Part 11

As most men perceive the faults of others without being aware of their own, so insane people easily detect the nonsense of other madmen, without being able to discover, or even to be made sensible of the incorrect associations of their own ideas. For this reason it is highly important, that he who pretends to regulate the conduct of such patients, should first have learned the management of himself. It should be the great object of the superintendant to gain the confidence of the patient, and to awaken in him respect and obedience; but it will readily be seen, that such confidence, obedience, and respect, can only be procured by superiority of talents, discipline of temper, and dignity of manners. Imbecility, misconduct, and empty consequence, although enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt. In speaking of the management of insane persons, it is to be understood that the superintendant must first obtain an ascendency over them. When this is once effected, he will be enabled, on future occasions, to direct and regulate their conduct, according as his better judgment may suggest. He should possess firmness, and, when occasion may require, should exercise his authority in a peremptory manner. He should never threaten but execute; and when the patient has misbehaved, should confine him immediately. As example operates more forcibly than precept, I have found it useful, to order the delinquent to be confined in the presence of the other patients. It displays authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. It also prevents the wanton exercise of force, and those cruel and unmanly advantages which might be taken when the patient and keeper are shut up in a private room. When the patient is a powerful man, two or more should assist in securing him: by these means it will be easily effected; for, where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger.

When the patient is in a furious state, and uncontrolable by kindness and persuasion, he will generally endeavour, by any means, to do as much mischief as possible to the person who opposes him; and instances are not rare where he has overcome the keeper. When the maniac finds his strength, or skill in the contest prevail, he is sure to make the most of such advantage, and the consequence of his victory has sometimes proved fatal to the keeper. On the other hand, it ought to be the object of the keeper to subdue the maniac without doing him any personal injury; and after he has overpowered, to confine him, and thus prevent him from attempting any further mischief. When the patient is a strong man, and highly irritated, it will be impossible for any keeper singly to overcome him without his most forcible exertions, and these cannot be put forth without great violence to the patient. But subduing the maniac, is not the only object, he must afterwards be secured by the straight-waistcoat, or by manacles. It will be seen, that the keeper, who, by the great exertion of his bodily powers, has become faint and exhausted, will be very little in a condition to secure the patient, as his hands must be employed with the implements necessary to confine him; moreover, the patient will have additional strength from the temperate manner, in which he is made to live; whereas, it is but too common, for the keeper to indulge in a diet and beverage, which induce corpulence and difficulty of breathing.[26]

As management is employed to produce a salutary change upon the patient, and to restrain him from committing violence on others and himself; it may here be proper to enquire, upon what occasions, and to what extent, coercion may be used. The term coercion has been understood in a very formidable sense, and not without reason. It has been recommended by very high medical authority to inflict corporal punishment upon maniacs, with a view of rendering them rational, by impressing terror.[27] From Dr. Mead's section on madness it would appear, that in his time flagellation was a common remedy for this disorder. "There is no disease more to be dreaded than madness. For what greater unhappiness can befal a man, than to be deprived of his reason and understanding, to attack his fellow creatures with fury, like a wild beast; to be tied down, _and even beat_, to prevent his doing mischief to himself or others."--_Medical Precepts and Cautions, page 74._

Dramatic writers abound with allusions to the whip, in the treatment of madness. "Love is meerely a madnesse, and I tel you, deserves as well a darke house, and a whip, as madmen do: and the reason why they are not so punish'd and cured, is, that the Lunacie is so ordinary, that the whippers are in love too."--_As You Like It, act III. scene 2._

Another instance to the same effect may be found in Mr. Dennis's comedy of Jacobite Credulity. "_Bull Junior._ Look you, old gentleman, I will touch this matter as gently as I can to you. Your friends taking notice, that you were grown something foolish, whimsical, absurd, and so forth, thought fit to have you sent to the College here, [Bedlam] that you might go through a course of philosophy, and be cudgel'd and firk'd into a little wisdom, by the surly Professors of this place."--_Select Works, vol. ii. p. 363._ And again, in the next page; "If thou canst give but so much as a reasonable answer to any thing; if thou either knowest what thou art, or where thou art, or with whom thou art, then will I be contented to be thought mad, and dieted and flogged in thy stead."

