Reminiscences of Lunacy Practice
200 Art. V.? :Author: James George Davey, M.D., Bristol.
I puepose in the following remarks to record the experience through twenty full years?or from January 1, 1853, to Decem- ber 31, 1872?as realised at Northwoods. Although such ” experience” included periods of time both anterior and sub- sequent to, or outside, the two dates here given, I prefer that this report should embrace only the time (twenty years) intermediate to the aforesaid dates.
The arrangement indicated may be said to give a certain order, or completeness, or fixity to the report, not otherwise attainable. I may, however, premise that I became the licensee of the North woods Asylum in June 1852. At this time there were 25 patients in the house?viz., 11 males and 14 females. Of these one only (a lady) appeared curable. On January 1, 1853, there were but 24 patients?viz., 11 males and 13 females. During the latter half of 1852 one gentleman was admitted, whilst another was removed, being “relieved.” The lady referred to above was discharged ” recovered so it happened that the number of patients was on the first day of 1853, 24 only, each of these being incurable. The gentleman admitted, it should be stated, had been insane for a period of not less than thirty years.
The annexed table conveys, at one view, a summary of the admissions, discharges, and deaths :? Admissions, Discharges, and Deaths at North woods during Twenty Years. Patients in the house on Jan. 1, 1853 …. Admitted during twenty years, from Jan. 1, 1853, to Dec. 31, 1872 Total cases under treatment during twenty years . Discharged and removed: Recovered Relieved . Not improved . Died Total discharged and died in twenty years Male Female Total
11 59 70 Male 23 18 7 16 64 13 71 84 Female 39 18 6 11 74 24 130 154 Total 62 36 13 27 138
Average numbers resident during twenty years . . 24. You “will see that of 130 admissions there have been discharged ” cured ” 62. Tiou will see also that*36 other patients have left the Asylum “relieved.” Thus 98 of the 130 admitted are disposed of, and in a manner no way unsatisfactory. To put the case in other words, and in round numbers, two patients in every three of the treated, viz. 154, left the Asylum either restored to health or ” relieved ;” the proportion of the former to the latter exceeding five to three.
Under the heading “not improved” but 13 appear; but for this you will be fully prepared when I put you in possession of the character and very unpromising nature of some at least of the 130 patients admitted. Thus 2 of these were more than seventy years of age; 9 were suffering from confirmed general paralysis; 5 were epileptics; 6 were reported as having been insane over five years; one was an idiot, and another was in an advanced state of phthisis pulmonalis; making a total of 24 incurables?individuals quite beyond the reach of anything else than a mere palliative treatment. In reference to the foregoing experience, it may be added that the highest number of admissions in one year was 14 in 1859 ; but 6 of these were transfers from the Fishponds Asylum. With this one exception the highest number of patients admitted in a single year was 9, and the lowest number was 3 ; the average admissions per annum was 6. As to the deaths, these reached through the twenty full years but 27, the particulars of which are recorded in the annexed table; four deaths you perceive took place in 1870, whilst in 1857, and again in 1861, not one occurred. On two different occa- sions, and for a short time, there were 30 patients under the roof?viz., 15 males and 15 females.
A reference to the last Report of the Commissioners in Lunacy will inform you that the ” proportion per cent, of the aggregate number of recoveries to the aggregate number of admissions” into all kinds of asylums during the past fifteen years is a fraction under 34 per cent. The honour of realising the highest average of recoveries during the period named rests, it is shown, with the ” Registered Hos- pitals “?in these the recoveries were as high as 38*91 per cent.?and the misfortune of realising the lowest average of recoveries in the same fifteen years is due to the “Private Homes,” their average being so low as 9*15 per cent. It is, as you will suppose, a source of no ordinary pleasure to myself to be in a position to demonstrate, as the result of twenty years’ experience at North woods, an aggregate proportion of recoveries to that of admissions amounting to but a fraction under 50 per cent.
Causes of Death in Twenty-seven Patients, between Jan. 1, 1853, and Dec. 31, 1872, on, during Twenty Yeaes. Cerebrospinal diseases Thoracic diseases Abdominal diseases General diseases . Local diseases Special causes of death Apoplexy?Sanguineous . >, Serous Epilepsy …. Exhaustion after mania . >? ,, melancholia ?> ? dementia General or progressive paralysis Total Valvular heart disease and anasarca . Acute pneumonic phthisis . Pleuropneumonia Phthisis pulmonalis . Angina pectoris Total . Briglit’s disease Diarrhoea …. Total Senile decay Syncopal asphyxia Total Carbuncle Suicide by hanging . Total 1 16 27
Furthermore, a reference to the last Report of the Com- missioners in Lunacy will inform you, that a comparison of the daily average number of patients through the same fifteen years with the number of deaths yields a percentage of 7-54 and that this, the lowest average at any kind of asylum, is due to the ? Registered Hospitals.” If, however, the number of deaths is compared, not with the daily average number of patients but with the total number under treatment through the whole time named, then again is the palm seen to be due to the ” Regis- tered Hospitals,” their number of deaths to each 100 of the total number under treatment being so low as 5*51. I have, then, an additional gratification in having realised at North- woods, during twenty years, a percentage of deaths?based on either one of the calculations adopted in the said Report of the Commissioners of Lunacy?yet below their lowest on record. It is well worthy of remark that insanity is not, per se, a very fatal disease, although the subjects of it die at a more rapid rate than the sane. The causes of death among the insane are, as the table just referred to shows so plainly, as frequently as not outside the organ primarily affected. The fact is doubtless to be viewed, if not as a consequence of, then in connection with, the wear-and-tear of the forces of life, involved so materially in the insufficient and disturbed sleep? i.e., the emotional and mental disturbance so characteristic of cerebro-mental disease. The whole organism is, as the rule, prostrated; it is in no position to recover its lost tone and energies?their recuperation becomes almost an impossibility. The due nutrition of the body is so materially interfered with, that each one of the many organs?the heart, the lungs, the liver, kidneys, and what not?is brought to the very verge of disease, and its susceptibilities to abnormal action so intensified, that to escape the consequences of exposure to even the most ordinary or diluted morbific agency can hardly be expected in very many of the insane. Hence, then, the frequent occurrence in them of heart-disease and dropsies, of phthisis and other chest affections, and of carbuncle?including, too, mollities ossum and allied states of the skeleton.