Our own countrymen have acquired the credit of managing insane people with
superior address; but it does not appear that we have arrogated to
ourselves any such invidious pre-eminence. Foreigners, who have visited
the public or private institutions of this country, may, perhaps, in their
relations, have magnified our skill in the treatment of this disease:
compared with a great part of the north of Europe, which I have visited,
we certainly excel.
Whether it be that we have more mad persons in England than in other
countries, and thereby have derived a greater experience of this
calamity; or, whether the greater number of receptacles we possess for the
insane, and the emoluments which have resulted from this species of
farming, have led persons to speculate more particularly on the nature and
treatment of this affection, may be difficult to determine. Dr. Pinel[24]
allows the reputation we have acquired; but, with a laudable curiosity, is
desirous to understand how we became possessed of it.
"Is it," he says, "from a peculiar national pride, and to display their
superiority over other nations, that the English boast of their ability in
curing madness by moral remedies; and at the same time conceal the cunning
of this art with an impenetrable veil? or, on the contrary, may not that
which we attribute to a subtile policy, be merely the effect of
circumstances? and, is it not necessary to distinguish the steps of the
English empirics from the methods of treatment adopted in their public
hospitals?
"Whatever solution may be given to these questions, yet, after fifteen
years diligent enquiry, in order to ascertain some of the leading features
of this method, from the reports of travellers; the accounts published of
such establishments; the notices concerning their public and private
receptacles, which are to be found in the different journals, or in the
works of their medical writers, I can affirm, that I have never been able
to discover any development of this English secret for the treatment of
insanity, though all concur in the ability of their management. Speaking
of Dr. Willis,[25] it is said, that sweetness and affability seem to
dwell upon his countenance; but its character changes the moment he looks
on a patient: the whole of his features suddenly assume a different
aspect, which enforces respect and attention from the insane. His
penetrating eye appears to search into their hearts, and arrest their
thoughts as they arise. Thus he establishes a dominion, which is
afterwards employed as a principal agent of cure. But, where is the
elucidation of these general principles to be sought; and, in what manner
are they to be applied according to the character, varieties, and
intensity of madness? Is the work of Dr. Arnold otherwise remarkable than
as a burdensome compilation, or a multiplication of scholastic divisions,
more calculated to retard than advance the progress of Science? Does Dr.
Harpur, who announces in his preface, that he has quitted the beaten
track, fulfil his promise in the course of his work? and is his section on
mental indications any thing but a prolix commentary on the doctrines of
the ancients? The adventurous spirit of Dr. Crichton, may justly excite
admiration, who has published two volumes on maniacal and melancholic
affections, merely on the authority of some observations drained from a
German Journal; together with ingenious dissertations on the doctrines of
modern physiologists, and a view of the moral and physical effects of the
human passions. Finally, can a mere advertisement of Dr. Fowler's
establishment for the insane in Scotland, throw any light on the
particular management of such persons, although it profess the purest and
most dignified humanity, successfully operating on the moral treatment of
madness?"
Dr. Pinel is deserving of considerable credit for directing the attention
of medical men to this very important point of the moral management of the
insane. I have also heard much of this fascinating power which the mad
doctor is said to possess over the wayward lunatic; but, from all I have
observed amongst the eminent practitioners of the present day, who
exercise this department of the profession, I am led to suspect, that,
although this influence may have been formerly possessed, and even to the
extent attributed to the late reverend doctor, it ought now to be lamented
among the _artes deperditae_. Could the attention of lunatics be fixed, and
could they be reduced to obedience, by
"Strong impression and strange powers which lie
Within the magic circle of the eye,"
all other kinds of restraint would be superfluous and unnecessarily
severe. But the fact is notoriously otherwise. Whenever the doctor visits
a violent or mischievous maniac, however controlling his physiognomy,
such patient is always secured by the straight waistcoat; and it is,
moreover, thought expedient to afford him the society of one or more
keepers.
It has, on some occasions, occurred to me to meet with gentlemen who have
imagined themselves eminently gifted with this awful imposition of the
eye, but the result has never been satisfactory; for, although I have
entertained the fullest confidence of any relation, which such gentlemen
might afterwards communicate concerning the success of the experiment, I
have never been able to persuade them to practise this rare talent tete a
tete with a furious lunatic.
However Dr. Pinel may be satisfied of our superiority in this respect, it
is but decorous to return the compliment, and if any influence were to be
gained over maniacal patients by assumed importance, protracted staring,
or a mimicry of fierceness, I verily believe that such pantomime would be
much better performed in Paris than in London.
