Many instances are recorded, of two opposite cases, by being thrown together, neutralizing, like an acid and alkali, each other; that is, the melancholy have been roused by the lively, and the lively depressed by the melancholy, and thus both have been brought into a better state.
Sometimes the insane have been cured by witnessing their own case caricatured in that of another. For instance, two proud men, the victims of their gradual and progressive false estimate of themselves, assume in their insane state, the same crown and kingdom, and by witnessing each other’s delusion, have been forced to feel that one must be in the wrong; and thus, one or both were brought to reflection, and ultimately to a more sound and sober state of mind.
Even the imbecile and idiot, are roused andimproved by such associations, more than they had been, even with every endeavour to improve them, while they were in a state of seclusion. I have lately had two very remarkable instances of this kind.
Imbeciles, though they were from birth, they improved after their arrival; the scene was very different to the solitude in which they had been placed; the common scenes and circumstances of life, had not had sufficient power to rouse the dormant and torpid state of their mental functions, while scenes and circumstances, that are in themselves very painful, were better calculated to arouse in their moping minds, something like feeble efforts of reflection. I have seen them behold the strange antics of others, with intense wonder and interest.—Often they will catch the contagion of laughter; and thus if the understanding has no part in the matter, their spirits, at all events, partake of the merriment of the scene around them; and though insanity, considered in the abstract, is a melancholy thing, yet it is a truth, that there is much more of merriment than melancholy among the insane. I believe their average of happiness is greater than would be found among the same number in the world. Those who look with prejudice from impressions receivedfrom a few extreme cases, of course make out a different conclusion. Again, there is another consideration, which further proves that the happiness of these imbeciles and ideots may be increased by such association. They have still the blind affections craving for food, and they here find food for their gratification, better suited to their state than they could find it in the world. These affections without understanding, are to the world repulsive. It is strength of affection, guided by strength of understanding, that so powerfully attracts and binds society together. In this sphere they cannot revolve; here, eccentric as it is, they have one better suited to their state.
I daily see ideots and imbeciles taught to walk arm in arm; evidently pleased and gratified that they have objects for their blind affections to rest upon. Besides this, it is a very singular and remarkable fact, that this exercise of their affections, has contributed to the improvement of their physical state. Whatever increases innocent enjoyment, and contributes to happiness, are excellent medicines. Peace and purity of mind are better than physic. This exercise of their blind affections conduces alike to their felicity, and to the preservation of their health, by innocently keeping alive the regular and happy exercise of their animal spirits, by the only outlet they possess,that of their blind and instinctive affections; and hence, it is very remarkable, that in consequence of their animal spirits being no longer pent up, as was formerly the case, they are not now so liable to those sudden bursts and irregular displays of passion, to which they had been the victims; and what is still more remarkable, they are in better health, and not so liable to cramps and colics, which had been the corresponding physical effects of their irregular nervous distribution; so that even with them the truth is evident, that it is not good to be alone; the little world they live in is better suited to amuse and contribute to their happiness, than the quietude of civilized life, from which they could receive no enjoyment, and to which they could only give pain.
It is also worthy of remark, that some patients sink more rapidly into moping idiotcy when kept in a state of perfect seclusion, than they even do in the society of those who are insane like themselves.
I have seen patients who had not been accustomed to any association, who were, on their first arrival, in appearance, manners, behaviour, especially in their mode of eating, and their dirty habits, scarcely human; it was evident from all this, that they had long been unaccustomed to the common conveniences and decencies of life, as well as from the astonishmentand delight they first exhibit, on these things being restored to them;—to see companions, and to find a table with the usual appendages of knives and forks, &c. evidently excited pleasing reminiscences and gave them additional life,—their improvement (externally, at any rate) was rapid, and, by continued attention, their restoration to habits of cleanliness complete.
To insure all these as well as many other advantages, and to make cure the primary object, requires not only that the proprietor should live amongst them, but also that he should be a medical man, and one who has experience, guided by upright principles and Christian feelings; for if medical men of talent and character could be induced to undertake this painful and anxious life, submitting cheerfully to all these sacrifices and inconveniences, much might be done to improve this neglected department of medicine, and augment the number of cures; at all events, most certainly increase the comforts of the incurable, and lessen the distressing apprehensions of those who fear the accession, or recurrence of mental aberration; yet notwithstanding the paramount importance of these things, so ignorant or so blinded by prejudice is the world on the subject, and so little aware of the talents and capabilities required for such a situation, that they consider the very name of a proprietor, and superintendant of an asylum, as absolutelysinking the character in public estimation; whereas no class of medical men, were they efficient, should be considered more honourable, because none can be more useful than those who devote themselves to the cure and comfort of persons in this most lamentable state.
