FOOTNOTES:
[14] Biographical Notice, prefixed to Graves’ “Studies in Physiology and Medicine,” 1863.
[15] Edinburgh Medical Journal, October 1, 1845.
[16] Edinburgh Medical Journal, November 1875, p. 473. See also British Medical Journal, October 9th, 1875.
[CHAPTER XXIV.]
CONOLLY, MAUDSLEY, AND MENTAL DISEASES.
The modern realisation of the association of mental with physical health, the annexation to the sphere of biology of the phenomena of mind, and the concurrent comprehension of the true attitude of the physician towards mental diseases, have doubtless put into the shade achievements less than a century old, and some of them dating from only fifty years ago. Yet the simple discontinuance of the system of restraint practised from time immemorial on almost all lunatics was perhaps a greater practical revolution than the biological one just referred to; and England stands in the forefront of this revolution.
The old lunatic asylums of this country were objects of dread and repulsion. Severity was considered to be an absolute necessity in their management. “The affrighted visitors,” says Conolly,[17] “saw that many were furious ... and it never occurred to them that habitual severity was the real cause of the habitual fury.” New Bethlem in Moorfields two centuries ago was a place of chains, manacles, and stocks. Down to 1770 the inmates were exhibited to the public at a charge of twopence, afterwards reduced to one penny.
The medical profession had become accustomed to neglect mental diseases, and to acquiesce in severe treatment. Cruelty became developed in ingenious forms. In some Continental asylums patients were terrified by the gradual ascent of water in a well in which they were chained. Machines were imagined by which a newly arrived lunatic could suddenly be raised to the top of a tower, and as suddenly lowered into a deep dark cavern; “if the patient could be made to alight among snakes and serpents, it would be better still.” A revolving chair was invented, in which the victim could be strapped and made to gyrate at the rate of one hundred revolutions per minute. This was eulogised as a potent means of quieting the unmanageable, and was supposed to induce the melancholy to take “a natural interest in the affairs of life.” We can only make this passing allusion to the way in which ingenuity was exhausted in devising methods of restraint and torture.
Nothing could have been worse than the condition of the Bicêtre and the Salpêtrière, the two large asylums of Paris, when Pinel was in 1793 appointed to the former by Cousin, Thouret, and Cabanis, then newly appointed administrators of the Parisian hospitals. Damp, dark cells, infested by rats, contained dirt-coated beings whose only comfort was a little straw, chained, brutally ill-treated, and attended by brutal criminals. For nearly ten years previously Pinel’s attention had been directed to the treatment of the insane, and now, in spite of difficulties which officials threw in his way, he succeeded in loosening the chains and ameliorating the treatment of the majority of the patients. Yet his reforms nearly cost him his life. Rumours were spread accusing him of some evil motive in unchaining dangerous lunatics, and a mob one day seized him, and uttered the well-known terrible cry “à la lanterne!” An old soldier of the French Guard, once a lunatic, whom he had released from chains, cured, and employed in his own service, was appropriately the means of his rescue. Thus was philanthropy once more justified of her children.
At this very period English public opinion had been excited by revelations of cruelty and consequent deaths in the old York Asylum. In 1791 a lady belonging to the Society of Friends was placed in this asylum; her friends were refused admission to visit her, and in a few weeks she died. Inquiries that were made showed great grounds for suspicion, although full details could not be obtained.[18] But with great promptitude William Tuke, a prominent Friend at York, whose family has continued famous for attention to the affairs of the insane, proposed early in 1792 the establishment of a “Retreat” at York for insane patients, in which sympathy should be substituted for unkindness, severity, and stripes. The account given by Samuel Tuke in 1813 of its management is still a model in many respects.[19]
Neither Pinel nor the Tukes were however bold enough entirely to dispense with mechanical coercion. In 1818 Esquirol, the true successor of Pinel in France, found maltreatment still generally prevalent in the provincial asylums of France. In England mechanical restraint continued to be largely employed till Conolly’s time, and survives in some private asylums to the present day. We cannot give further details on this head, but hasten to mention the names of two men, Dr. Charlesworth and Mr. Gardiner Hill, who must ever be remembered as the first to give up mechanical coercion entirely in the small asylum of Lincoln. Dr. Charlesworth, physician to the asylum, had for many years diligently watched the effects of mechanical coercion, and gradually lessened the number of instruments of restraint in the asylum. Finally, the total disuse of mechanical restraints was decided on, and put in practice by Mr. Gardiner Hill in 1836 in concert with Dr. Charlesworth, with the most gratifying results.