* As an additional and * It was in the year 1842, when Medical Superintendent of the Female Department at the Hamvell Asylum, and when much engaged and interested in post-mortem investigations there, that I detected the existence of mollities ossum (” ostco-Tiialacia”) in those dying insane. This very important fact is recorded and commented on at pp. 258 to 265 of my book, The Ganglionic Nervous System : its Structure, Functions, and Diseases (1858). I have therein referred to six cases wherein mollities ossum and insanity were found coexisting. The former, it is affirmed, ” may be confined to one or two bones, or even to portions of the same bone.” Of these six cases, four “were afflicted with ‘ general paralysis.’” In the Medical Times?No. 170. vol. vii. p. 195 (1842)?will be seen the record by myself of a highly instructive post-mortem examination of a female patient who died under my care at the Hanwell Asylum, and in which patient I found so many as six spontaneous fractures of the long bones, as well as a very considerable portion of the skeleton occupied or converted into a dark, semi-calcareous, grumous matter. It is within some half-dozen years that the complication of the two diseases above-named (mollities ossum and cerebro-mental disease) became to any extent recognised in the profession ; and when such was the case, the fact was not only ignored by the press, medical and non-medical, but treated as simply a very poor subterfuge, or as an apology, and a very lame one too, for the broken and crushed ribs of insane patients, inmates of our lunatic asylums. In this matter the Pall- Mali Gazette, the Lancet, and the Journal of the British Medical Association have much to answer for to the medical superintendents of asylums, of whatever kind, private or public.
It may be added here that the existence of soft and fragile, i.e. ” rickety,” bones in those dying insane has been found of late years by many medical men.
Thus Dr Thomas Dickson, Dr F. W. Moore, and Dr J. C. Browne are the authors practical demonstration of the foregoing remarks, let me refer to this other table :?
Structures and Organs affected, their Proportion, and Relation to Particular Forms of Mental Disease. 19 11 7 15 19 7 3 2 17 100 Form of Disorder Mania . Mania with epilepsy . Mania with general paralysis Melancholia Dementia . ? Ditto with epilepsy . Ditto with general paralysis Ditto with epilepsy and general paralysis . Not stated All forms . ? 2 3 24 15 52 24 I 18 26 44 ~ ? ?TS !& ? 9 20 16
It is extracted from a small book, The Nature and Proximate Cause of Insanity, which I published nearly a quarter of a century since, with the view to prove that, whatever may be the amount of morbid change in the brain and its coverings, how- ever broken up and softened the cineritious neurine, to what- ever extent adherent it may be to the pia mater, and altered in colour, &c., and that, however much or little the arachnoid may be thickened and opaque, and whatever may be the amount of fluid contained in its sac, or elsewhere about the cerebral membranes, the first cause or starting-point of madness must be sought elsewhere than in any one or more of such con- ditions?that, in fact, the truth of the matter lay much deeper down than is too generally suspected, and, what is more asserted.
That a morbid sensibility of the ultimate cell-structure of the grey matter of the convolutions lies at the root of insanity, through each one and all of its many varieties or phases of being, is at this time an accepted fact in pathology; and that of cases which prove the correctness of my own conclusions, arrived at in 1842; to the effect that there is a decided connection between brain disorder and bono degeneration ; and, furthermore, that such is, in its entirety, the sure and certain outcome of disease originating in the nervous system, i.e. in the ganglionic nervous system; on which system tho cerebro-spinal organism is, as its functions are, wholly subordinate and dependent.
this same “morbid sensibility” it is which, when continued, so damages the normal contractility of the capillaries, ” that their relaxation or distension is inevitable “:?a state of things this which is alone necessary to the creation and development of the several alterations of structure noted in the foregoing table. Truly, the disorganisations named above, and seen in the brain and its coverings, are the direct effects of inflammation, acute or chronic, sthenic or asthenic; but whatever the amount of inflammatory action there may be, it must be held as due originally to a deficient and impaired innervation; for how certainly is this indicated, or portrayed, in the too painful restlessness and agitation, the excitement without power, the incoherent and ceaseless speech, the rapid yet objectless mus- cular movements (the motions without force), the acute and oft-succeeding facial expressions, as well as by the rapid thread- like pulse, the cold or hectic skin, and failing vital powers, which mark so very generally the recently insane patient, whether male or female ? *
It may be, and very probably is, a source of some surprise to a few that, in the preceding Table of Admissions and Discharges, there is scarcely a mention made of the words mania, melancholia, monomania, dementia, &c., as so many kinds of insanity. The fact is, too much importance has up to this time been attached to these mere words; they fail to convey else than partially what they are designed to do. I have, for a long course of years, felt how inappropriate and unreliable such words are, as applied to individual cases of cerebro-mental disorder. Inasmuch as such words express only the most evident or the temporary signs or symptoms of any given case, and are, therefore, out of harmony or in little accord with a scientific pathology, the propriety of their use becomes very materially modified. Whilst admitting this, I would caution the student of medicine in accepting too eagerly the teachings of the late Dr Skae.
The views here expressed in regard to the nature and proximate cause of
insanity were originally broached in a paper entitled The Pathology of Insanity, published in 1843 in the Zoist, edited by the late Dr Elliotson. In my Contri- butions to Mental Pathology (1850) the same are repeated with much detail. Pre- cisely identical views in regard to the disease (insanity), its origin, progress, and termination (when not relieved or cured), in the several alterations of structure or disorganisation named in the text, were given to the public by Dr Henry Munro, in a book entitled Remarks on Insanity, its Nature and Treatment, published in 1851. Moreover, Dr John Hitchman has, on more occasions than one, thought himself the first to put such views before his medical brethren. I doubt not Dr. Hitchman’s originality, nor do I hesitate to admit that when he gave to the world, in his “Lectures on Insanity,” published in vol. ii. of the Lancet (1847), his con- victions concerning the nature and proximate cause of insanity, he had no kind of idea that he was but repeating my own. (See No. 26 of Journal of Psychological Medicine for April 1854.)
