Part 6

“The safety of those who attend upon the insane, is certainly an object of great importance; but it is worthy of enquiry whether it may not be attained, without materially interfering with another object, the recovery of the patient. It may also deserve enquiry, whether the extensive practice of coercion, which obtains in some institutions, does not arise from erroneous views of the character of insane persons; from indifference to their comfort, or from having rendered coercion necessary by previous unkind treatment.”

But there is another fact to be considered, not hitherto contemplated by any writer, and which is well expressed in a letter I received from a friend, in answer to one requesting his opinion in a case {57} wherein its importance has been shown to demonstration. He says, (and he is a man of great humanity,) “I am most solicitous that the distinction should be understood between those who cannot act and think or decide for themselves, and those who can, and who, sensible of their defective state, or of the approach even of absolute derangement, can of their own free will, place themselves in a situation, where they know that every medical and moral means will be used for their restoration. It is of the utmost importance, that the legislature should have it completely demonstrated to them, that there is a condition of the insane never contemplated by any legislator; the judicious management of which, is of the greatest consequence to them. Instead of the mental malady being allowed to proceed, until the sufferer is introduced into these retreats by force, its first approaches will be yielded to as soon as recognised, and the unhappy individual, whilst still in the possession of reason, will voluntarily or by gentle and affectionate solicitations, enter some refuge for mental distress, where, separated and secluded from the scenes and circumstances which were hurrying on intellectual destruction, he may, in a short period, in a condition of comparative happiness, escape the most tremendous calamity with which human nature can be assailed.”

I believe all the former evils connected with the management of the insane, have arisen from ignorance of their state; and therefore I am anxious to be perfectly understood, and labour most earnestly to correct this erroneous impression; and not only so, but I wish to prove the popular prejudice, that they are all ill treated, to be no where, as far as my knowledge extends, true or deserved; neither am I aware that this branch of medicine has been more abused than others; nor do I know in all my experience, of any unjust confinement for interest’s sake; there may be ignorance of the treatment required, but surely in these enlightened times, a medical man of any character can never lend himself to any thing so suicidal to his own fair character and prospects. I know, on the contrary, of evils arising from over caution in the other extreme. I am perfectly convinced that no insane person, should be without medical superintendance, and that to be placed singly in private houses, not medical, I know from experience to be sometimes most fatal and destructive; some few, it is true, are above all praise.

Sir Andrew Halliday after stating the number of insane, who are known and registered according to act of Parliament, says, “there is a number, if not equally great, at least nearly so, of whom the law takes no cognizance, and whose existence is known only to their relations and friends. These consist of individuals placed in solitary confinement, with persons who take only one patient. This is a state of things which ought not to be allowed to remain as it is, for a single hour, in this boasted land of liberty; I do not say, that it ever has taken place, though I have known one or two instances that might almost bear such a construction;—but I maintain that it may take place, for there is no law to prevent it; that individuals may have been sent into such seclusion, who never suffered from the pangs of madness; and it must be evident to every one who gives this subject the least consideration, that it only requires a faithful keeper, and that watchfulness, to retain such a person in prison for life. This number is said to have been prodigiously increased by the new Act.”

At the same time it must be allowed, that many incipient cases, requiring seclusion and separation from friends, would be aggravated by too sudden an introduction amongst masses of insane patients; and even by the very circumstance of arriving when there is the chance of exciting the usual horror and prejudice entertained against such places; but this ought not, and would not be the case, were the plans and systems of classification I have advocated, carried into practice. Every way and in every thing, we have imperfections and abuses; and it is much easier to condemn than to cure them; and they who at once believe abuses exist in proportion to the popular description that is given during some temporary excitement and prejudice, are not safe persons to have the important charge of removing them. I make these remarks, to show, that while a paternal government is justly, most anxious to protect the persons and property of those who can no longer protect and defend themselves, they should at the same time remember, that sanity of mind is still of much higher value; and that therefore concern about the property should not out weigh our concern for the cure.

I say nothing in the mean time, of the degrading suspicion and paralyzing interference, which the best and most conscientious man may under such system feel, in proceeding with the plans which, he from experience, knows to be essential to their restoration; but I contend, that the _common error in legislation_, _of making property of more value than life_, must here as well as wherever it is committed, have a baneful influence. In this instance, the acts or laws made under the influence of this very great and very selfish delusion, produce this very serious mischief, that they tend to increase the prejudice and aversion common to places of this description, some of which would otherwise be considered not merely unobjectionable places of residence, but places of seclusion, very agreeable in themselves, and most desirable as places of cure.