It is to be lamented, that general directions only can be given concerning
the management of insane persons; the address, which is acquired by
experience and constant intercourse with maniacs, cannot be communicated;
it may be learned, but must perish with its possessor. Though man appears
to be more distinguished from other animals by the capability he has of
transmitting his acquirements to posterity, than by any other attribute of
his nature, yet this faculty is deplorably bounded in the finer and more
enviable offsprings of human attainment. The happy dexterity of the
artisan, the impressive and delighting powers of the actor,
"And every charm of gentler eloquence,
All perishable--like the electric fire,
But strike the frame, and, as they strike, expire."
As most men perceive the faults of others without being aware of their
own, so insane people easily detect the nonsense of other madmen, without
being able to discover, or even to be made sensible of the incorrect
associations of their own ideas. For this reason it is highly important,
that he who pretends to regulate the conduct of such patients, should
first have learned the management of himself. It should be the great
object of the superintendant to gain the confidence of the patient, and to
awaken in him respect and obedience; but it will readily be seen, that
such confidence, obedience, and respect, can only be procured by
superiority of talents, discipline of temper, and dignity of manners.
Imbecility, misconduct, and empty consequence, although enforced with the
most tyrannical severity, may excite fear, but this will always be mingled
with contempt. In speaking of the management of insane persons, it is to
be understood that the superintendant must first obtain an ascendency over
them. When this is once effected, he will be enabled, on future occasions,
to direct and regulate their conduct, according as his better judgment may
suggest. He should possess firmness, and, when occasion may require,
should exercise his authority in a peremptory manner. He should never
threaten but execute; and when the patient has misbehaved, should confine
him immediately. As example operates more forcibly than precept, I have
found it useful, to order the delinquent to be confined in the presence of
the other patients. It displays authority; and the person who has
misbehaved becomes awed by the spectators, and more readily submits. It
also prevents the wanton exercise of force, and those cruel and unmanly
advantages which might be taken when the patient and keeper are shut up in
a private room. When the patient is a powerful man, two or more should
assist in securing him: by these means it will be easily effected; for,
where the force of the contending persons is nearly equal, the mastery
cannot be obtained without difficulty and danger.
When the patient is in a furious state, and uncontrolable by kindness and
persuasion, he will generally endeavour, by any means, to do as much
mischief as possible to the person who opposes him; and instances are not
rare where he has overcome the keeper. When the maniac finds his strength,
or skill in the contest prevail, he is sure to make the most of such
advantage, and the consequence of his victory has sometimes proved fatal
to the keeper. On the other hand, it ought to be the object of the keeper
to subdue the maniac without doing him any personal injury; and after he
has overpowered, to confine him, and thus prevent him from attempting any
further mischief. When the patient is a strong man, and highly irritated,
it will be impossible for any keeper singly to overcome him without his
most forcible exertions, and these cannot be put forth without great
violence to the patient. But subduing the maniac, is not the only object,
he must afterwards be secured by the straight-waistcoat, or by manacles.
It will be seen, that the keeper, who, by the great exertion of his bodily
powers, has become faint and exhausted, will be very little in a condition
to secure the patient, as his hands must be employed with the implements
necessary to confine him; moreover, the patient will have additional
strength from the temperate manner, in which he is made to live; whereas,
it is but too common, for the keeper to indulge in a diet and beverage,
which induce corpulence and difficulty of breathing.[26]
As management is employed to produce a salutary change upon the patient,
and to restrain him from committing violence on others and himself; it may
here be proper to enquire, upon what occasions, and to what extent,
coercion may be used. The term coercion has been understood in a very
formidable sense, and not without reason. It has been recommended by very
high medical authority to inflict corporal punishment upon maniacs, with a
view of rendering them rational, by impressing terror.[27] From Dr. Mead's
section on madness it would appear, that in his time flagellation was a
common remedy for this disorder. "There is no disease more to be dreaded
than madness. For what greater unhappiness can befal a man, than to be
deprived of his reason and understanding, to attack his fellow creatures
with fury, like a wild beast; to be tied down, _and even beat_, to
prevent his doing mischief to himself or others."--_Medical Precepts and
Cautions, page 74._
Dramatic writers abound with allusions to the whip, in the treatment of
madness. "Love is meerely a madnesse, and I tel you, deserves as well a
darke house, and a whip, as madmen do: and the reason why they are not so
punish'd and cured, is, that the Lunacie is so ordinary, that the whippers
are in love too."--_As You Like It, act III. scene 2._
Another instance to the same effect may be found in Mr. Dennis's comedy of
Jacobite Credulity. "_Bull Junior._ Look you, old gentleman, I will touch
this matter as gently as I can to you. Your friends taking notice, that
you were grown something foolish, whimsical, absurd, and so forth, thought
fit to have you sent to the College here, [Bedlam] that you might go
through a course of philosophy, and be cudgel'd and firk'd into a little
wisdom, by the surly Professors of this place."--_Select Works, vol. ii.
