Practical observations on insanity and the treatment of the insane; addressed particularly to those who have relatives or friends afflicted with mental derangement; also hints on the propriety of making the study of mental disorders a necessary adjunct to medical education

Preface

The best apology I can offer for the imperfect character of the following pages is, that they were dictated by an ardent desire to ameliorate the condition of a most unhappy portion of my fellow-creatures, and were chiefly written in the wards of a madhouse, during the short periods I could snatch from my duties as keeper, — amid the wild ravings of the maniac, the fatuous laugh of the idiot, and the desponding wailings of the hypochondriac.

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It will be seen that my observations are principally intended for those persons whose situation in life enables them to place their relatives or friends in private lunatic asylums ; but some of my remarks, will, I trust, be found of general application. I am equally anxious for the welfare of pauper lunatics, but unfortunately, in their case, circumstances will not admit of those means of care and cure which are within the reach of the affluent.

As this book may probably fall into the hands of many persons who have not read the minutes of the evidence given before the Committee of the House of Commons, and the report founded thereon, I have given some extracts therefrom in an Appendix : and I have done this in order to remove any impression which may exist, that I have exaggerated the evils of the system pursued in the treatment of the insane.

It may, perhaps, be objected that this report and the evidence apply only to pauper lunatics ; but it must be remembered that the owners of pauper asylums are also in most instances proprietors of houses for the reception of a better class of patients ; indeed both classes are frequently under the same roof; and where the disposition to cruelty and abuse exists, very little distinction will be made in the treatment of the pauper and the more respectable patient.

Chapter I. Introductory Remarks

Of the numerous "ills which flesh is heir to,' n I know of no one in which the best feelings of our nature are, or ought to be, more deeply interested, or which more imperiously demands our attention and sympathy, than aberration of intellect. To behold the good, the great, the virtuous, and the brave, reduced by the withering influence of this awful visitation, to a level with the beasts of the field, on which the bright beams of reason never dawned, is, indeed, calculated to excite, in eveiy feeling and philanthropic mind, sensations of the most painful nature. I envy not the man his feelings who can look unmoved on the ruins of intellect, and who can see, and unpitying see, his fellow-creatures bereft of that inestimable gift which alone adorns and dignifies the man, and which principally elevates him above the brute creation.

Behold yon stately form, marching with measured step along the gloomy avenue of trees ! See his hoary head, his wringing hands uplifted, while he mutters to the skies his imaginary woes, and ever and anon a tear steals down his pallid cheek !

There are the sad remains of as fine an intellect as ever graced the social circle ; the wit, the philanthropist, and the philosopher ; virtuous and good himself, his constant efforts were directed to assimilate mankind to his own standard ; his time and exertions were ever devoted to promote the happiness, and his purse was ever open to diminish the distress, of his fellow-creatures ; but an accumulation of unforeseen reverses, and the ingratitude of mankind, broke his manly heart, and even his giant mind bent beneath the storm.

See yon sylph-like figure, tripping with fairy step along the green parterre, decked in the fairest flowers of Spring ; now she plucks a rose and sings of long past joys ; — but now a thorn — she takes and places it in her bosom ; see her altered mien, — she stands transfixed as a statue, and a flood of tears gushes from her burning eyes.

She was once the fairest of the fair; the gayest amongst the gay ; the life, grace, and ornament of her circle :

" Grace was in all her steps, Heaven in her eye, " In every gesture dignity and love.''

But unrequited love ruined her mental fabric ; she

" Let concealment, like a worm i' the bud, " Feed on her damask cheek;"

B 2 and we behold her now with scarce one feature of her former self.

These are no imaginary pictures ; hundreds there are, the circumstances of whose maladies far exceed these, or any descriptions my humble pen could trace.

Hard indeed, then, must be that heart which could contemplate such scenes, and not feel a deep and anxious desire that every thing should be done to soothe such deep affliction, and eveiy effort which human benevolence could devise, be made to restore the unhappy sufferers to themselves and to society.

And yet, — "tell it not in Gath; publish it not in the streets of Ashkelon," these and such as these, have for ages past, and even in this enlightened country, been consigned to chains and dungeons, and subjected to the controul of mercenary wretches, who # would scarcely have been tolerated to look after the felon, the murderer, and others the most depraved and Avorthless of society. Whilst self-styled philanthropists have traversed the utmost limits of the empire to enquire into the situation, and improve the condition of convicts, they have passed heedlessly by the cold and loathsome dungeon, where the guiltless and unhappy maniac was pining in hopeless captivity ; where charity never came to calm the bewildered mind ; and where the benign voice of commiseration was never heard.

