It is highly desirable that the attendants on lunatics should possess this influence over their minds, but it will never be obtained by austerity and rigour; nor will assumed consequence and airs of self-importance be generally more successful; at the same time, it must be acknowledged that as insanity is often the consequence of over-indulgence, as well as of a system of tyranny, while under parental care, that therefore both extremes are to be, not only avoided, but their effects counteracted by a judicious and curative system of treatment, and that this will require to be varied according to the peculiarities of each individual case.
A private establishment, where cure and reformation are thus conjoined, becomes an interesting little world of its own. Though to live in this world is a life of ceaseless anxiety, there is such a perpetual succession of such an endless and inconceivable variety of strangeincidents and speeches, odd displays of feelings and manners, inside views of the human heart, and, as it were, of the invisible world, that the charms of novelty, the excitements of wonder, the enquiries of reason, and the demands of sympathy, keep the mind so alive, that I have often observed that the revolutions of the sun seem to run their course more rapidly now, than before I lived among them. And though the feeling of being excluded from rational society, often presents itself to the mind as a terrible sacrifice to those whose earliest and fondest wish was to live in the sphere of intellect and genius, yet we are often reminded that they are not always irrational, that some, are so only on a single point, while on every other they possess more than common powers of pleasing; others, are in a state of convalescence, and many of them are, for a while at least, grateful and amiable in the extreme; and it is delightful to see those who awake from a lost or raving state, as from a sound sleep or a disturbed dream, with all the freshness of joyous gratitude and celestial ecstacy, on suddenly beholding a new world of mind and matter bursting upon them. So that if we cannot always exist in an intellectual sphere, we are seldom without that of affection and gratitude; and though it is difficult to prevent, in such scenes as must often assail us, occasional paroxysmsof discontent and wearisomeness coming over us, they seldom last long, and they are sometimes cured, as well as brought on, by an occasional peep into the motley world.
Shut out from the world, one is as apt at one time, on again entering into it, to be as much oversurprised and delighted with the blessed fire-side scenes where the wise and good man resides, as one is at another time to be equally over-disappointed and revolted with the follies and miseries of the moral insanities which exist unrestrained among men in real life. Nor do I conceive we have more appalling consequences of disobedience to the natural and divine laws of our being, in this place, than can be seen in the world, walking in wantonness in the broad light of the noon-day sun.
Insanity is, no doubt, a terrible visitation, but why should we allow a false and unreasonable horror to increase it, and why should we thus sever our sympathy from a disease which more than any other requires it? The medicinal virtues of the fruits of charity are best proved amongst them. Grant that the disease arises from some remote or proximate ill-directed mental states. Why should we have more horror of insanity, than many other consequences of ill-regulated minds.—To me, the foul ward of some large public Hospital, is incomparably more horrible and loathsome.—Such direct consequences of wickedness present the object before us in an aspect that makes it difficult for us to exercise any feelings of commiseration towards them. Not so the insane! but these are views, however, into the consideration of which, I shall not enter in this place; but I mention or rather hint at the diseases of other organs, for the purpose of asserting that the reality and appearance of the miserable state of the insane is not so shocking as people imagine, but that still I allow it is an awful visitation.
But while I allow this, it is at the same time the strongest reason why we should be anxious to remove all those false and unreasonable horrors, which can only aggravate the calamity, by giving countenance to the imaginary necessity of having recourse to harsh measures,—one ceases with the other,—it will not only do this, but it will also, I repeat, remove those depressing feelings of degradation which, whenever reason gleams, is death to their hopes, and which often prevents their recovery, brings on relapses, and is the most painful and heartrending feeling they have to contend against in the critical and incipient stage of their convalescence.
By this system of greater liberality, it would soon be found, that patients would no longer consist of violent and extreme cases alone,but that every thing repulsive in their present state and aspect would quickly disappear, their whole character assume a milder form in reality as well as in appearance.—Indeed, this is already the case. All things are improved. Thus popular prejudice ought to cease, and a more favourable prepossession should occupy its place; and the world being fully persuaded, that there is much more to hope than to fear from a residence at such a place, persons at the commencement of the malady are easily induced to enter them of their own accord, or are sent by their friends without delay or reluctance, before the disease has passed the curable stage. “Cases,” as a friend of mine justly observes, “were this feeling fully established, would be relieved without proceeding to the utmost degree of severity; and we might confidently anticipate that when the decided excellence of such a system, as regards moral, intellectual, and physical management, is adequately understood, the premonitory symptoms, often slight and various, but generally significant, will no longer be disregarded: and incipient mental disease, arrested by the judicious means there pursued, will not be allowed to assume a form and magnitude constituting the most awful calamity to which man is subject:” and why should it be allowed to do so, when it may be asserted, without contradiction, that functional disordersof the brain, are less liable to end in disorganization, and possess a greater power of readjustment, than any other part of the human system—woe unto us if it were not so.
The advantages which may arise from this system will appear in a still more striking point of view, when we reflect that those cases which without proper care in the early stages of the disease ultimately become the worst and the most dangerous, are precisely those which are fatally neglected, in the first instance, and which are scarcely ever placed under any medical treatment or moral discipline until the evil is past all remedy. Cases of suspension and cases of gradual decay of mind, as well as cases of Hypochondria, are of this description. I had lately applications to receive three patients of the latter description, all of whom committed suicide during the delay between the application and the intended removal.
It is true, there are cases, which require a very delicate, and conditional sort of superintendance, and that harsh measures and indiscriminate treatment would, in many instances, be more injurious than even absolute neglect; but at the same time, it must be observed, that such persons generally require to be placed under some judicious and delicate restraint, from the fact that their vicious inclination (for in these cases the disease begins in chronic inflammationand ultimately softening of the cerebellum) leading them into vicious habits, would rapidly accelerate the disease and make it a confirmed and incurable case. I have had some cases of gradual decay of mind, which, if not curable, might, with care, have continued for years in a tolerable state, but when allowed their liberty only for one week, they so accelerated the progress of the disease by dissipation and excess, that they suddenly sank into hopeless idiotcy.