p. 363._ And again, in the next page; "If thou canst give but so much as a
reasonable answer to any thing; if thou either knowest what thou art, or
where thou art, or with whom thou art, then will I be contented to be
thought mad, and dieted and flogged in thy stead."
It also appears from Mr. Douce's valuable dissertation, that the
domesticated fool frequently underwent a similar castigation, to curb the
licentiousness of his discourse, or, as a punishment for the obscenity of
his actions. Indeed this system of corporal chastisement seems to have
been general, and may afford some apology for introducing, from a very
rare little book, an account of the manner of treating this malady in
Constantinople, about the middle of the 16th century.[28]
"_Of a place called Timarahane for the Correction of the Insane._
"The sultan Bajazet caused a building to be erected for the reception of
insane persons, in order, that they might not wander about the city, and
there exhibit their mad pranks. This building is constructed in the manner
of an hospital: there are about an hundred and fifty keepers appointed to
look after them; they are likewise furnished with medicines and other
necessary articles. These keepers, armed with cudgels, patrole the city in
search of the insane; and when they discover such, they secure them by the
neck and hands with an iron chain, and, by dint of the cudgel, convey them
to Timarahane. On entering this place, they are confined by the neck, with
a much larger chain, which is fixed into the wall, and comes over their
bed place, so that they are kept chained in their beds. In general, about
forty are confined there, at some distance from each other.
"They are frequently visited by the people of the city, as a species of
amusement. The keepers constantly stand over them with cudgels; for, if
left to themselves, they would spoil and destroy their beds and hurl the
tables at each other. At the times of giving them food, the keepers
examine them, and, if they notice any, who are disorderly, they beat them
severely; but, if they should by accident, find any, who no longer exhibit
symptoms of insanity, they treat them with greater regard."
What success may have followed such disgraceful and inhuman treatment, I
have not yet learned; nor should I be desirous of meeting with any one,
who could give me the information.
If the patient be so far deprived of understanding, as to be insensible
why he is punished, such correction, setting aside its cruelty, is
manifestly absurd: and, if his state be such, as to be conscious of the
impropriety of his conduct, there are other methods more mild and
effectual. Would any rational practitioner, in a case of phrenitis, or in
the delirium of fever, order his patient to be scourged? he would rather
suppose, that the brain, or its membranes, were inflamed, and that the
incoherence of discourse and violence of action were produced by such
local disease. It has been shewn by the preceding dissections, that the
contents of the cranium, in all the instances that have occurred to me,
have been in a morbid state. It should, therefore, be the object of the
practitioner, to remove such disease, rather than irritate and torment the
sufferer.--Coercion should only be considered as a protecting and salutary
restraint.
In the most violent state of the disease, the patient should be kept
alone in a dark and quiet room, so that he may not be affected by the
stimuli of light or sound, such abstraction more readily disposing to
sleep. As in this violent state there is a strong propensity to associate
ideas, it is particularly important to prevent the accession of such as
might be transmitted through the medium of the senses. The hands should be
properly secured, and the patient should also be confined by one leg; this
will prevent him from committing any violence. The more effectual and
convenient mode of confining the hands is by metallic manacles; for,
should the patient, as frequently occurs, be constantly endeavouring to
liberate himself, the friction of the skin against a polished metallic
body may be long sustained without injury; whereas excoriation shortly
takes place when the surface is rubbed with linen or cotton. Ligatures
should on all occasions be avoided. The straight waistcoat is admirably
calculated to prevent patients from doing mischief to themselves; but in
the furious state, and particularly in warm weather, it irritates, and
increases that restlessness which patients of this description usually
labour under. They then disdain the incumbrance of clothing, and seem to
delight in exposing their bodies to the atmosphere. Where the patient is
in a condition to be sensible of restraint, he may be punished for
improper behaviour, by confining him to his room, by degrading him, and
not allowing him to associate with the convalescents, and by withholding
certain indulgences, he had been accustomed to enjoy.