In many complaints, change of scene and association, are justly considered necessary to the restoration of health. It is not only the same in many cases of insanity but absolutely the first and most important step in every system which gives them a chance of restoration. Should then a bare residence in any place for the mere purpose of cure, be accompanied (in very many cases, it is unnecessary,) by an act which is considered as fixing the mark of degradation upon them, any more than it should in any other disease? This, instead of healing, is calculated to crush a heart already breaking; it is often fatal to their recovery! it is a principal cause of frequent relapses! They feel a stigma, thus fixed on their character, so confirming the prejudices of the world, and so encouraging that distressing and fatal look of suspicion towards them, that they are forced to feel that no one reposes any faith in them; and if this feeling does not ultimately destroy all comfort and confidence, all order and stability within them, it must very much weaken that concentration of energy so necessary to the successful exercise of all mental operations; and if their minds are weakened by previous attacks, and not well sustained by right principles, but on the contrary, like many others, merely regulated by worldly principles and considerations, then, they are not only deprived of the rock on which mind is based, but also of all the motives and objects which stimulate to mental action. In this state, what is mind but a sad wreck floating on the fathomless ocean of life, at the mercy of every wind and wave? To what else shall we compare its situation?—It is like a city broken down and without walls, any enemy may enter in, and overthrow it. Can we wonder then that persons whose minds are in this position, and whose prospects in life are thus blasted, should have a recurrence of the same awful visitation? or what is worse, that they should constantly feel their spirits paralyzed, and a melancholy gloom thus thrown over the remainder of their existence!

To make it necessary in all cases to have certificates, so far from being a security against abuse, is more likely to be a cloak for those who may wish to take advantage of the patient’s defenceless state; whereas in cases of voluntary seclusion, there can be no risk; for with such honourable confidence, we have at once, the proof and the security that it cannot and will not be abused. These, however, are not the most desirable inmates, as it regards the ease and comfort of the superintendant, and therefore no one can have any other motive in recommending this practice of voluntary seclusion, but that which arises from the conscientious consideration of its being more conducive to cure.

That all should have the sanction and concurrence of medical recommendation, is every way indispensable; but what I argue for is, that this should be done, in the manner best calculated to make it appear to the patient, that cure, and not mere confinement, is the object of the measure they are recommended to accede to without reluctance. That a great number will require certificates, and all the aid of authority, to make them submit to the measure, is certain; and in these cases, the law, so far from being a hardship, is a great convenience and advantage.

Again, violent and extreme cases may be said to certificate themselves, in these there can be no risk of making any mistake, and doing any injustice in the first instance; the injustice may be afterwards in improper treatment, and in over detention. But to prevent all such abuses, we must first make men perfect, and then we should have no diseases to cure. It is certain, that under a proper system, ameliorated by all these plans of procedure I have stated, it is astonishing how these violent and extreme cases would become less prominent. I believe they would not average five per cent. at any one time; and take the average of a number of years, and I suppose it would not be more than half that number. I am certain the proportion, during sixteen years of my experience, has been much less than even this; it is seven years since we had occasion to treat any one single case as a constantly furious and dangerous maniac; and even suppose, such cases, under the best management, were more frequent in occurrence, and continue in this state for some time, how easy it would be so to contrive an Establishment, that these violent cases should not annoy or disturb the rest; and when thus managed, so far from their influence being hurtful, they would become interesting and salutary objects of reflection and commiseration to those who are in a better state; and often, by example, would teach the greatest of all moral lessons, that which holds the primary place as a preventive, and is always a necessary adjunct in the business of restoration—self control.

In fact, every system of management that does not make this principle, of mildly calling forth and gently exercising this internal principle of self-control on matters that are least connected with the diseased parts of the brain, a constant and primary object of attention, is not merely defective, but exhibits very great ignorance of the attributes of mind, as well as of the causes and nature of its maladies; and it follows that, as a system, it must be without any clear principle to guide its physical and moral treatment. In all things, we ought to remember, and especially in a matter of such importance, that we can do good only so far as our knowledge extends; and even this knowledge is useless, unless we are zealously desirous and able to reduce it to practice. Whatever may be our proportion of knowledge, zeal, and ability, it cannot be arrogance, when called upon, to say, that I believe this principle is more brought into practice by the plans and arrangements I have described, than is the case with any system of treatment in any place that I have hitherto heard of or seen.

It is not known, as it ought to be, how powerful with the higher class of patients is the principle of honour; with many, a sense of religion; and with _all_, the fear of losing the approbation and friendship of those who are kind to them; as well as, from selfish motives, to secure the liberty and indulgences they have enjoyed. These means, and every principle which operates on human nature as checks on one part of the mind, and as encouragements to another, should be constantly and steadily kept in view, for the purpose of never losing an opportunity of instantly bringing them into useful, and of course successful, operation.

It is on this philosophical system of kindness, that every thing should be so contrived that the principle of internal self-control should be excited, and kept in exercise; and thus, being brought to depend somewhat on themselves, the depressing effects of the absolute restraint of fear, induced by harsh measures, and the tyranny into which a mere place of confinement with walls, and bolts and bars, must almost necessarily degenerate, is avoided.

The propriety of these measures will receive additional confirmation, when we come to consider the causes as well as the nature of the evils which we are called upon to combat; but it may in the mean time be sufficient to state the appalling fact, that insanity is very often the consequence of early over indulgence.—I have frequently had to remark that an only child,—the youngest, or one brought up by a grandmother,—were the victims of a system of gratifying the feelings, without due attention to the cultivation and exercise of the understanding, as the delegated power destined to guide the future man.

