The better to explain and
illustrate my ideas and views on the important subject of
Classification, I shall, in the first instance, give a brief
description of the present plans, arrangement, and manner of
proceeding, in my own establishment.
Fair Mead House, Leopard’s Hill Lodge, and Springfield,
with appendages to each, constitute my present establishment at
High Beach; and I wish to have it most distinctly and most fully
understood, that they are simply for classification, of a more
general or more specific nature; and consequently, besides the
advantages derived from having three houses, I have (as far as I
could) made arrangements in each for this purpose.
Leopard’s Hill Lodge, where I have more especially made
arrangements for the purpose of classification, consists of a
front, or what may be called the family portion of the house, and
galleries behind, with appropriate rooms for patients requiring
more restraint.
To show
that these houses are merely for the purposes of classification,
I may mention, that there is no sort of difference in the three
houses, excepting that in the one generally and latterly
inhabited by ourselves, we prefer having those to whom our
individual and more immediate attention may be useful. The
same patients are even sometimes at one house, and sometimes at
another, according to their state; and sometimes for the mere
purpose of change. In fact, the greater part of our first
class of patients have been occasionally at Leopard’s Hill,
and this with the knowledge and approval of their friends.
As I have published some hints on this point, and addressed
them to the Commissioners in Lunacy, I may be permitted, in order
to show I have long entertained the same views, to quote two or
three passages.
I there state, “that two establishments on the same
grounds should be allowed and encouraged for the purpose of
Classification. My reason for this alteration, in the Act
relative to such places, is, that large and crowded houses are
decidedly objectionable, from the greater chance of noise and
disturbance, from their being less healthy, and from their
assuming more of a prison-like appearance, than of a family
mansion. With two, we can adopt a better and more complete
method of classification; and it is a consideration of very
great importance, that in one of them the proprietor and his
family should reside, and devote themselves to recent, partial,
slight, or convalescent cases.”
As I conceive this plan of two establishments for the purposes
of classification, to be of the highest importance, and essential
to the moral regulation, as well as to the cure of the insane, so
far from avoiding any investigation of either the principle of
their adoption, or their mode of management, I wish the most
exact knowledge to be obtained of the one, and invite the fullest
scrutiny of the other.
I would have not only two establishments in the same grounds,
but these sufficiently separated so as to prevent annoyance; and,
not only this separation, but I would have one to consist of a
male and female part, sufficiently separated from each
other. This arrangement I have at my own establishments,
which consist of Fair Mead House, and of Leopard’s Hill
Lodge, for males, and Springfield for females, with appendages,
and separate cottages; and more especially, I would have each
house divided into a front and back part, and this front part so
contrived, that in appearance it should be sufficiently distinct
from the other, so that patients might feel, on recovery, that
removal to this part withdrew them from the more painful
associations of their past state, and afforded them solace and
encouragement; thus might their recovery be expedited, and the
chances of relapse lessened. In the domestic part of the
establishment, the proprietor and his family should reside.
In many cases, an entirely separate house is required. I
have known cases, the cure of which would have been apparently
blighted and blasted for ever, if they could not have been wholly
removed from, not merely the real, but the apparent, association
of former scenes and circumstances, and this without any change
in their servants and medical treatment and attendance, which is
also essential. Yet it is perfectly true, that in other
cases this association is not so injurious as most people would
imagine; the dawnings of the light of the understanding are, for
the most part, so gradual, and the mists of delusion so gently
steal away, that there would be a greater shock given by a sudden
transfer to rational scenes and real life, than by their
continuance in the place where they might be at the time.
I have often, with feelings of wonder and admiration, had
occasion to observe these occurrences. I have seen a
convalescent patient very much attracted by, and perfectly
delighted with, the strange remarks, speeches, and conduct of
another inmate, sometimes fancying it was meant purposely for his
amusement and diversion; and on whom, refined wit would have
been lost, while the incongruous combinations of unguided
thought, which no wit or ingenuity can equal, appears, and is the
very essence of wit to him. Notwithstanding the truth of
all this, there are other cases,—cases of more sudden
convalescence, where all this would shock and horrify, and
produce a revulsion of feeling, most dangerous to them in their
delicate and fragile state, and perhaps permanently fatal to
their recovery. This is more particularly the danger in the
incipient stage of convalescence in some violent cases of mania,
[5] and where I am quite certain delicate
and judicious attention have been essential; and where first,
perhaps, removal to the family part of the house, then removal
altogether to our own house, was apparently their salvation.
This was one of the cases apparently saved by such timely
attention, and which I intend hereafter to describe more
particularly, for the purpose of illustrating both the medical
and moral treatment of many similar cases of insanity. I
shall, however, state so much of the case now, as will be
sufficient to show, that there is not only a critical period of
the disease, when judicious medical and intellectual attention
arrests and prevents its transition into another and equally
dangerous form of over-excitation, so dangerous, that if allowed
to take its course, it not unfrequently ends in dementia, but
also, and more especially to show, that in all cases our moral
treatment must have in view the nature of the existing causes, in
order that we may be able to adopt the most suitable methods of
counteracting their effects,—a part of treatment which has
hitherto been either wholly overlooked, or else exercised without
much knowledge and discretion; although I am certain it is of
great importance in the treatment of all curable cases of
insanity, and in many cases so important, that by such methods we
may ultimately succeed in removing these causes altogether; and
removing them, remove also the fear of their again (at any future
time) being allowed to have any baneful operation.
This person, who was a dissenting minister, had always been
reckoned by all parties, one who entertained gloomy views in
religion, and pushed these into extremes; his zeal was equally
violent and vindictive, and he besides possessed a mind with
every opposite quality in excess, and which had always, as far as
I could ascertain, been in a state of irregular and discordant
excitation; it is quite certain that during many years
past, it had been habitually kept in a very painful and irritable
state, by several causes, and one more especially deserving
notice. He lived unhappily with his wife and her
friends,—instead of union and harmony, all was dislike and
contradiction, perpetual storms and altercations, which had just
before terminated in a separation between himself and them.
Thus, from the condition of his own unsettled and
ill-constituted mind, his gloomy and vindictive views in
religion, his variable and irritable temper, and from the nature
of the domestic excitement under which he had suffered most
severely, it was easy to trace the distressing and awful form of
his derangement to the causes which had produced it.
He was in a state of the most furious mania;—his was one
of the most violent and distressing cases I had ever seen.
It is impossible to convey any adequate conception of its
appalling nature. His language was obscene and vulgar, and
his horrible oaths and blasphemous speeches were poured forth for
some weeks without ceasing, and without sleep, with a volubility,
rapidity, and a voice so loud, and so foaming with passion, and
with such a frightful expression of countenance, that even those
most accustomed to such scenes, and of the strongest nerves,
trembled before him. He had a demoniac energy and
eloquence, which was, indeed, of the most harrowing and
awful kind. It was truly terrific! for even at a distance,
his voice sounded like a river escaping from some narrowed part,
and rushing with impetuosity over every thing that would impede
its course.
