ESSAY ON CLASSIFICATION. (continued 2)

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.

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.

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.

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.