It also appears from Mr. Douce's valuable dissertation, that the domesticated fool frequently underwent a similar castigation, to curb the licentiousness of his discourse, or, as a punishment for the obscenity of his actions. Indeed this system of corporal chastisement seems to have been general, and may afford some apology for introducing, from a very rare little book, an account of the manner of treating this malady in Constantinople, about the middle of the 16th century.[28]

"_Of a place called Timarahane for the Correction of the Insane._

"The sultan Bajazet caused a building to be erected for the reception of insane persons, in order, that they might not wander about the city, and there exhibit their mad pranks. This building is constructed in the manner of an hospital: there are about an hundred and fifty keepers appointed to look after them; they are likewise furnished with medicines and other necessary articles. These keepers, armed with cudgels, patrole the city in search of the insane; and when they discover such, they secure them by the neck and hands with an iron chain, and, by dint of the cudgel, convey them to Timarahane. On entering this place, they are confined by the neck, with a much larger chain, which is fixed into the wall, and comes over their bed place, so that they are kept chained in their beds. In general, about forty are confined there, at some distance from each other.

"They are frequently visited by the people of the city, as a species of amusement. The keepers constantly stand over them with cudgels; for, if left to themselves, they would spoil and destroy their beds and hurl the tables at each other. At the times of giving them food, the keepers examine them, and, if they notice any, who are disorderly, they beat them severely; but, if they should by accident, find any, who no longer exhibit symptoms of insanity, they treat them with greater regard."

What success may have followed such disgraceful and inhuman treatment, I have not yet learned; nor should I be desirous of meeting with any one, who could give me the information.

If the patient be so far deprived of understanding, as to be insensible why he is punished, such correction, setting aside its cruelty, is manifestly absurd: and, if his state be such, as to be conscious of the impropriety of his conduct, there are other methods more mild and effectual. Would any rational practitioner, in a case of phrenitis, or in the delirium of fever, order his patient to be scourged? he would rather suppose, that the brain, or its membranes, were inflamed, and that the incoherence of discourse and violence of action were produced by such local disease. It has been shewn by the preceding dissections, that the contents of the cranium, in all the instances that have occurred to me, have been in a morbid state. It should, therefore, be the object of the practitioner, to remove such disease, rather than irritate and torment the sufferer.--Coercion should only be considered as a protecting and salutary restraint.

In the most violent state of the disease, the patient should be kept alone in a dark and quiet room, so that he may not be affected by the stimuli of light or sound, such abstraction more readily disposing to sleep. As in this violent state there is a strong propensity to associate ideas, it is particularly important to prevent the accession of such as might be transmitted through the medium of the senses. The hands should be properly secured, and the patient should also be confined by one leg; this will prevent him from committing any violence. The more effectual and convenient mode of confining the hands is by metallic manacles; for, should the patient, as frequently occurs, be constantly endeavouring to liberate himself, the friction of the skin against a polished metallic body may be long sustained without injury; whereas excoriation shortly takes place when the surface is rubbed with linen or cotton. Ligatures should on all occasions be avoided. The straight waistcoat is admirably calculated to prevent patients from doing mischief to themselves; but in the furious state, and particularly in warm weather, it irritates, and increases that restlessness which patients of this description usually labour under. They then disdain the incumbrance of clothing, and seem to delight in exposing their bodies to the atmosphere. Where the patient is in a condition to be sensible of restraint, he may be punished for improper behaviour, by confining him to his room, by degrading him, and not allowing him to associate with the convalescents, and by withholding certain indulgences, he had been accustomed to enjoy.

In speaking of coercion, I cannot avoid reprobating a practice, which has prevailed in some private receptacles for the insane, but which, it is presumed, will henceforward be discontinued. I mean, the practice of half-stifling a noisy patient, by placing a pillow before the mouth, and forcibly pressing upon it, so as to stop respiration. It is unnecessary to enquire, how such wanton cruelty came to be introduced; it must have been the suggestion of ignorance, and the perpetration of savageness and brutality. Sighs, tears, sobs, and exclamations, are the unaffected language of passion, and come kindly to our relief, in states of sorrow and alarm. Indeed, they appear to be the natural remedies, to

"Cleanse the stufft bosom of that perillous stuffe, Which weighs upon the heart."

