ESSAY ON CLASSIFICATION.

The better to explain and illustrate my ideas and views on the important subject of Classification, I shall, in the first instance, give a brief description of the present plans, arrangement, and manner of proceeding, in my own establishment.

Fair Mead House, Leopard’s Hill Lodge, and Springfield, with appendages to each, constitute my present establishment at High Beach; and I wish to have it most distinctly and most fully understood, that they are simply for classification, of a more general or more specific nature; and consequently, besides the advantages derived from having three houses, I have (as far as I could) made arrangements in each for this purpose. Leopard’s Hill Lodge, where I have more especially made arrangements for the purpose of classification, consists of a front, or what may be called the family portion of the house, and galleries behind, with appropriate rooms for patients requiring more restraint.

To show that these houses are merely for the purposes of classification, I may mention, that there is no sort of difference in the three houses, excepting that in the one generally and latterly inhabited by ourselves, we prefer having those to whom our individual and more immediate attention may be useful. The same patients are even sometimes at one house, and sometimes at another, according to their state; and sometimes for the mere purpose of change. In fact, the greater part of our first class of patients have been occasionally at Leopard’s Hill, and this with the knowledge and approval of their friends.

As I have published some hints on this point, and addressed them to the Commissioners in Lunacy, I may be permitted, in order to show I have long entertained the same views, to quote two or three passages.

I there state, “that two establishments on the same grounds should be allowed and encouraged for the purpose of Classification. My reason for this alteration, in the Act relative to such places, is, that large and crowded houses are decidedly objectionable, from the greater chance of noise and disturbance, from their being less healthy, and from their assuming more of a prison-like appearance, than of a family mansion. With two, we can adopt a better and more complete method of classification; and it is a consideration of very great importance, that in one of them the proprietor and his family should reside, and devote themselves to recent, partial, slight, or convalescent cases.”

As I conceive this plan of two establishments for the purposes of classification, to be of the highest importance, and essential to the moral regulation, as well as to the cure of the insane, so far from avoiding any investigation of either the principle of their adoption, or their mode of management, I wish the most exact knowledge to be obtained of the one, and invite the fullest scrutiny of the other.

I would have not only two establishments in the same grounds, but these sufficiently separated so as to prevent annoyance; and, not only this separation, but I would have one to consist of a male and female part, sufficiently separated from each other. This arrangement I have at my own establishments, which consist of Fair Mead House, and of Leopard’s Hill Lodge, for males, and Springfield for females, with appendages, and separate cottages; and more especially, I would have each house divided into a front and back part, and this front part so contrived, that in appearance it should be sufficiently distinct from the other, so that patients might feel, on recovery, that removal to this part withdrew them from the more painful associations of their past state, and afforded them solace and encouragement; thus might their recovery be expedited, and the chances of relapse lessened. In the domestic part of the establishment, the proprietor and his family should reside.

In many cases, an entirely separate house is required. I have known cases, the cure of which would have been apparently blighted and blasted for ever, if they could not have been wholly removed from, not merely the real, but the apparent, association of former scenes and circumstances, and this without any change in their servants and medical treatment and attendance, which is also essential. Yet it is perfectly true, that in other cases this association is not so injurious as most people would imagine; the dawnings of the light of the understanding are, for the most part, so gradual, and the mists of delusion so gently steal away, that there would be a greater shock given by a sudden transfer to rational scenes and real life, than by their continuance in the place where they might be at the time.

I have often, with feelings of wonder and admiration, had occasion to observe these occurrences. I have seen a convalescent patient very much attracted by, and perfectly delighted with, the strange remarks, speeches, and conduct of another inmate, sometimes fancying it was meant purposely for his amusement and diversion; and on whom, refined wit would have been lost, while the incongruous combinations of unguided thought, which no wit or ingenuity can equal, appears, and is the very essence of wit to him. Notwithstanding the truth of all this, there are other cases,—cases of more sudden convalescence, where all this would shock and horrify, and produce a revulsion of feeling, most dangerous to them in their delicate and fragile state, and perhaps permanently fatal to their recovery. This is more particularly the danger in the incipient stage of convalescence in some violent cases of mania, [5] and where I am quite certain delicate and judicious attention have been essential; and where first, perhaps, removal to the family part of the house, then removal altogether to our own house, was apparently their salvation.

No. 106, admitted April 11th, 1820, aged 65.

This was one of the cases apparently saved by such timely attention, and which I intend hereafter to describe more particularly, for the purpose of illustrating both the medical and moral treatment of many similar cases of insanity. I shall, however, state so much of the case now, as will be sufficient to show, that there is not only a critical period of the disease, when judicious medical and intellectual attention arrests and prevents its transition into another and equally dangerous form of over-excitation, so dangerous, that if allowed to take its course, it not unfrequently ends in dementia, but also, and more especially to show, that in all cases our moral treatment must have in view the nature of the existing causes, in order that we may be able to adopt the most suitable methods of counteracting their effects,—a part of treatment which has hitherto been either wholly overlooked, or else exercised without much knowledge and discretion; although I am certain it is of great importance in the treatment of all curable cases of insanity, and in many cases so important, that by such methods we may ultimately succeed in removing these causes altogether; and removing them, remove also the fear of their again (at any future time) being allowed to have any baneful operation.

This person, who was a dissenting minister, had always been reckoned by all parties, one who entertained gloomy views in religion, and pushed these into extremes; his zeal was equally violent and vindictive, and he besides possessed a mind with every opposite quality in excess, and which had always, as far as I could ascertain, been in a state of irregular and discordant excitation; it is quite certain that during many years past, it had been habitually kept in a very painful and irritable state, by several causes, and one more especially deserving notice. He lived unhappily with his wife and her friends,—instead of union and harmony, all was dislike and contradiction, perpetual storms and altercations, which had just before terminated in a separation between himself and them.

Thus, from the condition of his own unsettled and ill-constituted mind, his gloomy and vindictive views in religion, his variable and irritable temper, and from the nature of the domestic excitement under which he had suffered most severely, it was easy to trace the distressing and awful form of his derangement to the causes which had produced it.

He was in a state of the most furious mania;—his was one of the most violent and distressing cases I had ever seen. It is impossible to convey any adequate conception of its appalling nature. His language was obscene and vulgar, and his horrible oaths and blasphemous speeches were poured forth for some weeks without ceasing, and without sleep, with a volubility, rapidity, and a voice so loud, and so foaming with passion, and with such a frightful expression of countenance, that even those most accustomed to such scenes, and of the strongest nerves, trembled before him. He had a demoniac energy and eloquence, which was, indeed, of the most harrowing and awful kind. It was truly terrific! for even at a distance, his voice sounded like a river escaping from some narrowed part, and rushing with impetuosity over every thing that would impede its course.