Had a short-hand writer taken down his ravings, it would have
proved that this picture is far from being an overcharged
one. One principle subject of his furious raving, was his
favourite doctrine of Election; or rather, perhaps, I ought to
say, his blasphemous doctrine of Reprobation. He was
constantly denouncing every one (and against myself he was
peculiarly severe) as lost, whose belief on this point was not,
even in phraseology, the same as his own;—calling on God to
execute vengeance upon them;—then blaspheming God, that his
prayers and commands were neither heard nor
obeyed;—taunting and cursing Him with a contempt which no
language can describe;—calling his clemency weakness, and
his not executing his decrees a proof he did not possess the
power he pretended to have. In fact no one could hear and
see him without feeling shocked, and without having a conviction
forced upon him that there must be something wrong—some
perversion of truth in those doctrines, as well as in his own
mental system, out of which all this dreadful spirit, and all
these terrific extremes originated, and of which this case
appeared a Satanic caricature. It is a truth, that there is no error
or perversion of truth that we may not perceive in reviewing the
history of mind caricatured, and perhaps in a still more striking
manner among those who are in confinement from being
directly denounced insane.
On the subsidence of his excitement, he was overwhelmed with
the perfect recollection of all he had uttered during the utmost
fury of his dreadful ravings, and his state was truly miserable
and deplorable. In this state I took great pains with him,
treated him with every possible kindness, and endeavoured to show
him every possible mark of my confidence: one instance of which
may be mentioned.—I gave him, at a very early period of his
convalescence, a set of manuscript sermons, all in loose slips,
and which he read with great pleasure, and preserved with great
care. They were affectionate moral discourses, strictly, I
believe, in agreement with the spirit of Christianity, though not
on any peculiar doctrines; for in these I had purposely avoided
all doctrinal points, although doctrinal views may, when properly
presented, be the best preventives, and in some cases the best
medicines, in the cure of insanity; but the circumstances in
which I was at that time placed, appeared to forbid even their
most cautious introduction, and were scarcely admissible to an
audience consisting of some of almost all denominations. However, he
said, the spirit of these discourses just suited his altered
state of mind, for he himself felt horror-struck at the views
which had led to such awful consequences.
Though no one can feel more than I do, the necessity of not
busily trying to proselyte or unhinge unnecessarily any
one’s settled opinions, yet this was an extreme case, and
in such cases, where cure seems to depend on the proper
administration of counteractive views, every other feeling should
give way to this conviction; but at the same time, every thing
depends on the judicious mode of stating these sounder
views. This case was a remarkable instance of the necessity
of such management; and where such views were apparently of the
utmost importance to his comfort and peace. But it would
require a separate Essay to defend what I conceive those sounder
views; and even were I to give this striking case as a specimen
of their happy influence, I still might lay myself open to cavils
and objections. I shall, therefore, in a separate Essay,
bring forth all the arguments, and exert all the power I possess
in their defence.
Though his furious state was so unusually violent, yet it was
of long duration, and after it had left him, it was some time
before he was able to overcome the painful reflections which came
over him; he however recovered, and returned home in the
September following, since which period I have received many, and
almost constant proofs of his great gratitude and attachment to
me, one of which is worthy of being stated.
In the autumn of 1824, he walked about a hundred miles to see
me, and not finding my place of residence, he called on a medical
acquaintance, to whom his description of my kindness and
attention, and their happy influence upon himself, were so
powerful and eloquent, that this new and accidental medical
acquaintance, became from that time to the present, my first and
warmest medical friend in encouraging me to establish myself in
my present residence, and to whom I have to attribute the origin
of all my success; so that this recovered patient’s
gratitude, who followed me unexpectedly, was the first step in my
progress, and was the sole foundation of every thing which
I have done or exists in this place. It was my only
introduction. I may be permitted, therefore, to acknowledge
my great obligations to the warm-heart friendship of the person,
of whose melancholy state I have just given a general
description, as well as, the medical friend to whom I have
alluded.
This case, I shall hereafter show, was apparently saved by
this separation from former associates, at this critical period
of convalescence, and he was one who required very superior and
intellectual attention.
He was a young man of some talents, and of various pursuits
and acquirements, by far too many to be perfect in any one.
Born with a large proportion of the family failing, his vanity
had been fed by flattery and example, so much so, that it might
be said he was bred in vanity’s hot-house; and ultimately,
from over excitation, and too little collision with the world, he
fancied himself a second Crichton. Of course with such an
estimate of himself, it could not be otherwise but that he was
constantly meeting with disappointments and mortifications, on
his entrance into his profession, and the real business of
life. From these causes, as well as from an increase at
this time, of parental embarrassments and mortifications, (and
home had always been an atmosphere of perpetual storms), from an
hereditary scrofulous habit, and from his self-made morbid state,
his mind was at last overwhelmed. But it is not my
intention to enter into all the details of his history, further
than to prove that the causes which produced his disease, and the
form his
insanity assumed, perfectly corresponded with each other.
On his arrival he was in a very exalted state of
over-excitation; he was the greatest of men in every mental
capacity and acquirement; all Philosophers, Poets, Painters, and
Linguists, that had been, or were in existence, were nothing in
comparison with himself, nor were their works to be compared with
those he intended to execute, and the basis of which he had
already formed in his own conception. Nothing could exceed
the vain and pompous displays of his talents and acquirements;
and it is impossible to conceive, from the difficulty he had to
support his pretensions, with the defects under which he then
laboured, what a very painful and ridiculous exhibition it
produced. Still his vanity and exaggerated estimate of
himself, combined with his ineffable contempt for others,
remained unchecked. One feature was very striking; he
possessed considerable powers of imitation, in the exercise of
which he took great delight, and in pouring forth his contempt
against others, he did it with the attitude and voice of Kemble;
it was almost impossible not to feel the force of his manner, and
against myself he was particularly severe, and his poignant
expressions of contempt and indignity were most provoking and
overwhelming. When, however, a change of state occurred, I
felt so interested for his trembling and doubtful situation, that I had
even a bed put up for him in my own room. I had always some
case of this kind about me, and no one can conceive the sacrifice
of health and comfort it cost me.
This case, as well as the last described, may perhaps be
detailed more particularly in their proper place, to illustrate a
general principle, of far more importance than even moral
treatment. And even in moral treatment it will appear how
important this general principle is, to enable us to perceive how
we may best counteract the effects which may have arisen from the
operation of baneful causes: for by it we shall be able to trace
errors to their source, and without this, we can never counteract
and cure them. And this we can only do with certainty, by
possessing correct views of the origin, nature, and constitution
of the human mind, and of the correspondence which exists between
physical effects, and mental or spiritual causes: out of which
views this general principle will be educed, and it will be found
to be of universal application.