I have known several such cases, who were never under any care, but left wholly to themselves, sink as suddenly into the same hopeless state.—Cases of Melancholia and Suicide, are often unsafe; the first is not a less decided case, though less avowed and acknowledged inclination to suicide; the other, though avowed will often pretend to be much better; sometimes even strongly confess their guilt in having allowed themselves to indulge in so dreadful a propensity; and all this, merely for the purpose of throwing their friends off their guard; when, the moment they suspend their vigilance, the suicide seizes with avidity whatever means or opportunity may be presented to him, to terminate his present miserable state of existence.
It is evident that to pursue this system, it will require great anxiety and vigilance, and that we must not care for labour or sacrificesbut seek to do good for the sake of the good to be done; and when this is the case, we shall be most desirous thoroughly to understand every form and species of the disease, for we shall then know that it requires that we should, with the utmost nicety be able to discriminate between the different forms and species of insanity, in order that we may discover, prescribe, superintend, or enforce the peculiar treatment which each case requires.
These conditional plans of superintendance must be allowed the widest range, a range which no inexperienced person, still less those who have false notions and impressions of the general character of the insane, can possibly imagine, and for which no acts or rules can give directions—How then can those without knowledge and experience pretend to undertake such a charge? Often we have only a choice of evils; and we must be less anxious about the risk of accidents, our own credit, or interest, than the cure or chances of good to be done. In some cases absolute confinement would rapidly make the patient’s state worse, and we must give either real or apparent liberty; a liberty which some would think imprudent.[95]—Yet I believe it is a fact, that there are the fewest accidents where to appearance the greatest liberty isgiven,[96]harsh measures always increase the evils which they would pretend to cure; but should one accident occur under this mild system, the person adopting it would be more blamed than he who had twenty accidents on the old plan.—With the first system, it is often difficult to persuade the friends of the patients to concur and co-operate.—The family dispositions often render this probable; nor can we always blame them: but he who undertakes this charge, while he endeavours to persuade and conciliate as far as possible, must in many cases feel himself called upon to act with decision.—If he adopts the fears and prejudices of others, then his system will become one of duplicity and tyranny, exciting suspicion and vindictiveness, destructive alike of all confidence and chance of cure; for unless we acquire the confidence of the patient, no good can be done; mutual distrust will end in absolute slavery and restraint to the patient, and inthe baneful habit of exercising the love of power on the part of those who have the superintendance.—Hence the evils apprehended by their friends as likely to arise out of the patient’s vindictive state, will be most effectually established and increased. Instead of the calming effects of a system of confidence and liberty, tranquillity, and peace, this contrary system will continue to goad, irritate, and inflame that part of the brain through which the mind, in this state, is operating; and in pursuing such a course we are clearly guilty of making that become fixed and permanent which otherwise might only have been of very temporary duration.
While nothing is more certain than that,in mostcases, too sudden a return to old scenes and associations is extremely dangerous, there are some others where I have known their returning home at an early period, or even at some critical point of convalescence, decidedly expedite and confirm their cure:—when there appear evident reasons to augur favourably of such a change, the trial should be made—we have only a choice of evils, and we must endeavour to choose the least.
It is remarkable, that many have, in an incipient state of convalescence, been placed on parole of honor; first, they are simply restricted to the garden, and afterwards the fields; and ifno breach of confidence occurs, they are allowed a pass key to go out and in when they please; and scarcely an instance has occurred in which they have taken advantage of this privilege to make their escape;—nor have they opened the doors to others.—Those who escape are always those who are not so trusted.
In some cases, I have known the convalescence of patients confirmed, not merely by placing them on their parole of honor, but by discharging them as patients, and inviting them to remain and consider themselves as voluntary visitors.
It is astonishing what a stimulus all this is to others to exert theirSELF-CONTROL, and to behave more correctly; and still more so, on promising that on their continuing correct for a given length of time, they shall have these indulgences. But all this shall be more minutely detailed under the Essay,Moral Treatment; when I shall state the effects produced by always treating them as rational beings, and allowing them, in proportion as they conduct themselves more rationally, to have the privileges of, and as far as possible to associate with, those who are so.—The efforts which (in consequence of this principle being observed in all our conduct towards them,) they constantly and anxiously make to be considered rational, is an acquisition of prodigious moment and when we see they possessit, we may pronounce it an excellent symptom of the returning control of the will and understanding.
This is in perfect accordance with the principle which stimulates men, in society, to the useful or baneful exercise of their understandings; and where it exists not, the mind will rapidly sink into a state of apathy and indifference,[99a]and I have no doubt, that many an insane patient who feels that he no longer possesses this stimulus to mental exertion and control, gives way to his foolish thoughts, and still more so, when he finds it more easy to give pleasure to others by their utterance than by endeavouring to talk rationally: thus he acquires the habit of talking nonsense, and hence this constitutes the character of many of the old insane, who might, I believe, have otherwise been brought into a more rational state.[99b]
We should never for our own ease encourage their delusions, but tell them (when we do notice them at all, for silence is often the most effectual reproof we can give; but when we are obliged to notice them, we must honestly, but with charity, tell them) what is false and dangerous, and which often has a good effect; and if it doesnot cure, it restrains them from talking on the subject of their delusions.
Many instances of cures on this principle are recorded, and many more of my own I shall have to state when I come to Moral Treatment.
Nothing can be worse than the common practice in public institutions of allowing idle visitors to amuse themselves by listening to, and of course encouraging, their conversation on the subject of their individual insanity.—When we do notice these delusions, and it must be seldom, it must be a very important and grave matter; and we must exert all our eloquence, and call forth the most overpowering arguments against the folly, wickedness and direful consequences of encouraging these delusions.
Dr. Crowther says, “Mad persons are frequently capable of being reasoned with; and it is sometimes in the power of the physician to remove false impressions from the patient’s mind, by a well-directed reply and judicious reasoning.”
Another patient imagined himself to be Jesus Christ; and in proof of it showed me a scar he had in his side, which, he said, had been occasioned by his having been pierced with a spear.—I remonstrated with him on his assertion, and remarked that our Saviour was wounded on the side opposite to that be had indicated as the part wounded in himself.—Convinced, and apparently ashamed at the consciousnessof the fallacy of his own reasoning, the patient recoiled, hid himself under the bed clothes, and never reverted to the impression under which he had previously laboured.
