Chapter V: Part 5

Paralytic affections are a much more frequent cause of insanity than has been commonly supposed, and they are also a very common effect of madness; more maniacs die of hemiplegia and apoplexy than from any other disease. In those affected from this cause, we are, on enquiry, enabled to trace a sudden affection, or fit, to have preceded the disease. These patients usually bear marks of such affection, independently of their insanity: the speech is impeded, and the mouth drawn aside; an arm, or leg, is more or less deprived of its capability of being moved by the will: and in most of them the memory is particularly impaired. Persons thus disordered are in general not at all sensible of being so affected. When so feeble, as scarcely to be able to stand, they commonly say that they feel perfectly strong, and capable of great exertions. However pitiable these objects may be to the feeling spectator, yet it is fortunate for the condition of the sufferer, that his pride and pretensions are usually exalted in proportion to the degradation of the calamity which afflicts him. None of these patients have received any benefit in the hospital; and from the enquiries I have been able to make at the private mad-houses, where they have been afterwards confined, it has appeared, that they have either died suddenly, from apoplexy, or have had repeated fits, from the effects of which they have sunk into a stupid state, and gradually dwindled away.

The paralytic require to be kept warm, and to be allowed a more nutritious diet and cheering beverage than insane patients of any other description. In the winter months they suffer extremely, and ought to be treated as hot-house plants. The fare of the workhouse is ungenial to this wretched state of existence, and therefore they seldom long continue a burden to the parish.

When insanity supervenes on epilepsy, or where the latter disease is induced by insanity, a cure is very seldom effected. In two instances I have known madness alternate with epilepsy: one, a man about forty-eight years of age, was a pauper in the Cripplegate workhouse, where he had been kept about three years on account of his epileptic fits, but, becoming insane, was admitted into Bethlem Hospital, therein he continued a year, without being at all benefited; during that time he had no epileptic fit. Being returned to the workhouse, he there recovered his senses in a few months, when his epileptic attacks returned, and continued with their usual frequency. About two years afterwards he was re-admitted into the hospital, his insanity having recurred, and continued there another year without experiencing any attack of epilepsy. The other was a young woman, who had been epileptic for many years until she became insane, when she lost her epileptic fits; these, however, were said to have returned in a short time after she had recovered from her insanity.

All authors who have treated this subject appear to agree respecting the difficulty of curing religious madness. The infrequent recoveries in this species of insanity, have caused thinking persons to suppose, that this disorder is little under the dominion of the medical practitioner; and, that restoration to reason in all cases is more the effect of accident, or of circumstances not "dreamt of in our philosophy," than the result of observation, skill, and experience. The idea that RELIGION; that which fastens us to the duties of this life; that which expounds the laws of God and of his creation to the ignorant; that which administers consolation to the afflicted; that which regulates man's conduct towards his fellow creatures, to exercise charity among them, and, from such benevolence, to purchase happiness to himself: to believe, that the cultivation of such exalted sentiments would decoy a human being into madness, is a foolish and impious supposition.

"Thou, fair Religion, wast design'd,
Duteous daughter of the skies,
To warm and chear the human mind,
To make men happy, good, and wise;
To point, where sits in love array'd,
Attentive to each suppliant call,
The God of universal aid,
The God, the Father of us all.

"First shewn by Thee, thus glow'd the gracious scene,
'Til Superstition, fiend of woe,
Bad doubts to rise and tears to flow,
And spread deep shades our view and heaven between."
_Penrose._

It is therefore sinful to accuse RELIGION, which preserves the dignity and integrity of our intellectual faculty, with being the cause of its derangement. The mind becomes refreshed and corroborated by a fair and active exercise of its powers directed to proper objects; but when an anxious curiosity leads us to unveil that which must ever be shrouded from our view, the despair, which always attends those impotent researches, will necessarily reduce us to the most calamitous state.