It is true that a spirit of enquiry has been abroad of late ; parliamentary committees have been instituted; the most atrocious cruelties have been brought to light ; and it has been proved beyond the possibility of a doubt, that so far from any curative measures having been resorted to in the treatment of the insane, the method pursued has been such as must have had the effect of driving to irretrievable madness thousands who, under a system of ordinary mildness, would have been restored to society.

Much good has undoubtedly been done by the exposure of the abuses which have existed ; but much more remains to be done, before this important branch of medical jurisprudence can be placed upon a footing commensurate with the advanced state of all other branches of medical science, and before the foul stain which the existence of these abuses has fixed upon the boasted institutions of our country can be expunged.

Chapter II. Introductory Remarks Continued

Much as we have reason to find fault with the barbarous system of treatment which has so long obtained in our lunatic asylums ; and much as we may feel inclined to congratulate ourselves that public indignation has been a means of correcting much of the evil, we must not lay the flattering unction to our souls that we have done all that humanity requires of us, in the reform of the system pursued in the treatment and care of lunatics. Our enquiries have extended chiefly to such institutions as may be considered of a public nature ; but we must not stop here. If enquiry were instituted, it would be found that grievous abuses exist in private asylums, and that these require to be subjected to a more rigid investigation, and placed under a more efficient controul.

Private asylums are springing up in every part of the country, and it becomes matter of serious consideration whether they are called for by the actual increase of Insanity ; whether they are instituted in consequence of the inefficient systems pursued in those already established, or of the incarceration of many persons who cannot consistently be brought under the denomination of lunatics.

There is a fashion in every thing ; and I am decidedly of opinion that the unhallowed influence of fashion has extended into regions whence reason and humanity ought for ever to have shut it out.

I have myself seen persons in lunatic asylums, for whose confinement I could not see even a colourable necessity : and I feel no hesitation in saying, that were a calm, candid, and philosophic enquiry made, hundreds of cases would be discovered of persons improperly incarcerated, who would stand a much better chance of being restored to health of mind, under the care of kind and considerate friends, than by being placed where every object around them must tend to excite a morbid state of feeling.

Within a very short period of time, we were satisfied with a sound and consistent definition of mental disease, and every case would arrange itself under one of the heads, Idiotcy, Lunacy, or Insanity; but our advanced state of civilization, and " the march of intellect," have brought their evils as well as benefits, and we have now the indefinite definition of " unsoundness of intellect," added to the catalogue.

The abuses, and even crimes, which may be perpetrated under this ambiguous mask, are too horrible for contemplation. Where shall we find the man or woman whose mental powers are so perfect and healthy, as not to come within the range of this imcomprehensible definition ? Where shall we find the being who is perfectly sane upon every point ? I may say with a high authority, "Let him who is without sin amongst you cast the first stone."

It is doubtless a matter of very great convenience to many persons, that there are places to which troublesome or eccentric relatives or friends may be packed off out of the way : and it is probably, at times, very convenient for some people to have the management of the property of others. An unfeeling and brutal husband may exasperate a sensitive and amiable woman by his neglect and cruelty, until with continued harassings, her mind becomes irritable and unsettled ; she may be in the way on other accounts, and the husband may be anxious to get rid of her ; he

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tells his own tale to a pliant physician, who calls to examine her, and the very questions he puts, implying doubts of her sanity, excite her to give irritable and incoherent replies, and she unconsciously seals her own doom ; and the gloomy walls of a mad-house, the association with lunatics, and a strait waistcoat, soon finish the work which villany began.

It may be said this is an extreme case ; but the question is, whether it is not with these extreme cases that half our mad-houses are filled.

I could adduce the case of an elderly female now confined in a lunatic asylum, who in every instance conducts herself with the most scrupulous propriety ; who converses as rationally upon general subjects as it is possible for a woman to do ; her demeanour and manner are those of a complete lady ; her only point of weakness is, fancying herself a lady of rank and title, and that unattended with any one circumstance which could render her obnoxious to society, and especially to those whose duty it is, and Avhose pleasure it should be, to humour and excuse her weakness, to comfort her declining days, and to smoothe her way to that bourne to which a few short years must conduct her.

Believing herself to be an injured woman, she secludes herself in her room, and refuses to adopt those means of air, exercise, or medicine, which might yet restore her mind to some degree of vigour.

Can we call this a case of idiotcy, or lunacy, or insanity ? No ; but then comes the new and fashionable form of expression, and we call it " unsoundness of intellect !"