In many points the insane are accessible to reason; and at all times and in all cases, as a rule, they should be treated as if they were still reasonable beings.—Many are able to detect ignorance, and can appreciate and respect knowledge: convicted ignorance in a superintendent is fatal to his influence and authority. To have the character of being intelligent, is of great service.—Nothing impresses them with this conviction so much, as proofs that you possess a key to unlock their minds—that you have a perfect insight into the peculiarities of each—can trace to its origin their insane state,—the evil of extremes,—and more especially can meet these with clear views of the truth of that which they have perverted.—But all this still more requires that you are not merely esteemed for talents, but also for goodness; then will your arguments and example be like oil on the stormy waves, calming turbulence and breathing peace even upon the victims of passion, misery, and distraction.
All this will be acknowledged to be of great importance, when it is considered that to call forth the exercise of self-control is the most powerful moral means of recovering the lost equipoise of mind. And that this may be done,is certain, for many have some power of self-control remaining, but self-control in a state of misdirection. Numbers also have many avenues of the mind still open, through which the understanding may be stimulated into active exercise, and the will turned into a right direction; and thus the same principle may in many cases ultimately become the means of promoting their restoration.
They generally know the points which others consider as proofs of their insanity, and they should be made ashamed to display them, but never directly irritated by a domineering opposition, which would only rouse the bad passions and the spirit of self-will to resist all means of counteraction.[102]—Hence where these rules are observed, it is often perceived that they will, on their first entrance, keep their delusions out of sight; so much so, that it is often for awhile difficult to discover their insanity.—The early prospect also of their liberation often induces this concealment: we must encourage this, but at the same time, they should see that we have the power to perceive when it is real, and when it is feigned for this purpose. When they know we judge from the state of the inner, and not the outward, man, the effect is wonderful.
It is not by any system of fear, as was once imagined, that all this is to be done.This is a restraining power, which must be seldom resorted to, and then only for specific and temporary purposes, and never of long duration, otherwise the mind will be thrown on itself, and feed on its notions. It should never be used except conjoined with the suspension and loss of sympathy which they have felt valuable, or for the sake of others whose comforts are not to be sacrificed merely that they may selfishly indulge in their absurd whims, and annoying conduct, or in their erroneous views and vicious propensities: for these reasons and purposes they must be separated, and if not corrected by occasional separation, then they must be classed with those whose comfort they cannot derange. They must feel all this as the effect of their conduct, and that their treatment depends on their behaviour; but any discipline or change must never be made without a self-evident cause, and never in the doing carry the air of tyranny, passion, or injustice.
All the principles applicable to the management of children, are equally applicable to them. Though we must watch every probable and threatening storm, we must not too eagerly anticipate its approach—we must wait until it breaks out and gives us an opportunity to justify the moral measures we conceive are best calculated to produce a beneficial influence.
As I have shown, we always endeavour mostsedulously (especially in the first instance begin with) to act on this principle. We treat nearly all on their arrival as if they came merely as visitors, and never alter our conduct until they cease to behave as other people; and then they cannot but blame themselves for their confinement or any change of treatment that their conduct renders necessary, and which must therefore be always sufficiently gross, even in their own estimation, to justify the change. As classification must be based on these moral views, there is necessarily included in this Essay much that will fail to be more minutely considered under the Essay, Moral Treatment, and much more that, it may at present appear, I have, altogether omitted—such as the obvious necessity of separating the vociferous, the dirty, the epileptic, &c. from the more rational, delicate, and nervous.
One principle is very important, hereafter to be enforced, which is, that some must be classed so that bad habits may be prevented by the constant presence of others to call forth the sense of shame to restrain them.
In fact, this plan of treatment should embrace every means conducive to the cure of its objects, such as domestic quiet, and the removal of every possible annoyance; and we are, above all things, carefully to avoid every appearance of restraint, and to adopt as little of the reality as is compatible with the security of the violent, dangerous,and discontented, who must be restrained, and if possible, without exciting or increasing their diseased state. We must do every thing we can to soothe and comfort the disappointed and melancholy, and diligently labour to heal the broken-hearted; we must ascertain causes and effects, and remove or counteract them; we must strive to correct or cure wrong notions and impressions; we must cultivate and strengthen better feelings and principles, and discourage all that is bad, or allow it to die away for want of nourishment and exercise: for such purposes the superintendant must be armed with medical and moral means at all points, and be above selfish considerations. To describe all this in detail, would be to write volumes. It is evident then, that every variety of suitable treatment should be adopted, according to the nature and circumstances of the case.
All this is not to be done by mechanism, nor by the strictest attention to any plan which some cold rules prescribe. Acts of Parliament can never make these places what they ought to be, and which it is of the first importance they should be; I mean places for the voluntary seclusion of an exhausted mind, or nervous invalid, and in every case as institutions not so much for the confinement, as for the cure, of the insane.
Acts of Legislation may interfere with, cramp,or destroy the heaven-born and heaven-directed energies of the mind.—It is dreadful to paralyze or destroy the spirit of kindness, guided by experience and wisdom, by confining it to rules which have merely for their object the prevention of evil, and not the production of good! Those who legislate, should be careful not to meddle in the province out of the reach of human interference. By so doing, they may destroy, but they can never give, the spirit by which alone good can be done.
The present system adds to the horrid association of these houses, (and for which some of these houses may be accused of all the blame,) and prevents them from becoming what I conceive would be of the first importance,—I mean places for the voluntary seclusion of an exhausted mind, or of a nervous invalid, which would be of the first advantage to them, and would besides take away the feeling of horror associated with such houses. It is so in France. On the same principle, those who are sent without their own concurrence, should never be treated as if they were insane; the names “Asylum,” “Patient,” “Keeper,” “Insanity,” should never be heard among them; many have been made worse by a contrary system of treatment; and I may also mention that I am more and more convinced of the necessity and efficacy of proper medical aid, and of course of a medical man, or of one having acquired medical experience,being amongst them,—I repeat “that no man ought to keep a house for the care of the Insane, who does not make cure his ruling motive for receiving, detaining, or discharging patients from his house.”