When the gloom and horror at present thrown around establishments for the insane shall be cleared away, Dante’s inscription over the gates of Hell, will be no longer applicable to them,
“Lasciate ogni speranza, voi, ché ntrate;”[55]
“Lasciate ogni speranza, voi, ché ntrate;”[55]
this, or perhaps another passage from Euripides, has been imitated by our Milton,
“Here hope never comes, which comes to all.”
“Here hope never comes, which comes to all.”
They will be considered houses of cure, or hospitals for the insane.
The erroneous and false impressions, concerning the character and state of the insane, will be corrected. The popular impression, that they are all violent and vociferous, destructive and dangerous, will be removed. Hitherto medical writers, by selecting the most striking cases, have contributed their share to this popular error. They have been led to do this, partly because they are cases, which more naturally arrest their own observation; but chiefly, because they are more easily described; make amore interesting picture, and are the most curable. A statement of the recovery of such patients, though it may serve to exalt the writer in public estimation, is wrong in itself, and very injurious in its influence; for it increases the unreasonable horrors and false impressions entertained about the insane, and propagates and perpetuates the evils of which the public and legislature complain. They receive impressions from extreme cases, which average about five per cent. then speak just as if all the insane were in a similar condition.
Mr. Samuel Tuke says, “Many errors in the construction, as well as in the management, of asylums for the insane, appear to arise from excessive attention to safety; people in general have the most erroneous notions of the constantly outrageous behaviour, or malicious dispositions of deranged persons; and it has in many instances, been found convenient to encourage these sentiments, to apologize for the treatment of the unhappy sufferers, or admit the vicious neglect of their attendants.”
In the construction of such places, cure and comfort ought to be as much considered as security; and I have no hesitation in declaring, that a system which, by limiting the power of the attendant, obliges him not to neglect his duty, and makes it his interest to obtain the good opinion of those under his care, providesmore effectually for the safety of the keeper, as well as of the patient, than all “the apparatus of chains, darkness, and anodynes.”
“The safety of those who attend upon the insane, is certainly an object of great importance; but it is worthy of enquiry whether it may not be attained, without materially interfering with another object, the recovery of the patient. It may also deserve enquiry, whether the extensive practice of coercion, which obtains in some institutions, does not arise from erroneous views of the character of insane persons; from indifference to their comfort, or from having rendered coercion necessary by previous unkind treatment.”
But there is another fact to be considered, not hitherto contemplated by any writer, and which is well expressed in a letter I received from a friend, in answer to one requesting his opinion in a case[57]wherein its importance has been shown to demonstration. He says, (and he is a man of great humanity,) “I am most solicitous that the distinction should be understood between those who cannot act and think or decide for themselves, and those who can, and who, sensible of their defective state, or of the approach even of absolute derangement, can of their own free will, place themselves in a situation, where they know that every medicaland moral means will be used for their restoration. It is of the utmost importance, that the legislature should have it completely demonstrated to them, that there is a condition of the insane never contemplated by any legislator; the judicious management of which, is of the greatest consequence to them. Instead of the mental malady being allowed to proceed, until the sufferer is introduced into these retreats by force, its first approaches will be yielded to as soon as recognised, and the unhappy individual, whilst still in the possession of reason, will voluntarily or by gentle and affectionate solicitations, enter some refuge for mental distress, where, separated and secluded from the scenes and circumstances which were hurrying on intellectual destruction, he may, in a short period, in a condition of comparative happiness, escape the most tremendous calamity with which human nature can be assailed.”
I believe all the former evils connected with the management of the insane, have arisen from ignorance of their state; and therefore I am anxious to be perfectly understood, and labour most earnestly to correct this erroneous impression; and not only so, but I wish to prove the popular prejudice, that they are all ill treated, to be no where, as far as my knowledge extends, true or deserved; neither am I aware that this branch of medicine has been more abused than others; nor do I know inall my experience, of any unjust confinement for interest’s sake; there may be ignorance of the treatment required, but surely in these enlightened times, a medical man of any character can never lend himself to any thing so suicidal to his own fair character and prospects. I know, on the contrary, of evils arising from over caution in the other extreme. I am perfectly convinced that no insane person, should be without medical superintendance, and that to be placed singly in private houses, not medical, I know from experience to be sometimes most fatal and destructive; some few, it is true, are above all praise.