In this case it is evident, a system of moral and intellectual
treatment was required, in order to counteract and cure the
effects which had arisen out of the soil in which he had existed,
very different from that which was necessary for the previous
case; and it is equally evident, without such knowledge, it is more
than probable that neither of these minds would ever have been
restored to their balance, or right state.
He recovered, and his character appeared much improved by his
severe visitation. He became very much attached to me, and
wrote a great deal for me, as my amanuensis. It is worthy
of remark, that he remained of choice for a considerable time
after his health was re-established, on account of the dread he
felt at returning to the place and circumstances where his
disease had arisen.
It is remarkable also, that after he had been some weeks in
private lodgings, assisting his father, in his profession at the
Assizes, he, the very night previous to their intended return
home, made his escape to America.
It is singular, that the first case I had, as an insane
patient, after I left York, was his sister.
I might select a great number of cases, where I conceive such
attention was apparently one principal cause of their recovery,
and which I took under my more immediate care on this account,
and to whom I devoted much of my time, and made many sacrifices
of my comfort and convenience.
In order to show the importance of such attention, it will be
necessary briefly to explain the description and character of the
cases to which I more particularly allude, and that it may appear that
these opinions are not new, I shall quote from the first part of
this volume already published. I there say, “What is
called mania and melancholia, are for the most part effects of
the same power being overactive, but overactive in different
directions.” If the distressing passions are
overactive, we have melancholia,—if the animal
propensities, we have furious mania,—and if the
exhilirating passions, we have an exuberance of joyous
activity.
“This is a view not before taken, and will account for
much of the difference in the effect from the same cause.
This melancholy, or state of depression, caused by the activity
of the depressing passions, is to be distinguished from the state
of exhaustion and debility, which succeeds some violent
paroxysms, or which follows an exhausted state of body and mind
from overexertion, and assumes either an apparent melancholy
character, from torpor or partial suspension of mind, or is in
reality a case of melancholia of the most miserable description,
from the exclusive activity of these depressing passions, which
are then more likely to become the sole masters of the field of
action.” [16]
In the former mentioned cases, it appears, that the exciting
and depressing passions alternately take on habitudes of action, so that
it is still over excitement, but the effects, from its direction
being different, are diametrically opposed to each other: in the
one case, as I have already said, this nervous energy is employed
in exciting into activity the passions which exhilirate: in the
other, those which depress us.
This excitement of the depressing and exhilarating passions
alternately, is the most striking characteristic of the
insane. It is true, that both these states or stages of the
disease, if long continued and not well managed, are necessarily
followed by a third state of exhaustion. The systems of
body and mind are wholly worn out by exertion, and require rest
to recruit and manifest their renewed power, but changes from one
state to another is only a partial exhaustion; another class of
feelings become active, while the former are suspended, so that
the melancholy and “high state” are for the most
part, states of mind or changes in the direction of its energies,
and not that the melancholy have less than the furiously
malignant or joyous maniac, of that power which is equally
necessary to mental activity of every description.
For instance, I have known the same person sent at one time as
patient under the influence of religious melancholy, originating
in erroneous extreme Calvinistic views; and at another period in
the most joyous state of religious excitement, from having come
under the influence of extreme Arminian views. On the same
principle, I have by the most laborious process of argumentation
and the statement of what I conceive right views, produced a
counter-impression, given another character and form to the
disease, and in some cases, on this principle, effected a cure.
[18]
As these cases are much more common, and these views of much
more importance than mankind, or even medical men imagine; and as
many who possess a susceptible constitution of mind, similar to
those whose cases I have described, are living in the world in
this fearful and continual state of mental excitation, and of
course, may be on the verge of the same precipice, it is right
they should be warned of the danger to which they expose
themselves.
It need scarcely be mentioned, that the present constitution
of society is not in a healthy state. It is not bound
together by that order and sympathy which should exist, but on
the contrary, discord and disseverment prevail to an extent which
seem to threaten its decomposition and destruction. But too
many individuals are intoxicated with the fury of their
various passions and inordinate desires, and mad with the endless
anxieties and reverses they produce. One part of society,
as well as one part of the mind, is at war with another. I
wish it, however, to be particularly observed, because I shall
have to revert to the fact hereafter, that it is not so much
these exciting causes, or even the sad effects of these feverish
and wasting passions, that are in themselves so dreadful and
fatal, as they are when accompanied or followed by the conflicts
and condemnations of conscience. Wherever there is the
endeavour to overturn and sacrifice some confirmed and good
principle, that which is lowest is encouraged to struggle for
pre-eminence, and the mind suffers extreme misery and
distraction.
It is in this way that we often find minds that have much that
is amiable about them, are soonest overthrown; but in all cases
when (as in this and what is in fatality next to this, perpetual
domestic discord) the fire of our spirits, which should
give life, health, and support to our exertions, is not united
and clothed with that wisdom which ought to diffuse itself in
every useful direction; it is in an altered and dangerous state,
producing, according to this alteration of state, disordered
function, acrid secretions, and if long continued,
disease; and when disease is established, its state is further
altered, so as literally to “eat up the flesh,” and in one
form or another burns, scathes, withers, and consumes us, [20] but I need not now enter into all the
various evils, miseries, and conflicts in which the mind is
involved, and the dangers to which it is exposed, nor the
corresponding physical effects, nor show that even were these
extremes exclusive and improper, activity does not exist, but
where the understanding seems most completely called forth; still
we have reason to fear that we pursue the important duties of
civil life, whether it be the weighty matters of legislation, or
the scarcely less responsible exercise of the learned
professions, or what ought to be the binding and sweet influence
of faithful dealings in trade, and our common intercourse with
each other, in an improper spirit, and from improper motives, and
not with that singleness and simplicity of heart for each
other’s good, which alone is useful and safe; which we
could not fail to do, were we sufficiently aware, that in as far
as we depart from this purity of spirit, our views of truth must
be perverted, and our healthy vital energies
changed, causing fever, paralysis, or some
morbid state, and all our sympathies poisoned and
deranged. But I might find enough of matter for
illustration without detailing the effects of over-excitation,
arising from our mad desires after wealth, fame, and distinction,
or even the consequent distracting and overwhelming miseries of
misfortune, poverty, and starvation, in the modes and amusements
of fashionable life, to which sensitive persons, and especially
those who have made themselves morbidly sensitive, become, as in
the case last stated, the victims.
Excitable and cheerful persons often fall into states of
depression, purely because they have drawn too largely and
exclusively on their exhilirating passions; whereas, had they
drawn equally on the depressing passions, they would have
tempered and balanced each other, and kept the mind in its right
state; and such is the constitution of the world we live in, that
our duties require that both should have their relative and
appropriate share of exercise.
