Description Of The Retreat An Institution Near York For Insane
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In 1813 AD, Samuel Tuke, minister for Quakers, devoted his life to the Retreat for the insane at York. Although he was unsure if the cause of insanity was spiritual/mind, or physical/body, but he strongly leaned towards the spiritual/mind etiology. "If we adopt the opinion, that the disease originates in the mind, applications made immediately to it, are obviously the most natural; and the most likely to be attended with success. If on the contrary, we conceive that mind is incapable of injury or destruction, and that, in all cases of apparent mental derangement, some bodily disease, though unseen and unknown, really exists, we shall still readily admit... In the present imperfect state of our knowledge, of the very interesting branch of the healing art, which relates to the cure of insanity; and unable as we generally are to ascertain its true seat in the complicated labyrinths. He made a powerful disclaimer against those who believed insanity was a physical disease: "We are, however, far from adopting it as a universal maxim, that maniacal symptoms are aggravated by bodily disorder." Most important, he believed the insane never lost their self control or freewill in action. "that madness, in all its forms, is capable of entire control". Unlike the tortures that took place at other mad houses, Tuke's treatments were kind and gentle, like warm baths: "The power of judicious kindness over this unhappy class of society, is much greater than is generally imagined." "The comfort of the patients is therefore considered of the highest importance, in a curative point of view." He highly questioned the standard practices of the day: bleeding, blisters, seatons, evacuants, cold baths, although he did practice them all at times as a lasts resort in isolated cases. He understood the importance of a good nights sleep and recommended lots of food, rather than opium: "difficulty of obtaining sleep for maniacal patients, and the unpleasant effects frequently produced by the use of opium ... however, a liberal supper would perhaps prove the best anodyne." He, like Pinel, used coercion, but much less than the other mad houses. The famous quote that Tuke "never allowed the use of chains" is misleading, since he invented a bed sized strait jacket with leather straps for all limbs, chest and waist to confine out of control people. "At each end is a leather strap one foot long, one inch and a half broad, and a quarter of an inch thick ; with a buckle fastened at the joining of the web and strap". So while Tuke refused to use chains of steel, but invented "chains of leather". In addition to straitjacket and confinement, Tuke used fear and intimidation with rewards and punishments for good and bad behaviour. He also used peer pressure to humiliate the insane into submission. He did not try to change the delusional thinking of the insane, but he expected them to pull their weight and behave like those who were not delusional. This model of functional delusion, is like saying: Let the delusional wives believe what they want as long as they do the dishes... and the delusional men can believe their delusions, as long as they go to work each day to support their families. The fundamental concepts Tuke used in the treatment of the insane were their inherent ability to exercise self control because insanity was a spiritual problem, not bodily disease. He noted that the insane die much younger than the general population: "melancholic patients seldom live long ... many die before thirty or forty". All of Tuke's treatments (attending church, kindness, coercion, warm baths, humiliation) pointed to the fact that he correctly suspected insanity was not a bodily disease, but caused by life choices and circumstances. (Description Of The Retreat For Insane, Samuel Tuke, 1813 AD)
Nature of Insanity:
Causes of Insanity:
A kinder, gentler approach:
The insane have Self control:
Treatments for insanity:
Fear was a treatment:
The positive influence of religion:
Description Of The Retreat For Insane, Samuel Tuke, 1813 AD
Description Of The Retreat An Institution Near York For Insane
(Persons Of The Society Of Friends)
Containing An Account Of Its Origin And Progress
The Modes Of Treatment
And a Statement Of Cases
CHAPTER IV. MEDICAL TREATMENT.
Character of the first Physician—Result of his experi-ments as to the general importance of Medical treat-ment—Of the reducing system in particular-Offbrcing the Patient to take medicine—Consequent bantam direction of the Physician Of the use of the Warm Bath in Melancholia—In Misnia--- Mode of using it Use of Cold Bath in a case of high Mania—Importanca of attention to the general health of the Insane-»--.Frequent extraordinary. sympathy between body and. mind. in this class of persons—Advantage of attention to the bodily health of Convalescents— Use of topical bleeding on the approach of a paroxysm------Necessity of close individual attention to Patients, an argument' against large Establishment a.—Difficulty of ob-taining ,S7eep----Mode practised at the Retreat Want of diacrimination in the medical treat-ment of Inaciwily.—Renvarke on the practice of Bethlem Hospital—Of 2nortffications of the extremities from cold or confinement—Of the capacity of Maniacs to bear cold--Of Diet----.
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Usual bill of fare—Of the antiphlogistic system— Doubt respecting the Diet of the Retreat Of the capacity of Maniacs to bear hunger—Beneficial effects of air and exercise.
THE experience of the Retreat, if it should con-tribute in some degree to the improvement, will not add much to the honour or extent of medical science. I regret that it will be the business of the present chapter, to relate the pharmaceutic means which have failed, rather than to record those which have succeeded.
The physician * first appointed to attend at the Retreat, was a man equally distinguished by medical knowledge, and indefatigable perseverance. He possessed too, (which rendered him peculiarly adapted to the place he filled,) a highly benevolent and un-prejudiced mind. His experience had not been great in that particular branch of his profession, which on this occasion claimed his attention ; but, as might be expected, he entered on his office with the anxiety and ardour of a feeling mind, upon the
*Dr. Thomas Fowler, author of " Medical Reports," &c. &c. MEDICAL TREATMENT. 111
exertion of whose skill, depended the dearest interests of many of his fellow-creatures. He determined to give a full trial of the means, which his own judgment might suggest, or which the superior knowledge and experience of others had already recommended. But the sanguine expectations, which he successively formed of benefit to be derived from various pharma-ceutic remedies, were, in great measure, as suc-cessively disappointed ; and, although the proportion of cures, in the early part of the Institution, was respectable; yet the medical means were so im-perfectly connected with the progress of recovery, that he could not avoid suspecting them, to be rather concomitants than causes. Further experi-ments and observations confirmed his suspicions ; and led him to the painful conclusion, (painful alike to our pride and to our humanity,) that medicine, as yet, possesses very inadequate means to relieve the most grievous of human diseases.
Bleeding, blisters, seatons, evacuants, and many other prescriptions, which have been highly recom-mended by writers on insanity, received an ample trial ; but they appeared to the physician too ineffica-cious, to deserve the appellation of remedies, except when indicated by the general state of the habit. As the use of antimaniaeal medicines was thus doubtful, a very strong argument against them arose, from the difficulty with which they were very frequently administered; as well as from the impossibility of employing powerful medicines, in a long continuance, without doing some injury to the constitution.The physician plainly perceived how much was to be done by moral, and how little by any known medical means. He therefore directed, with his usual humanity and modesty, that any medicine which he might pre-scribe, by way of experiment, should not be ad-ministered, where the aversion of the patient was great ; unless the general health strongly indicated its necessity; well aware, that otherwise, the probable good would not be equal to the certain injury.
There is, however, one remedy, which is very frequently employed at the Retreat, and which appears to have been attended with the happiest effects; and that is the warm bath. In the first years of the Institution, this remedy was not so much employed, as it is at present ; for it was natural to pay mo'A attention to such means, as medical writers, professing experience in the treatment of the maladies of the mind, had most strongly re-
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commended: and it is not a little remarkable, that, of the various means proposed for the cure of these disorders few, if any, are less recommended than the warm bath. This remedy, however, has been for several years, and it still is considered, at the Retreat, of greater importance and efficacy, in most cases of melancholia, than all the other medical means which have been employed.
Dr. Willis appears aware of the importance of warm bathing, in cases of insanity, by the answer which he gave to a. question upon that subject, from a select Committee of the House of Commons, on the " 9th of March, 1807." This remedy, however, at that time, had been employed for several years with great advantage at the Retreat.
2uestion. Are you of opinion, that warm and cold baths are necessary for lunatic patients ?"
Answer. I think warm baths may be very useful ; but, it can seldom happen that a cold bath will he required'k."
Vide Report from the Select Committee, appointed to inquire into the state of lunatics. Haslanes Observations, p. `,-12!).
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That this remedy deserves the attention it receives in this Institution, appears evident by the unusual number of recoveries, in cases of melancholia, to which class the warm bath is chiefly applied. In several cases where the use of this means has been necessarily suspended, the patient has evidently relapsed. No advantage has been found from its use, in case of mania ; indeed, it has been thought rather to aggravate the symptoms. The time of the patient's continuance in the bath, and the temperature at which it is used, are gradually increased ; the former from twenty minutes to nearly an hour ; and the latter, from 85 to 98 de-grees. The cold bath has been frequently tried in a variety of cases, both of melancholia and mania ; but the result of the experiments is said to be unfavourable to its general use. In one case, during a paroxysm of high ungovernable mania, immersion of the body, except the head, in the cold bath, for the space of one or two minutes, appeared essentially useful in quieting the patient ; but the remedy, in such cases, ought to be applied with great judgment ; and its application should always be witnessed by the master, or mistress of the family.
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Having shown the result of the experiments made by the respectable physician, who first attended the Retreat officially ; it is almost unnecessary to say, that his conclusions have, since, considerably in-fluenced his successors. This, however, has not been entirely the case. Anxious to remove the difficulties that have hitherto attended every attempt, to relieve this most deplorable of human maladies, they have had recourse to various means, suggested either by their own knowledge and ingenuity, or recommended by later writers ; but their success has not been such, as to rescue this branch of their profession, from the charge, unjustly exhibited by some against the art of medicine in general, of its being chiefly conjectural.
It must not, however, be supposed, that the office of physician, is considered at the Retreat, of little importance. The physician, from his office, some-times possesses more influence over the patients' minds, than the other attendants ; and in all cases where the mental disease, is attended by any bodily disorder ; and more especially when it has super-vened- any obvious malady, however slight ; judicious medical attention, has been found of the greatest advantage. The improvement of one part of the
system, has so frequently and regularly kept pace with that of the other, as to leave no doubt of the great importance of attention to the general health of insane patients. The inexplicable sympa-thy between body and mind, appears to exist, in a morbid degree, in this description of persons ; and to them, the remark of Dr. Beddoes, that there is more connexion between a sound mind and a sound body than is generally imagined, is peculiarly applicable. A degree of indigestion, or a fulness of the blood-vessels, which, in others, occasions only a head-ache, or a slight degree of mental inactivity, often produces, in habits where the tendency to insanity is strong, a violent maniacal paroxysm ; and has frequently been at-tended by an accession of the diseased symptoms ; or by a relapse when convalescence appeared approaching. We are, however, far from adopting it as a uni-versal maxim, that maniacal symptoms are aggravated by bodily disorder. On the contrary, several in-stances have occurred, at the Retreat, of what Dr. Ferrier has termed " conversions ;" in which the latter disease has apparently suspended or obliterated the former ; and many in which severe bodily indis- position has attended the patient, without any abatement of the maniacal symptoms. These in- stances by no means lessen the importance of attending to the bodily indications of insane persons ; more especially during lucid intervals, or the period of convalescence. From attention to this branch of medical treatment, very great advantage appears to have been derived, at the Retreat.
Topical bleeding has been found eminently useful, where the approach of a paroxysm, was indicated by a determination of blood to the head. In one case par, ticidarly, in which the paroxysms had preViously been frequent, their return was apparently delayed, for a great length of time, by the judicious use of the scari-fying instrument, applied to the shoulders and back of the neck; and on this means of prevention being with-held, a relapse shortly ensued. HenCe, we cannot but perceive the importance of insane patients being under the frequent observation of persons of knowledge, judgment, and probity. Hence also ari argument arises against very large Institutions, where the number of patients is too great, to come under the proper inspection of the superintendent ; and where they are therefore chiefly left to the care and man-agement of keepers, who too frequently possess
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few of the qualities necessary for their office, unless we consider as such,
" Limbs of British oak, and nerves of wire."
The difficulty of obtaining sleep for maniacal patients, and the unpleasant effects frequently pro-duced by the use of opium, are well known to medical practitioners. It occurred, however, to the sensible mind of the superintendent, that all animals in a natural state, repose after a full meal ; and, reasoning by analogy, lie was led to imagine, that a liberal supper would perhaps prove the best anodyne. He therefore caused a patient, whose violent excite-ment of mind indisposed him to sleep, to be supplied freely with meat, or cheese and bread, and good porter. The effect answered his expectation; and this mode of obtaining sleep, during maniacal paroxysms, has since been very frequently and successfully employed. In cases where the patient is averse to take food, porter alone has been used with evident advantage, always avoiding, in all cases, :my degree of intoxication.
Since writing the above, I have been informed, that a mode somewhat similar, was practised at a private establishment of some celebrity, in Lancashire. It
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was a regular custom in that house, for all the patients to be shut up in their lodging-rooms, for at least an hour after dinner ; and it is said, but I am not in possession of particular information on this point, that numerous cures were performed under this treatment. The application, however, of any single means, to all cases, can hardly be judicious.
