But a humane man may in the exercise of his humanity be injudicious, and by so doing inflict much actual suffering. The surgeon who to avoid inflicting pain should shrink from the complete removal of a malignant tumour, would fail to relieve the patient as he ought to have done. Therefore something more than humane feeling is required. Judgment must be exercised. Now, judgment and that common sense, or mother wit, which is so much better than mere routine practice, evidently characterized the early treatment of the Retreat. As benevolent feeling naturally led to the non-use of chains and the minimum resort to restraint which then seemed possible, so common sense led to the avoidance of the periodical bloodletting and emetics then in fashion. It is a remarkable fact that even then it was seen that insanity rarely calls for depressing remedies, and the observation was made and acted upon that excitement is often relieved by a directly opposite treatment. They allowed a liberal nourishing diet[132] in cases of violent mania; a free supply of meat, or bread and cheese, and porter, was found of the greatest service at supper in procuring sleep and reducing excitement. They had no faith in specifics and nostrums in the cure of insanity, but medical treatment was by no means despised, while a warm bath was found to be "of greater importance and efficacy, in most cases of melancholia, than all the other medical means which have been employed."[133]
With this, one cannot but contrast the old system, which was emphatically empirical and unscientific. It was continued without change from year to year, and it may truly be said that idleness and selfishness, still more than ignorance, constituted the vices of the old system. Those who treated the insane always encountered opposition by brute force, instead of by energy and patience, which surmount difficulties that to idleness are impassable mountains, and which selfishness would not, if it could, overcome. Again, from the commencement of the Retreat, the idea was entertained of making the institution a home; and with this view the arrangement and surroundings were made as cheerful and home-like as possible.
Another strong point was the employment of the patients; its vital importance was forcibly felt from the first. Dr. Delarive, who inspected the Retreat in 1798, particularly comments upon this novel feature of a mad-house. He found that an experiment recently made, that of inducing the patients to cultivate the land, giving to each a task proportionate to his strength, had answered well. It was found that they were fond of this exercise, and that they were much better after a day spent in this work than when they had remained in the house, or when they had taken an ordinary walk. Delarive went to see them at work, a sight so common now in our asylums that it seems strange it should have excited his surprise.
Of employment the author of the "Description" thus speaks: "The female patients in the Retreat are employed as much as possible in sewing, knitting, or domestic affairs; and several of the convalescents assist the attendants. Of all the modes by which the patients may be induced to restrain themselves, regular employment is perhaps the most generally efficacious; and those kinds of employment are doubtless to be preferred, both on a moral and a physical account, which are accompanied by considerable bodily action, that are most agreeable to the patient, and which are most opposite to the illusions of his disease."[134]
We find it insisted upon by those who had the management of the Retreat that moral treatment is of the greatest importance; that gentleness must take the place of violence;[135] that it is erroneous to suppose it necessary to commence an acquaintance with lunatics by an exhibition of physical strength; that every effort should be made to divert the mind of melancholiacs by bodily exercise, walks, conversation, reading, and other recreations; that the desire of esteem is a more powerful principle to appeal to than fear; that the best form of restraint is self-restraint; that patients should be treated as much as possible as rational beings, but that little or no advantage arises from reasoning with them on their particular delusions; that it is desirable to encourage the influence of healthy religious principle over the mind of the insane; that those who manage them should sedulously endeavour to gain their confidence and esteem, to arrest their attention and fix it on objects opposed to their delusions, to call into action every remaining power and principle of the mind, and to remember that in the wreck of the intellect the affections not unfrequently survive.
This recapitulation of the salient features of the practice of the Retreat renders it easy to understand the position taken by the managers of the institution in regard to mechanical restraints. When kindness failed to subdue maniacal excitement, when medical remedies exerted no calming influence, mild forms of restraint were reluctantly adopted, rather than maintain a conflict between patient and attendant. It appears from the Retreat archives that not more than five per cent., reckoning the night as well as the day, were restrained by strap or waistcoat.[136] It is notorious that, at the same period, it was the custom in some asylums, probably many, to chain to the bedstocks, at night, every patient in the house. Ferrus, to whom I have referred, did not find camisoles in use at St. Luke's in 1826, but "strong chains were employed to hold the excited patients. These chains, fixed at different heights to the sides of stoves (chauffoirs), have iron rings at the end, by means of which the arms or the legs of the patient are rendered completely immovable.... Far from fearing that a painful impression will be produced on the patients by chains, they think, on the contrary, that this apparatus exerts a beneficial influence upon them; that it intimidates, humbles them, and removes all desire to attempt to get rid of their fastenings." Ferrus says that at the Retreat he found a belt was employed, softly padded, to which the arms were attached. "We do not employ it in France," he says, "although it might in hot weather be preferable to the camisole.... The Retreat offers all the resources of art and the comforts of life (douceurs de la vie) compatible with the condition of insane persons."
Coercion was regarded at the Retreat as an evil—that is to say, it was "thought abstractedly to have a tendency to retard the cure, by opposing the influence of the moral remedies employed"—but at the same time "a necessary evil," an unhappy alternative in certain cases. Practically, as we have seen, the amount of restraint was small; but no rule of practice was laid down that it should never be resorted to. The abstract principle of non-restraint adopted at Lincoln and Hanwell was not enunciated. "We greatly prefer," observes the author of the "Description," "to lay down no absolute rule of non-restraint, but to refer to our resident officers the exercise of a sound discretion in each individual case." But the managers of the Retreat did undoubtedly lay down as a fundamental principle that "coercion will diminish or increase as the moral treatment of the patient is more or less judicious;"[137] and therefore, although they did not anticipate that personal restraint would be superseded by any other mode of treatment, this principle is broad enough to embrace all that has since followed in the way of non-restraint. The result, in the long run, of honestly carrying out the doctrine to its legitimate consequences, will not very widely differ from that reached by those who adopt "non-restraint" as an abstract theory in the first instance.
Justice would scarcely be done to those who interested themselves in mental diseases during the latter half of the eighteenth and the commencement of the nineteenth century, if we did not give the titles of some of the works bearing on insanity which issued from the press during this period. A treatise on Madness was written in 1757 by Batty. Perfect wrote "Methods of Cure in some Particular Cases of Insanity" in 1778, and "Select Cases of Insanity" in 1787, and "Annals of Insanity" fourteen years later. Perfect's treatment of insanity mainly consisted in bleeding, setons, electricity, and the administration of emetics, digitalis, and antimony. Dr. T. Arnold published his "Observations on the Nature, etc., of Insanity," 1782. Harper published "A Treatise on the Real Cause and Cure of Insanity" in 1789—a work ridiculed by Pinel. Faulkner wrote his "Observations on the General and Improper Treatment of Insanity" in 1790; and Pargeter his "Observations on Maniacal Disorders" in 1792. What, if any, beneficial effect these works produced upon the condition of the insane in the British Isles, I am unable to say. Haslam wrote his "Observations on Madness" in 1798, and he was the author of several other works; but, whatever their value and interest, we know but too well the condition of the patients in the asylum of which he was the apothecary. Crichton published his "Inquiry into the Nature and Origin of Mental Derangement"—a work, certainly, of merit and the result of practical observation. In 1802 appeared "De intellectûs facultatum conditione in mentis Alienationis diversis generibus," by Campbell (Edinburgh). Cox published his "Practical Observations on Insanity" in 1804. (See [Appendix B].)
Of Pinel, in relation to England, I must here say a few words.