Again, the arguments are endless to prove every thing should be done not toincrease,but diminish,the horrorassociated with these places. No act of Parliament can give knowledge and principle, and good feelings; and no Act should be made as a substitute for knowledge and principle and good feelings, which every one in his specific sphere should possess. No Act can give knowledge and principle, but an Act can carry with it so much opprobrium, that men of feeling and knowledge and principle, are deterred from undertaking a department of the profession, which the law supposes is only in the hands of base, unprincipled men. The aim of the Legislature should be, to add to its respectability, and to offer encouragement to those persons who possess that knowledge and principle and have it in effectual operation.
Mankind in general, are not made better by treatment that shows our want of confidence in them. Though the mild system is universally allowed to be, not only the most judicious, but that which ought exclusively to be adopted, it will be seen that it may be carried further than it has hitherto been done, and much greater latitude given than we have yet conceivedpossible, and all this with the best possible results.
The principles of human nature, its moral and physical laws, are illustrated among the insane, as well as sane; and if revolutions and abuses of liberty in the world are the unrestrained re-actions of the spirit of justice in men, against those who have neglected or improperly restrained them; so, in lunatic asylums, improper conduct towards the insane, or too much restraint, has given rise to much of the misdirection and irregularity in the display of their animal spirits; and be it observed, that here, as well as in the world, those men are the first to blame effects which they either themselves caused, or which it was their province to foresee, prevent, or cure.
When the understanding is enlightened, or the higher feelings cultivated, the impulses of our inferior feelings will assume a better character, and be less liable to abuse. In asylums, whatever mischief and malignity, are, by improper treatment produced, the attendants place the whole to the account of their insanity; very readily, and without any self-accusation, blaming, and perhaps, severely punishing effects which they themselves have either been the sole cause of, or which they might have prevented. Nor can we wonder that such evils have existed, if we consider how very difficult it is, to find combined kindness, understanding, and practicalusefulness in those who can be procured to attend upon them. Yet all this should exist in the character and conduct of those who undertake their management.
The grand principle of treatment is, to avoid even the appearance of unnecessary restraint, and to treat them with apparent confidence: such a plan of procedure will almost invariably excite their secret but proudest endeavours to preserve and retain this confidence. There is a secret power which holds the helm of the mind, and by its controlling and moral influence guides it more effectually than any rude restraints applied to the bones and muscles of the human frame.
There is no influence so powerful as the sphere of a moral influence.
It is painful to reflect on their former treatment; caged in iron-gratings and exhibited for money! Treated as wild beasts, they necessarily became like them, or worse! Devils in revenge and evil, Satans in deceit and delusion! Or if any portion of the man remained, think of the spirit writhing in agony, or sinking with despair within them! All this, and worse, in some despotic countries, even now exists; and in how many places are they not still made to drink the bitter cup of neglect and coldness, contempt and cruelty. Where do they receive, as they ought, judiciously and constantly, the cordial of sympathy and friendship? Where isevery appearance of confinement and injurious association carefully avoided, and every thing studied to make them feel at home, and all this combined with medical attendance? Say not all this is unnecessary; for if life, under any circumstances, cannot be said to exist without some association of sympathy, it is certain there are among the insane, cases of misery and wretchedness which absolutely require for their cure, as well as their comfort, all the moral kindness and medical attention we can possibly give them.
It has been an universal complaint, that there is nothing certain or fixed in the treatment of Insanity, and that it is presumed it is not yet fully understood. I am of opinion that no medical treatment in any case can be fixed as certain or judicious unless we understood the origin and nature of disease; and I have therefore devoted a considerable portion of this Essay to the consideration of the correspondence which exists between the causes and effects produced; and this I only consider as preliminary to a more full and adequate investigation of causes than I am aware has hitherto been made; but still, as preliminary to this important subject, I shall, in my next Essay, first give a general explanation of the origin and cause of disease, and this in agreement with a principle which I conceive to be of universal application.
As in the foregoing Essay on Classification, I have several times stated my objections against writers on Insanity selecting only extreme cases, by which, I conceive, impressions of horror against the Insane are increased to their prejudice; I shall, therefore, for theexpress purpose of exhibiting a fair specimenof the general character of the insane collectively, in their worst and most revolting state, add, in an Appendix to this Essay, about twenty of the oldest in age as well as in the duration of the disease, and of course of the most incurable cases, taken in regular rotation from the Register Book of the oldest Asylum in the kingdom, excepting Bedlam; containing, at the time the living characters were described, about one hundred of the same class. Now though these are taken from among those who had suffered all the brutalizing influence of the oldand neglected system of treatment, yet they do not, as a whole, exhibit so shocking a picture as previous popular prejudice would imagine. Notwithstanding this truth, it is proper to state, that they are incomparably a worse picture, than the same number would make, taken with equal fidelity and correctness, from among my own patients, admitted within the period of my own exclusive superintendance,—this would, therefore, be much better calculated to correct this injurious prejudice than that which Inowgive for this purpose: but they are too recent to be so introduced; yet as this would be a very striking contrast illustrating the effects of different treatment, I shall be prepared, should I live long enough for time to throw his dark veil over their memory, with the same number of cases, taken and described on the same principle.
I am the more anxious to do this at present, and fulfil this my future intention, because it may perhaps be laid to my charge, that in adducing cases illustrative of the principles contained in this Essay on Classification, as well as those which, from similar reasons, I may have hereafter to introduce, that I have been guilty, and may be guilty of the same error of selecting peculiar and extreme cases for my purpose; but I have been led into this, from the feeling that circumstances had forced upon me,however contrary to my previous intentions, something of a defensive attitude.
These are the reasons which have been my inducements in adding this Appendix; at the same time, to make the cases, in this naked form, as interesting and as useful as possible, I have not only drawn them with the most minute attention to truth, but to each I have appended some appropriate and useful observation.
Previous, then, to my entering upon the important subject mentioned at the end of this Essay, I shall now introduce these cases as a faithful portraiture of the Insane.
Thereis nothing recorded of this case, from which any correct information of the causes of the malady, or of its nature, when admitted, or of its progress since that period, can be drawn. Some of his relations are insane, and many of them exceedingly eccentric. His friends accuse some nurse of an improper application for the itch; yet, notwithstanding this accusation, the disease was gradual in its approach. He was gay when at Cambridge, and lost considerable sums at the gaming table. There is reason to believe that he had always been eccentric; and I have been told, that in his youth, he was proverbially called the proudand polite man.[114a]Whether this be correct or not, it is certain, that even now, though so little mind remains, he is soonest roused and offended, though otherwise very good-natured, by whatever questions his own importance.
