Source: Internet Archive/National Library of Medicine scan of the 1813 edition Source URL: https://archive.org/details/2575045R.nlm.nih.gov Public domain basis: Public-domain 1813 English text by Samuel Tuke.SiSSM^^ DESCRIPTION ft as f t. THE RETREAT, AN INSTITUTION NEAR YORK, ik '(IJMI ill • as* ife 4& OF THE SOCIETY OF FRIENDS. CONTAINING AN ACCOUNT OF ITS ORIGIN AND PROGRESS, THE MODES OF TREATMENT, AND A STATEMENT OF CASES. BY SAMUEL TUKE. WitJi an Elevation of the Jiuiiu PHILADELPHIA: PJBLrSHKD BY ISAAC VTS.WXK, No- 12 South Fourth StP 1813. m m is? ^••f^ ^3»»!=- ^»»& *=*»»e* -!§••&, ^ijfe, -^SJfe- -^ts&- mm #> €:> «# wMHr « ** DESCRIPTION or THE RETREAT* AN INSTITUTION NEAR YORK, FOR Sjnsane ^ergons OF THE SOCIETY OF FRIENDS. CONTAINING AN ACCOUNT OF ITS ORIGIN AND PROGRESS', THE MODES OF TREATMENT, AND A STATEMENT OF CASES. BY SAMUEL TUKE. 111th an Elevation of the Building PHILADELPHIA: TUBLISHED BY ISAAC PEIR No. 12 South Fourth Street. 1813.. TO WILLIAM TUKE, THE FIRST ACTIVE PROMOTER OF THE ESTABLISHMENT DESCRIBED IN THE FOLLOWING PAGES, AND TO WHOSE PERSEVERING EXERTIONS FOR ITS WELFARE, UNRELAXED AT THE ADVANCED AGE OF EIGHTY YEARS, MUCH OF ITS PRESENT REPUTATION MAY JUSTLY BE ATTRD3UTED; THIS WORK IS (WITHOUT HIS KNOWLEDGE) MOST RESPECTFULLY INSCRIBED, BY HIS AFFECTIONATE GRANDSON, SAMUEL TUKE, PREFACE, AT the present time, when a considerable degree of interest is excited respecting the treatment of insane persons, and when the government of our country has recently made it a subject of legislation, it is presumed that any account of existing institutions, which may throw light on the method of treating this deplorable class of our fellow-creatures, will not be unacceptable to the public. The Establishment which is described in the following pages, though on a small scale, has so far met the approbation of many judi- cious persons, who have had an opportunity of minutely inspecting its internal economy and management, that I have been induced to attempt such a representation's it is hoped will be useful to those who are engaged in similar institutions. Contemplating the loss of reason as pre- eminent in the catalogue of human afflictions; and believing that the experience of the Re- treat throws some light on the means of its mitigation, and also that it has demonstrated, Jbeyond all contradiction, the superior effica- A2 \ l PREFACE cy, both in respect of cure and security, of a mild system Of treatment in all cases of men- tal disorder, an account of that experience has long appeared to me, due to the public. They are not words of course when I say, I sincerely wish that the present work had been undertaken by some one more compe- tent to do it justice, from professional know- ledge, greater leisure, or superior ability. It seemed, however, to my mind, that the pre- sent was an important time for a publication of this nature, from the number of establish- ments which have been very recently formed, or which are now in contemplation. I therefore conceived that the injury of delay would pro- bably exceed the disadvantages arising from the many imperfections which I was well aware would attend my performance. If it should be thought to afford satisfactory evi- dence in favour of a more mild system of treatment, than has been generally adopted; if it should also prove, which I flatter my- self it will, the practicability of introducing such a system into establishments for the insane poor, whose situation has in general been too pitiable for words to describe, I shall esteem myself peculiarly happy in this publication. I shall then, having no pre- tensions to literary merit, confidently be- speak the candour of the reader, to the faults of imperfect arrangement or inelegant ex- pression. PREFACE. Vll It is probable that some readers will think, that a more minute account is given of the practices of the Retreat than was necessary; but inquiries, which have recently been made by intelligent persons interested in similar undertakings, may be alleged in justifica- tion. Apology, however, is due to the general reader for the length of the two first chap- ters, which have much exceeded the original design. This has been occasioned by the wishes of many subscribers to the Institu- tion, who could not obtain a regular series of reports, to have a particular detail of its origin and progress. It is much to be regretted, that we possess so few accounts of the mode of treatment, and the success of establishments, for the re- lief of insanity. The want of facts relative to this subject, and our disposition to hasty ge- neralization, have led to many conclusions, equally unfriendly to the progress of know- ledge, and the comfort of the patients. The interests of humanity and science, alike call upon us to communicate freely the discoveries we make, or the failures which happen to us, in a pursuit so intimately con- nected with the happiness of our species. If persons engaged in the management of the insane, were more generally to publish the re- sult of their observations, we might reasona- bly hope that the causes of this obscure and Viii PREFACE. affecting disorder would receive some illus- tration. We might at least confidently expect to ascertain, with greater precision, its general laws; and, from a comparison of the modes and success of various establishments, should be able to infer the most probable means of rescuing, or relieving the unhappy victims of this disease. It has been remarked, that " Physicians, attending generally to diseases, have not been reserved, in imparting to the public the amount of their labours and success: but, with regard to this disorder, those who have devoted their whole attention to its treatment, have either been negligent, or cautious of giving information respecting it."* Surely, as the intelligent Pinel observes, after a simi- lar complaint, " He who cultivates the sci- ence of medicine, as a branch of natural his- tory, pursues a more frank and open system of conduct, nor seeks to conceal the obstacles which he meets with in his course. What he discovers, he feels no reluctance to show; and the difficulties which he cannot master, he leaves, with the impression of his hand upon them, for the benefit of his successors in the same route, "f In justice to the work, as well as to indi- viduals, it is proper to state, that if the pub- lic are at all benefited by the information * Ilaslam's Observations! p. 244. -J- Treatise on Insanity, translated by Dr. Davis- PREFACE.. IX contained in the present publication, they are chiefly indebted to my worthy friend George Jcpson, the superintender.t and apothecary of the Retreat. Having filled these offices nearly from its commencement, and having, by his talents and humanity, carried into effect the benevolent wishes of the original promoters of this Establishment, beyond their most san- guine expectations, he was the only person who could furnish me with the documents which my plan rendered necessary: and had I not been assured of his cordial assistance, the work would not have been attempted. The arduous nature of the duties which he so usefully fulfils, will furnish sufficient apo- logy for his not having performed it, instead of furnishing the materials; and it affords me some satisfaction to reflect, that contemplat- ing the uncertainty of human life, a part at least of his knowledge is now communicated. I am also indebted to my friend Dr. Bel- combe, the present skilful physician to the Institution, for several valuable hints on the perusal of the manuscript; and to the widow of the late Dr. Fowler, for the readiness with which she communicated to me several very useful notes and papers which he had made or collected, during his attendance at the Retreat. I hope that my partiality for the establish- ment which I have endeavoured to describe, and my wish to present its objects and regu- X PREFACE. lations to the public eye, have not induced me to deviate from that candour and sobriety of representation, which the reader has a right to expect. I am not conscious of such a deviation: but I well know that strong at- tachments, unless carefully guarded, are apt to impose upon our judgment. That this, however, has not been the case in the present instance, I am encouraged to believe, from the very favourable and commendatory cha- racters which have been given ol the Institu- tion, by several well informed and impartial persons, by whom it has been visited, and minutely examined.* To support the statements given in this work of the modes of treatment at the Retreat, a few respectable testimonies in its favour are given in an Appendix. I am, however, far from imagining that this Asylum is a perfect model for others, either in regard to con- struction or management. If several im- provements have been successfully introdu- * It may be proper to observe, that, though the patients are never exhibited to gratify the curiosity of visiters, yet profes- sional persons, or those peculiarly interested in the subject, are permitted at all seasonable hours, to visit every part of the establishment- Tt would be well if this plan were generally adopted in other institutions of this nature, as the uncertainty of visiters arriving- would be some check upon neglect, or improper conduct. It may also be proper to state, that several persons about to engage in thje superintendence of similar establishments, have made a temporary residence in York, and have been permit- ted by the Committee of the Retreat to observe daily the economy of the house, and the mode of managing the pa- tients. PREFACE. XI ced, il is probable that many others remain unattempted. The managers will not, I trust, allow the approbation they have alrea- dy received, to induce a relaxation of their future endeavours to combine, in a still greater degree, the comfort with the security of the insane; but, on the contrary, that they will be stimulated by it to further exertions, and proceed, in some degree, upon the max- rm. that nothing has been done, whilst any thing remains to be done. TABLE OF CONTENTS. CHAPTER I.— HISTORICAL ACCOUNT. Origin — Difficulties — First Meeting of Friends on the subject in 1792 — Resolutions — Subscriptions — Meeting of Subscri- bers— Amount of Subscriptions, and general Opinion of Friends respecting the nstitution — Resolution of a Meet- ing in 1793 — Determination to build — Land purchased and Building commenced in 1794 — Amount of Subscriptions — Necessary to borrow Money- -Rules agreed upon in 1795 —-Additional Subscriptions at this time — House very near- ly completed — Committee appointed to engage Servants, and to admit Patients — West Wing ordered to be built First Month, 1796. Page 17—31 CHAPTER II— HISTORICAL ACCOUNT. Opening of the House — Physician appointed — Appointment and decease of the temporary Superintendent — Report of 1796 — Present Conductors engaged — Heport 1797 and 1798— Additional Building to the East Wing-— Report 1799 — Rule respecting recent cases of Insanity — Report 1800, stating the benefit of early admission — Report 1801 — Decease of Dr. Fowler — Dr Cappe appointed his succes- sor— Report 1802 — Decease of Dr. Cappe — Dr. Belcombe appointed Physician — Additional Building to the West Wing — Reports 1803 to 1809 — The Appendage proposed and agreed to — Reports 1810 and 1811— Report 1812, stating the Appendage to be occupied, &c. — General Remarks on the Institution — Summary of Annual Reports on the Finan- ces— Rules of the Institution — Account of the present domestic establishment. Page 32 — 61 CHAPTER HI— DESCRIPTION AND APPROPRIATION OF THE GROUNDS AND HOUSE. Situation — General aspect of the building — The Farm The Garden — The Courts for the different classes of Patients — Remarks — Application of the different parts of the Building to the use of the Patients — On attention to the comfort of the Insane — The Retreat not a perfect model for erections of this kind— Early Managers laboured b XIV CONTENTS. under the want of experience — The advantages of the Pudding described — Of its defects — Of the exce*siv< attention to safety in the construction of Hospitals for Uie Insane. I'age G2 — 70 CHAPTER TV— MEDICAL TREATMENT. Character of the first Physician — Hesult of his experime nt§ as to the general importance of Medical treatment — Of the reducing system in particular — Of forcing the Patient to take medicine — Consequent humane direction of the Physician— Of the use of the Warm Hath in Melancholia — In Mania — Mode of using it — Use of Cold Hath in a case of high Mania — Importance of attention to the general health of the Insane — Frequent extraordinary sympathy between body and mind in this class of persons — Advan- tage of attention to the bodily health of Convalescents— Use of topical bleeding on the approach of a paroxysm — Necessity of close individual attention to Patients, an argu- ment against large Establishments — Difficulty of obtaining Sleep — Mode practised at the Retreat — Want of discrimi- nation in the medical treatment of Insanity — Remarks on the practice of Bethlem Hospital — Of mortifications of the extremities from cold or confinement — Of the capacity of Maniacs to bear cold — Of Diet — Usual bill of fare — Of the antiphlogistic system — Doubt respecting the Diet of the Retreat — Of the capacity of Maniacs to bear hunger — Beneficial effects of air and exercise. Page 71 — 83 CHAPTER V — MORAL TREATMENT. SECTION I. INTRODUCTORY OBSERVATIONS. Importance of Management in a curative point of view — Power of self-control possessed by Maniacs — The disor- der generally partial, in regard to both the intellectual powers and affections — Of the malevolent dispositions evinced by Maniacs — Powerful effect of judicious kind- ness— Practices of the Retreat arranged under three heads. Page 84—88 SECTION II. — OF THE MEANS OF ASSISTING THE PATIENT TO CONTROL HIMSELF. Tower of self-restraint strongly evinced at the Retreat — Mo- tives for its exertion — Conclusion drawn hence respecting the excitement of Fear — Of the degree in which Fear may be usefully excited — Of the excitement of furious Mania by improper treatment; and of the efficacy of persuasion CONTENTS. XV and kind treatment towards inducing self-restraint — Argu- ment in favour of the terrific system. Of the attendants' behaviour to lunatics on first acquaintance — Analogy be- tween the judicious treatment of children and insane per- sons— Of the manner of speaking to Maniacs — Of reason- ing with the Patifrnt on the subject of his hallucination — Of the conversation adapted to melancholies — Beneficial effects of exercise and variety of object upon this class, illustrated by an affecting case — Advantage of regular la- bour in some cases — Desire of esteem a powerful princi- ple towards inducing self-restraint — Other means of cul- tivating it — The aid of Religion in promoting self-restraint — Hints to the attendants on the Insane. Page 89 — 103 SECTION III. OF THE MODES OF COERCION. General view of the nature of coercion used at the Retreat — Mode of coercing violent Maniacs, and Melancholies disposed to self-destruction— Experience of the Retreat in regard to indulging the ebullition of violent Maniacs — Causes of the too general use of coercion — Of the degree of force to be employed when coercion is necessary — Modes of coercing the less violent — Precautionary mea- sures—Necessity of experience to teach the best modes of restraint. Page 103—110 SECTION IV.— OF THE MEANS OF PROMOTING THE GENERAL COMFORT OF THE INSANE. Importance of promoting comfort as it regards cure — Various means of promoting it at the Retreat— Utility of rational society to convalescent Patients — The different kinds of amusing employments adapted to different classes of Pa- tients— On the introduction of books to the Insane — Im- portance of arresting their attention— Case — Difficulty of devising suitable employments. Page 111— 117 CHAPTER VI.— STATEMKNT OF CASES AND REMARKS. Table of Cases— Summaries drawn from it— Statements made by several other Institutions of the proportion of cures — Difficulty of estimating the curative means employed in different Asylums — Necessary inquiries previously to judging of different Reports— Difficulty of obtaining in- formation on the causes of the disease — The effect fre- quently mistaken for the cure— Approach of maniacal pa- roxysm described — Great ambiguity of the moral causes of Insanity— The most prevalent causes in the Retreat— XVI CONTEXTS. Few cases connected with religious impressions or intern* perence — The rules of the Retreat different from Hcthlem and Luke's Hospitals — Definition of the terms Dementia, Melancholia, and Mania — The time which constitutes an old case — The terms aired and recovered — Inquiry whe- ther Insanity is prejudicial to animal life — Drs. Monro and Crichton's opinions — Of the disorders to which the Insane are the most liable — The causes of Mortality in the Retreat — Ages of Patients. Page 118 — 136 Appendix. Page 139—144 DESCRIPTION OF THE RETREAT, $e. VX/VWVWV CHAPTER I. HISTORICAL ACCOUNT. Origin— Difficulties— First Meeting of Friends on the subject in 1792 — Resolutions — Subscriptions — Meeting of Subscri- bers—Amount of Subscriptions, and general Opinion of Friends respecting the Institution— Resolution of a Meet- ing in 1793— Determination to build— Land purchased and Building commenced in 1794— Amount of Subscriptions— Necessary to borrow Money- -Rules agreed upon in 1795 — Additional Subscriptions at this time — House very near- ly completed— Committee appointed to engage Servants, and to admit I'uiients— West Wing ordered to be built First Month, 1796. 1 HE history of the rise and progress of establish- ments, which have been peculiarly serviceable to so- ciety, like the biography of eminent men, is both inte- resting and useful. The inquisitive and speculative mind, loves to trace the causes of every striking ob- ject; and the practical philanthropist may derive con- siderable advantage, from an account of benevolent experiments that have been made by others. The origin of the Institution which forms the sub- ject of the following pages, has much the appearance of accident. In the year 1791, a female, of the Society 'A Friends, was placed at an establishment for insane persons, in the vicinity of the City of York; and her family, residing at a considerable distance, requested some of their acquaintance in the City to visit her. The visits of these Friends were refused, oq the ground ol the patient not being in a suitable state to be seen B 18 IIISTOUIOAL ACCOUNT. Cli by strangers: and, in a few weeks after her admission, death put a period to her sufferings. The circumstance was affecting, and naturally exci- ted reflections on the situation of insune persons, and on the probable improvements which might be adopt- ed in establishments of this nature. In particular, it M'as conceived that peculiar advantage would be deri- ved to the Society of Friends, by having an Institution of this kind under their own care, in which a milder and more appropriate system of treatment, than that usually practised, might be adopted; and where, du- ling lucid intervals, or the state of convalescence, the patient might enjoy the society of those who were of similar habits and opinions. It was thought, very just- ly, that the indiscriminate mixture, which must occur in large public establishments, of persons of opposite religious sentiments and practices; of the profligate and the virtuous; the profane and the serious; was calculated to check the progress of returning reason, and to fix, still deeper, the melancholy and misan- thropic train of ideas, which, in some descriptions of insanity, impresses the rnind. It was believed also, that the general treatment of insane persons was, too frequently, calculated to depress and degrade, rather than to awaken the slumbering reason, or correct its wild hallucinations. In one of the conversations to which the circum- stance before-mentioned gave rise, the propriety of attempting to form an Establishment for persons of our own Society, was suggested (o William Tuke, whose feelings where already much interested in the subject, and whose persevering mind, rendered him peculiarly eligible to promote such an undertaking. After mature reflection, and several consultations with his most intimate friends* on the subject, he was de- cidedly of opinion, that an Establishment for the in- • Among the most early and strenuous friends of this Es- tablishment, I wish to particularize the name of the excellent Lindley Murray? to whose steady endeavours, for promoting its welfare, die institution is much indebted. p. I. UI8T0RIC\L ACCOUNT 1 <>\ sane of our own Society, of every class in regard to property, was both eligible and highly desirable. It was necessary to excite a general interest in the Socie- ty on the subject. He therefore, after the close of the Quarterly Meeting at York, in the 3d Mouth, 179'..', stcd Friends to allow him to introduce to them a subject-, connected with the welfare of the Society, fie then stated the views which he, and those whom he had consulte 1, had taken of this subject; the cir- mnstance which had given rise to their interest respecting it. and the conviction which had resulted in their mincls, in favour of an Institution under the gov- ernment of Friends, for the care and accommodation of their own Members, labouring under that mo»t afflictive dispensation — the loss of reason. Few objections were then made, and several per- sons appeared to be impressed with the importance of the subject, and the propriety of the proposed measure. The Friends with whom the proposal originated, were requested to prepare the outline of a plan, for the consideration of those who might attend the next Quar- terly Meeting. Several objections, however,on * varie- ty of grounds, soon afterward appeared. Many Friends were acquainted with but few, if any, objects for such an Establishment; and they seemed to forget that there might probably be many cases with which they were not acquainted. Some were not sensible that am improvement could be made in the treatment of the insane; supposing that the privations, and severe treat- ment, to which they were generally exposed, were ne- cessary in their unhappy situation; and others, seemed rather averse to the concentration of the instances ol this disease amongst us. It was not, however, at all surprising that consider- able diversity of opinion, should prevail upon a subject which was entirely new, and foreign to the general inquiries of those to whom it was proposed; and we must not forget that there was a respectable number, who duly appreciated the advantages likely to accrue to the Society from the proposed Establishment, and 20 HISTORICAL ACCOUNT. Chap. I. who cordially engaged in the promotion of the design. To these persons, and to the steady exertions of iis chief promoter, whose mind was not to be deterred by ordinary difficulties, the Society of Friends, may justly be said to owe the advantages it derives from this ad- mirable Institution. Proposals for raising money and forming the Estab- lishment, were prepared and laid before Friends, at the conclusion of the next Quarterly Meeting; which were generally approved. A subscription was immedi- ately entered into; and the contributions were one hundred pounds, for a life-annuity of five percent, per annum; annual subscriptions /.1 1: 0 : 6 for three years certain, and donations amounting to M92 : 3v. The following minutes were also made at this Meeting, viz. "At a Meeting of Friends held at York the 28th of 6th Month, 1792, for the purpose of taking into consideration the propriety of providing a retired Habitation, with ne - cessary advice, attendance, &c. for the .Members of our Society, and others in profession with us. who may be in a state of Lunacy, or so deranged in micd (not Idiots) as to require such a provision; RESOLVED, " That persons of this description (who are truly objects of great sympathy and compassion,) are often, from the pe. culiar treatment which they reqiure, necessarily commit- ted, wholly, to the government of people- of other Socie- ties; by which means the state of their own minds, and the feelings of their near connexions, are rendered more dis- satisfied and uncomfortable than would probably be the ra.se, if they were under the notice and care of those, with .•horn they are connected in Religious Society. It appears, therefore, very desirable that an Institution should be formed, wholly under the government oi' Friends, for the relief and accommodation "f : ■ all ranks, Cb«p.t HISTORICAL ACCOUNT. 21 with respect to property. This would doubtless, in some degree, alleviate the anxiety of the relatives, render the minds of the Patients more easy in their lucid intervals, and consequently tend to facilitate and promote their re- covery- IT IS THEREFORE PROPOSED, 1st. " That, in case proper encouragement he given, Ground be purchased, and a Building be erected, suf- ficient to accommodate thirty patients, in an airy situ- ation, and at as short a distance from York as may be, so as to have the privilege of retirement; and that there be a few acres for keeping cows, and for garden ground for the family; which will afford scope for the patients to take exercise, when that may be prudent and suitable. 2d. M That the Institution be established and support- ed by annuities, donations, and annual subscriptions; and that the same (which should be altogether volun- tary) be promoted amongst Friends, within the corn- pass of this, and any other Quarterly Meeting. 3d. " That each Subscriber, by way of annuity, contributing a sum not less than Twenty Pounds, shall receive an interest of five per cent, per ann. during life; and as the undertaking may not be able to pay this interest, and otherwise maintain itself for the first three years, those entered as Subscribers for annual payments, be engaged for three years certain, in case the subscriber should so long live. 4th. " That a contribution of One Hundred Pounds, from any Quarterly Meeting in its collective capacity. paid to the Treasurer of this Institution before the year 1794; or a donation, at any time, of Twenty-five Pounds from any Friend; or a subscription of Fifty Pounds for an annuity, shall entitle such Quarterly Meeting, Donor, or Annuitant, respectively, to the privilege of nominating one fioor patient at a time on the lowest terms of admission. 5th "That the name of every Annuitant, Donor and B2 IUSTOWCAL ACCOUNT. Clmp. I Subscriber, be recorded in a book to be kept for that purpose; and that every Annuitant, Donor of not less than Two Guineas, and Subscriber of sums in any manner equal to Two Guineas, in the first three years, 'being and continuing a member of our Society,) shall be a Member of the Meetings which arc to be held for the government and superintendence of the Insti- tution. 6th. " That there be paid for board, washing, medi- cal advice, medicines, and all other things necessary txcept clothing, according to the circumstances of the patients or their friends, from four shillings to fifteen shillings per week, or higher in particular cases; and six shillings per week for the board of the Servant of a patient, in case the friends of any patient should in- cline to send one; which servant must be approved by the Committee. 7th. « That eight shillings per week and upwards, according to circumstances, be the terms for patients who come from the compass of any other Quarterly Meeting than Yorkshire, unless privileged agreeably to the 4th proposal. — These terms for patients to be subject to future alteration, if found necessary. " William Tuke is desired to get one thousand co- pies of these proposals printed, and circulated amongst Friends; with an account of the Subscriptions which have been or may be made previously to the printing thereof." A number of Friends, residing in different parts of the county of York, were appointed to solicit subscrip- tions from the members of their respective meetings, towards the proposed Establishment; and they were desired to bring an account of their success to the next Meeting, to be held three months from the time of the first. At the second Meeting, the additional subscriptions were few and trifling; consisting only of /.50 to the Annuities, 1.24 : 3s. to the Donations, and 1. 