Chapters in the History of the Insane in the British Isles Part 10

But a humane man may in the exercise of his humanity be injudicious, and by so doing inflict much actual suffering. The surgeon who to avoid inflicting pain should shrink from the complete removal of a malignant tumour, would fail to relieve the patient as he ought to have done.

Therefore something more than humane feeling is required. Judgment must be exercised. Now, judgment and that common sense, or mother wit, which is so much better than mere routine practice, evidently characterized the early treatment of the Retreat. As benevolent feeling naturally led to the non-use of chains and the minimum resort to restraint which then seemed possible, so common sense led to the avoidance of the periodical bloodletting and emetics then in fas.h.i.+on. It is a remarkable fact that even then it was seen that insanity rarely calls for depressing remedies, and the observation was made and acted upon that excitement is often relieved by a directly opposite treatment. They allowed a liberal nouris.h.i.+ng diet[132] in cases of violent mania; a free supply of meat, or bread and cheese, and porter, was found of the greatest service at supper in procuring sleep and reducing excitement. They had no faith in specifics and nostrums in the cure of insanity, but medical treatment was by no means despised, while a warm bath was found to be "of greater importance and efficacy, in most cases of melancholia, than all the other medical means which have been employed."[133]

With this, one cannot but contrast the old system, which was emphatically empirical and unscientific. It was continued without change from year to year, and it may truly be said that idleness and selfishness, still more than ignorance, const.i.tuted the vices of the old system. Those who treated the insane always encountered opposition by brute force, instead of by energy and patience, which surmount difficulties that to idleness are impa.s.sable mountains, and which selfishness would not, if it could, overcome. Again, from the commencement of the Retreat, the idea was entertained of making the inst.i.tution a home; and with this view the arrangement and surroundings were made as cheerful and home-like as possible.

Another strong point was the employment of the patients; its vital importance was forcibly felt from the first. Dr. Delarive, who inspected the Retreat in 1798, particularly comments upon this novel feature of a mad-house. He found that an experiment recently made, that of inducing the patients to cultivate the land, giving to each a task proportionate to his strength, had answered well. It was found that they were fond of this exercise, and that they were much better after a day spent in this work than when they had remained in the house, or when they had taken an ordinary walk. Delarive went to see them at work, a sight so common now in our asylums that it seems strange it should have excited his surprise.

Of employment the author of the "Description" thus speaks: "The female patients in the Retreat are employed as much as possible in sewing, knitting, or domestic affairs; and several of the convalescents a.s.sist the attendants. Of all the modes by which the patients may be _induced to restrain themselves, regular employment is perhaps the most generally efficacious_; and those kinds of employment are doubtless to be preferred, both on a moral and a physical account, which are accompanied by considerable bodily action, that are most agreeable to the patient, and which are most opposite to the illusions of his disease."[134]

We find it insisted upon by those who had the management of the Retreat that moral treatment is of the greatest importance; that gentleness must take the place of violence;[135] that it is erroneous to suppose it necessary to commence an acquaintance with lunatics by an exhibition of physical strength; that every effort should be made to divert the mind of melancholiacs by bodily exercise, walks, conversation, reading, and other recreations; that the desire of esteem is a more powerful principle to appeal to than fear; that the best form of restraint is self-restraint; that patients should be treated as much as possible as rational beings, but that little or no advantage arises from reasoning with them on their particular delusions; that it is desirable to encourage the influence of healthy religious principle over the mind of the insane; that those who manage them should sedulously endeavour to gain their confidence and esteem, to arrest their attention and fix it on objects opposed to their delusions, to call into action every remaining power and principle of the mind, and to remember that in the wreck of the intellect the affections not unfrequently survive.

This recapitulation of the salient features of the practice of the Retreat renders it easy to understand the position taken by the managers of the inst.i.tution in regard to mechanical restraints. When kindness failed to subdue maniacal excitement, when medical remedies exerted no calming influence, mild forms of restraint were reluctantly adopted, rather than maintain a conflict between patient and attendant. It appears from the Retreat archives that not more than five per cent., reckoning the night as well as the day, were restrained by strap or waistcoat.[136] It is notorious that, at the same period, it was the custom in some asylums, probably many, to chain to the bedstocks, at night, every patient in the house. Ferrus, to whom I have referred, did not find camisoles in use at St. Luke's in 1826, but "strong chains were employed to hold the excited patients. These chains, fixed at different heights to the sides of stoves (_chauffoirs_), have iron rings at the end, by means of which the arms or the legs of the patient are rendered completely immovable.... Far from fearing that a painful impression will be produced on the patients by chains, they think, on the contrary, that this apparatus exerts a beneficial influence upon them; that it intimidates, humbles them, and removes all desire to attempt to get rid of their fastenings." Ferrus says that at the Retreat he found a belt was employed, softly padded, to which the arms were attached. "We do not employ it in France," he says, "although it might in hot weather be preferable to the camisole.... The Retreat offers all the resources of art and the comforts of life (_douceurs de la vie_) compatible with the condition of insane persons."