Sir Andrew Halliday after stating the number of insane, who are known and registered according to act of Parliament, says, “there is a number, if not equally great, at least nearly so, of whom the law takes no cognizance, and whose existence is known only to their relations and friends. These consist of individuals placed in solitary confinement, with persons who take only one patient. This is a state of things which ought not to be allowed to remain as it is, for a single hour, in this boasted land of liberty; I do not say, that it ever has taken place, though I have known one or two instances that might almost bear such a construction;—but I maintain that it may take place, for there is no law to prevent it; thatindividuals may have been sent into such seclusion, who never suffered from the pangs of madness; and it must be evident to every one who gives this subject the least consideration, that it only requires a faithful keeper, and that watchfulness, to retain such a person in prison for life. This number is said to have been prodigiously increased by the new Act.”
At the same time it must be allowed, that many incipient cases, requiring seclusion and separation from friends, would be aggravated by too sudden an introduction amongst masses of insane patients; and even by the very circumstance of arriving when there is the chance of exciting the usual horror and prejudice entertained against such places; but this ought not, and would not be the case, were the plans and systems of classification I have advocated, carried into practice. Every way and in every thing, we have imperfections and abuses; and it is much easier to condemn than to cure them; and they who at once believe abuses exist in proportion to the popular description that is given during some temporary excitement and prejudice, are not safe persons to have the important charge of removing them. I make these remarks, to show, that while a paternal government is justly, most anxious to protect the persons and property of those who can no longer protect and defend themselves, theyshould at the same time remember, that sanity of mind is still of much higher value; and that therefore concern about the property should not out weigh our concern for the cure.
I say nothing in the mean time, of the degrading suspicion and paralyzing interference, which the best and most conscientious man may under such system feel, in proceeding with the plans which, he from experience, knows to be essential to their restoration; but I contend, that thecommon error in legislation,of making property of more value than life, must here as well as wherever it is committed, have a baneful influence. In this instance, the acts or laws made under the influence of this very great and very selfish delusion, produce this very serious mischief, that they tend to increase the prejudice and aversion common to places of this description, some of which would otherwise be considered not merely unobjectionable places of residence, but places of seclusion, very agreeable in themselves, and most desirable as places of cure.
In many complaints, change of scene and association, are justly considered necessary to the restoration of health. It is not only the same in many cases of insanity but absolutely the first and most important step in every system which gives them a chance of restoration. Should then a bare residence in any place for the mere purpose of cure, be accompanied (invery many cases, it is unnecessary,) by an act which is considered as fixing the mark of degradation upon them, any more than it should in any other disease? This, instead of healing, is calculated to crush a heart already breaking; it is often fatal to their recovery! it is a principal cause of frequent relapses! They feel a stigma, thus fixed on their character, so confirming the prejudices of the world, and so encouraging that distressing and fatal look of suspicion towards them, that they are forced to feel that no one reposes any faith in them; and if this feeling does not ultimately destroy all comfort and confidence, all order and stability within them, it must very much weaken that concentration of energy so necessary to the successful exercise of all mental operations; and if their minds are weakened by previous attacks, and not well sustained by right principles, but on the contrary, like many others, merely regulated by worldly principles and considerations, then, they are not only deprived of the rock on which mind is based, but also of all the motives and objects which stimulate to mental action. In this state, what is mind but a sad wreck floating on the fathomless ocean of life, at the mercy of every wind and wave? To what else shall we compare its situation?—It is like a city broken down and without walls, any enemy may enter in, and overthrowit. Can we wonder then that persons whose minds are in this position, and whose prospects in life are thus blasted, should have a recurrence of the same awful visitation? or what is worse, that they should constantly feel their spirits paralyzed, and a melancholy gloom thus thrown over the remainder of their existence!
To make it necessary in all cases to have certificates, so far from being a security against abuse, is more likely to be a cloak for those who may wish to take advantage of the patient’s defenceless state; whereas in cases of voluntary seclusion, there can be no risk; for with such honourable confidence, we have at once, the proof and the security that it cannot and will not be abused. These, however, are not the most desirable inmates, as it regards the ease and comfort of the superintendant, and therefore no one can have any other motive in recommending this practice of voluntary seclusion, but that which arises from the conscientious consideration of its being more conducive to cure.
That all should have the sanction and concurrence of medical recommendation, is every way indispensable; but what I argue for is, that this should be done, in the manner best calculated to make it appear to the patient, that cure, and not mere confinement, is the object of the measure they are recommended to accede towithout reluctance. That a great number will require certificates, and all the aid of authority, to make them submit to the measure, is certain; and in these cases, the law, so far from being a hardship, is a great convenience and advantage.