Had a short-hand writer taken down his ravings, it would have proved that this picture is far from being an overcharged one. One principle subject of his furious raving, was his favourite doctrine of Election; or rather, perhaps, I ought to say, his blasphemous doctrine of Reprobation. He was constantly denouncing every one (and against myself he was peculiarly severe) as lost, whose belief on this point was not, even in phraseology, the same as his own;—calling on God to execute vengeance upon them;—then blaspheming God, that his prayers and commands were neither heard nor obeyed;—taunting and cursing Him with a contempt which no language can describe;—calling his clemency weakness, and his not executing his decrees a proof he did not possess the power he pretended to have. In fact no one could hear and see him without feeling shocked, and without having a conviction forced upon him that there must be something wrong—some perversion of truth in those doctrines, as well as in his own mental system, out of which all this dreadful spirit, and all these terrific extremes originated, and of which this case appeared a Satanic caricature. It is a truth, that there is no error or perversion of truth that we may not perceive in reviewing the history of mind caricatured, and perhaps in a still more striking manner among those who are in confinement from being directly denounced insane.

On the subsidence of his excitement, he was overwhelmed with the perfect recollection of all he had uttered during the utmost fury of his dreadful ravings, and his state was truly miserable and deplorable. In this state I took great pains with him, treated him with every possible kindness, and endeavoured to show him every possible mark of my confidence: one instance of which may be mentioned.—I gave him, at a very early period of his convalescence, a set of manuscript sermons, all in loose slips, and which he read with great pleasure, and preserved with great care. They were affectionate moral discourses, strictly, I believe, in agreement with the spirit of Christianity, though not on any peculiar doctrines; for in these I had purposely avoided all doctrinal points, although doctrinal views may, when properly presented, be the best preventives, and in some cases the best medicines, in the cure of insanity; but the circumstances in which I was at that time placed, appeared to forbid even their most cautious introduction, and were scarcely admissible to an audience consisting of some of almost all denominations. However, he said, the spirit of these discourses just suited his altered state of mind, for he himself felt horror-struck at the views which had led to such awful consequences.

Though no one can feel more than I do, the necessity of not busily trying to proselyte or unhinge unnecessarily any one’s settled opinions, yet this was an extreme case, and in such cases, where cure seems to depend on the proper administration of counteractive views, every other feeling should give way to this conviction; but at the same time, every thing depends on the judicious mode of stating these sounder views. This case was a remarkable instance of the necessity of such management; and where such views were apparently of the utmost importance to his comfort and peace. But it would require a separate Essay to defend what I conceive those sounder views; and even were I to give this striking case as a specimen of their happy influence, I still might lay myself open to cavils and objections. I shall, therefore, in a separate Essay, bring forth all the arguments, and exert all the power I possess in their defence.

Though his furious state was so unusually violent, yet it was of long duration, and after it had left him, it was some time before he was able to overcome the painful reflections which came over him; he however recovered, and returned home in the September following, since which period I have received many, and almost constant proofs of his great gratitude and attachment to me, one of which is worthy of being stated.

In the autumn of 1824, he walked about a hundred miles to see me, and not finding my place of residence, he called on a medical acquaintance, to whom his description of my kindness and attention, and their happy influence upon himself, were so powerful and eloquent, that this new and accidental medical acquaintance, became from that time to the present, my first and warmest medical friend in encouraging me to establish myself in my present residence, and to whom I have to attribute the origin of all my success; so that this recovered patient’s gratitude, who followed me unexpectedly, was the first step in my progress, and was the sole foundation of every thing which I have done or exists in this place. It was my only introduction. I may be permitted, therefore, to acknowledge my great obligations to the warm-heart friendship of the person, of whose melancholy state I have just given a general description, as well as, the medical friend to whom I have alluded.

No. 195, admitted October 27th, 1821.

This case, I shall hereafter show, was apparently saved by this separation from former associates, at this critical period of convalescence, and he was one who required very superior and intellectual attention.

He was a young man of some talents, and of various pursuits and acquirements, by far too many to be perfect in any one. Born with a large proportion of the family failing, his vanity had been fed by flattery and example, so much so, that it might be said he was bred in vanity’s hot-house; and ultimately, from over excitation, and too little collision with the world, he fancied himself a second Crichton. Of course with such an estimate of himself, it could not be otherwise but that he was constantly meeting with disappointments and mortifications, on his entrance into his profession, and the real business of life. From these causes, as well as from an increase at this time, of parental embarrassments and mortifications, (and home had always been an atmosphere of perpetual storms), from an hereditary scrofulous habit, and from his self-made morbid state, his mind was at last overwhelmed. But it is not my intention to enter into all the details of his history, further than to prove that the causes which produced his disease, and the form his insanity assumed, perfectly corresponded with each other.

On his arrival he was in a very exalted state of over-excitation; he was the greatest of men in every mental capacity and acquirement; all Philosophers, Poets, Painters, and Linguists, that had been, or were in existence, were nothing in comparison with himself, nor were their works to be compared with those he intended to execute, and the basis of which he had already formed in his own conception. Nothing could exceed the vain and pompous displays of his talents and acquirements; and it is impossible to conceive, from the difficulty he had to support his pretensions, with the defects under which he then laboured, what a very painful and ridiculous exhibition it produced. Still his vanity and exaggerated estimate of himself, combined with his ineffable contempt for others, remained unchecked. One feature was very striking; he possessed considerable powers of imitation, in the exercise of which he took great delight, and in pouring forth his contempt against others, he did it with the attitude and voice of Kemble; it was almost impossible not to feel the force of his manner, and against myself he was particularly severe, and his poignant expressions of contempt and indignity were most provoking and overwhelming. When, however, a change of state occurred, I felt so interested for his trembling and doubtful situation, that I had even a bed put up for him in my own room. I had always some case of this kind about me, and no one can conceive the sacrifice of health and comfort it cost me.

This case, as well as the last described, may perhaps be detailed more particularly in their proper place, to illustrate a general principle, of far more importance than even moral treatment. And even in moral treatment it will appear how important this general principle is, to enable us to perceive how we may best counteract the effects which may have arisen from the operation of baneful causes: for by it we shall be able to trace errors to their source, and without this, we can never counteract and cure them. And this we can only do with certainty, by possessing correct views of the origin, nature, and constitution of the human mind, and of the correspondence which exists between physical effects, and mental or spiritual causes: out of which views this general principle will be educed, and it will be found to be of universal application.

In this case it is evident, a system of moral and intellectual treatment was required, in order to counteract and cure the effects which had arisen out of the soil in which he had existed, very different from that which was necessary for the previous case; and it is equally evident, without such knowledge, it is more than probable that neither of these minds would ever have been restored to their balance, or right state.