Coercion was regarded at the Retreat as an evil--that is to say, it was "thought abstractedly to have a tendency to r.e.t.a.r.d the cure, by opposing the influence of the moral remedies employed"--but at the same time "a necessary evil," an unhappy alternative in certain cases. Practically, as we have seen, the amount of restraint was small; but no _rule_ of practice was laid down that it should never be resorted to. The abstract principle of non-restraint adopted at Lincoln and Hanwell was not enunciated. "We greatly prefer," observes the author of the "Description," "to lay down no absolute rule of non-restraint, but to refer to our resident officers the exercise of a sound discretion in each individual case." But the managers of the Retreat did undoubtedly lay down as a fundamental principle that "_coercion will diminish or increase as the moral treatment of the patient is more or less judicious_;"[137] and therefore, although they did not antic.i.p.ate that personal restraint would be superseded by any other mode of treatment, this principle is broad enough to embrace all that has since followed in the way of non-restraint. The result, in the long run, of honestly carrying out the doctrine to its legitimate consequences, will not very widely differ from that reached by those who adopt "non-restraint" as an abstract theory in the first instance.

Justice would scarcely be done to those who interested themselves in mental diseases during the latter half of the eighteenth and the commencement of the nineteenth century, if we did not give the t.i.tles of some of the works bearing on insanity which issued from the press during this period. A treatise on Madness was written in 1757 by Batty. Perfect wrote "Methods of Cure in some Particular Cases of Insanity" in 1778, and "Select Cases of Insanity" in 1787, and "Annals of Insanity"

fourteen years later. Perfect's treatment of insanity mainly consisted in bleeding, setons, electricity, and the administration of emetics, digitalis, and antimony. Dr. T. Arnold published his "Observations on the Nature, etc., of Insanity," 1782. Harper published "A Treatise on the Real Cause and Cure of Insanity" in 1789--a work ridiculed by Pinel.

Faulkner wrote his "Observations on the General and Improper Treatment of Insanity" in 1790; and Pargeter his "Observations on Maniacal Disorders" in 1792. What, if any, beneficial effect these works produced upon the condition of the insane in the British Isles, I am unable to say. Haslam wrote his "Observations on Madness" in 1798, and he was the author of several other works; but, whatever their value and interest, we know but too well the condition of the patients in the asylum of which he was the apothecary. Crichton published his "Inquiry into the Nature and Origin of Mental Derangement"--a work, certainly, of merit and the result of practical observation. In 1802 appeared "De intellectus facultatum conditione in mentis Alienationis diversis generibus," by Campbell (Edinburgh). c.o.x published his "Practical Observations on Insanity" in 1804. (See Appendix B.)

Of Pinel, in relation to England, I must here say a few words.

The _Edinburgh Review_ of April, 1803, contains a review of Pinel's work, which deserves attention from the tone in which it is, for the most part, written. The Reviewer evidently thinks that England had very little to learn from France. The York Retreat had, indeed, been in active operation for some years, and the treatment pursued there might, no doubt, have borne comparison with that at the Bicetre, but to speak of Great Britain as a whole having a decided superiority over other countries in its moral treatment of maniacs was rather absurd. The Reviewer regards Pinel as the first author on the Continent who is fully sensible of the advantage of such moral treatment, and then observes, "To medical readers in this country many of our author's remarks will appear neither new nor profound, and to none will his work appear complete.... It may be considered as a sketch of what has already been done, with some notices of what the author intends to do; though he seems frequently to wonder, with a smile of self-approbation, at what he thinks his own discoveries." And again: "Dr. Pinel is desirous that France should have some claim to a judicious treatment of the disease of the mind, the honour of which has. .h.i.therto been exclusively confined to England."

