by Mark Stevens
Treatment
All patients enter this asylum with the expectation of recovery. They have been sent here because we can provide treatment at the forefront of modern medical care, which is universally acknowledged as the best method of achieving respite and for cure. Much of it has already been described, as it is inherent in the organisation and workings of the asylum.
The Moral Regime
The moral regime is the bedrock of asylum life. It is based on the kindness that any man might offer to his neighbour. This kindness seeks to remove any friction that might irritate the brain, and then to influence your mind’s reparation in positive ways. The object of this treatment is to subject you only to uplifting, healthy forces; it is both palliative and curative.
The first part of the moral regime – the removal of the patient from the immediate cause of illness – is the reason why your admission was recommended. This is the asylum in its proper role as a refuge from the evils of society. Your acute symptoms should subside in your new, soothing surroundings.
One might ask whether it is a kindness to detain a man so that he receives care and medical treatment? Quite apart from the statutory imperative that we are given, the detention of patients in the asylum is recognised as being the most efficient way to induce the patient to assist in their recovery. No matter what treatment is given to a lunatic outside of the asylum, there is no guarantee that he will follow his prescription, nor that his will be an environment conducive to improvement. Many men of higher birth are treated in their own homes, but that does not relieve their families and friends from the burdens of their illness. Any good physician would admit that some restriction of liberty is inevitable if a successful outcome is to be attained.
If you were very unwell at admission then you may not remember the process by which you came here or your first days under our care. This is quite common, and during such a phase we shall not attempt to practice the more active elements of the moral regime. However, once you are able to appreciate your surroundings we will begin to stimulate your mind towards the reception of healing thoughts.
Whilst the asylum is a refuge, it also promotes all that is healthy by methods tailored to suit your particular illness. With manifestations of mania, for example, the repression of strong emotion may be considered a good thing, and by discouraging manic action or expression we may discourage manic thoughts. If you are excited by the opposite sex, money or religion, then we may suggest that such topics are never mentioned in your presence. However, if you are melancholic, then it is unwise to quell emotion. Rather, we will interrupt your morbid thoughts with varied topics of conversation, thus diverting the mind from its own unhappiness.
The delusional patient requires a slightly more nuanced approach. Generally speaking, a polite but firm contradiction will be given in response to any statement of fantasy. However, staff will not attempt to argue with a delusion, for to do so is to validate its existence, and in such circumstances a delusion can only grow stronger. Instead, the right approach is to gently challenge it, wearing away at it like the tide against a stone until it is smoothed down to the smallest pebble. At this point the patient should still perceive their delusion but no longer fear it.
As you will have already gathered, physical activity and the routine of every day constitutes a great part of your treatment. Daily industrial occupation; regular meals of filling but unexceptional food; and plenty of fresh air – these are the cornerstones of your recovery. All of these elements improve the quality of the blood supplied to the brain and the strength of its flow.
It might be observed that the patient in our public asylums is afforded a greater chance of cure than the gentlemen in their private madhouses. For the food consumed by the pauper lunatic does not match the extravagant portions consumed in the private house, and the working patient obtains an industry denied to his better-off cousin. The gentleman is allowed to assume the obesity of madness while he sits before a well-stocked fire or ambles at his own pace.
In effect, the moral regime works by simply providing a distraction for a diseased mind, preventing it from fixating on its disordered thoughts. For activity keeps one’s focus hard upon it and there is no time for melancholy in the dance, or for mania as the seeds are sown. These processes are rhythmic and methodical; at once soothing and calming. Their persistent application is a patient’s therapy, and it will guide you ever-closer to recovery.
Of Medicines and Other Methods
It would be wrong, however, to assume that no medicine may be dispensed other than through this inspiring regime. At any one time, we estimate that around a quarter of our cases are considered curable, and so it is imperative that we use all options available. There is, indeed, much debate as to whether the moral regime has become too heavily relied upon by asylums, and if other beneficial options are wrongly avoided.
The moral regime has at its heart economy as well as practicality. Its prevalence is due to its success in both quietening the patients and in requiring only a prudent sum from the public rate. Our expenditure on drugs is relatively modest, comprising about the same amount that we spend on crops, and we strive to keep it so. Physicians can be at the mercy of sellers keen to peddle doses of some heroic new concoction, so our doctors have long understood the need to be cautious of the latest whim, no matter what the Olympian boast of the man who promulgates it. Nevertheless, occasionally other treatments will be offered if they are felt to be of worth.
Sedatives, such as morphine, are made available to calm manic patients if no other diversion is successful. Small doses of morphine dissolved into beer, wine or vinegar may be given during the day to encourage stillness, and particularly at night time as a sleeping draught. Over time, patients can even begin to recognise when they are losing control and request a dose. If morphine ceases to be effective, then chloral hydrate or Indian hemp may be substituted for it. Morphine can also be greatly beneficial to those suffering from melancholia, as it regulates their mood and brings relief from the exhaustion of their worries.