He recovered, and his character appeared much improved by his severe visitation. He became very much attached to me, and wrote a great deal for me, as my amanuensis. It is worthy of remark, that he remained of choice for a considerable time after his health was re-established, on account of the dread he felt at returning to the place and circumstances where his disease had arisen.

It is remarkable also, that after he had been some weeks in private lodgings, assisting his father, in his profession at the Assizes, he, the very night previous to their intended return home, made his escape to America.

It is singular, that the first case I had, as an insane patient, after I left York, was his sister.

I might select a great number of cases, where I conceive such attention was apparently one principal cause of their recovery, and which I took under my more immediate care on this account, and to whom I devoted much of my time, and made many sacrifices of my comfort and convenience.

In order to show the importance of such attention, it will be necessary briefly to explain the description and character of the cases to which I more particularly allude, and that it may appear that these opinions are not new, I shall quote from the first part of this volume already published. I there say, “What is called mania and melancholia, are for the most part effects of the same power being overactive, but overactive in different directions.” If the distressing passions are overactive, we have melancholia,—if the animal propensities, we have furious mania,—and if the exhilirating passions, we have an exuberance of joyous activity.

“This is a view not before taken, and will account for much of the difference in the effect from the same cause. This melancholy, or state of depression, caused by the activity of the depressing passions, is to be distinguished from the state of exhaustion and debility, which succeeds some violent paroxysms, or which follows an exhausted state of body and mind from overexertion, and assumes either an apparent melancholy character, from torpor or partial suspension of mind, or is in reality a case of melancholia of the most miserable description, from the exclusive activity of these depressing passions, which are then more likely to become the sole masters of the field of action.” [16]

In the former mentioned cases, it appears, that the exciting and depressing passions alternately take on habitudes of action, so that it is still over excitement, but the effects, from its direction being different, are diametrically opposed to each other: in the one case, as I have already said, this nervous energy is employed in exciting into activity the passions which exhilirate: in the other, those which depress us.

This excitement of the depressing and exhilarating passions alternately, is the most striking characteristic of the insane. It is true, that both these states or stages of the disease, if long continued and not well managed, are necessarily followed by a third state of exhaustion. The systems of body and mind are wholly worn out by exertion, and require rest to recruit and manifest their renewed power, but changes from one state to another is only a partial exhaustion; another class of feelings become active, while the former are suspended, so that the melancholy and “high state” are for the most part, states of mind or changes in the direction of its energies, and not that the melancholy have less than the furiously malignant or joyous maniac, of that power which is equally necessary to mental activity of every description.

For instance, I have known the same person sent at one time as patient under the influence of religious melancholy, originating in erroneous extreme Calvinistic views; and at another period in the most joyous state of religious excitement, from having come under the influence of extreme Arminian views. On the same principle, I have by the most laborious process of argumentation and the statement of what I conceive right views, produced a counter-impression, given another character and form to the disease, and in some cases, on this principle, effected a cure. [18]

As these cases are much more common, and these views of much more importance than mankind, or even medical men imagine; and as many who possess a susceptible constitution of mind, similar to those whose cases I have described, are living in the world in this fearful and continual state of mental excitation, and of course, may be on the verge of the same precipice, it is right they should be warned of the danger to which they expose themselves.

It need scarcely be mentioned, that the present constitution of society is not in a healthy state. It is not bound together by that order and sympathy which should exist, but on the contrary, discord and disseverment prevail to an extent which seem to threaten its decomposition and destruction. But too many individuals are intoxicated with the fury of their various passions and inordinate desires, and mad with the endless anxieties and reverses they produce. One part of society, as well as one part of the mind, is at war with another. I wish it, however, to be particularly observed, because I shall have to revert to the fact hereafter, that it is not so much these exciting causes, or even the sad effects of these feverish and wasting passions, that are in themselves so dreadful and fatal, as they are when accompanied or followed by the conflicts and condemnations of conscience. Wherever there is the endeavour to overturn and sacrifice some confirmed and good principle, that which is lowest is encouraged to struggle for pre-eminence, and the mind suffers extreme misery and distraction.

It is in this way that we often find minds that have much that is amiable about them, are soonest overthrown; but in all cases when (as in this and what is in fatality next to this, perpetual domestic discord) the fire of our spirits, which should give life, health, and support to our exertions, is not united and clothed with that wisdom which ought to diffuse itself in every useful direction; it is in an altered and dangerous state, producing, according to this alteration of state, disordered function, acrid secretions, and if long continued, disease; and when disease is established, its state is further altered, so as literally to “eat up the flesh,” and in one form or another burns, scathes, withers, and consumes us, [20] but I need not now enter into all the various evils, miseries, and conflicts in which the mind is involved, and the dangers to which it is exposed, nor the corresponding physical effects, nor show that even were these extremes exclusive and improper, activity does not exist, but where the understanding seems most completely called forth; still we have reason to fear that we pursue the important duties of civil life, whether it be the weighty matters of legislation, or the scarcely less responsible exercise of the learned professions, or what ought to be the binding and sweet influence of faithful dealings in trade, and our common intercourse with each other, in an improper spirit, and from improper motives, and not with that singleness and simplicity of heart for each other’s good, which alone is useful and safe; which we could not fail to do, were we sufficiently aware, that in as far as we depart from this purity of spirit, our views of truth must be perverted, and our healthy vital energies changed, causing fever, paralysis, or some morbid state, and all our sympathies poisoned and deranged. But I might find enough of matter for illustration without detailing the effects of over-excitation, arising from our mad desires after wealth, fame, and distinction, or even the consequent distracting and overwhelming miseries of misfortune, poverty, and starvation, in the modes and amusements of fashionable life, to which sensitive persons, and especially those who have made themselves morbidly sensitive, become, as in the case last stated, the victims.

Excitable and cheerful persons often fall into states of depression, purely because they have drawn too largely and exclusively on their exhilirating passions; whereas, had they drawn equally on the depressing passions, they would have tempered and balanced each other, and kept the mind in its right state; and such is the constitution of the world we live in, that our duties require that both should have their relative and appropriate share of exercise.

Persons, often, in company, think it necessary exclusively to exercise the exhilirating passions, and they return home not only with these feelings exhausted, but with the depression passions assuming in their turn an over-active state, and in this state they perhaps encourage a spirit of discontent, and peevishness, making sad havoc of domestic peace, and producing an unhealthy state of mind, an alteration in the state of the nervous energy, generating an acrid and morbific matter in the system, and ultimately disease, both in themselves and others. [22]

It is too well known that many who are all life and energy in company, sink on returning home, into this state of apathetic melancholy. This is especially the case with those persons who are betrayed by their buoyant spirits and powers of pleasing into extremes, exciting themselves by stimulus and other excesses; and as they are often minds originally of the most amiable constitution, they afterwards, when left to sober reflection, are overwhelmed with self-condemnation; and should they, to raise their sinking spirits, have again recourse to stimulus, the evil is increased, and the effects are terrific. It is to these painful and conscientious conflicts, as much, and perhaps more, than the mere physical effect of their excess, that the disorder and destruction of their minds are to be attributed.