We now come to the man who more than any other in England may be said to have established the non-restraint system so firmly that it will never be upset. John Conolly was born at Market Rasen in Lincolnshire, in 1794. His father, a member of a good Irish family, died young, and the care of a young family fell on his widow, whose maiden name was Tennyson, and whose patience and self-sacrifice her son ever affectionately acknowledged as the main influence which led to his own success. When his mother ultimately married a French gentleman, a political emigré, the latter taught his stepson French, and imbued him with a genuine taste for and knowledge of the language. Condillac’s essay “On the Origin of Human Knowledge” influenced his mental life. While in his teens his attention was first called to the subject of lunacy by an inspection of the Glasgow Asylum, and he never afterwards ceased to take the deepest interest in it.
At eighteen young Conolly became an officer in a militia regiment, in which capacity he served several years. While still young, he married in 1816 the daughter of Sir John Collins and went to reside in France, on the banks of the Loire. A year later he had decided to enter the medical profession, and in 1817 became a student at Edinburgh University. After a diligent career, in the course of which he was one of the presidents of the Royal Medical Society, he graduated M.D., and settled in practice as a physician at Chichester. Here he became intimately acquainted with Dr. (afterwards Sir John) Forbes, with whom he was afterwards much connected in literary matters.
Dr. Conolly did not remain very long at Chichester, but removed in 1823 to Stratford-on-Avon, where he wrote many contributions to and took part in editing the “Cyclopædia of Practical Medicine,” and the British and Foreign Medical Review. At Stratford he became alderman and mayor, established a public dispensary, and studied Shakespeare with enthusiasm. This occasioned him afterwards, while practising at Warwick in 1835, to take an active part as chairman of the committee formed for securing the preservation of Shakespeare’s tomb, and the restoration of the chancel of the church.
In 1827 Dr. Conolly was appointed Professor of the Practice of Medicine in London University, which appointment he only held four years, finding life as a London physician unsuitable to his tastes. In 1831 he again resorted to the country, establishing himself in Warwick.
The subject of insanity had long engaged Dr. Conolly’s attention. He had studied the question both abroad and at home, and had been for five years, (while residing at Stratford) inspecting physician to the Lunatic Houses for the County of Warwick, an office which he resumed when he settled in Warwick. He had unsuccessfully proposed to the council of the University that he should give his pupils clinical instruction on insanity in one of the lunatic asylums in London. “Thus,” says Sir James Clark,[20] “clinical instruction in mental diseases was thrown back for thirty years in this country.”
In 1830 Conolly published his valuable work, “An Inquiry concerning the Indications of Insanity, with Suggestions for the better Protection and Care of the Insane.” His objects were to render the recognition of insanity less difficult, by showing in what it differed from those varieties of mind which approached nearest to it; and to point out those circumstances which, even in persons decidedly insane, could alone justify various degrees of restraint. He lamented that during a student’s career he only saw cases of insanity by some rare accident. Every lunatic asylum was closed to him, and yet when qualified he might any day have to decide on a patient’s insanity. In view of some recent revelations a quotation from the introduction to this work (p. 3) is not inappropriate. “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 individuals have been received in courts of law, concerning persons with whom the deponents have never had an interview; and that on these depositions proceedings have been partly founded, of which the results were the imprisonment of lunatics, and restraint over their property. When the affair is conducted with more formality, and the suspected person is visited before being imprisoned, those who visit him are often very little acquainted with mental disorders, and come rather to find proofs of his insanity, which, to minds pre-possessed, 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 to comport himself, so as to avoid conviction that he was not of sound mind. His indignation would pass for raving; his moderation for the proverbial cunning of a lunatic.”