In contrast to those whose mental energy is in need of calming, stimulants may be prescribed from time to time for those in need of a tonic. Patients who are exhausted, sunken or sullen may find a short burst of new energy from spirits, while those who are weak from illness find a little brandy boosts their recovery. The only other drugs routinely prescribed are those for patients whose mental state worsens when their stomachs or bowels are disordered. Lunatics are well-known to be prone to constipation, and in these cases, purgatives such as castor oil, black draught of senna or croton oil are given to improve flow and regularity.
Dispensing is only ever done in a limited quantity. Purgatives may be decanted into bottles large enough for an attendant to administer over several days, but no more than one dose of a sleeping draught, such as laudanum, is ever issued. Accidents have occurred when attendants have been tempted to overdose the more afflicted patients.
Other treatments revolve around the use of water. If narcotics fail to induce sleep, for example, then a patient suffering from mania might be given a prolonged warm bath, while cold flannels or compresses are laid against their head. The resulting contrast between the heated body and the artificially cooled mind greatly calms the agitated man or woman. In a similar vein, patients are very rarely wrapped in warm, wet towels to stem manic activity. This is known as a ‘wet pack’, and is strictly limited in duration; too long an application and the towels cool, with the risk of inducing hypothermia. Cold water is generally no longer used in treatment, as it was never found to demonstrably cool hot blood; if a patient finds benefit from the application of cold water, then it is poured onto the head or upper body in small quantities, before the patient is quickly towelled dry.
In nearly all cases, these non-invasive treatments form the limits of our interventions in your malady. However, a brief word may be had on more fanciful notions, which are not entertained in this asylum but are often afoot in private medicine. It is a curiosity of the
age that the private patient, perhaps due to the greater funds at his disposal, is subjected more to drastic treatments which are doubtfully substantiated by evidence.
So it is that some private houses still subject their patients to procedures long since rejected by science. Bleeding – either by cupping the body, or by the application of leeches to the temples or shaven scalp – is used in the belief that a little blood loss will relieve the worst symptoms of mania or melancholia, presumably by taking away blood considered to be overheated or chilled. An umbrella-maker admitted this year with mania showed signs of having been cut and cupped about his heart. However, there is no empirical basis for the efficiency of bleeding and we have never practised it here.
Many private doctors also remain convinced that depression can find its root in the digestive function, and as a result their patients find themselves subject not just to laxatives, but to potions that encourage vomiting or urination. The trick, it seems, is to administer just enough of the poison – typically antimony or mercury – that the patient is laid low by its effects, but not so much that he descends deeper into melancholy. Such trial and error is not something for which we have the time or inclination to attempt.
Those private patients who suffer from anxiety, and feel their heads are full of worry, can find that their illness is treated by having the skin burnt at the neck so that it blisters. The theory is that this will emit the source of their congestion. That seems a cruel enough conjecture, but even these indignities are nothing when compared to those suffered by patients who exhibit more libidinous behaviour. For although all medical men acknowledge the danger to sanity caused by masturbation, some physicians have gone so far as to blister the offending organs on both male and female patients, while the more extreme practitioners have fashioned metal prisons for the male appendage or removed the female bud. You will be pleased to note that whatever debased form your own pleasures may take, such surgery will not be practised here. A little bromide of potassium may be prescribed to slacken your desire, and your arms may be placed above the blankets pulled quite tight at night, but nothing further.
More helpful experiments – including in some public asylums – have been undertaken recently with the use of electricity. In these experiments patients are attached to a battery and a low current is passed through them. There is a growing belief that the regular application of such currents can help decidedly with cases of melancholia, though there is as yet no acceptance that the ratepayers should fund the necessary equipment.
Restraint and Other Extreme Measures
It is perhaps well now to touch upon the nature of restraint, as this measure is doubtless something that you fear. Happily, we can brush away this concern as belonging to a previous, more unenlightened age than our own. Restraint is our last resort to exercise control over patients likely to cause harm to themselves or others, and in its stead gentle coercion is always to be preferred. Many patients respond quickly to the reminder that their discharge depends on them becoming demonstrably healthy, and a simple admonishment, delivered fairly but firmly, often results in an immediate improvement in their attitude.
If persistent problems are encountered, then our normal response is to restrict privileges. While labour and fresh air are important elements of your treatment, the way in which you obtain them is not. Playing cricket or walking outside the grounds are concessions that can be removed if necessary. Should such small adjustments not yield the required results, then patients can find themselves moved down the classes of ward until they reside with the dirty and destructive. For a patient who is able to control his or her emotions, such a shock can be considerably effective.
If, due to some emergency situation, restraint has to be used, then the most common mechanism is for two attendants to take the arms of a patient, escort them towards a bench, and then sit on either side of them. Each attendant then places one hand on the patient’s wrist, anchoring it to his thigh or to the arm of the seat, while one leg is wrapped around a leg of the patient. The rowdy resident thus immobilised, a situation of calm descends without fuss. A similar procedure can be adopted if the patient must be restrained upon the floor.