I mention these simple and common forms of irregular and discordant excitation, to shew that from such causes the susceptible mind gets into the habit which may terminate in the more fixed and serious form of alternate states of irresistible excitement of the exhilirating and depressing passions, constituting insane cases, just as we find those of the alternate over-excitement of the kindly and benevolent affections; or, of the angry and malevolent passions terminate in corresponding states.

How many persons live in this baneful domestic atmosphere of perpetual storm and sunshine? And hence, when the mind of one of these becomes morbid, and the malevolent passions assume the exclusive sway, they are said to hate those they formerly loved, which is simply the more permanent state of their former fits of anger; in fact, every form of incipient insanity may be traced with more or less ease, to these corresponding causes. This may not be popular doctrine, but it is the truth.

Many married persons get into this destructive habit of indulging in these extremes of anger and affection; and where they are known to have existed in no common measure, they propagate this their state of mind in their children, and which is afterwards most effectually and successfully educated by their conduct and example; and hence such domestic circles are fruitful soils in producing insane cases. I could state some fearful examples of the truth of these observations, but I would gladly throw a veil over these melancholy pictures of human nature. The sword may slay its thousands, but the demon of domestic strife is much more destructive to man’s life, health, and peace.

I mention all these matters, to show that such are exactly, in their incipient form, the cases which require the most delicate, intellectual, and laborious attention. The delusions which occur in an after stage, arise out of these habits, and until they appear without disguise, it is difficult for strangers to pronounce them insane; and yet these are causes which produce the worst and most incurable consequences; and if cure is to be effected, it can only be by a system of management, which by calming and tranquillising the mind, will best allow the physical effects to subside. But when this painful and irritable state of mind has been of long duration, and some chronic and inflammatory state of insiduous, slow, and gradual growth, is the consequence; then a longer time will be required before cure can be brought about. I may here remark, that it is absurd to suppose we can expect this, by moral or medical means singly,—they must always co-operate, and never be separated in the mind of him whose object is cure: and it is a most important and fearful consideration, that on their treatment depends the increase or diminution of their disease.

To show there is the greatest difficulty, delicacy, and anxiety required to be exercised in the management of these cases, it is only necessary to mention, that they are precisely those, who, as I have already said, though they are either in reality, or ultimately prove the worst and most dangerous cases, can nevertheless, in the incipient stage of the disease, and more especially immediately after being placed under moral restraint and medical care, exert their remaining power of self-control over their delusions and extravagances, so as to appear, for some considerable time, perfectly sane. Indeed, it may be considered as a general fact, that where the insane person preserves his individuality of character, and his alarming state is chiefly indicated by his having his prominent peculiarities in the natural constitution of his mind in a highly exaggerated and caricatured state, (which is always a most unfavourable prognostic, and more particularly if this exaggeration be grounded in self-love,) the incipient stage assumes this delusive appearance.

It is to such cases, in their incipient stage, that I have hitherto devoted myself, and which I have had for the last fourteen years constantly about me.

In devoting ourselves to such cases, we are doing no more than we conceive to be our duty, nor do I conceive this explanation makes, in all cases, our own house superior to others. In some cases, the reverse is the fact. This explanation is intended to show the necessity of classification, and division of labour. In many cases, so far from giving a preference to ourselves, I would give a preference to the surgeon, matron, and attendants at the other houses. In many cases, they become attached to them, and prefer remaining with them. Besides, a mere change is sometimes useful, and often operates as a powerful check;—they are in their favourite house,—they behave ill, and a threat of removal restrains them. All this requires attention, and is assisted by the arrangements described.

To show this is no new and fallacious view, manufactured and brought forward for the mere purpose of my own defence, I beg leave to quote from an explanation of the drawings and plans of the houses and grounds, which were, according to the Act of Parliament, sent to the Quarter Sessions at Chelmsford, now many years ago.—Speaking of Leopard’s Hill establishment, I said—

“At present there are no very violent cases, and some that were so are convalescent, and when patients become convalescent, they are often removed to my own house at Fair Mead, in order to relieve them from painful associations; by contributing in every way to their comfort and their happiness, and by devoting ourselves more particularly to them, we secure and expedite their cure; this removal is often most expedient and useful, but it sometimes happens, [27] that they prefer remaining amongst those to whom they have become attached; and they are then removed out of the galleries, and have apartments in the front and family part of the house.”

“Fair Mead House, I wish it to be distinctly understood, is an additional house in the same grounds, but at a sufficient distance to serve the purpose I have just stated,—the purpose of humane classification, according to their state. In fact, agreeable to these views, it may be considered as a necessary appendage to the others. It enables us the better to discharge a most important and delicate duty, that of more closely watching, and more directly and personally attending to patients during the incipient and critical stage of convalescence; a period when, wanting such attention, they are driven by a revulsion of feeling into their old state, or sink from exhaustion, and die.”

“Again, by having three houses separated in this way, and for these purposes, it not only enables us to divide the males from the females, but also to devote ourselves to those to whom a more delicate and intellectual attention may be useful, in this critical period of convalescence, and it also enables us to select such, whether old or recent cases, as are capable of participating in, and not deranging very much the enjoyments of the domestic and social circle. All which will include convalescents; some incipient cases; some that are melancholy; others that are imbecile; some that may be permanently deranged, but very full of good nature, and not troublesome; and some that are hopeless upon some specific point, but pretty correct on all others.”

Another consideration of greater moment is, that persons necessarily attach an importance to the house in which we more generally reside, and even some recent slight cases feel none of that painful repugnance in coming to us, that is usually felt on the bare mention of a place of confinement, [28] and many come not only without reluctance, but with voluntary pleasure. In my tables, sent to Lord Lyndhurst three years ago, I there show that more than one-third of the patients then received, had been so brought, and “that I had always held forth to them the promise that they were coming as visitors,” saying, “as long as you behave as such, you shall be treated as such.” When they forfeit this, they are deprived of their privileges, and, in some cases, they may be sent to Leopard’s Hill establishment; and in others, a threat of their being removed from this to Fair Mead, answers the same purpose.

