Part 8

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.