It is curious to find the Reviewer observing that Dr. Pinel appears to display very little sagacity and precision in saying that in some cases the brain is not affected. And again: "He conceives that the result of the examination of the periods of life most subject to insanity is alone sufficient to show how seldom it is owing to any organic affection of the brain or the cranium. But in this opinion there is some inconsistency. For he soon after states that in thirty-six dissections he found nothing more remarkable than in the brain of apoplectic and epileptic patients, or of persons who died from furor or convulsions.

Now, this is a confession that some deviations from the natural and healthy appearances were observed; and this is all that is contended for, and all that the present limited state of our knowledge authorizes us to affirm." The Reviewer adds, no doubt with truth, "If no organic affections are said to have been discovered, in some few instances, we should not reason negatively from such dissections, perhaps cursorily and ignorantly made, and with instruments ill adapted to detect minute and apparently trivial deviations from the natural structure."

The following snarl is also noticeable:--"He informs us that he has studied with considerable attention the writings of Locke, Harris, Condillac, Smith, and Stewart; but the quotation of great names is not always the surest proof of an accurate acquaintance with their works, and we are inclined to think that there is some ground for doubt in the present instance."

The Reviewer is severe on Pinel's cla.s.sification, which in the main has stood the test of all subsequent criticism to a remarkable degree. "It may," he says, "be ent.i.tled to the praise of ingenuity, but we doubt whether it is remarkable for its clearness and accuracy. Many of the distinctions seem absurd, and others not well founded. The several kinds of insanity are not distinct; they are only varieties of the same affection. All the symptoms mentioned under these five heads occur in the same patient. At different times he pa.s.ses through all the gradations from furious phrenzy to complete fatuity." This criticism has, of course, great force as opposed to all symptomological cla.s.sifications whatever, but not specially or mainly to Pinel's.

On the point whether madness can in certain cases be cured, Pinel's utterances are dismissed with downright contempt: "Instead of any new light being thrown upon this important question, or any new rules of conduct pointed out, our author gives a minute detail of two cases, where any ancient female of ordinary capacity could have decided as well as himself, and relates with laboured minuteness the contrary opinions of some eminent physicians on a late memorable occasion in this country." Pinel an old woman! It will probably be new to most, if not all, of our readers that this ill.u.s.trious man was regarded in this light by the leading Review of our country, when his writings first became known amongst us. The review ends, after crediting Pinel with some merit, and commending his work as containing some profitable instruction, with the exceedingly kind and patronizing observation that "we are therefore inclined to make _an indulgent allowance_ (!) for the imperfect execution of many parts of Dr. Pinel's essay, and to entertain hopes of further information from his diligence and discernment" (!!).

Insular conceit could surely scarcely go further. However, the Edinburgh Reviewer is forgotten and his name unknown; Pinel's name covered with glory, although not a popular hero; for when I made a pilgrimage to his grave in the great Paris cemetery, _Pere la Chaise_, in 1878, I was a solitary visitor, while crowds flocked to others, including that of Thiers, which is in close proximity to it. I am glad to see it announced that the _Societe Medico-psychologique_ of Paris is about to erect--not too soon--a statue to his memory.

The bold proceeding, as it seemed in those days, of freeing the lunatics at the Bicetre from their fetters, const.i.tutes Pinel's t.i.tle to honour--an honour of which no man will succeed in robbing him. He will be remembered when Dequin[138] is forgotten. Pinel, although his writings would have made him eminent as a physician had he never rendered his name ill.u.s.trious in reference to the insane, did not, as a study of his life abundantly proves, liberate the patients at the Bicetre from their chains in direct consequence of his medical knowledge of insanity, but mainly, if not entirely, from the compa.s.sion which he felt for their miserable condition. His knowledge, great before, was vastly increased after he had placed the patients in a more favourable state for medical observation; in fact, it is obvious that the opportunities of scientific research, and specially of observing the satisfactory progress of those labouring under the disease, were greatly augmented from the moment he introduced a humane system of treatment.

Had my sketch comprised France as well as England, I should have attempted to give a description of the work he performed in Paris. But I must not be tempted to go beyond my subject, and as a matter of fact the course of French and English reform in the treatment of the insane was entirely distinct and independent.[139]

FOOTNOTES:

[100] "By Tho. Fallowes, M.D., at his House in Lambeth-Marsh, and to be had there, or at Mr. Jones's Haberdasher in Hats, over against the _Pump_ in _Chancery_ Lane, and nowhere else," 1705. A second edition appeared in 1814.

[101] In his Review for 1706 there is a "Scheme for the Management of Mad-houses," with a case of abuse.

[102] As will be seen by the date, the elder Pitt and Fox.