Instituting a generous and tolerant survey of religious opinions, we see nothing in the solemn pomp of catholic worship which could disorganize the mind; as human beings, they have employed human art to render the impression more vivid and durable. The decorous piety, and exemplary life of the quaker has signally exempted him from this most severe of human infirmities. The established church of this country, of which I am an unworthy member, will delude no one, by its terrors, to the brink of fatuity: the solid wisdom, rational exposition, and pure charity, which flow through the works of Taylor, Barrow, Secker, and Tillotson, will inspire their readers with a manly confidence: the most enlightened of our species will advance in wisdom and in happiness from their perusal; and the simplicity and truth of their comments will be evident to those of less cultivated understanding. The pastors of this church are all men of liberal education, and many have attained the highest literary character; they are therefore eminently qualified to afford instruction. But what can be expected, when the most ignorant of our race attempt to inform the multitude; when the dregs of society shall assume the garb of sanctity and the holy office; and pretend to point out a privy path to heaven, or cozen their feeble followers into the belief that they possess a picklock for its gates? The difficulty of curing this species of madness will be readily explained from the consideration, that the whole of their doctrine is a base system of delusion, rivetted on the mind by terror and despair; and there is also good reason to suppose, that they frequently contrive, by the grace of cordials, to fix the waverings of belief, and thus endeavour to dispel the gloom and dejection which these hallucinations infallibly excite.

Although the faction of faith will owe me no kindness for the disclosure of these opinions, yet it would be ungrateful were I to shrink from the avowal of my obligations to methodism[23] for the supply of those numerous cases which has constituted my experience of this wretched calamity.

When the natural small-pox attacks insane persons it most commonly proves fatal. I was induced to draw this conclusion from consulting the records of Bethlem, where I found that few of those who had been sent to the Small-pox Hospital recovered; but subsequent experience has enabled me to point out this distinction: that those who have been in a furious state have generally experienced a fatal termination, and that those who recovered had the small-pox when they were in a state of convalescence from their insanity.

When patients, during their convalescence, become more corpulent than they were before, it is a favourable symptom; and, as far as I have remarked, such persons have very seldom relapsed. But it should also be observed, that many, who become stupid, and in a state, verging on ideotism, are very much disposed to obesity: these cases are not to be remedied.

In proportion as insanity has assumed a systematic character, it become more difficult of cure. It ought to be noticed, that this state of methodical madness implies, that the disease has been of some continuance; and, to use a figurative expression, has been more extensively rooted in the mind. Every occurrence is blended with the ruling persuasion, and the delusion becomes daily corroborated. As

--------------"Trifles, light as air,
Are to the jealous, confirmations strong
As proofs of holy writ;"

so in madness, circumstances wholly unconnected readily support the favourite system, and persons the most disinterested are supposed to form a part of the conspiracy.

CHAP. VII.

MANAGEMENT.

Our own countrymen have acquired the credit of managing insane people with superior address; but it does not appear that we have arrogated to ourselves any such invidious pre-eminence. Foreigners, who have visited the public or private institutions of this country, may, perhaps, in their relations, have magnified our skill in the treatment of this disease: compared with a great part of the north of Europe, which I have visited, we certainly excel.

Whether it be that we have more mad persons in England than in other countries, and thereby have derived a greater experience of this calamity; or, whether the greater number of receptacles we possess for the insane, and the emoluments which have resulted from this species of farming, have led persons to speculate more particularly on the nature and treatment of this affection, may be difficult to determine. Dr. Pinel[24] allows the reputation we have acquired; but, with a laudable curiosity, is desirous to understand how we became possessed of it.

"Is it," he says, "from a peculiar national pride, and to display their superiority over other nations, that the English boast of their ability in curing madness by moral remedies; and at the same time conceal the cunning of this art with an impenetrable veil? or, on the contrary, may not that which we attribute to a subtile policy, be merely the effect of circumstances? and, is it not necessary to distinguish the steps of the English empirics from the methods of treatment adopted in their public hospitals?

