Abstract
While considerable scholarly attention has been devoted to the Treatise on Insanity (1835) by James Cowles Prichard (1786–1848) and his theory of ‘moral insanity’, Prichard’s assessment of mortality among the insane which formed one succinct section of his Treatise – and comprises this Classic Text – has been largely ignored. It is significant for its generally upbeat prognostics, for its significant challenge to competing professional ascription of deaths associated with insanity to brain disease, and for its espousal of an aetiological model foregrounding non-cerebral, especially visceral, somatic morbidity.
James Cowles Prichard was the fourth son of a Bristol Quaker merchant. He studied for his MD during 1806–8 at Edinburgh University, arguably Britain’s foremost contemporary medical school. From 1816 he held the conjoint post of Physician to Bristol (Clifton) Infirmary and St Peter’s Hospital, attending their mixed general, fever and lunatic wards for three decades. Prichard also served as Visiting Physician to the Gloucester Lunatic Asylum. His career culminated in the crowning achievement of appointment as one of the first English Lunacy Commissioners (in accordance with the 1845 Lunacy Act). 1
An accomplished linguist, Prichard’s mental medicine reflected how deeply indebted he was to continental practitioners, in particular P Pinel, J-ED Esquirol, E-J Georget and the Paris school. His earliest substantial contribution was his Treatise on Diseases of the Nervous System (1822). 2 Prichard’s study – highlighting the aetiological basis of many nervous disorders in vascular and inflammatory (rather than cerebral) pathology – was reinforced by his extensive post-mortem observation of insane cases at Bristol. Contemporaneously Prichard’s work was lauded as ‘excellent’ by Esquirol, and recognized by British practitioners for its ‘systematic’ approach and authoritative account of epileptic disorders: ‘the best in the English language’. 3
Psychiatric historians’ attention to Prichard has been mainly devoted to his more widely read Treatise on Insanity (1835) and its novel concept of ‘moral insanity’. 4 Recent scholars have recognized both the conservatism, and the originality and importance of this work. 5 Augstein underlined the significant differences between Prichard’s moral insanity theory and Esquirol’s concepts of monomania and instinctive insanity, and his distinctive definition of it as a disorder of the will/feelings/impulses rather than an intellectual/cerebral malady. Augstein also demonstrated how Prichard’s religio-philosophical views resided at the heart of his rejection of materialist approaches. 6
Less scholarly attention has been accorded to other aspects of Prichard’s work, including his examination of mortality reproduced as our Classic Text below. Originally published as a contribution to the comprehensive Cyclopaedia of Practical Medicine (1833), 7 he recycled it virtually verbatim (as he did much of his large Cyclopaedia entry on ‘Insanity’) two years later in his Treatise on Insanity (1835). It is this more widely disseminated version of the text which has been relied on here. 8
In many respects, Prichard’s text is narrowly construed, heavily reliant on previous work by leading continental alienists, Esquirol, Georget and A-L Foville especially, but also the rather lesser known practitioners, Desportes, Director of the Paris hospitals 9 and Greding, Physician to Waldheim workhouse, Saxony. 10 Prichard’s analysis of mortality referenced only three British authorities, including Crichton, though merely for his reproduction of Greding’s findings on tubercular mortality in insanity. 11 Even in his extensive Chap. V discussion of necroscopical research, Prichard offered minimal citation of other British insanity specialists’ weighty discussions on mortality and morbid appearances, including Bethlem’s internationally renowned former apothecary Haslam. 12 The Clapham private madhouse practitioner GM Burrows’ works, which devoted six and eight pages respectively to such subjects, were frequently referenced, though their sections on mortality received minimal coverage. 13 Lacking original evidential underpinning, Prichard’s survey appears slight by comparison with the statistician Farr’s authoritative quantitative and comparative surveys of English asylum mortalities (1839, 1841). While Farr stressed ‘the considerable diversity of opinion’ on whether insanity was ‘a fatal disease’, he and most leading authorities tended towards the negative prognosis that asylum mortality rates were ‘much higher’ than in the general population. 14 This context coupled with Prichard’s propensity to minimize cerebral pathology (contradicting increasing trends in mental science) helps to explain why so few cited his survey. Significantly, it was on Farr not Prichard that Bucknill and Tuke relied in their (1858) Manual’s succinct section on mortality. 15
Prichard’s reliance on French statistics, plausibly attributed to the lack of easily accessible data from English asylums, found sympathy in the wider medical press. One contemporary reviewer ‘strongly’ recommended his mortality section as exemplifying his general success in condensing ‘much practical matter, of the highest value, into a very small space’. 16 This does not, however, fully mitigate previous historical criticism of Anglophone alienists for their haphazard analysis of second-hand statistical evidence. 17 Prichard’s (limited) address to mortality (consequent on degenerative conditions such as dementia and general paralysis) and to differential gender patterns was almost entirely reliant on Esquirol, with a modicum of evidential backing from Lancaster Asylum and St Peter’s Medical Officer.