1: la. to the Annual Subscriptions. Considerable ad- ditions were, however, brought to the third and fourth Chap. I. HISTORICAL ACCOUNT. £3 Meetings; and the active promoters of the Establish- ment, had the pleasure of witnessing an increase of interest in the minds of their friends in general, to- wards the subject. Variety of opinion, as might naturally be expected, still prevailed, with regard to the necessity of the pro- posed measure; and there was considerable diversity of sentiment, amongst those who approved of the general design, as to the best manner of executing it. At the fourth Meeting it was therefore thought ad- visable, to republish the proposals of the first Meet- ing, with an answer to the principal objections which had been made to them, and with an account of the subscriptions at that period. This paper, as it marks the progress of the Institution, and the general opin- ion of Friends respecting it, is given at length, with the exception of the Rules first proposed, which have been already inserted. " York, 5th of 4th Month, 1793. " At a Meeting of Friends it was agreed, that 1500 copies more of the preceding Proposals, with the following ad- ditional Minutes, and further Explanations, should be print- ed and circulated amongst Friends. "27th of 9th Month, 1792. " As the benefit of the proposed Institution is in- tended to be extended to those who are not strictly Members of our Society, it is the judgment of this Meeting, that subscriptions may also be received from such persons." " 5th of 4th Month, 1793. " It having been objected that, according to the ex- pression of the 7th Proposal, there appears to be an extraordinary privilege intended to Friends in York- shire, this Meeting thinks proper to disclaim having had such an intention. The prospect in forming the same was, that as the Subscriptions were set on foot in this County, they would amount to, at least, as 24, HISTORICAL ACCOUNT. Of many hundred pounds as there would be poor patienls belonging to this Quarterly Meeting, at any one time in the House. But, in order to remove all doubts on that head, it is agreed, that the Quarterly Meeting of York, shall not enjoy any privilege superior to other subscribing Counties; it being intended, that all Sub- scribers, whether they consist of Quarterly, or other Meetings, or of Individuals, shall enjoy the previlegeof recommending poorpatients,in proportionto their sub- scriptions, notwithstanding any expressions in the 4th or 7th proposals, that may bear adifferent construction. " In case any Quarterly Meeting be so small, or its members not in an eligible situation to raise One Hundred Pounds, the General Meeting of Subscribers shall have a power, on application, to extend the pri- vilege of the 4th proposal to such Meetings, on con- tributing a smaller sum, at the discretion of the said General Meeting. " It is agreed that when the Annuities and Donations amount to One Thousand Pounds, the application thereof shall be taken under consideration, by a Gene- ral Meeting of Subscribers." THE FOLLOWING IS THE PRESENT STATE OF SUBSCRIPTIONS. For Annuities. I : d. Yorkshire, one Subscriber, 100 0 0 Ditto, . . one 50 0 0 Suffolk, . two of I. 50 each, 100 0 0 Yorkshire, one 25 0 0 /. 275 0 0 Annual for Three Years. I. s. d. Yorkshire, three of two guineas 6 6 0 Ditto, . . sixteen of one guinea, 16 16 0 Ditto, • • one of half a guinea, 0 10 6 1. 23 12 6 Chap. I. HISTORICAL ACCOUNT. 25 Donations. \orkshire, one, 52 10 0 London, . one, 21 0 0 Suffolk, . several of /. 25 each, to one guinea, . . 118 1 0 Yorkshire, nine of ten guineas, 94 10 0 London, . one, 10 10 0 Yorkshire, one, 8 8 0 Ditto, . . two of six guineas, . ........... 12 12 0 Ditto, . . twenty-nine of five guineas, 152 5 0 Ditto, . . five of three guineas, 15 15 0 Ditto, . . ten of two guineas, 21 0 0 Ditto, . . one, 1 11 6 Ditto, . . seven of one guinea, 7 7 0 Ditto, . . two of half a guinea, 110 I 516 10 6 " As several objections have been made, especially by Friends at a distance, to some parts of the foregoing Plan, the fol- lowing remarks and explanations are added, in order to re- move them. " Some have thought that accommodations for so many as thirty patients, should not have been aimed at: But it is obvious, that the quantity of ground for exercise, ought not to be much, if any, less for fifteen than for thirty; that kitchens, parlours, and almost all parts of the building, except the number of patients' rooms, ought to be nearly the same; and that it would make little difference with respect to Physician and domestic Managers: So that to accommodate the pro- posed number, would not only lessen the expense of each patient, but extend the benefits of the Institution to Friends at a greater distance. •' The situation of York, and its distance from some parts, both in the North and South, have been staled as principal objections. With respect to the place, it was thought best to fix it at the beginning, as the con- sideration of so material a point afterwards, might have afforded a subject of much altercation; and the differ- JO HISTORICAL ACCOUJN I CJiap I ent views of Subscribers, might then produce diversi- ty of sentiments, to the great embarrassment of the undertaking. It should be attended to, that the pro- posal originated in Yorkshire; and that, though the views of Friends there, were not confined to that coun ty, they did not consider the Institution as likely to accommodate the Society in the whole nation; and therefore, whilst they judged York to be an eligible situation for a limited undertaking of this nature, they have been desirous that its privileges should be ex- tended to Friends in general, upon reasonable condi- tions; as patients, even in low circumstances, are oiler. sent very far; one, in particular, having been lately taken 120 miles to Manchester; and divers have been sent from Yorkshire to London. " It appears necessary, that General Meetings of the Subscribers should be held once a Year, to receive Reports of the preceding year's accounts, make Rules, and appoint Committees, &c. To collect sub- scribers for these purposes might be difficult, unless they were drawn together on some particular occa- sion: The Quarterly Meeting of York affords such an occasion better than any other, because it is larger, and Friends more frequently come to it from distant parts. Besides, if a Committee should meet Quarterly, it may then be conveniently appointed of Friends, residing in various and distant parts of the County. This Committee may appoint Visitors, and a Sub- committee of Friends conveniently situated, to taki the immediate oversight of the Institution, and to make report to them once a Quarter. " The price of land suitable for the purpose is much lower near York, than it is equally near most other populous places; and at such only, a good choice 01 medical assistance can be expected. The air also is healthy, and much more free from smoke than situa- tions near manufacturing towns; and the county being generally fruitful and not populous, provisions are considerably cheaper than at such places. It may be further observed, that at a general Conference since (>,,,!>. I. IIlSTOItlC.VL ACCOUNT. $7 the proposals were circulated, it was considered whe- ther York was the most proper place; when there ap- peared a general acquiescence, and not a dissenting voice. " With respect to the ohjections to the 4th proposal, it may be proper to remark, that a Quarterly Meet- ing being a standing body, its privilege is perpetual; but the right of a single Friend dies with him; and therefore, a Donation of /. lOO is required from the former, in its collective capacity, when only 1.25 Do- nation, or /.50 Subscription for an Annuity, is requir ed, to entitle a Friend to a similar privilege with a Quarterly Meeting. It should be attended to, that pa- tients, whose connexions are of ability to pay eight shillings per week or upwards, according to circum- stances, cannot be privileged under the 4th proposal. As to the other part of the objection to that proposal, it is apprehended that the minute now made will en- tirely remove it. " It hath been said, that there are already many public Institutions of the kind, which render this un- necessary. But it is evident, besides what has been remarked on this head, in the former publication, that several peculiar and important advantages, will accrue from an Institution confined to ourselves. For as the disorder is a mental one, and people of regular con- duct, and even religiously disposed minds, are not ex- empt from it, their confinement amongst persons in all respects strangers, and their promiscuous exposure to such company as is mostly found in public Institu- tions of this kind, must be peculiarly disgusting, and consequently augment their disorder. Nor is this idea merely chimerical; for it is well known, that the situa- tion of divers Members of our Society, hath from this cause, been unspeakably distressing. A circumstance which, it needs no arguments to prove, must greatly retard, if not totally prevent their cure. " It has hitherto been judged best not to trouble any Meeting of discipline with the establishment, or future management, of such an Institution, because matters 28 HISTORICAL ACCOUN 1 Chap. I of this sort are often worse than unedifying to these Meetings. So large a number of subscribers as there is likely to be, in the compass of York Quarterly Meeting, with others from distant parts who may at- tend, are likely to be fully competent to direct the management for many years to come; and, before they are materially reduced in number, it will undoubtedly become their concern to provide for a regular succes- sion. But though it would not be proper, to introduce the whole management of the business in any Meet- ing for discipline; yet the simple consideration of aid- ing the Establishment by subscriptions, may not be an improper subject for such a Meeting. If one or more hundred pounds, should be raised and paid in its name, (the sums given by each Friend being specified or not, as they may choose,) such Meeting will not be subject to any future trouble, except that of keep- ing up an appointment of a friend or two, as agents, to correspond with the Committee, and re con. mend patients, &c; similar to what has been done by divers Meetings, towards the support of hospitals in different parts of the nation. " To conclude — aw Institution of this nature must be fixed somewhere, and, unless it be on a very small scale, many patients must be sent from a considerable distance. Friends who think the object worthy their attention, may be encouraged to promote it, not only on a principle of charity to the poor, but even of com- passion to those in easy and affluent circumstances; who will doubtless think themselves benefited, though they may pay amply for it. Those who ha\e embarked in this undertaking, have not been influenced by in- terested views, nor are they requesting or desiiingany fa\ours for themselves. A malady, in maty instances, the most deplorable that human nature is subject to, hath excited their sympathy and attention; and they invite such Friends as approve of their design, to co- operate with them in an Establishment, which hath for its object, the mitigation of misery, and the resto- ration of those, who are lost to civil and religious so- Chap. J. HISTORICAL ACCOUNT. 29 ciety: in the prosecution whereof, they humbly rely on the favour of HIM, whose tender mercies are over all his works." Another Meeting of the friends to the Establish- ment, was held on the 27th of the 6th month, 1793, which adjourned to the time of the General Meeting at Ackwoflh School; where the sixth Meeting was held on the 31st of the 7th month. The Subscriptions offered For annuities amounted to /.325; the donations to A799:13:6, and the annual subscriptions to /.32:0:6. Inadequate as these funds were, even to purchase a sufficient quantity of land for the proposed Institution, in a suitable situation, the Meeting, deeply impressed with a sense of the importance and propriety of the proposed undertaking, confiding also in the generosity of their friends, when they should become more fully informed on the subject, nobly resolved to prosecute the Establishment in which they had so earnestly en- gaged. They accordingly appointed a number of Friends, to look out for a suitable situation and quanti- ty of land, in the vicinity of York; and to make a pur- chase, if they thought proper. It was not, however, till the latter end of the year, that the Committee were able to make an eligible purchase. They then obtain- ed the situation, which had first appeared to them in every respect desirable. Its distance was only half a mile from the walls of the city; the ground was elevat- ed, and the situation afforded excellent air and water, as well as a very extensive and diversified prospect. The quantity of land purchased, was nearly twenty acres; for which the sum of/.2325 was agreed to be given. This being more than the Establishment was thought likely to require, about eight acres were im- mediately disposed of for the sum of /.9 68, leaving above eleven acres at the cost of /.l 357. An architect, and an eminent builder in London were immediately consulted respecting the buildVp, and their plans and estimates were laid before a Meet- ing in the 4th month, 1794. The estimate for the cen. trc and the east wing, amounted to /. 1883: 4: 1; and. 30 HISTORIC \l. At ; oiN I . ftp I short as the fundi still were of the expenses about to be incurred, the Meeting came to the determination, that the building should be speedily proceeded with; us it was Imped this would encourage Friends to come forward with additional subscriptions. Notwithstand- ing the endeavours which had been used to circulate information, relative to the proposed Establishment, it was apprehended that Friends, in may counties, were but little acquainted with the design; it was therefore agreed, at a Meeting in the 9th month, 1794, to publish " fifteen hundred copies of the rules, with some small variations and explanations, and a list of Subscriptions." These were directed to be circulated, as much as possible, within the compass of every Quarterly and Monthly Meeting in the nation. The amount of subscriptions, of which an account was published at this time, was, for annuities /. 875; donations /. 1443: 19: 6; annual subscriptions engaged for three years /. 46: 4s. In the commencement of the following year, 179.5, the building was covered in, and the inside work in great forwardness; but the funds being entirely ex- pended, it was agreed, at a Meeting of Subscribers, " to borrow what might be necessary to complete the place for the reception of patients." At a Meeting in the sixth month, a set of rules were proposed for the government of the Institution, copies of which were ordered to be printed, and given to each subscriber, that they might be fixed at the next Meeting. This was held in the ninth month, and the proposed rules, with but little alteration, were agreed moon; but as modifications and additions have since be^n made, and the present rules will be found at the end of the 2d chapter of this work, it is unne- cessary 10 detail here those which were then published. The additions to the donations, at the close of this vear, amounted only to /. 275: 8s.; and those to the annual subscriptions, to I. 5: 5s. The building was now vi v nearly completed and. at a Meeting on the 1st of 1st month, 1796, a,Committee was appointed to Clinp . I. HISTORICAL ACCOUNT. 51 engage proper persons to fill the various departments in the family. The m-xt Meeting being informed, that the house was likely to he ready for the recep- tion of a few patients, on or before the first of the sixth month following, appointed the same Friends to treat for the reception of patients, until another meeting. The Committee appointed to attend to the buildings, recommended that the shell of the west wing should be carried up; and the Meeting directed that not only the shell, but the interior also should be completed. Variety of sentiment, as might be expected, still on tinned to exist, as to the propriety of establishing a distinct receptacle for the insane of the Society of Friends. Only one opinion, however, could reasonably be entertained, of the motives which actuated the stre- nuous supporters of such an Establishment; and they were gratified to observe, that the interest of their Friends respecting it, continued to increase, as the nature and object of their benevolent design became more fully considered and developed. Four years had now elapsed since the first Meeting of the friends to the proposed Establishment; and they felt, as will naturally be supposed, a mixture of anxie- ty and pleasure, in contemplating the progress of their undertaking. But, confirmed, by further inquiry and observation, in the estimation of its importance; and relying on the favour of HIM, whose " mercies are over all his works," they looked forward with confi- dence to an increase of liberality, towards an Institu- tion, which proposed to relieve the greatest of human afflictions. (II A ITER ir. HISTORICAL ACCOUNT. Opening of the House — Physician appointed — Appointment and decease of the temporary Superintendent — Report of 1796 — Present Conductors engaged — Report 1797 and 1798— Additional Building to the East Wing — Report 17j9 — Rule respecting recent cases of Insanity — R 1800, stating the benefit of early admission — Report l8ol — Decease of J)r. Fowler — Dr Cappe appointed his iuc- cesso. — Report 1802 — Decease of Dr. Cappe — Dr. Bel- combe appointed Physician — additional Building to the West Wing— Reports 1303 to 1809 — The Appendage proposed and agreed to — Reports 1810 and 1811 — Report 1812, stating the Appendage to be occupied, &.c. — Gene> ral Remarks on the Institution — Summary of Annual Re- ports on the Finances — Rules of the Institution. THE house being ready for the reception of pa- tients, according to the expectation given at the last Meeting; and a housekeeper and several servants be- ing provided, the house was opened on the 11th of the 5th month, 1796, and three patients were ad- mitted, early in the following month. A Physician, re- sident in the city, was appointed to attend the house; but a suitable person for the important office of super- intendent, was still wanted. The place, however, was temporal ily supplied by the kindness of Timothy Maud, of Biadford, a Friend of great worth, as well as medical knowledge, who had retired from practice. The death of this benevolent person, in little more than two months, deprived the Establishment of his valua- ble services; and was at this time a serious loss to tho Institution. At the general Meeting of subscribers, on the 30th of 6th month, 1796, I find the following minute res- pecting the finances of the Institution, viz. ' The Com- mittee reports, " that the additional wini^ of tie build- ing, as directed by the last Quarterly Meeting ol sub- scribers, is in great forwardness; that the donations to this Institution amount to L 1789: 2: C>; to which may Chap. It. HISTORICAL ACCOUNT. 33 be added fifty pounds fallen in by the decease of an annuitant; that the annual subscriptions amount to 1.5 \:9s.i that the Institution remains subject to the pay- ment of five per cent, per annum, to life-annuitants, on the sum of 1.875; and that the several sums bor- rowed on interest, towards completing the building, amount to /. 1,245." ' The difficulty of finding suitable persons to have the superintendency of the family, occasioned the Committee no small trouble and anxiety. In the fifth month, however, of the following year, the person who, at present, has the management of the female department*, was happily engaged; and very shortly afterwards, the present superintendent and apothecary entered on his arduous offices. The conductors, and still more, the unhappy objects of this Establishment, have, great reason to esteem as a blessing, the appoint- ment of these individuals. The utility and excellence of all Institutions, how- ever perfect in plan, must depend, in great measure, upon the immediate managers; and what the poet has said of political governments, applies with peculiar force to establishments for the insane; " Whate'er is best administer'd, is best." An inferior plan well executed, may be more bene- ficial than a better system, under neglected manage- ment. Perfection, however, can never be obtained, without excellence in system, as well as in practice. The Report brought by the Committee to the Gene- ral Meeting, in the 6th month, 1797, states, that the total of subscriptions to this time, was, for annuities /. 875; donations /. 2043:0:6; and for annual subscrip- tions /. 46:4s. The Committee in their Report, say: " In laying before Friends the state of this Institution, we appre- hend it will be no small satisfaction to them to be in- formed, that it is now agreeably supplied with mana- • Tlie matron, or female superintendent, has the general care of the patients, as well as of the domestic department. C 2 34 HISTORICAL ACCOUN 1 Cli;ip<_lJ gers. The patients are under the care of a Physician, who visits the house several times a week; a man friend, well approved, hath undertaken the office of superintendent; and a woman friend that of house- keeper; both of wiiom have likewise a general over- sight of the patients. These, with two men and three women-servants under them, form the present estab- lishment of the house. " Though the great debt with which the Institu- tion is encumbered, may lay those who have the care of it under some difficulties, yet they conceive they are such as will not be insuperable, provided the In- stitution continues to possess the good opinion of the Society, with respect to its object, and that the man- agement also prove satisfactory; in which case it is hoped, that subscriptions and legacies will come in, • continued liberality of the Inendsol tlus establishment, highly desirable and necessary. The directors, observe, at this time, in their Report of the state of the institution: " We have ugain the satisfaction to inform its friends and supporters, tli.it the funds have received some considerable addition since the last year; and that the improve nent in ma- ny of the patients, continues to be such. ;ts to afford us encouragement in the undertaking. — live patients have left the Institution since last year, so far recov- ered, as to render confinement unnecessary, though most of them were cases of long standing: several others are also much improved. Fifteen more pa- tients have been admitted, in most of whom the dis- order had existed for a considerable time; several of them hud been removed from other Institutions of this nature, and considered as incurable. On this ground, the generality of them afford little or no pros- pect of a perfect recovery; yet divers of these appear more comfortable to themselves, and are improved in their mental faculties. There are now in the house 33 patients, viz. 16 men, and 17 women; eight of them at the low rate of four shillings per week, the rest from eight shillings to two guineas. " The number of male patients having proved greater than was expected, an additional building has been undertaken, and is nearly completed; and also a separate piece of ground walled in for their accommo- dation. " We find ourselves justified in the expectation we expressed last year, that the income from the patients would be nearly sufficient for their support and at- tendance, as there appears a defect of only l. 14: 8: 1. From the number now in the house, we hope that no deficiency on that account will, in future, take place." The experience of the Retreat had already proved the great importance of placing the insane under pro- per care, in an early stage of the disorder; and with a view of encouraging persons in straitened circum- Chap II. HISTORICAL ACCOUNT. 39 stances, to adopt this salutary measure, the General Meeting determined," That in cases of derangement, not exceeding six months from their first appearance, those members of our society, whose circumstances, in case of continuance, would not conveniently admit of their paying more than 8s. per week; shall he en- titled to an abatement of 4.9. a week, for one year, if not sooner recovered. Those patients who, by the for- mer rule, would have been rated at 4s. per week, will, under this regulation, be admitted gratis, for a year, if necessary." From the Report brought to the General Meeting, in the 6th month, 1800, it appears, that the addition to the property of the Institution this year, was /. 800 : 0 : 2; out of which the expense of the new building, /. 578 : 15: 11, was defrayed. — The report at this time, gives the following general view of the state of the Establishment: » From the preceding statement, it appears, that the liberal contributions of Friends, have enabled the managers of the Institution, to discharge the expen- ses of the late additional building and furniture, besides which there is a small reduction of the debt. The very high pi ice of provisions has frustrated the ex- pectations which they formed last year, that the in- come from the patients would support the establish- ment, exclusive of the payment of life-annuities, and the interest of money borrowed. The deficiency, how- ever, does not amount to thiity pounds. " Eleven patients have heen admitted since the last year. Six have recovered, and been discharged; three have died, two of whom were considerably ad- vanced in years. There are at present in the house, 36 patients, viz. 15 men and 21 women; 11 of whom are at the low price of four shillings, and one at five shillings per week. Two patients, whose disorder was recent, and who formerly would have paid four shillings per week, were admitted gratis, in consequence of the agreement entered into last year. They are both re- covered and discharged. 40 HISTORICAL ACCOUNT. Cfc*p B " Experience has this year abundantly convinced us, of the advantage to be derived from an early attention to persons afflicted with disorders of the mind. CM" the eleven above reported to have been admitted, two were removed from another Institution, as incura- bles; and three others were confirmed cases. The re- maining six were recent instances; four of whom re- covered, and were discharged within the first quarter after their admission; the two others are evidently recovering, and will probably be dismissed within the same period. This consideration will, we hope, encourage the friends of those who are, or may be afflicted with this malady, to remove them early, and place them under proper care and treatment. " We feel satisfaction in having it in our power to demonstrate the advantages of this institution: and we trust that nothing now remains necessary to convince Friends of its utility, and to encourage them more generally to co-operate in its support." The income from the patients, in the following year, reported in the 6th month, 1801, considerably exceeded the preceding; but, the expenses of the fami- ly, owing to the increased high price of provisions in this year, exceeded that income about I. 65. This de- ficiency was, however, mote than compensated, by the liberality of the friends of the establishment; and there was an increase of property this year, of/. 145. The report of the General Meeting states: « There have been thirteen patients admitted since the last year. Seven have been discharged in a state of recove- ry; and two have died. The number now in the house is 40; viz. 24 women and 16 men. Besides the per- sons recovered, the condition of several others lias been so much meliorated, as to afford additional en- couragement to those who have interested themselves in this institution. Friends are now so generally con- vinced of its utility, as to render it unnecessary to say- much in its favour. We indulge a hope, that those who have not yet come forward in its support, will be induced to unite with their friends in this undertaking, Chap. ir. HISTORICAL LCCOl M 41 as the debt with which it is still encumbered, con- tinues to claim the assistance of those who feel for the afflictions of their fellow-creatures." In this year, the Retreat was deprived) by death, of the valuable services of Doctor Fowler, who had at- tended the Institution from its first opening; and whose, humane assiduity to relieve the unhappy ob- jects of his care, had obtained for him the highest es- teem of the managers and family. The Committee, in a conference with the subscri- bers of York, appointed Dr. Cappe his successor. In making their Report, in the year 1802, the managers had the satisfaction to find, the hope was realized, which they had several times expressed, that the income arising from the patients, would be suffi- cient to defray the expenses of the family. There was a balance, this year, in favour of tiie latter, of /. 