Persons, often, in company, think it necessary exclusively to
exercise the exhilirating passions, and they return home not only
with these feelings exhausted, but with the depression passions
assuming in their turn an over-active state, and in this state
they perhaps encourage a spirit of discontent, and peevishness,
making sad havoc of domestic peace, and producing an unhealthy state of
mind, an alteration in the state of the nervous energy,
generating an acrid and morbific matter in the system,
and ultimately disease, both in themselves and others. [22]
It is too well known that many who are all life and energy in
company, sink on returning home, into this state of apathetic
melancholy. This is especially the case with those persons
who are betrayed by their buoyant spirits and powers of pleasing
into extremes, exciting themselves by stimulus and other
excesses; and as they are often minds originally of the most
amiable constitution, they afterwards, when left to sober
reflection, are overwhelmed with self-condemnation; and should
they, to raise their sinking spirits, have again recourse to
stimulus, the evil is increased, and the effects are
terrific. It is to these painful and conscientious
conflicts, as much, and perhaps more, than the mere physical
effect of their excess, that the disorder and destruction of
their minds are to be attributed.
I mention these simple and common forms of irregular and
discordant excitation, to shew that from such causes the
susceptible mind gets into the habit which may terminate in
the more fixed and serious form of alternate states of
irresistible excitement of the exhilirating and depressing
passions, constituting insane cases, just as we find those of the
alternate over-excitement of the kindly and benevolent
affections; or, of the angry and malevolent passions terminate in
corresponding states.
How many persons live in this baneful domestic atmosphere of
perpetual storm and sunshine? And hence, when the mind of
one of these becomes morbid, and the malevolent passions assume
the exclusive sway, they are said to hate those they formerly
loved, which is simply the more permanent state of their former
fits of anger; in fact, every form of incipient insanity may be
traced with more or less ease, to these corresponding
causes. This may not be popular doctrine, but it is the
truth.
Many married persons get into this destructive habit of
indulging in these extremes of anger and affection; and where
they are known to have existed in no common measure, they
propagate this their state of mind in their children, and which
is afterwards most effectually and successfully educated by their
conduct and example; and hence such domestic circles are fruitful
soils in producing insane cases. I could state some fearful
examples of the truth of these observations, but I would gladly
throw a
veil over these melancholy pictures of human nature. The
sword may slay its thousands, but the demon of domestic strife is
much more destructive to man’s life, health, and peace.
I mention all these matters, to show that such are exactly, in
their incipient form, the cases which require the most delicate,
intellectual, and laborious attention. The delusions which
occur in an after stage, arise out of these habits, and until
they appear without disguise, it is difficult for strangers to
pronounce them insane; and yet these are causes which produce the
worst and most incurable consequences; and if cure is to be
effected, it can only be by a system of management, which by
calming and tranquillising the mind, will best allow the physical
effects to subside. But when this painful and irritable
state of mind has been of long duration, and some chronic and
inflammatory state of insiduous, slow, and gradual growth, is the
consequence; then a longer time will be required before cure can
be brought about. I may here remark, that it is absurd to
suppose we can expect this, by moral or medical means
singly,—they must always co-operate, and never be separated
in the mind of him whose object is cure: and it is a most
important and fearful consideration, that on their treatment
depends the increase or diminution of their disease.
To show there is the greatest difficulty, delicacy, and anxiety
required to be exercised in the management of these cases, it is
only necessary to mention, that they are precisely those, who, as
I have already said, though they are either in reality, or
ultimately prove the worst and most dangerous cases, can
nevertheless, in the incipient stage of the disease, and more
especially immediately after being placed under moral restraint
and medical care, exert their remaining power of self-control
over their delusions and extravagances, so as to appear, for some
considerable time, perfectly sane. Indeed, it may be
considered as a general fact, that where the insane person
preserves his individuality of character, and his alarming state
is chiefly indicated by his having his prominent peculiarities in
the natural constitution of his mind in a highly exaggerated and
caricatured state, (which is always a most unfavourable
prognostic, and more particularly if this exaggeration be
grounded in self-love,) the incipient stage assumes this delusive
appearance.
It is to such cases, in their incipient stage, that I have
hitherto devoted myself, and which I have had for the last
fourteen years constantly about me.
In devoting ourselves to such cases, we are doing no more than
we conceive to be our duty, nor do I conceive this explanation
makes, in all cases, our own house superior to others. In
some
cases, the reverse is the fact. This explanation is
intended to show the necessity of classification, and division of
labour. In many cases, so far from giving a preference to
ourselves, I would give a preference to the surgeon, matron, and
attendants at the other houses. In many cases, they become
attached to them, and prefer remaining with them. Besides,
a mere change is sometimes useful, and often operates as a
powerful check;—they are in their favourite
house,—they behave ill, and a threat of removal restrains
them. All this requires attention, and is assisted by the
arrangements described.
To show this is no new and fallacious view, manufactured and
brought forward for the mere purpose of my own defence, I beg
leave to quote from an explanation of the drawings and plans of
the houses and grounds, which were, according to the Act of
Parliament, sent to the Quarter Sessions at Chelmsford, now many
years ago.—Speaking of Leopard’s Hill establishment,
I said—
“At present there are no very violent cases,
and some that were so are convalescent, and when patients become
convalescent, they are often removed to my own house at Fair
Mead, in order to relieve them from painful associations; by
contributing in every way to their comfort and their happiness,
and by devoting ourselves more particularly to them, we
secure and expedite their cure; this removal is often most
expedient and useful, but it sometimes happens, [27] that they prefer remaining amongst
those to whom they have become attached; and they are then
removed out of the galleries, and have apartments in the front
and family part of the house.”
“Fair Mead House, I wish it to be distinctly understood,
is an additional house in the same grounds, but at a sufficient
distance to serve the purpose I have just stated,—the
purpose of humane classification, according to their state.
In fact, agreeable to these views, it may be considered as a
necessary appendage to the others. It enables us the better
to discharge a most important and delicate duty, that of more
closely watching, and more directly and personally attending to
patients during the incipient and critical stage of
convalescence; a period when, wanting such attention, they are
driven by a revulsion of feeling into their old state, or sink
from exhaustion, and die.”
“Again, by having three houses separated in this way,
and for these purposes, it not only enables us to divide the
males from the females, but also to devote ourselves to those to
whom a more delicate and intellectual attention may be useful,
in this critical period of convalescence, and it also enables us
to select such, whether old or recent cases, as are capable of
participating in, and not deranging very much the enjoyments of
the domestic and social circle. All which will include
convalescents; some incipient cases; some that are melancholy;
others that are imbecile; some that may be permanently deranged,
but very full of good nature, and not troublesome; and some that
are hopeless upon some specific point, but pretty correct on all
others.”