His sketch of the many forms of insanity does not, as I believe, cover the whole case. The really sound basis is wanting; because, simply, Dr Skae accepted not the discoveries of Grail and Spurzheim. The teachings of these famous physiologists are ignored in Dr Skae’s very highly commendable and pains- taking endeavours to advance mental science and simplify its nomenclature. My own opinion on this point I may be per- mitted to convey in a quotation from a pamphlet of my own, entitled Medico-Legal Reflections, written now a generation since:?” The term insanity conveys the idea of unsound mind, and in order to express its varieties, the words mania, melan- cholia, monomania, dementia are in common use. Such im- part no more than a general notion of the character of the affliction, or of its various symptoms or phases?symptoms or phases, bear in mind, which may or may not change or vary day by day, and this in even the same patient. Then, again, disease of the brain may be confined to a part, or it may affect the whole of the organ, the disease or impairment of function being at the same time the consequence of either excessive or diminished action?i.e., sthenic or asthenic; and in any case it may be organic or functional?furthermore, of either an idio- pathic or a symptomatic nature. The various signs or indi- cations of such several phases of mental disorder are recognised by the general term insanity.
” But if the morbid signs or conditions of the many organs of the body, including of course the brain, are severally indi- cated by well-marked or specific functional disturbance, it must follow that if the brain possesses?which it most certainly does?parts or organs, the offices of which in the animal economy subserve the purposes of Caution, Veneration, Self- esteem, Firmness, Acquisitiveness, Destructiveness, Combative- ness, Ideality, Gaiety, Hope, and so on through the whole of the primitive or undecomposable affections, sentiments, and intellectual powers?call them by whatsoever name we will? then we see, plainly enough, that a derangement of the mind (insanity), considered in the abstract, might be, as it is, caused by disease affecting one or two or more of such organs (functions) exclusively. Herein, then, we get at the only clue whereby to unravel whatever of mystery may attach to insanity, in the abstract, as well as to its many varieties and complications.” As complementary to the foregoing tables, and the remarks made in reference to them, I will divide the remainder of this paper into certain practical heads, and these shall follow each other in the following order, viz.:?
1st. The admission of patients. 2nd. Treatment of insanity?hygienic and medical. 3rd. Seclusion and restraint. 4th. Suicidal patients?their management, &c. Cases. 5th. Eefusal of food. Instrumental feeding?its use and abuse demonstrated. 6th. Discharge of patients?the responsibilities connected therewith. 7th. Conclusion.
In regard to the first matter named?the admission of patients. The removal of one mentally afflicted from his or her home and its surroundings to an asylum is no trifling affair; it requires to be effected with much circumspection, and only after the best consideration of all the circumstances of the case. To begin well is almost to command success. Now the common practice is not only to anticipate much trouble and many difficulties in connection with such removal, but to invent no end of equivocations, and even falsehoods, with the view to deceive the patient. Such a course of action can lead to no good?quite the contrary. In our intercourse with the insane we must ever be candid and truthful, for they are by no means ignorant of the kind or nature of the terrible disorder which is prostrating them, nor are they unaware of the aim and character of the attentions paid to them. Such being the case, and the said removal decided on, the patient should, as the very general rule, be told as much, fairly and plainly. This done, the matter becomes in no small degree simplified, or so I have found it. The patient acquiesces, or, at any rate, he manifests no prolonged or stubborn disapproval or resistance to his leaving home, and with a little careful management he is led to adopt your views so far as to allow himself to be dealt with as is seen best.
Now the object of such removal being to surround the patient with the most efficient curative means?to give him the benefits to be expected from new and altered conditions of being?it follows that asylum-life (so to put it) should combine the very best sympathies of our common nature with the most approved attention to sanitary matters, as well as to those strictly medical. The first great object is to assure the patient that his residence in the asylum is attended with no real loss to him?that he is still with friends who can and do sympathise with affliction?that no means will be neglected to promote his wellbeing and personal comfort?that the best and most approved remedies, both palliative and otherwise, will be sought for and adopted day by day, to meet the difficulties and dangers of his case, and to insure, as far as may be, the relief and cure of a too painful malady. The confidence of the patient gained, this sure foundation laid, the good result, the superstructure, may be hopefully anticipated. There must be no going back, no retrogression. Such the starting-point? the vantage-ground so gained must never be lost. And this can hardly be if asylum-life is what I have just said it should be?that is to say, if it embraces the laws of health in their entirety, and these are so contrived or disposed of as to create and sustain, so far as possible, among its inmates the mens sanci in corpora sano. Such laws (of health”), it need hardly be said, must be paramount in every asylum, and must fasten them- selves on the attentions of all concerned in its management. Without order, cleanliness, warmth, pure air, good and abundant food, a due amount of exercise, occupation, and amusement daily, not forgetting that kind and efficient yet discriminating attention and surveillance a real sympathy with suffering will ever beget and sustain, what of either relief or cure of mental disorder can be looked for or expected ?