Again, violent and extreme cases may be said to certificate themselves, in these there can be no risk of making any mistake, and doing any injustice in the first instance; the injustice may be afterwards in improper treatment, and in over detention. But to prevent all such abuses, we must first make men perfect, and then we should have no diseases to cure. It is certain, that under a proper system, ameliorated by all these plans of procedure I have stated, it is astonishing how these violent and extreme cases would become less prominent. I believe they would not average five per cent. at any one time; and take the average of a number of years, and I suppose it would not be more than half that number. I am certain the proportion, during sixteen years of my experience, has been much less than even this; it is seven years since we had occasion to treat any one single case as a constantly furious and dangerous maniac; and even suppose, such cases, under the best management, were more frequent in occurrence, and continue in this state for some time, how easy it would be soto contrive an Establishment, that these violent cases should not annoy or disturb the rest; and when thus managed, so far from their influence being hurtful, they would become interesting and salutary objects of reflection and commiseration to those who are in a better state; and often, by example, would teach the greatest of all moral lessons, that which holds the primary place as a preventive, and is always a necessary adjunct in the business of restoration—self control.
In fact, every system of management that does not make this principle, of mildly calling forth and gently exercising this internal principle of self-control on matters that are least connected with the diseased parts of the brain, a constant and primary object of attention, is not merely defective, but exhibits very great ignorance of the attributes of mind, as well as of the causes and nature of its maladies; and it follows that, as a system, it must be without any clear principle to guide its physical and moral treatment. In all things, we ought to remember, and especially in a matter of such importance, that we can do good only so far as our knowledge extends; and even this knowledge is useless, unless we are zealously desirous and able to reduce it to practice. Whatever may be our proportion of knowledge, zeal, and ability, it cannot be arrogance, when calledupon, to say, that I believe this principle is more brought into practice by the plans and arrangements I have described, than is the case with any system of treatment in any place that I have hitherto heard of or seen.
It is not known, as it ought to be, how powerful with the higher class of patients is the principle of honour; with many, a sense of religion; and withall, the fear of losing the approbation and friendship of those who are kind to them; as well as, from selfish motives, to secure the liberty and indulgences they have enjoyed. These means, and every principle which operates on human nature as checks on one part of the mind, and as encouragements to another, should be constantly and steadily kept in view, for the purpose of never losing an opportunity of instantly bringing them into useful, and of course successful, operation.
It is on this philosophical system of kindness, that every thing should be so contrived that the principle of internal self-control should be excited, and kept in exercise; and thus, being brought to depend somewhat on themselves, the depressing effects of the absolute restraint of fear, induced by harsh measures, and the tyranny into which a mere place of confinement with walls, and bolts and bars, must almost necessarily degenerate, is avoided.
The propriety of these measures will receive additional confirmation, when we come to consider the causes as well as the nature of the evils which we are called upon to combat; but it may in the mean time be sufficient to state the appalling fact, that insanity is very often the consequence of early over indulgence.—I have frequently had to remark that an only child,—the youngest, or one brought up by a grandmother,—were the victims of a system of gratifying the feelings, without due attention to the cultivation and exercise of the understanding, as the delegated power destined to guide the future man.
There are few minds, even amongst the insane, who are not accessible to the salutary influence of this kind and liberal mode of proceeding. It is true, that many paupers, who have long been subjected to a very different system, are scarcely receptive of any of the impressions which belong to human nature; but with a higher class of patients, this can seldom or never be the case, unless it be in cases of absolute dementia. Even in the height of the most furious paroxysms, it is astonishing how much may be done by liberality and kindness. Nothing but absolute necessity should justify absolute restraint. It must always be considered as an evil to which we are reduced, in order to avoid a greater. Whenever it is unnecessary,and continued too long, it will do more harm than good: the furious will be made more furious, and the suicide more determined to effect his purpose. Whenever the patient is indulged with more liberty and behaves better, we must have forbearance to the utmost extent, and submit to all possible risks, losses, and expenses, rather than again have recourse to it; and when it is repeated, the patient must be made, if possible, to feel that it is deserved.
Their faults, like those of children, must be viewed with pity. They are the wild displays of feeling, without understanding. We must make excuses for them; often overlook, as often visit them slightly, only seldom with seriousness, and always with moderation, justice, and prudence. No evil is greater than the evil of constantly chiding and suspiciously watching for faults. It is an evil spirit that poisons and inflames every thing within its sphere. A contrary spirit has a healing influence; and though it requires numerous attendants, and makes the whole business of superintending the insane a source of constant and intense anxiety and solicitude, yet it is pleasing to have it in my power to state many “striking” examples of its efficacy, but I shall, notwithstanding, content myself with only slightly glancing at two or three.
I shall not at present give the particulars of this interesting case, except so far as is necessary for the purposes of illustration.
When he came from a private Asylum, he was in a state of the most furious, destructive, and malignant excitement, and had been in this state for so many months, that he was considered by his friends as an incurable case.
I attribute his cure, chiefly to his being treated with apparent confidence, and induced to work with a spade, when even in his worst state—a state so dreadful, that the least word or wrong look would have roused him to commit some dreadful act of vengeance, and it therefore required two men to be constantly in attendance to watch him, and this without appearing to do so.