"Whatever solution may be given to these questions, yet, after fifteen years diligent enquiry, in order to ascertain some of the leading features of this method, from the reports of travellers; the accounts published of such establishments; the notices concerning their public and private receptacles, which are to be found in the different journals, or in the works of their medical writers, I can affirm, that I have never been able to discover any development of this English secret for the treatment of insanity, though all concur in the ability of their management. Speaking of Dr. Willis,[25] it is said, that sweetness and affability seem to dwell upon his countenance; but its character changes the moment he looks on a patient: the whole of his features suddenly assume a different aspect, which enforces respect and attention from the insane. His penetrating eye appears to search into their hearts, and arrest their thoughts as they arise. Thus he establishes a dominion, which is afterwards employed as a principal agent of cure. But, where is the elucidation of these general principles to be sought; and, in what manner are they to be applied according to the character, varieties, and intensity of madness? Is the work of Dr. Arnold otherwise remarkable than as a burdensome compilation, or a multiplication of scholastic divisions, more calculated to retard than advance the progress of Science? Does Dr. Harpur, who announces in his preface, that he has quitted the beaten track, fulfil his promise in the course of his work? and is his section on mental indications any thing but a prolix commentary on the doctrines of the ancients? The adventurous spirit of Dr. Crichton, may justly excite admiration, who has published two volumes on maniacal and melancholic affections, merely on the authority of some observations drained from a German Journal; together with ingenious dissertations on the doctrines of modern physiologists, and a view of the moral and physical effects of the human passions. Finally, can a mere advertisement of Dr. Fowler's establishment for the insane in Scotland, throw any light on the particular management of such persons, although it profess the purest and most dignified humanity, successfully operating on the moral treatment of madness?"

Dr. Pinel is deserving of considerable credit for directing the attention of medical men to this very important point of the moral management of the insane. I have also heard much of this fascinating power which the mad doctor is said to possess over the wayward lunatic; but, from all I have observed amongst the eminent practitioners of the present day, who exercise this department of the profession, I am led to suspect, that, although this influence may have been formerly possessed, and even to the extent attributed to the late reverend doctor, it ought now to be lamented among the _artes deperditae_. Could the attention of lunatics be fixed, and could they be reduced to obedience, by

"Strong impression and strange powers which lie
Within the magic circle of the eye,"

all other kinds of restraint would be superfluous and unnecessarily severe. But the fact is notoriously otherwise. Whenever the doctor visits a violent or mischievous maniac, however controlling his physiognomy, such patient is always secured by the straight waistcoat; and it is, moreover, thought expedient to afford him the society of one or more keepers.

It has, on some occasions, occurred to me to meet with gentlemen who have imagined themselves eminently gifted with this awful imposition of the eye, but the result has never been satisfactory; for, although I have entertained the fullest confidence of any relation, which such gentlemen might afterwards communicate concerning the success of the experiment, I have never been able to persuade them to practise this rare talent tete a tete with a furious lunatic.

However Dr. Pinel may be satisfied of our superiority in this respect, it is but decorous to return the compliment, and if any influence were to be gained over maniacal patients by assumed importance, protracted staring, or a mimicry of fierceness, I verily believe that such pantomime would be much better performed in Paris than in London.

It is to be lamented, that general directions only can be given concerning the management of insane persons; the address, which is acquired by experience and constant intercourse with maniacs, cannot be communicated; it may be learned, but must perish with its possessor. Though man appears to be more distinguished from other animals by the capability he has of transmitting his acquirements to posterity, than by any other attribute of his nature, yet this faculty is deplorably bounded in the finer and more enviable offsprings of human attainment. The happy dexterity of the artisan, the impressive and delighting powers of the actor,

"And every charm of gentler eloquence,
All perishable--like the electric fire,
But strike the frame, and, as they strike, expire."

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Speaking of the effects of management, on a very extensive scale, I can truly declare, that by gentleness of manner, and kindness of treatment, I have seldom failed to obtain the confidence, and conciliate the esteem of insane persons, and have succeeded by these means in procuring from them respect and obedience. There are certainly some patients who are not to be trusted, and in whom malevolence forms the prominent feature of their character: such persons should always be kept under a certain restraint, but this is not incompatible with kindness and humanity.