13:4: 1 1 ; and there was, on the whole, an increase of proper- ty belonging to the Institution, of /. 45: 5: 3. This in- crease, however, arose chiefly from subscriptions for annuities, as the unconditional donations and legacies were much less than usual. But, as the annual sub- scriptions were, this year, considerably enlarged, it did not appear that the attention or interest of the Society, in regard to this Institution, was in any degree di ni- nished; and the directors observe, at thic tinie, in their Report: " We trust that the benefit resulting from it, will continue to attract the liberality of Friends, which yet remains necessary, for discharging the payments to annuitants, and the interest of money borrowed; as well as to effect the desirable object of gradually re- ducing the debt." There were, at this time, in the house, thirteen men and twenty-nine women paients. At the close of tins year, the office of Physician again became vacant, by the death of Dr. Cappe; a man equally esteemed, for the gentle urbanity of his manners, the excellence of his understanding and dis- positions, and his professional attainments. He be- queathed, in his will, several valuable books to the D 42 HISTORICAL A.CCOUN'1 Clap. II library of the Institution, by the following clause: u T the Retreat) as a token of my respect for that admira- ble Institution, I leave all my books and pamphlets treating solely on the disorders of the mind, or, in any way solely relative to that subject; as, descriptions of asylums, 8cc." Dr. Belcombe, the present Physician, was appointed his successor, and we hope the Institution will long have the benefit of his valuable services. Applications for admission still increased; and, the present accommodation being too small, it was agreed, in the 3d month, 1803, that an additional building should be erected, at the end of the west wing. The income from the patients this year again ex- ceeded the expenditure, and the property of the Institu- tion experienced an increase of /. 258: 16: 3. The Report states, " The number of patients ad- mitted since the last year, is thirteen; six have been discharged, either recovered or improved, and one has died. There are now forty-eight in the house, viz. seventeen men and thirfy-one women." In the years 1804 and 1805, the income arising from patients, rather exceeded the expenses of the family; and there was an increase of property in these two years of /. 970, which fully defrayed the cost of the last new building. The average expense for each patient in the year 1804, was full /. 23 : 6 : 0 per an- num. The Reports were favourable as to the state of the patients, in proportion to the admissions; only four being admitted in 1 804, for want of room; but in 1 805, the number admitted was eleven. In these two years four died, and ten were discharged. Others were in a state of recovery, and it was believed that the situation of the whole was rendered as comfortable as their cir- cumstances would admit. In making up the accounts to the 3d month, 1806, it appeared that the expenditure exceeded the income from the patients, /. 48 : 7 : 9; and that there was a decrease in the property of the Institution, of /. 39 : II. HISTORICAL ACCOUNT. 4b 12 : 3. A very liberal and anonymous donation of /. 500, came in, very opportunely, about this time; and, in the following year, 1807, a favourable statement of the Institution's finances, was again presented; by which there appeared an increase of property, of /. 629 : 5 : 7. The income from the patients also exceeded the -urrent expenses on their account /. 24 : lis. In this and the preceding year, the number of pa- tients admitted, was twenty-one. Four died, and twelve were discharged, of whom ten were quite recovered; and there were in the house, at the time of each Re- port, fifty-three patients, viz. on the average of the two years, twenty men and thirty-three women. The Report in the year 1808, again exhibited a favourable account of the funds; and stated that I. 675 had been subscribed for annuities, since the last Report. The managers, however, endeavoured to engage the attention of their friends by stating, " that the Institu- tion is now subject to the payment of /. 136 : 5s. to annuitants, on the sum of /. 2725; and there still re- mains a debt of I. 1859 : 17 : 8 owing for principal and interest." In the course of the last year, fourteen patients were admitted, seven were discharged, recovered; and one died. There were, at this time, fifty-nine patients in the house, viz. twenty-five men and thirty-four wo- men. The same number of patients were reported in the following year, 1809; but it was still found that the accommodations were inadequate to the wants of the Society. Several applications were rejected for want of room; and it was, therefore, proposed to provide a separate house, to accommodate a few of those who might require the least extraordinary attention. Ten patients had been admitted since the preceding- annual Report: three had died, and seven had been ta- k en away; five of whom were recovered, andtwo remov- ed to other situations on occount of this house being too full. The income from the patients, again exceeded the expenditure, exclusive of the interest of mone* HI8T0RK \\. A i COUNT. Chap. II. and the payments to annuitants; and the property of ihe Institution was increased /. 431 : 13 : 7. The proposal to provide an additional house, was acceded to at the Quarterly Meeting in the 9th month; and an account was brought to the General Meeting in the 6th month, 18K), that premises bad been pur- chased for the sum of/. 1200; and that a few hundreds more would be required to make the necessary altera- tions, and to furnish the house. The Report published at this time stated, that as it was desirable the debt al- ready owing by the Institution, should not be increased, ' a subscription had been opened, and that /. 907 : 19*. had been offered towards the additional accommoda- tion proposed; but as that sum was considerably short of the occasion, it was hoped that other Friends would come forward with contributions to supply the defi- ciency. It also appeared, that from the very high price of provisions, the expenses of the family exceeded the in- come received from the patients; and that the property of the Institution was rather decreased. The Report also, states, " There have been five patients admitted since last year; six have been taken away, recovered, and two have died." The number of patients remain- ing in the house, was fifty-seven, viz. twenty-three men and thirty-four women. In the year 1811, eight patients were reported as admitted, and seven discharged; of whom six were re- covered, and the other much improved; one had died. The number remaining in the house, was the same as in the preceding year; with the variation of one in the proportion of the sexes, viz. twenty-four men and thirty-three women. The Report in this year exhibited a very favourable view of the finances, and proved the esteem in which the Institution was generally held. Donations to the amount of/. 1399 : 4s. had been received on account of the Appendage; and a legacy of /. 500 had been be- queathed to the Institution. The income from pa- tients this year, very nearly defrayed the expenses ol Chap. II. HISTORICAL ACCOUNT. 45 the family; and the property of the Institution was in- creased /. 1779 : 4 : 3. It is truly gratifying to observe the liberality with which this Institution has been hitherto supported by the Society; and I trust, if it continue to deserve their confidence, its funds will be yet more abundantly sup- plied. The introductory part of the Report for the last year, I shall here insert. " At a general Meeting of directors and subscribers, held at York the 25th of 6th month, 1812, the Com- mittee brought in the following Report: " From the state of the accounts which is now laid before the subscribers to this Institution, it will appear that the expenditure on account of the patients, has exceeded the income from them, to the amount of I. 53 : 9 : 1; but this sum, considering all circum- stances, and particularly the additional expenses of the Appendage, is no more than might be expected. We have, however, the satisfaction to state, that by means <>f donations and legacies, this deficiency has not only been supplied, but a surplus of /. 260 : 5 : 7 has ac- crued in the property of the Institution, above the to- tal balance of the last year. It will be observed, that a considerable sum on interest is still owing by the In- ".itution. " There have been only six patients removed during the last year; two of whom were recovered, and the others improved. Fifteen have been admitted, several of whom were confirmed cases, and who had been waiting some time till the Appendage was ready. None have died this year. There are now under the care of the Institution, sixty-six patients, viz. 26 men, and 40 women; of whom, four men, and eight women, are in the Appendage. This addition to the establishment, is fount to be a great advantage to the Society, by ad- mitting many patients, for whom accommodation was much wanted. It is, however, likely to occasion more expense than the income, from the increase of num- bers, will defray. Cut for this, and for all other exi- D2 46 H1ST0KICAL ACCOUNT. Chap II. gencics, we doubt not the liberality of Friends will sufficiently provide." It will be seen by the statement of the accounts published in the year 1812, which concludes the sum- mary of the finances, given in this chapter, that there is still a debt of/. 1745 : 10 : 10; for money borrowed, and interest upon it; and that the Institution remains liable also to the payment of/. 130 per annum for life- annuitants. If this debt were fully discharged, and the annual income materially increased, it is believed that several useful improvements might be made; and that an additional annual expenditure would promote the real welfare of the family. I confess, however, I do not wish to see the Retreat wholly independent of annual contributions. The gene- ral interest which this mode of support naturally occa- sions, and the constant stimulus which it must prove to those concerned in the management, to deserve the good opinion of the Society, cannot fail to have a salu- tary tendency. This chapter will be closed, with the present rules for the government of the Institution; but I wish, in concluding the present historical sketch of the Re- treat, to congratulate those who have interested them- selves in its establishment, on the satisfaction, which they must at present derive from the success of their benevolent exertions. The necessity for such an establishment has, on every account, been found much greater than was at first imagined, and, in the degree in which it has con- tributed to the comforts of the unhappy objects of its care, it has equally exceeded the expectations of its most sanguine promoters. 47 A SUMMARY OF THE ANNUAL statements of the finances, AS REPORTED From the General Meeting of the Directors and Subscribers, referred to in page 48, and commencing Sixth Month, 1797. State of the Funds up to the 31st of 3d Month, 1797. Property belonging to the Institution. I. s. d. Land and improvements, 1555 13 2 Buildings*, 3869 16 8| Furniture, 506 12 HA Cattle and provisions on hand, 38 16 Q2 J.5970 18 10 Debts owing by the Institution. To sundry persons on interest, Interest due thereon, Half a year due to annuitants, To patients' time unexpired, Owing on account of buildings, Ditto on land account, Ditto on furniture account, To W. Tuke, as treasurer, /. s. cl. 1945 0 0 19 14 8 20 12 6 24 11 8 911 13 7 2 19 6 11 9 10 365 15 2i 3501 16 1U Balance in favour of the Institution, 2669 1 10 I 5970 18 10 '* N. B. The Institution also remains subject to the payment of five per cent, per annum to life-annuitants, on the sum of I. 825. • The buildings include the Cold Bath, and divers additional buildings not in the first plan and estimate^ 48 HISTORICAL ACCOUNT. Chap. II. /. s. d. House expenses from 1st of 6th month, 1796, to 1st of 4th month, 1797, 316 13 0£ Income from the patients, 212 1 0" Expenditure above the income, 104 12 Qj Report, Sixth Month, 1798. /. ». d. Income from the patients, 388 9 10 Donations, 433 14 6 Annual subscriptions, 40 19 0 Subscription for an annuity, 100 0 0 A contingency, 2 10 0 /. t. d. 965 13 4 House expenses, including1 salaries artd servants' wages, cultivation of the land, &x. 434 0 0 Linen, wear and tear, 15 0 0 Furniture, ditto, 25 10 0 Physician and medicine, 39 2 10 Extra expenses, 6 17 10 /. s. d. Interest of money bor- rowed, 135 1 5 Ditto to annuitants, 41 15 6 520 10 8 176 16 11 697 7 7 Increase of property, /. 268 5 9 Sixth Month, 1799. I. s. d. Income from the patients, 678 9 0£ Donations and annual subscriptions, 449 12 6 Total income, 1128 1 6£ /. s. d. Expenses of the institution, 692 17 1^ Annuitants and interest of money, 190 3 31 3 883 0 5 Increase of property, Z. 245 1 1-g Chap. II. FINANCES. 49 Sixth Month, 1800. I. s. d- Income from the patients, 863 16 3j Legacies, donations, annual subscriptions, and subscriptions for annuities*, 1032 11 0 Total income, 1896 7 3^ Expenses of the establishment, /. 887 14 1-j Annuities and interest of money borrowed, 208 13 0 1096 7 U Increase of property, /. 800 0 2 Which was chiefly expended in new buildings. Sixth Month, 1801. I. s. d. I. *• d. Income from the patients, 997 14 0 Contributions, 416 2 0 1413 16 0 Expenses of the establishment, 1062 14 9^ Annuities and interest of money borrowed, 205 11 0 1268 5 9| Increase of property, /. 145 10 2^ Sixth Month, 1802. I. s. d. I. s. d. Income from the patients, 1082 U 11 Contributions, 239 18 0 Expenses of the establishment, 1069 6 Ill- Annuities and interest of money borrowed, 207 17 8 1322 9 11 1277 4 7| Increase of property, t. 45 5 3^ * As these particulars comprise all the usual modes of aid- ing the funds of this Institution, it is not thought needful to particularise them in the future summaries of receipts; nor does it appear necessary to repeat the items of expenditure, sriven in the two or three firit annual statements. 50 HISTORICAL ACCOUNT Chap. 11 Sixth Month, 1803. /. t. (I- I «• d. Income from the patients, 1114 10 M Contributions, J88 13U2 io 3\ Expenses of the establishment, 1029 5 10? Annuiues and int. of money borrowed^214 8 2 ^ Increase of property, /_2j8_16__3 Si'-rrt JlfonfA, 1804. /. s. 9 Committee. The terms of admission to be subject to future alteration, if found necessary; and, as the wearing of washing gowns and skirts is at present so much increased, that the washing of them in so large a family is attended with considerable inconvenience, it is agreed, that those belonging to the patients, shall be washed out of the house, and the expense charged to their respective accounts. 3d. A quarter of a year's maintenance for each patient, is to be paid in advance; and in case the pa- tient should be cured, or die before the expiration of the first quarter, no part thereof is to be returned; but, after the first quarter, return is to be made for the number of whole weeks unexpired, at the time of re- moval, or decease of a patient. 4th. As experience demonstrates, that the recove- ry of insane patients, frequently depends on their be- ing removed from their connexions, and put under proper care and treatment, in the early stages of the disorder, it is earnestly recommended to their friends, to remove them at an early period after the disorder appears to be fixed. And, as an additional induce- ment to persons in straitened circumstances, to adopt this salutary measure, it is concluded, that in de- rangements not exceeding six months from their first appearance, those Members of our Society, whose circumstances, in case of continuance, would not con- veniently admit of their paying more than eight shil- lings per week, shall be entitled to an abatement of four shillings a week for one year, if not sooner re- covered. Those patients who, by the former rule, would have been rated at four shillings per week, will, under this regulation, be admitted gratis for a year, if necessary: But, as some patients have come with dis- orders unconnected with insanity, and which require additional expense or attendance, it is judged neces- sary, that, in such cases, an additional charge shall be made, at the discretion of the Committee. 5th. On the admission of patients, the Committee should, in general, require a certificate signed by a 60 HISTORICAL ACCOUNT. Chap. II. medical person, to the following import: I do her thy certify, that A.B. ofC, aged years, is in a state of insanity, and proper to be received into a house pro- vided for the relief of persons of that description. It should also be stated whether the patient is afflicted with any complaint independent of insanity. It is also desirable, that some account should be sent, how long the patient has been disordered; whether any, or what sort of medical means have been used; and whether any disposition has appeared in the patient to injure him or herself, or any other person: with any other circumstances likely to throw light on the case rela- tive to his or her treatment. 6th. As the Committee is not to admit any patient, on lower terms than eight shillings per week, unless recommended by the agent of a privileged Meeting, or by a subscriber qualified according to the third rule respecting contributions, it is hoped that individual subscribers, will be cautious of recommending pa- tients, whose maintenance, or any part thereof, is paid by a monthly or other Meeting, to the saving of the expense of the members of such Meetings collective- ly; thereby rendering it unnecessary for them to sub- scribe to the Institution: But no discouragement is hereby intended, to the assistance of Friends whose circumstances, or those of their near connexions, are too strait to pay eight shillings per week. 7th. As, in many cases, it may be difficult for the friends of patients to procure suitable persons to con- duct them to the house, it is agreed that, on applica- tion, a proper person shall be sent from the Retreat, when it is convenient; the expenses only being paid by the patients' friends. 8th. Though it was the original design of this In- stitution, to accommodate such insane persons only, as are members of our Society; yet it was also consi- dered that cases might arise, wherein it might be desirable to extend such accommodation beyond the line of strict membership; but as an indiscriminate admittance of persons not in membership, would de.- Chap. II. RULES. 61 feat the special design of the Institution, by the ex- clusion of those who are members, the admitting, or not admitting of them, must always be left to the dis- cretion of the Commitee, and consequently time giv- en for consideration. 9 tli. The sending of patients without previous ap- plication, should, in all cases, be avoided, lest suitable accommodation be not at liberty for their reception; and Friends should also avoid bringing patients at late hours of the night. 10th. As circumstances may sometimes occur, wherein it is proper that the Committee should have a discretion to decline the admission of patients, though members of our Society; especially when the house is nearly full; it is agreed to vest such discre- tion in the Committee, until the Quarterly or General Meeting can be consulted; which Meeting shall de- termine the propriety of admitting or refusing such applications. JV. B. There are afiartmenis in which fiatienta with a servant may be accommodated, without mixing with the others. AN ACCOUNT OF THE FAMILY ESTABLISHMENT. Superintendent and apothecary — George Jepson. Female Superintendent — Katharine Jepson. Assistant to ditto. Two male attendants. One ditto, on a single patient. Three female attendants. One ditto, on a single patient. Cook, and a girl to assist. Laundry-maid. An assistant to'ditto, and to the nurses or female at- tendants. One labourer. One man who brews, bakes, &c. and, with the la- bourer, works in the garden. A gardener is occasionally employed. CHAPTER III. DESCRIPTION ANT) APPROPRIATION OF 1 UK GROUNDS AND HOI SE Situation — General aspect of the building' — The Farm — The Garden — The Courts for the different classes of Patients — Remarks — Application of the different parts of the Building- to the use of the Patients — On attention to the comfort of the Insane — The Retreat not a perfect model for erections of this kind — Early Managers laboured under the want of experience — The advantages of the Building described — Of its defects — Of the excessive attention to safety in the construction of Hospitals for the Insane. THE Retreat is situate on an eminenre, at the dis- tance of about half a mile from the eastern gate of the city of York. It commands a very delightful prospect, extending, on the south, as far as the eye can reach, over a wooded, fertile plain; and terminating on the north and east, by the Hambleton Hills and the Wolds; which are seen, in some places, at the distance of about twenty-five miles. The situation combines nearly all the circumstan- ces, which are usually considered favourable to lon- gevity; and the almost uniform health of the fami- ly, has confirmed the general observations on this subject. In the erection of the building, which is of brick, economy and convenience have been chiefly consulted. Dr. Dalarive describes the general appearance as being that of a rural farm; but, I confess, I cannot see the resemblance. The size of the panes of glass, certainly denies it the character of the modern mansion; at the same time, that the absence of bars before the win- dows, and the garden in front being defended from the road, only by a neat common hedge, prevent, en- tirely, the aspect of a place of confinement. There are eleven acres of land belonging to the Institution. This little farm is chiefly occupied in the growth of potatoes, and the support of the cows, which supply the family with milk and butter. Chap. III. DESCRIPTION, 8cc 63 The garden is on the north side of the house, and contains about one acre. This furnishes abundance of fruit and vegetables. It also affords an agreeable place tor recreation and employment, to many of the patients; being divided by gravel-walks, interspersed with shrubs and flowers, and sheltered from the in- trusive eye of the passenger, by a narrow plantation and shrubberry. On the south side of the house, are the courts for the different classes of patients. The circular wall which encloses the male and female patients' courts, arc about eight feet high; but, as the ground declines from the house, their apparent height is not so great; and the view from them of the coun- try is consequently not so much obstructed, as it would be if the ground was level. I cannot, how- ever, forbear observing, that the courts appear to be too small, and to admit of too little variety, to invite the patient to take exercise. The boundary of his excursion is always before his eye; which must have a gloomy effect on the already depres- sed mind. This might be considered as a serious de- fect, if it was not generally compensated, by taking such patients as are suitable, into the garden; and by frequent excursions into the city or the surrounding country, and into the fields of the Institution. One of these is surrounded by a walk, interspersed with trees and shrubs. The superintendent has also endeavoured to fur- nish a source of amusement, to those patients whose walks are necessarily more circumscribed, by supply- ing each of the courts with a number of animals; such as rabbits, sea-gulls, hawks, and poultry. These crea- tures are generally very familiar with the patients: and it is believed that they are not only the means of innocent pleasure; but that the intercourse with them, sometimes tends to awaken the social and benevolent feelings. The reader will probably wish to be informed, of 64 DESCRIPTION, &c. OF THE Chap. Ill the appropriation of its different parts, to the use of the patients. It will be proper first to mention, that there arc, at present, under the care of the Institution, twenty- four male and thirty-eight female patients; but, of these, four men and seven women arc in the building at some distance, distinguished by the name of the Appendage. These patients arc of the confirmed class, and are such as do not, in general, require ex- traordinary coercion. There are two day-rooms in the Retreat, on the ground floor, which are occupied by the men patients. The day-room in the extreme east building, and the court adjoining to it are occupied by the more vio- lent patients, and such as are least capable of ra- tional enjoyment. The number of patients in this room varies; but is usually from seven to ten. They are under the general care of one attendant; who also prepares the room for their reception in the morning, brings them their meals, and makes their beds. In his several offices, he is frequently assisted by some of those, who are under his care. The windows in the room are small, double sashes, of cast iron, placed at four feet and a quarter from the ground, and are not defended by any grating. This is not found necessary, although on an average there are not more than two male patients, under any personal restraint by armstraps, jacket, 8cc. The pa- tients are prevented from approaching too near the fire, by a circular iron guard. This projects about three feet and a half, is inclosed at the top, and opens in front by a small door, which is kept locked. An appartmentnear this day-room is used, when ne- cessary, for the entire seclusion of a violent patient. It is furnished with a bed, securely fastened to the ground. Light is, in great measure, but not entirely excluded; and care is taken to have the room proper- ly ventilated. This room also affords an opportunity of temporary confinement, by way of punishment, for any very GROUNDS AND HOUSE. 