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ART. VI.-An Account of some of the most important Diseases peculiar to Women. By Robert Gooch, M.D. London. 8vo.
HE work before us, being expressly devoted to medical subjects, cannot, as a whole, be appreciated by the non-professional reader. There are points, however, in medicine, forming that debateable land between technical and general knowledge, which few, who have attained to half the years allotted to our sojourn here, have not been forced to make the subjects of anxious thought; and of these the most painfully interesting is insanityto which Dr. Gooch has devoted two essays, distinguished in a very uncommon degree for originality, precision, and vigour of thought.*
The materials which our author has brought together will enable us to examine the validity-Of the opinions current in medicine as to the nature and treatment of insanity in general, and puerperal insanity in particular;-Of certain opinions current in society as to insanity; and, thirdly, of certain notions entertained in law respecting insanity, considered as a subject of legal medicine.
It is well known that some, who are quite sane at all other times, become deranged-sometimes a few days, sometimes several months, after confinement. We may quote the following
A lady, who I was told had had a " a brain fever" after her former lying-in, came to London to be attended by me in her next confinement. For nine days subsequent to a short and an easy labour, nothing indicated the approach of disease. On the tenth day, however, the shop of a piano-forte maker in Oxford-street caught fire: this occasioned a great bustle in the neighbourhood; as her sitting-room did not look into the street, it was kept from her knowledge during the day; but in the evening, while she was standing at her window, which looked into a yard at the back of the house, a piece of burning matter fell within her sight. I saw her about two hours afterwards, at nine in the evening: her manner was agitated. On being questioned as to her feelings, she kept silent for some time, and then answered abruptly: her pulse was quick; her look and manner odd and unnatural. I slept in the house. At four o'clock in the morning the nurse waked me, and said that her mistress had no sleep; that she was sitting up in bed talking to herself, but that instant had expressed a wish to see me. I rose and went to her; there was only a rushlight in a remote part of the chamber. As soon as she saw who I was, she told me to sit down and look at her. I said, "I do." "What do
The two essays to which we allude are entitled "Disorders of the Mind in Lyingin Women;" and "Thoughts on Insanity as an object of Moral Science."
"Nothing but yourself." "Look at my head." "I do." "Do you see nothing particular there?" "Nothing." "Then I was presumptuous: I thought that a glorious light came out of my temples and shone about my head; I thought I was the Virgin Mary.” The patient recovered in three weeks.'
The practical question to be determined is, what is the state of the body on which the disorder of mind depends? Our medicinal agents can only raze out the written troubles of the brain,' through their action on some portion of the organisation. It is of the last importance, therefore, to ascertain that peculiar state of organisation which accompanies insanity; and here Dr. Gooch is opposed not only to popular but to professional prejudices.
There is a strong disposition,' says he, to attribute raving of the mind to inflammation of the brain. Perhaps it originates thus:-that the disorder of the mind, with which we are most familiar, is drunkenness, which is known to be caused by spirits and cured by temperance: -mania is called brain fever; and the sight of a raving patient instantly suggests the thoughts of cupping-glasses, iced caps, low diet, and purgatives.'
Experience, however, according to our author, points to a very different conclusion: it teaches us that disorder of the mind may be connected with very opposite states of the circulation; sometimes with inflammation or active congestion, for which depletion is the shortest remedy; sometimes with an opposite condition of the circulation, which depletion will only aggravate: And, indeed, in order to prove that the excitement of the brain, in puerperal insanity, does not always depend on inflammation, nothing more is necessary than to look over the leading points of the cases narrated by Dr. Gooch as having fallen within his personal observation.
In one of these, the disease occurred in a pale lady without any heat of skin, or much quickness of pulse, and was not relieved by blood-letting: in another, it occurred in one whose constitution was drained and enfeebled by nursing: a third was habitually hysterical, pale, and from want of sufficient physical power always brought forth dead children: in a fourth, insanity followed immense loss of blood: in a fifth, it occurred in one in whom, for urgent reasons, large bleedings were essential to preserve life in a sixth, who had lived so low, and was of so irritable a constitution, that she appeared as if at the close of some disease which had been overlooked, mania showed itself, and was relieved not by bleedings or cupping, but by means which tranquillized, soothed, and sustained the patient. In a seventh, the attendant treated the case by moderate depletion, by leeching, cupping, purging, and low diet;-she died, not with the symptoms
of oppressed brain, but with those of exhaustion; and, on examining the body, the whole of the venous system was found extraordinarily empty of blood. In an eighth case, the practitioner, misled by the flushed face, fevered look, hardish pulse, and raving madness, ventured to take away blood; and, on the abstraction of a little more than a tea-cup full, the patient sunk under the stroke of the lancet as if shot. In another, the disease came on after one of those enormous bleedings resorted to for the relief of puerperal convulsion in both these cases, there was no evidence whatever to be found, after death, of inflammation of the brain. It is impossible to look at these results, gathered together by a competent observer and a faithful narrator, without coming to the conclusion that puerperal insanity is not necessarily a disease of congestion or inflammation, but is generally one of excitement without power. The insanity occurred, in almost every instance here adduced, in persons previously debilitated; and, when treated under the notion that its cause was inflammation or congestion, the patient either sunk rapidly, or was materially injured, or at best was not relieved. It may, however, be objected that these are cases selected to prove a point, and that they bear a small proportion to others in which the insanity is dependent on an overloaded state of the vessels of the brain.