After describing the condition of asylums and lunatics at that time, the author considers the constitution of the human understanding and the inequalities, weaknesses, and peculiarities of mind which do not amount to understanding, and the influence of stimuli, of age, and of disease on the mind, and then discusses the phenomena of insanity and the questions of treatment and protection. He insists on the necessity of the most scrutinising watchfulness over the servants employed in their care. In cases where patients would do themselves or others an injury he insists on watching, instead of mechanical means of restraint. He proposes a complete scheme for the care of all lunatics by the State, providing for perfect publicity of procedure. He finally points out the increasing liability of the nervous system to disorganisation owing to the increased pressure and more varied anxieties of modern life, an observation most fully justified by what has been established since his day.
This work, a most readable and interesting one, both to medical men and to general readers, was not received with nearly sufficient warmth. Too many were wedded to the old systems of treatment; too many knew nothing about the diseases of the mind, and their sympathy could not be aroused in favour of lunatics. So Conolly was left to his country work at Warwick, varied by one year’s residence at Birmingham, till 1839, when he was appointed Resident Physician to the Middlesex County Asylum at Hanwell, at that time the largest in England. He had taken the opportunity of visiting the Lincoln Asylum and gaining all the advantages possible from its experience. He was now satisfied that mechanical restraint was not only unnecessary, but possibly injurious. On few others had the non-restraint system gained a hold. Hanwell had the reputation of being one of the best-managed asylums in England, many patients being occupied in agricultural and other pursuits. Yet one year after Sir William Ellis’s resignation, when Conolly took office, “instruments of mechanical restraint of one kind or other were so abundant in the wards as to amount, when collected together, to about six hundred, about half of them being handcuffs and leg-locks.”
Conolly entered upon his duties on the 1st June 1839. The asylum then contained 800 patients, and he found forty under continuous mechanical restraint. In his first report to the Quarter Sessions, he informed the Justices that since the 21st of September not one patient had been under restraint. “No form of strait waistcoat, no handcuffs, no leg-locks, nor any contrivance confining the trunk, or limbs, or any of the muscles, is now in use. The coercion chairs, about forty in number, have been altogether removed from the wards.” In fact, they had been cut up to make a floor for the carpenter’s shop.
This was not accomplished without some trouble and anxiety. It took time to indoctrinate the officers and attendants with the principles of the new system, in which they were deprived of their old prop. The aid which he received from Miss Powell the matron was most valuable. In ten years not one case was admitted to Hanwell in which mechanical restraint was deemed necessary, although many suicidal patients were among them. In fact, the removal of restraint tended directly and powerfully to promote the recovery of these, by taking away the sense of degradation occasioned by such restraint, by bringing them within the sphere of medical remedial agents and of cheerful influences. The only substitutes allowed were in some cases seclusion of a patient in an ordinary sleeping apartment, and, in extreme cases, in a padded room in which the floor was a bed; such seclusion being immediately reported to the medical officers, and recorded, even when continued only for a few minutes. This was found sufficient to protect the other patients, to calm the refractory one, and act as a tonic and remedial influence. The shower-bath was rarely resorted to except for medical reasons; window-guards, clothing, and bedding of strong materials to prevent tearing, were only required in a few cases. “The great and only real substitute for restraint is invariable kindness,” says Dr. Conolly. “This feeling must animate every person employed in every duty to be performed.”
Dr. Conolly published the main results of his experience in his Clinical Lectures in the Lancet in 1846, and in a work on the Construction and Government of Asylums, in 1847. His annual reports to the Justices detailed the progress of his system, and he afterwards summarised them and published them collectively. At the end of ten years, finding the non-restraint system in no danger of being abandoned at Hanwell, Dr. Conolly ceased to be resident physician, and became visiting physician, attending at the asylum twice a week, and spending the greater portion of the day there. His interest in the patients, says Dr. Hitchman, seemed never to flag. He would always look out for something to commend in a patient, the hair better kept, clothes more neatly worn, &c., and addressing the patients in the most gentle, affectionate tones, he made his visits always a matter of longing. The old attendants at the hospital in after years spoke of Dr. Conolly’s untiring watchfulness in the first years of his experiment. He would visit the wards at all hours of the night to see that his orders were being obeyed, walking noiselessly along the corridors. He was kept up in his arduous duties by an elevated religious principle. “I feel grateful to God,” he wrote, “who has intrusted duties to me which angels might stoop to perform.” He suffered greatly from an affection of the skin, which kept him awake at night and ill at ease during the day; and hence was liable to fits of depression and irritability which sometimes made him appear impatient.