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

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

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

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

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

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

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

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

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

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

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

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

Concerning their diet, it is merely necessary to observe, that it should be light, and easy of digestion. The proper quantity must be directed by the good sense of the superintendant, according to the age and vigour of the patient, and proportioned to the degree of bodily exercise he may be in the habit of using; "but they should never be suffered to live too low, especially while they are under a course of physic."[33] To my knowledge, no experiments have yet been instituted respecting the diet of insane persons: they have never been compelled to live entirely on farinaceous substances. The diet of Bethlem Hospital allows animal food three times a week, and on the other days bread with cheese, or occasionally butter, together with milk pottage, rice milk, &c. Those who are regarded as incurable patients ought certainly to be indulged in a greater latitude of diet, but this should never be permitted to border on intemperance. To those who are in circumstances to afford such comforts, wine may be allowed in moderation, and the criterion of the proper quantity, will be that which does not affect the temper of the lunatic, that which does not exasperate his aversions, or render his philosophy obtrusive. Although it seems rational in all states of madness, that temperance should be strictly enjoined, yet an author of the present day[34] steps out of the trodden path, and seriously advises us, in difficult cases, to drown lunacy in intoxication; and, strange as it may appear, has taught us to await the feast of Reason from the orgies of Bacchus. "The conversion of religious melancholy into furious madness is a frequent occurrence, and is generally followed by recovery. This has suggested the _propriety_, in some cases that have resisted more common means, of producing a degree of excitement by means of stimuli, in fact, _keeping the patient for days in succession in a state of intoxication_, which has often occasioned an alleviation of symptoms, and sometimes _restored the sufferers to reason_."

Confinement is always necessary in cases of insanity, and should be enforced as early in the disease as possible. By confinement, it is to be understood that the patient should be removed from home. During his continuance at his own house he can never be kept in a tranquil state. The interruptions of his family, the loss of the accustomed obedience of his servants, and the idea of being under restraint, in a place where he considers himself the master, will be constant sources of irritation to his mind. It is also known, from considerable experience, that of those patients who have remained under the immediate care of their relatives and friends, very few have recovered. Even the visits of their friends, when they are violently disordered, are productive of great inconvenience, as they are always more unquiet and ungovernable for some time afterwards. It is a well-known fact, that they are less disposed to acquire a dislike to those who are strangers, than to those with whom they have been intimately acquainted; they become therefore less dangerous, and are more easily restrained. It ought to be understood that no interruption to this discipline should defeat its salutary operation. On this account more patients recover in a public hospital, than in a private house, appropriated for the reception of lunatics. In the former, the superintendants persist in a plan laid down, and seldom deviate from their established rules: such asylum being a place of charitable relief, they are indifferent about pleasing the friends and relatives of the patient, who cannot there intrude to visit them at their option. In a private receptacle emolument is the first object, and however wisely they may have formed their regulations, they soon feel themselves subordinate to the caprice and authority of those by whom they are paid.

It frequently happens, that patients who have been brought immediately from their families, and who were said to be in a violent and ferocious state at home, become suddenly calm and tractable when placed in the hospital. On the other hand it is equally certain, that there are many patients whose disorder speedily recurs after having been suffered to return to their families, although they have for a length of time conducted themselves, under confinement, in a very orderly manner. When they are in a convalescent state the occasional visits of their friends are attended with manifest advantage. Such an intercourse imparts consolation, and presents views of future happiness and comfort. But certain restrictions should be imposed on the visits of these friends; ignorant people often, after a few minutes conversation with the patient, will suppose him perfectly recovered, and acquaint him with their opinion: this induces him to suppose that he is well, and he frequently becomes impatient of confinement and restraint. From such improper intercourse I have known many patients relapse, and in two instances I have a well-founded suspicion that it excited attempts at suicide.

Many patients have received considerable benefit by change of situation, which occupies the mind with new objects, and this sometimes takes place very shortly after the removal.

"Haply the Seas and Countries different
With variable objects, shall expell
This something setled matter in his heart:
Whereon his Braines still beating, puts him thus
From fashion of himselfe."

In what particular cases, or stages of the disease, this may be recommended, I am not enabled, by sufficient experience, to determine.

CHAP. VIII.

REMEDIES FOR INSANITY.

_Bleeding._

Where the patient is strong, and of a plethoric habit, and where the disorder has not been of any long continuance, bleeding has been found of considerable advantage, and as far as I have yet observed, is the most beneficial remedy that has been employed. The melancholic cases have been equally relieved with the maniacal by this mode of treatment. Venesection by the arm is, however, inferior in its good effects to blood taken from the head by cupping. This operation, performed in the manner to which I have been accustomed, consists in having the head previously shaven, and six or eight cupping glasses applied on the scalp. By these means any quantity of blood may be taken, and in as short a time, as by an orifice made in a vein by the lancet. When the raving paroxysm has continued for a considerable time, and the scalp has become unusually flaccid; or where a stupid state has succeeded to violence of considerable duration, no benefit has been derived from bleeding: indeed these states are generally attended by a degree of bodily weakness, sufficient to prohibit such practice independently of other considerations.

