Observations on Insanity / With Practical Remarks on the Disease and an Account of the Morbid Appearances on Dissection

by John Haslam

METHOD OF CURE.

This part of the subject may be divided into management, and treatment by medicine.

As most men perceive the faults of others without being aware of their own, so insane people easily detect the nonsense of other madmen without being able to discover, or even to be made sensible of the incorrect associations of their own ideas. For this reason it is highly important, that he who pretends to regulate the conduct of such patients, should first have learned the management of himself. It should be the great object of the superintendant to gain the confidence of the patient, and to awaken in him respect and obedience: but it will readily be seen, that such confidence, obedience, and respect, can only be procured by superiority of talents, discipline of temper, and dignity of manners. Imbecility, misconduct, and empty consequence, although enforced with the most tyrannical severity, may excite fear, but this will always be mingled with contempt.

In speaking of the management of insane persons, it is to be understood that the superintendant must first obtain an ascendency over them. When this is once effected, he will be enabled, on future occasions, to direct and regulate their conduct, according as his better judgment may suggest. He should possess firmness; and, when occasion may require, should exercise his authority in a peremptory manner. He should never threaten, but execute: and when the patient has misbehaved, should confine him immediately. As example operates more forcibly than precept, I have found it useful, to order the delinquent to be confined in the presence of the other patients. It displays authority; and the person who has misbehaved becomes awed by the spectators, and more readily submits. It also prevents the wanton exercise of force, and those cruel and unmanly advantages which might be taken when the patient and keeper are shut up in a private room. When the patient is vigorous and powerful, two, or more should assist in securing him; by these means it will be easily effected; for, where the force of the contending persons is nearly equal, the mastery cannot be obtained without difficulty and danger.

As management is employed to produce a salutary change upon the patient, and to restrain him from committing violence on others and himself, it may be proper here to enquire, upon what occasions, and to what extent, coercion may be used. The term coercion has generally been understood in a very formidable sense, and not without reason. It has been recommended, by very high medical authority, to inflict corporal punishment upon maniacs, with a view of rendering them rational by impressing terror[9]. 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 practitioner, 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. We have seen, 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 practitioner to remove such disease, rather than irritate and torment the sufferer. Coercion should only be considered as a protesting 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 associate 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 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 scorn the incumbrance of cloathing, 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 associate with the convalescents, and by withholding certain indulgences he had been accustomed to enjoy.

As madmen frequently entertain very high, and even romantic notions of honour, they are 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 never 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.