It has been, and it still is very common, to treat in-sanity with too little discrimination. Of this practice we have a striking instance in one of our largest public Institutions. I presume not to pry further into the practices of this establishment, than I am enabled to do by the statements of the professional attendants, which have been recently published. The sur-geon informs us, that " The curable patients in Bethlem Hospital, are regularly bled about the commencement of June, and the latter end of July*:" and the apothecary to the same Institu-tion tells us ; " It has been for many years the prac-tice, to administer to the curable patients, four or five emetics in the spring of the year." He adds, " but on consulting my book of cases, I have me found that such patients have been particularly benefited by the use of this remedy." It appears that this indiscriminate treatment of insanity, is not confined to Bethlem Hospital.--Dr. Pine', after ridiculing the enormous catalogue of powders, extracts, juleps, electuaries, draughts, and epithems, which are recommended in books, as reme-dies of great virtue, in cases of insanity, says : "'What are we to think of the practice of repeated blood-letting, which is so universally the fashion of the present day, without attention to the distinctions of the existing cause, the varieties of sex, or of individual constitution ; and the different species and periods of the complaint?"
Dr. Arnold,4n the introduction to his Observations on Insanity, states, that one end he proposes by his remarks is, to point out " the great variety of those disorders, which are called by the general appellation of madness, insanity, or lunacy ; and, to put a stop to the usual practice of imprudently trusting their unhappy friends, who have the misfortune to be afflicted with so various, terrible, and obstinate a
Haslain's Observations on Madness, page 329. MEDICAL TREATMENT.
disease, to the common empirical practice of in-discriminate evacuation, not to mention harsh and cruel treatment, in the hands of any illiterate pre-tender !"
Under the head " Medical Treatment," as practiced in the Retreat, some may possibly inquire, what are the means employed in mortifications, arising from cold and confinement ? " a calamity, which," says a writer before alluded to, " frequently happens to the helpless insane, and to bed-ridden patients ; as my attendance in a large work-house, in private mad-houses, and Bethlem Hospital, can amply testify." Haslam also observes, that the patients in Bethlem Hospital, " are particularly subject to mortification's of the feet ; and this fact is so well established from former accidents, that there is an express order of the house, that every patient, under strict confinement, shall have his feet examined every morning and evening in the cold weather, by the keeper, and also have them constantly wrapped in flannel ; and those who are permitted to go about, are always to be found as near to the fire as they can get, during the winter season." Dr. Pinel also confesses, that " seldom has a whole year elapsed, during which no fatal accident has taken place, in the Hospital de Bicetre, (in France,) from the action of cold upon the extremities." Happily, in the Institution I am now describing, this calamity is hardly known ; and no instance of mortification has occurred, in which it has been, in any degree, connected with cold or confine, ment. Indeed, the patients are never found to require such a degree of restraint, as to prevent the use of considerable exercise, or to render it at all necessary to keep their feet wrapped in flannel.
It will be proper here to observe, that the experi-ence of the Retreat, fully confirms the opinion of several respectable modern writers, that maniacs are by no means exempted from the common effects of cold ; and it is to be hoped, for the sake of humanity, that the opposite opinion, alike barbarous and absurd, will be entirely exploded. The apothecary
* Observations on Madness, p. 84. to Bethlem Hospital, after stating that the patients are not exempt from the usual effects of severe cold, observes very justly : " From the great degree of insensibi.ity which prevails, in some states of mad-ness, a degree of cold would scarcely be felt by such persons, which would create uneasiness in those of sound mind ; but experience has shown that they suffer equally from severity of weather. When the mind is particularly engaged on any subject, external circumstances affect us less, than when unoccupied Every one must recollect., that in following up a favourite pursuit, his fire has burned out without his being sensible of the alteration of temperature; but when the performance has been finished, or he has become indifferent to it from fatigue, he then be-comes sensible to cold, which he had not experienced before."
In considering the medical treatment of the insane, we must not overlook the generally im-portant considerations of diet, air, and exercise. I do not find that many experiments have been made, at the Retreat, upon the subject of diet. The usual bill of fare for the patients on the charity, is such as I imagine will be considered adapted to person.); in common health. It is as follows
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Breakfast—Milk and bread, or milk porridge.
Dinner—Pudding and animal food five days in the week ; fruit pudding, and broth or soup, two days.
in the afternoon, the men have bread and beer, the women tea or coffee.
Supper—Generally the same as breakfast, or bread, cheese, and beer.
The superior patients have no particular diet, but live in all respects as the superintendents.
Those practitioners who are disposed to recom, mend a very spare diet, in nearly all cases of insanity, will probably be startled at this account of the mode of living at the Retreat ; and those more discrimi-nating persons, of whose curative means, the anti-phlogistic, or, in plain English, the reducing system, forms so essential a part of treatment, wherever " irritation or violence exists," may be disposed to consider our diet as more liberal than judicious. So many instances, however, have occurred of com-plete recovery, after a full trial, previously to ad-mission, had been ineffectually given to diet and medicaments of a reducing nature ; that the mana-gers of this establishment, feel no inclination to alter their present plan. I am assured by our phy-
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sician, who, in his own practice, has had extensive opportunity of observation, that he has seen very few cases, in which a low diet has produced a good effect. On the contrary, " those maniacs who refused their food, have had generally the strongest and most durable paroxysms, and their subsequent depression has been the most deplorable."
Case 74, affords very striking evidence in favour of a liberal, nourishing diet, even where great " irritation or violence exists." The patient was described as a furious, dangerous lunatic ; and the reducing system had been fully tried upon him, with an aggravation of his complaint. The opposite mode was then pursued ; and his appetite, from being long famished, was almost voracious for many days. It gradually lessened, till it arrived at the common standard. He took no medicine ; and under the treatment he met with, his irritation of mind gradually subsided, and his recovery was very rapid and complete.
I will, however, venture to express my doubts, whether the Retreat diet be sufficiently discrimina-tive. In most, if not in all cases of insanity, the animal spirits appear to be either excited or depressed
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beyond their proper bounds. Knowing, as we do, the effect of food upon ourselves, is it not rational to suppose, that an opposite or different diet, will, in some cases, be required in these opposite states of mind ? Pursuing the same track of analogy, which proved so successful in the discovery of the means of obtaining sleep, may we not be led to infer the diet, which is best adapted to some, at least, of the different classes of insanity ? The effect of diet upon our dispositions and habits, has been generally ad-mitted. Eschylus makes the king of Pelasgia say to the herald who threatened him with war,
" You shall be met by men whose lively blood,
" Dull draughts of barley wine have never clogg'd."
Every one will probably have observed, that after eating a hearty dinner, lie is indisposed either to mental or bodily exertion; nor can the different degrees of this indolent feeling which prevail, according to the quantity or nature of the food em-ployed, have escaped notice.
The difference in the French and English cha-racter, has been in part attributed to the different mode of living in regard to diet ? In France, melan-choly is said to be a stranger ; whilst with us, and
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certainly we have long bad more political right to be merry, melancholy, and hence suicide, is proverbially common*. Some writers are, however, of opinion, that this fatal propensity, does not, in any degree, arise from the cause we have just mentioned. Dr. Beddoes says, there are few countries in Europe, of which the inhabitants do not consume as much animal food as the corresponding classes of the English." Be this as it may, the importance of attention to diet, appears to me to derive sufficient
" I cannot," says a medical observer, " by any means persuade
myself that the excess of the English in animal food, has any thing to do with the frequency of self-murder, in their otherwise fortunate island. For in Bavaria, Austria, and other provinces of the German empire, far more butchers' meat is served up than in England, and far more eaten. Yet with us, suicide is a far more unfrequent occurrence. That we, in fact, eat a greater quantity of meat than the English, I was convinced of, by the entertainments at which I was present in London. And I still recollect with pleasure, an incident to this purpose that took place at Coventry. At an inn in that city, my fellow-travellers and myself bespoke all the articles in the bill of fare. They were about six, and we were obliged to re. peat our order to the waiter three several times, and at last were interrogated by the landlady herself, whether we had in earlie,t ordered all that meat. So simple is English fare. Salzburg Med. Clzirurg. Zectung. 1798, 1. 170."
11(aldoes' Essay on COUSUMp. page 111.
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support from the general effect of different kinds of food on our mental feelings.
After apologizing to the reader for this speculative digression, I return to the more useful detail of prac-tical results. The absurd notion respecting the capacity of maniacs generally to resist the action of cold, has been already mentioned. The supporters of this opinion, also generally observe, that insane persons commonly endure hunger without injury.— The latter sentiment is no less at variance with the experience of the Retreat, than the former. Some of the patients, more especially the melancholies and convalescents, besides their four usual meals in the day, require the intermediate refreshment of biscuit, with a glass of wine or porter ; and attention of this kind is considered almost essential to the recovery of many patients.
" General propositions," says Dr. Pinel, " have been too often advanced in regard to the capacity of maniacs to bear extreme hunger with impunity. I have known several, who were voracious to a ()Teat degree, and who languished, even to fainting, from want, or deficiency of nourishment. It is said of an asylum at Naples, that a low spare diet is a funda-
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mental principle of the Institution. It would be difficult to trace the origin of so singular a prejudice. Unhappy experience, which I acquired during seasons of scarcity, has most thoroughly convinced me, that insusficiency of food, when it does not altogether extinguish the vital principle; is not a little calculated to exasperate and prolong the disease s."
I would not have dwelt so long upon these mis-taken opinions, if they had not furnished a specious pretext for much practical barbarity ; and I am, therefore, anxious to see them ranked with the mar-vellous stories of the Phoenix and the Salamander.
Where various means are employed, it is difficult to say which is the operative one; but, whatever may be the means used, there is great reason to believe that a clear dry air, which the situation of the Retreat affords in an eminent degree, will facilitate their operation, and be favourable to the recovery of insane persons. To reason again from analogy ; the general effects of fine air upon the animal spirits, would induce us to expect especial benefit from it, in cases
Dr. Davis's translation of " Pinel's Treatise on Insanity," p. 31.
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of mental depression ; and to pay all due respect to the physician, who,
" Gives melancholy up to Nature's care, " And sends the patient into purer air."
Several instances have occurred, in which melan-choly patients, have been very much improved by their journey to the Retreat ; and it is the decided opinion of the manager of this Institution, that, in such cases, close confinement is of all things the most detrimental.
Importance of Management in a curative point of view -- Power of self-controt possessed by Maniacs Time disorder generally partial, in regard to both the intellectual powers and affections—Of the malevo-lent dispositions evinced by Maniacs—Powerful effect of judicious kindness Practices of the Retreat arranged under three heads.
WHATEVER theory we maintain in regard to the remote causes of insanity, we must consider moral treatment, or management, of very high importance. If we adopt the opinion, that the disease originates in the mind, applications made immediately to it, are obviously the most natural ; and the most likely to be attended with success. If on the contrary, we conceive that mind is incapable of injury or destruction, and that, in all cases of apparent mental derangement, some bodily disease, though unseen and unknown, really exists, we shall still readily admit, from the reciprocal action of the two parts of our system upon each other, that the greatest attention is necessary, to whatever is calculated to affect the mind. In the present imperfect state of our knowledge, of the very interesting branch of the healing art, which relates to the cure of insanity ; and unable as we generally are to ascertain its true seat in the complicated labyrinths of our frame, the judicious physician is very frequently obliged to apply his means, chiefly to the alleviation and suppression of symptoms.
Experience, however, has happily shown, in the Institution whose practices we are attempting to describe, that much may be done towards the cure and alleviation of insanity, by judicious modes of management, and moral treatment. The super-intendent, who is also the apothecary of the Retreat, after more than fifteen years experience, fully unites with the intelligent Dr. Pinel, in his comparative esti-mate of moral and medical means. The doctor thus
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expresses himself : " Attaching, as I do, little import-ance to pharmaceutic preparations; and, all-sufficiency, in curable cases, to physical and moral regimen, I intend not to devote many of my pages, to the exclu-sive consideration of drugs and medicaments."
It is a matter of no small difficulty, to convey more than the general principles which influence the conduct of those, who have the management of the insane. It is unhappily, in great measure true, that " the address which is acquired by experience, and constant intercourse with maniacs, cannot be com-municated : it may be learned ; but it must perish with its possessor*." It appears, however, to me, that a free detail of different modes of management, can hardly fail to increase our stock of correct general principles, on this important subject.
Insane persons generally possess a degree of con-trol over their wayward propensities. Their intel-lectual, active, and moral powers, are usually rather perverted than obliterated ; and it happens, not unfrequently, that one faculty only is affected. The disorder is sometimes still more partial, and can only be detected by erroneous views, on one particular subject. On all others, the mind appears to retain its wonted correctness. The same partial perversion, is found to obtain in this disease with regard to the affections.
