Physician and patient

by Worthington Hooker

The conversation and the conduct of such patients often exhibit no signs of aberration of mind, which would strike the common observer, even when the disease has existed for some length of time. And when physicians assert that they are insane, some of their friends are apt to doubt in regard to it, and sometimes they even controvert the assertion. Of many cases of this character which have come under my observation, I will allude to but two. One of them is the case of a lady, whose insanity, which had taken the form of religious ultraism, had been coming on very gradually for a long time. Though it was of so deep a character as to be absolutely incurable, many even very sensible persons among her acquaintances expressed their doubt of the necessity of taking her to an Insane Hospital, and probably would have cast blame upon me for so doing, had she not at one time summoned her friends around her, and after giving some singular directions and parting counsels, retired to her chamber and laid herself down to die. Such palpable acts as this, are often the first evidence that convinces the friends of a patient of the reality of his insanity. Though it may have existed for weeks or months, they perhaps have thought him to be nervous and ‘in a strange way,’ as it is expressed, but they have not really supposed him to be insane.

The other case which I will mention is one which was brought to the consideration of the civil authority of the town. I was called upon to testify in relation to it. The proofs of this gentleman’s insanity, which I adduced, were even made the subject of ridicule by a portion of that wise body of men, and yet his insanity very soon became so decided that he might be seen from day to day in our streets picking up rags and strings and bits of wood and coal.

The delusions of some patients are confined to some particular subjects. Upon these their insanity will appear in their conversation, while upon all other subjects they are perfectly rational. A man, who conversed with the utmost propriety on all other topics, on being asked if he believed in Jesus Christ, said at once, ‘I am Jesus Christ.’ A lady, who had very ambitious desires in relation to her husband’s standing in society, became insane upon this point alone, and while she was as rational as ever on all other subjects, she constantly poured a storm of reproach and abuse upon him, because he was not as great a man as she wished and expected he would be. A lady, who had been much fatigued in preparing for house-keeping, upon going into her new abode contracted a feeling in regard to the house, which was something more than a mere dislike—it was a horror. She could not bear to be in it, especially if she were alone. She had an impression, ill-defined but unconquerable and ever present, that something dreadful would happen to her if she remained there. She said that she had rather live anywhere else, even in the poorest shanty. Her friends thought that it was a foolish notion, which she could overcome if she would make the effort. But they were mistaken. She was really insane on that one point. I recommended that she should be permitted to stay away from her house so long as she desired it, and that her mind should be diverted by journeying and visiting. A few weeks sufficed to remove the delusion. I once knew a similar case in which the patient was not removed, and her misery finally drove her to the commission of suicide.

It may be remarked of these cases of monomania, as it is termed, that they do not ordinarily retain the same definite and exclusive character which they at first have. If the insanity continue for some length of time, other delusions are apt to be added to the original one.

Moral insanity is a form of the disease which is scarcely believed to exist by the community at large, and our courts of justice are very reluctant to recognise it, and will not do so without the most indisputable and abundant evidence. And yet this form of insanity is by no means rare. Many cases of it are found in our Retreats; and the outrages, which such patients commit, are occasionally made the subject of investigation before our legal tribunals. It is an insanity of the moral sense, affecting the intellect little if at all. Dr. Bell in speaking of it says, “There is insanity of conduct, but not of conversation; the persons afflicted are capable of reasoning with correctness and energy upon premises not only false, but which they know to be false, and frequently display the greatest ingenuity in giving reasons for and explaining away their eccentric and unjustifiable conduct, and accounting for the change which, they will admit, has occurred in the whole tone and temper of their dispositions and propensities.

“It is a form of disease in which, perhaps more than in any other, acts which, in a rational and responsible being would be crimes, are committed. It occurs, at times, as the sequel of violent attacks of mania,—it passes into decided mania or demency,—it alternates with intellectual derangements; all which circumstances afford an adequate presumption of its being a genuine form of insanity.”[40]

“Sometimes” says Professor Smith of New York, in a very excellent description of this form of insanity, “it shows itself in the abandonment of ordinary habits and pursuits; in carelessness of one’s own affairs with random indulgence in follies and gross sensualities. Sometimes it is seen in the form of ardent devotion to a succession of projects, each suddenly conceived and embraced, with, it is believed the certain prospect of rapidly amassing wealth, or advancing in honor and happiness—and each as suddenly given up in disgust. In some cases there is an uncontrollable disposition to merriment, boisterous hilarity, and sportive and mischievous conduct towards others. Occasionally the more striking phenomena are inflated pride, exquisite vanity, and contempt of ordinary things. Frequently it assumes the character of melancholy or deep gloom, attended with fondness for solitude, and forebodings of evil when all around and in prospect is inviting and joyous. A form not uncommon displays itself in an unaccountable partiality for particular persons, and a dislike of the nearest and dearest friends, with a disposition to revile and injure them. The more serious varieties are those in which there is a suicidal propensity, or a feeling of necessity to commit some dreadful crime—for example, to destroy a certain individual, perhaps a relative, as a tender and beloved child—an act, the execution of which, the reasoning power strongly opposes, and the conscience prevents by awakening the feeling of horror. These restraining forces, however, are not always sufficient to curb the strong propensity. Sometimes, as if urged irresistibly by some demoniac influence, the fatal deed is perpetrated; and instant relief from the burning passion is obtained; the homicide feels that a part of his destiny is fulfilled, and hence an emotion of satisfaction spreads over his mind. But such relief is not always durable; regret and remorse may succeed, and rankle long and deep in the soul.”[41]

I will pass on now to a few remarks upon the treatment of insanity.

The past history of the treatment of this disease is to a great extent a history of tyranny and cruelty. The errors and abuses which have generally marked the management of the insane, till within a few years, are numerous and truly horrible. But these errors and abuses are fast passing away. Ever since the wise and humane physician, Pinel, entered in 1792 the Bedlam of France, in whose cells three hundred maniacs were chained, and in the short space of a few days knocked off the chains from fifty-three of them with none but happy results, the management of the insane has been becoming steadily more wise and merciful from year to year.[42] In producing this change throughout the community, the public institutions for the insane have had a great agency. I will therefore pass at once to the consideration of the usefulness of these institutions, as the best mode which I can adopt for developing the principles to be observed in the treatment of insanity.

The advantages of Retreats, or Hospitals for the Insane, may be summed up under three heads, which I will notice separately.