Now the views given above as to the seat and nature of the proximate cause of cerebro-mental disease will have prepared the reader to anticipate in no slight degree my notions regard- ing its strictly medical treatment. If we would relieve the morbicl sensibility of the grey neurine, if we would allay the consequent restlessness and sleeplessness in him insane, if we would counteract the damaged nutritive processes occurring to the brain, and repair the sympathetic derangements of the several vital organs, we must, to begin, seek the pretty sure aid of the chloral hydrate or other sedatives, as the biineconate of morphia and clilorodyne. In cases of violent mania, when the patient resists, and will not take medicine, the subcutaneous injection of the salts of morphia may be employed with sure and excellent effects. The hot bath, with the free use of cold water to the head, or (what is better) the careful application of the sether-spray to the scalp, will frequently be found an excellent hypnotic, and as such afford much relief to the patient. Those who have witnessed the experiments by Dr Richardson, of London, with his tether-spray on animals and birds will be well prepared to endorse this opinion. Nothing can more effectually diminish the calibre of the bloodvessels, and so lessen the volume of blood circulating through, or rather in contact with, the brain, and withal restore the bond fide, organic, and normal condition of the cerebral circulation, anterior to and during sleep, than this sether-spray. Useful, even indispensable, as sedatives of one kind or the other are in madness, and however much they can, and do, soothe and calm the patient, allaying his emotional extrava- gance or excess of feeling; yet must it be borne in mind that we have to combat a formidable evil in the wear-and-tear of the forces of life, in the undue pressure imposed on the nutritive processes common alike to the brain and the many- vital organs, and whereby, as has been remarked, they are brought to the very verge of diseased action. To counteract this ” formidable evil” we must have recourse to a liberal dietary, including, as the general rule, wine and good beer, and, it may be, brandy or some other spirit. Now and then, though rarely, one sees a case of sthenic mania, the conse- quence?more generally than otherwise?of local injury; but even such cases will hardly bear a lowering or antiphlogistic treatment. If you abstract blood by cupping, or by the aid of leeches, you must allow, at the same time, plenty of good fluid, meat, rice, milk, and eggs?also, perhaps, bitter beer, or some light claret wine.
During my residence in Ceylon, from 1844 to 1849 inclusive, the principal charge of the Government General Hospital devolved occasionally on myself. At such times I have had to treat cases of injury to the head inducing insanity. Such injuries are unusually frequent at Colombo, where the cocoa- nut plantations abound; and so it was the opportunity was afforded me of realising the really sound and practical value of the late Mr. Guthrie’s teaching in regard to Injuries to the Brain Causing Madness. In the book referred to the surgeon is cautioned ” against the indiscriminate use of the lancet in such cases, employed with the view of reducing inflammation of the brain, or of its investing membranes.” It is added, “that the persistence of mental derangement, regarded as an effect of local injury, may or may not call for the abstraction of blood, and other evacuants; that it is very commonly found necessary to administer sedatives, as Dover^s Powder, to allay the irritability present in the parts within the cranium; and (such is the liability of the patient to sink from direct physical exhaustion?the conse- quence of the mischief done to the brain) that the strength must be supported throughout, by the administration of good beef-tea, and the like.”
But to venture on the treatment of even a case of acute idiopathic insanity, omitting “a liberal dietary,” and for- bidding the use of stimulants, would be to diminish very materially the chances of cure in any given case, and to multiply the number of those incurably insane.
To withhold such a dietary from those chronically affected? the inmates, for example, of the large county and borough asylums?would be to increase the percentage of deaths among them to a frightful degree. This much is demonstrated in the histories of such institutions, and especially in the history of the large asylum at Hanwell. When, some five and thirty years since, I became officially connected with Hanwell?when, too, I carried into practice the foregoing views as to the dietary ?the Honse Committee were with some difficulty led to approve “the extra diet list” suggested. What struck me at Ceylon, on my arrival there in 1844, was the insufficient and poor quality of the food allowed both to the European and Cingalese insane, and the high death-rate. From information given me, I discovered that the island contained nearly 500 lunatics; that these were scattered much about?some in the gaols, and more in the leper hospitals; and that the mortality among them was so high as 33 per cent. But the partial collection of the insane, European and native, into a new asylum?the completion and organisation of which was my especial mission? followed as this was by an altered and a liberal dietary, by the better feeding of my patients, brought the death-rate down to, first, 23*3 per cent, per annum, then to 15, and at length, and after four or five years, down to 7*50 per cent, per annum. However, so little understood were the above facts, in so far as the experience at the new asy- lum at Colombo was concerned, that it was suggested to me, officially, that ” the excitement” of lunacy could be re- lieved only by a ” spare diet.” I need hardly add that the proportion of recoveries was materially added to, whilst the number of deaths, as above shown, was much reduced. The mean average of the first (the recoveries) went up from, say, 6 per cent, per annum to nearly 40 per cent, per annum, whilst the death-rate fell, as is seen, from 33 per cent, per annum to 7*50 per cent.
It may be added here, that a comparison of the six years preceding my arrival in the colony with that of the same period succeeding it?or during my sojourn in the colony?shows a falling-off during the latter six years in the number of deaths to the extent of 20 per cent, per annum; and the like com- parison, in so far as the ratio of cures is concerned, yields an increase in favour of the latter six years of nearly 40 per cent. But this result of treatment was not reached without much struggling with old prejudices and ignorances. The Com- missariat Department, acting under the friendly advice of medical authorities of long experience with disease within the tropics, insisted on it that ” so much nutriment could hardly be beneficial to lunatic patients, who are generally in a state of great excitement and fury” as that I required for them.
It is quite impossible to dwell on experience such as the above without a keen appreciation of the teachings and good results of medical science, as adapted to the mind’s disorders or abnormalities.
The good effects of a liberal dietary may be enhanced by the use of medicines of a tonic and stimulant character?for example, the citrate of ammonia and iron, the citrate of quinine and iron, the syrup of quinine with iron and strychnia, and the compounds of cod-liver oil with quinine or iron or strychnia. The solution of phosphorus manufactured by King, of Crawford-street, Montague-square, London, is a valuable medicine in cases of debility involving the great nervous centres. One or other of these medicines, if given discriminatingly, does good, and promotes the return of health. ?the mens sccna in corpore sano.
