An inquiry concerning the indications of insanity : with suggestions for the better protection and care of the insane

Introduction

For many years past, during five of which I held the appointment of Inspecting Physician to the Lunatic Houses for the County of Warwick, I have availed myself, both in this and in other countries, of such opportunities as presented themselves to me of examining the correctness of the opinions contained in the following pages.

In offering them for the examination of others, my desire is to render the recognition of insanity less difficult, by showing in what it differs from those varieties of mind which approach the nearest to it ; and to point out those circumstances which, even in persons decidedly insane, can alone justify various degrees of restraint.

That an inquiry of a difficult nature, and opposed, in this country, by peculiar obstacles, must be incomplete, I freely admit. The interests of the public greatly require that medical men, to whom alone the insane can ever properly be entrusted, should have opportunities of studying the forms of insanity, and of preparing themselves for its treatment, in the same manner in which they prepare themselves for the treatment of other disorders. They have at present no such opportunities. During the term allotted to medical study, the student never sees a case of insanity, except by some rare accident. Whilst every hospital is open, every lunatic asylum is closed to him; he can study all diseases but those affecting the understanding,— of all diseases the most calamitous. The first occurrence, consequently, of a case of insanity, in his own practice, alarms him : he is unable to make those distinctions which the rights and the happiness of individuals and of families require ; and has recourse to indiscriminate, and, generally, to violent or unnecessary means; or gets rid of his anxiety and his patient together, by signing a certificate, which commits the unfortunate person to a mad-house. In the plan of his medical study, therefore, attention to diseases affecting the mind forms hardly any part ; and it has thus happened that many individuals have been ignorantly confined, and unjustly detained in houses for the reception of lunatics ; and persons of all ages, suffering under temporary mental derangement, from temporary causes, shut up with the incurable : nor is it any exaggeration to say.

that such treatment has m many cases destroyed all hope of recovery.

Let no one imagine that even now it is impossible or difficult to effect the seclusion of an eccentric man ; or easy for him, when once confined, to regain his liberty. The timidity, or ignorance, or, it may be, a dishonest motive, of relatives, leads to exaggerated representations ; and the great profit accruing from a part of practice, almost separated from general medicine, cannot but now and then operate against proper caution in admitting such representations. When men's interests depend upon an opinion, it is too much to expect that opinion always to be cautiously formed, or even in all cases honestly given. The most respectable practitioners in this department openly justify the authorising of restraint, before the patient is seen, and on the mere report of others : and it seems that depositions to the insanity of indivi^ duals have been received in courts of law, concerning persons with whom the deponents have' never had an interview ; and that ori these depositions proceedings have been partly founded/ 6>f which the results were the imprisonment ^f lunatics, and restraint over their property. When the affair is conducted with more formality, and the suspected person is visited before beiMg imprisoned, those who visit him are often very Httle acquainted with mental disorders, and come rather

B 2 to find proofs of his insanity, which, to minds prepossessed, are seldom wanting, than cautiously to examine the state of his mind. If a person of sound mind were so visited, and knew of the visit beforehand, it would not be quite easy for him so to comport himself, as to avoid furnishing conviction that he was not of sound mind. His indignation would pass for raving ; his moderation, for the proverbial cunning of a lunatic. A man of an undisturbed understanding, suddenly surprised by the servants of a lunatic asylum, with handcuffs ready, and a coach waiting to carry him off, would infallibly exhibit some signs, easily construed into proofs that he was " not right in his head : " a man of shy and eccentric habits, if exposed to a similar outrage, would manifest his feelings in modes still more peculiar, and furnish abundant proofs of undeniable madness : and if the attempt was made on an individual of susceptible nervous system, of irritable temperament, suffering too under some temporary cause of discomposure or affliction, no one who has ever attended to the inequalities of his own mind can doubt, that his mental government would be sufficiently shaken to warrant any restraint or coercion on the part of those who would seldom be found reluctant to restrain and coerce.

Once confined, the very confinement is admitted as the strongest of all proofs that a man must be

INTRODUCTION. O

mad. When, after suffering so much wrong, he has an opportunity of speaking to the appointed visitors of the house, — supposing him to be confined where he can be visited, and supposing him not to give way to his feehngs, but to control them, — ^his entreaties, his anxious representations, his prayers for hberty, what do they avail! The keeper of the asylum is accustomed to all these things ; he knows that the truly and dangerously insane can act in the same way ; and from ignorance, in the absence of any bad intention, does away with all the effect of the patient's words. The visitors, knowing nothing of the shades of disordered mind, or not reflecting upon them, are told that they see " the best of him ; " that it is one of his " good days ; " that he is often " dreadfully violent ; " or that if left to himself " he will commit suicide : " and they shrink from the responsibihty of deciding where they know it is very possible they may be wrong.