I consider it a point of the very first importance, that truth should never be violated; we must, therefore, on no account, at any time, deceive them, and more especially in the first instance. If we begin by destroying confidence, we destroy the basis on which alone all moral good can be effected. Without truth there can be no confidence. It is quite a mistake to suppose a system of deceit is necessary for the purpose of more quietly accomplishing their removal from home. I can conscientiously assert that my own experience proves the contrary, and that I have not found in a tithe of the cases which I have had to manage, any very great difficulty in persuading them willingly to accompany me, more especially if I had sufficient time given me to ingratiate myself into their good opinion and confidence, which I do, by fully explaining the object of their removal, the treatment I intend to adopt, and the means to be used to make them as happy as possible in the new circumstances in which they are about to be placed. Whenever this was done, and I found them in a state to understand it, which is the case in a greater number of instances than most persons imagine, they have then almost invariably been persuaded to come willingly, without using any arts of deception.

I delicately, but candidly tell them, that they are considered to be insane, that the disease has produced some change in their usual mode of feeling and thinking, that the object of the proposed visit is their good, and that if they will only go willingly along with me, I pledge myself they shall be treated as visitors, unless their own conduct should oblige me to act otherwise towards them. If after all the pains I take, (and no pains can be too great to accomplish my object in this faithful way,) they still refuse, I then tell them, that their going is a matter quite settled, and cannot possibly be altered; that they may as well make a merit of necessity, and like rational beings, go at once with cheerfulness, and good-will, in order that they may still receive the good which I have promised them.

If after such explanations they do consent to go willingly, or even without much force, a grand point is accomplished; for in this case, suppose after their arrival they grossly commit themselves, and justly forfeit their claim to the treatment I have promised them, and I am obliged to abridge them of the liberty they had really given them, they then feel and often acknowledge the justice of any change in their treatment, which is the result of their gross misconduct, and they exert themselves with the hope of regaining the liberal privileges they have forfeited, and thus from their desire to be considered and treated as visitors, they put forth into operation what is of the greatest importance, the valuable principle of self-control.

In most cases, while nothing is more consoling to their afflicted spirits than friendship, and the society of those they love, nothing is more grievous to them than its loss. To form such a feeling, is very difficult; but by beginning and proceeding on these principles, showing them that truth and justice and kindness are the basis of our actions, we establish a wonderful moral influence over them.

It will often happen, however, in stating to them that their minds are not considered in a right state, they will stoutly deny it. I then assure them, I shall be very glad to find they are right, and hope they will not force upon me by their conduct, a different conviction. Stating to them very gravely, what I understand has led to this conclusion, saying, if we judge by the acknowledged rules of the world, they must confess there is something very unusual and strange in their words and actions; but at the same time, I trust they will not in future commit or lose themselves, as it appears they must have done. In which case I promise them I will myself befriend them, and endeavour to replace them as soon as possible, in the confidence of their friends, but which I can only do when their conduct will enable me to transfer to their friends the confidence it has given me. Many, of course, assert, that what others call insanity, they know to be correct and proper; then I say, we must have time to examine it at leisure, that it is too weighty a matter to determine in haste. Where the person cannot be made to comprehend all this reasoning, of course other methods must be adopted, according to the nature, exigencies, and the state of each patient. In fact, it is impossible to state all that is, or ought to be done on these occasions; we can only hint at the spirit of the procedure, for every separate case requires its own appropriate plan of procedure.

To show the propriety and advantages in this method of proceeding, I shall state the important fact, that some few have at once been cured, without removal from home, by the powerful influence of its candour and honesty.—And in all cases, when, after all this labour and delicacy, they are removed, and are, subsequently, on the same principles, and in the same spirit, treated with every possible indulgence, and the greatest degree of forbearance, even overlooking many lesser faults, and waiting, until, as we say, “they break out and commit themselves,” in some very decided manner, so as to furnish us (even in their own estimation) with a very palpable plea to abridge them of their indulgencies, they have then forced upon them the conviction of their error, and are obliged to acknowledge the justice of any change that is made.

It is singular, that many have on this plan been speedily cured by the self-restraint this system conspired with other things to give them; and many others have recovered without ever feeling or considering themselves as having been treated as insane patients; and most of them do not consider themselves as under any confinement whatever. Not more than about 3 p. cent. suffer any personal restraint, and not one for years under any constant personal coercion, and we have, at times, been for months together with not more than one patient whom we were afraid of trusting in the grounds alone.

I must more particularly advert to this most powerful argument in favour of this plan, which is, that it conduces to form the habit of self-control, which is the habit above all others which ought ever be our aim to form. It ought to be the primary object in every moral plan of cure. But I shall have some further observations to make on this principle, and the various means which tend to form and increase it, in another place. I only hint at these things at this time, for the purpose of showing that all these delicate, modified, conditional, and encouraging plans of superintendance are assisted by the arrangements I have described.

In fact, so important have I considered this plan of Classification, that when I first came to Leopard’s Hill Lodge, I contrived the best way I could, with my means, to have a family and front part of the house, independent of the galleries; and should I be called upon to extend my plan to meet my increasing success, and should my life be spared, and time and health permit me to follow out my views and to build an Asylum upon a larger scale, I should keep these principles of Classification, as well as many others, in view, in the plan I should adopt, for I am more and more confirmed that they are extremely important; and I may mention as proofs, that at all the houses we have had parties in the front part, who would, in their conduct and pursuits, and social enjoyments, put to shame many families who are reckoned perfectly sane. We have visiting parties from house to house, with the usual amusements of cards, chess, billiards, cricket, &c. For some months we published a weekly newspaper of considerable interest. Nor is it unworthy of notice, that some articles of a very superior kind in our critical Journals have been written in this place; all which gives it more an air of social enjoyment and comfort, than the coldness and repulsiveness usually attendant on the loss of liberty, and forms within ourselves a little world of interest, better suited, I believe, to the state of the inhabitants than the real world could be to them. It is, in fact, a System of Classification, originating, if not in the most enlightened, at any rate in the most humane considerations of the various states and maladies of mental aberration, and which enables us to exercise a powerful influence over those under our care. It is in agreement with our conviction of the importance of that which may be laid down as a maxim, that, if the mind be maintained in a state of tranquillity, the affections are more likely to be brought into a right state, the effects of functional disorder, or even disease, to subside; the mists of delusion to clear away; and the light of the understanding to resume its province.

The last and most important consideration is, that this plan has induced several (especially before the letter and spirit of the law were opposed thereto) to return voluntarily on their perceiving symptoms of their returning malady.

I could give, were it not that motives of delicacy forbid me, some very striking and interesting cases, illustrative of these facts and these principles, and the beneficial results which arise out of them.

One of these cases, illustrative of this necessity of more delicate and intellectual treatment in certain states of mental aberration, I am advocating, I may mention. It is that of a lady who had been, upwards of seventeen years, in alternate states of excitement and depression, and in confinement all this time, whose recovery I attribute, combined with medical means, principally to such attention.