Of the patients admitted at Northwoods, the majority pre- sented signs of more or less disturbance of the organs concerned in digestion. The prima} viae, of which we hear nowadays much too little, though so commonly at fault, are ignored or put on one side, for the sake, as it appears to me, of certain imaginary germs, and the means whereby such may be poi- soned or slain withal. However, we may be quite sure of this : so long as such primes vice are depraved, or incompetent to the right discharge of their important offices in the animal economy ?so long may we bother our patients with sedatives of whatever kind, and with tonics, vegetable or mineral?so long- may we direct what they may eat, drink, and avoid?so long suggest what we may in the matter of hygiene, &c. &c.? so long, I say (the, prima} vice being in an abnormal state), will all prove in vain, and of no real good.
I am never satisfied as to the real state of a patient until I have examined, with care, the alvine and renal excretions. If such are found to be normal, both as regards quantity and quality, well and good. But this is, I believe, rarely the case ; for the bowels are perhaps constipated, or the stools are wanting in bile, though diarrhoea is present. The urine is seldom seen in a natural state in the early stages of insanity. It is generally thick and turbid, of a high specific character, and abounding in the salts of urea. In patients of a melancholic tendency the urine will, very likely, be found to contain also oxalic acid, or oxalate of lime crystals. Now, such a state of things tells us, plainly enough, that ” the sewage of the body ” (so named by the late Grolding Bird) has been and is insufficiently discharged; and that, therefore, the entire organism is being damaged (poisoned) by the contact of nitrogenised substances, the product of that metamorphosis of tissue ever going on in each of us. If such sewage, or retained nitrogenous substances, are?as is asserted and believed?not less poisonous than the deadly secretion of the puff-adder is to a person into whose blood its fatal bite has conveyed it, then indeed must it be our very first endeavour to rid the system of our patients of all such. This we can do by purgatives, fairly and fully adapted, in the matter both of frequency and potency, to individual circum- stances or cases.
The seclusion and restraint of the insane are matters which have begotten of late much warm discussion. Doubtless there was a time when both of these very important means of relief and erne of the disordered mind were much and dread- fully abused. But of this I am confident, that the right use of both seclusion and mechanical restraint has been, and is now, somewhat neglected?and this with the sad and humiliating effect of aggravating disease, and of adding not a little to the difficulties and dangers of asylum management. The total disuse of seclusion, and not less the entire abandonment of restraint, though advocated by one or more medical men engaged in asylum practice, is, as it appears to me, not only absurd, but sometimes mischievous; and it may be more even than this. Many a superintendent has, it is to be feared, been ere now deterred from the employment of seclusion and restraint, when one or the other was urgently needed. Seclusion?in itself an invaluable sedative, and, not unfrequently, the very best sub- stitute for chloral hydrate and suchlike?is, no doubt, from time to time too long delayed, or altogether omitted, and the doubtful surveillance of attendants sought in its stead. There are, of course, cases to which seclusion is especially adapted?cases the symptoms of which are aggravated by any other or the more ordinary resources of our art?i.e., by the presence of attendants, by outdoor exercise, or diversion in any way. Remedies, of whatever kind, must be selected, regard being had to the requirements, or peculiarities, or susceptibilities of any one patient. A gentleman now at Northwoods secludes himself voluntarily, if not in the padded room, then in his bedroom. He feels wretched and excited at such times, and when alone he is relieved. As an exception to this rule of his, he will sometimes prefer to walk, which he does in good earnest, with long and rapid strides, up and down the garden, or airing- court, so called. A medical friend suffering from an acute form of mania came under my care not a long time since. The excitement reached now and then a painful climax; his rage and disorder knew then no bounds. At such times I gave him a full dose of the syrup of chloral, and had him secluded in a padded room. The external senses being there without any kind of stimulus to action else than the four padded and sombre -coloured walls, and the subdued light admitted through the darkened glass composing the skylight of the apartment, he became quieted. Brought as he was into a state of merely subjective life, what so likely as to induce the required cerebral inaction or repose?what so likely, also, to aid the good effects of the chloral? The paroxysm was invariably relieved by such a proceeding. After two or three hours he became so far com- posed as to be easily managed and kept right?in other words, to be brought within the wholesome and benign influence of those about him.
In so far as mechanical restraint is concerned, I may be permitted to record the annexed case. Nine years ago I had under my care at North woods a lady, the subject of dementia of long standing. Her bodily health was so much reduced that she was unable even to sit, unsupported, in a chair. So feeble had she become, that she could walk only when rest- ing, or supporting herself, on the arm of an attendant. In such a state of mental and bodily prostration you will not be surprised to learn that, in spite of the best attention we could give her, she ran the risk of an occasional fall. She did, in fact, every now and then tumble forward as she sat in her chair ?a padded armchair?and falling on the floor, suffered much from mental agitation and alarm, and, in addition thereto, from sundry hurts and bruises. Attendants took their turn to wait on this poor lady, to gently support or restrain her, and in the hope, and with a view, to the prevention of accidents such as those named. However, their patience, it was found, became too severely taxed, they tired of their occupation; they came to regard the patient as something akin to a nuisance, or a hard task. Such feelings, and such an estimate of the case, begat on their parts less and less of gentleness and sympathy. Ere very long it was made evident to me that the said support or re- straining care of attendants, carried out, as it was, for the most part, with much kind and consistent regard for and on behalf of this deeply afflicted lady, resolved itself into a question of choice between two evils. Acting, then, on the principle, that of evils the greater should ever give place to the less, or that one the more easily borne, I directed a common shawl to be so wrapped about the patient and the chair that she could no longer fall from it to the floor, &c. &c. You will not fail to bear in mind that this restraint, or rather support, was not continuous by any means ; it was used only for short and convenient periods through the day, and as a relief or change, not only to the patient, but also to the attendants. You may be surprised to learn that this very case was made the excuse, by a late Chairman of the Gloucester Quarter Sessions, to call on me to answer a charge of “being guilty of a mean and inhuman economy,” adopted ” at the cost of a patient’s welldoing.” This late Chairman told the Court that the above form of restraint was but ” the symbol of rigorous and parsimonious treatment of lunatics, now happily abolished, and which must ever be discountenanced by those in high authority.” The issue of the matter was, I was compelled to abandon the use of the shawl, and put yet again the poor lady alluded to into the exclusive and doubtful or hazardous care of the attendants. So were my hands tied, and the comparative well-doing of my patient prevented. Of two evils, the one or the other of which was indispensable, I was put under the necessity of accepting the greater of them. Hard lines such as this for patients, and not less hard, perhaps, for the doctors, in whose hands rests both the patient’s well-doing and their own reputation. You will perhaps agree with me when I add, in the words of Cowper?