Though it frequently happens, that indifference or disgust towards the tenderest connexions, is an early and distressing symptom of insanity ; when,
Observations on Madness, by John Ilaslam, p. 277, 2d edition ; from which all the quotations in this work are taken. The Retreat, at an early period, derived advantage from the first edition of these Observations.
" forgotten quite,
" AU former scenes of dear delight,
" Connubial love, parental joy ;
" No sympathies like these his soul employ ;"
yet the existence of the benevolent affections, is often strongly evidenced, by the patient's attachment to those who have the immediate care of them, and who treat them with judgment and humanity. The apothecary to Bethlem Hospital says*, " I can truly declare, that by gentleness of manner, and kindness of treatment, I have seldom failed to obtain the con-fidence, and conciliate the esteem, of insane persons ; and have succeeded by these means in procuring from
* Observations, p. 293.
theta respect and obedience." The superintendents of the Retreat give precisely the same evidence ; and I firmly believe, that a large majority of the instances, in which the malevolent dispositions are peculiarly appa-rent, and are considered as characterizing the disorder, may readily be traced to secondary causes ; arising from the peculiar circumstances of the patiet„ or may readily be traced to secondary causes ; arising from the peculiar circumstances of the patiet„ or from the mode of management.
A patient confined at home, feels naturally a degree of resentment, when those whom he has been accustomed to command, refuse to obey his orders, or attempt to restrain him. We may also, I con-ceive, in part, attribute to similar secondary causes, that apparent absence of the social affections, and that sad indifference to the accustomed sources of domestic pleasure, of which we have just been speaking. The unhappy maniac is frequently un-conscious of his own disease. He is unable to account for the change in the conduct of his wife, his children, and his surrounding friends. They appear to him cruel, disobedient, and ungrateful. His disease aggravates their conduct in his view, and leads him to numerous unfounded suspicions. Hence, the estrangement of his affections may frequently be the natural consequence, of either the proper and
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necessary, or of the mistaken conduct of his friends towards him.
In such cases, the judicious kindness of others appears generally to excite the gratitude and affection of the patient. Even in those deplorable instances where the ingenious humanity of the superintendent fails to conciliate, and the jaundice-like disease, changes the very aspect of nature, and represents all mankind as the leagued enemies of the patient, the existence of the social affections, has often been strikingly evidenced, by attachment to some of the inferior animals.
There are, undoubtedly, cases in which the disorder is chiefly marked by a mischievous malevolent dis-position; but of these, very few have occurred at the Retreat. There have, however, been many patients, in whom these dispositions have been occasionally conspicuous, or easily excited by improper treat-ment.
The outline of the character of the insane, which we have now exhibited, must be considered as con-fined to two states of the disease, mania and melan-cholia, It frequently happens, however, that a
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greater or less degree of imbecility, succeeds the more violent excitement of the mind ; and a sufficient number of cases of this description have occurred, to warrant me in asserting, that even in these hope-less instances of mental alienation *, considerable
* I adopt this term from an opinion, that the ti/ii%m. of the French, conveys a more just idea of this disorder, than those expressions winch imply, in any degree, the " abolition of the thinking faculty." The following case, related to me by a medical friend, will serve to show that even in idiocy, the mind may be rather suppressed than destroyed. A young woman, who was employed as a domestic servant, by the father of the relater, when he was a boy, became insane, and at length sunk into a state of perfect idiocy. In this condition she remained for many years, when she was attacked by a typhus fever ; and toy friend, having then practised some time, attended her. He was surprised to observe, as the fever advanced, a development of the mental powers. During that period of the fever, when others were delirious, this patient was entirely rational. She recognized, in the face of her medical attenibmt, the son of her old master, whom she had known so many years before ; and she related many circumstances respecting his family, and others, which had happened to herself in her earlier days. But, alas! it was only the gleam of reason ; as the fever abated, clouds again enveloped the mind ; she sunk into her former deplorable state, and remained in it until her death, which happened a few years afterwards. I leave to the metaphysical reader, further speculation on this, certainly, very curious case.
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warmth of affection is frequently evinced ; and that patients of this class may, in general, be easily amused and pleased.
if the preceding sketch is correct, it would not, I apprehend, be difficult to infer theoretically, the general principles of moral treatment and manage. went ; but I have happily little occasion for theory, since my province is to relate, not only what ought to be done, but also what, in most instances, is actually performed.
The moral treatment of the insane, seems to divide itself into three parts ; and under these, the practices of the Retreat may be arranged. We shall therefore inquire, I. By what means the power of the patient to control the disorder, is strengthened and assisted. II. What modes of coercion are employed, when- restraint is absolutely necessary. III. By what means the general comfort of the insane is promoted.
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OF THE MEANS OF ASSISTING THE PATIENT TO CONTROL HIMSELF:
Power of self-restraint strongly evidenced at the Retreat Motives for its exertion Conclusion drawn hence respecting the excitement of Fear Of the degree in which Fear may be usefully ex-cited Of the excitement of furious Mania by improper treatment ; and of the efficacy of per-suasion and kind treatment towards inducing self- restraint Argument in favour of the terrific system. Of the attendants' behaviour to lunatic's on first acquaintance -Analogy between the judi- cious treatment of children and insane persons Of the manner of speaking to Alaniacs Of reasoning with the Patient on the subjeclofhis hallucination:— Of the conversation adapted to melancholic's-Beneficial effects of exercise and variety of object upon this class, illustrated by an-affecting case Advantage of regular labour in some cases Desire of esteem a powerful principle towards inducing self-restraint Other weans cf cultiva- ting it The aid of Religion in promoting self- restraint—Hints to the attendants on the Insane,
WE have already observed, that most insane persons, have a considerable degree of self command; and that the employment and cultivation of this remaining power, is found to be attended with the most salutary effects. Though many cannot be made sensible of the irrationality of their conduct or opinions; yet they are generally aware of those particulars, for which the World considers them proper objects of confinement. Thus it frequently happens, in the Institution we are describing, that a patient, on his first introduction, will conceal all marks of mental aberration. Instances have occurred, in which the struggle has been so successful, that persons, who, on undoubted authority, have been declared to be unmanageable at borne; and to have shown very striking marks of insanity ; have not, for a very considerable time, exhibited sufficient symp-toms of the disorder, to enable the physician to declare them, non compos mentis. Doubtless the idea that their early liberation, for which most are anxious, and their treatment during their con-tiement, will depend, in great measure, on their conduct, has a tendency to produce this salutary restraint, upon their wayward propensities.— Hence, also, the idea seems to have arisen, that madness, in all its forms, is capable of entire control, by a sufficient excitement of the principle of fear. This speculative opinion, though every day's ex-perience decidedly contradicts it, is the best apology
which can be made for the barbarous practices that have often prevailed in the treatment of the insane.
The principle of fear, which is rarely decreased by insanity, is considered as of great importance in the management of the patients. But it is not allowed to be excited, beyond that degree which naturally arises from the necessary regulations of the family. Neither chains nor corporal punish-ments are tolerated, on any pretext, in this establish-ment. The patients, therefore, cannot be threatened with these severities; yet, in all houses established, for the reception of the insane, the general comfort of the patients ought to be considered ; and those who are violent, require to be separated from the more tranquil, and to be prevented, by some means, from offensive conduct, towards their fellow-sufferers. Hence, the patients are arranged into classes, as much as may be, according to the degree in which they approach to rational or orderly conduct.
They quickly perceive, or if not, they are in-formed on the first occasion, that their treatment depends, in great measure, upon their conduct. Coercion thus flowing as a sort of necessary consequence, and being executed in a manner which marks the reluctance of the attendant, it seldom exasperates the violence of the patient, or pro-duces that feverish and sometimes furious irrita-bility, in which the maniacal character is com-pletely developed ; and under which all power of self-control is utterly lost.
There cannot be a doubt that the principle of fear, in the human mind, when moderately and judiciously excited, as it is by the operation of just and equal laws, has a salutary effect upon society. It is a principle also of great use in the education of children, whose imperfect knowledge and judg-ment, occasion them to be less influenced by other motives. But where fear is too much excited, and where it becomes the chief motive of action, it certain. ly tends to contract the understanding, to weaken the benevolent affections, and to debase the Mind. As the poet of Liberty has well sung,
" All constraint,
" Except what wisdom lays on evil man, " Is evil; hurts the faculties, impedes
" Their progress in the road of science, blinds " The eye-sight of discovery ; and begets,
" In those that suffer it, a sordid mind, " Bestial, a meagre intellect, unfit
To he the tenant of man's noble form."
COWPER'S TASK, BOOK V.
It is therefore wise to excite, as much as possible, the operation of superior motives ; and fear ought only to be induced, when a necessary object cannot otherwise be obtained. If this is the true scale of estimating the degree in which this principle is, in general, to be employed, it is found, at the Retreat, equally applicable to the insane.
That the continual or frequent excitement of the sensations of fear, should " bid Melancholy cease to mourn," is an idea too obviously absurd in theory, to require the refutation of experience. There has, however, unhappily been too much experience on this subject ; and hence we may perhaps, in great degree, explain, why melancholy has been consider-ed so much less susceptible of cure than mania. To the mild system of treatment adopted at the Retreat, I have no doubt we may partly attribute, the happy recovery of so large a proportion of melancholy patients.
Is then the violent excitement of the principle of fear, better adapted to enable the maniac to control his wanderings, and to suppress his emotions ? Is it not, well known, that the passions of many maniacs, are extremely irritable ? and, when once excited,
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are not all moral means to subdue them, as in-effectual as the attempt would be to quench, by artifical means, the fires of Etna ?
If it be true, that oppression makes a wise man mad, is it to be supposed that stripes, and insults, and injuries, for which the receiver knows no cause, are calculated to make a madman wise ? or would they not exasperate his disease, and excite his re-sentment ? May we not hence most clearly perceive, why furious mania, is almost a stranger in the Retreat ? why all the patients wear clothes, and are generally induced to adopt orderly habits ?
The superintendent of this Institution is fully of opinion, that a state of furious mania, is very often excited by the mode of management. Of this opinion, a striking illustration occurred in this Institution, some years ago. A patient, of rather a vindictive and self-important character, who had previously conducted himself with tolerable pro-priety, one (lay, climbed up against a window, which overlooked the court where he was confined, and amused himself by contemplating the interior of the room. An attendant, who had not been long in office, perceiving his situation, ran hastily
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towards him, and, without preamble, drew him to the ground. The patient was highly incensed ; a scuffle immediately ensued, in which he succeeded in throwing his antagonist ; and had not the loud vociferations of this attendant alarmed the family, it is probable that he would have paid for his rash conduct, by the loss of his life. The furious state of the patient's mind did not continue long ; but, after this circumstance, he was more vindictive and violent.
In some instances, the superintendent has known furious mania temporarily induced, by the privations necessary on a relapse, after a considerable lucid interval, during which the patient had enjoyed many privileges, that were incompatible with his disordered state. Here we may suggest the expediency, where it is possible, of employing such of the attendants to control the patient during his paroxyms, as had little intercourse with him in his lucid interval. Instances of furious mania have been, however, very rare ; but a considerable number of patients have been admitted, who were reported to be so furiously insane, as to require constant coercion.
The evidence of attendants, who have been em-ployed, previously to the admission of patients into
146 MORAL TREATMENT.
the Retreat, is not considered a sufficient reason for any extraordinary restraint ; and cases have oc, curred, in which persuasion and kind treatment, have superseded the necessity of any coercive means.
Some years ago a man, about thirty-four years of age, of almost Herculean size and figure, was brought to the house. He had been afflicted several times before ; and so constantly, during the present attack, had he been kept chained, that his clothes were con-trived to be taken off and put on by means of strings, without removing his manacles. They were however taken off, when he entered the Retreat, and he was ushered into the apartment, where the superintendents were supping. He was calm ; his attention appeared to be arrested by his new situation. He was desired to join in the repast, during which he behaved with tolerable propriety. After it was concluded, the superintendent conducted him to his apartment, and told him the circumstances on which his treatment would depend ; that it was his anxious wish to' make every inhabitant in the house, as comfortable as pos, sible; and that he sincerely hoped the patient's conduct would render it unnecessary for him to have recourse to coercion. The maniac was sensible of the kindness of his treatment. He promised to restrain
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himself, and he so completely succeeded,_ that, during his stay, no coercive means were ever em-ployed towards him. This case affords a striking example of the efficacy of mild treatment. The patient was frequently very vociferotis, and threatened his attendants, who in their defence were very desir-ous of restraining him by the jacket. The super-intendent on these occasions, went to his apartment ; and though the first sight of him seemed rather to increase the patient's irritation, yet after sitting some time quietly beside him, the violent excitement subsided, and he would listen with attention to the persuasions and arguments of his friendly visiter. After such conversations, the patient was generally better for some days or a week ; and in about four months he was discharged perfectly recovered.
Can it be doubted, that, in this case, the disease had been greatly exasperated by the mode of man-agement ? or that the subsequent kind treatment, had a great tendency to promote his recovery ?