No. 335 was first admitted of her own accord, March 5th, 1826, aged 56; discharged May the 4th, 1826; again returned of her own accord, June 30th, 1826 [36]

This case was a most striking sample of a great number of a similar description, who are the subjects and victims of this perverse and irregular mental excitation, which become, without proper management, more confirmed cases of mania and melancholia, which continuance in this state for a sufficient time, produces disease, and disorganization of the brain, and ultimately terminates in incurable dementia, either of a partial or more general character.

She was a person of a highly sanguine temperament, possessing by nature great capabilities, but her intellectual powers had not, by education or circumstances in life, been so much developed and increased as her energetic feelings, which were most excitable, strong, and active. If her education had equalled her natural endowments, her understanding would have assumed no common pre-eminence, and in which case her feelings would probably have been brought under due subordination. It was not, however, so much even the defects of her education, as the circumstances of her life, and especially those connected with her religious associations, which were incomparably more calculated to increase the strength and activity of her feelings, than to call forth and cultivate her intellectual powers; indeed, instead of any such cultivation in any proportionate degree, there is every reason to believe, these associations had a paralysing influence; nor perhaps were any habits of self-control, or any mental restraint whatever, formed or acquired in this connection, except that which operated too exclusively on her religious and conscientious fears; and hence, without entering into the details of her history, the result was the formation of a character, such as is most common under the present artificial systems and circumstances in modern times, ill formed to withstand the effects of adverse or prosperous fortune.

It was her lot to pass through these extremes, and after suffering many reverses, mortifications, disappointments, bereavements, and some matters of a private and most afflictive nature, she had a rheumatic fever, when the explosion took place; then the weak and over-exercised parts of her mind displayed themselves in an irregular and increased degree. Her state was an exaggeration of her former energetic and acute nervous sensibility, operating alternately on the depressing, and exhilirating passions.

When she came to me, for she had been in various places previous to this period, she was in a state of religious melancholia. Her conscientious fears were dreadful, and her misery extreme. She conceived herself condemned to eternal punishment—she was already in torture. When in this terrible state, she had more power to engage one’s commiseration, than any patient I ever had. Her descriptions of her own state were extremely eloquent and affecting, and her appeals for sympathy were overpowering and irresistible, and I was absolutely worn out and overcome by the fatigue and misery I endured in my efforts to console and restore her. I shall always continue to feel the painful effects of my anxious exertions in this and several similar cases of melancholia; but no case and perhaps no number of cases, shook and overwhelmed my nervous system as this did, (unless it be one through whom I had a nervous fever); not merely because of her extreme agony, but my own health and spirits were then in a very depressed state, having been for years a martyr to chronic enteritis and gastritis. I mention this to account for the obligation I felt myself under, to dissever my sympathies from this overwhelming influence, and to transfer her to the kind care of Mrs. Allen, to whose lively and cheerful disposition, uniform and judicious kindness, combined with great firmness and gentleness, soothed and softened her melancholy state, and, in time, tempered the extremes to which she had been subject, and kept her spirits in a better direction.

One great art in this management was that of Mrs. Allen’s making her useful as her deputy in every thing in the house, either in matters of a household nature, or in attending upon others. And notwithstanding her own miserable state, no one was ever more qualified for a nurse, or better understood every thing connected with the arrangements of the table; and her very perfection in all these matters, had, before Mrs. Allen came, been the cause of an increase rather than a relief to her misery, for she became the object of great jealousy and dislike to my housekeepers and matrons, on this score: but now it became a source of employment, amusement, and diversion. Though she long continued to possess, for the most part, this disposition to fall into the same miserable state, yet it never afterwards degenerated into that dreadful agony and distraction I have described. At times it ceased altogether, and her more happy state supervened, when she was full of hope and self-esteem, of life and activity, the very antipodes of her former state. But it is altogether astonishing how both these states were lessened and kept in check by Mrs. Allen’s manners, combining the most inflexible firmness with admirable tact and good nature. When all her almost exhaustless fund of sympathy failed, it was always found a sufficient check, and at once to call forth our patient’s powers of self-control, for Mrs. Allen to say that she really could not bear the association of her miserable state any longer, and that they must separate; and it was very seldom necessary to hold out the threat, that she must be removed into the gallery and back part of the house.

Perseverance in this system of unwearied and perhaps unequalled kindness, gradually mitigated and diminished these alternate states of excitement and depression; thus shewing to demonstration, that in this way, with the aid of medical treatment, the excitement of the depressing and the exhilirating passions may be checked and restrained, so that in time they may regain their due equilibrium;—that instead of these cases degenerating, as they have almost always done, into hopeless cases of mania or melancholia, and often terminating in complete dementia, they, by this system, might in process of time regain the due equipoise, or the relative and appropriate share of the exercise of the different functions of mind, and be brought, as in the case just described, to repossess the greatest of blessings, the healthy action of the feelings and faculties in the discharge of those duties which constitute alike the object, the usefulness, and the happiness of her present existence.

I mention such cases, because I shall hereafter do all I can to draw attention to similar mental states, as the common causes of insanity. That almost all cases begin in this way, but that they are disguised or kept from our view, with those who possess self control, until (unless the tendency be cured by such efforts to disguise it) they at last burst forth into some form of insanity; and indeed insanity itself may be defined generally, the uncontrolled over-excitement, imbecility, suspended or paralysed state of one or more of the mental functions, arising from some previous faulty state of action. I shall have to show hereafter how all these cases might in their incipient and curable stage have their specific modes of moral and medical treatment applied in order to counteract and cure them; and by this method incurable cases would be almost unknown.

At the same time let it be observed, that such treatment requires much more delicate and intellectual attention than is in the power of those who for the most part live amongst the insane, and, have the direct and important management of them; and that, in justice to ourselves, I have a right to assert, that where such treatment has existed, and does exist, it is not a matter which money can remunerate, and that in this case there was no pecuniary reward. It was no such inducement that had any influence in regulating the conduct which we pursued with such unwearied diligence; and not merely was there no pecuniary reward, but even gratitude was wanting for a time; for this attention was so delicate, that she was always made to feel she was the person conferring rather than receiving favours; so that when she was relieved from her depressed state, and it was superseded by the excitement of the exhilirating passions, her self esteem dwelt only on the favours she imagined she had been conferring. She was useful, but her usefulness was more for her own good than for ours. Indeed, we paid the price of patient endurance to a degree and extent which can never be conceived or known, still less was she in a state to perceive or appreciate our motives, therefore she conceived, and was confirmed in the impression that she was actually the person to whom obligation and gratitude were due. This impression was the last remains of her disease, or of that over-excitement of the exhilirating passions, which with the longer-continued paroxysms of the over-excitement of the depressing passions, constituted the character of her case; and she left us, not merely before the “high state” had solely subsided, but at the very time when we felt it to be our duty to restrain and subdue it, and of course when she felt most mortified, and was least able to perceive and appreciate our motives, but which she has since done to our entire satisfaction.