In 1852, on his resignation of the appointment of visiting physician, Conolly’s connection with Hanwell practically ceased, and a piece of plate and his own portrait by Sir W. Gordon were presented to him at a public meeting by Lord Shaftesbury. In his reply on this occasion Dr. Conolly said: “Those who know me well will believe me when I say there never was an occasion when the sense of merit was less reflected from the breast of the recipient of a public honour, than it is from me at this moment.” He further stated that when he had first heard of the establishment of Hanwell Asylum, he was seized with a restless desire to become one day its head.
Many objects of philanthropy had Dr. Conolly’s untiring advocacy, both before and after his retirement from Hanwell. Public middle-class lunatic asylums, the education of medical men in mental diseases, the establishment of idiot asylums, especially that at Earlswood, were among these. He was the first doctor applied to by Mrs. Plumbe in regard to the foundation of Earlswood, and his co-operation with Dr. Andrew Reed was of the most essential service to the enterprise.
Dr. Langdon Down, formerly Medical Superintendent at Earlswood, wrote in regard to Conolly: “His visits were the most refreshing incident of my recollection in connection with the asylum. Entering on my work (in 1858) as an untried man, and finding myself allied to an institution which had become unpopular at the Lunacy Board, I was mainly decided on holding a position which had so much to overwhelm one by the influence of Dr. Conolly. That influence was magical. The humility of his character was only equalled by the real love he manifested for the mentally afflicted.
“At the visits of the Board of Management, he would steal away from his colleagues, and was to be found holding loving intercourse with the little members of my charge in a way that one has never seen before or since. Moreover, he so encouraged every official in his or her work, that the savour of his visit lasted till he again returned.... For myself, I have often had to seek his counsel, and never without being struck with his judgment and the fascination of his influence, the high resolve he inspired in one, and what willingness he exhibited to maintain, co-equally with the responsibility, the power of the Medical Superintendent, and thus to prevent a repetition of those evils which he had so bitterly to lament in his own experience.”
The years after Conolly left Hanwell were busily occupied with a large practice, especially in mental cases. In a few years his unceasing labour told on him, and he suffered much from chronic rheumatism and neuralgia. Finally he was compelled to retire from practice, when he took up his residence at Lawn House, Hanwell, whence he could see the asylum in which he had spent so many anxious hours. He finally lost mental energy, and was unable to complete several treatises and records of experience which he was contemplating. He, however, left an enduring memorial of his life-work in “The Treatment of the Insane without Mechanical Restraints,” 1856, written in a most readable style. We must not omit to mention his courses of lectures on Insanity at the College of Physicians and at the Royal Institution, his papers on Infantile Insanity, and finally “A Study of Hamlet,” in which he brings the most skilfully marshalled arguments to prove that Hamlet’s was a real and not a feigned madness. As to Hamlet’s treatment of Ophelia in Act II., Scene 1, and more especially in the scene where Hamlet and Laertes met over her grave, he remarked; “The picture of madness here is too minutely true, its lights and shades are too close to nature to have been painted as a mere illustration of feigning, and of feigning without intelligible purpose.” Both Sir Theodore and Lady Martin (Miss Helen Faucit) considered his exposition most satisfactory, and that it settled the question finally.
Conolly was carried off, after years of weakness, by an attack of paralysis with convulsions, which was fatal in a few hours, on March 5, 1867. Few have left behind them a brighter record as physician and philanthropist.