'Their very number,' says Dr. Gooch, gives a negative to this suspicion ten cases can never form a small proportion of the experience of one individual, however extensive his opportunities of seeing the disease may be; for puerperal insanity is, not like fever, a disease in which an experienced physician counts his cases by hundreds. Dr. William Hunter said that, in the course of his practice, he had met with about twenty or thirty. There can be no mistake, unless, by some extraordinary accident, all my cases have been exceptions to the gene. ral rule-an incredible supposition. They surely prove that those cases of puerperal mania, which are attended by a very rapid pulse, which Dr. William Hunter said generally die, and which he attributed to paraphrenitis, do not depend on that state of the brain which requires depletion, but on a more exhausting excitation of the nervous system, which requires soothing and sustaining treatment.'
In the latest works written on the subject of insanity, opinions diametrically opposed to these are promulgated; the ancient regime of shaving, cupping, bleeding, is recommended, and opiates discountenanced. From these directions it would be inferred that the generality of cases depended on congestion, and required depletion, which is the reverse of the fact. The real inflammatory phrensies of puerperal women are rare. Inflammatory head-aches are not uncommon, but their progress is very different from that of puerperal insanity: the delirium, if
slighter, and follows the pain and the fever; while in puerperal insanity, the incoherence of mind is excessive, and the pain and fever accidental,-sometimes occurring, and sometimes not.
Those who may not feel satisfied with the views so strongly insisted on by Dr. Gooch, will do well to consider the influence of large bleedings on the circulation of the brain. Throughout Dr. Kelly's experiments on animals bled to death, the vessels of the brain, so far from being drained of blood, were found full. But (which is still more conclusive) Dr. P. M. Latham has recorded, in an admirable essay on the epidemic at the Millbank Penitentiary, a series of observations which prove that the very disease, which is commonly supposed to arise from excess of power, originated from a want of it. The Penitentiary was exposed to the depressing influences of malaria; the prisoners were suddenly put upon low diet, each person being allowed only one ounce and a quarter of meat daily. After a short time, they wasted in bulk and strength; the men could only labour half as long as before, and the women fainted at their work. This simple debility ushered in, first, scurvy, dysentery, low fevers, and, at last, affections of the brain and nervous system, such as convulsion, delirium, apoplexy, and mania. When bleeding was tried, the patients fainted after losing four or five ounces, and were not better, but perhaps worse'; yet, on examination, the vessels of the brain were found full, and sometimes there was fluid effused.
Here, then, we have three different sets of experiments, proving that that which exhausts the system does not necessarily diminish excitement of the brain; and so far we think Dr. Gooch's position complete. The error which pervades the profession and the public arises from viewing only one side of the question, and consists in taking the condition of mind—the raving, as a criterion of the treatment, instead of the state OF THE BODY. Because there is the excitement of the brain, it is immediately argued that excitement must depend on excited vessels, inflammation, and congestion, and must be relieved by bleeding and starving.' Instead of this, the inquiry should be-Is the raving really accompanied with the marks denoting vascular fulness?-is the pulse hard and strong, the eye red, the head painful, the face flushed? If so, this is a case in which depletion would be resorted to by Dr. Gooch,* and by every other sensible man. But to treat mania accompanied by an opposite state of the circulation, by cupping and low diet, merely because there is raving, is not only a grave error in theory, but a fatal one in practice.
Having made out the principle, we shall not enter into the novel details so admirably stated in the work before us, lest our * Vide Case xii. p. 153,
critical remarks should be converted into a medical essay. It must suffice to say, that by far the greater number of those affected with puerperal insanity recover completely; that they who have been once affected, are not necessarily liable to be attacked the next time; and that the vast majority of womankind escape altogether; that the treatment should be soothing and sustaining, and that, as a general rule, the patient should be removed from the presence of friends, and confided to the care of experienced attendants.
There are exceptions, however, to this last clause; and it is right that the public should be roused from their apathy respecting the treatment of maniacs; it is right that the friends of the afflicted should know that all hope is not left behind even when the gates of the cell are closed, that, however judicious the treatment, however attentive the conduct of hirelings, there are cases in which the presence of those once loved has proved blessed medicine, and reason has returned to the brain in the train of kindly emotions suddenly re-awakened in the heart.
A lady, twenty-eight years of age, of good constitution but of susceptible mind, became affected with melancholia a few months after her second lying-in. Towards the end of her pregnancy, a frightful incident had occurred to a near relation, which affected her so deeply that she often spent the night sleepless, sitting up in bed thinking of her misfortune, and dreading that she should lose her reason after her confinement. Having nursed her child without feeding it, for three or four months, with much unnecessary anxiety and exertion, she grew thin and weak, and experienced so much confusion of mind that she could not arrange her domestic accounts. She became low spirited-she knew not why; she was advised to wean her child, took some light tonic, went to the sea-side, but at the end of a month returned home, having derived little benefit from her absence. Her spirits became gradually more depressed, and it was impossible to persuade her that she had not some fatal disease: one day it was cancer-another, inflammation of the bowels; and to such a height did her apprehensions arise, that her husband was often brought home by some alarming message, and found her, with a solemn air and in a low whisper, giving directions to her servants, whom she had assembled round her, what to say if she should expire before their master arrived. She now grew much worse, and there was no longer any doubt about her complaint. She was seen by a physician of extensive experience in these diseases, and sent into the country. Many weeks passed: sometimes she was better, sometimes worse; now accusing herself of the deepest depravity, and meditating schemes of self-destruction; then again convinced of the absurdity of her notions, and struggling against the load which weighed on her heart. In this way many weeks passed: at length the disease came upon her with more violence than ever, and, in her self