Though, like many old men, he is fond of dozing away his time in bed, he has, notwithstanding, seasons of greater animation, when he seems more busily occupied with his own thoughts, often talking to himself; repeating very correctly passages committed to memory, probably forty years ago.[114b]
At these periods, unless teased or vexed in the way already stated, he is very good-natured and polite; and from his general manners, and particularly in the modulation of his voice, he still appears, in spite of the coarseness of his dress,[114c]the remains of a perfect gentleman. At these times, he is, for the most part, very happy, laughing and playing like a little child;and his very mischievous tricks—throwing stones, writing on the walls, tearing his clothes in order to make some little fanciful change and decoration of his dress, seem to be done rather as resources for regular employment or amusement, than from any malicious design or delight to be mischievous.
The slight changes or states of excitement described in this case, are in my opinion, the mere fluctuation of his animal spirits. I shall hereafter make further remarks (see ob. 5) on this subject; and therefore, in the mean time, (to obviate the objections which may be brought against this view,) I shall only observe that when we consider the defective and uncontrolled state of mind,[115]in these old and incurable cases of insanity, any change or increase of their animal spirits must, though perhaps depending on causes which equally affect the sane, display itself in them, in a very different manner.
There is no statement of this case on record, from which any satisfactory information can be derived; nor have I been able to obtain any account of his former life, or the nature or treatment of his case. There has been nothing of late years to distinguish his case from many old ones, whose minds have sunk into the torpid state, except it be, which is scarcely worthy of notice, that he has sometimes stood on his head to say his prayers; sometimes spit in his pocket; and, when provoked, used indecent language; otherwise his state of mind has not, for many years, exhibited any observable alteration.[116]He will be best known when I say, that he is singled out from the rest, as a little, timid, old-looking man, uniformly sitting in a moping, creeping posture.
No. 2 page 116
This man is not more of an idiot than the one just described, yet there is much less appearance of mind about him; but his mental powers had not formerly been so much evolvedand improved by education; and the mind, like the soil we tread on, once properly broken up and cultivated, will, in defiance of neglect, long retain traces of its former improved state. Besides his want of early culture, being one of the middle class of patients, he was wholly left without mental food or exercise. There was, under the old system, a complete sacrifice of the lowest, utter neglect of the middle, for the sake of the higher class of patients; so that there was, with the middle class, for the most part, no intellectual interest excited by social converse and attention; nor, on the other hand, were the malignant passions kept alive by brutal treatment: and hence we now find amongst this class, the greatest proportion[117]of those whose minds have sunk into torpid inactivity; and not so much because they are lost, but because, from their want of excitement, they have too long continued in this motionless state. It is true, that their minds may, by the first attack, have undergone some great shock, to derange or paralyse the more perfect performance of its functions; but it is certain, thatafterwards, no means were used to resuscitate or feed the powers of the mind into renewed vigour and activity. Few, even in the perfect possession of their faculties, could bear to be excluded from the air and sunshine of social life, and mingle only with beings in this melancholy state, without feeling its effects upon them. We are not to wonder, then, that those whose spirits have thus been prematurely entombed within them, should have become almost as dead to themselves and the world, as if the soul had already left them. To prevent these consequences, I shall state all that I think ought to be done, in another number of this work; which I conceive is the most interesting part in the treatment of insanity.
There is nothing on record about this case, nor have I been able to obtain any information of his previous history.
His mind is not in so defective or deranged a state, as strangers and superficial observers are, from appearances, apt to imagine. It is true, he seems stupid and churlish, always silent unless spoken to, and then he answers with abruptness and impatience, in a murmuring, grumbling, and almost unintelligible manner, putting his words oddly together, like a child,or one unused, or too lazy, to articulate, and not that his answers are absolutely irrational.
No. 3 page 118
He plays well at draughts and whist, but his doing so appears to depend more on old habits,[119a]than on the present exercise of his faculties; which, though, as already observed, they are not wholly lost, yet, from his torpor, age, and the natural obstinacy of his disposition, he is disinclined to exert himself out of his usual course: and though his constant habits of employment and amusement in the house, make up for him a considerable stock of felicity, and aid in procuring the degree of health and spirits he enjoys, and the degree of mind he still possesses; yet he is so extremely obstinate and tenacious of his own mode of procedure, that any attempts to oppose him, will arouse his temper into fits of angry passion.[119b]
There is nothing particular to observe here, unless it be the obvious remark, that from his age and confinement for such a number of years, among beings who, for the most part, have no commerce with right feelings andthoughts, it is wonderful that any thing like powers of mind should still remain; or that he should, excluded from the excitement and collision of the world, possess any inclination to exercise them; but this is most probably owing to the amusements and employments already stated; and for the sake of drawing attention to this fact, have I been induced to make any observation on this case.
There is no statement of this case on record; but I have been informed, it was the consequence of injury on the head. He is a hopeless, and the most striking, case of idiotcy, at present in the house: a poor, simple, innocent, dangling, pouting, starved-looking creature, with a bluish red nose, and his head hanging forwards, saliva running over his falling lip—generally moving about to gratify his childish curiosity. Yet, as little mind as there is about him, still even he has fluctuations of the animal spirits: sometimes he is depressed and miserable; at other times he is animated and happy. When depressed, he for the most part repeats, in a feeble, plaintive tone,—“poor creature.” When animated and happy, he will throw his arms about in a most laughable manner, to the great amusement of other patients; so muchso, that it is impossible to convey any conception of it, unless it be by making an old person try to imitate the frisky movements of an infant’s arms. These exhibitions are of rare occurrence. He will mumble over a tune very correctly,[121a]but has seldom any words. He is pleased with striking objects, particularly such as have glaring colours about them; and women, or their dress, arrest his attention.[121b]
No. 4 page 120
There is likewise no statement of this case on record, from which any satisfactory information can be drawn.