All constraint, Except what wisdom lays 011 evil men, Is evil, hurts the faculties, impedes The progress in the road of Science.
and, it may be said also, delays the advent of truth. But exclusive systems of whatever kind, call them by what- ever names we may?by Teetotalism or Alcoholism, Puseyism or Sectarianism, Hydropathy-ism, Mesmerism, including what may be called Restraint-ism?will have their own little day, yet is each one of them doomed to be beaten back to its fair proportions and legitimate belongings. We are assured of this, as a mere fact, by the growth even now of better and sounder views of the ” non-restraint system,” so designated. In the Journal of the British Medical Association for November 23, 1873, there is seen these words?they appear as editorial remarks:?
NON-RESTRAINT IN LUNACY.
“In the opinion of the Edinburgh Medical Journal, although England may justly claim the merit of having done much to introduce a more humane treatment of the insane, there is no chance of our insular notion about totally dispensing with restraint being adopted, either on the continent of Europe or in America, while, of late years, in Great Britain there has been a steady and powerful reaction against the extreme views of the 1 non-restraint’ men. Superintendents, like Dr. Lauder Lindsay of the Perth, Dr Yellowlees of the Glamorgan, and Dr Murray Lindsay of the Derby Asylums, have gained the distinction of boldly stating views which were getting every year more general and more decided, that the utter abrogation of mechanical restraint in all cases of mania was a notion only fit for doctrinaires who do not understand the real exigencies of asylum superintendence. In a notice in the Allgemeine Zeitschrift fur Psychiatrie (1871, p. 604) of Dr. Ivellogg’s Report on English Asylums, the writer remarks :?’ As for no restraint, he holds the strict carrying out of it as a sentimental humbug (a true word)?(fiir einen Sentimentalitatshumbug. Ein wahres Wort). From private accounts and the most important journals of England, there is preparing a powerful opposition against the extrava- gances of no restraint.’ In like manner, the superintendent of an asylum of eight hundred lunatics, in France, gives his views on the subject in the Annales Medico-Psychologiques (1871, pp. 375, 376) : ‘ Whatever the English doctors may say, these means (camisole, manchettes) are better than confinement in a cell and the manual force of keepers. Almost constant imprisonment in dark and padded cells cannot but become hurtful to the patients in all points of view. As for the oversight and repression of keepers, this measure often gives rise to frequent struggles and scenes of disorder and tumult in the ward, for the other patients become excited in their turn. It may be retorted, in defence of the system generally employed in France, that the no-restraint of the English (surveillance and repression by the keepers, and constant isolation in cells) is only physical restraint in disguise.’”
Some of these words may have been better chosen, or of a milder character, and not so highly coloured. They contain, nevertheless, a large proportion of truth. In these Reminiscences of Lunacy Practice the subject of Suicidal Insanity could hardly escape attention. During my experience at North woods I have had admitted several patients?ladies and gentlemen?in whom the tendency to suicide has been more or less marked. I regret to add that two of such (ladies ‘* did succeed in killing themselves. Two gentlemen were admitted with cut throats, and a third suc- ceeded in inflicting a throat-wound on himself when in the asylum. Of these three gentlemen, one of the first alluded to died, not of the wound, for this had quite healed, but from cerebral exhaustion, after protracted mania; the other got well. The third is still at Nortliwoods, in a state approaching dementia. In reference to the two ladies, they were in a sense, and as cases exceptional to the rule, sacrificed to the ” non- restraint ” system. In the absence of mechanical restraint, the proper care of them was attempted through the aid of trained attendants. Two such were engaged for either lady expressly; they occupied the same bedroom with either lady. Especial supervision was enforced. Orders of the most unequivocal and decided character were given, and repeated again and again, to the effect that these patients should on no account be left alone and unprotected, &c. &c. But all to no purpose. They both succeeded in their original design; they both seized or made the opportunity to elude the watching of those having the direct or immediate care of them. They hanged themselves? the one to a portion of the bedstead, the other to a small curtain- rod. The knees almost of both of these ladies were seen in near contact with the floor when found suspended and dead. Is it right to trust altogether to attendants in cases such as these ? Can it be expected that they (attendants) will not get tired of their work ??that the monotonous character of the occupation will not in the long run prostrate them, replace them as we may and do ? Attendants are but mortal?every fair allowance must be made for them. Granting?which is not always the fact?that they do really credit the continued existence in the patient of the prompting to suicidal acts, the fear is, they will succumb, or be thrown off their guard, even the best of them; and their care and watchfulness decline.
It is worthy of remark that, with all my asylum experience (from 1840 to this time) I have had to do with but three deaths from suicide, and only two of these occurred at North- woods. The fact is due, in great part, to the protection afforded by patients to each other, the consequence of the aggregation of the insane. My charge at Hanwell consisted of some 550 insane women?at Colney Hatch of about 900. These severally kept, in a measure, their fellow-sufferers from the committal of the suicidal act, apart from, and in addition to, the general sur- veillance inseparable from^ the^ mere numbers of attendants under the same roof. Nor is this the only advantage connected with the aggregation of the insane. “Within the last two years I have found it necessary to desire the removal of two gentle- men from Northwoods, whose violence was occasionally so intense, and whose strength withal so great, that when under the influence of acute mental emotion (mania) great risks were incurred lest my small staff (three) of attendants should prove the weaker party. They were removed to one of the large asylums, where, of course, the number of attendants was such as to prevent the possibility of any risks of a like kind. In fact, their new surroundings were, in a degree, salutary, moving them to the exercise of some restraint over their mad impulses. The gentlemen alluded to were in the full possession of their mere knowing faculties ; they knew well right from wrong, and the consequences?good and bad?which follow, or are likely to follow, on either their controllable or uncontrol- lable impulses.