In speaking of coercion, I cannot avoid reprobating a practice, which has
prevailed in some private receptacles for the insane, but which, it is
presumed, will henceforward be discontinued. I mean, the practice of
half-stifling a noisy patient, by placing a pillow before the mouth, and
forcibly pressing upon it, so as to stop respiration. It is unnecessary to
enquire, how such wanton cruelty came to be introduced; it must have been
the suggestion of ignorance, and the perpetration of savageness and
brutality. Sighs, tears, sobs, and exclamations, are the unaffected
language of passion, and come kindly to our relief, in states of sorrow
and alarm. Indeed, they appear to be the natural remedies, to
"Cleanse the stufft bosom of that perillous stuffe,
Which weighs upon the heart."
The mild and rational practice of Bethlem Hospital, tolerates these
involuntary ejaculations. It is there considered, that a noisy and
loquacious maniac, has not the power to control his utterance of sounds,
which, from the habitual connexion between ideas and speech, must
necessarily follow. It is there only viewed as a symptom, or part of the
disorder; and that, if the cause cannot be suppressed, the effect should
not be punished.
As madmen frequently entertain very high, and even romantic notions of
honour, they are often rendered much more tractable by wounding their
pride, than by severity of discipline.
Speaking of the effects of management, on a very extensive scale, I can
truly declare, 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. There are certainly some patients who are not to
be trusted, and in whom malevolence forms the prominent feature of their
character: such persons should always be kept under a certain restraint,
but this is not incompatible with kindness and humanity.
It would, in this part of the work, be particularly gratifying to my
feelings if I could develope this _English secret_ for the moral
management of the insane, which has been so ardently, yet unsuccessfully
sought after by Dr. Pinel. For fourteen years I have been daily in the
habit of visiting a very considerable number of madmen, and of mixing
indiscriminately among them, without ever having received a blow or
personal insult. During this time I have always gone alone, and have never
found the necessity for the assistance or protection of a keeper. The
superintendant of the Bicetre, according to Dr. Pinel's account, is
usually attended by his keepers, [gens de service] though he is said to
possess[29] "une fermete inebranlable, un courage raisonne et soutenu par
des qualites physiques les plus propres a imposer, une stature de corps
bien proportionnee, des membres pleins de force et de vigeur, et dans des
momens orageux le ton de voix le plus foudroyant, la contenance la plus
fiere et la plus intrepide." Not being myself endowed with any of these
rare qualities; carrying no thunder in my voice, nor lightning in my eye,
it has been requisite for me to have recourse to other expedients. In the
first place, it has been thought proper to devote some time and attention
to discover the character of the patient, and to ascertain wherein, and on
what points, his insanity consists: it is also important to learn the
history of his disorder, from his relatives and friends, and to enquire
particularly respecting any violence he may have attempted towards himself
or others.
In holding conferences with patients in order to discover their insanity,
no advantage has ever been derived from assuming a magisterial importance,
or by endeavouring to stare them out of countenance: a mildness of manner
and expression, an attention to their narrative, and seeming acquiescence
in its truth, succeed much better. By such conduct they acquire confidence
in the practitioner; and if he will have patience, and not too frequently
interrupt them, they will soon satisfy his mind as to the derangement of
their intellects.
When a patient is admitted into Bethlem Hospital, if he be sufficiently
rational to profit by such tuition, it is explained to him, by the keepers
and convalescents, that he is to be obedient to the officers of the
house, and especially to myself, with whom he will have daily intercourse;
they point out to him, that all proper indulgences will be allowed to good
behaviour, and that seclusion and coercion instantly succeed to
disobedience and revolt. As _nemo repente turpissimus_, so no one in an
instant, from a state of tranquillity, becomes furiously mad: the
precursory symptoms are manifold and successive, and allow of sufficient
time to secure the patient before mischief ensues; it is principally by
taking these precautions that our patients are observed to be so orderly
and obedient. The examples of those who are under strict coercion, being
constantly in view, operate more forcibly on their minds than any precepts
which the most consummate wisdom could suggest. In this moral management,
the co-operation of the convalescents is particularly serviceable; they
consider themselves in a state of probation, and, in order to be
liberated, are anxious, by every attention and assistance, to convince the
superintendants of their restoration to sanity of mind. From mildness of
treatment, and confidence reposed in them, they become attached, and are
always disposed to give information concerning any projected mischief.
