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blishments of the description alluded to,* in which are to be found, I doubt not, many interesting examples of every form of insanity; and medical students, if permitted to visit them, and there observe the symptoms and progress of such cases, would evidently be better qualified than they are at present, to give opinions in courts of law as to the sanity of individuals, and to superintend the management of cases when entrusted to their care. Yet, it is equally evident that certain restrictions should be imposed, to confine this privilege to persons qualified to derive advantage from it, and careful not to abuse it ; for it would be hurtful to many of the patients to be visited by an indiscriminate number of thoughtless young men, who would perhaps feel no regard for the peculiar nature of the patient's malady, and exercise no control over their own conduct and conversation ; for even a single word, a silent action, or a passing look, might be erroneously attributed to improper motives, and, by disturbing the tranquillity of the patients, be productive of much injury. I need scarcely observe how often in these cases, offence has been taken where none was meant, and how frequently the best intentioned, and perhaps most ingenious efforts to please, have failed to produce the wished for effect. Merely to accost some patients, to cough in their hearing, even though not in sight, or to perform any other unmeaning action, whereto their disordered mind may have attached some peculiar importance or unkind intention, is occasionally quite sufficient to irritate their feelings, and excite that unhealthy action in the diseased organ, which is so prejudicial to their recovery. Now, as these asylums were originally intended for the recovery and relief of the unhappy sufferers, it would be worse than useless to sacrifice their utility as places of refuge, to the vain hope of making them nurseries of science. I say vain, because if either the number or injudicious remarks of the students were permitted to disturb the tranquillity of the patients, no treatment could be expected to succeed. For, as in mere injuries of the body, rest has been found to be more conducive to recovery than the exhibition of medicines, so, in this class of diseases likewise, it is absolutely indispensable; and, it is extremely probable, that this necessary rest would be interrupted by the questions which a young student would propose to the patients, in his anxiety to avail himself of the advantages afforded by his attendance at the lunatic asylum. I am therefore of opinion, that it would be infinitely preferable to have these institutions closed against the admission of stu
* St Patrick's Asylum, founded by the celebrated Dean Swift, and the Rich. mond Asylum, which affords accommodation to 300 patients. Incurable lunatics and idiots are likewise accommodated at the House of Industry. I am not quite certain of the numbers admitted there, or at St Patrick's Asy. lum ; but they are considerable.
dents, rather than permit the feelings of the patients to be outraged, and their recovery retarded, in the manner just described. But if there can be found amongst medical studentsas I believe there can—some ardently desirous of obtaining information upon every subject connected with their profession, anxious to relieve the sufferings of their fellow-creatures, and willing to submit to every wholesome restriction, which the governors, medical and moral, may think fit to impose, then I am satisfied, that the doors of these institutions may be thrown open to such students, without injury to the patients, and with advantage to science.
I need scarcely, upon this point, make any allusion to the private establishments which accommodate the richer classes of society, and which, from a due regard to the feelings of relatives, must be closed against intrusion ; for, even though accessible, they would afford the student such very inferior opportunities to pursue his investigations, that it is a matter of much greater professional importance to endeavour to obtain access to those larger asylums where attendance would be really an advantage.
My second suggestion is, that lectures upon insanity, and the matters connected with it, should be instituted in our various professional colleges and schools. Although few cities in the world are supplied with a greater number, or a higher order, of teachers of the various branches of medical science than Dublin, we have to lament that this array of talent and industry is too exclusively directed to lower and less important diseases than those which affect the human mind. In illustration of this, I may state that an eminent professor of the practice of physic, when compelled by want of time to omit a portion of his course, selected this very class of diseases as that which could be most safely discarded. Perhaps he acted more judiciously in not entering upon the subject at all, than he would have done had he glanced at it in the superficial and obscure manner in which it is usually alluded to; and I cannot help remarking here, that as, in ordinary cases, clinical lectures convey more practical information to the student than any others, so probably the best lectures which could be instituted upon insanity would be those which refer to actual cases, and illustrate at once the degree of disease, and the details of treatment. It is greatly to be wished that the medical profession of the British islands may direct their attention to this subject, with the view I have just hinted at. Other countries have already set us the example, and our continental brethren bear away the uncontested prize: but I venture to assert, that our resources in this department of medical investigation are not inferior to theirs, if we but knew how to use them; nor is there so little vet to be ascertained in this field of research, that we may leave them to complete, without disturbance, the discoveries they have begun.