Besides this, there is the ready and indisputable Certificate, signed by a medical man, — physician, surgeon, or apothecary, stating that the man is mad and must be confined in a lunatic asylum. It matters not that the certificate is probably signed by those who know little about madness or the necessity of confinement; or by those who have not carefully examined the patient: a visitor fears to avow, in the face of such a document, what may be set down as mere want of

§ INTRODUCTION.

penetration in a matter wherein nobody seems in doubt but himself; or he may even be tempted to affect to perceive those signs of madness which do not exist. The owner of the lunatic asylum is & most respectable man, — a neighbour, a friend, perhaps ; and the asylum is his fortune ; to depreciate it, or to cast a doubt upon a case where he has none, may be to ruin him : and the sense of duty in an honorary visitor could hardly lead him to run such a risk, even in cases of more flagrant mismanagement than are now commonly to be met with.

Of all these matters the public are not altogether unsuspicious, and hence arises an evil of an opposite description: for the occasional detection of mistakes, and the dread of committing a beloved relative to a lunatic asylum ; the opinion that to pronounce an individual insane is equivalent to pronouncing a sentence of separation from every friend, and an abandonment of all care of him to strangers; does really prevent in some instances such interference as the interests and comfort of families require ; and those to whom temporary superintendence and slight restraint would be salutary, are allowed to ruin their fortunes, or to make a whole family wretched, because restraint, when once determined on, is seldom apportioned to the individual case, but is indiscriminate and excessive and uncertain in its termination.

No provision of the Legislature can prevent the occurrence of these grievous mistakes, unless opportunities are at the same time given of making medical men as familiar with disorders of the mind as with other disorders ; and thus of rescuing lunatics from those whose interest it is to represent such maladies as more obscure, and more difficult to manage than any other. It would be some compensation for the unavoidable evils of public lunatic asylums, if each establishment of that kind became a Clinical school, in which, under certain restrictions, medical students might prepare themselves for their future duties to the insane. It is true that insane patients are not always in a state to be visited by pupils, and that a very strict discipline would be necessary to prevent disorder or impropriety : but such discipline is quite practicable ; and such arrangements might be made as would at once guard those patients from disturbance whom disturbance might injure, and present a sufficient number of instructive examples to the student. In some cases, also, the change of persons and of conversation would be actually beneficial to the patients ; and would only be what they are now accustomed to, during the visits of persons who come to see them from mere curiosity. Among the many intelHgent young men resorting to the London schools of medicine and surgery, some would soon be found who would zealously study

O INTRODUCTION.

mental disorders^ and by acting under the physician or medical superintendent, most materially assist him. Opportunities would then be afforded of trying every variety of medical and of mental or moral treatment, and particularly of practising all those methods of influencing the mind, which, separately slight, are, in connection, very availing ; and being only practicable at favourable moments, not only require great discretion, but a degree of superintendence which is at present impossible. We should then see how much could really be done in these affections, and should hear no more of mistakes which have from time to time afforded so much matter for litigation, so much personal uneasiness, and, in some cases, so much oppression and fraud.

Every man is interested in this subject; for no man can confidently reckon on the continuance of his perfect reason. Disease may weaken, accident may disturb, anxiety may impair it; and if every departure from sound mind may subject the person so affected to an indiscriminate treatment, including deprivation of property and personal liberty, no man can be sure that he may not, with a full consciousness of his sufferings and wrongs, be one day treated as if all sense and feeling were in him destroyed and lost; — torn from his family, from his home, from his innocent but eccentric pursuits, and condemned, for an indefinite period, to pass his melancholy days among the idiotic and the mad.

It would be idle to talk of the feelings not being engaged in an inquiry of this kind. Every feeling prompts us to the investigation. Yet, I trust, in the following attempt to prosecute it, I shall be found to have taken facts and well-established examples for my guide, and to have offered no opinions which have not received some confirmation from observation and experience.*

* It is my desire to avoid direct allusion to recent circumstances, which, belonging to the system followed with respect to cases of supposed lunacy, rather than to the individuals concerned, have reflected very undeserved odium on a gentleman with whose kindness and skill in the treatment of his patients I have had opportunities of being acquainted. I allude to Dr. Burrows ; who has assuredly been treated with unjust severity. With the opinions yet prevalent in society on the subject of insanity, sufficient allowance is not made for the extremely difficult position in which those individuals are placed who receive lunatics under their care ; and who are often at once responsible for any accident that may happen from the lunatic's conduct from the moment they are applied to, and at the same time subject to unmeasured condemnation if they fall into mistakes not always easy to be avoided in the anxious circumstances in which applications, often of a very hasty and pressing nature, are made to them.