Now supposing this lady's friends could find any plausible excuse for sending her from home, or that they did not choose to be troubled with her eccentricities ; would it not have been more humane and reasonable on their parts to place her in comfortable lodgings, under the care of some kind and attentive matron, where she might have been treated with the respect due to her station ; rather than to have consigned her to a mad-house, to the society of lunatics, and to the controul of strangers?

Another instance I may mention, of a fine youth about twenty years of age, who is in every respect in full possession of his mental faculties ; and whose only disorder appears to be deficiency of mental energy. It cannot even be called weakness of intellect, for when he is by any means roused to exertion, he not only evinces a sound judgment and discriminating powers, but is capable for a time of considerable mental labour, in studying a language for instance, or any other subject to which he may apply himself. Can any one suppose for a moment that a mad-house is a proper place for such a character as this ?

Does the company of lunatics, and the con troul of a keeper, offer any chance of restoring this young man to his mental powers ? The obvious course would be to place him in situations where every thing around, would tend to rouse and awaken into activity his latent energies, such as change of scene, lively society, and plentiful exercise.

I could mention other cases, but I think enough has been said to prove that persons are improperly confined; and the principle once admitted, is sufficient to shew the necessity of a strict and efficient inquisition into lunatic asylums.

In these cases I do not see that any positive blame attaches to the proprietors or superintendents ; they are mere passive agents ; they depend for their existence upon the patronage of the medical profession, and it would be too much to expect of human nature, that they should run counter to their own interests, and dictate to the attesting physicians who are, and who are not proper objects for admission.

In many instances, indeed, the form of a physician's certificate is altogether dispensed with ; in most of these cases probably the insanity is so palpable, that no doubt can exist of the propriety of controid ; but if this practice is once allowed, there will be no end to the abuses to which it will lead.

It is true that commissioners are appointed, whose duty it is to inspect lunatic asylums, and to scrutinize their management ; but their visits are like those of angels,

" Few and far between ;"

and are generally mere visits of courtesy ; for as to any useful purpose, their controid is a mere dead letter, inasmuch as they have no power to inflict a penalty, or even to refuse a licence for the future, however gross may be the abuses they have detected.

I cannot but remark that the friends of patients are often extremely culpable in allowing them to be dragged off to a lunatic asylum without any previous enquiry into its character, and merely because Dr. such-a-one recommended it; when, probably, this Dr. knows no more about the regulations and management of the house than the greatest stranger. I could name more than one physician who recommend asylums, whose portals they never entered, and who have consequently taken upon credit all the glowing representations which interested parties have given of the perfections of their institutions.

In other instances the most odious abuses have been proved to exist in certain asylums and yet their proprietors still continue to enjoy the public patronage, and their houses are crowded with respectable patients. This certainly evinces great want of feeling on the part of their friends, and I can only wish that they were themselves subjected, for a few months, to the same discipline which they occasion to be inflicted upon others.

. The extravagant rates which are paid by some for the support of their insane friends is another prolific source of evil. When the proprietor of an asylum is receiving four or five hundred a year with a patient, it is too much to expect that he will be very anxious for his recoveiy. It may perhaps be said that this observation applies to the medical profession generally, and that, when a physician or apothecary gets a good patient, he may not be very anxious to part with him ; but it must be remembered, that the inducement to abuse is infinitely greater in one case than in the other, and that the patient of the physician or apothecary is under the scrutinizing eyes of anxious and affectionate relatives or friends, who would soon discover if they were trifled with ;

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while in a lunatic asylum there is every facility for abuse.

It is said of an oriental monarch, that he pays his physicians only when he is in health ; and, were this principle generally adopted, it would be attended with advantage. A modification of it, however, I would adopt, had I a relative or friend insane. I would pay just so much as would cover the expenses of board, &c, and agree to pay a handsome premium when the patient should be discharged cured.

Chapter III. On Incipient Insanity

I now proceed to offer a few observations to the notice of those, whose misfortune it may be to have relatives or friends afflicted with mental derangement ; and I wish most particularly to press upon their minds the importance of an early attention to any appearance which may indicate incipient insanity. For it is a fact which will not admit of dispute, that, as the disorder increases in duration, it increases in intensity, and consequently every moment

c 2 of delay diminishes the chance of recovery. In this respect there is a great analogy between mental and bodily disorders. In bodilydisorders, if prompt attention be paid to the exciting cause, a long train of consecutive evil is arrested, and probably the life of the patient saved. How many persons, who are now lingering in painful and hopeless sickness, can trace its progress from the neglect of some trifling cause. And in mental disease, inattention to its incipient state, will often check a malady which, neglected, would proceed from stage to stage, until confirmed and incurable madness would be the result.