He was induced to work with willingness, by being brought to believe he had the contrivance, management, and superintendance, of some improvements in the place; such as some alterations in the garden, and especially that of making a new road from one house to another, which now bears his name. It was observed, that after a hard day’s work, especially if he had profusely perspired, he had a more sound night’s sleep, and awoke somewhat improved in the morning; it is, however, to be remarked,that all this time he continued to have a regular system of medical treatment, which consisted in small repeated bleedings with leeches, averaging about three times in the fortnight, with purgatives, alteratives, and salines. It is impossible to conceive the delicacy that was observed towards him. Not a word or a look was done to offend him, let him speak or act ever so provokingly; and he was as perverse and as provoking, as it is possible to conceive a perfect dæmon to be. His was the exclusive excitement of anger and malignity, combined with the most acute cunning to effect his destructive purposes. The serpent, the wolf, the tiger, and vulture, seemed all that remained of the man. In this state, to bring the better parts of his mind into life, was a great difficulty. However, perseverance in this system restored him; and never was gratitude greater, or more substantially evinced, than has been by his conduct, and by that of his friends.
I can truly say, with Dr. Haslam, that “by gentleness of manner and kindness of treatment, I have seldom failed to obtain the confidence, and conciliate the esteem, of insane persons; and have succeeded, by these means, in procuring from them respect and obedience;” and I am of the same opinion with Mr. Samuel Tuke, wherein he states “that a large majorityof the instances, in which the malevolent dispositions are peculiarly apparent, and are considered as characterising the disorder, may readily be traced to secondary causes; arising from the peculiar circumstances of the patient, or from the mode of management.”
It is worthy of remark, that where the patients have known the superintendants when in a convalescent state, or in a state still capable of estimating the kindness shown to them, they will much more readily submit, and show much less of anger and vindictiveness, even in their insane state. This effect will be still more striking, if they have been in a place where a severer system is practiced, and where they have become depraved and brutalised, by being subject to too much coercion. Of this I shall state as much of a very interesting case as may illustrate this great and important principle.
This patient, on her first admission, was suspicious, vindictive, and implacable,—refusing food, and medicines, &c.—after recovery, and returning voluntarily, she was confiding, affectionate, and submissive, comparatively, even in her worst state.
On my seeing her at her own home, at the time of her second admission, she instantlysaid. “Good God! had you been here three days before, you had saved me!” On asking if she would like to return with me, she instantly said, “above all things in the world.” She came, and was apparently well in about ten days, and so continued for about seven weeks, when she returned home: but in less than a week she came back in the most raving and furious state, and yet nothing apparently dangerous or vindictive; on the contrary, she showed affection and attachment to us all; and if she displayed any vindictiveness, it was connected with some past recollections: but this has been slight and evanescent, compared to that which she exhibited in her former state;—a testimony, even from among the insane, which shows how much depends on the directions we give to each other’s mental energies. In this case, long walks in the most secluded parts of the forest, often removed or lessened an approaching paroxysm, and always superseded the necessity of having recourse to any restrictive measures. She is now perfectly recovered, and returned home.
Now, it is evident that ferocious and furious maniacs are those, wherein a direct system of coercion is said to be essential; and yet it is evident, that these are cases where it must do the greatest injury. They are those in whichthe animal part is excited and inflamed, and of course all causes of irritation must increase it. It is adding fuel to the fire, which already burns too fiercely—it is lacerating a wound which requires to be mollified with ointment. The best-tempered house-dog becomes savage by being constantly chained.
Restraint and coercion are only justified when used either from absolute necessity, or as the mildest species of discipline; and then in all instances itmustbe proportioned to the causes and exigencies of the case; or when they are so violent, or so unconscious of their own state, or so bent on their own destruction, that there is less evil to be feared by restraint, than by indulgence.—But even here, popular feelings, prejudices, and fears, must not be the judges.
The word coercion has been used, but it conveys an erroneous impression, as if some degree of punishment were necessarily included in the restraint which the safety of others and of the patients require; but so far from this being the case, it ought never to be forgotten, that if the murderous and destructive maniac are made to feel, that with this necessary restraint is conjoined the indulgence of a vindictive spirit of retaliation, it will have an injurious influence, aggravate the disease, and of course will progressively increase the necessity and rigour of the restraint.
In cases of determination to suicide, it should be made to appear to the patient, what in truth it always should be—the kindest guardianship and protection. In cases of some lesser faults, or such as breaking or tearing, instead of restraint, a small dark closet I have found more useful than the strait waistcoat; yet neither the one nor the other, have, now for a long time, (seven years at least) scarcely ever been resorted to, for more than an hour or so; but to be able to do all this requires a superabundance of servants and attendants, and these must be serious, active, laborious, and vigilant as possible.