Chapter II. The Present Condition Of Lunatic Houses And Lunatics

The first visit to a Lunatic Asylum is commonly made with mingled curiosity and apprehension. A scene of riot and disorder, and even some degree of danger, are expected ; sights and sounds of the most painful description, and a spectacle of confusion and of suffering. With the exception, therefore, of travellers who are determined to see every thing, and of certain intelligent and benevolent individuals who are deterred by no fear of personal inconvenience from visiting any place in which human wretchedness exists, these establishments have few visitors. Travellers content themselves with writing down the number of patients, the general plan of treatment, as far as an hour's visit can show them it, and memorandums of a few striking cases. Those who visit the asylums with the design of inquiring into and improving them, are seldom able to penetrate into private institutions ; and feel afraid to obtrude their imperfect observations on those who live among the insane in large establishments, which they only see on a few occasions in the year, and perhaps never without a degree of mental agitation unfavourable to calm observation. To these circumstances it must be attributed, that for so long a period very gross enormities were practised in public institutions for the insane, without any control and without remark ; and that even at this day so many circumstances exist, in the best conducted establishments, that is to say, in the pubHc ones, and so many more in the private ones, unfavourable to the persons who have the misfortune to be shut up in them.

Yet there is little in a well-conducted asylum to shock or to alarm the feelings of a spectator who is familiar with other forms of suffering ; even the worst of maladies will be found not incapable of many alleviations. To those who are habituated to the spectacle, or who may think it not an unworthy attempt to try to become so, I think the following observations will appear naturally to arise from it.

When we contemplate the inmates of such an estabhshment, we cannot fail to perceive that, although all of them may be labouring under disorders interfering with and modifying the manifestations of mind, the degrees and shades of affection are very variable, and almost infinite : that, like the persons without the walls of the institution, each individual has a distinct character, his own trains of thought, his own peculiar habits, his own pursuits.

If, then, we find that each individual is subjected, or that most of the individuals are subjected, to the same, or very nearly the same treatment, it is reasonable to presume that many of them will never be benefited by it. The confinement of lunatics is one general circumstance of treatment to which those whom I have supposed to be the object of contemplation are subjected. They are confined with persons so far similarly affected, that all are of unsound mind ; yet the confinement which some among the crowd before us may require, must be detrimental to some of the rest. The confinement which was necessary to many of them on the first invasion of the malady, must be hurtful to some as the malady declines. Conversation and reasoning, which would at one time have been quite thrown away upon them, may be attended to at another time, and be salutary.

How far, then, are the two important parts of the treatment of insane persons, the medical part and the moral and mental part, provided for ? Is the first as indiscriminate in all its particulars as in the article of confinernent ? Was it continued only for the first few days or weeks of the patient's illness, and is it now abandoned ? Is the moral and mental treatment as much neglected, as the spectacle of this wild assemblage seems to indicate ? Is it disregarded ? If not disregarded, how is its efficient application combined with these appearances of its applicatiDn being impossible ? Let us consider all the circumstances which may elucidate these questions.

A man is deemed a lunatic ; a certificate has been signed, to the effect that confinement in a lunatic asylum is necessary to his recovery : the patient is taken away from his family ; abandoned by his usual medical attendant ; waited upon by strangers, and his whole management confided to a person whose profession it is to cure lunatics ; to one who, if he is a medical practitioner, seldom professes to think the mind worthy of particular consideration ; or, it may be, to one who is altogether ignorant both of bodily and mental disease. The care of lunatics being generally lucrative, it has happily followed that many respectable, well-educated, and humane individuals have, in different parts of the country, devoted their time and their talents to their management. But there are many exceptions : the prospect of certain profit allures some capable of no feeling but a desire for wealth, and the most ignorant and uneducated men, or women, are, in some instances, the keepers of houses for the reception of lunatics. The patients are transmitted, like stock in trade, from one member of a family to another, and from one generation to another ; they come in youth to the father, they linger out their age with the son. An uniform system of restraint is enjoined, which saves all trouble; and a book of prescriptions is bequeathed as a substitute for the physician or apothecary. When an occasional, perhaps an annual visit of inspection is made, as was recently the case, and the patients are dressed, and the house is set in order, it is forgotten that, with very rare exceptions, the same miserable prisoners are for ever presented to the visitors ; at each visit declining more and more into imbecility % that some have lost the power of motion ; that others have lost the habit of speech ; that some have become desperate ; and some, after vain desperation, suHen; and that of those first seen, a very large proportion will remain in the institution to the end of their lives. It may be, that in the interval which has passed since the last visit, one or two lunatics have been received, have got better, and have returned to their homes. But the majority of the incurable is still immense, and of those, if we inquire into their history, we shall find many who came to the establishment in the prime of life, or in youth ; and when we curiously trace the remains of intellectual light, or the vestiges of grace and beauty in these unhappy beings, we too seldom remember the possibility that more of both might have been spared, under a different system of management.