His personal appearance, and moping manners, were so very like the case described, No. 2, that it was common for those in the house to mistake the one for the other. He, like many other old and incurable cases, sat in a solitary, half-dozing state, his head reclining against the fire-guard, and seemed, when roused, like one who wakened out of his sleep unrefreshed. He was most remarkable for his extreme goodnature, and excellent disposition.[122a]When on his death-bed, his gratitude and affection to his attendant (who was certainly an excellent nurse) were very pleasing. He had been long sinking from disease of the lungs, constantly coughing and spitting; and, latterly, purulent matter, in a very great quantity. He died on the 13th April, 1822.
There is no statement of his case, and I have not been able to collect much information about him. It is said, he received a severe wound, and the mark remains on the upper back part of his head.[122b]Report says, that he fancied himself in love with a farmer’s daughter, and walked whole nights before her father’s door, without the slightest previous acquaintance with the object of his choice. This would seem rather the effect than the cause—a common mistake; they are constantly confounded together, or mistaken for each other. It is certain, that his neighbours were obliged to send him to a place of confinement, for thisreason—whenever he saw any cattle in a poor pasture, he, from the impulse of his nature, invariably removed them into a better.
No. 6 page 122
He is well known through the house, and even through the town; and on this account, I feel some hesitation and difficulty in attempting to describe his case.
He is a general favourite, and every one meets him, and he meets every one, with a welcome, good-natured smile, and he appears so much pleased to entertain them with some extraordinary ridiculous tale, that a stranger would suppose he talked absurdly, on purpose to amuse him.[123]Notwithstanding all his talk, he is most industrious, and the most useful man in the house; does his work most correctly and systematically; delights in going upon errands amongst his acquaintances in town, always delivering the messages properly; and the moment he has done so, begins with his own strange nonsense, to the great delight of his hearers. His spirits are always even, he has regular exercise, and his good nature is proverbial; nothing vexes him, unless it be, threatening that another shall be employed instead ofhim, to do the work he has been in the habit of doing for his favourites in the house.—His delight is, night or day, to be of service to others, so that his energies are wholly and regularly expended in being useful, making himself happy, and pleasing all who come near him.
Probably his astonishing correctness in delivering messages, &c., in the midst of so much apparent confusion of mind, may be thus explained:—From the pre-eminence of his good nature, the desire to please still retains some hold over the rest of his faculties, and, perhaps, also over the extreme extravagance of his conversation, which may arise from the same cause. We have only to imagine, that his erroneous tales were, in the first instance, listened to (a fact, this, of injudicious treatment, which is too common,) with seeming assent and delight, until he found, from daily experience, that to please others, he had only to encourage his foolish thoughts, and utter them, and then the habit would insensibly grow upon him, until it became inveterate; and hence is explained another singularity about him,—that in his present manner of talking, it appears as if he were talking absurdly for the very purpose of amusing others. It is now, however, certain, thatit would be not only useless, but cruel, to try, by direct means, to prevent it. Yet, though we are not to tease and vex him, by contradiction, or by refusing to listen to his tales; it ought to be remembered, that in this and all other cases, we ought never, on any account, to violate the truth.
Though we should never forget to exercise prudence, we must be careful that truth still presides at the helm, otherwise it may degenerate into cunning; then what we call prudence, is vicious and mischievous; and yet, men persuade themselves while doing so, that some evil is avoided, or some good is secured. No power of the mind should ever be so exercised, as to require the suspension or sacrifice of another. To exercise every virtue in its place, and to give to each “its relative and appropriate share,” is the perfection at which we should ever aim. This principle, as it is the best prevention, so also it is the best remedy in the cure, of insanity.
No statement of this case, from which any information can be drawn: it is, however, certain, that insanity is in the family.
Among the old cases, we have none that arrests the attention of strangers so much asthis, and he never fails to attract the gaze of idle curiosity. His habits of circumgyration, with sudden stops and starts,—his strange air of abstractedness, a sort of excogitative look, apparently puzzled to find something out,—odd way of talking to himself, as if he himself were some other person, saying, “what a noise the fellow makes,” “I think the fellow’s a fool,” and striking his face in apparent anger,—strange mode of mentioning names once familiar to him,—putting a question,—seeming to listen, and giving an answer quite foreign to it, are most striking, and such as no descriptive powers can enable another to conceive, without seeing him. When noticed or teased, and sometimes without, he strikes and scratches, in a way that would seem either like a bad habit that had been taught him; or half frolic and half mischief, and which, by provocation, becomes more serious; otherwise, he is sensible of kind treatment; and now, from increasing age, and perhaps from being, on the whole, less teased, he exhibits less of this disposition. This state of continued exertion and restlessness, is followed by a proportional degree of depression, and, after being recruited by sleep, returns. These regular alternate states of excitement and restlessness, of depression and sleep, last each for several days, and this for many years’ duration. When most excited, hemakes a strange loud singing noise, stamps with his feet, strikes his head and face, and exhibits various incommunicable indications of surprise, pleasure, or anger, just as his mind happens to be agitated, like one in a dream, with the floating and shattered images of times gone by, passing confusedly through his mind.
I am unable to ascertain, from any traditionary treatment of this case, whether the habit of gyration originated in some diseased imagination; or was merely, as I believe is more frequently the case, a habit which he had acquired from long confinement in a small space. This habit was common in former times, when they were confined in cells, and had no airing grounds; and yet some writers, without attending to this circumstance, have called it a symptom common to insanity! in this way, many things have been called symptoms, which have been, in fact, indications of improper treatment. The peculiar states of excitement and depression, so striking in this case, and which is so common with the old insane, as to have been called the chronic type of the incurable, I shall endeavour to show, how, in many instances, it may be explained on a different principle.
Dr. Halloran, in his practical observationson Insanity, says,—“Chronic insanity is that form of the disease, which, having passed through the acute and convalescent stages, has assumed the more permanent character, and is known by the frequent exacerbation of the original accession; also, finally, under circumstances of less violence, and with symptoms subacute in relation to the primary affection.” He adds,—“There are few Practioners of the most ordinary discernment, who will not feel themselves disposed to acknowledge that cases of insanity, precisely of this form, compose the greater majority of those committed to their care.” He further says,—“That these paroxysms are for the most part periodical in their approach; for though of shorter duration, they continue pertinaciously unyielding.”