This Classic Text is noteworthy, nevertheless, for three reasons. Firstly, Prichard offers a more hopeful prognostic evaluation of the effects of lunacy on bodily health than had many other alienists. 18 Broadly sympathetic to Quaker moral therapy, Prichard opens with the unequivocal assertion: ‘Insanity is not to be reckoned among the diseases which are very dangerous to life’. Thus, he loudly echoed Tuke’s persuasive employment of the York Retreat’s mortality statistics to show that ‘insanity is not essentially prejudicial to animal life’. 19 Prichard similarly argued for the significant insulation of physiological functions dependent on the brain from the pathological processes associated with most insanities. His conviction was explicitly grounded on somewhat circumscribed evidence of lunatic longevity, exemplified by Desportes’ Salpêtrière research. Moreover, it derived from an understanding of insanity as primarily related to somatic disease located in the viscera rather than the cerebrum.
Prichard’s prognostic positivism was partially extended to assessment of mortality attributed to ‘exhaustion’ from prolonged nervous/maniacal excitement, which medico-psychologists had long identified as primary in causing lunatics’ deaths. Exhaustion comprised a significant share of the published mortality statistics emerging from British and European asylums between 1800 and 1860. Prichard offered a short but stereotypically graphic outline of the condition’s deplorable consequences. Accepting that ‘some maniacs die completely worn out and exhausted’, he nonetheless mitigated such perilous prognosis by highlighting the usual retreat of life-threatening symptoms on application of appropriate sedative means.
Secondly, undercutting his onus on insanity as non-prejudicial to longevity, Prichard also accented lunatics’ peculiar propensity to various disorders profoundly deleterious to organic life. Confirming his earlier (1822) conclusions, he substantially referred insane mortality to apoplexy, paralysis, convulsions, and a whole symptomatic range ascribed to ‘cerebral congestion’. Prichard also affirmed the dangerous susceptibility of the insane to congestive diseases of the bowels, liver, heart and intestine. He additionally verified the common conjunction of insanity with fevers, and with pulmonary and tubercular disease, arguing, on the authority of Esquirol and Greding’s autopsies, that insanity often elicited latent phthisis.
Finally, and more importantly, Prichard averred the primary origin of mental diseases and associated mortalities in non-cerebral bodily sites, in particular the viscera. The work of the Dublin physician Percival had previously disposed him to recognize visceral pathology in mental maladies. 20 Subsequently, his conviction grew firmer, encouraged by the finding of Calmeil, Esquirol’s assistant at Charenton, that ‘death seldom follows as the simple consequence of cerebral disease’. 21 Prichard increasingly parted company with Georget, Foville et al.’s consensus that insanity was merely ‘an idiopathic Disease of the Brain’. 22
Prichard remained tentative in his emerging conviction as to the (non-accidental) connection between thoracic and abdominal diseases and insane mortality, partly because contemporary pathological research was inconclusive in establishing linkages. Prichard’s ideas evolved significantly, however, subsequent to both his 1822 and his 1833/35 texts. By the 1840s, he was diverging markedly from Anglo-French preoccupation with morbid cerebral changes and phrenological synonyms of mind-brain, towards the approaches of Jacobi and the German Nasse school. 23 More critically assessing the implications of Greding’s autopsies, Prichard contended that the congestion or ‘serous effusion’ frequently found in lunatics’ skulls was ‘an effect rather than a cause’. 24 Esquirol’s linkage between melancholia and tubercular lung diseases was likewise redrawn by Prichard as a ‘supervening’ rather than causative connection. Prichard ended his career surer than ever that it was morbid changes ‘in the organs subservient to physical life’ that explained the commonest manifestations of and mortalities from insanity. 25 By the 1850s, pace Prichard however, many leading authorities were tending to relate the majority of mental diseases to ‘the congestion theory of the pathology of insanity’. 26
Classic Text No. 89
‘Of the Termination of Insanity in Death’, by James Cowles Prichard (1835) 27
Insanity is not to be reckoned among the diseases which are very dangerous to life. The state of the brain on which it depends, though incompatible with the continuance in a sound state of those functions with which the mental operations are associated, is yet such as to carry on other processes, dependent on the brain, which are subservient to physical existence.