Medical authorities agree in ascribing mental disorders to* corporeal disease, not to any specific corporeal disease, but to any disease capable of disturbing the functions, or impairing the structure of the brain. I fully concur in this belief : but we do not find in insanity, as in consumption, such invariable disorganization or impairment as would account for the long continuance of the malady, or for the small proportion of cures effected. We observe also with respect to cases of insanity, an indifference to medical treatment, which is not observed in other cases of corporeal disease ; and, admitting the want of full and strict analogy between the two cases, the reasonable conclusion is, that the disorder is imperfectly understood and insufficiently attended to.

That it should be imperfectly understood, cannot be a matter of surprise, for it has been very superficially studied. Some of the most manifest conditions of bodily disorder which occasion insanity,, such as violent determination of blood to the head,, and inflammation of the brain or its membranes, have not escaped attention, and what is called the; medical treatment of insanity, generally consists of a few proceedings founded on the supposition of the invariable existence of one of these states. When an unruly patient enters a common lunatic house, he is bled, dressed in a strait waistcoat, has his head shaved, is subjected to the shower bath, put upon low diet, kept in darkness, and compelled to swallow some active purgative medicine. If measures of this kind, which may be well enough suited to active delirium, do not effect any amendment, the medical resources of the establishment are at an end. Starvation, imprisonment, loneliness, and threats are then resorted to ; or if the proprietor of the house happens to be very alert, some desperate, or some unjustifiable experiment is tried ; whirling round upon an horizontal wheel, intoxication, or some strange method of astonishing the patient ; such as leading him blindfold and headlong into a cold bath. At last peace is effected. The patient is exhausted ; or his excitement is succeeded by what is called the low state ; or he has learned cunning, and moderates his actions. In a few cases, the disease is soon at aa end, and it is possible the amendment may be perceived, and the patient restored to his family : possible, but not as a general fact, probable ; for the patient is seldom seen by those who are judges of his amendment : a few minutes every two or three days seeming to be the maximum of medical attendance in the best circumstances ; and many weeks, or months, passing over in other cases, without the patient being seen by any medical man at all.

Too often, the low state, considered but a continuance of the malady in another form, is succeeded by another paroxysm of excitement, and the rest of a miserable life is passed in hopeless alternations between the two. \ But by far the most lamentable part of the present system of lunatic houses is, that a residence in them is detrimental in exact proportion to the favourable nature of the case. For a hopeless lunatic, for a raving madman, for a melancholy wretch who seems neither to see nor to hear, or for an utter idiot, a lunatic asylum is a place which affords all the comfort of which such unfortunate persons are capable. It is a far different place to two-thirds of those who are confined there. The crowd of most of our asylums is made up of odd but harmless individuals, not much more absurd than numbers who are at large. When eccentric habits are growing upon a man who continues to mix in society, they may be checked by his own efforts, on observing the surprise or the amusement which is caused by them. The starts of irritability, and the gloom of discontent, are alike corrected by prudential feelings, or by regard for others, or by the continual interruptions of business or pleasure. In an asylum for lunatics, the eccentric man makes little or no effort to correct his eccentricity ; nor the irritable man his irritability ; and the man of gloom sits in motionless despondency from morning until night, without the salutary disturbance of duty, or necessary exertion, or the visit of a cheerful friend. To all these patients, confinement is the very reverse of beneficial. It fixes and renders permanent what might have passed away, and ripens eccentricity, or temporary excitement or depression, into actual in-

c sanity ; — and this is not the worst part of the evil ; for even when a patient has suffered no aggravation of his disorder during its greatest severity, the danger is not passed : nay, it is increased as his convalescence advances; for when that otherwise happy change commences, the sights and sounds of a lunatic asylum hecome, if they were not before, both afflicting and unsalutary. That, during the unconfirmed stage of convalescence, when reason is struggling through the cloud which has obscured it, some mental diS well as medical treatment is required, is, I presume, what no man will deny, who has really ever thought upon the subject. But can it be applied — is it possible that it should be applied — in the generality of cases in our lunatic asylums ? A slight recollection of the circumstances in which a lunatic patient is placed, will furnish a ready ] answer to the question.