A third suggestion is, to have all'establishments for the treatment of insanity built upon a large and extensive scale.' :Were they so constructed, not only would the students derive proportionally great advantages from 'attendance on them, being thereby enabled to see a greater number and variety of cases than could be accommodated in smaller institutions, but also the facilities of cure would be much increased. For in such places, suitable employment and amusement can be more easily afforded to each of the inmates, and the possibility is greatly increased of intercourse amongst the convalescent patients, which has the tendency to relieve that feeling of loneliness so prejudicial to recovery, and so apt to occur when their number does not exceed one or two. It is quite obvious, that, even although the medical attendant should devote the whole of his time either directly or indirectly to the cure of his patients, he cammot always be present; and from peculiarity of taste or of temper in his patients, his presence at any time will not be equally acceptable to all. Upon such occasioris, or under such circumstances, I conceive it is absolutely injurious to leave the patient altogether to himself, or to the company of a person in a different rank in life from his own. In the former case he begins to ponder on his melancholy condition, and sinks into despondency; in the latter, propriety of taste is offended by the coarseness of his companion. But when, under proper restrictions, rational intercourse is permitted amongst the convalescent patients, a cultivated mind is both occupied and pleased by the society and sympathy of equals. In some instances I have known this intercourse productive of greater advantages than conversation, even with the physician. The inorbid state of the patient's mind frequently produces dislike to the medical attendant, and suspicion even of his kindness: advice from him will be disregarded, and arguments perverted, because they are supposed to arise from interested or improper motives; but a remonstrance from a fellow-sufferer seems the essence of affection,—and the intention, whatever it may have been, is immediately abandoned, and tranquillity is restored. I have known many instances of patients determining to commit some desperate design, but defeated by an underplot in which another patient acted a part, and by his timely and successful advice prevented the necessity of resorting to restraint.
In advocating this opinion, I have ventured to differ from some authors, * who condemn large establishments as tending
See Letter of Mr Bakewell to the Chairman of the Committee of House of Commons, 1815.
to create a horror in the minds of the patients, and thus prevent their recovery.
These writers conceive, that as some incurable patients must be confined for life in all large establishments, each new inmate must fear that he is to be added to the number of those in that deplorable condition. But as it is the duty of every person to report the result of bis own experience for the general advantage, I am bound to say, that, out of a large number of cases in an establishment with which I am intimately acquainted, I recollect but one in which the patient either alluded to, or expressed dislike at, the circumstance of his being confined with insane persons; a patient, too, that recovered in spite of his feeling upon this point. In many cases, indeed, the patients expressed annoyance at being contined, but this was altogether independent of the place or circumstances of their confinement.
That such a feeling was not oftener manifested by the patients, may probably be accounted for by the attention which was paid to their classification; in proof of which may be stated the fact, that, in several instances (I distinctly recollect four), members of the same family were at one time in the house without either of them being aware of the condition or confinement of the other. Of course, large establishments are advisable only when they are so arranged as to provide for the classification of the patients, and the separation of such as might by conduct or conversation interrupt that tranquillity which is essential to the health of the convalescent and to the recovery of the insane. I believe that few asylums exhibit such, a number of real recoveries and amendments in proportion to the total number of patients, as the large public pauper asylums. In these we can conceive no adequate motive which could influence the managers to falsify or exaggerate the returns; whereas in all private establishments the reverse is obviously the case, and any statement of cures and amendments coming from such quarters is not to be received with equal confidence. Certainly there may be some peculiarity in the constitution and circumstances of the poorer classes, giving rise to this superiority in the success of their treatment; but the facility with which, in large pauper asylums, suitable employment can be provided, seems to me quite sufficient to account for the difference.
In the fourth place, I would suggest that all establishments, both for the poorer and the richer classes of society, should be placed under the care and management of Government., At present, the Government of the country exercises a control over all private Lxunatic Asylums, through the agency of inspectors, -whose occasional visits prevent the occurrence of any
of those gross and lamentable abuses which were formerly so common ; hut I humbly suggest that some public body should be en
trusted with the management of, and not merely a controlling power over all of them; and that such allowances should be made to the medical officers, as will secure the services of the ablest in the profession, and enable them to devote the whole of their attention to the responsible duties of their office. These duties, I hesitate not to assert, are the most difficult, as well as the most important, in the whole range of medical practice, and it would be absurd to intrust them to a person of inferior medical education from the paltry motive of economy. 10
I am aware that were this suggestion carried into effect, the consequences would be hurtful to the pecuniary interests of many who have undertaken this difficult and important trust. I have been told by the friends of patients to whom the observation was made, that they could not feel the same confidence in the management of Lunatic Asylums, under such circumstances, as they do at present, when the proprietor is labouring to support his own reputation amidst much honourable rivalry and some secret suspicions ; and I am farther aware that it would be more difficult to conceal the name and rank of the patient than it is at present: but I am recommending those measures which appear to me most likely to facilitate the successful treatment of insanity, and one of these is, that the mind of the physician should be undisturbed by the many cares and anxieties which devolve upon the proprietors of such places, and left free to study and to treat the cases that come before him. And farther, whenever he recommended any mode of treatment, he would be unfettered by the fear that his counsel might be supposed to be dictated by self-interest. I have known instances where, from this very circumstance, removal to or continuance in an asylum was not advised, though the patient's state seemed to require it, lest it should have been supposed to have emanated from this unworthy motive and the patient's advantage was sacrificed to this delicacy of feeling.
Another advantage following the adoption of this suggestion would be, that the statistics of insanity might be carefully compiled. The uses to which accurate and properly prepared tables could be applied are too many to be enumerated here: some documents lately published by Sir A. Halliday, comprise nearly all the information we are possessed of on this subject ; and its imperfect nature furnishes a strong argument against the continuance of the present system of separate and independent asylums.
Farther, I would recommend that all such establishments should be properly adapted to the state and health of the patients. Some are continually talking aloud, singing, or shouting, either to create disturbance, or to enjoy the gratification