It may probably be urged, and I am very well aware of it, that there is a considerable class of patients, whose eccentricities may, in great measure, be controlled ; and who may be kept in subjection
and apparent orderly habits, by the strong excite-ment of the principle of fear. They may be made to obey their keepers, with the greatest promptitude ; to rise, to sit, to stand, to walk, or run at their pleasure ; though only expressed by a look. Such an obedience, and even the appearance of affection, we not unfrequently see in the poor animals who are exhibited to gratify our curiosity in natural history ; but, who can avoid reflecting, in observing such spectacles, that the readiness with which the savage tiger obeys his master, is the result of treatment, at which humanity would shudder ; and shall we pro-pose by such means,
" To calm the tumult of the breast,
" Which madness has too long possest ; " To chase away the fiend Despair,
" To clear the brow of gloomy Care ;
" Bid pensive Alelancholy cease to mourn,
" Calm Reason reassume her seat; " Each intellectual power return?"
If those who are friendly to what may be termed the terrific system of management, could prove, that, notwithstanding it may fix for life, the misery of a large majority of the melancholics ; and drive many of the more irritable maniacs to fury or desperation ; yet that it is still, in its operation upon a large scale,
adapted to promote the cure of insanity,, they would have come apology for its discriminate adoption. If, on the contrary, a statement of the proportion of Cures in the Retreat, shall sufficiently prove the superior efficacy of mild means, would not those, who are adopting an opposite line of treatment, do well to reflect on the awful responsibility which attaches to their conduct ? Let us all constantly remember, that there is a Being, to whose eye darkness is light ; who sees the inmost recesses of the dungeon, and who has declared: " For the sighing of the poor, and the crying of the needy, I will arise."
From the view we have now taken of the propriety of exciting fear, as a means of promoting the cure of insanity, by enabling the patient to control himself, it will, perhaps, be almost superfluous to state as our opinion, that the idea, which has too generally, obtained, of its being necessary to commence an ac-quaintance with lunatics, by an exhibition of strength, or an appearance of austerity, is utterly erroneous. The sentiment appears allied to that cruel system, probably dictated by indolence and timidity, which has so long prevailed, and unhappily still prevails, in manor receptacles for the insane.
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There is much analogy between the judicious treat-ment of children, and that of insane persons. Locke has observed, that " the great secret of education, lies in finding the way to keep the child's spirit easy, active, and free; and yet, at the same time, to restrain him from many things he has a mind to, and to draw him to things which are uneasy to him." It is highly desirable that the attendants on lunatics should possess this influence over their minds ; but it will never be obtained by austerity and rigour ; nor will assumed consequence, and airs of self-importance, be generally more successful.
Much familiarity with maniacal patients, on their first introduction to a new situation, is not thought,. in general, to be advisable. It might, in some in-staixes, have a tendency to lessen that authority, which is, occasionally, necessary for the attendant to exert. There may also be a few cases in which a distant, and somewhat important manner, may be as-sumed with advantage ; but, generally speaking, even with regard to the more violent and vociferous maniacs, a very different mode is found successful ; and they are best approached with soft and mild per-suasion. The superintendent assures me, that in these cases, he has found it peculiarly necessary
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to speak to the patient in a kind, and somewhat low tone of voice. So true are the maxims of antiquity,
4 4A soft answer turneth away wrath."—soLOMON.
" Soft speech
Is to distemper'd wrath, medicinal."—EsctirLus,
It must, however, be understood, that the per-suasion which is extended to the patients, is confined to those points which affect their liberty or comfort. No advantage has been found to arise from reasoning with them, on their particular hallucinations. One of the distinguishing marks of insanity, is a fixed false conception, which occasions an almost total inca-pacity of conviction. The attempt, therefore, to refute their notions, generally irritates them, and rivets the false perception more strongly on their minds. There have been a few instances, in which, by some striking evidence, the maniac has been driven from his favourite absurdity ; but it has uni-formly been succeeded by another equally irrational. [Let the wives believe what they want as long as they do the dishes... and the men as long as they go to work each day to support their families.]
In regard to melancholics, conversation on the subject of their despondency, is found to be highly injudicious. The very opposite method is pursued. Every means is taken to seduce the mind from its
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favourite but unhappy musings, by bodily exercise, walks, conversation, reading, and other innocent recreations. The good effect of exercise, and of variety of object, has been very striking in several instances at this Institution. Some years ago, a patient much afflicted with melancholic and hypo-chondriacal symptoms, was admitted by his own request. He had walked from home, a distance of 2.00 miles, in company with a friend ; and on his arrival, found much less inclination to converse on the absurd and melancholy views of his own state, than he had previously felt*.
# Though this patient was much less disposed to converse upon the subject, his hypochondriacal ideas remained, as the following description of himself, taken nearly verbatim front his own mouth, will prove: " I have no soul; I have neither heart, liver, nor lungs; nor any thing at all in my body, nor a drop of blood in my veins. My bones are all burnt to a cinder : I have no brain ; and my head is sometimes as hard as iron, and sometimes as soft as a pudding." A fellow patient, also an hypochondriac, amused himself in versifying this affectingly ludicrous description in the following lines:
A miracle, my friends, come view, A man, admit his own words true, Who lives without a soul;
Nor liver, lungs, nor heart has he, Vet, sometimes, can as cheerful be As if he had the whole.
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This patient was by trade a gardener, and the superintendent immediately perceived, from the effect of this journey, the propriety of keeping him employed. He led him into the garden, and con-versed with him on the subject of horticulture ; and soon found that the patient possessed very superior knowledge of pruning, and of the other departments of his art. Ile proposed several improvements in the management of the garden, which were adopted, and the gardener was desired to furnish him with full employment. He soon, however, showed a reluctance to regular exertion, and a considerable disposition to wandering, which had been one of the previous
His head (take his own words along) Now hard es iron, yet ere long
Is soft as any jelly ;
All burnt his sinews, and his lungs ; Of his complaints, not fifty tongue Could find enough to tell ye.
Yet he who paints his likeness here, Has just as much himself to fear,
He's wrong from top to toe;
Ah friends ! pray help us, if you can, And make us each again a man, That we from hence may go.
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features of his complaint. The gardener was re-peatedly charged to encourage him in labour, and to prevent his leaving the premises. But, unhappily, the superior abilities of the patient, had excited a jealousy in the gardener's mind, which made him dislike his assistance ; and it may therefore be pre-sumed, that he obeyed his instructions very im-perfectly.
The poor man rambled several times from the grounds of the Institution ; which, in his state of mind, excited considerable anxiety in the family. Of course it became necessary to confine him more within doors. Ile frequently, however, walked out ; and the superintendent took many opportunities to attend him into the fields or garden, and to engage him for a time in steady manual labour. As his disorder had increased, it became difficult to induce him to exert himself; but even in this state, when he had been some time employed, lie seemed to forget his distressful sensations and ideas, and would converse on general topics with great good sense.
In this truly pitiable case, the superintendent several times tried the efficacy of lOng walks, where the greatest variety and attraction of circum-
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stances were presented ; but neither these, nor the conversation which he introduced, were able to draw the patient so effectually from the " moods of his own mind," as regular persevering labour in the garden. It is not improbable, however, that the superior manner in which the patient was able to, execute his work, produced a degree of self-com-placency which had a salutary effect ; and that, had his education enlarged his curiosity, and encouraged a taste and observation respecting the objects of nature and art, he might have derived much greater advantage, as many patients obviously do, from variety of conversation and scenery.
The circumstances of this patient did not allow him a separate attendant, and the engagements of the superintendent were too numerous and important" to permit him to devote to this case the time and attention which it seemed to require. He has frequently expressed to me, the strong feelings of regret, which were excited in his mind, by the unsuccessful treatment of this patient ; the case certainly points out the great importance of exercise and labour, in the moral treatment of insanity; more especially in cases of melancholy.
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This patient, after remaining several years in the house, (lied of an acute inflammation of the bowels. His situation for a considerable time previously to his death; was most deplorable, and has often reminded ma. of the affecting description, which our great poet gives of the state of our first father, after his expulsion from the happy seat of primeval in-nocence:
" On the ground,
Outstretch'd he lay, on the cold ground, and oft Cor,;'d his creation, death zh; oft accus'd
" Of tardy execution.'
The female patients in the Retreat, are employed, as much as possible, in sewing, knitting, or domestic affairs; and several of the convalescents assist the at-tendants. Of all the modes by which the patients may be induced to restrain themselves, regular employment is perhaps the most generally effica-cious; and those kinds of employment are doubt-less to be preferred, both on a moral and physi-cal account, which are accompanied 'by consider-able bodily action ; that are most agreeable to the patient, and which are most opposite to the illusions
of his disease.
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In an early part of this chapter, it is stated, that the patients are considered capable of rational and. honourable inducement ; and though we allowed ,fear a considerable place in the production of that restraint, which the patient generally exerts on his entrance into a new situation ; yet the desire of esteem is considered, at the Retreat, as operating, in general, still more powerfully. This principle in the human mind, which doubtless influences, in a great degree, though often secretly, our general manners ; and which operates with peculiar force on our intro-duction into a new circle of acquaintance, is found to have great influence, even over the conduct of the insane. Though it has obviously not been sufficiently powerful, to enable them entirely to resist the strong irregular tendencies of their disease; yet when properly cultivated, it leads many to struggle to conceal and overcome their morbid propensities; and, at least, materially assists them in confining their deviations, within such bounds, as do not make them obnoxious to the family.
This struggle is highly beneficial to the patient, by strengthening his mind, and conducing to a salutary habit of self-restraint; an object which
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experience points out as of the greatest importance, in the cure of insanity, by moral means.
That fear is not the only motive, which operates in producing self-restraint in the minds of maniacs, is evident from its being often exercised in the presence of strangers, who are merely passing through the house ; and which, I presume, can only be accounted for, from that desire of esteem, which has been stated to be a powerful motive to con-duct.
It is probably from encouraging the action of this principle, that so much advantage has been found in this Institution, from treating the patient as much in the manner of a rational being, as the state of his mind will possibly allow. The super-intendent is particularly attentive to this point, in his conversation with the patients. He introduces such topics as he knows will most interest them ; and which, at the same time, allows them to dis-play their knowledge to the greatest advantage, If the patient is an agriculturist, he asks him questions relative to his art ; and frequently consults him upon any occasion in which his knowledge may be useful. I have hea,rd one of the worst patients in the house, who,
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previously to his indisposition, had been a consider-able grazier, give very sensible directions for the treatment of a diseased cow.
These considerations are undoubtedly very material, as they regard the comfort of insane persons ; but they are of far greater importance, as they relate to the cure of the disorder. The patient feeling himself of some consequence, is induced to support it by the exertion of his reason, and by restraining those dispositions, which, if indulged, would lessen the respectful treatment he receives; or lower his character in the eyes of his companions and attendants. [The power of peer pressure]
They who are unacquainted with the character of insane persons, are very apt to converse with them in a childish, or, which is worse, in a domineering manner ; and hence it has been frequently remarked by the patients at the Retreat, that a stranger who has visited them, seemed to imagine they were children.
The natural tendency of such treatment is, to degrade the mind of the patient, and to make him indifferent to those moral feelings, which, under judicious direction and encouragement, are found capable, in no small degree, to strengthen the power of self-restraint; and which render the resort to coercion, in many cases, unnecessary. Even when it is absolutely requisite to employ coercion, if the patient promises to control himself on its removal, great confidence is generally placed upon his word. I have known patients, such is their sense of honour and moral obligation, under this kind of engagement, hold, for a long time, a successful struggle with the violent propensities of their disorder ; and such attempts ought to be sedulously encouraged by the attendant.
Hitherto we have chiefly considered those modes of inducing the patient to control his disordered propensities, which arise from an application to the general powers of the mind ; but considerable advan-tage may certainly be derived, in this part of moral management, from an acquaintance with the previous habits, manners, and prejudices of the individual. Nor must we forget to call to our aid, in endeavouring to promote self-restraint, the mild but powerful in-fluence of the precepts of our holy religion. Where these have been strongly imbued in early life, they become little less than principles of our nature ; and
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their restraining power is frequently felt, even under the delirious excitement of insanity. To encourage the influence of religious principles over the mind of the insane, is considered of great consequence, as a means of cure. For this purpose, as well as for others still more important, it is certainly right to promote in the patient, an attention to his accustomed modes of paying homage to his Maker.
Many patients attend the religious meetings of the Society, held in the city; and most of them are assem-bled, on a first day afternoon, at which time the super-intendent reads to them several chapters in the Bible. A profound silence generally ensues ; during which, as well as at the time of reading, it is very gratifying to observe their orderly conduct, and the degree in which those, who are much disposed to action, re-strain their different propensities.