Improvement in the treatment of the insane and the knowledge of mental diseases has progressed rapidly in late years, owing to the efforts and studies of many workers, among whom Drs. Bucknill, Tuke, Hood, Lockhart Robinson, and Forbes Winslow are conspicuous. The record of their work would lead us into too wide a field. But the life-work of one of the sons-in-law of Dr. Conolly, Henry Maudsley, is of a character which for good or ill has exerted, and is exerting, a powerful influence on younger minds. We come here into a region of work influenced by the philosophy of Darwin and Herbert Spencer, applied to the physiology and pathology of mind, and to the relationship between body and mind. The time is not yet come for an impartial estimate of the striking works which Dr. Maudsley has brought forth in fertile succession, in addition to his extensive labours as one of the editors of the Journal of Mental Science. But it is certain that every one who would place himself in a position to estimate the strength of the so-called “materialistic” school, whether he be a metaphysician, a doctor, or a person of average culture, must read Dr. Maudsley’s works. They are written fearlessly, and for the most part with admirable lucidity, displaying a knowledge of literature and philosophy not often met with, combined with great practical experience in mental phenomena.
Henry Maudsley was born near Giggleswick, in Yorkshire, on February 5, 1835. After receiving his early education at Giggleswick School, he proceeded to University College, London, and took the M.B. degree at London University in 1856, with the distinction of University Scholar in Medicine. He proceeded to the M.D. degree in 1857. During the years 1859-1862 he was Resident Physician to the Manchester Royal Lunatic Hospital. Returning later to London he became for a time Professor of Medical Jurisprudence at his old college, and later Consulting Physician to the West London Hospital.
In an article on “The Theory of Vitality,” which Dr. Maudsley published in the British and Foreign Medico-Chirurgical Review in 1863 (republished in “Body and Mind,” 1870), he showed remarkable power for a young man of twenty-eight. His conclusion was that the conscious mind of man blends in unity of development with the unconscious life of nature. He looked for the harmonisation of the idealism of Plato and the realism of Bacon as the expressions of the same truths.
In 1867 Dr. Maudsley published an important work on the Physiology and Pathology of Mind. It was intended to treat of mental phenomena from a physiological rather than from a metaphysical point of view and secondly, to bring the manifold instructive instances presented by the unsound mind to bear upon the interpretation of the obscure problems of mental science, and to do what he could to put an end to the inauspicious divorce between the two branches of his subject. He energetically exposed the shortcomings of psychologists and metaphysicians, and naturally encountered severe criticism, and it may be allowed that some of his expressions were those of youthful enthusiasm rather than of matured wisdom. But the book had such merits, that a second edition was called for in the next year, and before long exhausted, after which the book was out of print for some years.
At length Dr. Maudsley republished in a modified form the “Physiology of Mind” in a separate volume of 550 pages (1876), putting it forward as a disquisition, by the light of existing knowledge, concerning the nervous structures and functions which are the probable physical foundations of those natural phenomena, which appear in consciousness, or feelings, and thoughts. In this work he says (p. 47) “that the subjective method—the method of interrogating self-consciousness—is not adequate to the construction of a true mental science has now seemingly been sufficiently established. That is not to say that it is worthless; for when not strained beyond its capabilities, its results must, in the hands of competent men, be as useful as they are indispensable.... That which a just reflection teaches incontestably, the present state of physiology illustrates practically. Though very imperfect as a science, physiology has made sufficient progress to prove that no psychology can endure except it be based upon its investigations.”
Meanwhile Dr. Maudsley had been called upon in 1870 to deliver the Gulstonian Lectures at the College of Physicians, and these were published in a small book under the title “Body and Mind: an Inquiry into their Connection and Mutual Influence, specially in Reference to Mental Disorders.” The first lecture expounded the physical conditions of mental function in health; the second described some forms of mental degeneracy which showed prominently the operation of physical causes from generation to generation, and the relationship of mental disorders to other diseases of the nervous system. The third included a general survey of the pathology of the mind, and the relations of morbid states of body to disordered mental function.
Meanwhile some important medico-legal cases had brought into prominence Dr. Maudsley’s belief that there are many forms of mental disease in which a patient ought not to be held criminally responsible for his actions, although he might be fully cognisant of their nature. This was definitely expressed as far back as 1864 in a pamphlet entitled “Insanity and Crime,” a medico-legal commentary on the case of George Victor Townley, by the editors of the Journal of Mental Science. It was in 1872 more fully developed by Dr. Maudsley in his “Responsibility in Mental Disease,” which has gone through numerous editions.