Considering how much we are the creatures of habit, it might naturally be
hoped, and experience justifies the expectation, that madmen might be
benefited by bringing their actions into a system of regularity. It might
be supposed, that as thought precedes action, that whenever the ideas are
incoherent, the actions will also be irregular. Most probably they would
be so, if uncontroled; but custom, confirmed into habit, destroys this
natural propensity, and renders them correct in their behaviour, though
they still remain equally depraved in their intellects.
We have a number of patients in Bethlem Hospital, whose ideas are in the
most disordered state, who yet act, upon ordinary occasions, with great
steadiness and propriety, and are capable of being trusted to a
considerable extent. A fact of such importance in the history of the human
mind, might lead us to hope, that by superinducing different habits of
thinking, the irregular associations would be corrected.
It is impossible to effect this suddenly, or by reasoning, for madmen can
never be convinced of the folly of their opinions. Their belief in them is
firmly fixed, and cannot be shaken. The more frequently these opinions are
recurred to, under a conviction of their truth, the deeper they subside in
the mind, and become more obstinately entangled:[30] the object should
therefore be to prevent such recurrence by occupying the mind on different
subjects, and thus diverting it from the favorite and accustomed train of
ideas.
As I have been induced to suppose, from the appearances on dissection,
that the immediate cause of this disease probably consists in a morbid
affection of the brain, it may be inferred, that all modes of cure by
reasoning, or conducting the current of thought into different channels,
must be ineffectual, so long as such local disease shall continue. It is,
however, likely that insanity is often continued by habit; that incoherent
associations, frequently recurred to, become received as truths, in the
same manner as a tale, which, although untrue, by being repeatedly told,
shall be credited at last by the narrator, as if it had certainly
happened. It should likewise be observed, that these incorrect
associations of ideas are acquired in the same way as just ones are
formed, and that such are as likely to remain as the most accurate
opinions. The generality of minds are very little capable of tracing the
origin of their ideas; there are many opinions we are in possession of,
with the history and acquisition of which, we are totally unacquainted. We
see this in a remarkable manner in patients who are recovering from their
insanity: they will often say such appearances have been presented to my
mind, with all the force and reality of truth: I saw them as plainly as I
now behold any other object, and can hardly be persuaded that they did not
occur. It also does not unfrequently happen, that patients will declare,
that certain notions are forced into their minds, of which they see the
folly and incongruity, and yet complain that they cannot prevent their
intrusion.
As the patient should be taught to view the medical superintendant as a
superior person, the latter should be particularly cautious never to
deceive him. Madmen are generally more hurt at deception than punishment;
and, whenever they detect the imposition, never fail to lose that
confidence and respect which they ought to entertain for the person who
governs them.
In the moral management of the insane, this circumstance cannot be too
strongly impressed on the mind of the practitioner: and those persons, who
have had the greatest experience in this department of medical science,
concur in this opinion. The late Dr. John Monro expressly says, "The
physician should never deceive them in _any_ thing, but more especially
with regard to their distemper; for as they are generally conscious of it
themselves, they acquire a kind of reverence for those who know it; and by
letting them see, that he is thoroughly acquainted with their complaint,
he may very often gain such an ascendant over them, that they will readily
follow his directions."[31]
Very different directions are, however, issued by a late writer,[32] and
which, on account of their novelty, contrivance, and singular morality,
deserve the consideration of the reader.
"The _conscientious physician_, in the execution of his duty, attempting
the removal of these deplorable maladies, is under the necessity of
occasionally deviating from the accustomed routine of practice, of
stepping out of the beaten track, and, in some cases, that have resisted
the usual methods, is warranted in adopting any others, that have _only_
the slightest _plausibility_, or that promise the smallest hope of
success. Thus, the employment of what may be termed _pious frauds_: as
when _one_ simple erroneous idea stamps the character of the disease,
depriving the affected party of the common enjoyments of society, though
capable of reasoning with propriety, perhaps, with ingenuity, on every
subject, not connected with that of his hallucination, the correction of
which has resisted our very best exertions, and, where there is no obvious
corporeal indisposition, it certainly is allowable to try the effect of
certain deceptions, contrived to make strong impressions on the senses,
by means of _unexpected_, _unusual_, _striking_, or apparently
_supernatural_ agents; such as after waking the party from sleep, either
suddenly or by a gradual process, by _imitated thunder_, or soft music,
according to the peculiarity of the case; _combating_ the erroneous
deranged notion, either by some _pointed sentence_, or signs _executed in
phosphorus_ upon the wall of the bed chamber; or by some _tale_,
_assertion_, or _reasoning_; by one in the character of an _angel_,
_prophet_, or _devil_: but the actor in this drama must possess much
_skill, and be very perfect in his part_."