In pursuing these desirable objects, let not the inexperienced, but judicious attendant, expect too immediate effects from his endeavours, or be dis-heartened by occasional disappointment. Let him bear in mind, what the great Lord Bacon has ad-mirably said, that " It is order, pursuit, sequence, and interchange of application, which is mighty in
nature ; which, although it require more exact know. ledge in prescribing, and more precise obedience in observing, yet is recompensed with the magnitude of effects." *
I am sensible that what is here stated, is but an imperfect view of the principles and modes, by which self-restraint is induced at the Retreat. To par-ticularize all the principles of the mind, which may be usefully excited in promoting this salutary object, would be an enumeration of our intellectual powers and affections. I will only further observe upon this head, by way of general summary, that the attendant on the insane, ought sedulously to endeavour to gain their confidence and esteem ; to arrest their attention, and fix it on objects opposite to their illusions ; to call into actl)n, as much as possible, every remaining power and principle of the mind ; and to remember that, in the wreck of the intellect, the affections not unfrequently survive.
* Works, Svo edition, vol. i. p. 125.
OF THE MODES OF COERCION.
General view of the nature of coercion used at the Retreat
Mode of coercing violent Maniacs, and Aldan-
cholics disposed to self-destruction Experience of
the Retreat in regard to indulging the ebullition of violent Maniacs —Causes of the too general use of coercion Of the degree of force to be employed when coercion is necessary—Modes of coercing the less violent Precautionary measures Necessity of experience to teach the best modes of restraint.
WITH regard to the second point, the necessity of coercion, I have no hesitation in saying, that it will diminish or increase, as the moral treatment of the patient is more or less judicious. We cannot, how-ever, anticipate that the most enlightened and in-genious humanity, will ever he able entirely to supersede the necessity of personal restraint.
Coercion is considered, as the ingenious author of " Observations on Madness" says it should be, " only as a protecting and salutary restraint." The mode of it ought to be subject to the consideration
1154 MORAL TREATMENT.
of its effect on the mind of the insane. Some means of coercion have obviously a greater tendency than others, to irritate or degrade the feelings. Hence, the use of chains has never been permitted in the Retreat. In the most violent states of mania, as the author just quoted observes, " the patient should be kept alone, in a dark* and quiet room ; so that he may not be affected by the stimulus 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 patients of this class, who are not disposed to injure themselves, are merely confined by the strait-waistcoat ; and left to walk about the room, or lie down on the bed, at pleasure. But in those desperate cases of melan-choly, attended with tedium vit, in which there is a strong determination to self-destruction, it becomes necessary to confine the patient, during the night, in a recumbent posture. For this purpose, the superintendent has invented a very simple apparatus ; which answers all the purposes of security ; and allows the patient to turn and otherwise change his posture in bed*.
Our superintendent prefers a gloomy, to an entirely dark apartment.
t The necessity for this mode of treatment is very rare at the Retreat.
MORAL TREATMENT. 165
It has been suggested, that in cases of high mania, the violent excitement would be best reduced, by indulging it in the greatest practicable degree. The experience of the Retreat, leads to an opposite con-clusion ; viz. that such a degree of restraint as would not be materially painful, in a state of calmness, has a tendency to abate the paroxysm. The association
* This apparatus consists of a strong, linen, girth web, three inches and a half broad, and five feet and a half long. At each end is a leather strap one foot long, one inch and a half broad, and a quarter of an inch thick ; with a buckle fastened at the joining of the web and strap. At eighteen inches from the upper end of the web, a piece of the same materials, fourteen inches long, placed trans-versely, is strongly sewed to it. Each end of this cross piece is provided with two straps one inch and a quarter broad, and about three-sixteenths of an inch thick. One of these straps is five inches long, provided with a buckle, and a piece of leather inside the buckle to prevent it from hurting the arm. The other strap is fifteen inches long, with holes to buckle to the -former ; and both are strongly sewed together with the web between them. At twenty-one inches from the lower end of the web, are fixed transversely, two leather straps of the same strength as those last described. Both are between mental and bodily action, and the degree in have recourse to restraint, where it was not absolutely which the latter is \veil known to excite the former, necessary ; except in those cases where it was likely sufficiently illustrate the cause of this fact. to have a salutary moral tendency. Except in the case of violent mania, Ivhich is far from being a frequent occurrence at the Retreat,. coercion, when requisite, is considered as a necessary evil ; that is, it is thought abstractedly to have a ten-. dency to retard the cure, by apposing the influence' of the moral remedies employed.. It is therefore used very sparingly ; and the superintendent has often assured me, that he would rather run some risk, than strongly- sewed together on the web, by the middle; one extenditig-:;ix inches beyond the web on each side, and provided at each end with a buckle and a guard, as before-mentioned: the other is two feet long, with perforations at each end. When in use, the main strap passes longitudinally over the lower bed-clothes, and is fastened to the head and feet of the bedstead, by a. proper Maple fixed in the of each, and is buckled tight. The patient is placed upon it; the cross web at the upper end is placed under the shoulders, and each pair of straps at the ends of this transverse piece, encloses one arm ; but is not buckled so tight as to hurt the patient. The lower gait of straps each enclose one thigh, just above the knee, in like manner..
In many cases of violent excitement, this is found sufficient ; but where the patient is ingenious, or disposed.to self-injury, the addition of the strait-waistcoat is needful,
I feel no small satisfaction in stating upon the authority of the superintendents, that during the last year, in which the number of patients has generally been sixty-four, there has not been occasion to seclude, on an average, two patients at one time. I am also able to state, that although it is occasionally necessary to restrain by the waistcoat, straps, or other means, several patients at one time ; yet that the average number so restrained does not exceed four, including those who are secluded.
The safety of those who attend upon the Insane, is certainly an object of great importance ; but it is worthy of inquiry whether it may not be attained, without materially interfering with another object,— the recovery of the patient. It may also deserve inquiry, 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.
168 MORAL TREATMENT.
The power of judicious kindness over this unhappy class of society, is much greater than is generally imagined. It is perhaps not too much to apply to kind treatment, the words of our great poet,
" She can unlock,
" Tile clasping charm, and thaw the numbing spell."—MILTON.
In no instances has this power been more stri-kingly displayed ; or exerted, with more beneficial effects, than in those deplorable cases in which the patient refuses to take food. The kind persuasions and ingenious arts of the superintendents, have been singttlarly successful in overcoming this distressing symptom ; and very few instances now occur in which it is necessary to employ violent means for supplying
the patient with food.
Some patients who refuse to partake of the family meals, are induced to eat by being taken into the larder, and there allowed to help themselves. Some are found willing to eat when food is left with them in their rooms, or when they can obtain it un-observed by their attendants. Others, whose determi-nation is stronger, are frequently induced, by re-peated persuasion, to take a small quantity of nutritious liquid ; and it is equally true in these,
MORAL TREATMENT. 169
as in general cases, that every breach of resolution weakens the power and disposition to resistance.
Sometimes, however, persuasion seems to strengthen the unhappy determination. In one of these cases, the attendants were completely wearied with their endeavours; and on removing the food, one of them took a piece of the meat which had been repeatedly offered to the patient, and threw it under the fire-grate; at the same time, exclaiming, that she should not have it. The poor creature, who seemed governed by the rule of contraries, im-mediately rushed from her seat, seized the meat from the ashes, and devoured it. For a short time, she was induced to eat, by the attendants availing themselves of this contrary disposition but it was soon rendered unnecessary, by the removal of this unhappy feature of the disorder.
There are, it must be confessed, some cases in which ingenious arts, and kind persuasions, prove alike unsuccessful ; and it becomes necessary to supply the patient by force with a sufficient quantity of food, to support life. This is, perhaps, the most painful duty, which the attendant has to perforM. It is usually done at the Retreat in the following
170 MORAL TREATMENT.
manner : The patient is placed in a rocking chair, which of course allows the height and position of the head to be varied, as circumstances may require The most difficult part of the business is, if I may use the expression, to unlock the mouth. For this purpose, the superintendent, after trying a variety of instruments, generally employs the handle of a small door lock key, and having pressed it between the teeth, he turns it round by the other end, and thereby raises the mouth at his pleasure. Another attendant then introduces the food, which is in a liquid state, and contained in a strong spoon. I am very glad to be able to say, that there is seldom occasion for the frequent repetition of this operation ; and also that it has not, in a single instance, been the occasion of any injury to the patient*. The
*" It is a painful recollection, to recur to the number of interesting females I have seen, who, after having suffered a temporary dis-arrangement, and undergone the brutal operation of spouting, in private receptacles for the insane, have been restored to their friends without a front tooth in either jaw. Unfbrttulately the task of forcing patients to take food or medicines, is consigned to the
rude hand of an ignorant and unfeeling servant, It should always be performed by the master or mistress of the mad-house, whose
reputations ought to be responsible for the personal integrity of the
unhappy beings committed to their care."
Ito Aani's Observations on Madness, note, page 137.
MORAL TREATMENT. 171
teeth of few persons meet with perfect regularity, and this circumstance greatly facilitates the insertion of the instrument which keeps them asunder. It is found necessary to convey the point of the spoon, half way over the tongue; for when the liquid is not conveyed into the throat, it is frequently ejected.
The attendants at the Retreat, feel themselves to
danger of injury from the patients, wheT—are unconfined ; many of whom, previously to their admission, have been accustomed to much severity. No instance has occurred of any serious injury
done by a patient, to any of the attendants ; and at no period has there been manifested a general spirit of dissatisfaction, or a tendency to revolt.
The common attendants, are not allowed to apply any extraordinary coercion to the patients, by way of punishment, or to change, in any degree, the usual mode of treatment, without the permission of the superintendents. This limitation to their power is of the utmost importance, as it obliges them to se-ek the good opinion of the patient, and to endeno
to govern rather by the influence of esteem of severity.
l72 MORAL TREATMENT.
When it is deemed necessary to apply the strait- waistcoat, or any other mode of coercion, to a violent patient, such an ample force is employed, as precludes the idea of resistance from entering the patient's mind ; and hence, irritation, or additional excite-ment, is generally, in a great degree, prevented.
Where such force cannot be obtained, and the case is urgent, courage and confidence will generally overcome the violence of the patient ; for the opinion appears to be well founded, that maniacs are seldom truly courageous. The superintendent was one day walking in a field adjacent to the house, in company with a patient, who was apt to be vindictive on very slight occasions. An exciting circumstance occurred. The maniac retired a few paces, and seized a large stone, which he immediately held up, as in the act of throwing at his companion. The super-intendent, in no degree ruffled, fixed his eye * upon the patient, and in a resolute tone of voice, at the same time advancing, commanded him to
My worthy friend does not, however, lay any claim tee
Those strange power$, which lie
t, Within the magic circle of the ey-e." MORAL TREATMENT. 173
lay down the stone. As he approached, the hand of the lunatic gradually sunk from its threatening position, and permitted the stone to drop to the ground. He then submitted to be quietly led to his apartment *.
Some of the more irritable patients, who are neither vindictive nor violent, require, occasionally, a degree of restraint, to prevent them from injuring their companions, or destroying their clothes. This class is chiefly found among those whose intellects are weakened. These are sometimes restrained by straps which pass round the ankles, and prevent the patient from kicking ; or are confined, when necessary, by arm-straps, fixed to a belt which encircles the waist. These straps allow the patient to use his hands sufficiently to feed himself; and are abundantly less uneasy than the strait-waistcoat. Some of the female patients of this description, have the straps made of green morocco leather, and they will sometimes even view their shackles as ornaments. The reader will find an account of several precautionary means in the third chapter. To those, I here wish to add, that the patients, who take their meals in the
# See another circumstance respecting this patient, related page 13.
174 MORAL TREATMENT.
galleries, or day-rooms, are not allowed the use of knives and forks*. Their meat is divided into small pieces by the attendant, and they eat it with a spoon. It is also the business of the attendant to take the patient's clothes out of the lodging-room, nncl examine the pockets every night.
I conceive it useless to enter into more minute details of the modes of coercion and restraint, since experience alone can fully teach the best means of exercising them ; and the attendant who possesses a good understand-ing, and has taken a just view of the character of the insane, will soon perceive for himself, the necessary degree, time, and mode of coercion, which those who are placed under his care require. But they who have had an opportunity of observation, and they only, can conceive the difficulty of entirely subduing the vindictive feelings, which the incon-sistent, but often half rational, conduct of the pzttient, frequently excites in the minds of the inferior at-tendants.
The superintendent hopes to be able to contrive a knife and fork that may be entrusted to most of the-patients with safety ; as it would be much more agreeable to many of them, than eating all their Iced VI ill; a s-000n.
MORAL TREATMENT. 175
It is therefore an object of the highest importance, to infuse into the minds of these persons, just senti-ments, with regard to the poor objects placed under their care ; to impress upon them, that " coercion is only to be considered as a protecting and salutary restraint ;" and to remind them, that the patient is really under the influence of a disease, which deprives him of responsibility ; and frequently leads him into expressions and conduct the most opposite to
character and natural dispositions :
" Bound in Necessity's iron chain, Reluctant Nature strives in vain; Impure, unholy thoughts succeed,
And dark'ning o'er his bosom roll; Whilst madness prompts the ruthless deed,
Tyrant of the misguided soul."
