Milton,
“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 a more 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, provides more 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
medical and 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 in all
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; that individuals 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, they should 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 the
_common 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 (in very 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 overthrow it. 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 to without 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 so to 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 called upon, 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
with _all_, 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.
_No._ 372.
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
majority of 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.
_No._ 395, _admitted Dec._ 3, 1829.
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 instantly said. “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 which the 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 it _must_ be 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 these habits, 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.
_No._ 421.
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 a
medical 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.
_No._ 396.
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 he seems 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 at
suitable 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 mental and 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 combating these 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. Here we 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 superintendant conducted 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 subsequent kind
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?”
“If those who are friendly to what may be termed the terrific system of
management, could prove, 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.’”
* * * * *
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 strange
incidents 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 paroxysms of 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 disorders of 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 inflammation and 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 sacrifices but
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 is given, {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 in the 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 most_ cases, 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 if no 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 their
SELF-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 possess it, 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 does not 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 consciousness of 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 most sedulously (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
to _increase_, _but diminish_, _the horror_ associated 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
conceived possible, 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 practical usefulness 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 is every 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.
APPENDIX
TO THE
ESSAY ON CLASSIFICATION.