It is of great service to establish a system of regularity in the actions
of insane people. They should be made to rise, take exercise, and food, at
stated times. Independently of such regularity contributing to health, it
also renders them much more easily manageable.
Concerning their diet, it is merely necessary to observe, that it should
be light, and easy of digestion. The proper quantity must be directed by
the good sense of the superintendant, according to the age and vigour of
the patient, and proportioned to the degree of bodily exercise he may be
in the habit of using; "but they should never be suffered to live too low,
especially while they are under a course of physic."[33] To my knowledge,
no experiments have yet been instituted respecting the diet of insane
persons: they have never been compelled to live entirely on farinaceous
substances. The diet of Bethlem Hospital allows animal food three times a
week, and on the other days bread with cheese, or occasionally butter,
together with milk pottage, rice milk, &c. Those who are regarded as
incurable patients ought certainly to be indulged in a greater latitude
of diet, but this should never be permitted to border on intemperance. To
those who are in circumstances to afford such comforts, wine may be
allowed in moderation, and the criterion of the proper quantity, will be
that which does not affect the temper of the lunatic, that which does not
exasperate his aversions, or render his philosophy obtrusive. Although it
seems rational in all states of madness, that temperance should be
strictly enjoined, yet an author of the present day[34] steps out of the
trodden path, and seriously advises us, in difficult cases, to drown
lunacy in intoxication; and, strange as it may appear, has taught us to
await the feast of Reason from the orgies of Bacchus. "The conversion of
religious melancholy into furious madness is a frequent occurrence, and is
generally followed by recovery. This has suggested the _propriety_, in
some cases that have resisted more common means, of producing a degree of
excitement by means of stimuli, in fact, _keeping the patient for days in
succession in a state of intoxication_, which has often occasioned an
alleviation of symptoms, and sometimes _restored the sufferers to
reason_."
Confinement is always necessary in cases of insanity, and should be
enforced as early in the disease as possible. By confinement, it is to be
understood that the patient should be removed from home. During his
continuance at his own house he can never be kept in a tranquil state. The
interruptions of his family, the loss of the accustomed obedience of his
servants, and the idea of being under restraint, in a place where he
considers himself the master, will be constant sources of irritation to
his mind. It is also known, from considerable experience, that of those
patients who have remained under the immediate care of their relatives and
friends, very few have recovered. Even the visits of their friends, when
they are violently disordered, are productive of great inconvenience, as
they are always more unquiet and ungovernable for some time afterwards. It
is a well-known fact, that they are less disposed to acquire a dislike to
those who are strangers, than to those with whom they have been intimately
acquainted; they become therefore less dangerous, and are more easily
restrained. It ought to be understood that no interruption to this
discipline should defeat its salutary operation. On this account more
patients recover in a public hospital, than in a private house,
appropriated for the reception of lunatics. In the former, the
superintendants persist in a plan laid down, and seldom deviate from
their established rules: such asylum being a place of charitable relief,
they are indifferent about pleasing the friends and relatives of the
patient, who cannot there intrude to visit them at their option. In a
private receptacle emolument is the first object, and however wisely they
may have formed their regulations, they soon feel themselves subordinate
to the caprice and authority of those by whom they are paid.
It frequently happens, that patients who have been brought immediately
from their families, and who were said to be in a violent and ferocious
state at home, become suddenly calm and tractable when placed in the
hospital. On the other hand it is equally certain, that there are many
patients whose disorder speedily recurs after having been suffered to
return to their families, although they have for a length of time
conducted themselves, under confinement, in a very orderly manner. When
they are in a convalescent state the occasional visits of their friends
are attended with manifest advantage. Such an intercourse imparts
consolation, and presents views of future happiness and comfort. But
certain restrictions should be imposed on the visits of these friends;
ignorant people often, after a few minutes conversation with the patient,
will suppose him perfectly recovered, and acquaint him with their opinion:
this induces him to suppose that he is well, and he frequently becomes
impatient of confinement and restraint. From such improper intercourse I
have known many patients relapse, and in two instances I have a
well-founded suspicion that it excited attempts at suicide.
Many patients have received considerable benefit by change of situation,
which occupies the mind with new objects, and this sometimes takes place
very shortly after the removal.
"Haply the Seas and Countries different
With variable objects, shall expell
This something setled matter in his heart:
Whereon his Braines still beating, puts him thus
From fashion of himselfe."
In what particular cases, or stages of the disease, this may be
recommended, I am not enabled, by sufficient experience, to determine.