But the measure of control or its converse in the insane patient lies not so much in the knowing faculties as in the moral sense ; this it is which supplies the bond fide power to do or not to do. Such power may be and is strengthened by an appeal, at one time to the higher and ennobling faculties, and at another time to the lower, the selfish passions of our nature. Correction of both the sane and the insane there must ever be, but this correction, to be used with the best effect, requires to be served with various and dissimilar adjuncts. It has been said that?
Love, The deep recesses of the maddened brain Can reach, when violence fails, and gentleness, Demoniac fury quickly can assuage, When nought beside has power.
I fear the poet may have been a shade more practical. Love and gentleness go a very long way, and can do great things, But the admixture of some fear of consequences heightens the good effects of “correction,” not infrequently, on even the insane mind; and this fact is demonstrable in the mental histories of the two patients transferred from North- woods to the larger asylum. Evidence to the same effect is seen in the case of an elderly lady now under my care. Her habits are not always what is looked for in a person reputed cleanly, but she is encouraged, and with very fair success, to obey the calls of nature, and so to promote her personal comfort, by an appeal to her ” alimentiveness,” or the offer of an extra piece of fruit-tart, or a sweet biscuit; for both which dainties she has, seemingly, the relish of a practised gourmand. She fears to lose the indulgence of an appetite, and hence, not unfrequently, a due control over a bad and filthy tendency is reached.
The asylum superintendent has one very marked diffi- culty to contend with, one which is very common to his experience. The refusal of food by the insane is an ever- recurring affair. This is sometimes but one of the many signs or symptoms of suicidal insanity. When it is so, the patient is generally of a melancholic turn. Now and then the refusal of food is the outcome of delusions: for instance, the patient is apprehensive, or possibly believes, that poison has been added to the food offered to him, and hence it is he refuses to take it. A deranged religious feeling, or a perverted action of the organ of ” veneration ” (to write phrenologically), does sometimes lie at the root of this particular symptom of morbid mind. I am now attending a patient in whom such a state of things did, until recently, exist. For forty days about I kept him alive by instrumental feeding. During the same period, and for a similar first-cause or origin, I was required to use the catheter, and, what is more, to rely, to a great extent, on the use of copious enemata for the due relief of the bowels. It may be added that during the same forty days it was necessary to keep the strictest watch on Mr. Gr., lest he should commit suicide.
After several narrow escapes?and one of these from the con- sequences of a severe and self-inflicted wound on the forearm, done when an attendant was within a few feet of him?I was driven to the occasional use of the old-fashioned strait- waistcoat. This case was one in which the refusal of food may- be regarded?apart from its complications?as due to delusions of a religious character. Mr. Gr. was fed with the aid of a funnel- shaped machine, the nipple of the instrument, on the end of the elastic tubing attached to the apex of it being inserted into one or other nostril. This simple affair is well adapted for some patients, but not for all. It is very simple, easy of application, and succeeds well when the patient offers but little resistance. The whole contents of the funnel may be made to pass by its own weight into the tubing, and through the stopcock attached to the nipple, as that occupies the inlet to one or other of the nostrils, and onwards through the inferior nares and the pharynx, thence to the oesophagus and stomach with but little trouble. There is just this one point to be attended to?the operator must keep the finger and thumb on the stopcock, and so prevent the too rapid passage of the beef-tea or milk, &c. through it and the nostril, so that the excitomotory act which occurs to the pharynx may not be interrupted or drawn on too eagerly.
When a positive resistance is offered, and the patient has a fair share of strength to back up such resistance, the use of the stomach-pump is advisable. Last year I admitted two patients, a gentleman and a lady, each of whom I had occasion to feed with the stomach-pump pretty nearly every day, and this for weeks. The gentleman died?he was over seventy years of age ; the lady was eventually discharged ” recovered.” In the more common cases of refusal of food no such instrumental means as those referred to here are necessary. Such refusal being the result merely of some temporary or fleeting caprice, due not unfrequently to the hysterical tem- perament, calls more generally than otherwise for no very marked attention.
It is important, however, to bear in mind that the refusal of food by the insane may exist independently, more or less, of the mind’s disorder, and may arise from a state of dyspepsia. When this is the case, if we clear out the bowels, and so render the secretions normal, such refusal will trouble us no longer. It does not follow, then, that because a lunatic refuses to eat lie should always be fed. This fact I would further illustrate by the annexed case, that of an elderly gentleman, the subject of long-standing melancholia. Although slowly dying, and in the most natural manner possible, it was hoped to save him by forcible feeding?i.e., by the artificial introduction of food into his stomach. But this organ not being in a state to receive aliment, and the system itself fast losing its natural and vital endowments, of what utility could food be to this dying man ? The following sentence, quoted in Pereira’s work on ” Diet,” from the late Dr John Conolly, is so much to the point that I venture to introduce it here :?