The mild and rational practice of Bethlem Hospital, tolerates these involuntary ejaculations. It is there considered, that a noisy and loquacious maniac, has not the power to control his utterance of sounds, which, from the habitual connexion between ideas and speech, must necessarily follow. It is there only viewed as a symptom, or part of the disorder; and that, if the cause cannot be suppressed, the effect should not be punished.

As madmen frequently entertain very high, and even romantic notions of honour, they are often rendered much more tractable by wounding their pride, than by severity of discipline.

Speaking of the effects of management, on a very extensive scale, I can truly declare, that by gentleness of manner, and kindness of treatment, I have 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. There are certainly some patients who are not to be trusted, and in whom malevolence forms the prominent feature of their character: such persons should always be kept under a certain restraint, but this is not incompatible with kindness and humanity.

It would, in this part of the work, be particularly gratifying to my feelings if I could develope this _English secret_ for the moral management of the insane, which has been so ardently, yet unsuccessfully sought after by Dr. Pinel. For fourteen years I have been daily in the habit of visiting a very considerable number of madmen, and of mixing indiscriminately among them, without ever having received a blow or personal insult. During this time I have always gone alone, and have never found the necessity for the assistance or protection of a keeper. The superintendant of the Bicetre, according to Dr. Pinel's account, is usually attended by his keepers, [gens de service] though he is said to possess[29] "une fermete inebranlable, un courage raisonne et soutenu par des qualites physiques les plus propres a imposer, une stature de corps bien proportionnee, des membres pleins de force et de vigeur, et dans des momens orageux le ton de voix le plus foudroyant, la contenance la plus fiere et la plus intrepide." Not being myself endowed with any of these rare qualities; carrying no thunder in my voice, nor lightning in my eye, it has been requisite for me to have recourse to other expedients. In the first place, it has been thought proper to devote some time and attention to discover the character of the patient, and to ascertain wherein, and on what points, his insanity consists: it is also important to learn the history of his disorder, from his relatives and friends, and to enquire particularly respecting any violence he may have attempted towards himself or others.

In holding conferences with patients in order to discover their insanity, no advantage has ever been derived from assuming a magisterial importance, or by endeavouring to stare them out of countenance: a mildness of manner and expression, an attention to their narrative, and seeming acquiescence in its truth, succeed much better. By such conduct they acquire confidence in the practitioner; and if he will have patience, and not too frequently interrupt them, they will soon satisfy his mind as to the derangement of their intellects.

When a patient is admitted into Bethlem Hospital, if he be sufficiently rational to profit by such tuition, it is explained to him, by the keepers and convalescents, that he is to be obedient to the officers of the house, and especially to myself, with whom he will have daily intercourse; they point out to him, that all proper indulgences will be allowed to good behaviour, and that seclusion and coercion instantly succeed to disobedience and revolt. As _nemo repente turpissimus_, so no one in an instant, from a state of tranquillity, becomes furiously mad: the precursory symptoms are manifold and successive, and allow of sufficient time to secure the patient before mischief ensues; it is principally by taking these precautions that our patients are observed to be so orderly and obedient. The examples of those who are under strict coercion, being constantly in view, operate more forcibly on their minds than any precepts which the most consummate wisdom could suggest. In this moral management, the co-operation of the convalescents is particularly serviceable; they consider themselves in a state of probation, and, in order to be liberated, are anxious, by every attention and assistance, to convince the superintendants of their restoration to sanity of mind. From mildness of treatment, and confidence reposed in them, they become attached, and are always disposed to give information concerning any projected mischief.

Considering how much we are the creatures of habit, it might naturally be hoped, and experience justifies the expectation, that madmen might be benefited by bringing their actions into a system of regularity. It might be supposed, that as thought precedes action, that whenever the ideas are incoherent, the actions will also be irregular. Most probably they would be so, if uncontroled; but custom, confirmed into habit, destroys this natural propensity, and renders them correct in their behaviour, though they still remain equally depraved in their intellects.