The quantity of blood to be taken, must be left to the discretion of the practitioner: from eight to sixteen ounces may be drawn, and the operation occasionally repeated, as circumstances may require.

In some cases where blood was drawn at the commencement of the disease from the arm, and from patients who were extremely furious and ungovernable, it was covered with a buffy coat; but in other cases it has seldom or never such an appearance. In more than two hundred patients, male and female, who were let blood by venesection, there were only six whose blood could be termed sizy.

In some few instances hemoptysis has preceded convalescence, as has also a bleeding from the hemorrhoidal veins. Epistaxis has not, to my knowledge, ever occurred.

Before particular remedies, to be employed for the cure of mania and melancholia, are recommended, it may be necessary to give some directions concerning the means to be used for their certain administration.

Maniacs in general feel a great aversion to become benefited from those medicinal preparations which practitioners employ for their relief; and on many occasions they refuse them altogether. Presuming that some good is to be procured by the operation of medicines on persons so affected, and aware of their propensity to reject them, it becomes a proper object of enquiry how such salutary agents may most securely, and with the least disadvantage, be conveyed into the stomachs of these refractory subjects. For the attainment of this end various instruments have been contrived, but that which has been more frequently employed, and is the most destructive and devilish engine of this set of apparatus, is termed a _spouting_ boat. It will not be necessary to fatigue the reader with a particular description of this coarse tool, except to remark, that it is constructed somewhat like a child's pap boat; and is intended to force an entrance into the mouth through the barriers of the teeth.[35]

In those cases, where patients have been obstinately bent on starving themselves, or where they have become determined to resist the introduction of remedies calculated for their relief, I have always been enabled to convey both into their stomachs, at any time, and in any quantity that might be necessary, by the employment of an instrument, of which the figure and dimensions are here given.

Since the use of this very simple and efficient instrument, which I constructed about twelve years ago, I can truly affirm, that no patient has ever been deprived of a tooth, and that the food or remedy has always been conveyed into the stomach of the patient.

The manner in which this compulsory operation is performed, consists in placing the head of the patient between the knees of the person who is to use the instrument: a second assistant secures the hands, (if the straight-waistcoat be not employed) and a third keeps down the legs. As soon as the mouth is opened, the instrument may be introduced; it presses down the tongue, and keeps the jaws sufficiently asunder to admit of the introduction of the medicine, which should be contained in a vial, or tin pot with a spout, to allow it to run in a small stream. The nose of the patient being held by the left hand of the person who uses the instrument, a small quantity of the medicine is to be poured into the mouth, and when deglutition has commenced, is to be repeated, so as to continue the act of swallowing until the whole be taken.

A little address will obviate the determination of the patient to keep his teeth closed: he may be blindfolded at the commencement, which never fails to alarm him, and urges him to enquire what the persons around him are about: causing him to sneeze, by a pinch of snuff, always opens the mouth previously to that convulsion, or tickling the nose with a feather commonly produces the same effect.

With delicate females, where one or more of the grinder-teeth are wanting, the finger may be introduced on the inside of the cheek, which being strongly pressed outwards will prevent the patient from biting, and form a sufficient cavity to pour in the liquid. With a wish of speaking confidently on this subject, I have usually performed the business of forcing, more especially amongst the females, and it has, in some degree, rewarded my trouble; it has ascertained the practicability of administering remedies; and it has also afforded the consolation, that, where the means employed have produced no good, the patient has sustained no injury.

_Purging._

An opinion has long prevailed, that mad people are particularly constipated, and likewise extremely difficult to be purged. From all the observations I have been able to make, insane patients, on the contrary, are of very delicate and irritable bowels, and are well, and copiously purged, by a common cathartic draught. That, which has been commonly employed at the hospital, was prepared agreeably to the following formula:

[Precsription] Infusi sennae [ounce] iss ad [ounce] ij
Tincturae sennae [dram] i ad [dram] ij
Syrupi spinae cervinae, [dram] i ad [dram] ij.

but, within the last seven years, the tinctura jalapij has been substituted for the tinctura sennae. It is so far an improvement, that it operates more speedily, and produces less griping.