But even this view of the subject is not exempt from danger ; if the attendant does not sufficiently consider the degree in which the patient may be influenced by moral and rational inducements. These contradictory features in their character, frequently render it exceedingly difficult to insure the proper treatment of de-ranged persons. To consider them at the same
176 MORAL TREATMENT.
time both as brothers, and as mere automata; to ap-plaud all they do right ; and pity, without censuring, whatever they do wrong, requires such a habit of philosophical reflection, and Christian charity, as is certainly difficult to attain.
MORAL TREATMENT 177
OF THE MEANS OF PROMOTING THE GENERAL COMFORT OF
Importance of promoting comfort as it regards cure— Various means of promoting it at the Retreat Utility of rational society to convalescent Pat ients-The different kinds of amusing employments adapted
to different classes of Patients On the introduction
of books to the Insane Importance of arresting
their attention—Case—Dtlficulty of devising suitable employments.
IN considering our first division of this subject, viz. the modes by which self-restraint may be induced, we have anticipated many of the means by which the comfort of this unhappy class of our fellow beings is promoted ; indeed we might, without im-propriety, have included all these means under our former division ; since whatever tends to promote the happiness of the patient, is found to increase his desire to restrain himself, by exciting the wish not to forfeit his enjoyments ; and lessening the irritation of mind, which too frequently accompanies mental derangement.
17f3 MORAL TREATMCNT.
The comfort of the patients is therefore considered of the highest importance, in a curative point of' view.The study of the superintendents to promote it with all the assiduity of parental, but judicious attention, has been, in numerous instances, rewarded by an almost filial attachment. In their conversation with the patients, they adapt themselves to their particular weaknesses ; but, at the same time, endeavour to draw them insensibly from the sorrow, or the error, which marks the disease.
The female superintendent, who possesses an un-common share of benevolent activity, and who has the chief management of the female patients, as well as of the domestic department, occasionally gives a general invitation to the patients, to a tea-party. All who attend, dress in their best clothes, and vie with each other in politeness and propriety. The best fare is provided, and the visiters are treated with. all the attention of strangers. The evening generally passes in the greatest harmony and enjoyment. It rarely happens that any unpleasant circumstance occurs ; the patients control, in a wonderful degree, their different propensities ; and the scene is at once curious, and affectingly gratifying,
MORAL TREATMENT. 179
Some of the patients occasionally pay visits to the friends in the city; and female visiters are appointed every month, by the Committee, to pay visits to those of their own sex; to converse with them, and. to propose to the superintendents, or the Committee, any improvements which may occur to them. The visiters sometimes take tea with the patients, who are much gratified with the attention of their friends, and mostly behave with propriety.
It will be necessary here to mention, that the visits of former intimate friends, have frequently been attended with disadvantage to the patients ; except when convalescence had so far advanced, as to afford a prospect of a speedy return to the bosom of society. It is, however, very certain, that as soon as reason begins to return, the conversation of judicious, indifferent persons, greatly increases the comfort ; and is considered almost essential to the recovery of many patients. On this account, the convalescents of every class, are frequently introduced into the society of the rational parts of the family. They are also permitted to sit up till the usual time for the family to retire to rest, and are allowed as much liberty as their state of mind will admits.
180 MORAL TREATMENT.
Those who have had the opportunity of observing the restoration of reason, will be aware, that she does not, in general, at once, resume her lost empire over the mind. Her approach resembles rather the gradual influx of the tide ; she seems to struggle to advance, but again and again is compelled to recede. During this contest, the judicious attendant, may prove the most valuable ally of reason ; and render to her the most essential assistance, in the recovery of her lawful throne :
In some cases, however, the cloud which envelopes the mind is suddenly dispersed, and the patient seems to awake at once as out of a dream. In others the progress of recovery is gradual and uniform :
" Lucid order dawns;
And as from chaos old the jarring-seeds
" Of Nature, at the voice divine, repair'd
" Each to its place, 'till rosy earth unveil'd
" Her fragrant bosom, and the joyful sun
" Sprung up the blue serene ; by swift degrees
" Thus disentangled," [reason entire]
The Pleasures of Imagination, Book III. 1. 396.
As indolence has a natural tendency to weaken the mind, and to induce ennui and discontent, every kind
MORAL TREATMENT. 181
of rational and innocent employment is encouraged. Those who are not engaged in any useful occupation, are allowed to read, write, draw, play at ball, chess, drafts, &c.*
The attendant will soon perceive what kind of em-ployment or amusement, is best adapted to the different patients under his care. He will observe that those of the most active and exciting kind, will be best adapted to the melancholy class, where they can be induced to engage in them ; and that the more sedentary employments, are generally preferable for the maniacal class. No strict rule, however, can properly be laid down on this subject ; and the in-clination of the patient may generally be indulged, except the employment he desires obviously tends to foster his disease. The means of writing, are, on this account, sometimes obliged to be withheld from the patient, as it would only produce continual essays on his peculiar notions ; and serve to fix his errors more completely in his mind. Such patients are, however, occasionally indulged, as it is found to give
It is, perhaps, almost unnecessary to state, thatr playing for money, or gaming of any kind, is nut allowed.
18'2 MORAL TREATMENT, MORAL TREATMENT. 183
them temporary satisfaction ; and to make them more easily led into suitable engagements*.
This indulgence in the means of writing, frequently leads to curious effusions, both in prose and poetry. The following specimen of the latter, will probably interest the reader. He will be sur-prised to learn, that the patient, at the time of its composition, laboured under a very considerable degree of active mania. This is not the only instance in which we have been reminded of the lines of the poet,
" Great wit to madness, sure, is near allied..
" And thin partitions do their bounds divide."
ADDRESS TO MELANCHOLY. SPIRIT of darkness ! from yon lonely shade
Wheto fade the virgin roses of the spring; Sprit of darkness, hear thy fav'rite maid
'To Sorrow's harp her wildest anthem sing,
Alt ! how has Love despoil'd my earliest bloom,
And flung my charms as to the wintry wind; A h ! how has Love hung o'er thy trophied tomb,
The spoils of genius, and the wreck of mind.
High rides the moon the silent heavens along;
Thick fall the dews of midnight o'er the ground ; Solt steals the Lover, when the morning song
Of waken'd warblers thro' the woods resound.
Then I, with thee, my solemn vigils keep,
And at thine altar take my lonely stand ;
Again my lyre, unstrung, I sadly sweep,
Whi'e Low leads up the dance, with harp in hand.
There certainly requires considerable care in the selection of books for the use of the insane. The works of imagination are generally, for obvious reasons, to be avoided ; and such as are in any de-gree connected with the peculiar notions of the patient, are decidedly objectionable. The various branches of the mathematics and natural science, furnish the most useful class of subjects on which to employ the minds of the insane ; and they should, as much as possible, be induced to pursue one sub-ject steadily. Any branch of knowledge with which
High o'er the woodlands Hope's gay meteors shone, Arid thronging thousands bless'd the ardent ray ; I turn'd, but found Despair on his wild roam,
And with the demon bent my hither-way.
Soft o'er the vales she blew her bugle horn,
Oh ! where MARIA, whither dost thou stray ? Return, thou false maid, to th' echoing sound,
I flew, nor heeded the sweet syren's lay.
Hail, Melancholy ! to yon lonely towers
I turn, and hail thy time-worn turrets mine, Where flourish fair the night-shade's deadly flowers, And dark and blue, the wasting tapers shine.
There, 0 my EDWIN ! does thy spirit greet
In fancy's maze thy lov'd and wandering maid; Soft thro' the bower thy shade MARIA meets,
And leads thee onward thro' the myrtle glade.
184 MORAL TREATMENT,
the patient has been previously acquainted, may be resumed with greater ease ; and his disposition to pursue it will be encouraged by the competency which he is able to exhibit.
I met with a striking instance, of the advantage of attention to this point, some years ago. It was related to me by a person of great respectability, who was himself the subject of the case. He stated, that a few years before that time, his mind had been greatly depressed without any apparent cause. The
0, come with me, and hear the song of eve,
Far sweeter, far, than the loud shout of morn;
List to the pantings of the whispering breeze, Dwell on past woes, or sorrows yet unborn.
We have a tale; and song may charm these shades, Which cannot rouse to life'MmtiA's mind,
Where Sorrow's captives bail thy once lov'd maid, Po joy a stranger, and to grief resign'd.
F,nwirt, farewell ! go, take my last adieu,
Ah ! could my bUrsting bosom tell thee more, `)ere, parted here, from love, from life, and you, I pour my song as on a foreign shore.
But stay, rash youth, the sun has climlid on high,
The night is past, the shadows all are gone,
For gust MARIA breathe the eternal sigh,
A nd waft thy sorrows to the gales of morn.. MORAL TREATMENT. 185
most dismal thoughts continually haunted his mind, and he found the greatest difficulty, in confining his attention, for the shortest time, to one subject. He felt entirely indifferent to his business and his family ; and, of course, he neglected them. It was with great difficulty he was induced to take sufficient food to support life. His body became emaciated, and his mind more and more enfeebled.
In this state, as he was one day musing upon his miserable condition, he perceived, by the faint glim-merings of remaining reason, the still worse state to which be must be reduced, if he continued to indulge his gloomy reflections and habits. Alarmed with the prospect of the future, he resolved to exert the power which he still possessed to control his un. happy dispositions, and to regain the habit of atten-tion. For this purpose, he determined, immediately to apply himself to mathematics, with which lie had been well acquainted in his youth, and also to adopt a more liberal regimen.
The first attempt to go through the easiest pro-blem, cost him indescribable labour and pain. But he persisted in the endeavour ; the difficulty of fixing his attention gradually lessened ; he overcame his
1 86 MORAL TREATMENT.
tendency to abstinence ; and very shortly recovered the use of his faculties and his former temper of mind.
Perhaps few persons, in the situation which I have described, would have had the courage to form such resolutions ; and still fewer, the fortitude to perform them. The ease, however, certainly points out what may possibly be done ; and how important it is, in a curative point of view, to encourage the patient in steady mental pursuit.
The managers of this Institution, are far from imagining that they have arrived at a state of perfec-tion in the moral treatment of insanity. If they have made any considerable approaches towards it, their progress has only served to convince them how much more may probably be effected, and to fill them with regret, that so little ingenuity has hitherto been ex-erted to increase the comforts of insane persons. "neve is no doubt, that if the same exertions were used for this purpose, as are frequently employed to amuse the vain, the frivolous, and the idle, many more gleams of comfort would be shed over the un-happy existence of lunatics ; and the proportion of cures would be still materially increased.
MORAL TREATMENT. 187
What a reflection upon human nature, that the greatest calamity to which it is incident, should have been frequently aggravated by those who had the power, and whose duty it was to employ means of mitigation. Hence, we may derive a practical comment on the observation of the wise Montesquieu, which every one interested in establishments for the insane ought constantly to remember : " Cest une experience eternelle, que tout homme qui a du pouvoir est porte, a en abuser ; it va jusqu' a ce qu'il trouve des limites. Qui le diroit ! La vertu meme a besoin des limites*.
L'Esprit des Loix, Liv. II. Cap. IV.
Experience continually demonstrates, that men who possess power, are prone to abuse it: they are apt to go to the utmost limits. May it not be said, that the most virtuous require to be limited?
STATEMENT OF CASES AND REMARKS.
Table of Cases Summaries drawn from il—State-
ments made by several other Institutions of the proportion of cures —Difficulty of estimating the curative means employed in different Asylums Necessary inquiries previously to judging of different
Reports—Difficulty of obtaining information on the causes of the disease Theeffect frequently
mistaken for the cure—Approach of maniacal paroxysm described—Great ambiguity of the moral causes of Insanity -----The most prevalent causes in the Retreat—Few cases connected with religious
impressions or intemperance The rules of the
Retreat different from Bethlein and Luke's Hospitals —Definition of the terms Dementia, Melancholia, and Mania—The time which constitutes an old
case The terms cured and recovered Inquiry
whether Insanity is prejudicial to animal life
Drs. Monro and Crichton's opinions Of the dis-
orders to which the Insane are the most liable The
causes of Mortality in the Retreat Ages of
192 Tt," TABLE OF CASES.
t Fr-S ;i.' TABLE OF CASES.
26 32 M RC Man. 6, 1798 6,98 D. 43 40 S OC Mel, 9, 1799 Remains Dom
27 24 S OC Mel. 7, Remains 14 19 S R C Man. 9, 11, 1801 Recov.
28 24 S 0 C Man. 7, Remains 45 30 S 0 C Man. 9, Remains
29 36 M RC Man. 8, 11, 1798 M. I. 46 36 S 0 C Man. 3, 1800 7, 08 D. Dem.