Another consideration of greater moment is, that persons
necessarily attach an importance to the house in which we more
generally reside, and even some recent slight cases feel none of
that painful repugnance in coming to us, that is usually felt on
the bare mention of a place of confinement, [28] and many come not only without
reluctance, but with voluntary pleasure. In my tables, sent
to Lord Lyndhurst three years ago, I there show that more than
one-third of the patients then received, had been so brought, and
“that I had always held forth to them the promise that they
were coming as visitors,” saying, “as long as you
behave as such, you shall be treated as such.” When they
forfeit this, they are deprived of their privileges, and, in some
cases, they may be sent to Leopard’s Hill establishment;
and in others, a threat of their being removed from this to Fair
Mead, answers the same purpose.
I consider it a point of the very first importance, that truth
should never be violated; we must, therefore, on no account, at
any time, deceive them, and more especially in the first
instance. If we begin by destroying confidence, we destroy
the basis on which alone all moral good can be effected.
Without truth there can be no confidence. It is quite a
mistake to suppose a system of deceit is necessary for the
purpose of more quietly accomplishing their removal from
home. I can conscientiously assert that my own experience
proves the contrary, and that I have not found in a tithe of the
cases which I have had to manage, any very great difficulty in
persuading them willingly to accompany me, more especially if I
had sufficient time given me to ingratiate myself into their good
opinion and confidence, which I do, by fully explaining the
object of their removal, the treatment I intend to adopt, and the
means to be used to make them as happy as possible in the new
circumstances in which they are about to be placed.
Whenever this was done, and I found them in a state to understand
it, which is the case in a greater number of
instances than most persons imagine, they have then almost
invariably been persuaded to come willingly, without using any
arts of deception.
I delicately, but candidly tell them, that they are considered
to be insane, that the disease has produced some change in their
usual mode of feeling and thinking, that the object of the
proposed visit is their good, and that if they will only go
willingly along with me, I pledge myself they shall be treated as
visitors, unless their own conduct should oblige me to act
otherwise towards them. If after all the pains I take, (and
no pains can be too great to accomplish my object in this
faithful way,) they still refuse, I then tell them, that their
going is a matter quite settled, and cannot possibly be altered;
that they may as well make a merit of necessity, and like
rational beings, go at once with cheerfulness, and good-will, in
order that they may still receive the good which I have promised
them.
If after such explanations they do consent to go willingly, or
even without much force, a grand point is accomplished; for in
this case, suppose after their arrival they grossly commit
themselves, and justly forfeit their claim to the treatment I
have promised them, and I am obliged to abridge them of the
liberty they had really given them, they then feel and often
acknowledge the justice of any change in their treatment, which is
the result of their gross misconduct, and they exert themselves
with the hope of regaining the liberal privileges they have
forfeited, and thus from their desire to be considered and
treated as visitors, they put forth into operation what is of the
greatest importance, the valuable principle of self-control.
In most cases, while nothing is more consoling to their
afflicted spirits than friendship, and the society of those they
love, nothing is more grievous to them than its loss. To
form such a feeling, is very difficult; but by beginning and
proceeding on these principles, showing them that truth and
justice and kindness are the basis of our actions, we establish a
wonderful moral influence over them.
It will often happen, however, in stating to them that their
minds are not considered in a right state, they will stoutly deny
it. I then assure them, I shall be very glad to find they
are right, and hope they will not force upon me by their conduct,
a different conviction. Stating to them very gravely, what
I understand has led to this conclusion, saying, if we judge by
the acknowledged rules of the world, they must confess there is
something very unusual and strange in their words and actions;
but at the same time, I trust they will not in future commit or
lose themselves, as it appears they must have done. In which
case I promise them I will myself befriend them, and endeavour to
replace them as soon as possible, in the confidence of their
friends, but which I can only do when their conduct will enable
me to transfer to their friends the confidence it has given
me. Many, of course, assert, that what others call
insanity, they know to be correct and proper; then I say, we must
have time to examine it at leisure, that it is too weighty a
matter to determine in haste. Where the person cannot be
made to comprehend all this reasoning, of course other methods
must be adopted, according to the nature, exigencies, and the
state of each patient. In fact, it is impossible to state
all that is, or ought to be done on these occasions; we can only
hint at the spirit of the procedure, for every separate case
requires its own appropriate plan of procedure.
To show the propriety and advantages in this method of
proceeding, I shall state the important fact, that some few have
at once been cured, without removal from home, by the powerful
influence of its candour and honesty.—And in all cases,
when, after all this labour and delicacy, they are removed, and
are, subsequently, on the same principles, and in the same
spirit, treated with every possible indulgence, and the greatest
degree of forbearance, even overlooking many lesser
faults, and waiting, until, as we say, “they break out and
commit themselves,” in some very decided manner, so as to
furnish us (even in their own estimation) with a very palpable
plea to abridge them of their indulgencies, they have then forced
upon them the conviction of their error, and are obliged to
acknowledge the justice of any change that is made.
It is singular, that many have on this plan been speedily
cured by the self-restraint this system conspired with other
things to give them; and many others have recovered without ever
feeling or considering themselves as having been treated as
insane patients; and most of them do not consider themselves as
under any confinement whatever. Not more than about 3 p.
cent. suffer any personal restraint, and not one for years under
any constant personal coercion, and we have, at times, been for
months together with not more than one patient whom we were
afraid of trusting in the grounds alone.
I must more particularly advert to this most powerful argument
in favour of this plan, which is, that it conduces to form the
habit of self-control, which is the habit above all others
which ought ever be our aim to form. It ought to be the
primary object in every moral plan of cure. But I shall
have some further observations to make on this principle, and the
various means which tend to form and increase it, in another
place. I only hint at these things at this time, for the
purpose of showing that all these delicate, modified,
conditional, and encouraging plans of superintendance are
assisted by the arrangements I have described.
In fact, so important have I considered this plan of
Classification, that when I first came to Leopard’s Hill
Lodge, I contrived the best way I could, with my means, to have a
family and front part of the house, independent of the galleries;
and should I be called upon to extend my plan to meet my
increasing success, and should my life be spared, and time and
health permit me to follow out my views and to build an Asylum
upon a larger scale, I should keep these principles of
Classification, as well as many others, in view, in the plan I
should adopt, for I am more and more confirmed that they are
extremely important; and I may mention as proofs, that at all the
houses we have had parties in the front part, who would, in their
conduct and pursuits, and social enjoyments, put to shame many
families who are reckoned perfectly sane. We have visiting
parties from house to house, with the usual amusements of cards,
chess, billiards, cricket, &c. For some months we
published a weekly newspaper of considerable interest. Nor
is it unworthy of notice, that some articles of a very superior
kind in our critical Journals have been written in this
place; all which gives it more an air of social enjoyment and
comfort, than the coldness and repulsiveness usually attendant on
the loss of liberty, and forms within ourselves a little world of
interest, better suited, I believe, to the state of the
inhabitants than the real world could be to them. It is, in
fact, a System of Classification, originating, if not in the most
enlightened, at any rate in the most humane considerations of the
various states and maladies of mental aberration, and which
enables us to exercise a powerful influence over those under our
care. It is in agreement with our conviction of the
importance of that which may be laid down as a maxim, that, if
the mind be maintained in a state of tranquillity, the affections
are more likely to be brought into a right state, the effects of
functional disorder, or even disease, to subside; the mists of
delusion to clear away; and the light of the understanding to
resume its province.
