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 passion, 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 ejaculations. 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 assistance or protection of a keeper. The superintendant of the Bicêtre, according to Dr. Pinel’s account, is usually attended by his keepers, [gens de service] though he is said to possess[29] “une fermeté inébranlable, un courage raisonné et soutenu par des qualités physiques les plus propres á imposer, une stature de corps bien proportionnée, des membres pleins de force et de vigeur, et dans des momens orageux le ton de voix le plus foudroyant, la contenance la plus fiére 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 assuming 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 practitioner; 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 turpissimus, 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 principally 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 assistance, 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 associations would be corrected.