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 associations, 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 associations 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 circumstance cannot be too strongly impressed on the mind of the practitioner: 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, assertion, 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 quantity 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 instituted 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 butter, together with milk pottage, rice milk, &c. Those who are regarded as incurable patients ought certainly to be indulged in a greater latitude of diet, but this should never be permitted to border on intemperance. To those who are in circumstances to afford such comforts, wine may be allowed in moderation, and the criterion of the proper quantity, 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.