The last and most important consideration is, that this plan
has induced several (especially before the letter and spirit of
the law were opposed thereto) to return voluntarily on their
perceiving symptoms of their returning malady.
I could give, were it not that motives of delicacy forbid me,
some very striking and interesting cases, illustrative of these
facts and these principles, and the beneficial results which
arise out of them.
One
of these cases, illustrative of this necessity of more delicate
and intellectual treatment in certain states of mental
aberration, I am advocating, I may mention. It is that of a
lady who had been, upwards of seventeen years, in alternate
states of excitement and depression, and in confinement all this
time, whose recovery I attribute, combined with medical means,
principally to such attention.
This case was a most striking sample of a great number of a
similar description, who are the subjects and victims of this
perverse and irregular mental excitation, which become, without
proper management, more confirmed cases of mania and melancholia,
which continuance in this state for a sufficient time, produces
disease, and disorganization of the brain, and ultimately
terminates in incurable dementia, either of a partial or more
general character.
She
was a person of a highly sanguine temperament, possessing by
nature great capabilities, but her intellectual powers had not,
by education or circumstances in life, been so much developed and
increased as her energetic feelings, which were most excitable,
strong, and active. If her education had equalled her
natural endowments, her understanding would have assumed no
common pre-eminence, and in which case her feelings would
probably have been brought under due subordination. It was
not, however, so much even the defects of her education, as the
circumstances of her life, and especially those connected with
her religious associations, which were incomparably more
calculated to increase the strength and activity of her feelings,
than to call forth and cultivate her intellectual powers; indeed,
instead of any such cultivation in any proportionate degree,
there is every reason to believe, these associations had a
paralysing influence; nor perhaps were any habits of
self-control, or any mental restraint whatever, formed or
acquired in this connection, except that which operated too
exclusively on her religious and conscientious fears; and hence,
without entering into the details of her history, the result was
the formation of a character, such as is most common under the
present artificial systems and circumstances in modern times, ill
formed to withstand the effects of adverse or prosperous
fortune.
It was her lot to pass through these extremes, and after
suffering many reverses, mortifications, disappointments,
bereavements, and some matters of a private and most afflictive
nature, she had a rheumatic fever, when the explosion took place;
then the weak and over-exercised parts of her mind displayed
themselves in an irregular and increased degree. Her state
was an exaggeration of her former energetic and acute nervous
sensibility, operating alternately on the depressing, and
exhilirating passions.
When she came to me, for she had been in various places
previous to this period, she was in a state of religious
melancholia. Her conscientious fears were dreadful, and her
misery extreme. She conceived herself condemned to eternal
punishment—she was already in torture. When in this
terrible state, she had more power to engage one’s
commiseration, than any patient I ever had. Her
descriptions of her own state were extremely eloquent and
affecting, and her appeals for sympathy were overpowering and
irresistible, and I was absolutely worn out and overcome by the
fatigue and misery I endured in my efforts to console and restore
her. I shall always continue to feel the painful effects of
my anxious exertions in this and several similar cases of
melancholia; but no case and perhaps no number of cases, shook and
overwhelmed my nervous system as this did, (unless it be one
through whom I had a nervous fever); not merely because of her
extreme agony, but my own health and spirits were then in a very
depressed state, having been for years a martyr to chronic
enteritis and gastritis. I mention this to account for the
obligation I felt myself under, to dissever my sympathies from
this overwhelming influence, and to transfer her to the kind care
of Mrs. Allen, to whose lively and cheerful disposition, uniform
and judicious kindness, combined with great firmness and
gentleness, soothed and softened her melancholy state, and, in
time, tempered the extremes to which she had been subject, and
kept her spirits in a better direction.
One great art in this management was that of Mrs.
Allen’s making her useful as her deputy in every thing in
the house, either in matters of a household nature, or in
attending upon others. And notwithstanding her own
miserable state, no one was ever more qualified for a nurse, or
better understood every thing connected with the arrangements of
the table; and her very perfection in all these matters, had,
before Mrs. Allen came, been the cause of an increase rather than
a relief to her misery, for she became the object of great
jealousy and dislike to my housekeepers and matrons, on this
score: but now it became a source of employment, amusement, and
diversion. Though she long continued to possess, for the
most part, this disposition to fall into the same miserable
state, yet it never afterwards degenerated into that dreadful
agony and distraction I have described. At times it ceased
altogether, and her more happy state supervened, when she was
full of hope and self-esteem, of life and activity, the very
antipodes of her former state. But it is altogether
astonishing how both these states were lessened and kept in check
by Mrs. Allen’s manners, combining the most inflexible
firmness with admirable tact and good nature. When all her
almost exhaustless fund of sympathy failed, it was always found a
sufficient check, and at once to call forth our patient’s
powers of self-control, for Mrs. Allen to say that she really
could not bear the association of her miserable state any longer,
and that they must separate; and it was very seldom necessary to
hold out the threat, that she must be removed into the gallery
and back part of the house.
Perseverance in this system of unwearied and perhaps
unequalled kindness, gradually mitigated and diminished these
alternate states of excitement and depression; thus shewing to
demonstration, that in this way, with the aid of medical
treatment, the excitement of the depressing and the exhilirating
passions may be checked and restrained, so that in time they may
regain their due equilibrium;—that instead of these cases
degenerating, as they have almost always done, into hopeless
cases of mania or melancholia, and often terminating in complete
dementia, they, by this system, might in process of time regain
the due equipoise, or the relative and appropriate share of the
exercise of the different functions of mind, and be brought, as
in the case just described, to repossess the greatest of
blessings, the healthy action of the feelings and faculties in
the discharge of those duties which constitute alike the object,
the usefulness, and the happiness of her present existence.
I mention such cases, because I shall hereafter do all I can
to draw attention to similar mental states, as the common causes
of insanity. That almost all cases begin in this
way, but that they are disguised or kept from our view, with
those who possess self control, until (unless the tendency be
cured by such efforts to disguise it) they at last burst forth
into some form of insanity; and indeed insanity itself may be
defined generally, the uncontrolled over-excitement, imbecility,
suspended or paralysed state of one or more of the mental
functions, arising from some previous faulty state of
action. I shall have to show hereafter how all these cases
might in their incipient and curable stage have their
specific modes of moral and medical treatment applied in order to
counteract and cure them; and by this method incurable cases
would be almost unknown.