[103] The physician referred to at p. 87.

[104] 14 Geo. III., c. 49 (1774).

[105] "The Early History of Charles James Fox," by G. O. Trevelyan, 1880.

[106] Letter written July 30, 1767.

[107] "Lady Chatham also, when writing confidentially to Lord Shelburne in the autumn of 1767, observes, 'I wish I could say there was any material change in the state of my Lord's health, but we are forbid to expect that, until he can have a fit of gout.'"

[108] "History of England from the Peace of Utrecht," vol. v. pp. 166, 188 (edit. 1853).

[109] Page 203.

[110] See "Evidence before the House of Commons." See also "Debates on the Regency," Hansard, vol. xxvii.

[111] "American Journal of Insanity," July, 1855.

[112] See the last edition, corrected by himself (1780), of his "Primitive Physic, or an Easy and Natural Method of curing most Diseases."

[113] Page 82.

[114] "The State of the Prisons in England and Wales, with Preliminary Observations," by John Howard, F.R.S., 3rd edit., 1784.

[115] Ray, _American Journal of Insanity_, vol. iv. p. 112.

[116] "Review of the Early History of the Retreat," by S. Tuke. 1846.

[117] "Lettre addressee aux Redacteurs de la Bibliotheque Britannique sur un nouvel etabliss.e.m.e.nt pour la guerison des Alienes" (1798). Par Dr. Delarive, p. 29.

[118] "Review of the Early History of the Retreat," p. 14.

[119] The physician who gave his name to the well-known solution of a.r.s.enic. Author of a treatise on a.r.s.enic, 1786, and one on Rheumatism in 1795. Jepson resigned in 1822, and died in 1836.

[120] "Description of the Retreat," by S. Tuke, p. 62.

[121] Pages 11, 12.

[122] The _British Review_ (vol. vi. No. xii.), in reviewing this book, observed: "In 1813 Mr. Samuel Tuke published his 'Description of the Retreat,' the celebrated work, the t.i.tle of which we have placed among others at the head of our article.... The Retreat has been conducted from the beginning upon the principle that the utmost practicable degree of gentleness, tenderness, and attention to the comforts and feelings of the patients was in the first place due to them as human beings; and in the next place was infinitely the most promising means of effecting their recovery. The object of this work of Mr. Tuke was to describe the system of management which had been pursued in the Retreat; to make known the success which had attended it; and to point out more distinctly than had ever yet been done, the principle upon which that management was founded (the principle of gentleness, and of regard to the feelings of the patients) as the grand principle which ought to regulate the management of every establishment of the kind. The service which Mr. Tuke professed to render to the public by his book was a.s.suredly of importance, and his book has performed it well.... In having pointed out this as the governing principle, he has rendered a service to humanity of the greatest importance. It is this characteristic circ.u.mstance which will render the publication of his book an era in the history of the treatment of this calamity. The book has already met with great and almost universal attention. It has by the nation been much more than approved; it has been applauded and admired."

The reviewer continues: "One thing we may venture to say, that it was hardly possible for a book to be written in a manner less calculated to give offence to anybody.... Yet this book gave prodigious offence. It has been regarded as a libel upon the York Asylum, and an attack upon it has appeared in the newspapers." This was a letter signed "Evigilator,"

who was in reality the superintendent of the above inst.i.tution. This led to a long and heated correspondence. About the same time a charge of ill treatment of a patient in the York Asylum was made by a magistrate (Mr.

G.o.dfrey Higgins of Doncaster), whose persistent endeavours to bring this and other cases to the light of day were beyond praise, and happily proved successful at last.

The writer has in his possession a ma.s.s of private letters which pa.s.sed between his father and Mr. Higgins on these cases, which indicate their combined endeavours, made (under the fiercest opposition) to reform the horrible abuses which had converted a well-intentioned charity into a h.e.l.l upon earth. Mr. Higgins was the author of a book on Mahomet, the remarkable work on the Celtic Druids (1827), and of "Anacalypsis"

(1836).

[123] April, 1814, pp. 190, 194, 198.

[124] (1) "Practical Hints on the Construction and Economy of Pauper Lunatic Asylums; including Instructions to the Architects who offered Plans for the Wakefield Asylum, and a Sketch of the most approved Design." York, 1815. (2) "On the Construction and Management of Hospitals for the Insane," by Dr. Jacobi, with Introduction by Samuel Tuke, 1841. Born 1784; died 1857. An Honorary Member of the Medico-Psychological a.s.sociation.