65 offensive acts, which it is thought the patient had the power to restrain; but this very rarely occurs; and I am happy to say, the appartment is frequently unoccu- pied; or in other words, there is not, on an average, from any cause, one male patient in a state of seclu- sion during the day. The day-room in the east wing, adjoining the par- lour, and the male patients' court, accommodate the superior class, in regard to behaviour, and to capacity of rational enjoyment. There are two windows in the room, which afford an agreeable view of the country. They are three feet and a half wide by six feet high, each containing 48 panes of glass, or 24 in each sash. The frames of the sashes are of cast iron,- about one inch and a half square; the glass-bars are about five- eights of an inch thick, and each pane of glass is about six inches and a half by seven and a half. Airjis admit- ted through the windows, by placing the upper cast iron sash, not glazed, immediately over the lower one, and hanging a glazed wooden sash, precisely of the same dimensions, on the outside of the iron frame. In this manner the double sash windows, in genera], es- pecially in the patients' apartments, are all effectually secured, without an appearance of any thing more than common sashes with small squares. It is not found necessary here, in general, to protect the fire by a guard, as in the other day-room. The number of patients in tins room, who are intrusted to one atten- dant, is at present twelve. The offices are similar to those of the attendant, in the other day-room. Patients of the higher class, in regaid to property, arid who can be intrusted to leave the gallery, take their meals with the superintendent and the female patients of the same class, in the dinintr-mom, of the centre building. The convalescents of the lower class, many of whom have been, previously to their disorder, in respectable situations, are frequently admitted to take their meals in this room; as the change is found essentially to promote their recovery. All the lodging-rooms on the ground floor, and F 66 DESCRIPTION, be. OF nil'. Chap. ED those of the second story, in the extreme cast building, are appropriated to male patients. The general size of the windows in these rooms, is three feet by three feet six inches. They are placed between six ;nul seven feet from the floor, and reachjto the ceiling; t lie height of each room, being about nine feet. Many of these windows were originally boarded up, except one row of panes; but experience has proved this precaution to be generally unnecessary; and the shutters arc most of them removed. The frames of the shashes are of cast iron, as already described page 65; but these windows being only a single sash, air is admit- ted Fat the upper row of panes, consisting of six squares, by not glazing one half, and having a small wooden slide, with three panes of glass in it, to open and shut as occasion requires. Air is also admitted into the patients' rooms through a small wicket in the door, which is thus constructed: The door has six flat pannels, and the two upper ones have a small wicket between them, hung with two joints on one edge, and bevelled on the other edge to prevent its passing through. Thus, when shut, it is even with the pannels. Over the wicket, slides, in a groove, a piece that completes the appearance of the munnion, or middle stile of the door; and when this is in its usual place, it leaves no appearance different from that of a common door. This contrivance not only admits air, for ventilation, but affords an opportunity for the at- tendants, quietly to look in, if a patient's situation re- quires such attention. Each door is secured by a small, spring, mortice lock; and also a bolt on the outside: but the grating sound of the latter, is very objectiona- ble; and it appears that a strong, spring, mortice lock, would afford sufficient security in all cases. The furniture in the bed-rooms varies, according to the terms upon which the patient is admitted, and to his state of mind. The bedsteads of that class of patients, who are insensible to the usual] calls of nature, have circular wood bottoms, perforated with holes; beneath which is placed a receiver. The bed is merely clean straw, over which is laid a blanket; up- Chap III. GROUNDS AND HOUSE. 67 on this the patient sleeps, and is covered with blankets. The other patients, of whatever rank, have the usual kind of beds or mattrasses. The beds of those who are not of the lowest class, are of better quality. They are half-headed, and furnished with curtains, put up in so slight a manner, as to prevent the possibility of any danger arising from this indulgence. An air of neatness and comfort is thus given to the rooms; and, though some have been disposed to contemn as super- fluous the attention paid to the lesser feelings of the patients, there is great reason to believe, it has been of considerable advantage. The » single patient's day-room," and the chamber adjoining, in the front of the centre building, on the second story, are occupied by a male patient who has a distinct attendant. These rooms would not be ineli- gible for the accommodation of a person in any rank of life. The other three day-rooms on the second story, are occupied by female patients. The more refractory class usually occupy that in the extreme west building, and the « female patients' court." There are upon the ground floor, two rooms for the entire seclu- sion of patients during the day, when necessary. These, however, like that appropriated to the same class of male patients, are very frequently unoccupied; and, on an average, there is not one female patient, re- quiring solitary confinement during the clay. The number in the day-room assigned to the worst class, is generally from ten to twelve. The other day-rooms, are not occupied by distinct classes of patients, either in regard to circumstances, or to state of mind; except that if a patient finds the society in one room unpleasant, she is removed to the other. Each of these rooms has a female attendant or nurse, who, with the assistance of some of the convalescents, does every thing for the patients under her care, except preparing their food. The windows arc double sashes, undefended by any grating, as already described. The fires in all the female patients' day-rooms, are at pre- sent protected by guards. 68 DESCRIPTION, &c. OF THE Chap. IB. There are about five or six patients of the superior > lass both in respect of terms and disorder, who occu- py the dining-room as a day-room. The bed-rooms of this class, are in the atic of the centre building; and nothing particular appears in the manner of the fur- niture; though the curtains are not hung upon rods as usual; but are slightly attached to the head of the bed. These chambers are very comfortable, and the prospect from them is most delightful: one of them is used as a day-room, by a patient who has a distinct attendant. The windows are double sashes; and are placed at the usual height from the floor. The doors are secured by the spring locks. The attention which is due to the comfort of the insane, and the degree iti which it is compatible with their security, appear to have been, till very recently, objects of little general consideration. It is not, there* lure, to be supposed, that the Retreat, which has now been erected seventeen years, and which was originally intended for only thirty patients, should be a perfect model for establishments of this kind; though every c are was exercised in its first construction. Indeed, it is hardly probable, as the class of persons, both as to rank and disease, in different establishments, n.unt be various, that the arrangements in any one, can be precisely followed in another. The promoters of this Institution, as they observed in one of their early Reports, could not be supposed to be superior to those disadvantages, to which the want of experience naturally exposed them. When it is also considered, that they were unable to form any probable opinion, of the proportions of the different classes of patients, either in regard to rank or disease; and that the number has, unhappily, so much exceed- ed their expectations, it will not be surprising, that i he building has several imperfections, but rather that it possesses so many advantages. It has been already observed, that the aspect of a place of confinement is prevented, by the substitution of cast iron window frames for the bars, which, in Chap. m. GROUNDS AND HOUSE. 6^ similar places, usually guarded the avenues of light. This contrivance unites the advantages of security, neatness, and durability. There are not in this house any cells under ground. All the rooms, except three which derive their light from an adjoining gallery, have glass windows. Iron bars and shutters, are too often substituted for glazed windows,, in rooms appro- priated to the insane. The obvious consequence is, that the air, however cold, cannot be kept out of the apartment, without the entire exclusion of light. The distance at which the lodging-room windows are placed from the ground, is, in many instances, a necessary precaution, to prevent the injury of the patient, or the destruction of glass. There has not, however, appeared occasion for this precaution, to the extent in which it seems to have been anticipated; and it would perhaps be better, if, in a few more of the gallery lodging-rooms, the windows would allow the patient to view the surrounding country. It may be proper to observe, that, in the galleries, each patient lodges in a distinct apartment. One circumstance, which I much regret, in the construction of this building, is, that there are rooms on both sides of the galleries; for, though a large por- tion of light is admitted, by the window at each ex- tremity of the building, yet, the galleries on the ground floor, at least, are rather gloomy. I observe with pleasure, in a very ingenious ac- count and plan of a new asylum at Glasgow*, that the galleries have rooms on one side, and windows on the other. This cannot fail to give an air of cheerfulness, highly desirable in such establishments. Many errors in the construction, as well as in the management of asylums for the insane, appear to arise from excessive attention to safety. People, in • " Remarks on the Construction of Public Hospitals," by Wm. Stark, Esq. architect. This work, as well as •' Observa- tions on the Treatment of Lunatics," by Robert Reid, Esq. architect, deserves the attention of those who are engaged in such undertakings. F2 70 DESSRU'TlOX, be. Chap. Ilf- general, have the most erroneous notions of the con- stantly outrageous behaviour, or malicious dispositions, of deranged persons; and it has, in too many in- stances, been found convenient to encourage these false sentiments, to apologize for the treatment of the unhappy sufferers, or admit the vicious neglect of their attendants*. In the construction of such places, cure and com- fort ought to be as much considered, as security; «nd, I have no hesitation in declaring, that a system which, by limiting the power of the attendant, obliges l.im not to neglect his duty, and make it his interest to obtain the good opinion of those under his care, provides more effectually for the safety of the keeper, as well as of the patient, than all " the apparatus of chains, darkness, and anodynes." * I once accidentally visited a house for insane persons, in which security was made a. primary object- Here I saw three of the keepers, in the middle of the day, earnestly employed Th— - playing at earth.' CHAPTER IT. MEDICAL TREATMENT. character of the first Physician— Result of his experiments as to the general importance of Medical treatment — Of the reducing system in particular— Of forcing the Patient to take medicine— Consequent humane direction of the Phvsician— Of the use of the Warm Bath in Melancholia— \n 'Mania— Mode of using it— Use of Cold Bath in a case of high Mania— Importance of attention to the general healtii of the Insane— Frequent extraordinary sympathy between body and mind in this class of persons— Advan- tage of attention to the bodily health of Convalescents- Use of topical bleeding on the approach of a paroxysm — Necessity of close individual attention to Patients, an argu- ment against large Establishments— Difficulty of obtaining Sleep— Mode practised at the Retreat— VV ant of discrimi- nation in the medical treatment of Insanity — Remarks on the practice of Bethlem Hospital— Of mortifications of the extremities from cold or confinement — Of the capacity of Maniacs to bear cold— Of Diet— Usual bill of fare— Of the antiphlogistic system — Doubt respecting the Diet of the Retreat — Of the capacity of Maniacs to bear hunger — Beneficial effects of air and exercise. THE experience of the Retreat, if it should contri- bute in some degree to the improvement, will not add much to the honour or extent of medical science. I regret that it will be the business of the present chap- ter, to relate the pharmaceutic means which have fail- ed, rather than to record those which have succeeded. The physician* first appointed to attend at the Re- treat, was a man equally distinguished by medical knowledge, and indefatigable perseverance. He pos- sessed too, (which rendered him peculiarly adapted to the place he filled,) a highly benevolent and unpreju- diced mind. His experience had not been great in that particular branch of his profession, which on this occasion claimed his attention; but, as might be ex- pected, he entered on his office with the anxiety a.nd ardour of a feeling mind, upon the exertion of whose • Dr. Thomas Fowler, author of " Medical Reports," &c. Stcr 72 MEDICAL TREATMENT. Lhap. IV. skill, depended the dearest interest of many of his fel- low-creatures. He determined to give a full trial of the means, which his own judgment might suggest, or which the superior knowledge and experience of others had already recommended. But the sanguine expectations, which he successively formed of benefit to be derived from various pharmaceutic remedies, were, in great measure, as successively disappointed; and, although the proportion of cures, in the early part of the Institution, was respectable; yet the medical means were so imperfectly connected with the pro- gress of recovery, that he could not avoid suspecting them, to be rather concomitants than causes. Further experiments and observations confirmed his suspi- cions; and led him to the painful conclusion, (painful alike to out' pride and to our humanity,) that medicine, as yet, possesses very inadequate means to relieve the most grievous of human diseases. Bleeding, blisters, seatons, evacuants, and many other prescriptions, which have been highly recom- mended by writers on insanity, received an ample trial; but they appeared to the physician too ineffica- cious, to deserve the appellation of remedies, except when indicated by the general state of the habit. As the use of antimaniacal medicines was thus doubtful, a very strong argument against them arose, from the difficulty with which they were very frequently ad- ministered; as well asfrom the impossibility of employ- ing powerful medicines, in a long continuance, without doing some injury to the constitution. The physician plainly perceived how much was to be done by moral, and how little by any known medical means. He there- fore directed, with his usual humanity and modesty, that any medicine which he might prescribe, by way of experiment, should not be administered, where the aversion of the patient was great; unless the general health strongly indicated its necessity; well aware, that otherwise, the probable good would not be equal to the certain injury. There is, however, one remedy, which is very fie- Chap. IV. MEDICAL TREATMENT. 73 quently employed at the Retreat, and which appears to have been attended with the happiest effects; and that is the warm bath. In the first years of the Insti- tution, this remedy was not so much employed, as it is at present; for it was natural to pay most attention to such means, as medical writers, professing experi- ence in the treatment of the maladies of the mind, had most strongly recommended: and it is not a little remarkable, that, of the various means proposed for the cure of these disorders, few, if any, are less re- commended than the warm bath. This remedy, how- ever, has been for several years, and it still is consi- dered, at the Retreat, of greater importance and effica- cy, in most cases of melancholia, than all the other medical means which have been employed. Dr. Willis appear* aware of the importance of warm bathing, in cases of insanity, by the answer which he gave to a question upon that subject, from a select Committee of the House of Commons, on the " 9th of March] 180r." This remedy, however, at that time, had been employed for several years with great advan- tage at the Retreat. w Question. Are you of opinion, that warm and cold ba:hs are necessary for lunatic patients?" " Answer. I think warm baths may be very useful; but, it can seldoui happen that a coM bath will be re- quired."* ^ That tl»is remedy deserves the attention it receives in this Institution, appears evident by the unusual number of recoveries, in cases of melancholia, to which class the warm bath is chiefly applied. In several cases where the use of this means has been necessari- ly suspended, the patient has evidently relapsed. No advantage has been found from its use, in case of ma- nia; indeed, it has been thought rather to aggravate the symptoms. The time of the patient's continuance in the bath, and the temperature at which it is used, are * Vide Report from the Select Committee, appointed, to in quire into the state of lunatics, flatlam's Obecwatiom, p. 3 35 74 MEDICAL TREATMENT. ip. IV. gradually increased; the former from twenty minutes to nearly an hour; and the latter, from 85 to 98 decrees. The cold bath has been frequently tried in a variety of cases, both of melancholia and mania; but the lcsuk of the experiments is said to be unfavourable to its general use. In one case, during a paroxysm of high ungovernable mania, immersion of the body, except the head, in the cold bath, for the space of one or two minutes, appeared essentially useful in quieting the patient; but the remedy, in such cases, ought to be applied with great judgment; and its application should always be witnessed by the master, or mistress of the family. Having shown the result of the experiments made by the respectable physician, who first attended the Retreat officially; it is almost unnecessary to say, that his conclusions have, since, considerably influenced his successors. This, however, has not been entirely the case. Anxious to remove the difficulties that have hitherto attended every attempt, to relieve this most deplorable of human maladies, they have had recourse to various means, suggested either by their own knowledge and ingenuity, or recommended by later writers; but their success has not been such, as to res- cue this branch of their profession, from the charge, unjustly exhibited by some against t^ie art of medicine in general, of its being chiefly conjectural. It must not, however, be supposed, that the office of physician, is considered at the Retreat, of little im- portance. The physician, from his office, sometimes possesses more influence over the patients' minds, than the other attendants; and in all cases where the men- tal disease, is attended by any bodily disorder; and more especially when it has supervened any obvious malady, however slight; judicious medical attention, has been found of the greatest advantage. The im- provement of one part of the system, has so frequent- ly and regularly kept pace with that of the other, as to leave no doubt of the great importance of attention to the general health of insane patients. The inexplica- €hap IV. MEDICAL TREATMENT. 75 bic sympathy between body and mind, appears to ex- ist, in a morbid degree, in this description of persons; and to them, the remark of Dr. Beddoes, that there is more connexion between a sound mind and a sound body than is generally imagined, is peculiarly applica- ble. A degree of indigestion, or a fullness of the blood- vessels, which, in others, occasions only a head-ache, or a slight degree of mental inactivity, often produces, in habits where the tendency to insanity is strong, a vio- lent maniacal paroxysm; and has frequently been at- tended by an accession of the diseased symptoms; or by a relapse when convalescence appeared approach- ing. We are, however, far from adopting it as a univer- sal maxim, that maniacal symptoms are aggravated by bodily disorder. On the contrary, several instances have occurred, at the Retreat, of what Dr. Ferrier has termed « conversions;" in which the latter disease has apparently suspended or obliterated the former; and many in which severe bodily indisposition has attend- ed the patient, without any abatement of the maniacal symptoms. These instances by no means lessen the importance of attending to the bodily indications of insane persons; more especially during lucid intervals, or the period of convalescence. From attention to this branch of medical treatment, very great advantage appears to have been derived, at the Retreat. Topical bleeding has been found eminently useful, where the approach of a paroxysm, was indicated by a determination of blood to the head. In one case par- ticularly, in which the paroxysms had previously been frequent, their return was apparently delayed, for a great length of time, by the judicious use of the scari- fying instrument, applied to the shoulders and back of the neck; and on this means of prevention being with- held, a relapse shortly ensued. Hence, we cannot but perceive the importance of insane patients being un- der the frequent observation of persons of knowledge, judgment, and probity. Hence also an argument arises against very large Institutions, where the num- 76 MEDICAL TREATMENT4. Chap. IV. ber of patients is too great, to come under the pro- per inspection of the superintendent; and where they are therefore chiefly left to the care and management of keepers, who too frequently possess few of the qualities necessary for their office, unless we consider as such, " Limbs of British oak, and nerves of wire." The difficulty of obtaining sleep for maniacal pa- tients, and the unpleasant effects frequently produced by the use of opium, are well known to medical prac- titioners. It occurred, however, to the sensible mind of the superintendent, that all animals in a natural state, repose after a full meal; and, reasoning by anu- ology, he was led to imagine, that a liberal supper would perhaps prove the best anodyne. He there- fore caused a patient, whose violent excitement of mind indisposed him to sleep, to be supplied freely with meat, or cheese and bread, and good porter. The effect answered his expectation; and this mode of ob- taining sleep, during maniacal paroxysms, has since been very frequently and successfully employed. In cases where the patient is averse to take food, porter alone has been used with evident advantage, always avoiding, in all cases, any degree of intoxication. Since writing the above, I have been informed, that a mode somewhat similar, was practised at a private establishment of some celebrity, in Lancashire. It was a regular custom in that house, for all the patients to be shut up in their lodging-rooms, for at least an hour after dinner; and it is said, but I am not in pos- session of particular information on this point, that numerous cures were performed under this treatment. The application, however, of any single means, to all cases, can hardly be judicious. It has been, and it still is very common, to treat in- sanity with too little discrimination. Of this practice we have a striking instance in one of our largest pub- lic Institutions. I presume not to pry further into the practices of this establishment, than I am enabled to Chap. 1\ MEDICAL TREATMENT; 77 do by the statements of the professional attendants, which have been recently published. The surgeon informs us, that "The curable patients in Bethlem Hospital, are regularly bled about the commence- ment of June, and the latter end of July:"* and the apothecary to the same Institution tells us; " It has been for many years the practice, to administer to the curable patients, four or five emetics in the spring of the year." He adds, « but on consulting my book of rases, / have not found that such patients have been particularly benefited by the use of this remedy. "f It appears that this indiscriminate treatment of insanity, is not confined to Bethlem Hospital.— Dr. Pinel, after ridiculing the enormous catalogue of pow- ders, extracts, juleps, electuaries, draughts, and epi- thems, which are recommended in books, as remedies of great virtue, in cases of insanity, says: " What are we to think of the practice of repeated blood-letting, which is so universally the fashion of the firesent day, without attention to the distinctions of the existing < uise, the varieties of sex, or of individual constitution; and the different species and periods of the com- plaint?" Dr. Arnold, in the introduction to his Observations on Insanity, states, that one end he proposes by his remarks is, to point out " the great variety of those disorders, which are called by the general appellation of madness, insanity, or lunacy; and, to put a stop to the usual practice of imprudently trusting their un- happy friends, who have the misfortune to be afflicted with so various, terrible, and obstinate a#desease, to the common emfiirical practice of indiscriminate evac- uation, not to mention harsh and cruel treatment, in the hands of any illiterate firetender.'" Under the head " Medical treatment," as practised in the Retreat, some may possible inquire, what are the means employed in mortifications, arising from • Crowther on Insanity, page 102. t Haslam's Observations on Madness, page o29- Ci 78 MEDICAL TREATMENT. Chap VI. cold and confinement? " a calamity, which," says a writer before alluded to, " frequently happens to the helpless insane, and to bed-ridden patients; us ray at- tendance in a large work-house, in private mad-houses, and Bethlem Hospital, can amply testify*." Ilaslam also observes, that the patients in Bethlem Hospital, " are particularly subject to mortifications df the feet; and this fact is so well established from former accidents, that there is an express order of the house, that every patient, under strict confinement, shall have his feet examined every morning and even- ing in the cold weather, by the keeper, and also have them constantly wrapped in flannel; and those who are permitted to go about, arc always to be found as near to the fire as they can get, during the winter season. "t Dr. Pinel also confesses, that " seldom has a whole year elapsed, during which no fatal accident has taken place, in the Hospital de Bicetre, (in France,) from the action of cold upon the extremities." Happily, in the Institution I am now describing, this calamity is hardly known; and no instance of mor- tification has occurred, in which it has been, in any degree, connected with cold or confinement. Indeed, the patients are never found to require such a degree of restraint, as to prevent the use of considerable ex- ercise, or to render it at all necessary to keep their feet wrapped in flannel. It will be proper here to observe, that the experi- ence of the Retreat, fully confirms the opinion of seve- ral respectable modern writers, that maniacs arc by no means exempted from the common effects of cold; and it is to be hoped, for the sake of humanity, that the opposite opinion, alike barbarous and absurd, will be entirely exploded. The apothecary to Bethlem Hospital, after stating that the patients are not ex- empt from the usual effects of severe cold, observes very justly: " From the great degree of insensibility which * Crowther, p. 61. f Observations on Madness, p- 84. 1\. MEDICAL TB1ATMENT. 79 prevails, in some states of madness, a degree of cold would scai cely be felt by such persons, which would create uneasiness in those of sound mind; but experi- ence has shown that they suffer equally from severity of weather. When the mind is particularly engaged on a \y subject, extcrn.il circumstances affect us less, than when unoccupied. Every one must recollect, that in following up a favourite pursuit, his fire has burned out without his being sensible of the alteration of temperature; but when the pci lormance has been finished, or he has become indifferent to it from fa- ll- uc, he then becomes sensible to cold, which he had iiot experienced before." In considering the medical treatment of the insane, we must not overlook the generally important consi- derations of diet, air, and exercise. I do not find that many experiments have been made, at the Retreat, upon the subject of diet. The usual bill of fare for the patients on the charity, is such as I imagine will be considered adapted to persons in common health. It is as follows: Breakfast — Milk and bread, or milk porridge. Dinner, — Pudding and animal food five days in the week; fruit pudding, and broth or soup, two days. In the afternoon, the men have bread and beer, the women tea or coffee. Sufifier — Generally the same as breakfast, or bread, cheese, and beer. The superior patients have no particular diet, but live in all respects as the superintendents. Those practitioners who are disposed to recom- mend a very spare diet, in nearly all cases of insanity, will probably be startled at this account of the mode of living at the Retreat; and those more discrimina- ting persons, of whr se curative means, the antiphlo- gistic, or, in plain English, the reducing system, forms so essential a part of treatment, wherever" ir- ritation or violence exists," may be disposed to con- sider our diet as more liberal than judicious. So ma- 30 MEWCAL TREATMENT. Chap. IV. ny iastanr.es, however, have occurred of complete re- covery, after a full trial, previously to admission, had been ineffectually given to diet and medicament reducing nature; that the managers of this establish- ment, feel no inclination to alter their present plan. I am assured by our physician, who, in his own prac- tice, has had extensive opportunity of observation, that he has seen very few cases, in which a low diet has produced a good effect. On the contrary, " those maniacs who refused their food, have had generally the strongest and most durable paroxysms, and their subsequent depression has been the most deplorable." Case 74, affords very striking evidence in favour of a liberal, nourishing diet, even where great " irrita- tion or violence exists." The patient was described as a furious, dangerous lunatic; and the reducing system had been fully tried upon him, with an aggravation of his complaint. The opposite modev^is then pursued; and his appeiito, from being long famished, was al- most voracious for many days. It gradually lessened, ■till it arrived at the common standard. He took no medicine; and under the treatment he met with, his irritation of mind gradually subsided, and his recove- ry was very rapid and complete. I will, however, venture to express my doubts, whe- ther the Retreat diet be sufficiently discriminative. In -most, if not in all cases of insanity, the animal spirits appear to be either excited or depressed beyond their proper bounds. Knowing, as we do, the effect of food upon ourselves, is it not rational to suppose, that an opposite or different diet, will, in some cases, be re- quired in these opposite states of mind? Pursuing the same track of analogy, which proved so successful in the discovery of the means of obtaining sleep, may we not be led to infer the diet, which is best adapted to some, at least, of the different classes of insanity? The effect of diet upon our dispositions and habits, has been generally admitted. Eschylus makes the king of Pelusgia say to the herald who threatened htm with war, Chap. IV. MEDICAL TREATMENT. 