At the same time let it be observed, that such treatment
requires much more delicate and intellectual attention than is in
the power of those who for the most part live amongst the insane,
and, have the direct and important management of them; and that,
in justice to ourselves, I have a right to assert, that where
such treatment has existed, and does exist, it is not a matter
which money can remunerate, and that in this case there was no
pecuniary reward. It was no such inducement that had any
influence in regulating the conduct which we pursued with such
unwearied diligence; and not merely was there no pecuniary
reward, but even gratitude was wanting for a time; for this
attention was so delicate, that she was always made to feel she
was the person conferring rather than receiving favours; so that
when she was relieved from her depressed state, and it was
superseded by the excitement of the exhilirating passions, her
self esteem dwelt only on the favours she imagined she had been
conferring. She was useful, but her usefulness was
more for her own good than for ours. Indeed, we paid the
price of patient endurance to a degree and extent which can never
be conceived or known, still less was she in a state to perceive or
appreciate our motives, therefore she conceived, and was
confirmed in the impression that she was actually the person to
whom obligation and gratitude were due. This impression was
the last remains of her disease, or of that over-excitement of
the exhilirating passions, which with the longer-continued
paroxysms of the over-excitement of the depressing passions,
constituted the character of her case; and she left us, not
merely before the “high state” had solely subsided,
but at the very time when we felt it to be our duty to restrain
and subdue it, and of course when she felt most mortified, and
was least able to perceive and appreciate our motives, but which
she has since done to our entire satisfaction.
She has now been upwards of three years in the world, engaged
in useful and active duties, and though she may be liable to
extremes, and be too susceptible of the action of exciting
causes, yet I have every reason to believe, that experience has
taught her the necessity of counteracting and restraining their
baneful influence. I am told by her friends, that now
collision with the world having smoothed down the peculiarities
which her long seclusion had contracted, her character appears
much improved.
I might detail many such cases, and prove that cures
have apparently been effected by this intellectual and delicate
attention, and more especially in some slight and incipient
cases. But I may also state, that many cases of the most
serious kind have been so treated, and have recovered. I
particularly have in view, two cases of the most determined
suicidal melancholy, that were so delicately treated and watched,
that they were not themselves aware for months, they were even in
a place of confinement, or they had an eye of anxiety constantly
watching over them. To this watchfulness and constant
exertion to amuse and divert them, I principally attribute the
gradual diminution of their melancholy, and ultimately their
recovery. These cases, No. 412, and 373, have each returned
three or four times of their own accord, and have each time,
under this system, gradually recovered.
Is it not then of importance that we should do every thing
possible to lessen the present feelings of horror associated with
such places? then might we expect to find them come of their own
accord, have confidence in their medical friend, concur and
co-operate in the plan marked out for their cure, and the
consequence would be, that we should find them generally
recover.
And was a most distressing case of hypochondria, which had
from various causes been increasing upon him for about twenty
years; and when he so came, he was in the most depressed and
melancholy state possible. His whole mucous membrane had
long suffered from chronic inflammation, and was in a state of
the greatest irritability. He was, in less than nine
months, altogether another being; his habits were altered, and
his health greatly re-established; and this person was one whose
cure was partly to be attributed to my mode of amusing him.
I do not mean to enter into his particular history, or his
medical treatment, for it would itself make a volume; but I
introduce a brief notice of his cure, for the sake of
illustrating the foregoing principles of Classification, and to
show that a variety of methods are necessary to accomplish the
object we ought ever to have in view, and that it would never
answer to apply indiscriminately the same medical or moral
treatment to any two cases.
A plan was proposed to spend an hour at least with him every
evening, and this hour I devoted to that of detailing to him a
history of my own life, always contriving, in the style of the
Arabian Nights Entertainments, to break off suddenly at some
point of interest; and these conversations, had they been
committed to writing, would have formed some very amusing
volumes. The great art and merit of the plan consisted not
merely in making them amusing, but in contriving to introduce,
without appearing intentionally to do so, (that I might not in
his over sensitive state offend him), facts and views calculated
to counteract the errors and bad habits into which he had
fallen.
In all cases it is necessary to know every extreme view and
error to which the human mind is liable, and where these exist,
as inmost cases of insanity, to endeavour to counteract them by
clear and beautiful views of the truth.
What is of the greatest consequence, is that it is still more
necessary to know the best mode of making truth admissible and
effectual; for it ought never to be forgotten, that in all cases
where error and delusion exist, even if we know those views which
are best calculated to counteract and remove them, still more
depends on the manner, circumstances, and spirit in which we
present and apply them. I am anxious to draw attention to
this truth, because it appears to me the world at present has no
adequate conception of this great and necessary art in its
propagation: still less does it appear that mankind, nor even
many medical men, have formed any proper estimate of the vast
importance of such a system in the treatment of the insane: a
system, however, which requires that we should be fully acquainted
with the history of man, and be able to perceive the causes and
effects of false and perverted views of philosophy, morals, and
religion, and above all that we should possess a knowledge of the
constitution of the human mind, with all the specific differences
of every individual case.
I mention this case with others, to show that there are many
instances where something more than common attention is required,
and that to such patients we devote ourselves, and have them at
our own house for this purpose. These are precisely those
who are over excitable. They form a large proportion of the
insane, and in their incipient stage, their minds are rather in a
state of perversion, than absolutely lost or deranged; whose cure
depends on correcting this perversion, and restoring the relative
and appropriate share of activity and energy to each function, in
the exact measure, proper place, and according to the order of
their right distribution.
If then, these houses serve these various purposes, who is
best able to judge when such purposes can be best served?
The exact moment lost can never be regained! a wrong word, or
even look, may unhinge, and bring on a relapse! It is a
species of discipline like that of a nursery;—children
commit some fault, and are removed from the objects of their
affection as their punishment; and no punishment is greater or
more effectual. Some of our circle break out into passion,
or give way to some strong propensity; they are told it
won’t do, and are removed: they soon promise to behave
better, and return. The causes are sudden and unexpected,
and sometimes trivial; and this mild medicine, instantly
administered, has a wonderful influence. Sometimes the
attendants will be better suited for some specific cases at one
house than at the other; and it may be injustice to other
patients to change them, but great justice to change the patient
on their account.
When I state to patients’ friends these matters, and the
difference of these houses, I say decidedly, that in those cases
to whom our attention, and the comforts of the domestic circle
may be useful,—those friends should, if they possess the
means, prove, by a corresponding remuneration, that they duly
estimate such delicate attention; particularly as they do
generally acknowledge that it is not in the power of money to
compensate for the expenditure of so much feeling, and being
subjected to so much annoyance. In all cases where it
appears this attention and placing them in our domestic circle,
will contribute to their comfort or their cure, we, as a matter
of feeling and of duty, treat them with equal kindness and
attention, always giving considerations of comfort and of cure,
the first place.
