By Robert Gardiner Hill, Member of the Royal College of Surgeons, London ;
House Surgeon of the LincolnLunatic Asylum.
1839. 344

THIS lecture recommends total abolition of restraint in asylums. It may be demanded, what mode of treatment do you adopt, in place of restraint ? How do you guard against accidents ? How provide for the safety of the attendants ? In short, the substitute of coercion is what The answer may be summed up in a few words, viz.- Classification - watchfulness - vigilant and unceasing attendance by day and by night - kindness, occupation and attention to health, cleanliness and comfort, and the total absence of every description of other occupation of the attendants. This, in a proper building, with a sufficient number of strong and active attendants, best calculated to restore the patient ; and all instruments of coercion and torture absolutely and in every case rendered unnecessary. Patients disposed to suicide should always be placed in an open dormitory under watch. Nothing else can prevent suicide under any system whatever. An attendant never to have more than 12 or 15 patients under his care : that number of violent patients requires at least two. Laws of France assign one keeper to every ten patients. In the treatment of the insane, medicine of little avail, except (of course) when suffering from other diseases. Moral treatment, with a view to induce habits of self-control, is all and everything. The use of the lancet, leeches, cupping.glasses, blisters, drastic purgatives, and shaving the head totally proscribed at Lincoln, as at Gloucester. Bowels kept open, general health attended to, and allowed a generous diet, but no fermented liquors. Patient should be aware that he is observed, though not suspected of wrong ; and aware also that the person who observes him is powerful enough to control him. Out-door employments with moderate exercise, cheerful society, the occasional presence of friends, and even of visiters, healthy recreations and amusements, the enjoyment of the sweet music of spring, of a calm summer evening, the care of a garden or a shrubbery, or the cultivation of rare and choice flowers-all unite to induce a healthy tone of mind. No patient should be compelled to work. Sedentary employments not good. Offices of religion soothing and favourable to many : has found the evening service, and the calm and sober strain of piety, which pervades the Liturgy, well adapted to them. Religious excitement of the feelings always bad. Feelings should be consulted as far as possible : should never be terrified-bath of surprise, rotary chair, and all such devices, cannot have a good effect.

Wherever restraint may become necessary, owing to the imperfect adaptation of the building, or to a want of sufficient attendants, the most simple means should be selected ; thinks a darkened room here preferable to any other restraint. At Lincoln, on misconduct, a patient is immediately removed to the refractory patients' gallery, where he remains 345 until he has pledged himself that his future conduct shall be more orderly : this the only method employed to induce self-control. A maniac is seldom known to break his word. Violent cases and suicides would be extremely rare, if non-restraint generally adopted, in conjunction with dormitories and night-watches : in dispensing with restraint altogether, the latter must be the case, or the attempt would be attended with extreme danger ; without them, it would be necessary to restrain such as exhibit a tendency to suicide ; under this system, cases of insensibility to natural calls would be seldom met with. The watch-rooms at Lincoln contain eight beds each, for those destroying bedclothing and to epileptics ; two open dormitories containing 18 beds for patients disposed to self-destruction, adjoin them : have a watchman and a clock ingeniously contrived to denote when he is off his duty. Has never had any difficulty in calming a patient in a state bordering on violence ; has generally found one or two kind expressions sufficient to assuage any feelings of anger or violence; and much will always depend on the demeanour of the superintendent, as well as of the attendants : the latter should be tall and powerful in appearance, as a diminutive person would be liable to be attacked ; they should be able to control without even the appearance of anger, and their demeanour and directions should be firm and decisive.

Case.-1838, April 12th. Readmitted this afternoon; æt. 20; brought in a strait waistcoat, in a state of the greatest excitement : five persons could scarcely bring her. A Baptist, single ; attacked a week since ; former three years ago, recovering after three months' stay in establishment. Raves chiefly on religious topics, and is subject to violent and sudden fits of phrenzy. During the former attack attempted self-destruction by jumping into a stone-pit; occasionally destroys her wearing apparel. Grief and religious excitement assigned as the immediate exciting cause. 8 P.M. Been very active in her personal exertions, and is unable to control herself. April 13. Been under watch, and restless the whole of the night ; she is still very active in her personal exertions, but more tractable than yesterday. April 14th. Become quiet and orderly. April 15th. Continues calm and well-behaved. April 18th. Lost all disposition towards any inordinate action, and been removed to the moderate patients' gallery. Judges certainly, that the irritation of personal restraint had occasioned the excitement she at first exhibited. Strait waistcoat was instantly taken off on her admission. April 20. Been removed to the convalescent patients' apartments, and now employed in needlework. From April 20 to June 11 inclusive. Employed in household-work, needlework, &c., &c. June 11, discharged and engaged as kitchen-maid.

