Insanity is, no doubt, a terrible visitation, but why should we allow a false and unreasonable horror to increase it, and why should we thus sever our sympathy from a disease which more than any other requires it? The medicinal virtues of the fruits of charity are best proved amongst them. Grant that the disease arises from some remote or proximate ill-directed mental states. Why should we have more horror of insanity, than many other consequences of ill-regulated minds.—To me, the foul ward of some large public Hospital, is incomparably more horrible and loathsome.—Such direct consequences of wickedness present the object before us in an aspect that makes it difficult for us to exercise any feelings of commiseration towards them. Not so the insane! but these are views, however, into the consideration of which, I shall not enter in this place; but I mention or rather hint at the diseases of other organs, for the purpose of asserting that the reality and appearance of the miserable state of the insane is not so shocking as people imagine, but that still I allow it is an awful visitation.
But while I allow this, it is at the same time the strongest reason why we should be anxious to remove all those false and unreasonable horrors, which can only aggravate the calamity, by giving countenance to the imaginary necessity of having recourse to harsh measures,—one ceases with the other,—it will not only do this, but it will also, I repeat, remove those depressing feelings of degradation which, whenever reason gleams, is death to their hopes, and which often prevents their recovery, brings on relapses, and is the most painful and heartrending feeling they have to contend against in the critical and incipient stage of their convalescence.
By this system of greater liberality, it would soon be found, that patients would no longer consist of violent and extreme cases alone, but that every thing repulsive in their present state and aspect would quickly disappear, their whole character assume a milder form in reality as well as in appearance.—Indeed, this is already the case. All things are improved. Thus popular prejudice ought to cease, and a more favourable prepossession should occupy its place; and the world being fully persuaded, that there is much more to hope than to fear from a residence at such a place, persons at the commencement of the malady are easily induced to enter them of their own accord, or are sent by their friends without delay or reluctance, before the disease has passed the curable stage. “Cases,” as a friend of mine justly observes, “were this feeling fully established, would be relieved without proceeding to the utmost degree of severity; and we might confidently anticipate that when the decided excellence of such a system, as regards moral, intellectual, and physical management, is adequately understood, the premonitory symptoms, often slight and various, but generally significant, will no longer be disregarded: and incipient mental disease, arrested by the judicious means there pursued, will not be allowed to assume a form and magnitude constituting the most awful calamity to which man is subject:” and why should it be allowed to do so, when it may be asserted, without contradiction, that functional disorders of the brain, are less liable to end in disorganization, and possess a greater power of readjustment, than any other part of the human system—woe unto us if it were not so.
The advantages which may arise from this system will appear in a still more striking point of view, when we reflect that those cases which without proper care in the early stages of the disease ultimately become the worst and the most dangerous, are precisely those which are fatally neglected, in the first instance, and which are scarcely ever placed under any medical treatment or moral discipline until the evil is past all remedy. Cases of suspension and cases of gradual decay of mind, as well as cases of Hypochondria, are of this description. I had lately applications to receive three patients of the latter description, all of whom committed suicide during the delay between the application and the intended removal.
It is true, there are cases, which require a very delicate, and conditional sort of superintendance, and that harsh measures and indiscriminate treatment would, in many instances, be more injurious than even absolute neglect; but at the same time, it must be observed, that such persons generally require to be placed under some judicious and delicate restraint, from the fact that their vicious inclination (for in these cases the disease begins in chronic inflammation and ultimately softening of the cerebellum) leading them into vicious habits, would rapidly accelerate the disease and make it a confirmed and incurable case. I have had some cases of gradual decay of mind, which, if not curable, might, with care, have continued for years in a tolerable state, but when allowed their liberty only for one week, they so accelerated the progress of the disease by dissipation and excess, that they suddenly sank into hopeless idiotcy.
I have known several such cases, who were never under any care, but left wholly to themselves, sink as suddenly into the same hopeless state.—Cases of Melancholia and Suicide, are often unsafe; the first is not a less decided case, though less avowed and acknowledged inclination to suicide; the other, though avowed will often pretend to be much better; sometimes even strongly confess their guilt in having allowed themselves to indulge in so dreadful a propensity; and all this, merely for the purpose of throwing their friends off their guard; when, the moment they suspend their vigilance, the suicide seizes with avidity whatever means or opportunity may be presented to him, to terminate his present miserable state of existence.
It is evident that to pursue this system, it will require great anxiety and vigilance, and that we must not care for labour or sacrifices but seek to do good for the sake of the good to be done; and when this is the case, we shall be most desirous thoroughly to understand every form and species of the disease, for we shall then know that it requires that we should, with the utmost nicety be able to discriminate between the different forms and species of insanity, in order that we may discover, prescribe, superintend, or enforce the peculiar treatment which each case requires.
These conditional plans of superintendance must be allowed the widest range, a range which no inexperienced person, still less those who have false notions and impressions of the general character of the insane, can possibly imagine, and for which no acts or rules can give directions—How then can those without knowledge and experience pretend to undertake such a charge? Often we have only a choice of evils; and we must be less anxious about the risk of accidents, our own credit, or interest, than the cure or chances of good to be done. In some cases absolute confinement would rapidly make the patient’s state worse, and we must give either real or apparent liberty; a liberty which some would think imprudent. [95]—Yet I believe it is a fact, that there are the fewest accidents where to appearance the greatest liberty is given, [96] harsh measures always increase the evils which they would pretend to cure; but should one accident occur under this mild system, the person adopting it would be more blamed than he who had twenty accidents on the old plan.—With the first system, it is often difficult to persuade the friends of the patients to concur and co-operate.—The family dispositions often render this probable; nor can we always blame them: but he who undertakes this charge, while he endeavours to persuade and conciliate as far as possible, must in many cases feel himself called upon to act with decision.—If he adopts the fears and prejudices of others, then his system will become one of duplicity and tyranny, exciting suspicion and vindictiveness, destructive alike of all confidence and chance of cure; for unless we acquire the confidence of the patient, no good can be done; mutual distrust will end in absolute slavery and restraint to the patient, and in the baneful habit of exercising the love of power on the part of those who have the superintendance.—Hence the evils apprehended by their friends as likely to arise out of the patient’s vindictive state, will be most effectually established and increased. Instead of the calming effects of a system of confidence and liberty, tranquillity, and peace, this contrary system will continue to goad, irritate, and inflame that part of the brain through which the mind, in this state, is operating; and in pursuing such a course we are clearly guilty of making that become fixed and permanent which otherwise might only have been of very temporary duration.
While nothing is more certain than that, in most cases, too sudden a return to old scenes and associations is extremely dangerous, there are some others where I have known their returning home at an early period, or even at some critical point of convalescence, decidedly expedite and confirm their cure:—when there appear evident reasons to augur favourably of such a change, the trial should be made—we have only a choice of evils, and we must endeavour to choose the least.
It is remarkable, that many have, in an incipient state of convalescence, been placed on parole of honor; first, they are simply restricted to the garden, and afterwards the fields; and if no breach of confidence occurs, they are allowed a pass key to go out and in when they please; and scarcely an instance has occurred in which they have taken advantage of this privilege to make their escape;—nor have they opened the doors to others.—Those who escape are always those who are not so trusted.