30 50 W OC Man. 7, 9,02 D. 47 27 M R C Man. 3, 6, 1800 Recov.
31 60 W 0 C Man. 9, 1,00 D. Imp; 48 22 S RC Man. 4, 12, Recov.
32 22 S RC Mel. 10, Remains M. I. 49 60 M R C Mel. 4, 12, Recov.
33 43 S OC Man. I 1 , Remains 50 17 S R C Man. 6, 11, 1801 Recov.
34 46 M OC Mel. 11, 6, 00 D. 51 68 M 0 C H. M. 6, Remains
35 54 S OC Mel. 12, 3, 05 D. 52 22 S OC Mel. 6, Remains
36 38 S R C Mel. 12, 6, 1799 Recov. 53 22 S 0 C Man. 7, Remains Dem.
37 26 S 0 C Man. 2, 1799 9, 00 D. Imp. 54 25 S 0 C Man. 7, Remains
38 50 S 0 C Man. 3, 5, 01 D. Imp. 55 37 S RC Man. 8, 11, 1812 Recov.
39 48 M 0 C H. M. 5, 6,09 D. 56 27 S R C Man. 10, 4, 1802 Recov.
40 60 S OC Dem. 5, 4,00 D. 57 34 S RC Mel. 10, 5, 1801 Recov.
41 24 S OC Mel. 6, 10, 1803 Recov. 58 40 S OC Man. 12, 4, 1811 Recov.
42 20 S R. C Mel. 8, 10, Recov.
APPARENT CAUSE, ck, No. 27. Succeeded disappointment of affections.
No. 28. Contusion of the skull.-Habit predisposed to the disorder. No. 30. Succeeded the death cf his wife.
No. 32. Di:order hereditary-Excited by ocer.attention to her mother
in her last ill.net,s, and the subsequent sorrow. N.. 33. Succeeded disappointment of affections. No. 34. Succeeded disappointment in business. No. 37. Epilepsy.
No. 38. Hereditary.
No. 42. Hereditary-Succeeded means used to check violent perspi-ration, which supervened a pleuritic attack.
APPARENT CAUSE, d-c.
No. 45. Hereditary.
No. 46. Supervened epilepsy.
No. 47. Succeeded the failure of her husband in business.
No. 48. Succeeded the failure of her father in business.
No. 49. Very melancholy temperament.
No. 53. Succeeded disappointment of the affections.
No. 54. Naturally of weak intellect.
No. 55. Constitutional-Succeeded Hysteria, brought on by the deans
of a friend.
No. 56. Constitutional...Appeared to be excited by irregdlar conduct. No. 57. Succeeded disappointment of affection,=
No. 58. Constitutional.
194 TABLE OF CASES.
59 25 S OC Man. 12, 1800 Remains 73
60 50 OC Man. 2, 1801 5, 1802 Recov. 74 34
61 69 M RC Mel. 3, 5,06 D. 75
62 20 OC Dem. 5, Remains 76
63 66 RC Mel. 8, 3, 1802 Recov. 77
64 21 S RC Mel. 10, 3, Recov. 78 38
65 25 S RC Mel. 10, 7, Recov. 79 56
66 30 S RC Man. II, Remains 80
67 22 S RC Man. 12, 5, 1808 Recov. 81 49
68 28 S RC Mel. 3, 1802 9, 1802 Recov. 82 28
69 35 S RC Man. 3, Remains 83 60
70 52 M RC Mel. 5, 9, 1806 M. I. 84 43
71 50 OC Man. 7, 8, Recov. 85
72 45 M OC Mel. 7, 6, 1803 Recov.
APPARENT CAUSE, 4-c.
No. 59. Very ricketty in childhood—Forehead peculiarly narrow. Nu. GO. Constitutional.
No. 61. Succeeded the failure of her husband in business.
No. 62. Constitutional.
No. 63. Succeeded embarrassment of his affairs. Second attack. No. 64. Disappointment of the affections.
No. 65. Succeeded the death of her father.
No. 66. Constitutional—Accelerated by a fright.
No. 67. Constitutional. No. 68. Constitutional. No. 70. Tlie supposed loss of her husband, who was shipwrecked,
No. 72. Supervened parturition,
APPARENT CAUSE, 81c.
No. 73. The warm bath appeared useful in this case, which has rarely happened in cases of mania.
No. 74. Intemperance—Had been deranged several times before. No. 75. Attributed to a disappointment of the affections, and being reduced in circumstances.
No. 76. Constitutional.
No. 77. Constitutional—Cessation of copious perspiration of the head. No. 78. General debility of body and mind.
No. 80. Constitutional.
No. 81. Over-attention to business.
No. 82. Constitutional—The disorder first marked by religious anxiety. No. 83. Succeeded fever.
No. 84. Constitutional.
* Mania and 'Melancholia intermitting.
196 TABLE OF CASES. TABLE OF CASES. 197
86 31 S 0 C Man. 6, 1804 4, 1806 Recur. 97 40 S 0 C Man. 7,1805 Remains
87 58 M R C Mel. 7, Remains Imp. 98 65 S 0 C Mel. 8, 4,06D.
88 52 M 0 C Man. 7, 10, 1804 M. I. 99 55 M 0 C Mel. 9, 2, 1807 Recov.
89 60 S 0 C Man. 10, Remains 100 19 S 110 Man. 9, 8, 1806
90 28 S R C Mel. 1, 1805 8, 1805 Recor. 101 50 M 0 C Man. 12, Remains
91 54 M 00 Man. 2, 12, M. I. 102 54 S 0 C Man. 1,1806 2, 11D.
92 83 S 00 Man. 4, Remains 103 23 S 0 C Man. 1, 8, 06 D.
93 39 W RC Mel. 5, 9, 1806 Reeov. 104 50 S R C Mel. 4, 6, 06D.
94 44 S RC Man. 5, 11, Recov., 105 52 M 0C Man. 6, 11, 1806 Imp.
95 18 S 0 C Man. 5, Remains Dent. 106 59 W 0 C Man. 6, 9, 1811 Imp.
96 39 S 0 C Man. 7, Remains Imp. 107 64 W 0 C Mel. 7, 9, Imp.
108 40 S 00 Man. 7, Remains
APPARENT CAUSE, kte. 109 34 S 0 C Man. 12, Remains
No. 86. Succeeded the imprudent use of mercury. 110 60 M 0 C Man. 12, 11, 1810 Imp.
111 30 W R C Mel. 1, 1807 5,1807 Recov.
No. ST. Constitutional. 112 60 M 0 C Man. 2, 12,1812 Rccov.
No. SS. First appearance of the disorder marked by trilling,ludierduS
No. 89. Attended with violent head-aches.
No. 90. Constitutional, excited by misfortune and over-exertion.
No. 91. Attributed to the imprudent use of mercury.
No. 93. Constitutional—Opium pill taken in ale always successful
in obtaining sleep. No. 94, Constitutional.
No. 95. No assignable cause. No. 96. Constitutional. *
APPARENT CAUSE, 6:c.
No. 99. Constitutional.
No. 100. Succeeded great anxiety of mind.
No. 103. Constitutional, connected with bodily disease.
No. 104. Naturally of a weak capacity.
No. 105. Constitutional—Excited by interest on political Subjects, and occasional inebriety.
No. 107. Excited by loss of a son and other afflictions.
No. 108. Connected with the breaking offs matrimonial acquaintance No. 109. Constitutional.
No. 110. Had been previously confined many years.
No. 111. Constitutional—Excited by the death of his wire.
No. 112. No apparent cause. O
132 33 S RC Mel. 1, 1809 9,1810 Recov. 145 40
133 15 OC Man. 3, 8, V. M. I. 146
134 50 OC Dem. 6, 9, 09, D 147
135 68 RC Mel. 7, 4, 1812 V. M. I. 148 60
136 21 C 8, 2,1810 Recov. 119
137 23 S 13C Mel. 1,1810 6, Recov.
138 23 RC Man. 8, 4,1811 Recov.
139 50 S C Man. 7, Remains
140 40 RC Man. 2, 1811 Remains
141 34 S OC Man. :3, 9, 1812 Recov.
112 25 S RC Man. 3, 6, 1811 Recov.
113 28 RC Mel. 3, Remains
144 40 C 4, 2,1812 Imp.
4, 1812 Remains
302 STATEMENT OF CASES
recent cases. Thirty-one of these patients have laboured under mania ; of whoa],
2 have died,
6 remain in the house,
21 have been discharged perfectly recovered,* and 21, so much improved, as not to require further confinement.
The remaining thirty recent cases, have been of the melancholic class ; of whom,
5 have died,
4 remain in the house,
19 have been discharged perfectly recovered, and 2, so much improved, as not to require further confinement.
AND REMARKS. 203
11 have died,
31 remain in the house ',
5 have been removed by their friends improved,
10 have been discharged perfectly recovered, and
4, so much improved, as not to require further confinement.
Of the twenty-one melancholics,
6 have died,
6 remain in the house,
1 has been removed by the friends of the patient, somewhat improved,
6 have been discharged perfectly recovered, and 2, so much improved, as not to require further confinement.
The old, or what are usually termed, incurable cases, which have been admitted, consist of sixty- one of the maniacal, twenty-one of the melan-cholic class, and six cases of dementia. Of the former,
a Patients who have recovered, and have returned to the Institution relapsed, are not noticed in this summary as being re-covered; unless they have finally been discharged in that state. No case of this kind, is considered as forming more than one in-stance of admission dr recovery.
Of the six cases of dementia,
2 have died,
9 have been discharged as not suitable objects, and 2 remain in the house.
The present master of St. Luke's Hospital, stated, in the year 1807, before a select committee of the House of Commons, on " the state of Lunatics," that " the average number of curable patients ad-
* Several of these are improved, as may be seen in the table,.
420-1 STATEMENT OF CASES
mitted annually is as follows : Males 110. Females 153. Total 263. The numbers discharged are as follows : Cured, Males 37. Females 71. Total 108. Uncured, Males and Females 100. Unfit from various causes, 28. Dead 27."
Haslam, the apothecary to Bethlem Hospital, states, that in a period of ten years, from 1784 to 1794, 1664 patients were admitted ; of whom 574 were discharged cured, and 1090, uncured. It appears also, from the same authority, that " In the course of the last twenty years, seventy-eight patients," who had been ill more than twelve months, " have been received, of whom only one has been discharged cured. This patient, who was a woman, has since relapsed twice, and was ultimately sent from the hospital uncured*."
The same author informs us, that " patients who are in a furious state, recover in a larger proportion than those who are melancholic. An hundred violent, and the same number of melancholic cases, were selected : of the former, sixty-two were discharged
AND REMARKS. 205
well; of the latter, only twenty-seven: subsequent experience has confirmed this fact." *
We learn from an interesting paper, by Dr. Pinel, in the Journal de Physique t, that in the hospital de la Salpetriere in France, 1002 patients were ad-mitted, in three years and nine months ; of whom 473 were discharged cured. It is proper to state, that of the 1002 patients, 388 had been previously under care in other hospitals ; and it does not ap-pear certain that the rest were all of them recent
It is obvious, that we cannot form a just estimate of the importance of the curative means, employed in different asylums, from a bare comparison of the numbers stated to be admitted, and to be discharged,
as cured, from each.
Before we attempt to draw any inference from reports of this kind, it is necessary to inquire par-ticularly,
t Tome lxvii. Septembre, an 1508.
Observations on Madness, p. 251.
206 STATEMENT OF CASES AND REMARKS. 207
I. The principal causes of the disease in the cases great reason to suspect, that the imputed cause is,
admitted into the establishments, whose statements in reality, no more than the first overt act, sufficiently
we are comparing. characteristic to force attention.
IL The rules of the establishment, in regard to the admission of old or recent cases, and also in respect of the dismissal of patients.
III. The precise meaning of the terms employ-ed in the Reports, especially that of cured or recovered.
I will venture to offer a few remarks on each of these heads, to enable the reader to judge of the peculiar circumstances of our establishment ; and that he may compare with greater advantage the report here exhibited, with the statements of other hospitals.
I. OF THE CAUSES OF THE DISEASE.
It is extremely difficult to obtain correct infor mating upon this subject. The delicacy or negli-gence of the friends of the patients, forms a considerable impediment ; but where these do not arise, and when what is conceived to be the exciting cause, is freely stated, there is frequently
The approach of a maniacal paroxysm, is gener-ally marked by an uncommon flow of spirits, and great warmth of the passions. For a time, these are not unusually kept in considerable subjection ; but the mind, in this state, seeks for situations unfavourable to its calmness. The mental excitement of some, leads them to form indiscreet and hasty attachments, which, leading to disappointment, hastens or perhaps induces the complete developement of the disorder. Some rush into imprudent commercial engage-ments ; and others devote themselves to religious speculations. These often run from one place of worship to another, preferring those where the passions are most excited. Hence arises the ambiguity, which obtains in regard to most of the moral causes of insanity.