I have known cases where the patient himself, on feeling his destructive propensity coming upon him, requested that he might be placed under restraint, and he felt afterwards more comfortable, from the conviction that he was safer in that state. In such a case, the request should be readily attended to, as being not merely unobjectionable, but likely to have a beneficial influence.
It has been, that restraint was resorted to, from the idleness and carelessness of keepers; and in these cases, when restrained, being neglected, they acquired dirty habits, very often, simply from the effect of custom inducing a disregard and insensibility to the discomfort of their filthy state; sometimes they acquired thesehabits, from, in the first instance, a determined vindictive motive of teasing those whom they thought had acted unjustly towards them, as the only means they had in their power of gratifying their revenge. In cases of debility and approaching marasmus, the effects of retention, when they are thus deprived of the power of relieving themselves, soon destroys the natural and healthy functions of the sphincters. I have often known a contrary system cure all these habits especially in the two first class of cases mentioned; though, in other respects, the mind remained the same. In the case last described, good and judicious management may retard the progress of the disease; but the system gradually decays, like a tree stripped of its bark by lightning.
As a proof, we have only a choice of evils, and we must always choose the least, I shall state a case.
This patient who had been several times under my care, was one who was soon made worse both in his bodily and mental state, by any restraint, however mild; and therefore we submitted to the losses which his very destructive habits occasioned, rather than have recourse to them. These losses were enormous. By this treatment, he so far recovered, that amedical friend, who had known him all his life, declared, on an accidental interview in the grounds, that his mind seemed in a state of integrity, as perfect as he had ever known it to be previous to the accession of any symptoms of Insanity.
In this state, he was removed by his friends from, I believe, parsimonious motives, to Bedlam, and this was done in spite of my positive opinion, declared in writing, that it would be fatal to his bodily and mental health, and that he would sink under the depressing effects of his situation. In less than six months, he was covered with ulcers, and a mass of disease. In this state he was removed to his own house in the country, where he recovered his bodily health, but his mind is gone for ever.
I could adduce, to illustrate the same principle, many cases similar to the last, and indeed so powerfully have I felt impressed with its importance, that I have frequently written letters to, and had conversations with, the friends of patients, stating, that from the nature and state of their case, we had only a choice of evils, and therefore it was better to run the risk of rather overmuch liberty, than the positive evils of goading and exasperating them by what is generally deemed, particularly in these cases, necessary restraints and confinement.In most instances, they have not only fully entered into my views, and given me their necessary co-operation, but also readily agreed, that, if in consequence of this liberty any accident should happen, they would acquit me of all blame, and we have hitherto been most providentially favoured in having none of any moment. It is true, one very peculiar patient takes advantage of this indulgence, and visits his friends without leave of absence; but so far from any blame or anger on the part of his friends against us on this account, they are pleased to see him, and he is always on these occasions very happy with the idea of having given us so much trouble, and at the same time, he shows he esteems our kindness by willingly, readily, and cheerfully returning to us. Indeed as we have no case which better illustrates the principle for which I am contending, I shall here introduce so much of its description, as may be necessary for the purpose of enforcing its importance.
It is a case, where little insanity is observable in his conversation, but appears almost altogether in this constant propensity to indulge in destructiveness—breaking windows, tearing his clothes, &c. The more costly the articles he destroys, the more pleasure heseems to have in the indulgence of this propensity for mischief and evil. By over-much confinement and coercion, this patient would soon have become a settled case of furious and destructive mania; but by great liberality, and using restraint occasionally, the habit is much lessened: still, however, the propensity exists, and might be easily aggravated. A week of the usual coercive measures, would make this case degenerate into one equally malignant and murderous as that of Walsh, whose character is given in the Sketches of Bedlam.
A great number of cases might be adduced in support of these views; but I trust these may suffice to enforce the argument in favour of the system, which some have blamed, as being too liberal and indulgent. I have therefore quoted a few such cases, both as an illustration of my views and motives, and also as the best apology and vindication I can give in my own defence.