This conclusion is established in a most convincing manner by the duration of insanity, and the cases even of longevity which occur among lunatics. We are informed by M. Desportes that among the lunatics at Bicêtre in the beginning of the year 1822, one had been lodged there fifty-six years, three upwards of forty years, twenty-one more than thirty years, fifty upwards of twenty years, one hundred and fifty-seven more than ten years. At the Salpêtrière the entry of patients was dated, seven cases from fifty to fifty-seven years, eleven from fifty to sixty, seventeen from forty to fifty.
I. The morbid state of the brain is, however, liable to increase beyond the limit above adverted to, and then the usual phenomena dependent on severe cerebral disease are manifested. It is well known that lunatics are subject in a much greater proportion than other persons to apoplexy, paralysis, convulsions, and all the trains of symptoms depending on different degrees or modifications of cerebral congestion. * 28
II. Another mode by which madness brings on a fatal termination is by the exhaustion arising from continued excitement. There are many cases of maniacal disease in which the ceaseless excitement of the feelings, the constant hurry of mind and agitation of body, the total want of rest and sleep, and the febrile disturbance of the system which frequently ushers in the attack of madness, and is a prominent feature in cases of this description, bring on a very marked reduction of strength as well as of flesh: the degree of emaciation is sometimes extreme. In general this state of excitement gradually abates, or the means adopted to lessen it and tranquillize the system are attended with success; but this is not uniformly the case, and some maniacs die completely worn out and exhausted. It is in part owing to this cause that the mortality among lunatics is more considerable during the two first years from the period of their attack than in the succeeding years, a fact which appears to be established by the calculations of M. Esquirol. In the Salpêtrière the number of deaths is even much greater in the first year than in the second. Of seven hundred and ninety lunatics who perished in that hospital between the years 1804 and 1814, it appears that three hundred and eighty-two died in the first year from their admission, two hundred and twenty-seven in the second year, and one hundred and eighty-one during the seven succeeding years.
Many lunatics are carried off by diseases of the abdominal and thoracic viscera, which are complicated with madness. Pathology does not enable us to explain the connection between organic diseases of the lungs or bowels and disorders in the condition of the brain, and hence many have been inclined to regard the combinations of morbid states to which we now advert as accidental. They are perhaps too numerous to be attributed to chance. The combination of madness, as well as of some other affections of the brain and nervous system, with morbid states of the liver and of the intestinal canal, was pointed out some years since in my work On Diseases of the Nervous System. The conjunction of insanity with pulmonary phthisis is a fact established beyond doubt by the observations of M. Esquirol, who remarks that phthisis often precedes the appearance of melancholia, or accompanies it. The disease of the lungs is in such instances latent; the patients lose their strength, become emaciated and suffer under slow fever, sometimes attended with cough and diarrhoea; the phenomena of madness rather increase than abate under these circumstances, and continue until death. On the examination of the body, the lungs are found tuberculated or affected by melanosis. *
Diseases of the heart are not unfrequently [sic] complicated with madness. We are assured by M. Foville, that, of the bodies of lunatics which he examined after death during three years, five out of six displayed some organic disease of either the heart or the great vessels. This was very frequently hypertrophy of the heart. These morbid changes, however, are probably, as M. Foville has observed, more frequently results of the continued agitation, the violent efforts and cries, which in such patients bring on diseases in the thoracic organs, than predisposing causes of cerebral disorder. That this, in some instances at least, is the true explanation of such facts I am convinced from my own observation.
Diseases of the intestinal canal, whether they exist or not at the onset of the maniacal attack, are among the frequent causes of death. A state of obstinate constipation often continues for a long time, attended by its usual accompaniments. It gives way, and is followed by or alternates with diarrhoea, which wastes the strength of the patient and terminates in a fatal dysentery. When the body is examined, the intestines are found sometimes distended and loaded with indurated matter, at others empty and pale, with disease of the mucous coat, discoloured and abraded patches or ulceration, and gangrenous spots.