It will be seen by a reference to the list of Apparent Causes, in the preceding table, that a large number of the cases admitted into our establishment, have been connected with some strong mental emotion, to which the disorder has been attributed. The human mind does not like un-certainty ; and the relatives of the insane, are generally anxious to fix on some particular circum-stance, as the cause of disease. To imagine it to be a constitutional malady, gives to it a character of hopelessness, from which our pride and our affection alike recoil.In several instances, however, where the cause has been decidedly expressed, a more accurate history of the paroxysm and previous habits of the patient, has led to conclusions, widely different from those which had been formed by more partial, or less inquisitive fritaids.
The instances attributed to disappointed affections, which have occurred in the Retreat, form, perhaps, about the same proportion to the whole, that they do in other similar establishments ; and nearly all writers agree, in declaring the great ambiguity of this apparent cause of insanity.
Very few of the cases admitted into the Retreat, have been, in their commencement, at all connected with religious impressions ; and in most of the cases which have occurred, inquiry has proved, that the un-happy religious notions, have not been excited by any external means ; but have arisen spontaneously in the mind ; and have been either preceded or attended by other symptoms of approaching insanity.
In one instance, the disorder came on during the singing in a Methodist meeting-house ; but an extraordinary excitement had been previously observed ; which, it is at least highly probable, led the patient to the place where the ebullition of his mind, could no longer be repressed.
This is one of the cases which, in vulgar estima-tion, is attributable to the Methodists; and if the apothecary of Bethlem Hospital, who professes himself under great obligations to this sect, for a great proportion of his patients, had an opportunity of fully investigating the origin of similar cases, lie would probably find himself not so much indebted to Methodism, as lie at present imagines ; and his remarks upon this head, would perhaps be found equally just with his observation, that '' the decorous piety, and exemplary life of the Quaker, has signally exempted him from this most severe of human infirmities." The surgeon to Bethlem Hospital says : " As for the opinion which some entertain, of the prevalent effect of Methodism, in producing insanity, proof, in place of bold and bare assertion, is required to settle this point." We may, however, conclude, from the statements of the apothecary, that religious impressions have been the apparent cause of disorder in a great number of the patients admitted into Bethlem Hospital; which certainly has not been the case at the Retreat. In this respect, therefore, a material difference obtains. with regard to the prevalent causes of disease, in the two Institutions; and, consequently, before a just comparison can be made, it will be necessary to decide the probability of cure, in cases of in-sanity, apparently arising from religious impres-sions. Haslam considers the disease, under these circumstances, as peculiarly incorrigible; and the cases which have been admitted under notice at the Retreat, are too few to enable us to form a general opinion. Only three cases have occurred, which can at all be considered as coming under this de-scription ; but it is worthy of remark, that two of them have been completely recovered, and the other considerably improved.
Intemperance is another very prevalent, and less ambiguous cause of insanity, in most public In.
"Crovi.ther's Practical Remarks, p. 85.
AND REMARKS. 211
stitutions. This has not, however, been the occasion of disorder in more than three of the cases admitted into the Retreat. In one of these, the habit had be-come inveterate ; but the violence and intensity of the mind upon all subjects which interested it, had long previously marked a constitutional tendency to the disease. This patient was discharged improved, but he still requires care. The other two patients both recovered. Haslam, however, considers in-temperance as one of the more unfavourable causes
of the disorder.
In several cases admitted into the Retreat, the disorder has been obviously connected with epilepsy; and it is so well known, that such cases rarely admit of relief, that they are not admitted into St. Luke's hospital. I am not aware that the prevalent causes of disease, in the cases admitted into our establish-ment, differ from the generality of similar places in other respects, than those which I have already
It will, I trust, be readily admitted, that the habits and principles of the Society of Friends, are at least not more unfriendly to mental sanity, than those of other societies ; and this opinion will derive some
212 STATEMENT OF CASES
confirmation, from observing the large number of cases, in which the disease has been ascertained to be constitutional'or hereditary. In a great number of instances, information on this head could not be obtained ; and we may therefore safely presume, that the proportion is considerably larger than appears in the statements.
II. OF THE RULES OF THE ESTABLISHMENT, &C.
The object of the Retreat, being to furnish a com-fortable shelter for insane persons, as well as to promote their recovery, its original rules made no distinction between old and recent cases ; and did not, in any degree, limit the time of patients' con-tinuance in the house. The only restriction relates to idiots ; and this appears to have been generally understood as applying, chiefly, to cases of original absence of intellect.
In these respects, the circumstances of this esta-blishment, differ materially from those of some of our largest public institutions.
It appears, from the statement of the master of St. Luke's Hospital, made before a Committee of the
AND REMARKS. 213
House of Commons, that, in this Institution, " The average number of patients at one time is 3003" and that " the average number of incurable patients, in the house at one time, is 115." All patients are discharged from this Asylum at the end of the first year ; and if not then recovered, may be entered on the incurable list, to be admitted when a vacancy offers; but it appears that only a certain number of this class of patients are permitted to be in the house at one time. The rules of this hospital do not admit patients, " troubled with epileptic or convulsive fits."
By the following quotation from Haslam, it appears, that the rules of Bethlem Hospital guard against the admission of old cases : " Although patients who have been affected with insanity more than a year, are not admissible into the hospital, to continue there for the usual time of trial for cure, viz. a twelvemonth ; yet, at the discretion of the Com-mittee, they may be received into it from Lady-day to Michaelmas ; at which latter period they are re-moved. In the course of the last twenty years, seventy- eight patients of this description have been received."
There are, however, a number of patients in Bethlem, who have been there many years ; and I
214 STATEMENT OF CASES
therefore conclude, that a certain proportion is permitted, as in St. Luke's, to remain on the in-curable establishment,—But, as Haslarn states, that from the year 1784 to 1794, out of 1664 cases ad-mitted, 1090 were discharged uncured, I presume- that the number of patients in this hospital, who have been afflicted with insanity more than a year, is comparatively very small.
It will be seen that a large majority of the cases admitted into the Retreat, have not been recent. In several instances, the disorder had existed from fifteen to twenty years previously to their admission ; and, of course, no reasonable hope could be entertained of the patients' recovery. The total proportion of cures cannot, therefore, be expected to be large. I will not, however, omit to mention, that the number of these must have been fewer, if the rules had limited the time of continuance in the house, as is the case in the two charitable Institutions above mentioned. But, it must also be observed, that several patients who have been sane at the expiration of twelve months, have remained in the house from three to six months longer on probation, or at their own request, until a suitable situation offered for them.
AND REMARKS. 9 15
Others, who have been apparently well at the end of twelve mouths, have relapsed before they quitted the house ; and I cannot avoid attributing to the premature discharge of insane persons, many of the relapses which occur after they leave the places provided for their care. Several of the symptoms which mark the disorder in its incipient 'state, also mark an advanced stage of convalescence. In either case, though no absolute act of insanity is committed, the mind is unable to bear that stimulus or exertion, which would be even salutary to it, in a state of perfect sanity.
III. EXPLANATION OF TERMS.
It will have been observed that the cases, in the preceding tables, are arranged under three classes, viz.
Dementia, Melancholia, and Mania.
The first comprehends those cases in _which the mental powers appear materially weakened ; which are attended with a general irritability, or are subject to occasional maniacal paroxysms, rendering the patients dangerous to themselves or others. Idiocy, or mere imbecility of mind, as has been already stated, is not admissible into the Retreat ; though persons who sink into that state, are not necessarily
216 STATEMENT OF CASES
Under the class,Melancholia, all cases are included, in which the disorder is chiefly marked by depression of mind, whether it is, or is not, attended by general false notions. Those cases, however, are distin-guished, in which the melancholy feelings are immediately connected with hypochondriasis.
In the third class, Mania, all those cases are included, in which the disorder is not chiefly marked by weakness of intellect, or mental depression.
In regard to the division of the cases into old and recent, it will be proper to observe, that those of more than twelve months standing, are considered under the former, and all the others under the latter division.
I know not what degree of sanity is generally thought sufficient to warrant the application of the term, cured.' In the preceding tables, the term recovered, is applied only where the patient is fully competent to fulfil his common duties, or is restored to the state he was in, previously to the attack.
AND REMARKS. 217
in the performance of her own cure, the term re-covered, is adopted in preference to that of cured.
I will conclude this chapter by considering, whether insanity is essentially prejudicial to animal life.
Dr. Monro, in his reply to Dr. Battie's Treatise on Madness, gives the following evidence upon this sub-ject : " Although I do not remember to have seen more than four instances, where I could say, the fury of madness was the immediate occasion of death, I have great reason to believe that madness destroys two- thirds of those, who are afflicted with it through life."
Dr. Crichtont tells us that, " melancholic patients seldom live long. They often terminate their own existence in the attacks of the disorder; but, even when carefully watched, and when every care is taken of them, they never attain old age. Many die before thirty or forty ; and few live beyond sixty; but P. great deal of diversity, in this respect, arises from the difference of the time of life when they are first
As we have not discovered any antimaniacal spe- t An Inquiry into the Nature and Origin of Mental Derangement,
cific., and profess to do little more than assist Nature, by Alexander Crichton, M. D. Vol. 11. p, 236.
218 STATEMENT OF CASES
seized with the complaint."—Dr. C. refers us in this place to " Greding's Aphorisms," which form an Appendix to his work. It is there stated, that " the greater number of insane people fall into a state of atrophy, or decay, towards the close of their life: for it has been found, that of one hundred maniacs, sixty- eight died in this way ; of twenty-six epileptic maniacs, there were thirteen ; of sixteen epileptic idiots, only four ; and of twenty-four melancholic, there were twenty ; and lastly, of thirty idiots, there were twenty-one who died of this kind of con-sumption."
The next sentence states " Hydrothorax to be the disease to which they are most subject ;" and a suc-ceeding aphorism informs us, that " consumption, from an ulcerated state of the lungs, appears to be another disease which Olen terminates the existence of insane people." Not to dwell on the seeming contradiction in these statements ; that two distinct diseases are each of them represented as being the most frequent occasion of death among insane per-sons, it i8 perhaps matter of doubt, whether the frequency of these diseases, is not more connected with the mode of treatment, than with the mental disorder.
AND REMARKS. 219
Of the twenty-six deaths which have occurred
in the Retreat since its establishment, a period of 16 y ears, three have been in consequence of epilepsy, and two of apoplexy, with which the patients were affected previously to their ad-mission, and which appeared to be the causes of derangement. Seven patients have died in a state of atrophy ; but of these, three appeared to be in the last stage of decay at the time of their admission. Three patients have died of general dropsy, two of inflammation of the intestines, two of external in-flammation, one of hemorrhage from the stomach, one of erysipelas, one of convulsions, and one of fever. Three cases, in which the unhappy disposition of the patient to injure himself, proved fatal, complete the statement of causes of mortality in this Institu-tion. It is no small satisfaction to be able to add, that the three melancholy cases just mentioned, are the only instances of the kind ; and that in the last eight years, during which the average number of patients has been fifty-six, no circumstance of this
kind has occurred.
It may be proper to state, that the average number of patients in this Institution at one time, since its
220 STATEMENT OF CASES, &c,
establishment, is 46 ; and the following summary shows the ages of the patients at present in the house
15 to 20 years inclusive 2 PRIEJVDIX,
20 to 30 8
30 to 40 12
40 to .50 20
.50 to 60 7
60 to 70 11
70 to 80 4
80 to 90 2
One of the patients is 87 years of age ; and it is remarkable, has been subject to very frequent and
violent paroxysms of vociferous mania, during the last ten years.
The number of deaths, in this Institution, is too small to admit any decided inferences to be drawn, as to the general causes of mortality amongst insane persons ; but the ages of those now in the house, as well as the general result in regard to the number of deaths, will perhaps fully justify an opinion, that
insanity is not essentially prejudicial to animal life.
THE Author hopes he shall be justified in presenting the reader with the sentiments of some respectable persons, who have care-fully inspected the Retreat. His view in doing so, is to confirm the testimony which he has given in tire preceding pages, of the practices of this Institution, and which might be suspected of partiality, if it were not supported by the evidence of disinterested persons, who were qualified to judge on the occasion.
In the year 1798, Dr. DELARIVE, of Geneva, after having examined a great number of public and private establishments of a similar nature, visited the Retreat. It was then in its infancy, but, the Doctor was so far pleased with the general management, as to write a very favourable description of it, in a letter addressed to the editors of " The British Library." This letter afterwards appeared on the Continent in a separate form*, from a copy of which the following extracts are made.
After describing the evils which have existed in the treatment of the insane in public hospitals, which he observes would lead one to suppose, that madmen were employed in tormenting other madmen, he says, " The respectable society of Quakers have at length endeavoured to remedy these evils
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