There are few minds, even amongst the insane, who are not accessible to the salutary influence of this kind and liberal mode of proceeding. It is true, that many paupers, who have long been subjected to a very different system, are scarcely receptive of any of the impressions which belong to human nature; but with a higher class of patients, this can seldom or never be the case, unless it be in cases of absolute dementia. Even in the height of the most furious paroxysms, it is astonishing how much may be done by liberality and kindness. Nothing but absolute necessity should justify absolute restraint. It must always be considered as an evil to which we are reduced, in order to avoid a greater. Whenever it is unnecessary, and continued too long, it will do more harm than good: the furious will be made more furious, and the suicide more determined to effect his purpose. Whenever the patient is indulged with more liberty and behaves better, we must have forbearance to the utmost extent, and submit to all possible risks, losses, and expenses, rather than again have recourse to it; and when it is repeated, the patient must be made, if possible, to feel that it is deserved.

Their faults, like those of children, must be viewed with pity. They are the wild displays of feeling, without understanding. We must make excuses for them; often overlook, as often visit them slightly, only seldom with seriousness, and always with moderation, justice, and prudence. No evil is greater than the evil of constantly chiding and suspiciously watching for faults. It is an evil spirit that poisons and inflames every thing within its sphere. A contrary spirit has a healing influence; and though it requires numerous attendants, and makes the whole business of superintending the insane a source of constant and intense anxiety and solicitude, yet it is pleasing to have it in my power to state many “striking” examples of its efficacy, but I shall, notwithstanding, content myself with only slightly glancing at two or three.

_No._ 372.

I shall not at present give the particulars of this interesting case, except so far as is necessary for the purposes of illustration.

When he came from a private Asylum, he was in a state of the most furious, destructive, and malignant excitement, and had been in this state for so many months, that he was considered by his friends as an incurable case.

I attribute his cure, chiefly to his being treated with apparent confidence, and induced to work with a spade, when even in his worst state—a state so dreadful, that the least word or wrong look would have roused him to commit some dreadful act of vengeance, and it therefore required two men to be constantly in attendance to watch him, and this without appearing to do so.

He was induced to work with willingness, by being brought to believe he had the contrivance, management, and superintendance, of some improvements in the place; such as some alterations in the garden, and especially that of making a new road from one house to another, which now bears his name. It was observed, that after a hard day’s work, especially if he had profusely perspired, he had a more sound night’s sleep, and awoke somewhat improved in the morning; it is, however, to be remarked, that all this time he continued to have a regular system of medical treatment, which consisted in small repeated bleedings with leeches, averaging about three times in the fortnight, with purgatives, alteratives, and salines. It is impossible to conceive the delicacy that was observed towards him. Not a word or a look was done to offend him, let him speak or act ever so provokingly; and he was as perverse and as provoking, as it is possible to conceive a perfect dæmon to be. His was the exclusive excitement of anger and malignity, combined with the most acute cunning to effect his destructive purposes. The serpent, the wolf, the tiger, and vulture, seemed all that remained of the man. In this state, to bring the better parts of his mind into life, was a great difficulty. However, perseverance in this system restored him; and never was gratitude greater, or more substantially evinced, than has been by his conduct, and by that of his friends.

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I can truly say, with Dr. Haslam, that “by gentleness of manner and kindness of treatment, I have seldom failed to obtain the confidence, and conciliate the esteem, of insane persons; and have succeeded, by these means, in procuring from them respect and obedience;” and I am of the same opinion with Mr. Samuel Tuke, wherein he states “that a large majority of the instances, in which the malevolent dispositions are peculiarly apparent, and are considered as characterising the disorder, may readily be traced to secondary causes; arising from the peculiar circumstances of the patient, or from the mode of management.”

It is worthy of remark, that where the patients have known the superintendants when in a convalescent state, or in a state still capable of estimating the kindness shown to them, they will much more readily submit, and show much less of anger and vindictiveness, even in their insane state. This effect will be still more striking, if they have been in a place where a severer system is practiced, and where they have become depraved and brutalised, by being subject to too much coercion. Of this I shall state as much of a very interesting case as may illustrate this great and important principle.

_No._ 395, _admitted Dec._ 3, 1829.

This patient, on her first admission, was suspicious, vindictive, and implacable,—refusing food, and medicines, &c.—after recovery, and returning voluntarily, she was confiding, affectionate, and submissive, comparatively, even in her worst state.

On my seeing her at her own home, at the time of her second admission, she instantly said. “Good God! had you been here three days before, you had saved me!” On asking if she would like to return with me, she instantly said, “above all things in the world.” She came, and was apparently well in about ten days, and so continued for about seven weeks, when she returned home: but in less than a week she came back in the most raving and furious state, and yet nothing apparently dangerous or vindictive; on the contrary, she showed affection and attachment to us all; and if she displayed any vindictiveness, it was connected with some past recollections: but this has been slight and evanescent, compared to that which she exhibited in her former state;—a testimony, even from among the insane, which shows how much depends on the directions we give to each other’s mental energies. In this case, long walks in the most secluded parts of the forest, often removed or lessened an approaching paroxysm, and always superseded the necessity of having recourse to any restrictive measures. She is now perfectly recovered, and returned home.

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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.