In protracted cases death either results from increase in the disease of the brain, which disease up to a certain degree had only interfered with the operations subservient to the mental faculties, but at length becomes incompatible with the merely physical functions of the same organ; or it is the result of accidental disorders, which, owing to the peculiar state of the brain and other organs in lunatics, are more than usually fatal to them.
Many lunatics in the advanced stage labour under a degree of cachexia bordering on scurvy. The skin is beset with scaly or papular eruptions, or discoloured in patches; furunculi appear in different parts of the body, which are much disposed to become sloughy; the gums become red and sore, and bleed; the surface of the body is cold, with a clammy perspiration; diarrhoea and abdominal pains accompany these symptoms; the patient apparently suffers under defective nutrition and a gradual decay of physical life, and dies in a state of extreme emaciation or marasmus. 29
The preceding are perhaps the natural results of the diseases under which lunatics suffer in connection with their original complaint. A great number, however, are carried off by disorders which may be considered as accidental, but to which the condition of body in patients of this description renders them more than other individuals liable. Fevers which assume more or less of the typhoid character, severe catarrhs, and pulmonary affections, are the most frequent of these. It will be supposed that fevers which affect the brain are fatal to lunatics, and such is the fact in a very marked degree.
The diagnosis of accidental diseases in lunatics presents, as M. Georget has well observed, remarkable difficulties. Some patients of this description are continually making unfounded complaints, deceived by their erroneous or fancied sensations. “On the other hand, many lunatics labour under very severe affections without revealing them by any expression, either because these affections are latent and do not occasion suffering, or because the disturbed state of their minds does not allow their sensations to reach the centre of perception. In this last relation the medical treatment of lunatics is much more obscure and difficult than that of young children, because the latter are conscious of their ailments, and express them by their cries. When we observe a lunatic, who had previously been agitated and furious, become morose and taciturn, and at the same time lose his appetite, seek repose, and display a suffering and dejected expression, we ought to examine him carefully: he is threatened with some acute disease. The development [sic] of symptoms will soon point out the seat and nature of the complaint, and consequently by what remedies it is to be opposed. But chronic affections are so slow in their approach and concealed in respect to their symptoms, that they often reach to a very advanced stage before their existence is suspected, unless the organs affected are examined before their diseased condition has manifested itself. We find the lungs full of tubercles, with cavernous excavations and abscesses, or in a state of atrophy, in the bodies of individuals who had neither coughed nor expectorated, nor experienced pain or dyspnoea during life; they had become gradually debilitated, had taken to their beds, and after a continually increasing emaciation, had at length sunk. The disorganization of the lungs had only been discovered by the aid of auscultation and percussion. We must not then wait for the expression of complaints on the part of lunatics, in order to have due watchfulness excited to the means which are necessary for preserving their existence.” 30
The following table given by M. Esquirol, in his statistical report of the Royal House of Charenton, 31 serves to illustrate the comparative mortality resulting from different forms of madness.
Table of mortality in relation to different varieties of derangement.
“The mortality fell chiefly on persons in a state of dementia. This,” as M. Esquirol observes, “is to be expected, since dementia is almost always the ultimate condition to which continued insanity leads, of whatever form, and because dementia is the form of disease with which paralysis is chiefly complicated. There is likewise to be remarked a great difference between the numbers of men who sink under dementia and those of women: thus we have in the former eighty-nine, and twenty-six in the latter. Next to dementia mania is the most fatal, and it is more destructive to men than to women: this, however, is explained by the circumstances that we admit more men than women, and that men are more subject to mania than women.”* 32
It appears generally that the mortality at Charenton was much greater among the male than among the female patients. This is attributed in part to the comparatively greater prevalence of general paralysis among the former. The fact is equally striking in the reports of some English hospitals, as in that of the Lancaster Lunatic Asylum, given in a previous section, in which the deaths of males are 344 in 997, or about 1 in 3, and those of females are 233 in 753, or about 1 in 31/5. Among the lunatics in St. Peter’s Hospital in Bristol, the difference is still greater in the relative numbers of deaths of males and females; and Mr. Brady, the intelligent medical officer under whose immediate care the patients are placed, has assigned this difference to the cause suggested by M. Esquirol.
With respect to the mortality at different seasons, it is observed by M. Esquirol that in general the months of December, January, and February, are the most fatal to deranged persons. 33