From the observations which I have to suggest, it will be seen, that I conceive in some instances, in opposition to Dr. Halloran, and some others, that the chronic type, or the paroxysms of some of the permanently insane, are merely an exhibition of the irregular increase in the stock of their animal spirits, and not an exacerbation or new accession of the disease: and that even, in many cases, where the alternating changes of excitement and depression are most striking, I believe they first originated in those fluctuations of the animal spirits, common to all of us; in someinstances, it is true, (and the case last described is one,) singularly modified, not merely by the state of mental alienation, but by circumstances connected with their confinement. Before, however, I endeavour to explain these singular modifications, it appears necessary to premise some observations on one of the causes which conspires to produce them, which cause is connected with the atmosphere.
But as I intend to devote an Essay on Atmospheric influence, I shall content myself with asserting, in the mean time, that there is some common cause, or causes, assigned either to atmospherical changes, or co-ordinate with these changes, affecting the animal spirits of the sane and the insane—of the healthy and diseased, (in all, the manifestation is according to individual state,) is generally, and indeed, I might perhaps say, universally admitted, that the fact will require no further proof, either to introduce or confirm its truth. There is then a certain periodicity in the excitement and depression of our spirits, as well as in all our diseases, mental or corporeal, so absolutely certain, that it must be the conjoined effect of some order in the operations of nature, and cannot be explained on the principle of accidental or apparent coincidence, by which credulous and superstitious minds are often deceived.
Though the artificial habits and constitutions of men must modify these influences, we still, notwithstanding, often perceive the effects are simultaneous in time, and sometimes that they preserve the same type, and as such artificial modifications do not exist in the same degree in the animal creation, especially in those undomesticated, on the contrary, these influences are so uniform on them, that the signs and symptoms of their presence are the barometers of rural life, it follows that these very modifications in men, when rightly perceived, are additional proofs of their being the effects of one cause.
Even in man the influence of seasons, climate, and all violent atmospherical changes, are so striking as to be admitted by all, because they are so powerful as to overwhelm all artificial counteracting modifications; but, as it regards all common and minor influences, even when the effect on the mass are coincident in time, they are in individuals so modified by the specific habits, the state of the health, and the peculiar state of mind, that they become so much disguised, and of course so much less obvious to common observation, that even some medical men will deny atmospherical influences altogether when held forth as objects of scientific investigation, and ridicule as fanciful the man who maintains a firm and well-groundedphilosophical faith in them; this is most inconsistent, and is like admitting a clock may mark hours, but cannot mark minutes as they pass.—It is the child who has just discovered the use of the hour, but not of the minute hand, of a time-piece.
The philosopher knows that the unobserved and silent influence is the most important, and that the striking results are the mere indexes of its secret movements.
Let ignorance pretend to admire these striking results, and laugh at him who is anxious to discover the cause which produces them; he has incomparably more interest and pleasure, his eyes more open, and his understanding more exercised in these common facts, than other men, while yet he deems them as nothing compared to the end they serve; they are indeed interesting in themselves, but to him they are most interesting, because he considers them the means, but still only as the means, by which he obtains the noblest object which the light of his reason can discover—the discovery of those principles, or of that order of operation of the cause which produces them.
Medical libraries are full of books on the influence of seasons and climate, miasmata, malaria, and other local causes of disease: and they admit also that the influences of all these are such, that almost all diseases commonto man will exhibit altered and corresponding symptoms under these varying circumstances, proving they participate in, and are conjoined (or “tinged as it were,” as it is said by some,) with them.
All this, however, I leave for the Essay on the Atmosphere, but I mention these facts and observations in the mean time for the sake of this argument, that if all these modifications are admitted to exist among the sane, how much more strikingly must the peculiar circumstances, the singular habits, and the altered state of mind of the insane, modify the effects of this influence:—so strikingly, that I have no doubt, from these causes, may be explained the very singular exhibitions in this last-mentioned case. Where the particular state of mind, and the peculiar circumstances connected with his confinement, have superinduced in the system the irregular accumulation and expenditure of the nervous energy, so that, though the increase of the animal spirits was, in the first instance, the common effect of a cause operating in and through all, every where,—yet, operating through, and modified by, the peculiarities connected with his case, has in time produced in him, as well as in a less striking degree in others, and in fact, in many, though certainly not in all cases of insanity, effects so very singular and striking.
Again, these changes of the atmosphere, which produce these effects on the sane, seem, on the insane, in many cases, to be wholly expended in producing fluctuations on the animal spirits (not in bodily effects,) so expended, as if this increase of the vital energies were neither subject to the usual laws of corporeal nor intellectual distribution. These insane, consequently, are less subject to disease from these causes, as if they, no longer responsible, paid not, therefore, the price of the use and abuse of the energies continually imparted to all. It is true, that the life they lead, not only removes them from many causes of disease, but the very nature of their diseased state, also, renders the mind more susceptible of impressions, for, beside their excited state, by being shut out from the world, they necessarily give to trifles all the importance of weightier matters, and thus it is, that by their being the victims of mental excitement,[133a]which is every where a protection against prevailing diseases, they are not so liable to be attacked by the prevailing epidemics.[133b]
Whatever influences prevail externally, they must in all cases, sane and insane, be counteracted and modified by internal influences.
But to enter upon this investigation is not at present my intention, therefore I shall not now examine the question, whether the epidemics of different times, and the character of all diseases, which always partake, more or less, of the prevailing epidemic, can bewholly[134]explained as being caused by some difference in the prevailing state of the weather. I shall only remark that it is certain such seasons and states of the weather are equally fruitful in the production of insanity and in the excitement of those already insane. Yet, from these internal mental or moral influences, it is evident that neither insanity nor epidemic diseases can prevail exactly in proportion to the state of the weather, unless it could be proved there always existed a correspondence between the state of the weather and the moral and physical susceptibilities or predisposition of the persons exposed to its influence.
At the same time I assert that our moral state has more to do with disease, either directly or indirectly, than is generally credited, yet these moral causes are necessarily every where physical in their operation, so that the assertionthat our physical corresponds with our moral state, and what we call physical causes are the effects of this state, need not alarm us, in fact, the interesting truth is now demonstrated,[135]that health and longevity correspond with our moral state, (though this is true as a general principle, there are many real and apparent exceptions,) in fact, natural and moral effects co-operate, just as the circulation depends on the nervous energy, so the nervous energy depends greatly on our mental condition.