81 " Yon shall be met by men whose lively blood, Dull draughts of barley wine have never cloggM." livery one will probably have observed, that after •uting a hearty dinner, he is indisposed either to men- tal or bodily exertion; nor can the different degrees of this indolent feeling which prevail, according to the quantity or nature of the food employed, have escaped notice. The difference in the French and English charac- ter, has been in part attributed to the different mode of living in regard to diet. In France, melancholy is said to be a stranger; whilst with us, and certainly we have long had more political right to be merry, melancholy, and hence suicide, is proverbially common.* Some writers are, however, of opinion, that this fatal propen- sity, does not, in any degree, arise from the cause we have just mentioned. Dr. Bctkloes says, " there are few countries in Europe, of which the inhabitants do not consume as much animal food as the correspond- ing classes of the English." Be this as it may, the im- portance of attention to diet, appears to me to derive sufficient support from the general effect of different kinds of food on our mental feelings. After apologizing to the reader for this speculative • " I cannot," says a medical observer, " by any means persuade myself that the excess of the English in animal food, has any thing to do with the frequency of self-murder, in their otherwise fortunate island. For in Bavaria, Austria, and other provinces of the German empire, far more butchers' meat is served up than in England, and far more eaten. Yet with us, suicide is a far more unfrequent occurrence. That we, in fact, eat a greater quantity of meat than the English, I was con- vinced of, by the entertainments at which I was present in London. And I still recollect with pleasure, an incident to this purpose that took place at Coventry. At an inn in that city, my fellow-travellers and myself bespoke all the articles in the bill of fare. They were about six, and we were obliged to repeat our order to the waiter three several times, and at last were interrogated by the landlady herself, whether we had in earnest ordered^ all that meat. So simple is English fare. — Salzburg Med Cwfrvrg. Zectung. 1798, I. 170." Beddoes' Essay on Consump- page HI. G2 82 MEDICAL TREATMENT. Cl.ap. IV. digression, I return to the more useful detail of prac- tical results. The absurd notion respecting the capaci- ty of maniacs generally to resist the action of cold, has been already mentioned. The supporters of this opin- ion, also generally observe, that insane persons com- monly endure hunger without injury. — The latter sentiment is no less at variance with the experience of the Retreat, than the former. Some of the patients, more especially the melancholies and convalescents, besides their four usual meals in the day, require the intermediate refreshment of biscuit, with a glass of wine or porter; and attention of this kind is consider- ed almost essential to the recovery of many patients. « General propositions," says Dr. Pinel, « have been too often advanced in regard to the capacity of maniacs to bear extreme hunger with impunity. I have known several, who were voracious to a great degree, and who languished, even to fainting, from want, or defi- ciency of nourishment. It is said of an asylum at Na- ples, that a low spare diet is a fundamental principle of the Institution. It would be difficult to trace the ori- gin of so singular a prejudice. Unhappy experience, which I acquired during seasons of scarcity, has most thoroughly convinced me, that insufficiency of food, when it does not altogether extinguish the vital princi- ple, is not a little calculated to exasperate and prolong , the disease."* I would not have dwelt so long upon these mistaken opinions, if they had not furnished a specious pretext for much practical barbarity; and I am, therefore, anx- ious to see them ranked with the marvellous stories of the Phoenix and the Salamander. Where various means are employed, it is difficult to say which is the operative one; but, whatever may be the means used, there is great reason to believe that a clear dry air, which the situation of the Retreat affords in an eminent degree, will facilitate their opera- • Dr. Davis's translation of " Pinel's Treatise on Insau- '*y,» p. 31. Chap. IV. MEDICAL TREATMENT. 83 tion, and be favourable to the recovery of insane per- sons. To reason again from analogy; the general ef- fects of fine air upon the animal spirits, would induce us to expect especial benefit from it, in cases of men- tal depression; and to pay all due respect to the physi- cian, who, " Gives melancholy up to Nature's care, And sends the patient into purer air." Several instances have occurred, in which melan- choly patients, have been very much improved by their journey to the Retreat; and it is ihe decided opinion of the manager of this Institution, that, in such cases, close confinement is, of all things, the most detri- mental. CHAPTER V. MORAL TREATMENT. SECTION I. INTRODUCTORY OBSERVATIONS. Importance of Management in a curative point of view- Power of self-control possessed by Maniacs — Tlie disor- der generally partial, in regard to both the intellectual powers and affections — Of ihe malevolent dispositions evinced by Maniacs — Powerful effect of judicious kind- ness— Practices of the Retreat arranged under three heads. WHATEVER theory we maintain in regard to the remote causes of insanity, we must consider moral treatment, or management, of very high importance. If we adopt the opinion, that the disease originates in the mind, applications made immediately to it, are obviously the most natural; and the most likely to be attended with success. If, on the contrary, we con- ceive thatmindis incapable of injury or destruction, and that, in all cases of apparent mental derangement, some bodily disease, though unseen and unknown, really exists, we shall still readily admit, from the re- ciprocal action of the two parts of our system upon each other, that the greatest attention is necessary, to whatever is calculated to affect the mind. In the present imperfect state of our knowledge, of the very interesting branch cf the healing art, which relates to the cure of insanity; and unable as we gene- rally are to ascertain its true seat in the complicated labyrinths of our frame, the judicious physician is very frequently obliged to apply his means, chiefly to the alleviation and suppression of symptoms. Experience, however, has happily shown, in the Institution whose practices we are attempting to de- scribe, that much may be done towards the cure and alleviation of insanity, by judicious modes of manage- ment, and moral treatment. The superintendent, who Chap. V MORAL TREATMENT. 85 is also Uic apothecary of the Retreat, after more than fifteen years experience, fully unites with the intelli- gent Dr. Pin el, in his comparative estimate of moral and medical means. The doctor thus expresses him- self: '' Attaching, as I do, little importance to pharma- ceutic preparations; and, all-sufficiency, in curable cases, to physical and moral regimen, I intend not to devote many of my pages, to the exclusive considera- tion of drugs and medicaments." It is a matter of no small difficulty, to convey more than the general principles which influence the con- duct of those, who have the management of the in- sane. It is unhappily, in great measure true, that " the address which is acquired by experience, and con- stant intercourse with maniacs, cannot be communi- cated: it may be learned; but it must perish with its possessors."* It appears, however, to me, that a free detail of different modes of management, can hardly fail to increase our stock of correct general principles, on this important subject. Insane persons generally possess a degree of con- trol over their wayward propensities. Their intellec- tual, active, and moral powers, are usually rather per- verted than obliterated; and it happens, not unfre- quently, that one faculty only is affected. The disor- der is sometimes still more partial, and can only be -detected by erroneous views, on one particular subject. On all others, the mind appears to retain its wonted correctness. The, same partial perversion, is found to obtain in this disease with regard to the affections. Though it frequently happens, that indifference or disgust to- wards the tendercst connexions, is an early and dis- tressing symptom of insanity; when, " forgotten quite, All former scenes of dear delight, • Observations on Madness, by John Haslam, p. 277, 2d edition; from which all the quotations in this work are taken. The Retreat, at an early period, derived advantage from the first edition of these Observations- 86 MORAL TREATMENT. Chap. H Connubial love, parental joy; No sympathies like these his soul cmplm ," yet the existence of the benevolent affections, is often strongly evidenced, by the patient's attachment to those who have the immediate care of them, and who treat them with judgment and humanity. The apothe- cary to Bethlem Hospital says,* " I can truly declare] that by gentleness of manner, and kindness of treat- ment, I inve seldom failed to obtain the confidence, and conciliate the esteem, of insane persons; and have succeeded by these means in procuring from them respect and obedience." The superintendents of the Retreat give precisely the same evidence; and I firm- ly believe, that a large majority of the instances, in which the malevolent dispositions are peculiarly appa- rent, and are considered as characterizing the disorder, may readily be traced to secondary causes; arising from the peculiar circumstances of the patient, or from the mode of management. A patient confined at home, feels naturally a de- gree of resentment, when those whom he has been accustomed to command, refuse to obey his orders, or attempt to restrain him. We may also, I conceive, in part, attribute to similar secondary causes, that ap- parent absence of the social affections, and that sad in- difference to the accustomed sources of domestic plea- sure, of which we have just been speaking. The un- happy maniac is frequently unconscious of his own disease. He is unable to account for the change in the conduct of his wile, his children, and his surrounding friends. They appear to him cruel, disobedient, and ungrateful. His disease aggravates their conduct in his view, and leads him to numerous unfounded sus- picions. Hence, the estrangement of his affections may frequently be the natural consequence, of either the proper and necessary, or of the mistaken conduct of his friends towards him. In such cases, the judicious kindness of others ap- pears generally to excite the gratitude and affection * Observations, p. 293- ( hap. \ . MORAL TREATMENT. 87 of the patient. Even in those deplorable instances where the ingenious humanity of the superintendent fails to conciliate, and the jaundice-like disease, changes the very aspect of nature, and represents all mankind as the leagued enemies of the patient, the existence of the social affections, has often beep strik- ingly evidenced, by attachment to some of the inferior animals. There are, undoubtedly, cases in which the disorder is chiefly marked by a mischievous malevolent dis- position; but of these, very few have occurred at the Retreat. There have, however, been many patients, in whom these dispositions have been occasionally conspicuous, or easily excited by improper treatment. The outline of the character of the insane, which we have now exhibited, must be considered as confined to two states of the disease, mania and melancholia. It frequently happens, however, that a greater or less degree of imbecility, succeeds the more violent ex- citement of the mind; and a sufficient number of cases of this description have occurred, to warrant me in asserting, that even in these hopeless instances of mental alienation,* considerable warmth of affection * I adopt this term from an opinion, that the aliene, of the French, conveys a more just idea of this disorder, than those expressions which imply, in any degree, the " abolition of the thinking faculty" The following case, related to me by a me- dical friend, will serve to show that even in idiocy, the mind may be rather suppressed than destroyed. A young woman, who was employed as a domestic servant, by the father of the relater, when lie was a boy, became insane, and at length sunk into a state of perfect idiocy. In this condition she re- mained for many years, when she was attacked by a typhus fever; and my friend, having- then practised some time, atlen- ed her. He was surprised to observe, as the fever advanced, a development of the mental powers. During that period of the fever, when others were delirious, this patient was entirely rational. She recognized, in the face of her medical attendant, the son of her old master, whom she had known so many years before; and she related many circumstances respecting his family and others, which had happened to herself in her ear- lier days. Butt aha', it was only the gleam of reason; as the 88* MORAL TREATMENT. Chap. V is frequently evinced; and that patients of this class may, in general, be easily amused and pleased. If the preceding sketch is correct, it would not, I apprehend, be difficult to infer theoretically, the gene- ral principles of moral treatment and management; but I have happily little occasion for theory, since my province is to relate, not only what ought to be done, but also what, in most instances, is actually performed. The moral treatment of the insane, seems to divide itself into three parts; and under these, the practices of the Retreat may be arranged. We shall therefore inquire, I. By what means the power of the patient to con- trol the disorder, is strengthened andassissted. II. What modes of coercion are employed, when restraint is absolutely necessary. III. By what means the general comfort of the in- sane is promoted. fever abated, clouds again enveloped the mind; she sunk into her former deplorable state, and remained in it until her death, which happened a few years afterwards. I leave to the metaphysical reader, further speculation on this, certainly, very curious case. Chap. V. MORAL TREATMENT 89 SECTION IT. OF THE MEANS OF ASSISTING THE PATIENT TO CONTROL HIMSELF. Tower of self-restraint strongly evinced at the Retreat — Mo- tives for its exertion— Conclusion drawn hence respecting the excitement of Fear— Of the degree in which Fear may be usefully excited— Of the excitement of furious Mania by improper treatment; and of the efficacy of persuasion and kind treatment towards inducing self-restraint— -Argu- ment in favour of the terrific system. Of the attendants' behaviour to lunatics on first acquaintance — Analogy be- tween the judicious treatment of children and insane per- sons—Of the manner of speaking to Maniacs— Of reason- ing with the Patient on the subject of his hallucination— Of the conversation adapted to melancholies — Beneficial effects of exercise and variety of object upon this class, illustrated by an affecting case — Advantage of regular la- bour in some cases — Desire of esteem a powerful princi- ple towards inducing self-restraint — Other means of cul- tivating it — The aid of Religion in promoting self-restraint — Hints to the attendants on the Insane. WE have already observed, that most insane per- sons, have a considerable degree of self command; and that the employment and cultivation of this remaining power, is found to be attended with the most salutary effects. Though many cannot be made sensible of the irrationality of their conduct or opinions; yet they are generally aware of those particulars, for which the world considers them proper objects of confinement. Thus it frequently happens, in the Institution we are describing, that a patient, on his first introduction, will conceal all marks of mental aberration. Instances have occurred, in which the struggle has been so success- ful, that persons, who, on undoubted authority, have been declared to be unmanageable at home; and to have shown very striking marks of insanity; have not, for a very considerable time, exhibited sufficient symp- toms of the disorder, to enable the physician to declare them, non com/tos mentis. Doubtless the idea that th< ir early liberation, for which most are anxious, and the ir treatment during their confinement, will depend, in H SK) MOB u, n;r \t\ii.\ i great measure, on their conduct, has a tendency to produce this salutary restraint, upon their wayward propensities. — Hence, also, the idea seems to have arisen, that madness, in all its forms, is capable ol en- tire control, by a sufficient excitement of the principle of fear. This speculative opinion, though every das perience decidedly contradicts it, is the best apology which can bemade for the barbarous practices that have often prevailed in the treatment of the insane. The principle of fear, which is rarely decreased by insanity, is considered as of great importance in the management of the patients. But it is not allowed to be excited, beyond that degree which naturally arises from the necessary regulations of the family. Neither chains nor corporal punishments are tolerated) on any pretext, in this establishment. The patients, therefore, cannot be threatened with these severities; yet, in all houses established for the reception of the insane, the general comfort of the patients ought to be consider- ed; and those who are violent, require to be separated from the more tranquil, and to be prevented, by some means, from offensive conduct, towards their fellow- sufferers. Hence, the patients are arranged into classes, as much as may be, according to the degree in which they approach to rational or orderly conduct. They quickly perceive, or if not, they are informed on the first occasion, that their treatment depends, in great measure, upon their conduct. Coercion thus flowing as a sort of necessary consequence, and being executed in a manner which marks the reluctance of the attendant, it seldom exasperates the violence of the patient, or produces that feverish and sometimes fu- rious irritability, in which the maniacal character is completely developed; and under which aU power of self-control is utterly lost. There cannot be a doubt that the principle of fear, in the human mind, when moderately and judiciously exci ed, as it is by the operation of just and equal laws, has a salutary effect upon society. It is a principle also of great use in the education_of children, whose im- (jlup. V. MOKVL TREATMENT. 91 perfect knowledge and judgment, occasion them to be less influenced by other motives. But where fear is too much excited, and where it becomes the chief motive of action, it certainty tends to contract the un- derstanding to weaken the benevolent affections, and to debase the mind. As the poet of Liberty has well sung, — — " All constraint, Except what wisdom lays on evil man, Is evil; hurts the faculties, impedes Their progress in the road of science, blinds The eye-sight of discovery; and begets, In those that suffer it, a sordid mind, Bestial, a meagre intellect, unfit To be the tenant of man's noble form." cowper's task, book v. It is therefore wise to excite, as much as possible, the operation o£ superior motives; and fear ought only to be induced, when a necessary object cannot other- wise be obtained. If this is the true scale of estimat- ing the degree in which this principle is, in general, to be employed, it is found, at the Retreat, equally ap- plicable to the insane. That the continual or frequent excitement of the sensations of fear, should " bid Melancholy cease to mourn," is an idea too obviously absurd in theory, to require the refutation of experience. There has, how- ever, unhappily been too much experience on this subject; and hence we may perhaps, in great degree, explain, why melancholy has been considered so much less susceptible of cure than mania. To the mild sys- tem of treatment adopted at the Retreat, I have no doubt we may partly attribute, the happy recovery of so large a proportion of melancholy patients. Is then the violent excitement of the principle of fear, belter adapted to enable the maniac to control his wanderings, and to suppress his emotions? Is it not we-11 known, that the passions of many maniacs, are extremely irritable? and, when once excited, are not all moral means to subdue them, as ineffectual as the 92 MORAL TREATMENT. Chup. V. attempt would be to quench, by artificial means, the fires of Etna? If it be true, that oppression makes a iui.se man mad, is it to be supposed that stripes, and insults, and injuries, for which the receiver knows no cause, are calculated to make a madman wise? or would the) not exasperate his disease, and excite his resentment? May we not hence most clearly perceive, why furious mania, is almost a stranger in the Retreat? why all the patients wear cloths, and are generally induced to adopt orderly habits? The superintendent of this Institution is fully of opinion, that a state of furious mania, is very often ex- cited by the mode of management. Of this opinion, a striking illustration occurred in this Institution, some years ago. A patient, of rather a vindictive and self- important character, who had previously conducted himself with tolerable propriety, one day, climed up against a window, which overlooked the court where he was confined, and amused himself by contemplat- ing the interior of the room. An attendant, who had not been long in office, perceiving his situation, ran hastily towards him, and, without preamble, drew him to the ground. The patient was highly incensed; a scuffle immediately ensued, in which he succeeded in throwing his antagonist; and had not the loud vocifera- tions of this attendant alarmed the family, it is proba- ble that he would have paid for his rash conduct, by the loss of his life. The furious state of the patient's mind did not continue long; but, after this circumstance, he was more vindictive and violent. In some instances, the superintendent has known furious mania temporarily induced, by the privations necessary on a relapse, after a considerable lucid in- terval, during which the patient had enjoyed many privileges, that were incompatible with his disordered state. Here we may suggest the expediency, where it is possible, of employing such of the attendants to control the patient during his paroxyms, as had little intercourse with him in his lucid interval. Instances Chap. t. MORAL TREATMENT. 93 of furious mania have been, however, very rare; but a considerable number of patients have been admitted, who were reported to have been so furiously insane, as to require constant coercion. The evidence of attendants, who have been employ- ed, previously to the admission of patients into the Retreat, is not considered a sufficient reason for any extraordinary restraint; and cases have occurred, in which persuasion and kind treatment, have superseded the necessity of any coercive means. Some years ago, a man, about thirty-four years of age, of almost Herculean size and figure, was brought to the house. He had been afflicted several times be- fore; and so constantly, during the present attack, had he been kept chained, that his clothes were contrived to be taken off and put on by means of strings, without removing his manacles. They were, however, taken off, when he entered the Retreat, and he was ushered into the apartment, where the superintendents were supping. He was calm; his attention appeared to be arrested by his new situation. He was desired to join in the repast, during which he behaved with tole- rable propriety. After it was concluded, the superin- tendent conducted him to his apartment, and told him the circumstances on which his treatment would de- pend; that it was his anxious wish to make every inhai< bitant in the house, as comfortable as possible; and that he sincerely hoped the patient's conduct would render it unnecessary for him to have recourse to coercion. The maniac was sensible of the kindness of his treat- ment. He promised to restrain himself, and he so completely succeeded, that, during his stay, no coer- cive means were ever employed towards him. This case affords a striking example of the efficacy of mild treatment. The patient was frequently very vocife- rous, and threatened his attendants, who in their de- fence were very desirous of restraining him by the jacket. The superintendent on these occasions, went to his apartment; and though the first sight of him seem.- ed rather to increase the patient's irritation, yet after H2 94 MORAL THEATM1 ,'■ V. sitting some time quietly beside him, the violent ex- citement subsided, and he would listen with attention to the persuasions and arguments of his friendly visiter. After such conversations, the patient was generally better for some days or a week; and in about four months he was discharged perfectly recovered. Can it be doubted, that, in this case, the disease had been greatly exasperated by the mode of management? or that the subsequent kind treatment, had a great tendency to promote his recovery? It may probably be urged, and I am very well aware of it, that there is a considerable class of patients, whose eccentricities may, in great measure, be con- trolled; and who may be kept in subjection and ap- parent orderly habits, by the strong excitement of the principle of fear. They may be made to obey their keepers, with the greatest promptitude; to rise, to sit, to stand, to walk, or run at their pleasure; though only expressed by a look. Such an obedience, and even the appearance of affection, we not unfrequently see in the poor animals who are exhibited to gratify our curiosity in natural history; but who can avoid re- flecting, in observing such spectacles, that the readi- ness with which the savage tiger obeys his master, is the result of treatment at which humanity would shud- der; and shall we propose by such means, " To calm the tumult of the breast, Which madness has too long possest; To chase away the fiend Despair, To clear the brow of gloomy Care; Bid pensive Melancholy cease to mourn, Calm Reason reassume her seat; Each intellectual power return?" If those who are friendly to what may be termed the terrific system of management, could prove, that, notwithstanding it may fix for life, the misery of a large majority of the melancholies; and drive many of the more irritable maniacs to fury or desperation; yet that it is still, in its operation upon a large scale, -adapted to promote the cure of insanity, they would Chap. MORAL TREATMENT. 