We have a number of patients in Bethlem Hospital, whose ideas are in the most disordered state, who yet act, upon ordinary occasions, with great steadiness and propriety, and are capable of being trusted to a considerable extent. A fact of such importance in the history of the human mind, might lead us to hope, that by superinducing different habits of thinking, the irregular associations would be corrected.

It is impossible to effect this suddenly, or by reasoning, for madmen can never be convinced of the folly of their opinions. Their belief in them is firmly fixed, and cannot be shaken. The more frequently these opinions are recurred to, under a conviction of their truth, the deeper they subside in the mind, and become more obstinately entangled:[30] the object should therefore be to prevent such recurrence by occupying the mind on different subjects, and thus diverting it from the favorite and accustomed train of ideas.

As I have been induced to suppose, from the appearances on dissection, that the immediate cause of this disease probably consists in a morbid affection of the brain, it may be inferred, that all modes of cure by reasoning, or conducting the current of thought into different channels, must be ineffectual, so long as such local disease shall continue. It is, however, likely that insanity is often continued by habit; that incoherent associations, frequently recurred to, become received as truths, in the same manner as a tale, which, although untrue, by being repeatedly told, shall be credited at last by the narrator, as if it had certainly happened. It should likewise be observed, that these incorrect associations of ideas are acquired in the same way as just ones are formed, and that such are as likely to remain as the most accurate opinions. The generality of minds are very little capable of tracing the origin of their ideas; there are many opinions we are in possession of, with the history and acquisition of which, we are totally unacquainted. We see this in a remarkable manner in patients who are recovering from their insanity: they will often say such appearances have been presented to my mind, with all the force and reality of truth: I saw them as plainly as I now behold any other object, and can hardly be persuaded that they did not occur. It also does not unfrequently happen, that patients will declare, that certain notions are forced into their minds, of which they see the folly and incongruity, and yet complain that they cannot prevent their intrusion.

As the patient should be taught to view the medical superintendant as a superior person, the latter should be particularly cautious never to deceive him. Madmen are generally more hurt at deception than punishment; and, whenever they detect the imposition, never fail to lose that confidence and respect which they ought to entertain for the person who governs them.

In the moral management of the insane, this circumstance cannot be too strongly impressed on the mind of the practitioner: and those persons, who have had the greatest experience in this department of medical science, concur in this opinion. The late Dr. John Monro expressly says, "The physician should never deceive them in _any_ thing, but more especially with regard to their distemper; for as they are generally conscious of it themselves, they acquire a kind of reverence for those who know it; and by letting them see, that he is thoroughly acquainted with their complaint, he may very often gain such an ascendant over them, that they will readily follow his directions."[31]

Very different directions are, however, issued by a late writer,[32] and which, on account of their novelty, contrivance, and singular morality, deserve the consideration of the reader.

"The _conscientious physician_, in the execution of his duty, attempting the removal of these deplorable maladies, is under the necessity of occasionally deviating from the accustomed routine of practice, of stepping out of the beaten track, and, in some cases, that have resisted the usual methods, is warranted in adopting any others, that have _only_ the slightest _plausibility_, or that promise the smallest hope of success. Thus, the employment of what may be termed _pious frauds_: as when _one_ simple erroneous idea stamps the character of the disease, depriving the affected party of the common enjoyments of society, though capable of reasoning with propriety, perhaps, with ingenuity, on every subject, not connected with that of his hallucination, the correction of which has resisted our very best exertions, and, where there is no obvious corporeal indisposition, it certainly is allowable to try the effect of certain deceptions, contrived to make strong impressions on the senses, by means of _unexpected_, _unusual_, _striking_, or apparently _supernatural_ agents; such as after waking the party from sleep, either suddenly or by a gradual process, by _imitated thunder_, or soft music, according to the peculiarity of the case; _combating_ the erroneous deranged notion, either by some _pointed sentence_, or signs _executed in phosphorus_ upon the wall of the bed chamber; or by some _tale_, _assertion_, or _reasoning_; by one in the character of an _angel_, _prophet_, or _devil_: but the actor in this drama must possess much _skill, and be very perfect in his part_."

It is of great service to establish a system of regularity in the actions of insane people. They should be made to rise, take exercise, and food, at stated times. Independently of such regularity contributing to health, it also renders them much more easily manageable.