Whether, however, the causes of diseases are more of a mental or corporeal character, is not now the question to decide.
For though in the Essay I propose to give on atmospheric influence, I shall endeavour to point out the various causes which may give rise to an irregular display of the spirits of the insane, I am far, however, from denying, that there are alternate states of excitement and depression, of better and worse days, which we may not be able to trace to these causes, but which may depend on principles similar to other physical intermittents, just as we have periodical head-aches, having their accession and intermission most frequently every alternate day, and yet, even in these cases, I have been able to discover the origin of these head-aches, aswas my own case, to alternate sleepless and distressing nights. Looking at these periodical exacerbations of insanity, without tracing them up to their first causes, they seem like the operation of some disturbing cause, requiring a given time to arrive at their crisis, or to produce the effect, and when produced, to subside again, and this cause, thus viewed in its less remote operation, seems altogether of a physical nature. But this periodicity, which I also advocate, will be more fully examined in the third section of the Essay on Atmospheric Influence, in which some observations will be ventured on lunar influence.
Let the reader in the mean time take it for granted that such an influence exists; we shall then be able to examine the modifying influence which the peculiar state of the mind, in each, among the insane, must have over their manner of exhibiting these alterations in their animal spirits, especially among the old incurable cases, labouring, as it has been said, under the chronic form of insanity.
Often, after the first attack, their minds are left in an imperfect state; yet, notwithstanding this inability to discharge the functions of mind properly, they generally retain their physical energies, enjoy vigorous health, and, of course, the flow of their animal spirits dependent thereon, is more likely to be improved thanotherwise; with respect to mind, however, they not merely want volition, and the common motives and principles of control over themselves, but there have been circumstances connected with their confinement, which, co-operating with the excitement, (the cause of which I shall hereafter attempt to explain,) have formed in the system regular periodical returns of these states; so that, at these periods, they not only, more obviously, exhibit these changes in their spirits, and, of course, display without disguise, their peculiarities of mind, as children do, and sometimes as even men do, when warmed with friendship, or with wine; but they also do so in a higher degree, and, of course, with all their latent imperfections of mind, in a much more striking manner; they then “show themselves,” their peculiar character and defects; nor should this explanation of the periodical return of these states of excitement, from the above-mentioned co-operating causes, surprise us; we may every day witness the operation of the same principle, among men possessed of reason.
We all know, whoever gratifies any passion, or accustoms the system to any artificial stimulus, at stated periods, invariably finds the difficulty of resisting this passion, and his inclination for this stimulus greatest, at the usual period of gratification: and so it is with theexpenditure of animation; in fact, nothing is more certain, than that both mind and body become the slave of those customs, which the manner of our living, and moral conduct, and the circumstances through which we have passed, have fastened around us. Now, as the circumstances and treatment of the insane, have hitherto been different from common life, (the object ought to be, in the treatment of the insane, to resemble common life as much as possible;) and as they are without control over themselves, their mode of displaying their more animated state, must be as different from the civilized man, as the civilized man is from the savage. If, then, habits of civilization may be called a second nature, here it may be said, that a third has been superinduced.
From these circumstances and states of mind, it appears, that, instead of their stock of animal spirits being expended, under the guidance of a moral agency, and regularly diffused over their existence, they are subject to mere physical influence, and become the sport of every eddying wind that blows; and therefore we find every possible variety and irregularity exhibited.—A perfect contrast to that of the good and wise man, if such a one can be found, whose balance of mind is preserved, whose spirits are tranquil and even, who enjoys perpetualsunshine within, and diffuses peace and serenity around him.
Thus, because when their spirits are buoyant, they strangely exhibit their inherent defects of mind, it has in many instances been mistaken for an exacerbation or a returning accession of the disease, and called the chronic type of old incurable cases.
It further appears, that this view is correct, from the fact, that if their manner of talking and acting, in expending their increased flow of spirits, is improperly encouraged or exasperated, then we find their individual and latent defects become more obvious; but with proper treatment, they gradually die away: in fact, these appearances are more or less perceptible, in a great measure, according to the spirit and conduct of the superintendant; and even, under him, to that of their respective attendants. Of this, I could give some striking illustrations. It is astonishing how much the increased flow of the spirits will be dark, gloomy, and vindictive; or light, cheerful, and full of kindliness; just as we by our treatment excite and keep alive one part of the mind or another. The same principle might be illustrated also, on a larger scale, by surveying the conduct of different parties and governments in the world; and on a smaller scale we see every one in authority, a magistrate, a gentleman, a minister,a pastor, the captain of a ship, and a parent, stamp their character on the sphere in which they move.
Were it the place, nothing could be more instructive than examples to demonstrate the correctness of these observations.
The preceding case, I consider, is one of these examples. I have said, that for the most part, these states of excitement and depression, are merely an irregular exhibition in the accumulation and expenditure of the animal spirits, and not always to be considered, according to Dr. Halloran’s view, as the remains of the disease in the state of a returning paroxysm, and that which characterises the permanently insane; but that this originated in, and depended on, causes which equally affect the animal spirits of the sane and insane, with this difference, that in the insane, as in this case, they are modified by the peculiar state of mind, and the sort of treatment they have received.
Grant that, from the state of his mind, any little increase of animation would resemble, in a slight degree, that which he now exhibits, then I am, by the help of facts, in this and some other cases of a similar nature, justified in saying, that I have been able to trace the process and progress of these changes, from small beginnings to their present state. Iknow, from the best information, that his manner and appearance were, when excited, so laughable and striking, that the attendants and their friends, from want of proper feeling, or perhaps mere thoughtlessness, actually made him a source of private sport and amusement, and thus increased his excited state, which, in the course of time, assumed its present peculiar and amusing form.[141]
A minute detail of all these things, together with unnecessary and injudicious confinement, I am certain, would prove all this.
In many cases, and especially in the last, I have been able to trace, as I have already said, the process and progress of these changes, from small beginnings to their present state. In some cases, any little increase of animation gave rise to manners and conversation, which were extremely amusing, and such as tempted silly and unthinking people, as well as the other patients, to encourage by listening or assenting too much to them, or to exasperate by wantonly making them a source of sport and amusement; conduct which cannot be too strongly deprecated, especially during the critical period of their convalescence.