Mechanical restraint – that is, restraint with the use of some sort of physical aid – is viewed as barbarous, and for many decades has been practically obsolete. Only in the rarest cases, for instance where self-harm is imminent or wounds are required to heal, is such restraint countenanced. During the last decade we have had only four occasions to use it, and any incidence is of such significance that the Commissioners in Lunacy require the details to be recorded in a special book. Restraint is never contemplated lightly.
If mechanical restraint is employed then various options are available. At its simplest, restraint can be achieved by placing the patient in bed and pulling sheets and blankets or wet towels tight around them, tucking them into the frame so that they cannot be loosened easily. It is very rare indeed that we bring out the asylum strait-waistcoat, a contraption that alone cannot still a troubled patient and is also an unsubtle piece of apparatus with disturbing connotations.
There have been so few recent incidents of strapped restraint that perhaps some examples of its use might suffice to reassure you. Two spring to mind: a demented, paralytic patient whose frustrations grew into a frenzy, leading to them nearly severing an artery; and a male patient who attempted to gouge out one of his testicles. In both cases, there seemed little option but to put a temporary stop to free movement of the patients’ arms.
If we fail to quell your violent behaviour through all other means and the strait-waistcoat is deployed on you, then you may also be placed in seclusion. This term is used to describe a period of isolation where you will be locked inside a single room. Unless you are at risk of self-harm, this will be one of our normal single rooms, though if you are judged in danger it may be necessary to place you in a padded room. Such an experience is apt to jolt an upset patient back towards the more normal expression of their senses.
Seclusion is less intrusive than restraint as a means of control, and it is the preferred method for coping with severe outbursts. Manic patients who shout and swear upon the wards, or who defame the Queen may find themselves dealt with in this way. Once again, seclusion is not a matter to be taken without reflection, and it needs to be sanctioned by a medical officer. Each hour spent in isolation must also be recorded and reported to the Commissioners in Lunacy, who are keen to see that it is employed only for medical reasons and never as a punitive action.
The final item associated with restraint is the rather unpleasant subject of forcible feeding. If you persistently refuse your food, yet are quite manifestly well, then the decision may be taken to intervene. At the simplest level it may be necessary for an attendant to hold your nose and then place the food into your mouth with a large spoon. If this non-intrusive process fails to work, then it is more likely that direct force-feeding into the stomach will be required.
We only resort to such enforced digestion if you are severely debilitated through either refusal or inability to take food, and it tends to be a treatment only for the most demented of our patient group. Should it be necessary, you will be placed in a chair, restrained by a sheet, and with your head rested against a pillow, before a tube is passed into your body. The old-fashioned method was to send the tube directly down the throat, though modern medicine has provided us with tubes small enough to fit through a nostril. The orifice chosen may depend upon the number of teeth you have, for a mouth full of teeth is more likely to bite down upon a tube, and wedges used to open such mouths are at risk of slipping.
Once the tube has been passed into the patient, it is customary to inject a liquid food through a syringe or to let gravity move the liquid from a bag resting above the head and down into the stomach. Fortifying fare such as port wine, brandy, eggs or beef tea are customary during force-feeding as they are easy to pass. Nevertheless, it is not a gentle procedure, and so only our most senior staff undertake it. Last
year, fewer than one in twenty men and women required this remedy, and then for a duration of one to two weeks only.
Difficult Behaviours and Their Management
Having touched on the physical aspects of treatment, we must also consider the physical manifestations of mental illness. An asylum is home to the full range of human emotions and their bodily outpouring, and so painful incidents are bound to occur and need to be managed. There are three types of common event you will almost certainly witness during your stay: fits, violence and attempts at suicide.
Epileptics are always identified at admission because their fits can cause injury. Staff will enquire whether the patient has any forewarning of fits, or observe themselves whether a fit can be predicted. If so, they have an opportunity to move the patient to safety, placing them on the floor away from furniture before the rigours of a fit take hold.
Because of the special requirements of their condition, we try as much as possible to group the epileptics into their own wards. Within these wards we can provide furniture and fittings of softer material, and without sharp points, while beds and chairs can be modified so that they are lower, and closer to the floor should a patient fall. Epileptic patients can also be issued with special clothing such as hats padded with straw. Treatment for epileptics is broadly the same as for other patients, though those with very regular fits are more likely to find themselves sedated, or given bromide of potassium which can reduce the prevalence and violence of a seizure.
Epileptic fits are by far the most common form of outburst on the wards. One of the fallacies about asylums is that they are full of violent patients. This is profoundly untrue. Nor are certified lunatics more quickly provoked to violence than their non-lunatic brethren. However, where greater restrictions are placed on the freedom of a person is it always possible that violence towards their fellows, windows, furniture or staff may arise.