I take the most favourable case for the asylum : — I will suppose a person to have been received into the establishment unconscious of the change, — a thing which happens very rarely. The patient is insensible, and suffers nothing. But this state will not last long. The patient recovers some degree of consciousness ; his vehemence and passion abate ; or a load of despondency and horror begins to be cleared away from him. He tries, very feebly and imperfectly, to recover broken chains of thought : recollections of past circumstances return to him, as to one awaking from a deep sleep, or from a troubled dream ; perhaps the recollections of his family, of his home, and of suspended affections. Who can paint the surprise and alarm which must naturally arise from the unexplained confusion around him ! Shocked and affrighted, he may relapse into his madness and be lost. Or, if his mind has recovered more power, he may understand that he is surrounded by mad people, — the raving, the abandoned, the miserable ; that his friends have given him up ; that he is written in the list of men degraded from the possession of reason, and that he may continue to be confined for ever. Bewildered in his attempts to remember how long it is since he saw those dear to him ; perhaps left for days without one rational person to whom to express his doubts and fears ; and in his halfrecovered state, almost despairing of being ever restored to " the cheerful ways of men," the chances against his perfect restoration are fearful ; and most powerful causes of returns and aggravations of his mental malady are accumulated upon him. — To say that persons in this state are not left, are not abandoned, is by no means satisfactory to those who have opportunities of knowing how little of the time of the superintendent is, or can be, commonly devoted to the professed objects

c 2 of his care, and yet who, hke children, demand constant watching and attention. In maladies of the mind, there are many moments when a servant is in no degree a sufficient substitute for the physician.

Let it be recollected that in two-thirds, or, I might say, in four-fifths of the cases of reception, the patient is not unconscious of what is done to him. He knows that he is removed, that he is confined wdth mad people ; he knows, or at least he suspects, too, that he is not " in his right mind :" — the effect of this consciousness, such objects being presented to it, is never beneficial. The sensitive and timid, and those who have been accustomed to refined society, thus incur a degree of suffering which materially lessens the hope of recovery : they are in a constant state of dissatisfaction, and often express themselves in the most affecting terms concerning the degradations to which they are subjected by coarse and mean attendants ; and feel very keenly the contempt evinced for them on all occasions, whatever they may do or say. I have seen numerous examples of this kind, in which it was evident that although the patients were not yet sufficiently restored to return to their families without superintendence, a continued residence in the asylum was gradually ruining the body and the mind. If, contrary to all probability, such patients are rescued from the asylum, they retain a most painful recollection of what they have witnessed and undergone ; and I have known this circumstance long continue a source of irritation to a mind which might otherwise have been kept in a state of tranquillity. But how few are happy enough to escape ! After many hopeless years, such patients become so much accustomed to the routine of the house, as to be mere children ; and are content to remain there as they commonly do, until they die.

I have more than once read the announcement of such a death with a feeling approaching to pleasure ; when I have recalled to my mind the monotonous wretchedness of the unhappy patient's existence ; debarred from home, from the sight of friends, from the society of their families *, not permitted, notwithstanding many and moving supplications, ever to behold the still beloved faces of their children — shut out from even a hope of any change that might be beneficial to them — and when I have recollected, too, how unwelcome were any representations of the possibility of an individual, though unequal to the cares of a family, being yet capable of social and soothing family enjoyments ; and that, in short, those who had the charge of them, and those who sent them into confinement, were equally immoveable in their sentence of confinement for life.

On patients of less feeling, the effect of lining constantly among mad men or mad women is a loss of all sensibility' and self-respect or care ; or, not unfrequently, a perverse pleasm'e in adding to the confusion, and diversifjTiig the eccentricity of those about them. Their minds become childish, and their amusements fiivolous or mischievous. In both cases the disease gi'ows inveterate. Paroxysms of violence alternate ^vith fits of sullenness ; both are considered fmiher proofs of the hopelessness of the case, and at last all hope is tnily enough destroyed.