She has now been upwards of three years in the world, engaged in useful and active duties, and though she may be liable to extremes, and be too susceptible of the action of exciting causes, yet I have every reason to believe, that experience has taught her the necessity of counteracting and restraining their baneful influence. I am told by her friends, that now collision with the world having smoothed down the peculiarities which her long seclusion had contracted, her character appears much improved.

I might detail many such cases, and prove that cures have apparently been effected by this intellectual and delicate attention, and more especially in some slight and incipient cases. But I may also state, that many cases of the most serious kind have been so treated, and have recovered. I particularly have in view, two cases of the most determined suicidal melancholy, that were so delicately treated and watched, that they were not themselves aware for months, they were even in a place of confinement, or they had an eye of anxiety constantly watching over them. To this watchfulness and constant exertion to amuse and divert them, I principally attribute the gradual diminution of their melancholy, and ultimately their recovery. These cases, No. 412, and 373, have each returned three or four times of their own accord, and have each time, under this system, gradually recovered.

Is it not then of importance that we should do every thing possible to lessen the present feelings of horror associated with such places? then might we expect to find them come of their own accord, have confidence in their medical friend, concur and co-operate in the plan marked out for their cure, and the consequence would be, that we should find them generally recover.

No. 373 came of his own choice,

And was a most distressing case of hypochondria, which had from various causes been increasing upon him for about twenty years; and when he so came, he was in the most depressed and melancholy state possible. His whole mucous membrane had long suffered from chronic inflammation, and was in a state of the greatest irritability. He was, in less than nine months, altogether another being; his habits were altered, and his health greatly re-established; and this person was one whose cure was partly to be attributed to my mode of amusing him. I do not mean to enter into his particular history, or his medical treatment, for it would itself make a volume; but I introduce a brief notice of his cure, for the sake of illustrating the foregoing principles of Classification, and to show that a variety of methods are necessary to accomplish the object we ought ever to have in view, and that it would never answer to apply indiscriminately the same medical or moral treatment to any two cases.

A plan was proposed to spend an hour at least with him every evening, and this hour I devoted to that of detailing to him a history of my own life, always contriving, in the style of the Arabian Nights Entertainments, to break off suddenly at some point of interest; and these conversations, had they been committed to writing, would have formed some very amusing volumes. The great art and merit of the plan consisted not merely in making them amusing, but in contriving to introduce, without appearing intentionally to do so, (that I might not in his over sensitive state offend him), facts and views calculated to counteract the errors and bad habits into which he had fallen.

In all cases it is necessary to know every extreme view and error to which the human mind is liable, and where these exist, as inmost cases of insanity, to endeavour to counteract them by clear and beautiful views of the truth.

What is of the greatest consequence, is that it is still more necessary to know the best mode of making truth admissible and effectual; for it ought never to be forgotten, that in all cases where error and delusion exist, even if we know those views which are best calculated to counteract and remove them, still more depends on the manner, circumstances, and spirit in which we present and apply them. I am anxious to draw attention to this truth, because it appears to me the world at present has no adequate conception of this great and necessary art in its propagation: still less does it appear that mankind, nor even many medical men, have formed any proper estimate of the vast importance of such a system in the treatment of the insane: a system, however, which requires that we should be fully acquainted with the history of man, and be able to perceive the causes and effects of false and perverted views of philosophy, morals, and religion, and above all that we should possess a knowledge of the constitution of the human mind, with all the specific differences of every individual case.

I mention this case with others, to show that there are many instances where something more than common attention is required, and that to such patients we devote ourselves, and have them at our own house for this purpose. These are precisely those who are over excitable. They form a large proportion of the insane, and in their incipient stage, their minds are rather in a state of perversion, than absolutely lost or deranged; whose cure depends on correcting this perversion, and restoring the relative and appropriate share of activity and energy to each function, in the exact measure, proper place, and according to the order of their right distribution.

If then, these houses serve these various purposes, who is best able to judge when such purposes can be best served? The exact moment lost can never be regained! a wrong word, or even look, may unhinge, and bring on a relapse! It is a species of discipline like that of a nursery;—children commit some fault, and are removed from the objects of their affection as their punishment; and no punishment is greater or more effectual. Some of our circle break out into passion, or give way to some strong propensity; they are told it won’t do, and are removed: they soon promise to behave better, and return. The causes are sudden and unexpected, and sometimes trivial; and this mild medicine, instantly administered, has a wonderful influence. Sometimes the attendants will be better suited for some specific cases at one house than at the other; and it may be injustice to other patients to change them, but great justice to change the patient on their account.

When I state to patients’ friends these matters, and the difference of these houses, I say decidedly, that in those cases to whom our attention, and the comforts of the domestic circle may be useful,—those friends should, if they possess the means, prove, by a corresponding remuneration, that they duly estimate such delicate attention; particularly as they do generally acknowledge that it is not in the power of money to compensate for the expenditure of so much feeling, and being subjected to so much annoyance. In all cases where it appears this attention and placing them in our domestic circle, will contribute to their comfort or their cure, we, as a matter of feeling and of duty, treat them with equal kindness and attention, always giving considerations of comfort and of cure, the first place.

Besides, most cases are improved by association with those of a different character. I have seen many old torpid cases, and a still greater number of recent cases of suspension of mind, cured by being placed occasionally among those who were in a more lively state, and this after every other means had failed.—And it is reasonable, for nothing can exceed the comic effect of the strange and laughable speeches and manners of some among this class of patients; and, in the case, the treatment of which was altogether mistaken or mis-represented, there was surely nothing incredible or unreasonable in saying I preferred, that this lady should have the chance of being roused out of her torpid state, by remaining at Leopard’s Hill Lodge, where of course, she might have these means occasionally put in force; for all the females were then at that house, and at the same time, she did possess the advantage of every possible delicacy of attention from Mrs. Allen, who was, with her children and an additional number of servants, then living altogether at that house.

The case No. 335, was, as I have already mentioned, always soonest roused out of her melancholy condition, by being placed for a short time in the midst of such association. It would be contrary to the economy of providence, as exemplified by the constitution of society, to place all the melancholy in one class, and all the lively in another. The truth of this argument receives additional confirmation, when we consider, which I am prepared to prove, that insanity in many cases, is produced by, and consists of, an aggravation of the original peculiarity of character, and therefore it is evident, that such collision, like collision in the world, is making one extreme tend to correct another, though of course, the worst and most dangerous cases of every description, are not in their treatment included in this principle.

Many instances are recorded, of two opposite cases, by being thrown together, neutralizing, like an acid and alkali, each other; that is, the melancholy have been roused by the lively, and the lively depressed by the melancholy, and thus both have been brought into a better state.

