Part 7

It has been, that restraint was resorted to, from the idleness and carelessness of keepers; and in these cases, when restrained, being neglected, they acquired dirty habits, very often, simply from the effect of custom inducing a disregard and insensibility to the discomfort of their filthy state; sometimes they acquired these habits, from, in the first instance, a determined vindictive motive of teasing those whom they thought had acted unjustly towards them, as the only means they had in their power of gratifying their revenge. In cases of debility and approaching marasmus, the effects of retention, when they are thus deprived of the power of relieving themselves, soon destroys the natural and healthy functions of the sphincters. I have often known a contrary system cure all these habits especially in the two first class of cases mentioned; though, in other respects, the mind remained the same. In the case last described, good and judicious management may retard the progress of the disease; but the system gradually decays, like a tree stripped of its bark by lightning.

As a proof, we have only a choice of evils, and we must always choose the least, I shall state a case.

_No._ 421.

This patient who had been several times under my care, was one who was soon made worse both in his bodily and mental state, by any restraint, however mild; and therefore we submitted to the losses which his very destructive habits occasioned, rather than have recourse to them. These losses were enormous. By this treatment, he so far recovered, that a medical friend, who had known him all his life, declared, on an accidental interview in the grounds, that his mind seemed in a state of integrity, as perfect as he had ever known it to be previous to the accession of any symptoms of Insanity.

In this state, he was removed by his friends from, I believe, parsimonious motives, to Bedlam, and this was done in spite of my positive opinion, declared in writing, that it would be fatal to his bodily and mental health, and that he would sink under the depressing effects of his situation. In less than six months, he was covered with ulcers, and a mass of disease. In this state he was removed to his own house in the country, where he recovered his bodily health, but his mind is gone for ever.

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I could adduce, to illustrate the same principle, many cases similar to the last, and indeed so powerfully have I felt impressed with its importance, that I have frequently written letters to, and had conversations with, the friends of patients, stating, that from the nature and state of their case, we had only a choice of evils, and therefore it was better to run the risk of rather overmuch liberty, than the positive evils of goading and exasperating them by what is generally deemed, particularly in these cases, necessary restraints and confinement. In most instances, they have not only fully entered into my views, and given me their necessary co-operation, but also readily agreed, that, if in consequence of this liberty any accident should happen, they would acquit me of all blame, and we have hitherto been most providentially favoured in having none of any moment. It is true, one very peculiar patient takes advantage of this indulgence, and visits his friends without leave of absence; but so far from any blame or anger on the part of his friends against us on this account, they are pleased to see him, and he is always on these occasions very happy with the idea of having given us so much trouble, and at the same time, he shows he esteems our kindness by willingly, readily, and cheerfully returning to us. Indeed as we have no case which better illustrates the principle for which I am contending, I shall here introduce so much of its description, as may be necessary for the purpose of enforcing its importance.

_No._ 396.

It is a case, where little insanity is observable in his conversation, but appears almost altogether in this constant propensity to indulge in destructiveness—breaking windows, tearing his clothes, &c. The more costly the articles he destroys, the more pleasure he seems to have in the indulgence of this propensity for mischief and evil. By over-much confinement and coercion, this patient would soon have become a settled case of furious and destructive mania; but by great liberality, and using restraint occasionally, the habit is much lessened: still, however, the propensity exists, and might be easily aggravated. A week of the usual coercive measures, would make this case degenerate into one equally malignant and murderous as that of Walsh, whose character is given in the Sketches of Bedlam.

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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.’”

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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.