95 have some apology for its discriminate adoption. If, on the contrary, a statement of the proportion of cures in the Retreat, shall sufficiently prove the superior efficacy of mild means, would not those, who are adopting an opposite line of treatment, do well to re- flect on the awful responsibility which attaches to their conduct? Let us all constantly remember, that there is a Being, to whose eye darkness is light; who sees the inmost recesses of the dungeon, and who has declared, « For the sighing of the poor, and the crying of the needy, I will arise." From the view we have now taken of the propriety of exciting fear, as a means of promoting the cure of insanity, by enabling the paaent to control himself, it will, perhaps, be almost superfluous to state as our opinion, that the idea, which has too generally, ob- tained, of its being necessary to commence an ac- quaintance with lunatics, by an exhibition of strength, or an appearance of austerity, is utterly erroneous. The sentiment appears allied to that cruel system, probably dictated by indolence and timidity, which has so long prevailed, and unhappily still prevails, in many receptacles for the insane. There is much analogy between the judicious treat- ment of children, and that of insane persons. Locke has observed, that " the great secret of education, lies in finding the way to keep the child's spirit easy, active, and free; and yet, at the same time, to restrain him from many things he has a mind to, and to draw him to tilings which are uneasy to him." It is highly desirable that the attendants on lunatics should pos- sess this influence over their minds; but it will never be obtained by austerity and rigour; nor will assumed consequence, and airs of self-importance, be generally more successful. Much familiar itxj with mani?cal patients, on their first introduction to a new situation, is not thought, in general, to be advisable. It might, in some instances, have a tendency to lessen that authority, which is, occasionally, necessary for the attendant to exert. There 96 MORAL TREATMENT. Chap. V. may also be a few cases in which a distant, and some- what important manner, may be assumed with advan- tage; but, generally speaking, even with regard to the more violent and vociferous maniacs, a very different mode is found successful; and they are best approach- ed with soft and mild persuasion. The superintendent assures ine, that in these cases, he has found it pecu- liarly necessary to speak to tie patient in a kind, and somewhat low tone of voice. So true are the maxims of antiquity, " A soft answer turned) away wrath." — Solomon. ■ " Soft speech •'Is to dislemper'd wrath, medicinal." — Eschylus. It must, however, be understood, that the persua- sion which is extended to the patients, is confined to those points which affect their liberty or comfort. No advantage has been found to arise from reasoning with them, on their particular hallucinations. One of the distinguishing marks of insanity, is a fixed false con- ception, which occasions an almost total incapacity of conviction. The attempt, therefore, to refute their no- tions, generally irritates them, and rivets the false perception more strongly on their minds. There have been a few instances, in which, by some striking evi- dence, the maniac has been driven from his favourite absurdity; but it has uniformly been succeeded by ano- ther equally irrational. In regard to melancholies, conversation on the sub- ject of their despondency, is found to be highly inju- dicious. The very opposite method is pursued. Every means is taken to seduce the mind from its favourite but unhappy musings, by bodily exercise, walks, con- versations, reading, and other innocent recreations. The good effect of exercise, and of variety of object, has been very striking in several instances at this Institution. Some years ago, a patient much afflicted wit'> melancholic and hypochondriacal symptoms, was admitted by his own request. He had walked from, home, a distance of 200 miles, in company with a friend; Chap. V. MORAL TREATMENT. 97 and on his arrival, found much less inclination to con- verse on the absurd and melancholy views of his own state, than he had previously felt.* This patient was by trade a gardener, and the su- perintendent immediately perceived, from the affect of this journey, the propriety of keeping him employ- ed. He led him into the garden, and conversed with him on the subject of horticulture; and soon found that the patient possessed very superior knowledge of pruning, and of the other departments of his art. He proposed several improvements in the management of the garden, which were adopted, and the gardener was desired to furnish him with full employment. He soon, however, showed a reluctance to regular exertion, and * Though this patient was much less disposed to converse upon the subject, his phypochondriacal ideas remained, as the following description of himself, taken nearly verbatim from his own mouth, will prove: •' I have no soul; I have neither heart, liver, nor lungs; nor any thing at all in my body, nor a drop of blood in my veins- My bones are all burnt to a cinder: I have no brain; and my head is sometimes as hard as iron, and sometimes as soft as a pudding." A fellow patient, also an hypochondriac, amused himself in versifying this affectingly ludicrous description in the following lines: A miracle, my friends, come view, A man, admit'his own words true, Who lives without a soul; Nor liver, lungs, nor heart has he, Yet, sometimes, can as cheerful be As if he had the whole. His head (take his own words along) Now hard as iron, yet ere long Is soft as any jelly; All burnt his sinews, and his lungs; Of his complaints, not fifty tongues Could find enough to tell ye. Yet he who paints his likeness here, Has just as much himself to fear, He 's wrong from top to toe; Ah friends! pray help us, if you can, \nd make us each again a man, That we from hence may go. 98 MORAL TREATMENT. < 'hap. V. a considerable disposition to wandering, winch had been one of the previous features of his complaint. The gardener was repeatedly charged to cue uraged him in labour, and to prevent his leaving t he premises. But, unhappily, the superior abilities of the patient, had excited a jealousy in the gardener's mind which made him dislike his assistance; and it may i i ere fore be presumed, that he obeyed his instructions very imperfectly. The poor man rambled several times from the grounds of the Institution; which, in his stale of mind, excited considerable anxiety in the family. Of course it became necessary to confine him more within doors, lie frequently, however, walked out; and the superin- tendent took many opportunities to attend him into the fields or garden, and to engage him for a time in steady manual labour. As his disorder had increased, it became difficult to induce him to exert himself; but even in this state, when he had been some time employed, he set' led to forget his distressful sensa- tions and ideas, and would converse on general topics with great good sense. In this truly pitiable case, the superintendent several times tried the efficacy of long walks, where the great- est variety and attraction of circumstances were pre- sented; but neither these, nor the conversation which he introduced, were able to draw the patient so effec- tually from the " moods of his own mind," as regular persevering labour in the garden. It is not improbable, however, that the superior manner in which the pa- tient was able to execute his work, produced a degree of self-complacency which had a salutary effect; and that, had his education enlarged his curiosity, and en- couraged a taste and observation respecting the objects of nature and art, he might have derived much greater advantage, as many patients obviously do, from variety of conversation and scenery. The circumstances of this patient did not allow him a separate attendant, and the engagements of the su- perintendent were too numerous and important, to per- Chap. V. MORAL TREATMENT. 99 mit him to devote to this case the time and attention which it seemed to require. He has frequently expres- sed to me, the strong feelings of regret, which were excited in his mind, by the unsuccessful treatment of this patient; the case certainly points out the great im- portance of exercise and labour, in the moral treatment of insanity; more especially in cases of melancholy. This patient, after remaining several years in the house, died of an acute inflammation of the bowels. His situation for a considerable time previously to his death, was most deplorable, and has often reminded me of the affecting description, which our great poet gives of the state of our first lather, after his expulsion from the happy seat of primeval innocence: ________ " On the ground, Outstretch'd he lay, on the cold ground, and oft Curs'd his creation, death as oft accus'd Of tardy execution." The female patients in the Retreat, are employed, as much as possible, in sewing, knitting, or domestic affairs; and several of the convalescents assist the at- tendants. Of all the modes by which the patients may be induced to restrain themselves, regular employ- ment is perhaps the most generally efficacious; and those kinds of employment are doubtless to be prefer- red, both on a moral and physical account, which are accompanied by considerable bodily action; that are most agreeable to the patient, am! which are most op- posite to the illusions of his disease. In an early part of this chapter, it is stated, that the patients are considered capable of rational and honourable inducement; and though we allowed fear a considerable place in the production of that restiaint, which the patient generally exerts on his entrance in- to a new situation; yet the desire of esteem is consider- ed, at the Retreat, as operating, in general, still more powerfully. This principle in the human mind, Which doubtless influences, in a great degree, though often secretly, our general manners; and which operates with peculiar force on our introduction into a new cir- 100 MORAL TREATMENT. Cbap. V cle of acquaintance , is found to have great influence, even over the conduct of the insane. Though it has obviously not been sufficiently powerful, to enable them entirely to resist the strong irregular tendencies of their disease; yet when properly cultivated, it leads many to struggle to conceal and overcome their mor- bid propensities; and, at least, materially assists them in confining their deviations, within such bounds, as do not make them obnoxious to the family. This struggle is highly beneficial to the patient, by strengthening his mind, and conducing to a salutary habit of self-restraint; an object which experience points out as of the greatest importance, in the cure of insanity by moral means. That fear is not the only motive, which operates in producing sclf-reatraint in the minds of maniacs, is evident from its being often exercised in the presence of strangers, who are merely passing through the house; and which, I presume, can only be accounted for, from that desire of esteem, which has been stated -to be a powerful motive to conduct. It is probably from encouraging the action of this principle, that so much advantage has been found in this Institution, from treating the patient as much in the manner of a rational being, as the state of his mind will possible allow. The superintendent is particularly attentive to this point, in his conversation with the pa- tients. He introduces such topics as he knows will most interest them; and which, at the same time, al- lows them to display their knowledge to the greatest advantage. If the patient is an agriculturist, he asks him questions relative to his art; and frequently con- sults him upon any occasion in which his knowledge may be useful. I have heard one of the worst pa- tients in the house, who, previously to his indisposi- tion, had been a considerable grazier, give very sen- sible directions for the treatment of a diseased cow. These considerations are undoubtedly very material, as they regard the comfort of insane persons; but they are of far greater importance, as they relate to the Uhap.V. MORAL TREATMENT. 101 cure of the disorder. The patient feeling himself of some consequence, is induced to support it by the ex- ertion of his reason, and by restraining those disposi- tions, which, if indulged, would lessen the respectful treatment he receives; or lower his character in the eyes of his companions and attendants. They who are unacquainted with the character of insane persons, are very apt to converse with them in a cl ildish or, which is worse, in a domineeiing manner; and hence it has been frequently remarked by the pa- tients at the Retreat, that a stranger who has visited them, seemed to imagine they were children. The natural tendency of such treatment is, to de- grade the mind of the patient, and to make him indif- ferent to those moral feelings, which, under judicious direction and encouragement, are found capable, in no small degree, to strengthen the power of self-restraint; and which render the resort to coercion, in many ca- ses, unnecessary. Even when it is absolutely requisite to employ coercion, if the patient promises to control himself on its removal, great confidence is generally, placed upon his word. I have known patients, such is their sense of honour and moral obligation, under this kind of engagement, hold, for a long time, a successful struggle with the violent propensities of their disorder; and such attempts ought to be sedulously encouraged by the attendant. Hitherto we have chiefly considered those modes of inducing the patient to control his disordered propen- sities, which arise from an application to the general powers of the mind; but considerable advantage may certainly be derived, in this part of moral manage- ment, from an acquaintance with the previous habits, manners, and prejudices of the individual. Nor must we forget to call to our aid, in endeavouring to pro- mote self-restraint, the mild but powerful influence of the precepts of our holy religion. Where these have been strongly imbued in early life, they become little less than principles of our nature; and their restrain- ing power is frequently felt, even under the delirious I 102 MORAL TREATMENT. Chap. Y excitement of insanity. To encourage the influence of religious principles over the mind of the insane, is considered of great consequence, as a means oi cure. For this purpose, as well as for others still more im- portant, it is certainly right to promote in the patient, an attention to his accustomed modes of paying ho- mage to his Maker. Many patients attend the religious meetings of the Society, held in the city; and most of them are assem- bled, on a first day afternoon, at which time the super- intendent reads to them several chapters in the Bible. A profound silence generally ensues; during which, as well as at the time of reading, it is very gratifying to observe their orderly conduct, and the degree in which those, who are much disposed to action, re- strain their different propensities. In pursuing these desirable objects, let not the in- experienced, but judicious attendant, expect too im- mediate effects from his endeavours, or be dishearten- ed by occasional disappointment. Let him bear in mind, what the great Lord Bacon has admirable said, that " It is order, pursuit, sequence, and interchange of application, which is mighty in nature; which, al- though it require more exact knowledge in prescrib- ing, and more precise obedience in observing, yet is recompensed with the magnitude of effects."* I am sensible that what is here stated, is but an im- perfect view of the principles and modes, by which self-restraint is induced at the Retreat. To particular- ize all the principles of the mind, which may be use- fully excited in promoting this salutary object, would be an enumeration of our intellectual powers and af- fections. I will only further observe upon this head, by way of general summary, that the attendant on the insane, ought sedulously to endeavour to gain their confidence and esteem; to arrest their attention, and fix it on objects opposite to their illusions; to call into action, as much as possible, every remaining power * Works, 8vo edition, vol. i. p. 125. V. MORAL TREATMENT. 103 and principle of the mind; and to remember that, in the wreck of the intellect, the affections not unfre- particularly important to prevent the accession of such as might be transmitted through the medium of the senses."* The patients of this class, who aic not dis- posed to injure themselves, are merely confined by the strait-waistcoat; and left to walk about the room, or lie down on the bed, at pleasure. But in those des- perate cases of melancholy, attended with tedium vita, in which there is a strong determination to self- destruction, it becomes necessary to confine the pa- tient, during the night, in a recumbent posture. For this purpose, the superintendent has invented a very simple apparatus; which answers all the purposes of security; and allows the patient to turn and otherwise change his posture in bed.f It has been suggested, that in cases of high mania, the \iolenl excitement would be best reduced, by in- * The necessity for this mode of treatment is very rare at the Retreat. f Tb is, apparatus coiwists of a strong, linen, girth web, three inches ami a half broad, and five feet and a half long. At each end it, a leather strap one foot long, one inch and a half broad, and a quarter of an incli thick; with a hiirkle fastened at the joining of the weh and strap. At eighteen inches from the upp< V end of the web, a piece of the same materials, four. teen inches long, placed transversely, is strongly sewed to it. Each end of this cross piece is provided with two straps one inch and a quarter broad, and about three-sixteenths of an inc.!) thick. One of these straps is five inches long, provided with a buckle, and a piece of leather inside the buckle to pre- vent it from huitingthe arm. The other strap is fifteen inches long, with holes to buckle to the former; and both are strong- ly sewed together with the web between them. At twenty- one inches from the lower end of the web, are fixed trans- versely, two leather straps of the same strength as those last described. Both are strongly sewed together on the weh, by the middle; one extending six inches beyond the web on each side, and provided at each end with a buckle and a guard, as be- fore mentioned: the otheris two feet long, with perforation-, a'. each end. When in use, the main strap passes longitudinally over the lower bed-cloths, and is fastened to the head and feet of the bedstead, by a proper staple fixed in the centre of each, and is buckled tight. The pat ent is placed upon it; the cross web at the upper end is placed uudcr the shoulders.and each Chap. V. MORAL TREATMENT. 105 dulging it in the greatest practicable degree. The ex- perience of the Retreat, leads to an opposite conclu- sion; viz. that such a degree of restraint as would not be materially painful, in a state of calmness, has a ten- dency to abate the paroxysm. The association be- tween mental and bodily action, and the degree in which the latter is well known to excite the former, sufficiently illustrate the cause of this fact. Except in the case of violent mania, which is far from being a frequent occurrence at the Retreat, coer- cion, when requisite, is considered as a necessary evil; that is, it is thought abstractedly to have a tendency to retard the cure, by opposing the influence of the moral remedies employed. It is therefore used very sparingly; and the superintendent has often assured me, that he would rather run some risk, than have re- course to restraint, where it was not absolutely neces- sary; except in those cases where it was likely to have a salutary moral tendency. I feel no small satisfaction in stating upon the au- thority of the superintendents, that during the last year, in which the number of patients has generally been sixty-four, there has not been occasion to seclude, on an average, two patients at one time. I am also able to state, that although it is occasionally necessary to restrain by the waistcoat, straps, or other means, se- veral patients at one time; yet that the average num- ber so restrained does not exceed four, including those who are secluded. The safety of those who attend upon the Insane, is certainly an object of great importance;but it is worthy of inquiry whether itmay not be attained, without mate- rially interfering with another object, — the recovery of pair of straps at the ends of this transverse piece, encloses one arm; but is not buckled so tight as to hurt the patient. The lower pair of straps each encloses one thigh, just above the knee, in like manner. In many cases of violent excitement, thisi6 found sufficient; but where the patient is ingenious, or disposed to self-injury, the addition of the strait-waistcoat is needful. I 2 MHMHMWI 106 MORAL THEAIMIAI ,> N the patient. It may also deserve inquiry, whether the extensive practice of coercion, Which obtains in some Instiutions, docs not arise fiom erroneous views of the character of insane persons; from indifference to their comfort; or from having rendered coercion ne- cessary by previous unkind treatment. The power of judicious kindness over this unhappy class of society, is much greater than is generally ima- '. It is perhaps not too much to apply to kind treatment, the words of our great poet, " She can unlock, The clasping charm, and thaw the numbing spell." — Milton. In no instances has this power been more strikingly displayed; or exerted, with more beneficial effects, than in those deplorable cases in which the patient re- fuses to take food. The kind persuasions and ingen- ious arts of the superintendents, have been singularly successful in overcoming this distressing symptom; and very few instances now occur in which it is neces- sary to employ violent means for supplying the pa- tient with food. Some patients who refuse to partake of the family meals, are induced to cat by being taken into the lar- der, and there allowed to help themselves. Some are found willing to eat when food is left with them in their rooms, or when they can obtain it unobserved by their attendants. Others, whose determination is stronger, are frequently induced, by repeated persua- sion, to take a small quantity of nutritious liquid; and it is equally true in these, as in general cases, that every breach of resolution weakens the power and dis- position to resistance. Sometimes, however, persuasion seems to strength- en the unhappy determination. In one of these cases, the attendants were completely wearied with their en- deavours; and on removing the food, one of them took a piece of the meat which had been repeatedly offer- ed to the patient, and threw it under the fire-grate; at the same time, exclaiming, that she should not have it. Chap. V. MORAL TREATMENT. 107 The poor creature, who seemed governed by the rule of contraries, immediately rushed from her seat, seiz- ed the meat from the ashes, and devoured it. For a short time, she was induced to eat, by the atttendants availing themselves of this contrary disposition; but it was soon rendered unnecessary, by the removal of this unhappy feature of the disorder. There are, it must be confessed, some cases in which ingenious arts, and kind persuasions, prove alike un- successful;'and it becomes necessary to supply the pa- tient by force with a sufficient quantity of food, to sup- port life. This is, perhaps, the most painful duty, which the attendant has to perform. It is usually done at the Retreat in the following manner: The patient is placed in a rocking chair, which of course allows the height and position of the head to be varied, as cir- cumstances may require. The most difficult part of the business is, if I may use the expression, to unlock the mouth. For this purpose, the superintendent, after trying a variety of instruments, generally employs the handle of a small door lock key, and having pressed it between the teeth, he turns it round by the other end, and thereby raises the mouth at his pleasure. Another attendant then introduces the food, which is in a liquid state, and contained in a strong spoon. I am very glad to be able to say, that there is seldom occasion for the frequent repetition of this operation; and also that it has not, in a single instance, been the occasion of any injury to the patient.* The teeth of few persons meet • " It is a painful recollection, to recur to the number of interesting females 1 have seen, who, after having suffered a temporary disarrangement, and undergone the brutal opera- tion of spouting, in private receptacles for the insane, have been restored to their friends without a front tooth in either jaw. Unfortunately the task of forcing patients to take food or medicines, is consigned to the rude hand of an ignorant and unfeeling servant. It should always be performed by the master or mistress of the mad-house, whose reputations o'ught to be responsible for the personal integrity of the unhappy be- ings committed to their care." Uaslum's Observations on Madness, note, pagt 13r« 108 MORAL TREATMENT. Clap. V with perfect regularity, and this circumstance greatly facilitates the insertion of the instrument which keeps them asunder. It is found necessary to convey the point of the spoon, halfway over the tongue; for when the liquid is not conveyed into the throat, it is frequent- ly ejected. The attendants at the Retreat, feel themselves in no danger of injury from the patients, who are uncon- fined; many of whom, previously to their admission, have been accustomed to much severity. No instance has occurred of any serious injury being done by a pa- tient, to any of the attendants; and at no period has there been manifested a general spirit of dissatisfac- tion, or a tendency to revolt. The common attendants, are not allowed to apply any extraordinary coercion to the patients, by way of punishment, or to change, in any degree, the usual mode of treatment, without the permission of the superintendents This limitation to their power is of the utmost importance, as it obliges them to seek the good opinion of the paiient, and to endeavour to govern rather by the influence of esteem than of severity. When it is deemed necessary to apply the strait- waistcoat, or any other mode of coercion, to a violent patient, such an ample force is employed, as precludes the idea of resistance from entering the patient's mind; and hence, irritation, or additional excitement, is gen- erally, in a great degree, prevented. Where such force cannot be obtained, and the case is urgent, courage and confidence will generally over- come the violence of the patient; for the opinion ap- pears to be well founded, that maniacs are seldom tru- ly courageous. The superintendent was one day walk- ing in a field adjacent to the house, in company with a patient, who was apt to be vindictive on very slight occasions. An exciting circumstance occurred. The maniac retired a few paces, and seized a large stone, which he immediately held up, as in the act of throw- ing at his companion. The superintendent, in no de- Oup. V. MOttAL TREATMENT. 