This medicine seldom fails of procuring four or five stools, and frequently a greater number.

In confirmation of what I have advanced, respecting the irritable state of the intestines in mad people, it may be mentioned, that the ordinary complaints, with which they are affected, are diarrhoea and dysentery: these have heretofore been very violent and obstinate.

Perhaps it may be attributed to superior care that the occurrence of these complaints has, of late years, been comparatively rare, contrasted with the numbers who were formerly attacked with such diseases; and, when they do happen, an improved method of treatment has rendered these intestinal affections no longer formidable or fatal.

In those very violent diarrhoeas, which ordinarily terminate in dysentery, from five to ten grains of the pilula hydrargyri have been given according to the sex, constitution, and nature of the complaint, once or twice a day, and with general success.

It may be necessary to add, that it is proper, during the course of this mercurial remedy, which shortly arrests the disease, to keep the bowels in an open state, by some of the milder purgatives employed every third or fourth day.

Diarrhoea very often proves a natural cure of insanity; at least, there is sufficient reason to suppose, that such evacuation has very much contributed to it. The number of cases, which might be adduced in confirmation of this remark, is considerable; and the speedy convalescence, after such evacuation, is still more remarkable.

In many cases of insanity there prevails a great degree of insensibility, so that patients have scarcely appeared to feel the passing of setons, the drawing of blisters, or the punctures of cupping. On many occasions, I have known the urine retained for a considerable time, without complaint from the patient, although it is well ascertained, that there is no affection more painful and distressing than distension of the bladder.

Of this general insensibility the intestinal canal may be supposed to partake; but this is not commonly the case; and, if it should frequently prevail, would be widely different from a particular and exclusive torpor of the primae viae.

But, sometimes, there arises a state of disease in maniacs, where the stomach and intestines are particularly inert. The patient refuses to take food, and is obstinately constipated: the tongue is foul, and the skin is tinged with a yellowish hue: the eyes assume a glossy lustre, and exhibit a peculiar wildness. In this state, I have given two drachms of the pulvis jalapij for a dose, and which, on some occasions, has procured but one stool, so that it has been necessary several times to repeat the same quantity. After the bowels have been sufficiently evacuated, the appetite commonly returns, and the patient takes food as usual.

Much mischief may be produced, if it be attempted to force food into the stomach in such a case, which the ignorance of keepers may attempt, supposing it to originate in the obstinacy of the patient. In order to continue the bowels in a relaxed state, after they have been sufficiently emptied of their contents, the following formula has been employed with advantage:

[Precsription] Infusi sennae, [ounce] vijss
Kali Tartarizati, [ounce] ss
Antimonij Tartarizati, gr 1ss
Tincturae jalapij, [dram] ij

From two to three table spoonsful may be given once or twice a day, as occasion may require.

There are some circumstances unconnected with disease of mind, which might dispose insane persons to costiveness. I now speak of such as are confined, and who come more directly under our observation. When they are mischievously disposed they require a greater degree of restraint, and are consequently deprived of that air and exercise which so much contribute to regularity of bowels. It is well known that those who have been in the habits of free living, and who come suddenly to a more temperate diet, are very much disposed to costiveness. But to adduce the fairest proof of what has been advanced, I can truly state, that incurable patients, who have for many years been confined in the Hospital, are subject to no inconveniences from constipation. Many patients are averse to food, and where little is taken in, the egesta must be inconsiderable.

To return from this digression: it is concluded, from very ample experience, that cathartic medicines are of the greatest service, and ought to be considered as an indispensable remedy in cases of insanity. The good sense and experience of every practitioner must direct him as to the dose, and frequency with which these means are to be employed, and of the occasions where they would be prejudicial.

_Vomiting._

However strongly this practice may have been recommended, and how much soever it may at present prevail, I am sorry that it is not in my power to speak of it favourably. In many instances, and in some where blood-letting had been previously employed, paralytic affections have within a few hours supervened on the exhibition of an emetic, more especially where the patient has been of a full habit, and has had the appearance of an increased determination to the head.