” The cases of refusal of food by insane patients are chiefly of two kinds:?’ one, in which food is refused in consequence of some delusion, or some vow, or from mere obstinacy?the patient being in tolerable bodily health, or certainly not incapable of digesting food; another, in which it is utterly repugnant to a stomach in a high state of disorder.’ In the first description of cases, if all other means (such as varying the food, persuasion, &c.), ‘tried with the utmost patience, fail, it is justifiable, and even necessary, to introduce food into the stomach by artificial means.’ This is usually effected by the stomach-pump. ‘ In the second, the condition of the patient is entirely different. The tongue is red, or thickly coated; the bowels are disordered; there is present a low kind of fever; the brain is highly excited, and the patient almost too feeble to stand or walk, except by sudden and frantic efforts. His face is pale, the eyes are sunk and wild in their expression, and the whole frame is emaciated to an extreme degree. All these are so many sure signs of death ensuing on long-continued disease of the brain, with all its com- plications. Nowhere except in a lunatic asylum would such signs of sinking life be recorded as the result of food being refused. The aversion to take food arises, in such cases, as in cases of fever, from the general and terrible disorder of the system?from a diseased con- dition of the stomach itself, among other organs, associated with a brain disturbed to excess. To force food into the enfeebled and dying stomach of such patients would not be sanctioned by any well-regulated hospital, or by any competent physician; and their distinction ought not to be overlooked because they occur in an hospital for the insane.’”
The discharge of patients is a matter involving no small responsibility. The annexed case proves as much. J. P. was admitted at Northwoods in 1859. The case was one of par- oxysmal mania, the then present one being the third attack?the intervals on the two former occasions being fourteen and four-and- a-half years. The disorder was, I learnt, each time indicated by the presence of delusions, under the pressure of which he sus- pected those about him of designs inimical to himself; such delusions being followed by a disposition of violence, when he showed both a ” suicidal and homicidal disposition.” Such were the insane antecedents of my patient. On admission, however, he appeared simply agitated, but even this agitation proved but temporary. J.P. was under my care some four months; and during the whole of that time he was, to all appearance, rather well than otherwise. He was at no time treated as a patient, but after a few weeks joined daily my family circle. He rode out with me, accompanied one of my sons on shooting excur- sions, and went hither and thither as he pleased. In fact, we stood, in relation to each other, rather as old friends than any- thing else. Time went on, and I felt at length that I could detain J. P. no longer?that he was no fit and proper inmate for an asylum; I wrote to this effect to his wife. Now it was.
I was made to understand that, having regard to past expe- rience, his nearest relatives wished to be relieved of him. However, after much delay, and in spite of the opposition offered to me?on insisting that an attendant must be found for J. P., even though he should become (which he did) a boarder in the house of a medical man, and on advising at the same time, that, having regard to certain facts in the history of his case (facts “which were kept from my own knowledge” till they could be kept no longer), razors and suchlike should be carefully and persistently kept from him?J. P. was formally and legally discharged as ” cured.” Yet further to prepare for a relapse, or accidents, I entrusted to him, having confidence: in his honour and very fair promises, a letter of introduction to the medical man, with whom he took up his residence, in which 1 detailed all necessary facts, leaving, as I thought, nothing undone in the matter. On the twentieth day after leaving- Northwoods, he (J. P.) killed with a razor one of the female servants in the household of which he had become a member. On this the fourth attack no premonitory symptoms appeared?no delusions were manifest. Though it was given on evidence that J. P. was, to all appearance, quite well within a few hours of the sad and fatal casualty, yet was the whole of the blame sought to be attached to it, visited on myself. The responsibility was: shirked by all parties who had to do with J. P.?by the relatives and near friends, who resisted the employment of an attendant, and who, moreover, supplied J. P. with his razors; by the Com- missioners, who, after the murder of the poor girl, raised a strong objection to the manner and circumstances of J. P.’s discharge; and by the Visitors, who declined to move in the case in any way, either before or after his discharge from North- woods, though they failed not to give expression to very unqua- lified terms of disapproval after the sad event named.
It would seem that either one of two conditions represented the abnormal mental being of J. P. He may have concealed the insanity which afflicted him, resisted, by a strong effort of the will, the exposure of his delusions, and controlled for a given time the superadded impulse to violence, or the existence of his homicidal promptings; for the insane homicide, like him, sui- cidally inclined, does not ” wear his heart upon his sleeve for daws to pick at.” It is indeed surprising, as Dr Maudsley “affirms, ” how sane apersonmay appear who all the while has a greater derangement than was ever suspected, until some- thing happens to elicit the evidence of it.”
If such were not true of J. P., then the killing of the young woman was due to a paroxysm of transitory mania, or?what is much the same thing?to an uncontrollable impulse to violence, the effect probably, or accompaniment, of long-standing though latent disease; the paroxysmal impulse holding much the same relation to the brain, that an epileptic fit does to the central nervous system, or an attack of angina to the heart. It may be stated here that J. P. was acquitted, at his trial, on the ground of insanity. He became a patient of the late Sir C. Hood’s, at Bethlehem Hospital, who, speaking of his case, after an observation of several months, said that, ” from that time to the present, although he had watched him with no ordinary care, he did not know that he could attach any parti- cular symptom of insanity to him;” and that, ” supposing he was a private patient in my asylum, and the Commissioners in Lunacy asked me why I detained him, I do not know that I ?could give any definite reason for it.”
I doubt not the case of J. P., as here recorded, is well cal- culated to put alienist physicians on their guard, and therefore it is I have narrated it. It is hoped, nevertheless, that the details given will not lead to delays in the discharge of recovered patients. The question, ” To be or not to be” cannot at all times be hastily disposed of, by even the best informed and most experienced.
In concluding these Reminiscences of Lunacy Practice, I may express a hope that the expectant treatment of disease, now so largely recognised and adopted in general practice, may not take a like hold on the mind of the alienist physi- cian. It has been urged that much of the medical treat- ment of insanity is little better than useless, and further, that the use of sedatives does but encumber the cell-structure of the brain with a restraining influence which is scarcely more tolerable or remedial than the wretched mechanical contrivances of the olden time, devised to restrain the morbid muscular movements of the frenzied. But it is to the zealous and wise adaptation, day by day, of the various remedial means?hygienic, moral, and medical?to individual cases of lunacy we must look for the best results?for the largest amount of relief to our suffering patients, and the highest number of cures among those so terribly afflicted?as all insane persons must ever be held to be.
See liis ” Responsibility in Mental Disease,” pp. 190 to 193.
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.