109 gree ruffled, fixed his eye* upon the patient, and in a resolute tone of voice, at the same time advancing, commanded him to lay down the stone. As he ap- proached, the hand of the lunatic gradually sunk from its threatening position, and permitted the stone to drop to the ground. He then submitted to be quiedy led to his apartment. t Some of the more irritable patients, who are neither vindictive nor violent, require, occasionally, a degree of restraint, to prevent them from injuring their compan- ions, or destroying their cloths. This class is chiefly found among those whose intellects are weakened. These are sometimes restrained by straps which pass round the ankles, and prevent the patient from kicking; or are confined, when necessary, by arm-straps, fixed to a belt which encircles the waist. These straps allow the patient to use his hands sufficiently to feed him- self; and are abundantly less uneasy than the strait- waistcoat. Some of the female patients of this descrip- tion, have the straps made of green morocco leather, and they will sometimes even view their shackles as ornaments. The reader will find an account of several precaution try means in the third chapter. To those, I here wish to add, that the patients, who take their meals in the galleries, or day-rooms, are not allowed the use of knives and forks. j Their meat is divided into small pieces by the attendant, and they eat it with a spoon. It is also the business of the attendant to take the patient's cloths out of the lodging-room, and examine the pockets every night. • My worthy friend does not, however, lay any claim to " 'those strange powers, which lie Within the magic circle of the eye." | See another circumstance respecting this patient, related page 13. t The superintendent hopes to be able to contrive a knife and fork that may be entrusted to most of the patients with safety; as it would be much more agreeable to many of them, than eating all their food with a spoon. 110 MORAL TREATMENT. Cliap. V, I conceive it useless to emer into more minute de- tails of the modes of coercion and restraint, since ex- perience alone can fully teach the best means of ex- ercising them; and the attendant who possesses a good understanding, and has taken a just view of the cha- racter of the insane, will soon perceive for himself, the necessary degree, time, and mode of coercion, which those who are placed under his care require. But they who have had an opportunity of observation, and ihty only, can conceive the difficulty of entirely subduing|the vindictive feelings, which the inconsistent, but often half rational, conduct of the patient, frequently excites in the minds of the inferior attendants. It is therefore an object of the highest importance, to infuse into the minds of these persons, just senti- ments, with regard to the poor objects placed under their care; to impress upon them, that M coercion is only to be considered as a protecting and salutary re- straint;" and to remind them, that the patient is real- ly under the influence of a disease, which deprive! him of responsibility; and frequently leads him into expressions and conduct the most opposite lo his cha- racter and natural dispositions: " Round in Necessity's iron chain, Reluctant Nature strives in vain; Impure, unholy thoughts succeed, And d&rk'nmg o'er his bosom roll; Whilst madness prompts the ruthless deed, Tyrant of the misguided soul." But even this view of the subject is not exempt from danger; if the attendant does not sufficiently con- sider the degree in which the patient may be influenc- ed by moral and rational inducements. These contra- dictory features in their character, frequently render k exceedingly difficult to insure the proper treatment of deranged persons. To consider them at the same time both as brothers, and as mere automata; to ap- plaud all they do right; and pity, without censuring, whatever they do wrong, requires such a habit of philosophical reflection, and Christian charity, as is certainly difficult to attain. ■i«,uu Chap. V. MORAL TREATMENT. Hi SECTION I V. OF THE MEANS OF PROMOTING THE GENERAL COM- FORT OF THE INSANE. Importance of promoting comfort as it regards cure — Various moans of promoting it at the Retreat— Utility of rational society to convalescent Patients — The different kinds of amusing epmloyments adapted to different classes of Pa- tients—On the introduction of books to the Insane — Im- portance of arresting their attention— Case — Difficulty of devising suitable employments. IN considering our first division of this subject, viz. the modes by which self-restraint may be induced, we have anticipated many of the means by which the comfort of this unhappy class of our fellow beings is promoted; indeed we might, without impropriety, have included all these means under our former division; since whatever tends to promote the happiness of the patient, is found to increase his desire to restrain him- self, by exciting the wish not to forfeit his enjoyments; and lessening the irritation of mind, which too fre- quently accompanies mental derangement. The comfort of the patients is theiefore considered of the highest importance, in a curative point of view. The study of the superintendents to promote it with all the assiduity of parental, but judicious attention, has been, in numerous instances, rewarded by an almost filial attachment. In their conversation with the patients, they adapt themselves to their particular weakness; but, at the same time, endeavour to draw them insensibly from the sorrow, or the error, which marks the disease. The female superintendent, who possesses an un- common share of benevolent activity, and who has the chief management of the female patients, as well as of the domestic department, occasionally gives a general invitation to the patients, to a tea-party. All who at- tend, dress in their best clothes, and vie with each other in politeness and propriety. The best fare is pro- 112 MORAL TREATMENT. CL. vided, and the visiters are treated with all the atten- tion of strangers. The evening generally passts in the greatest harmony and enjoyment. It rarely happens that any unpleasant circumstance occurs; the patients control, in a wonderful degree, their different propen- sities; and the scene is at once curious, and affectingly gratifying. Some of the patients occasionally pay visits to the friends in the city; and female visiters are appointed every month, hy the Committee, to pay visits to those of their own sex; to converse with them, and to pro- pose to the superintendents, or the Committee, any improvements which may occur to them. The visiters sometimes take tea with the patients, who are much gratified with the attention of their friends, and mostly behave with propriety. It will be necessary here to mention, that the visits of former intimate friends, have frequently been at- tended with disadvantage to the patients; except when convalescence had so far advanced, as to afford a pros- pect of a speedy return to the bosom of society. It is, however, very certain, that as soon as reason begins to return, the conversation of judicious, indifferent per- sons, greatly increases the comfort; and is considered almost essential to the recovery of many patients. On this account, the convalescents of every class, are fre- quently introduced into the society of the rational parts of the family. They are also permitted to sit up till the usual time for the family to retire to rest, and are allowed as much liberty as their state of mind will ad- mit.* Those who have had the opportunity of observing the restoration of reason, will be aware, that she does not, in general, at once, resume her lost empire over the mind Her approach resembles rather the gradual influx ol the tide; she seems to struggle to advance, bu igain and again is compelled to recede. During * The patients usually rise at stven in summer, and eight in vinter; and the common time of going to bed is eight o'clock. (.Lap. \. MOHAL TKEA I.MEM. 11 J this contest, the judicious attendant, may prove the moat valuable ally of reason; and render to her the most essential assistance, in the recovery of her lawful throne. In some cases, however, the cloud which envelopes the mind is suddenly dispersed, and the patient seems to awake at once as out of a dream. In others the pro- gress of recovery is gradual and uniform: " Lucid order dawns; And as from chaos old the jarring seeds Of Nature, at the voice divine, repair'd Each to its place, 'till rosy earth unveil'd Her fragrant bosom, and tlie joyful sun Sprung up the- blue serene; by swift degrees Thus disentangled," [reason entire] " Emerges." The Pleasures of Imagination, Book III. I. 396. As indolence has a natural tendency to weaken the mind, and to induce ennui and discontent, every kind of rational and innocent employment is encouraged. Those who are not engaged in any useful occupation, are allowed to read, write, draw, play at ball, chess, drafts, &c* The attendant will soon perceive what kind of em- ployment or amusement, is best adapted to the differ- ent patients under his care. He will observe that those of the most active ?nd exciting kind, will be best adapted to the melancholy class, where they can be induced to engage in them; and that the more seden- tary employments, are generally preferable for the maniacal class. No strict rule, however, can properly be laid down on this subject; and the inclination of the patient may generally be indulged, except the em- ployment he desires obviously tends to foster his dis- ease. The means of writing, are, on this account, sometimes obliged to be withheld from the patient, as it would only produce continual essays on his pe- culiar notions; and serve to fix his errors more com- * It is, perhaps, almost unnecessary to state, that, playing for money, or gaming of any kind, is not allowed. K 114 MORAL TREATMENT. Chap. V pletely in his mind. Such patients are, however, occasionally indulged, as it is found to give them temporary satisfaction; and to make them more easily led into suitable engagements.* There certainly requires considerable care in the selection of books for the use of the insane. The works of imagination are generally, for obvious reasons, to be * This indulgence in the means of writing, frequently leads to curious effusions, both in prose and poetry. The following specimen of the latter, will probably interest the reader- Mi "will be surprised to learn, that the patient, at the time of in composition, laboured under a < ery considerable degree of active mania. This is not the only instance in which we have been reminded of the lines of the poet, " Great wit to madness, sure, is near allied, And thin partitions do their bounds divide." ADDRESS TO MELANCHOLY. Spirit of darkness! from yon lonely shade Where fade the virgin roses of the spring; Spirit of darkness, hear thy fav'rile maid To sorrow's harp her wildest anthem sing. Ah! how has Love despoiPd my earliest bloom, And flung my charms as to the wintry wind; Ah! how has Love hung o'er thy trophied tomb, The spoils of genius, and the wreck of mind. Iligh rides the moon the silent heavens along; Thick fall the dews of midnight o'er the ground; Soft steals the Lover, when the morning song Ofwaken'd warblers through the woods resound- Then I, with thee, my solemn vigils keep, And at thine altar take my lonely stand; Again my lyre, unstrung, I sadly sweep, While Love leads up the dance, with harp in hand. High o'er the woodlands Hope's gay meteors shone, And thronging thousands bless'd the ardent ray; Iturn'd, but found Despair on his wild roam, And with the demon bent my hither-way. Soft o'er the vales she blew her bugle horn, Oh' where Maria, whither dost thou stray? Return, thou false ma:d, to th' echoing sounds I flew, nor heeded the sweet syren's lay. Chap. V, MORAL TREATMENT. 115 avoided; and such as are in any degree connected with the peculiar notions of the patient, are decidedly objectionable. The various branches of the mathema- tics and natural science, furnish the most useful class of subjects on which to employ the minds of the in- sane; and they should, as much as possible, be induced to pursue one subject steadily. Any branch of know- ledge with- which the patient has been previously ac- quainted, may be resumed with greater ease; and his disposition to pursue it will be encouraged by the competency which he is able to exhibit. I met with a striking instance, of the advantage of attention to this point, some years ago. It was related to me by a person of great respectability, who was himself the subject of the case. He stated, that a few years before that time, his mind had been greatly depressed without any apparent cause. The most dis- Hail, Melancholy! to yon lonely towers I turn, and hail thy time-worn turrets mine, Where flourish fair the night-shade's deadly flowers* And dark and blue, the wasting tapers shine. There, O my Edwin! does thy spirit greet In fancy's maze thy lov'd and wandering maid; Soft through the bower thy shade Maria meets, And leads thee onward through the myrtle glade, O, come with me, and hear the song of eve, Far sweeter, far, than the loud shout of morn; List to the pantings ofthe whispering breeze, Dwell on past woes, or sorrows yet unborn. We have a tale; and song may charm these shades, Which cannot rouse to life Maria's mind, Where Sorrow's captives hail thy once lov'd maid, To joy a stranger, and to grief re sign'd. Edwin, farewell! go, take my last adieu, Ah! could my bursting bosom tell thee more, Here, parted here, from love, from life, and you, I pour my song as on a foreign shore. But stay, rash youth, the sun has climb'd on high, The night is past, the shadows all are gone, For lost Maria breathe the eternal sigh, And waft thy sorrows to the gales of morn. 116 mo;. ci. rnal thoughts continually haunted his mind, an found the greatest difficulty, in confinin ntion, lor the shortest time, to one subject. He felt entirely indifferent to his business and his family; and, of course, he neglected them. It was with great difficulty he was induced to take sufficient food to support life. His body became emaciated, and his mind more and more enfeebled. In this state, as he was one day musing upon his miserable condition, he perceived, by the faint glim- merings of remaining reason, the slill worse state to which he must be reduced, if he continued to indulge his gloomy reflections and habits. Alarmed with the prospect of the future, he resolved to exert the power which he still possessed to control his unhappy dis- positions, and to regain the habit of attention. For this purpose, he determined, immediately to apply himself to mathamatics, with which he had been well acquaint* ed in his youth, and also to adopt a more liberal re- gimen. The first attempt to go through the easiest pro- blem, cost him indescribable labour and pain. But he persisted in the endeavour; the difficulty of fixing his attention gradually lessened; he overcame his tendency to abstinence; and very shortly recovered the use of his faculties and his former temper of mind. Perhaps few persons, in the situation which I have described, would have had the courage to form such resolutions; and still fewer, the fortitude to perform them. The case, however, certainly points out what may possibly be done; and how important it is, in a curative point of view, to encourage the patient in stea- dy mental pursuit. The managers of this Institution, are far from ima- gining that they have arrived at a state of perfection in the moral treatment of insanity. If they have made any considerable approaches towards it, their progress has only served to convince them how much more may probably be effected, and to fill them with regret, Chap. V. MORAL TREATMENT. 117 that so little ingenuity has hitherto been exerted to in- crease the comforts of insane persons. There is no doubt, that if the same exertions were used for this purpose, as are frequently employed to amuse the vain, the frivolous, and the idle, many more gleams of comfort would be shed over the unhappy existence of lunatics; and the proportion of cures would be still materially increased. What a reflection upon human nature, that the greatest calamity to which it is incident, should have been frequently aggravated by those who had the power, and whose duty it was to employ means of mitigation. Hence, we may derive a practical com- ment on the observation of the wise Montesquieu, which every one interested in establishments for the insane ought constantly to remember: " Cest une experience eternelle, que tout hommequi a dupouvoir est porte, a en abuser; il va jusqu' a ce qu'il trouve des limites. Qui le diroit! La vertu meme a besoin des limites.* L'Esfirit des Loix, Liv. II. Cafi. IF. * Experience continally demonstrates, that men who pos- sess power, are prone to abuse it: they are apt to go to the utmost limits. May it not be said, that the most virtuous re- quire to be limited? K2 I "ZWO+.1 •»» « CHAPTER vr. STATEMENT OF CASKS AM) REMARKS. Table of C:ises— Summaries drawn from it — Statement! made by several other Institution! of the proportion of CUT Difficulty of estimating the curative means employed in different Asylums — Necessary inquiries previously to judging of different Reports — Difficulty of obtaining in- formation on the causes of the disease — Tin effect fre- quently mistaken for the cure — Approach of maniacal pa- roxysm described — Great ambiguity of the moral causes of Insanity — The most prevalent causes in the Retreat — Few cases connected with religious impressions or inlcm- perence — The rides of the Retreat different from Bet Idem and Luke's Hospitals — Definition of the terms Dementia, MSelantMHa, and JttatiU — The time which constitutes an old case — The terms enrrrf and recovered — Inquiry whe- ther Insanity is prejudicial to animal life — Drs. Monro and Crichton's opinions — Of the disorders to which the Insane are the most liable — The causes Of Mortality in the Retrcnit — Ages of Patients. TABLE OF CASES Admitted into the Retreat, from its' opening in the year 1796, to the end of the year 1811; exhibiting the result, or pre- sent state of each.* CCj* In the following table, M. signifies married; S. single; W. widower, or widowj O. (J. old case; R. C. recent case; Mo. month; Man. mania; Mel. melancholia; H. M. hypochondriac melancholy; Dem. dementia, or maniacal'imbecility; 96 1). 04 D. &c. died 1796, 1804, &c; Recov. recovered; Imp. improved; M. I. much improved; V. M. I. very much improved- "3 i 9 D O u E «H ** a S £ u o 0 E5 a. <- yi 2 0 Cm O fco < Cm o 4> c c/5 u o O ■c ° 8.2 a It Mo. rt =3 « Mo. 1 65 M oc Man. 6, 1796. 3, 1808 Imp. 2 eo S oc Man. 6, Remains •jThe design of exhibiting the state of the patients to a later period than that of their admission, is, obviously, to allow time Chap. VI. TABLE OF CASL> 119 Number. Age of Males 6 u u* •■*- o V fc/3 3 55 L O 5, 1800 Recov. 14 55 M OC Mel. 12, 11, 1798 Recov. 15 32 s OC Mel. 12, Remains 16 45 s OC Man. 2, 1797 12, 1798 M. I. 17 74 w OC H.M. 4, 10, 1804 M. I. 18 54 s OC Man. 5, 1, 1811 Imp. 19 72 s OC Man. fi Remains 20 47 s OC Man. r, 7, 05D. Imp. 21 45 s RC Man. 1, 1798 1, 1799 M. I. 22 24 s OC Man. 2, 7, 09D. APPARENT CAUSES, &c. No. 3. Disappointment of the affections. No. 5. Supervened epilepsy. No. 10. Succeeded a disappointment of the affections. No. 13. Constitutional. No. 15. Constitutional. No. 16. Succeeded disappointment in business. No. 17- Constitutional. No. 19. Succeeded disappointment of affections. No. 21. Constitutional. to see the effect of their being placed in the Institution. It may not, however, be improper to add, that from the end of the year 1811, about fifteen months, fourteen patients have been ad- mitted; and that in the three months since the end of 1812, four patients have recovered, and no death has occurred. 120 TABLE OF CASES. Chap. VI a ° c ™ c . -a »5 « ; * I Hi 1 &"s : o o « g f S g-j 23 | fc ■< «< m O Q £ ca = Mo. Mo. 23 20 S RC Man. 3, 1798 6, 1798 Recov. 24 45 S OC Man. 3, 7, 1806 Recov. 25 45 S OC Man. 6, 3, Recov. 26 32 M RC Man. 6, 6, 980. 27 24 S OC Mel. 7, Remains 28 24 S OC Man. 7, Remains 29 36 M RC Man. 8, 11, 1798 M.I. 30 50 W OC Man. 7, 9,02 0. 3160 W OC Man. 9, 1, 000. Imp. 32 22 S RC Mel. 10, Remains M. I. 33 43 S OC Man. 11, Remains 34 46 M OC Mel. 11, 6,000. 35 54 S OC Mel. 12, 3,050. 36 38 S RC Mel. 12, 6, 1799 Recov. 37 26 S OC Man. 2,1799 9,000. Imp. 38 50 S OC Man. 3, 5,010. Imp. 39 48 M OC H.M. 5, 6,090. 40 60 S OC Dem. 5, 4,000. 41 24 S OC Mel. 6, 10, 1803 Recov. 42 20 S RC Mel. 8, 10, Recov. 43 40 S OC Mel. 9, Remains Dem. 44 19 S RC Man. 9, 1 1, 1801 Recov. APPARENT CAUSES, &c No. 23- Succeeded family misfortunes. No. 25. Succeeded disappointment of affections. No. 27- Succeeded disappointment of affections. No. 28. Contusion of the skull. — Habit predisposed to the disorder. No. 30. Succeeded the death of his wife. No. 32. Disorder hereditary — Excited by over-attention to her mother in her last illness, and the subsequent sorrow. No. 33. Succeeded disappointment of affections. No. 34. Succeeded disappointment in business. No. 37- Epilepsy. No. 38. Hereditary. No. 42. Hereditary— Succeeeded means used to check vio- lent perspiration, which supervened a pleuritic attack. Vliap. M. TABLE OF CASES. 121 'A O V fc/3 C C O C 0J "B Number. Age of M fcu O V to < fa O c Old or Re Descripti Disord T3 1 V Mo. Mo. 63 66 w RC Mel. 8, 1801 3, 1802 Recov. 64 21 s RC Mel. 10, 3, Recov. 65 25 s RC Mel. 10, 7, Recov. 66 30 s RC Man. Hi Remains 67 22 s RC Man. 12, 5, 1808 Recov. 68 28 s RC Mek 3, 1802 9, 1802 Recov. 69 35 s RC Man. 3> Remain* 70 52 M RC Mel. 5, 9, 1806 M. I. 71 50 S OC Man. 7, 8, Recov. 72 45 M OC Mel. 7, 6, 1803 Recov. 73 22 s RC Man. 7, 4, Recov. 74 34 s RC Man. 8, 12, 1802 Recov. 75 60 s OC Man. 9, Remains 76 28 s RC Mel. Hi 6, 1803 Recov. 77 31 s OC Mel. Hi 8, 1809 Recov. 78 38 s OC Mel. Hi 4,05/). Dem. APPARENT CAUSES, Wc. No. 63. Succeeded embarrasment of his affairs. Second at> tack. No. 64. Disappointment of the affections. No. 65. Succeeded the death of her father- No. 66. Constitutional— Accelerated by a fright. No. 67. Constitutional. No. 68. Constitutional. . No. 70. The supposed loss of her husband, who was ship, wrecked, but saved. No. 72. Supervened parturition. No. 73. The warm bath appeared useful in this case, which has rarely happened in cases of mania. _ No. 74. Intemperance— Had been deranged several times Mo. Vs. Attributed -to a disappointment of the affections, and being reduced in circumstances. No. 76. Constitutional. . No. 77. Constitutional— Cessation of copious perspiraU'.-i of the head. . . , No 78. General debility of body and muid. Chap. VI TABLE OF CASES. 12v e 9 e 6m "o he < u O o M ° «a .£ U 3 2 * Mo. Mo 93 18 S OC Man. 5, ] 805 Remains Dcm. 96 39 S OC Man. 7, Remains Imp. 97 40 S OC Man. 7, Remains 98 65 S OC Mel. 8, 4,06.). 99 55 M OC Mel. 9, 2, 1807 Recov. 100 19 S RC Man. 9, 8, 1806 Recov. 101 50 M OC Man. 12, Remains 102 54 S OC Man. 1,1806 2,1173. 103 23 S OC M.n. 1, 8, 06D. Mel. 104 50 S RC Mel. 4, 6,067J. 105 52 M OC Man. 6, 11, 1806 Imp. 106 59 W OC Man. 6, 9, 1811 Imp. 107 64 W OC Mel. 7, 9, Imp. 108 40 S OC Man. 7, Remains 109 34 S OC Man. 12, Remains APPARENT CAUSES, Sic. No. 95. No assignable cause. No 96. Constitutional.* No. 99. Constitutional. No 100. Succeeded great anxiety of mind. No. 1U3. Constitutional, connected with bodily disease.. No. 104. Naturally of a weak capacity No. lo5. Constitutional — Excited by interest on political subjects, and occasional inebriety. No ll)7. Rxcited bj loss ofa son and other afflictions No 1'j8. Connected with tlie breaking' oil' a matrinioni.il acquaintance. No. 109. Constitutional. * This patient, from motives of humanity, had been confin- ed at home twenty years. It had been deemed i keep him mostly chained, and he was gene: ally naked. The only confinement t>> which he has been subjected treat, Is arm -straps, and these art He has been induced to wear clothes, and adopt general orderly habits. ■Clia-ii. VI TABLE OF CASES. 125 S j a * ° ■3 6 5 « £ — y» 6 ■a a 111 Mo. o Discharged-, Deceased, Sc In what 3tat 12, 1806 11, 1810 Imp. 1, 1807 5, 1807 Recov. 2, 12, 1812 Recov. 4, Remains Imp.* 7, 10, 1808 Recov. 7, 10, Recov. 9, 4, Recov. 10, io, orA 10, 1, 1808 t 1, 1808 Remains Dem. 2, Remains Dem. % < < co o a 110 60 M OC Man. 111 : WRC Mel. 112 60 M C)C Man. 113 55 S OC Man. 114 26 S RC Man. 115 24 S RC Man. 116 S RC Man. 1 17 57 M RC Man. 18 73 S OC Dem 10, 119 43 S RC \ 120 21 S OC Man. ~ I 27 S OC Man. 4, Remains APPARENT CAUSES, &c. No. 1 10. Had been previously confined many years. \o. 111. Constitutional — Excited by the death of his wife. No. 112- No apparent cause. No. 113. Constitutional. No. 117- Connected with apoplexv. No 119. Constitutional No. 180. Occasioned by violent fear.§ No. l£l. Constitutional. * This case is almost an exact copy of No. 96. The poor man had near!) lost llie use of his limbs, and, for a considerable time after his admission, required to be led about like an infant, lie now walks without assistance, requires no coercion, and evidently enjoys the change in his situation. On one of his friends visiting him at the Retreat, and inquiring of him what he called the plate, lie replied, with great earnestness, " Eden, Eden, Eden." t Not a suitable object. i Dementia, with occasional fits of mania. § This young man appears to have been naturally of a ti- morous disposition, and the family in which he was an ap- prentice, m st inhumanly amused themselves in exciting dreadful apprehensions in his mind. One day, the servant maid, dressed herself in men's clothes, and, armed with a pis- tol, entered the room in which he was alone. Pointing it at L 126 TABLE OF CA Chap. VI. •£ ° ° ■£ S £.2 g-o -=3 | fc < < as o e > efl « Mo. Mo. 122 46 W RC * 4, 1808 7, 1808 Rccov. 7, 18) 1 12, 1812 Recov. 123 21 S RC Man. 5, 1808 Remains Imp. 124 44 S OC Mel. 6, 7, 12/;. Man 125 36 S RC Mel. 6, Remains Man. 126 38 M RC Mel. 8, 11,08L>. 127 50 S RC Mel. 8,1808 4, 1810 Rccov. 6, 18 10 9, 1812 Rccov. i 28 23 S OC Man. 8, 1808 3, 1809 Recov. 129 75 M OC Mel. 9, .12, 1808 M.I. 130 60 W OC Mel. 10, Remains Imp. 131 35 M RC Mel. 10, 12, 1809 Recov. 132 33 S RC Mel. 1, 1809 9, 1810 Rccov. 133 15 S OC Man. 3, 8, V.M.I 134 50 M OC Dtm. 6, 9,09/;. 135 68 W RC Mel. 7, 4, 1812 V.M.I. APPJREjXT CAUSES, He. No. 122. Constitutional. No. 123. Constitutional. No. 124. Constitutional. No. 125. Constitutional. No. 126. Connected with apoplexy. No. 127. Constitutional. No. 128. Constitutional. No 129 Constitutional. No. 130. Excited by family troubles. No. 131. Constitutional. — Induced by an unhappy marnagc. No. 132. Constitutional. No. 134. Injury of the skull. No. 135. Consntutional. — Had been in the same state before. his head, she pretended to shoot him. The pistol, of course, was not loaded, but its effects were sufficiently injurious. The poor object of this brutish sport, no longer possessed the command of his reason He became extremely violent, and, after remaining at home some years, was removed to the Ho- treat; where he remains in a state of hopeless imbecility! Surely some punishment should await this intellectual murder! * Mania, with occasional depression of spirits. Chap. VI. TABLE OF CASES. 127 £ V "m % •*- o u to < i c fa 0 & < 3 - o u "Ss .E CO § » t-. o a 5 u '5*3 .e-s H 3M 1 o. ? Discharged, Deceased, &< ■u 136 21 s RC * 8, 1809 2, 1310 Recov. 137 23 s RC Mel. 1, 1810 6, Recov. 138 23 s RC Man. 8, 4, 1811 Recov. 139 50 s OC Man. 7, Remains 140 40 s RC Man. 2, 1811 Remains 141 34 s OC Man. 3, 9, 1812 Recov, 142 25 s RC Man. 3, G, 1811 Recov 143 28 s RC Mel. 3, Remains 144 40 s OC t 4, 4, 1812 2, 1812 Remains Imp. 145 40 M RC Man. 6, 1811 4, 1812 Recov. 146 25 s RC Man. 8, Remains 147 49 s OC Man. 8, Remains 148 60 s OC Man. 9, Remains Imp 149 30 s OC Dem. 12, 9, 1812 * APPARENT CAUSES, &c. No. 136. Disappointment. No. 137. Constitutional. No. 138. Constitutional. No. 139. Constitutional. No. 140. Constitutional— Perplexing circumstances in bu- siness. No. 141. Constitutional. — Induced by fright. No. 142. Constitutional. — Succeeded low fever. No. 143. Constitutional. — Disappointment in the affections. No. 144. Constitutional. No. 145. No assignable cause. No. 146. No cause assigned. No. 147. Had been previously confined in several houses. No. 148. Constitutional. No. 149, Constitutional. • Mania and Melancholia intermitting, t Mania and Melancholia alternately. t Not a suitable object. 