In 1879 the “Pathology of Mind” appeared in a separate and enlarged form, and contains a systematic exposition of the subject, introduced by an account of sleep, dreaming, somnambulism, and allied states. He then proceeds to deal with the causation of insanity, both social and material, and then further expounds the symptoms of insanity, treating it as one disease with varied manifestations, and then delineating the clinical groups of mental disorders met with in practice and which the physician has to deal with. One great merit of the book is, that the clinical pictures it contains are drawn from life. An extract from chapter iv., dealing with the influence of conditions of life on the production of insanity, will show how at every step Dr. Maudsley introduces considerations bearing on morality.
“The maxims of morality which were proclaimed by holy men of old as lessons of religion indispensable to the well-being and stability of families and nations, are not really wild dreams of inspired fancy, nor the empty words which preachers make them; founded on a sincere recognition of the laws of nature working in human events, they were visions of eternal truths of human evolution. Assuredly the ‘everlasting arms’ are beneath the upright man who dealeth uprightly, but they are the everlasting laws of nature which sustain him who, doing that which is lawful and right, leads a life that is in faithful harmony with the laws of nature’s progress; the destruction which falls upon him who dealeth treacherously and doeth iniquity, ‘observing not the commandments of the Lord to obey them,’ are the avenging consequences of broken natural laws. How long will it be before men perceive and acknowledge the eternity of action, good or ill, and feel the keen sense of responsibility, and the strong sentiment of duty which so awful a reflection is fitted to engender? How long before they realise vividly that under the reign of law on earth sin or error is inexorably avenged, as virtue is indicated, in its consequences, and take to heart the lesson that they are determining in their generation what shall be predetermined in the constitution of the generation after them?”
A later important work is “Body and Will,” 1883. “Its justification from my standpoint,” says Dr. Maudsley, “is, that I have been engaged all my life in dealing with mind in its concrete human embodiments, and that in order to find out why individuals feel, think, and do differently, and in what way best to deal with them so as to do one’s duty to oneself and to them, I have had no choice but to leave the barren heights of speculation for the plains on which men live and move and have their being. It is not enough to think and talk about abstract minds and their qualities when you have to do with concrete minds that must be observed, and studied, and managed.”
This work deals with questions too vast to be summarily discussed; but one aspect of Dr. Maudsley’s mind is well expounded in the following extract:—
“In nature, as we see it, we seem to see a conflict of warring opposites; gravitation opposed, or rather indeed complemented, by repulsion; chemical affinities by chemical repulsions; magnetic attraction by electric repulsion; evolution by dissolution; conservation by revolution, quiet or catastrophic; love by hate; self-love by love of kind; heaven by hell. Certain it is that hate and destruction are just as necessary agents as love and production in nature, which could no more be, or be conceived to be, without the one than without the other; and to call the one good more than the other, however necessary from the standpoint of human egoism, is just as if one were to call gravitation good and repulsion bad, as gravitation, had it self-consciousness, would no doubt do. In order to have a theory of cosmogony that shall cover all the facts, it has always been necessary to supplement a good principle by a bad principle, a God of love and creation by a God of hate and destruction. And it must always be so. We may, agreeably to the logic of our wishes, comfort ourselves in our pilgrimage by entertaining the hope and belief of the working out of good through evil and of the permanence of good after the disappearance of evil, just as, if it were useful and pleasing to us to cherish the illusion, we might persuade ourselves that repulsion will one day be annihilated and gravitation endure, or that evolution will continue and dissolution cease to be; but if we look at the matter in the cold spirit of strictly rational inquiry we shall always find abundant reason to believe that the sum of the respective energies of good and evil remains a constant quantity, the respective distribution only varying, and that we might as well try to increase the height of the mountain without increasing the depth of the valley, as to increase the good in the world by purging it of its so-called evil.”
Dr. Maudsley became a Fellow of the College of Physicians in 1869, has been President of the Medico-Psychological Association, and received the LL.D. degree from Edinburgh University in 1884.