Observations on Madness and Melancholy Part 9

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

CHAP. VIII.

REMEDIES FOR INSANITY.

_Bleeding._

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

The quant.i.ty of blood to be taken, must be left to the discretion of the pract.i.tioner: from eight to sixteen ounces may be drawn, and the operation occasionally repeated, as circ.u.mstances may require.

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

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

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

Maniacs in general feel a great aversion to become benefited from those medicinal preparations which pract.i.tioners employ for their relief; and on many occasions they refuse them altogether. Presuming that some good is to be procured by the operation of medicines on persons so affected, and aware of their propensity to reject them, it becomes a proper object of enquiry how such salutary agents may most securely, and with the least disadvantage, be conveyed into the stomachs of these refractory subjects.

For the attainment of this end various instruments have been contrived, but that which has been more frequently employed, and is the most destructive and devilish engine of this set of apparatus, is termed a _spouting_ boat. It will not be necessary to fatigue the reader with a particular description of this coa.r.s.e tool, except to remark, that it is constructed somewhat like a child's pap boat; and is intended to force an entrance into the mouth through the barriers of the teeth.[35]

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

[Ill.u.s.tration]

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

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

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

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

_Purging._

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

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