Part 8

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.

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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.

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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.

Restraint and coercion are only justified when used either from absolute necessity, or as the mildest species of discipline; and then in all instances it must be proportioned to the causes and exigencies of the case; or when they are so violent, or so unconscious of their own state, or so bent on their own destruction, that there is less evil to be feared by restraint, than by indulgence.—But even here, popular feelings, prejudices, and fears, must not be the judges.

The word coercion has been used, but it conveys an erroneous impression, as if some degree of punishment were necessarily included in the restraint which the safety of others and of the patients require; but so far from this being the case, it ought never to be forgotten, that if the murderous and destructive maniac are made to feel, that with this necessary restraint is conjoined the indulgence of a vindictive spirit of retaliation, it will have an injurious influence, aggravate the disease, and of course will progressively increase the necessity and rigour of the restraint.

In cases of determination to suicide, it should be made to appear to the patient, what in truth it always should be—the kindest guardianship and protection. In cases of some lesser faults, or such as breaking or tearing, instead of restraint, a small dark closet I have found more useful than the strait waistcoat; yet neither the one nor the other, have, now for a long time, (seven years at least) scarcely ever been resorted to, for more than an hour or so; but to be able to do all this requires a superabundance of servants and attendants, and these must be serious, active, laborious, and vigilant as possible.

I have known cases where the patient himself, on feeling his destructive propensity coming upon him, requested that he might be placed under restraint, and he felt afterwards more comfortable, from the conviction that he was safer in that state. In such a case, the request should be readily attended to, as being not merely unobjectionable, but likely to have a beneficial influence.

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

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

No. 421.

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

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

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

No. 396.