And not only should this care be taken, when the disorder has actually made its appearance ; but where an hereditary or constitutional tendency to insanity exists,* all that

* Many extraordinary instances of predisposition might be

related ; and in some cases it has shewn itself at a very early

eriod of life. I knew a female who, at eight years of age, circumstances will possibly admit should be done to diminish the chances of that excitement which may call the latent evil into activity. It behoves parents who are aware of this error in their own systems, to bring up their children with habits of regularity, to repress with care every predominancy of feeling which may, if permitted to increase with their years, eventually become a nucleus for the latent disease ; and, if possible, to place them in such situations as may allow of little alternation of circumstances ; for even a humble life, with regularity, is better than a higher sphere, subject to the vicissitudes and anxieties of wealth and fortune.

began to collect trumpery picturesto adorn the walls of the workhouse in which she felt assured she should close her existence. This impression remained with her during life ; it absorbed every other feeling, and under its influence, and to avert the fate to which she conceived herself doomed, she ultimately committed suicide.

Amongst the many exciting causes which bring into activity a predisposition to insanity, I know of no one more certain in its effects, and more baleful in its influence, than a belief in those gloomy dogmas of religion, which are propounded by ignorant and bigoted fanatics ; representing the allwise and merciful author of our being as a God of terror and of vengeance ; denouncing the great majority of mankind as being in a state of irremediable reprobation, and as certain of inheriting eternal perdition. Those who have been at all conversant with the insane can bear ample testimony to the awful consequences of propagating these false notions of religion.

When, therefore, any feelings of this description are observable as making a deep impression upon minds in which there may exist a predisposition to insanity, the greatest care should be taken to correct such erroneous notions, and to present more benignant views to the mind.

I knew an amiable and benevolent lady, the mother of a numerous family, whose mind sunk under these awful impressions. She became a confirmed lunatic, and it was truly pitiable to see the state of horror in which she passed her existence ; " Do you not see," said she, " the very stones rise up in judgment against me?"

There are various other exciting causes, which it is unnecessary here to enumerate. I may just observe that in young persons, especially females, of warm imaginations and ardent minds, the passion of love is frequently productive of the most serious consequences. When one of our own sex enters the lists of love, there is no arbitrary ordination of society to prevent him from pursuing his object, and he generally attains the consummation of his wishes. But the softer sex are forbidden the exercise of this franchise, and, however ardent and intense the passion may be, the rigid rules of etiquette and propriety render concealment absolutely necessary ; and thus the destructive worm rankles in the breast, and undermines the fragile fabric of the mind ; and at times produces a morbid state of feeling, to which I shall hereafter more particularly allude.

The artificial distinctions which wealth has created in society are also productive of mischief from this cause, inasmuch as disparity of circumstances frequently presents an insurmountable barrier to the union of persons who may have formed a mutual attachment ; and inexorable and avaricious parents have often to blame themselves, that their children are consigned for life to the oblivion of a madhouse.

When any symptom of mental aberration, an unusual depression of spirits, or a trifling eccentricity of conduct, is observed in any member of a family, it is generally looked upon with indifference. Time, the grand panacea, time is depended upon to remove the disorder with the remembrance of the cause which produced it. But time steals on, the malady increases, and it is at length discovered that the patient is really deranged ; a physician is applied to, and after calling a few times, and extracting a few guineas for doing nothing, he recommends a removal to a lunatic asylum ! Now let us pause, and consider upon what rational ground such a measure is to be taken, and then examine by the same rule what the probable consequence must be to the unhappy patient.

In most cases, the circumstance of the mind having become affected by causes which, had it been " made of sterner stuff," it would have combated unscathed, is a fair presumption of the sensitive feelings of the patient. Brought up probably in the bosom of a tender and affectionate family, surrounded by the endearments of the social circle, and blessed perhaps with every comfort life can bestow ; what, I ask, must be the effect on such a mind, on being torn from all these ties, consigned to the cheerless gloom of a mad-house, to the society of lunatics, and to the controul of strangers, whose humanity and tenderness are at any rate problematical ?

Even admitting for a moment that private lunatic asylums are in every respect what we could wish them to be, what consolation, or chance of cure can they offer in a case like this 1 What avail the most humane regulations ? What avails medical skill ? What avails classification ? Will the company of the melancholy cheer the hypochondriacal 1 Or will the society of the maniac restore the tone of the excited mind ? Alas ! none of these can " minister to a mind diseased."

