This part of the subject may be divided into management, and treatment by
medicine.
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 vigorous and powerful, 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.
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
be proper here to enquire, upon what occasions, and to what extent,
coercion may be used. The term coercion has generally 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[9].
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. We have seen, 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 protesting 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 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 scorn the incumbrance of
cloathing, 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.
As madmen frequently entertain very high, and even romantic notions of
honour, they are 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 never 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.
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 uncontrouled; 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 may 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: 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, 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: 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 complain that they cannot prevent their intrusion.
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.
As the patient should be taught to view the 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.
Confinement is always necessary in cases of insanity, and should be
enforced as early in the complaint 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 frequently happens, that patients who have been brought immediately
from their families, and who have been said to be in a violent and
ferocious state, become suddenly calm and tractable, when placed in the
hospital. On the other hand, it is equally certain, that there are many
patients, who have for a length of time conducted themselves in a very
orderly manner under confinement, whose disorder speedily recurs after
being suffered to return to their families. 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.
Many patients have received considerable benefit by change of situation,
and this sometimes takes place very shortly after the removal. In what
particular cases, or stages of the disease, this may be recommended, I am
not enabled by sufficient experience to determine.