Physician and patient

by Worthington Hooker

1. In sending a patient to a Retreat you take him away from all those mental associations under which his insanity originated. These associations are so many points of attachment, by which his malady is fastened upon him; and it is therefore almost a sine qua non in the cure to release him from their influence. The power of these associations is most strikingly shown in the renewal of the insanity, in those who are returned to their homes before their restoration is fairly confirmed. Change of scene, as is known to every one, has a good effect upon invalids generally; but it is especially true of those invalids whose disease is insanity. Accordingly a very important part of the treatment of the insane in a Retreat, consists in such a management of their occupations and amusements, as will best divert their minds from those channels of thought and feeling, in which they have previously run.

2. The insane are ordinarily subjected to a more judicious medical treatment in a Hospital than they are among their friends. It is the testimony of all who have had charge of the insane, that their restoration depends mostly upon regimen, or the regulation of their occupations and amusements, bodily and mental, and very little indeed upon medicine. It is undoubtedly true, that the deranged are very often injured by too much positive medication prior to their admission to a Retreat. They are first dosed by their friends, and the physician who is called in, having had perhaps but a limited experience in insanity, places too high an estimate on the curative power of remedies in this malady, and gives the patient altogether too much medicine. It was once very common to bleed the insane. But it is now settled by the accumulated experience of the profession, that very few of them require this measure, and that most of them would certainly be injured by a reducing practice.

3. In sending a patient to a Retreat, you place him under a better moral and mental management than he can have among his friends. There is a peculiar tact requisite for the proper management of the insane, which some seem to possess naturally, and which is much improved by actual practice. In the selection of attendants in our Retreats special regard is of course had to the possession of this qualification. The attendants are therefore skilful in managing the insane mind. They are free from those errors which are so common in the community in relation to the treatment of insanity, and which often do so much harm to the insane while they continue under the care of their friends at their homes. Some of these errors it will be profitable to notice briefly in this connection.

It is very common for the friends of the insane to attempt to reason them out of their delusions. If the derangement be of a religious type, the clergyman, or some excellent friend, endeavors by argument to convince the patient of his error. This is in vain, and worse than in vain. It uniformly does harm. It does nothing but strengthen the patient’s confidence in his notions, and make him more earnest and obstinate in their defence.

It is quite common still, though not so much so as it once was, to practice deception upon the insane. This ruinous error I comment upon in the chapter on Veracity in our Intercourse with the Sick, to which I refer the reader.

Another error which is frequently committed, is to pursue a timid course at one time and a violent one at another, instead of one which is both mild and firm throughout. This error has been the cause of the practice of much unnecessary cruelty in the domestic treatment of the insane.

These and other errors are for the most part avoided by the attendants in our Hospitals. They have no needless collisions with the patients in regard to their notions and delusions. They practice no deception upon them, but win their confidence by an open and candid intercourse. Their conduct towards them is marked with mildness, and they make use of no more restraint than is absolutely necessary, and that with calm firmness, instead of impetuous and noisy violence.

It is a common observation that the deranged are apt to look upon their most intimate friends as their enemies; while, on the other hand, they are ordinarily much attached to their attendants and physicians. The reasons of this I will briefly notice. In every family, however warm may be its attachments, and however strong may be the control of principle in its members, there must be differences of taste and feeling and opinion, and a mutual yielding on these points is absolutely essential to the maintenance of harmony and peace. Now if one of the members of that family become deranged, his self-restraint is gone, and he no longer does his part of the yielding. He becomes unreasonable, obstinate, opinionative. There is no more agreeing to differ on his part. All the points of difference between him and his friends become now to him so many battle grounds; and those whom he fights he is apt to hate. The injudicious discussions and disputes, which friends are disposed to hold with the insane, add to the difficulty. Then too the deceptions, which most persons feel themselves authorized to practice in such cases are certain to confirm the enmity, by destroying the confidence of the insane in their candor and honesty. I need not stop to show, that there is an absence of all these circumstances in the intercourse between the insane and their attendants in a Retreat.

The reader cannot have failed to see in the course of my remarks, that it is very important that the insane should early come under proper treatment. The first indications of insanity should be noticed, and measures should at once be taken to convey the patient to some Retreat. The delay which is so apt to occur in relation to those, in whom the malady comes on slowly and imperceptibly, is one great reason why so many of them are incurable. If these could all in the very beginning be removed away from the influences, which have produced and are maturing their insanity and be placed under proper treatment, many more of them would undoubtedly recover than now do.

Among the most helpless and pitiable of the miserable in this world are the insane poor. Ordinary sickness requires only ordinary care. But insanity is a malady, which not only often requires more care than other sickness, but a care which is, as you have seen, of a peculiar character—such as the comfortless home, the want, and the ignorance of the poor are unfit to supply. It is the duty of society therefore to make systematic and ample provision for the proper care of this class of the insane. In many of the states some provision has been made for them, but it is very inadequate. The provision in Connecticut is an annual appropriation placed in the hands of the Governor to be dispensed by him to applicants till the whole sum is expended. In this way a large number of the insane poor have secured to them a residence for a suitable period in the Retreat at Hartford. This is well so far as it goes, but it is not sufficient. All the insane poor in the State should be provided for. And the expense need not be very great if a proper plan be adopted. A portion of the expense, one third or one half, should be defrayed in each case by the town where the patient resides. In this way any improper use of the public benefaction would be guarded against, for the local authorities would, in behalf of the towns, secure a suitable examination of the pecuniary circumstances of the patients. Such a plan would be a truly economical one. For many, who, with the scanty and irregular provision which is now made, are left to become hopelessly insane, and to be therefore lasting burdens to the towns in which they reside, would under a better plan be restored and become able to support themselves.