I have witnessed cases in which the most serious consequences have ensued from placing patients in an incipient state of insanity in contact with confirmed lunatics. I remember a gentleman whose disorder was an excessive state of nervous irritability ; he was a tradesman in affluent circumstances, and lived in a style suitable to his means. His friends deemed it necessary that he should be removed to a lunatic asylum ; and the comforts provided for him there, were far inferior to what he had been used to at home. In a very short time the change caused an accession of excitement, so that he became troublesome, and disturbed the more peaceable patients in that part of the house in which he was lodged, and he was removed into the common ward, and placed amongst lunatics of all classes. Never shall I forget the dreadful state of agitation in which he continued during the whole of one day ; he refused to sit down, or to take any food, and stood shaking like an aspen leaf, his wild eyes wandering from patient to patient, as their gestures or exclamations attracted his attention.

Was such treatment as this calculated to remove nervous irritability ? Or would it not more probably have the effect of rendering the patient for ever the inmate of a madhouse ?

Having thus, I think satisfactorily, shewn that it is improper to place persons in an incipient state of insanity in lunatic asylums, it will naturally be expected that I should suggest some plan better calculated to promote the chances of recovery.

And now, as some persons may suppose that in these remarks I am influenced by an undue prejudice against lunatic asylums, I beg the reader to institute a candid enquiry in his own mind, whether what I advance is not founded in reason. I wish' no principle to be admitted on my dictum, but that every opinion

I offer should be weighed in the balance of sober judgment. What I have hitherto stated has been in reference to incipient insanity ; when I come to speak of confirmed lunatics, I shall have to admit more generally the utility of these establishments, when placed under proper controul.

Chapter IV. On The Treatment Of Incipient Insanity

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Having thus stated my opinion that lunatic asylums afford no facilities or advantages for the successful treatment of the early stages of insanity, I shall proceed to offer such observations as I think calculated to promote this desirable object.

The first thing to be attended to obviously is, to discover the exciting cause ; in some cases this is very obscure and difficult to trace, but in most instances it sufficiently developes itself.

Every means should be resorted to, to divert the mind from those objects which may have a tendency to recall associations which have influenced the morbid workings of the mind ; change of scene, and lively society are desirable ; but where practicable, I know of nothing so likely to have a beneficial effect as travelling ; the continual occurrence of fresh objects, perpetually engaging the attention, prevents the mind from dwelling upon unpleasant recollections.

In some cases it becomes necessary to remove the patient from home, and even from the society of friends ; and here the strictest care should be taken that every accommodation and comfort be provided, to which he had previously been accustomed ; and nothing should be said or done, to lead him to suppose that he is considered insane : it should merely be stated that he is going into the country for the benefit of his health.

Now some difficulty may exist in providing a suitable place of retreat and proper attendants ; but this, I apprehend, may be easily obviated, as there are hundreds of respectable persons of small incomes in the country who woidd be glad to take charge of a patient, and upon much lower terms than he could be provided for in a lunatic asylum. Lodgings, or a small cottage, at any rate, might easily be provided ; and as for attendants, there are numbers of both sexes who would cheerfully undertake the task, and under whose care the patient would stand a much better chance of kind treatment, than under the " well instructed keepers," who are supplied from lunatic asylums. Some care should, of course, be taken in the selection of proper persons, and strict enquiry should be made into their tempers and moral character. Now let us imagine a patient thus situated, in cheerful and comfortable country lodgings, with every little luxury provided for him which could administer to his health or amusement, and

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under the care of some kind and considerate attendant. Does not such a course offer the better chance of recovery ? Or would the reader still prefer to have a beloved wife, child, or friend consigned to a private madhouse ?

It may be objected, that you cannot by these means secure the advantage of the superior medical treatment which most lunatic asylums afford, from the circumstance of the medical attendant having devoted himself almost exclusively to this subject.

But I would sooner trust entirely to the means before mentioned than secure this superiority of medical skill, attended with the disadvantages of lunatic asylums. And if enquiry were to be made into this boasted superiority, it would soon vanish into a mere shadow, and it would be found that no assistance is secured in this respect, but what may be afforded by any medical man of tolerable skill in his profession.

It is now generally known that all mental disorders are dependent upon actual disease of the brain, and that, in the present state of medical science, our direct means of acting upon this organ are very limited ; we must, therefore, turn our attention to the state of the health generally. It may be safely asserted, that the most important thing to be attended to is the state of the digestive organs. There are other means which may occasionally be resorted to with good effect, such as the warm or cold bath, the exhibition of tonics, &c. ; but which would suggest themselves to any professional man of skill and judgment^