Besides, most cases are improved by association with
those of a different character. I have seen many old torpid
cases, and a still greater number of recent cases of suspension
of mind, cured by being placed occasionally among those who were
in a more lively state, and this after every other means had
failed.—And it is reasonable, for nothing can exceed the
comic effect of the strange and laughable speeches and manners of
some among this class of patients; and, in the case, the
treatment of which was altogether mistaken or mis-represented,
there was surely nothing incredible or unreasonable in saying I
preferred, that this lady should have the chance of being roused
out of her torpid state, by remaining at Leopard’s Hill
Lodge, where of course, she might have these means occasionally
put in force; for all the females were then at that house, and at
the same time, she did possess the advantage of every possible
delicacy of attention from Mrs. Allen, who was, with her children
and an additional number of servants, then living altogether at
that house.
The case No. 335, was, as I have already mentioned, always
soonest roused out of her melancholy condition, by being placed
for a short time in the midst of such association. It would
be contrary to the economy of providence, as exemplified by the
constitution of society, to place all the melancholy in one class, and
all the lively in another. The truth of this argument
receives additional confirmation, when we consider, which I am
prepared to prove, that insanity in many cases, is produced by,
and consists of, an aggravation of the original peculiarity of
character, and therefore it is evident, that such collision, like
collision in the world, is making one extreme tend to correct
another, though of course, the worst and most dangerous cases of
every description, are not in their treatment included in this
principle.
Many instances are recorded, of two opposite cases, by being
thrown together, neutralizing, like an acid and alkali, each
other; that is, the melancholy have been roused by the lively,
and the lively depressed by the melancholy, and thus both have
been brought into a better state.
Sometimes the insane have been cured by witnessing their own
case caricatured in that of another. For instance, two
proud men, the victims of their gradual and progressive false
estimate of themselves, assume in their insane state, the same
crown and kingdom, and by witnessing each other’s delusion,
have been forced to feel that one must be in the wrong; and thus,
one or both were brought to reflection, and ultimately to a more
sound and sober state of mind.
Even the imbecile and idiot, are roused and improved by
such associations, more than they had been, even with every
endeavour to improve them, while they were in a state of
seclusion. I have lately had two very remarkable instances
of this kind.
Imbeciles, though they were from birth, they improved after
their arrival; the scene was very different to the solitude in
which they had been placed; the common scenes and circumstances
of life, had not had sufficient power to rouse the dormant and
torpid state of their mental functions, while scenes and
circumstances, that are in themselves very painful, were better
calculated to arouse in their moping minds, something like feeble
efforts of reflection. I have seen them behold the strange
antics of others, with intense wonder and interest.—Often
they will catch the contagion of laughter; and thus if the
understanding has no part in the matter, their spirits, at all
events, partake of the merriment of the scene around them; and
though insanity, considered in the abstract, is a melancholy
thing, yet it is a truth, that there is much more of merriment
than melancholy among the insane. I believe their average
of happiness is greater than would be found among the same number
in the world. Those who look with prejudice from
impressions received from a few extreme cases, of course
make out a different conclusion. Again, there is another
consideration, which further proves that the happiness of these
imbeciles and ideots may be increased by such association.
They have still the blind affections craving for food, and they
here find food for their gratification, better suited to their
state than they could find it in the world. These
affections without understanding, are to the world
repulsive. It is strength of affection, guided by strength
of understanding, that so powerfully attracts and binds society
together. In this sphere they cannot revolve; here,
eccentric as it is, they have one better suited to their
state.
I daily see ideots and imbeciles taught to walk arm in arm;
evidently pleased and gratified that they have objects for their
blind affections to rest upon. Besides this, it is a very
singular and remarkable fact, that this exercise of their
affections, has contributed to the improvement of their physical
state. Whatever increases innocent enjoyment, and
contributes to happiness, are excellent medicines. Peace
and purity of mind are better than physic. This exercise of
their blind affections conduces alike to their felicity, and to
the preservation of their health, by innocently keeping alive the
regular and happy exercise of their animal spirits, by the only
outlet they possess, that of their blind and instinctive
affections; and hence, it is very remarkable, that in consequence
of their animal spirits being no longer pent up, as was formerly
the case, they are not now so liable to those sudden bursts and
irregular displays of passion, to which they had been the
victims; and what is still more remarkable, they are in better
health, and not so liable to cramps and colics, which had been
the corresponding physical effects of their irregular nervous
distribution; so that even with them the truth is evident, that
it is not good to be alone; the little world they live in is
better suited to amuse and contribute to their happiness, than
the quietude of civilized life, from which they could receive no
enjoyment, and to which they could only give pain.
It is also worthy of remark, that some patients sink more
rapidly into moping idiotcy when kept in a state of perfect
seclusion, than they even do in the society of those who are
insane like themselves.
I have seen patients who had not been accustomed to any
association, who were, on their first arrival, in appearance,
manners, behaviour, especially in their mode of eating, and their
dirty habits, scarcely human; it was evident from all this, that
they had long been unaccustomed to the common conveniences and
decencies of life, as well as from the astonishment and delight
they first exhibit, on these things being restored to
them;—to see companions, and to find a table with the usual
appendages of knives and forks, &c. evidently excited
pleasing reminiscences and gave them additional life,—their
improvement (externally, at any rate) was rapid, and, by
continued attention, their restoration to habits of cleanliness
complete.
To insure all these as well as many other advantages, and to
make cure the primary object, requires not only that the
proprietor should live amongst them, but also that he should be a
medical man, and one who has experience, guided by upright
principles and Christian feelings; for if medical men of talent
and character could be induced to undertake this painful and
anxious life, submitting cheerfully to all these sacrifices and
inconveniences, much might be done to improve this neglected
department of medicine, and augment the number of cures; at all
events, most certainly increase the comforts of the incurable,
and lessen the distressing apprehensions of those who fear the
accession, or recurrence of mental aberration; yet
notwithstanding the paramount importance of these things, so
ignorant or so blinded by prejudice is the world on the subject,
and so little aware of the talents and capabilities required for
such a situation, that they consider the very name of a
proprietor, and superintendant of an asylum, as absolutely sinking the
character in public estimation; whereas no class of medical men,
were they efficient, should be considered more honourable,
because none can be more useful than those who devote themselves
to the cure and comfort of persons in this most lamentable
state.
When the gloom and horror at present thrown around
establishments for the insane shall be cleared away,
Dante’s inscription over the gates of Hell, will be no
longer applicable to them,
“Lasciate ogni speranza, voi, ché
ntrate;” [55]
this, or perhaps another passage from Euripides, has been
imitated by our 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.
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.
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.
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.
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.