In all violent cases, there is one remark that must not be forgotten—that when it is possible, good may often be expected from violent exercise, always taking care that the patient is in a state to bear the fatigue, and still more so if he undertakes any sort of exercise with voluntary pleasure. In cases, however, sinking into marasmus,—cases which I class under those of gradual decay of mind—exercise must be undertaken atsuitable seasons, and when in a proper state, and must always be gentle and moderate. Besides, though the greatest good may be expected in almost all cases from labour and exercise, properly regulated, and willingly undertaken, it is to be remarked, that while, with a great proportion of a pauper class of patients, various kinds of labour and exercise are, from their previous habits, easily adopted, and soon, by vigilant management, reduced to a regular system, and such system is of paramount importance to their health and mental restoration; yet with a higher class of patients, who had not acquired at an early period of life regular habits of industry, even the attempt to do the same thing might be altogether as difficult and injurious; and therefore though exercise is of very great importance, this should not make us overlook the necessity of not urging and compelling them to it in a way to cause irritation, unless indeed, in some extreme perverse cases, who must be forced to walk or ride rather than their health suffer from deficiency of air and exercise. What I mean is, that we must avoid doing a positive evil where the good is only probable. For though exercise is one of the most powerful means of withdrawing the determination of the nervous energy and blood from the head, and distributing them properly through the whole system, and thus combining a mentaland physical power of diversion to the train of thoughts which injuriously occupy and produce a destructive fire in the mind, fatal to its existence; yet in these cases, we may produce a greater irritation by unnecessary compulsion. It is well known, that in many cases, besides the animal and angry passions being very active, pride and vanity are with many, if not the whole cause and very seat, often parts of the disease; and that when once excited, all moral means to restrain and subdue them are as futile as it would be to attempt by artificial aid to quench the fury of a burning volcano.
I have often, however, known the violent maniacal excitement very much lessened in force, and bettered in direction, by being allowed, with an attendant, to ramble, and dance, and scream about, in the secluded parts of the forest, for a whole day together, and which superseded the necessity of the straight waistcoat.[80]
When this class of patients cannot be induced to walk, they may be pleased with carriage exercise, and in cases of approaching marasmus, where much fatigue would be injurious, airings will amuse and help to invigorate their feeble system, and perhaps, retard in some degree, the progress of destruction.
Though I have incidentally been led to notice the importance of employment and amusement, as a remedial measure of great efficacy among the insane; and though I could adduce many further striking proofs of its being apparently the sole cause of cure; I feel, to do so in this place, would be to forestall and usurp a subject to which I intend (as it deserves) to devote a separate essay; yet I cannot help saying, that I have some recent cases in proof of its efficacy, that were it not that their peculiar character and employment is so striking, that to describe them, would be almost to name them, I should feel tempted to bring them forward, for the purpose of proving that, among a better class of patients, this employment must never, on any account, be made a disagreeable task, but a matter of pleasurable choice, if we mean it to have a beneficial influence. This is often very difficult; a task requiring great tact and no selfishness. I believe, considering the class of patients we have under our charge, I am justified in asserting, that there is no place where a greater number, or more pains have been taken, and greater sacrifices made, so to employ and amuse them.
Dr. Gregory used to mention the fact of a farmer, who, by giving his patients, on their first admission, convincing proofs of his undoubted strength and pugilistic pre-eminence,brought them to a state of passive obedience and non-resistance, and then made them work; and, it is said, cured them.
No doubt many would be cured by this system, and these would propagate his fame; but whether the quality and proportion of those who would be injured by such a system, were greater evils than the good which was thus effected, we have now no means of ascertaining; nor is it necessary to know this, before we venture to condemn a system so perfectly savage and quackishly indiscriminate in its practice.
Where pride and vanity, angry passions, and love of power, are active, we cannot, with impunity, force them to work against their inclination; at the same time, it is our duty to lay the axe to the root of the evil, and restrain, and if possible subdue, these inordinate passions; but what I assert, is, that these are very difficult and dangerous passions to encounter, and they are not, with this class, to be restrained and subdued by the mere authority of a tax-master. When we encounter them, it must be with great mental power and moral force; and this, even, to be exercised with effect, requires, that we first make ourselves beloved and respected by them. Oh! it is a difficult and delicate thing to preserve that spirit, in combatingthese provoking cases, which alone has the power to overcome and cure them.
A state of furious mania is frequently the effect of injudicious management. Of this opinion, Mr. S. Tuke says, “a striking illustration occurred in this Institution, some years ago. A patient, of rather a vindictive and self-important character, who had previously conducted himself with tolerable propriety, one day climbed up against a window, which overlooked the court where he was confined, and amused himself by contemplating the interior of the room. An attendant, who had not been long in office, perceiving his situation, ran hastily towards him, and, without preamble, drew him to the ground. The patient was highly incensed: a scuffle immediately ensued, in which he succeeded in throwing his antagonist; and had not the loud vociferations of this attendant alarmed the family, it is probable that he would have paid for his rash conduct, by the loss of his life. The furious state of the patient’s mind did not continue long; but, after this circumstance, he was more vindictive and violent.”
