allow him certain ablutions before and after meals, and with this I judged it best to comply; day after day he was accordingly plunged into a cold bath, and a very spare diet was, in consequence, adopted voluntarily, but the quantity of nutritious ingesta gradually diminishing, and it being too obvious that self destruction was still uppermost in the mind, the bathing system was abandoned, and spouting again became absolutely necessary; but the. resistance never diminished, and it is not easy to conceive the difficulties we had to surmount, so that it became almost a dubious point to decide whether duty enjoined persisting in this terrible process or resigning him to his fate; but I was determined to try the effects of the circulating swing as a last resource, into which he was placed as an inanimate lump, with his eyes shut; after a few circumvolutions one eye was observed to be occasionally opened, and at length both, a degree of alarm seemed next excited, then nausea, and retching to vomit; the motion was then suspended, and he was consulted as to his unwillingness to comply with my requisitions, but he still refusing, the gyrations were renewed, when the former effects were soon obvious, and the motion being increased, full vomiting ensued; he now begged to be liberated, and promised compliance with my wishes; he was taken out, put to bed, and slept for some hours, when food was offered, but, as usual, refused; he was reminded of his promise, and threatened with an immediate repetition of the swing; this succeeded, and for some days the prognosis seemed more favourable, but the reluctance to eating returned, and recourse was again had to the swing, two or three times, with the former success, till at length he yielded entirely to my wishes, and by very simple management, botk mind and body were at length perfectly restored, and I have the pleasure of knowing that he continues well, and I am confident owes his life and reason to the swing.
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