Sometimes the insane have been cured by witnessing their own case caricatured in that of another. For instance, two proud men, the victims of their gradual and progressive false estimate of themselves, assume in their insane state, the same crown and kingdom, and by witnessing each other’s delusion, have been forced to feel that one must be in the wrong; and thus, one or both were brought to reflection, and ultimately to a more sound and sober state of mind.

Even the imbecile and idiot, are roused and improved by such associations, more than they had been, even with every endeavour to improve them, while they were in a state of seclusion. I have lately had two very remarkable instances of this kind.

No. 425 and 429.

Imbeciles, though they were from birth, they improved after their arrival; the scene was very different to the solitude in which they had been placed; the common scenes and circumstances of life, had not had sufficient power to rouse the dormant and torpid state of their mental functions, while scenes and circumstances, that are in themselves very painful, were better calculated to arouse in their moping minds, something like feeble efforts of reflection. I have seen them behold the strange antics of others, with intense wonder and interest.—Often they will catch the contagion of laughter; and thus if the understanding has no part in the matter, their spirits, at all events, partake of the merriment of the scene around them; and though insanity, considered in the abstract, is a melancholy thing, yet it is a truth, that there is much more of merriment than melancholy among the insane. I believe their average of happiness is greater than would be found among the same number in the world. Those who look with prejudice from impressions received from a few extreme cases, of course make out a different conclusion. Again, there is another consideration, which further proves that the happiness of these imbeciles and ideots may be increased by such association. They have still the blind affections craving for food, and they here find food for their gratification, better suited to their state than they could find it in the world. These affections without understanding, are to the world repulsive. It is strength of affection, guided by strength of understanding, that so powerfully attracts and binds society together. In this sphere they cannot revolve; here, eccentric as it is, they have one better suited to their state.

I daily see ideots and imbeciles taught to walk arm in arm; evidently pleased and gratified that they have objects for their blind affections to rest upon. Besides this, it is a very singular and remarkable fact, that this exercise of their affections, has contributed to the improvement of their physical state. Whatever increases innocent enjoyment, and contributes to happiness, are excellent medicines. Peace and purity of mind are better than physic. This exercise of their blind affections conduces alike to their felicity, and to the preservation of their health, by innocently keeping alive the regular and happy exercise of their animal spirits, by the only outlet they possess, that of their blind and instinctive affections; and hence, it is very remarkable, that in consequence of their animal spirits being no longer pent up, as was formerly the case, they are not now so liable to those sudden bursts and irregular displays of passion, to which they had been the victims; and what is still more remarkable, they are in better health, and not so liable to cramps and colics, which had been the corresponding physical effects of their irregular nervous distribution; so that even with them the truth is evident, that it is not good to be alone; the little world they live in is better suited to amuse and contribute to their happiness, than the quietude of civilized life, from which they could receive no enjoyment, and to which they could only give pain.

It is also worthy of remark, that some patients sink more rapidly into moping idiotcy when kept in a state of perfect seclusion, than they even do in the society of those who are insane like themselves.

I have seen patients who had not been accustomed to any association, who were, on their first arrival, in appearance, manners, behaviour, especially in their mode of eating, and their dirty habits, scarcely human; it was evident from all this, that they had long been unaccustomed to the common conveniences and decencies of life, as well as from the astonishment and delight they first exhibit, on these things being restored to them;—to see companions, and to find a table with the usual appendages of knives and forks, &c. evidently excited pleasing reminiscences and gave them additional life,—their improvement (externally, at any rate) was rapid, and, by continued attention, their restoration to habits of cleanliness complete.

To insure all these as well as many other advantages, and to make cure the primary object, requires not only that the proprietor should live amongst them, but also that he should be a medical man, and one who has experience, guided by upright principles and Christian feelings; for if medical men of talent and character could be induced to undertake this painful and anxious life, submitting cheerfully to all these sacrifices and inconveniences, much might be done to improve this neglected department of medicine, and augment the number of cures; at all events, most certainly increase the comforts of the incurable, and lessen the distressing apprehensions of those who fear the accession, or recurrence of mental aberration; yet notwithstanding the paramount importance of these things, so ignorant or so blinded by prejudice is the world on the subject, and so little aware of the talents and capabilities required for such a situation, that they consider the very name of a proprietor, and superintendant of an asylum, as absolutely sinking the character in public estimation; whereas no class of medical men, were they efficient, should be considered more honourable, because none can be more useful than those who devote themselves to the cure and comfort of persons in this most lamentable state.

When the gloom and horror at present thrown around establishments for the insane shall be cleared away, Dante’s inscription over the gates of Hell, will be no longer applicable to them,

“Lasciate ogni speranza, voi, ché ntrate;” [55]

this, or perhaps another passage from Euripides, has been imitated by our Milton,

“Here hope never comes, which comes to all.”

They will be considered houses of cure, or hospitals for the insane.

The erroneous and false impressions, concerning the character and state of the insane, will be corrected. The popular impression, that they are all violent and vociferous, destructive and dangerous, will be removed. Hitherto medical writers, by selecting the most striking cases, have contributed their share to this popular error. They have been led to do this, partly because they are cases, which more naturally arrest their own observation; but chiefly, because they are more easily described; make a more interesting picture, and are the most curable. A statement of the recovery of such patients, though it may serve to exalt the writer in public estimation, is wrong in itself, and very injurious in its influence; for it increases the unreasonable horrors and false impressions entertained about the insane, and propagates and perpetuates the evils of which the public and legislature complain. They receive impressions from extreme cases, which average about five per cent. then speak just as if all the insane were in a similar condition.

Mr. Samuel Tuke says, “Many errors in the construction, as well as in the management, of asylums for the insane, appear to arise from excessive attention to safety; people in general have the most erroneous notions of the constantly outrageous behaviour, or malicious dispositions of deranged persons; and it has in many instances, been found convenient to encourage these sentiments, to apologize for the treatment of the unhappy sufferers, or admit the vicious neglect of their attendants.”

In the construction of such places, cure and comfort ought to be as much considered as security; and I have no hesitation in declaring, that a system which, by limiting the power of the attendant, obliges him not to neglect his duty, and makes it his interest to obtain the good opinion of those under his care, provides more effectually for the safety of the keeper, as well as of the patient, than all “the apparatus of chains, darkness, and anodynes.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

No. 372.

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

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

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

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

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

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

No. 395, admitted Dec. 3, 1829.

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

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

Now, it is evident that ferocious and furious maniacs are those, wherein a direct system of coercion is said to be essential; and yet it is evident, that these are cases where it must do the greatest injury. They are those in which the animal part is excited and inflamed, and of course all causes of irritation must increase it. It is adding fuel to the fire, which already burns too fiercely—it is lacerating a wound which requires to be mollified with ointment. The best-tempered house-dog becomes savage by being constantly chained.