“In some instances, the superintendant has known furious mania temporarily induced, by the privations necessary on a relapse, after a considerable lucid interval, during which the patient had enjoyed many privileges that were incompatible with his disordered state. Herewe may suggest the expediency, where it is possible, of employing such of the attendants to control the patient during his paroxysms, as had little intercourse with him in his lucid interval. Instances of furious mania have been, however, very rare; but a considerable number of patients have been admitted, who were reported to be so furiously insane as to require constant coercion.
“The evidence of attendants, who have been employed, previously to the admission of patients into the retreat, is not considered a sufficient reason for any extraordinary restraint; and cases have occurred, in which persuasion and kind treatment have superseded the necessity of any coercive means.
“Some years ago, a man, about thirty-four years of age, of almost Herculean size and figure, was brought to the house. He had been afflicted several times before; and so constantly, during the present attack, had he been kept chained, that his clothes were contrived to be taken off and put on by means of strings, without removing his manacles. They were, however, taken off, when he entered the Retreat, and he was ushered into the apartment where the superintendants were supping. He was calm: his attention appeared to be arrested by his new situation. He was desired to join in the repast, during which he behaved with tolerable propriety. After it was concluded, the superintendantconducted him to his apartment, and told him the circumstances on which his treatment would depend; that it was his anxious wish to make every inhabitant of the house as comfortable as possible; and that he sincerely hoped the patient’s conduct would render it unnecessary for him to have recourse to coercion. The maniac was sensible of the kindness of his treatment. He promised to restrain himself, and he so completely succeeded, that, during his stay, no coercive means were ever employed towards him. This case affords a striking example of the efficacy of mild treatment. The patient was frequently very vociferous, and threatened his attendants, who in their defence were very desirous of restraining him by the jacket. The superintendant, on these occasions, went to his apartment; and though the first sight of him seemed rather to increase the patient’s irritation; yet after sitting some time quietly beside him, the violent excitement subsided, and he would listen with attention to the persuasions and arguments of his friendly visitor. After such conversations, the patient was generally better for some days or a week; and in about four months he was discharged, perfectly recovered.”
“Can it be doubted, that, in this case, the disease had been greatly exasperated by the mode of management? or that the subsequentkind treatment had a great tendency to promote his recovery?”
“It may probably be urged, and I am very well aware of it, that there is a considerable class of patients, whose eccentricities may, in great measure, be controlled; and who may be kept in subjection and apparent orderly habits, by the strong excitement of the principle of fear.—They may be made to obey their keepers, with the greatest promptitude; to rise, to sit, to stand, to walk, or run at their pleasure; though only expressed by a look. Such an obedience, and even the appearance of affection, we not unfrequently see in the poor animals who are exhibited to gratify our curiosity in natural history: but who can avoid reflecting, in observing such spectacles, that the readiness with which the savage tiger obeys his master, is the result of treatment, at which humanity would shudder; and shall we propose by such means
“To calm the tumult of the breast,Which madness has too long possest;To chase away the fiend Despair,To clear the brow of gloomy care;Bid pensive Melancholy cease to mourn,Calm Reason reassume her seat;Each intellectual power return?”
“To calm the tumult of the breast,Which madness has too long possest;To chase away the fiend Despair,To clear the brow of gloomy care;Bid pensive Melancholy cease to mourn,Calm Reason reassume her seat;Each intellectual power return?”
“If those who are friendly to what may be termed the terrific system of management, couldprove, that notwithstanding it may fix for life the misery of a large majority of the melancholies; and drive many of the more irritable maniacs to fury or desperation; yet that it is still, in its operation upon a large scale, adapted to promote the cure of insanity; they would have some apology for its discriminate adoption. If, on the contrary, a statement of the proportion of cures in the Retreat, shall sufficiently prove the superior efficacy of mild means, would not those, who are adopting an opposite line of treatment, do well to reflect on the awful responsibility which attaches to their conduct. Let us all constantly remember, that there is a Being, to whose eye darkness is light; who sees the inmost recesses of the dungeon, and who has declared, ‘For the sighing of the poor, and the crying of the needy, I will arise.’”
“From the view we have now taken of the propriety of exciting fear, as a means of promoting the cure of insanity, by enabling the patient to control himself, it will, perhaps, be almost superfluous to state as our opinion, that the idea, which has too generally obtained, of it being necessary to commence an acquaintance with lunatics, by an exhibition of strength, or an appearance of austerity, is utterly erroneous. The sentiment appears allied to that cruel system, probably dictated by indolence and timidity,which has so long prevailed, and unhappily still prevails, in many receptacles for the insane.”
“There is much analogy between the judicious treatment of children, and that of insane persons. Locke has observed that ‘the great secret of education, lies in finding the way to keep the child’s spirit easy, active, and free; and yet, at the same time, to restrain him from many things he has a mind to, and to draw him to many things which are uneasy to him.’”