128 STATEMENT 0F( .,,. M The preceding statements are given, to enable the reader to judge of the efficacy of the modes of t ment, practised in the Retreat. It appears, that, from the opening of this Institution, in the year 1796, to the end of the year 1811, one hundred and forty-nine patients have been admitted. Of this number, only sixty-one have been recent ca- ses. Thirty-one patients have laboured under mania; of whom, 2 have died, 6 remain in the house, 21 have been discharged perfectly recovered,* and 2 so much improved, as not to require furthci confinement. The remaining thirty recent cases, have been of the melancholic class; of whom, 5 have died, 4 remain in the house, 19 have been discharged perfectly recovered, and 2 so much improved, as not to require further confinement. The old, or what are usually termed, incurable ca- ces, which have been admitted, consists of sixty-one of the maniacal, twenty-one of the melancholic class-, and six cases of dementia. Of the former, , 1 1 have died, 31 remain in the houset, 5 have been removed by their friends improved, 10 have been discharged perfectly recovered, and 4 so much improved, as not to require further confinement. Of the twenty-one melancholies, 6 have died, 6 remain in the house, * Patients who have recovered, and have returned I fnslitution relapsed, are not noticed in this summary as recovered; unless they have finally been discharged in thai stale. No case of this kind, is considered as forming than one instance of admission or recovery. j Several of these are improved, as may be seen in the table (Jhap. VI. AND REMARKS. 129 1 has been removed by the friends of the pa- tient, somewhat improved, 6 have been discharged perfectly recovered, ami 2 so much improved, as not to require further confinement. Of the six cases of dementia, 2 have died, . 2 have been discharged as not suitable objects, and 2 remain in the house. _ The present master of St. Luke's Hospital, stated, in the year 1807, before a select committee oj the House of Commons, on •' the state of Lunatics," that « the average number of curable patients admitted annually is as follows: Males 1 10. Females 153. Total 262. The numbers discharged are as follows: Cured, Males 37. Females 71. Total, 108. Uncured, Males and females 100. Unfit from various causes, 28. Dead 27." r Haslam, the apothecary to Bethlem Hospitial, states, that in the period of ten years, from 1784 to 1794, 1664 patients were admitted; of whom 574 were discharged cured, and 1090, uncured. It appears also, from the same authority, that " In the course of the last twenty years, seventy-eight patients," who had heen ill more than twelve months, ' have been re- ceived, of whom only one has been discharged cured. This patient, who was a woman, has since relapsed twice, and was ultimately sent from the hospital un- cured*." The same author informs us, that " patients who are in a furious state, recover in a larger proportion than those who are melancholic. An hundred violent, and the same number of melancholic cases, were selected: of the former, sixty-two were discharged well; of the latter, only twenty-seven: subsequent ex- perience has confirmed this fact."t We learn from an interesting paper, by Dr. PineU * Observations on Madness, p. 2SL t.rage 257. 130 "i \ n.\n \ r £>F„CASEf in the Journal ilc PhysiqucN that in the hospital ebeen, in their commencement, at all connected with religious impressions; and in most of the cases L^li STATEB SES p. VI. which have occurred, inquiry has proved, th tl t lie un- happy religious notions, have not been excited by any externa] means; but have arisen spontaneously in llie mind; and liavc been either preceded or attended by other symptoms of approaching insanity. In one instance, the disorder came on during the singing in a Methodist meeting-house; but an extra- ordinary excitement had been previously observed; which, It is at least highly probable, led the patient to the place where the ebullition of his mind, could no longer be repressed. This is one of the cases which, in vulgar estima- tion, is attributable to the Methodists; and if the apothecary of Bethlem Hospital, who .professes him- self under great obligations to this sect, for a great proportion of his patients, had an opportunity of Fully investigating the origin of similar cases, he would probably find himself not so much indebted to Metho- dism, as he at present imagines; and his remarks up- on this head, would perhaps be found equally just with his observation, that " the decorus piety, and ex- emplary life of the Quaker, has signally exempted him from this most severe of human infirmities." The turgeon to Bethlem Hospital says: " As for the opin- ion which some entertain, of the prevalent effect of Methodism, in producing insanity, proof, in place of bold and bare assertion, is requested to settle this point."* We may, however, conclude, from the state- ments of the apothecary, that religious imprefi have been the apparent cause of disorder in a number of the patients admitted into Bethlem Hospi- tal; which certainly has not been the case at the He- treat. In this respect, therefore, a material difference obtains, with regard to the prevalent causes of disease, in the two Institutions; and, consequently, before a just comparison can be made, it will be necessary to decide the probability of cure, in cases of insanity, ap- parently arising from the religious impressions. Has- • Crowther's Practical Remarks, p. 83. Gljup. VJ AND HEM AUKS, 133 iam considers the disease, under these circumstances, as peculiarly incorrigible; and the cases which have been admitted under notice at the Retreat, are too few to enable us to town a general opinion. Only three ca- ses have occurred, which can at all be considered as aoming under this description; but it is worthy to re- mark, that two of them have been completely recov- ered, and the other considerably improved. Intemperance is another very prevalent, and less ambiguous cause of insanity, in most public Institu- tions. This has not, however, been the occasion of dis- order in more than three of the cases admitted into the Retreat. In one of these, the habit had become in- veterate; but the violence and intensity of !.e mind upon all subjects which interested it, had long previ- ously marked a constitutional tendency to the dis- ease. This patient was discharged improved, but he still requires care. The other two patients both recov- ered. Haslam, however, considers intemperance as one of the more unfavourable causes of the disorder. In several cases admitted into the Retreat, the dis- order has been obviously connected with epilepsy; and it is so well known, lhat such cases rarely admit of re- lief, thai they are not admitted into St. Luke's hospi- tal. I am not aware that the prevalent causes of dis- ease, in the cases admitted into our establishment, differ horn the generality of similar places in other respect^, than those which I have already stated. It will, I trust, be readily admitted, that the habits and principles of the Society of Friends, are at least not more unfriendly to mental sanity, than those of other societies; ar.d this opinion will derive some con- firmation, from observing the large number of cases, in which the disease has been ascertained to be con- stitutional or hereditary. In a great number of instan- ces, information on this head could not be obtained; and we may therefore safely presume, that the pro- portion is considerably larger than appears in the statements. 134 statement of cASi n. ; i II OF THE RULES OF THE ESTABLISHMENT, Sec. The objtct of the Retreat, being to furnish a com- fortable shelter for insane persoiiB, as well .is to pro- mote their recovery, its original rules made no dis- tinction between old and recent cases; and did not, in any degree, limit the time of patients continuance in the house. The only restriction relates to idiots; and this appears to have been generally understood as applying, chiefly, to cases of original absence of in- tellect. In these respects, the circumstances of this esta- blishment, differ materially from those of some of our largest public institutions. It a^cars, from the statement of the master of St. Luke's Hospital, made before a Committtee of the House of Commons, that, in this Institution, " The average number of patients at one time is 300;" and that " the average number of incurable patients, in the house at one time, is 1 15." All patients are dis- charged from this Asylum at the end of the first year; and if not then recovered, may be entered on the in- curable list, to be admitted when a vacancy offers; but it appears that only a certain number of this class of patients are permitted to be in the house at one time. The rules of this hospital do not admit patients " troubled with epileptic or convulsive fits." By the following quotation from Haslam, it appears, that the rules of Bethlem Hospital guard against the admission of old cases: " Although patients who have been affected with insanity more than a year, are not admissible into the hospital, to continue there for the usual time of trial for cure, viz. a twelvemonth; yet, at the discretion of theCommitee, they may be receiv- ed into it from Lady-day to Michaelmas; at which lat- ter period they are removed. In the course of the last twenty years, seventy-eight patients of this descrip- tion have been received." There are, however, a number of patients in Beth- lem, who have been there many years; and I there- fore conclude, that a certain proportion is permitted, Chap. VI. AND REMARKS. 135 as In St. Luke's, to remain on the uncurable establish- ment.— But, as Haslum states, that from the year 1784 to 1794, out of 1664 cases admitted, 1090 were dis- charged uncurcd, I presume that the number of pa- tients in this hospital, who have been afflicted with insanity more than a year, is comparatively very small. It will be seen that a large majority of the cases admitted into the Retreat, have not been recent. In several instances, the disorder had existed from fif- teen to twenty years previously to their admission; and, of course, no reasonable hope could be entertain- ed of the patients' recovery. The total proportion of cures cannot, therefore, be expected to be large. I will not, however, omit to mention, that the number of these must have been fewer, if the rules had limi- ted the time of continuance in the house, as is the Case in the two charitable Institutions above mention- ed. But, it must also be observed, that several pa- tients who have been sane at the expiration of twelve months, have remained in the house from three to six months longer on probation, or at their own request) until a suitable situation offered for them. Others, who have been apparently well at the end of twelve months, have relapsed before they quitted the house; and I cannot avoid attributing to the pre- mature discharge of insane persons, many of the re- lapses which occur after they leave the places pro- vided for their care. Several of the symptoms which mark the disorder in its incipient state, also mark an advanced stage of convalescence. In either case, though no absolute act of insanity is committed, the mind is unable to bear that stimulus or exertion, which wovdd even be salutary to it, in a state of per- fect sanity. III. EXPLANATION OF TERMS. It will have been observed that the cases, in the preceding tables, are arranged under three clases, viz. Dementia, Melancholia, and Munia. The first compr< hends those cases in which the menial powers appear materially weakened; which are 136 ISES ;>. \l. attended with a general irritability, or arc subject to occasional maniacal paroxysms, rendering the patients dangerous to themselves or others. Idiocy, or mere imbecility of mind, as has been already stated, is not admissible into the Retreat; though persona who sink into that state, are not necessarily dischai Under the class, Melancholia, all casts are includ- ed, in winch the disorder is chiefly marked by depres- sion of mind, whether it is, or is not, attended by gen- eral false notions. Those cases, however, are distin- guished, in which the melancholy feelings are imme- diately connected with hypochondriasis. In the third class, .Mania, all those cases are includ- ed, in which the disorder is not chiefly marked by weakness of intellect, or mental depression. In regard to the division of the cases into old and recent, it will be proper to observe, that those of more than twelve months standing, are considered under the former, and all the others under the latter division. I know not what degree of sanity is generally thought sufficient to warrant the application of the term, l ciired* In the preceding tables, the term reco- vered, is applied only where the patient is fully com- petent to fulfil his common duties, or is restored to the stale he was in, previously to the attack. As we have not discovered any antimaniacal spe- cific, and profess to do little more than assist Nature, in the performance of her own cure, the term rcco- ■ l. is adopted in preference to that of run d. I will conclude this chapter by considering, whe- ther insanity is essentially prejudicial to animal life. Dr Monro, in his reply. to Dr. liattie's Treatise on Madness, yjves the following evidence upon this sub- ject: " Although I do not remember to have seen more than four instances, where I could sav, the fury of madness w.,s the immediate occasion of death, I have great reason to believe that madness destroys two-thirds of those, who are afflicted with it through life."* * I'-,; (lu.p.si AND REMARKS' 137 Dr. Crichton* tells us that," melancholic patients seldom live long. They often terminate their own ex- istence in the attacks of the disorder; but, even when carefully watched, and when every care is taken of them, they never attain old age. Many die before thirty or forty; and few live beyond sixty; but a great deal of diversity, in this respect arises from the differ- ence of the time of life when they are first seized with the complaint." — Dr. C. refers us in this place to « Greeting's Aphorisms," which form an appendex to his work. It is there stated, that " the greater number oi insane people fall into a state of atrophy, or decay, towards the close of iheir life: for it has been found, that of one hundred maniacs, sixty-eight died in this way; of twenty -six epileptic maniacs, there were thir- teen; of sixteen epileptic idiots, only four; and of twenty-four melancholic, there were twenty; and last- ly, of thirty idiots, there were twenty-one who died of this kind of consumption." The next sentance states " Hydrothorax to be the disease to which they are most subject;" and a suc- ceeding aphorism informs us, that " consumption from an ulcerated state of the lungs, appears to be another disease which often terminates the existence of insane people." Not to dwell on the seeming contradiction in tiiese statements; that two distinct diseases are each of them represented as being the most frequent occa- sion of death among insane persons, it is perhaps mat- ter of doubt, whether the frequency of these diseases, is not more connected with the mode of treatment, than with the mental disorder. Of the twenty-six deaths which have occurred in the Retreat since its establishment, a period of 16 years, three have been in consequence of epilepsy, and two of apoplexy, with which the patients were affec- ted previously to their admission, and which appeared to be the causes of derangement. Seven patients have died in a state of atrophy; but of these, three appear- t Vn Inquiry into the Nature and Origin of Mental De- rangement, by Alexander Crichton, M. D. Vol. II. p. 263. M 138 STATEMENT OF CASES p. 1\ ed to be in the last stage of decay at the time of their admission. Three patients have died of general drop- sy, two of inflammation of the intestines, two of ex- terna) inflammation, one of hemorrhage from the stomach, one of erysipelas, one ot convulsions, and one of fever. Three cases, in which the unhappy dispo- sition of the patient to injure himself, proxed fatal, complete the statement of causes of mortality in this Institution. It is no small satisfaction to be able to add, that the three melancholy cases just mentioned, are the only instances of the kind; and that in the last eight years, during which the average number of pa- tients has been fifty-six, no circumstance of this kind has occurred. It may be proper to state, that the average number of patients in this Institution at one time, since its estab- lishment, is 46; and the following summary shows the ages of the patients at present in the house: 15 to 20 years inclusive 2 20 to 30 - - - - 8 30 to 40 . - - - 12 40 to 50 - - - - 20 50 to 60 - - - - 7 60 to 70 - - - - 11 70 to 80 - - - - 4 80 to 90 - - - - 2 One of the patients is 87 years of age; and it is re- markable, has been subject to very frequent and violent paroxysms of vociferous mania, during the last ten years. The number of deaths, in this Institution, is too small to admit any decided inferences to be drawn, as to the general causes of mortality amongst insane per- sons; but the ages of those now in the house, as well as the general result in regard to the number of deaths, will perhaps fully justify an opinion, that insan- ity is not assentially prejudical to animal life. APPENDIX. THE Author hopes he shall be justified in present- ing the reader with the sentiments of some respecta- ble persons, who have carefuHy inspected the Retreat. His view in doing so, is to confirm the testimony which he has given in the preceding pages, of the practices of this Institution, and which might be sus- pected of partiality, if it were not supported by the evidence of disinterested persons, who were qualified to judge on the occasion. In the year 1798, Dr. Delarive, of Geneva, after, having examined a great number of public and private establishments of a similar nature, visited the Retreat. Jt was then in its infancy, but, the Doctor was so far pleased with the general management, as to write a very favourable description of it, in a letter addressed to the editors of " The British Library." This let- ter afterwards appeared on the Continent in a separate form,* from a copy of which the following extracts are made. After describing the evils which have existed in the treatment of the insane in public hospitals, which he observes would lead one to suppose, that madmen were employed in tormenting other madmen, he says, " The respectable society of Quakers have at length 'endeavoured to remedy these evils; it has been desir- ous of securing to those of its members, who should have the unhappiness to lose their reason, without pos- sessing a fortune adequate to have recourse to expen- sive establishments, all the resources of art, and all the comforts of life, compatible with their situation. A vol- untary subscription furnished the funds; and, about * Lettre adressee aux Rddacteurs de la Bibliotheque Britan- nique sur un nouvel etablissemeRt pour laguerison des Alines. 140 APPENDIX. two years since, an establishment, which appears to unite many advantages, with all possible econi was founded near the city ol York. u If the mind shrinks for a moment at the aspect of this terrible disease, which seems calculated to hum- ble the reason of man; it must afterwards feel pleasing emotions, in considering all that an ingenious benevo- lence has been able to invent, to cure and comfort the patients afflicted with this malady. " This house is situated a mile from York, in the midst of a fertile and cheerful country; it presents not the idea of a prison, but rather that of a large rural farm. It is. surrounded by a garden. There is no bar or grating to the windows, their place is supplied by a means of which I shall afterwards give an account. "* After a general view of the economy of the Retreat, and the general treatment of the patients, the Doctor thus concludes his letter: — " You will perceive that in the moral treatment of the insane, they do not consider ihem as absolutely deprived of reason; or, in other words, as inaccessible to the motives of fear, hope, feel- ing, and honour. It appears, that they consider them * «' La respectable Socie^e des Quakers a enayi dernierc- ment de reinedier a ces maux; elle a desire assurer a ceux d« ses membres qui auroicnt le malheur dc perdre la raison sans avoir une fortune suffisante pour recourir aux ctablissc- mens dispendieux, toutes les ressources de Part et toutes les douceurs de la vie compatibles aver, leur etat; une 6ouscrip- tion volontaire a fourni les fonds. et depuis deux ans environ, un dtablissement cjuiparoit r6ynir beaucoup d'avantages toute 1 'economic possible, a£te fonde pres de la ville d'Vork. Si Pame se fletrit un momenta Paspect de cette terrible ma- ladie qui semble faite pour humilier la raison humaine, on eprouve ensuite de douccs emotions en considerant tout ce qu'une bienveillance ingenieuse a su inventer pour la guerir ou la soulager. " Cette maisoB est situ£e a un mille de York au milornt d'une campapne fertile et riante: ce n'est point Pidec d'une prison qu'ellefait naitre, mais plutotcelle d'une grande f rustique, elle est enlouree d'un jardin feime. Point d> ieau, point de grillages aux fenctres, on y a suppled par un moyen dont je rendrai compte ci-apres." — P. 5, 6. APPENDIX. 141 rather as children, who have too much strength, and who make a dangerous use of it. Their punishments and rewards must be immediate, since that which is dis- tant has no effect upon them. A new system of edu- cation must be adopted to give a fresh course to their ideas. Subject them at first;* encourage them after- wards, employ them, and render their employment agreeable by attractive means. I think that if we could find still stronger means to excite feelings of benevo- lence in their minds, we should accelerate their reco- very by the agreeable emotions which accompany all the iffections. But it is evident, that every needless res' raint, excites in them the vindictive passions, to which they are but too prone, and prolongs the con- tinuance of the disease."! A Few years since, W. Stark, Esq. Architect, of Glasgow, who was engaged to prepare apian of an Asylum for that city and the west of Scotland, visited the Retreat. The following extract is made from his valuable " Remarks on the Construction and Man- agement of Lunatic Asylums," published in the year 1810. " In some asylums, which I have visited, * If this maxim was ever acted upon at the Retreat, it is now in great measure exploded. See page 146. ■J- " Vous voyez, que dans le traitement moral on ne con- sidere pas les fous comme absolument prives de raison, e'est- a-dire, comme inaccessibles aux motif de crainte, d'esperance, de sentimens et d'honneur. On les considere plutot, ce sem- ble, comme des enfans qui ont un superflu deforce et qui en faisoient un emploi dangereux. 11 leur faut des peines et des recompenses presentes: tout ce qui est un peu eloigne n'a point d'effet sureux. [1 faut leur appliquer un nouveau sys- teme d'education,donner un nouveau cours a leursidees, les suhjuKuer d'abord, les encourager ensuite, les appliquer au travail, leur rendre ce travail agrdablepar des moyens attray- ans. Jepenseque si on pouvoit encore trouver des mobiles plus forts pour exciter en eux la bienveillance, on accelereroit leur retablissement par les sentimens agre"ables qui accom- pagnent toutes les aifections sociales- Mais on sent bien au moins que toute contrainte inutile, excitant chez eux les passions vindicatives auxquelles ils ne sont que trop porteY, prolongs la durce de la m;dadie."— P. 29, 30. 142 APPENDIX. chains are fixed to every tabic, and to every bed-| in others, they are not to be found wit bin the ' The idea of inflicting corporal punishment is h Id in abhorrence; and rods or whips arc considered as en- gines of power, too dreadful to be committed to the hands of servants, who may soon convert them into instruments of oppression. " In such asylums, however, there are no appear- ances of insubordination. The whole demeanour <>f the patients, on the contrary, is most remarkably sub- missive and orderly. The one to which I especially allude, the Retreat, or Quaker asylum, near York, it may be proper to mention, is occupied by a descrip- tion of people, whose usual habits in Kfe are highly re nlar and exemplary; but the chief cause of its su- periority will be found to lie in the government of the asylum. It is a government of humanity and of con- summate skill, and requires no aid from the arm of violence, or the exertions of brutal force. " At the Retreat, they sometimes have patients brought to them, frantic, and in irons, whom they at once release, and, by mild arguments and gentle arts, reduce almost immediately to obedience and orderly behaviour. A great deal of delicacy appears in the at- tentions paid to the smaller feelings of the patients. The iron bars, which guarded the windows, have been avoided, and neat iron sashes, having all the appear- ance of wooden ones, have been substituted in their place; and, when I visited them, the managers were occupied in contriving how to get rid of the bolts with which the patients are shut up at night, on account of their harsh ungrateful sound, and of their commu- nicating to the asylum somewhat of the air and charac- ter of a prison. " The effects of such attentions, both on the happi- ness of the patients, and the discipline of the Institu- tion, are more important than may at first view be ima- gined. Attachment to the place and to the managers, and an air of comfort and of contentment, rarely ex- hibited within the precincts of such establishments, APPENDIX. 143 sre consequences easily discovered in the general de- meanour of the patients."* THE following testimony is extracted from an ac- count lately published of the Lunatic Asylum at Edinburgh; and we are authorized to state, that it comes from the pen of Dr. Duncan, sen. who visited the Retreat in the year 1812, after having seen most of the Institutions of a similar nature in Britain. " That the government of the Insane requires a cer- tain degree of restraint, both for the safety of the in- dividual and of others, no one can doubt. But very different opinions have been entertained with regard to the utmost degree of coercion, which is necessary in any case. Now, however, this point may be consi- dered as in some degree settled by experience. The fraternity denominated Quakers have demonstrated, beyond contradiction, the very great advantage result- ing from a mode of treatment in cases of Insanity, much more mild than was before .introduced into al- most any Lunatic Asylum, either at home or abroad. That fraternity, who have been long and jus'ly cele- brated for charity and humanity, have established in the neighbourhood of the city of York, The Retreat, as they term it, a building appropriated to deranged members of their own community. In the manage- ment of this Institution, they have set an example which claims fie imitation, and deserves the thanks, of every sect and every nation. For, without much haz- ard of contradiction from those acquainted with the subject, it may be asserted, that the Retreat at York, is at this moment the best-regulated establishment in Europe, either for the recovery of the insane, or for their comfort, when they are in an incurable state. "f Dr. Naudi, president of the Maltese Hospital, af- ter carefully inspecting the Retreat in the present year, gave the following testimony respecting it: •Pages 11, 12. fPage 15- 144 APPENDIX. " I am very glad to have been at York, to oh- the Retreat there, kept by the Society of Friends. This house, or Retreat, for the troubled in mind, I think is one of the best things I saw in England on the same subject; and having observed many others on the Continent, I dare say that it is the best in all the world. The situation of the building out of the town, a large garden around it, the propriety of the rooms, the cleanliness of the patients, the way in which they are kept, as for dressing, as for feeding them, is very remarkable to be observed."* • Dr. N. had studied the English language, only nine months. THE END. NM-. Wi$t, TtHdL •■'• ?»A '^ Isaav Peirce, of Philadelphia, Proposrs to publish by subscription, DICTIONARY 5S; Arts and Sciences. IN THREE VOI BY G« GREGORY, D. D. Doctor in Philosophy and tnber the Imperial University of Y\ stle Literarv and rary Member of the i lain to the LordBishu rical and A* oral, the Economy of Nature, &.c &c. »N'DTTIONS. ' Subscriptions received South Fourth Street, PhiladelJ H? A NEW AND COMPLETE & 4 I. It will be printed on a superfine paper, with a new j$V tyi r the purpose, and oe comprised in three I jjfttt quarto volumes of at ieast 800 pages each. II. One number, or half volume, will be published every three mouths, till completed, and will contain f/fjj? about twentv-fivt engraved plates. !T III. It will be delivered to subscribers at five d & lars per half volume, payable on deli'. frg? IV. The work will be put to pre ficient number of subscribers shall l-.- i