Case.-1838, April 5-æt. 52. Received this morning. A labourer, married, with a family of six children ; attended the church regularly, and also for many years attended the Wesleyan meetings. First attack in his 29th year, when confined thirteen weeks in Mr. ----'s establishment at----,where he recovered. This, the second attack, commenced ten days since, and no assignable cause except some recent religious excitement. Subject to sudden fits of phrenzy, in one of which he escaped from his friends in a state of nudity ; has conceived a strong dislike to the persons who have taken an active part in restraining him. No injurious attempts. In a strait waistcoat since commencement of the attack: three men accompanied him hither. 8 P. M. Since admission 346 been rolling about the floor of the refractory patients' gallery; has also been jumping and running to and fro; has just run violently against the gallery door and broken it. April 6. Very restless and incoherent, and has been so the whole of the night ;-again rolling on the floor of the gallery-have desired the attendants not to leave him, for fear he should get hurt by any of the other patients. April 7. Though not so active in his personal exertions, he is still restless,-complains of thirst.; have ordered the attendant to offer him cold water frequently during the day and night. Has slept under watch since his admission. April 10. He is not so restless, and is certainly improved in health. April 14. He continues to improve. April 18. Lost all disposition to any inordinate action, and has this morning been removed to the moderate patients' gallery. April 21. He is rational, quiet, and well-behaved. April 28. Been employed in household work and in gardening, since the 18th instant. From April 29 to June 11 inclusive. Been employed in the wash-house ; occasionally been allowed to go to town with an attendant. June 11. Discharged recovered.

Case.-1838, April 23. Æt. 28 ; received this morning ; married ; a labourer ; a Methodist; always been considered a sober, industrious, and respectable person. First attack, coming on a few weeks since, previous to which, for a fortnight or three weeks observed to be more than usually devout and enthusiastic in his religious exercises. Subject to sudden fits of phrenzy, but certificate does not state whether dangerous or otherwise. Religious excitement assigned as immediate exciting cause. Appears that the malady has been much aggravated by the use of the strait waistcoat and other instruments of restraint. Bound down to bedstead for three or four last weeks, and health much injured in consequence. Appearance ghastly, and from long confinement has not the proper use of his lower extremities. Large sores upon his back. 7 P.M. Quiet since his admission, but restless, talkative, and noisy. April 24. Been under watch ; passed a restless night ;-somewhat noisy this morning, and talks much on religious subjects, fancying that he has converted to his own views the workmen employed at the Union. April 25. Now tractable. April 26. Improving. April 30. Quiet and orderly, and removed to moderate patients' gallery. May 1st. Rational, calm, wellbehaved, and removed to convalescent patients' apartment. Gaining strength rapidly, and recovering the proper use of his lower extremities. From May 1st to 25 improving in health. May 26. Recovered his health. Been permitted this day to go beyond the walls, accompanied by an attendant and one of the other patients. From May 26 to June 11. Employed in the garden, yards, &c. June 11. Discharged recovered.

Case.-Æt. 50. Received Jan. 19th, 1838 ; two children. Attack about 7 months since ; raves on various topics ; subject to sudden and violent fits of phrenzy, and very prone to destroy property. Immediate exciting cause, loss of husband, who died insane. Patient attended on him during his illness, and up to his death, when-she herself became insane. Very violent, and has been confined in a strait waistcoat since commencement of attack. Insensible to the ordinary calls of nature. Jan. 20. Passed a restless night. Blankets in a strong case : very active in her personal exertions; and is noisy, and unruly. Jan. 22. Very refractory and quarrelsome. Jan. 25. Noisy, and refractory. Jan. 26. Continues noisy and refractory. Jan. 27. Continues. inattentive to the 341 ordinary calls of nature. Has destroyed her pillow-case and night-gown. Her blankets are enclosed in a strong case. Jan. 29. Tears her clothes, and commits other acts of gross extravagance. A strong dress has been purchased for her. Jan. 30. Continues to indulge her destructive propensity. 1 have desired a nurse to sit by her in the daytime. Feb. 9. Has by some means effected an opening into her blanket-case, and destroyed its contents-four blankets. Have ordered the pieces to be collected and quilted in the case. Feb. 10. Much quieter during the night than for some time past. The nurse is obliged to remain with her in the daytime, or else she would not only destroy her clothes, but those belonging to the other patients. Feb. 11. Been very restless during the night. I have desired the attendant on watch to visit her occasionally, which can be done without neglecting the other patients, by having another nurse to sleep in the watch-room, and both to watch alternately. Feb. 25. Very violent and abusive. March 8. Very incoherent and disorderly. April 9. Still inattentive to the ordinary calls of nature, and shows a strong inclination to destroy property. April 19. Withdrew woollen rags from case by a hole made with her teeth. Removed to watch-room, and every natural want strictly and regularly attended to. Result, quietude during the whole night, and attention to the require. ments of nature. Confined in a strait waistcoat for many months previous to her admission. April 26. Continues attentive to the ordinary calls of nature, being under watch. Has certainly the power to control herself, and has lately endeavoured to do so in the daytime as well as during the night. Previous to her removal to the watch-room, told that if cleanly in her habits, she should be treated like the other patientsinstead of straw, having a flock-bed. Promised to be clean, and kept her word thereafter. May 1st. Though very incoherent and mischievous in the daytime, yet is far more orderly than she used to be. May 7. Clean and orderly. 1839. Feb. 14. Continued so ever since. Had she been put under restraint, she might have continued for ever a loathsome object, insensible to the call of nature ; for the case was and is incurable. Recent observation has convinced me that if' dormitories could be provided for the insensible patients also (those not attending to the wants of nature), such might speedily be restored to habits of cleanliness. This plan has been attended with the happiest effect in some late instances; and indeed we have now few patients who are dirty in the daytime; why then in the night ? Simply because they can be atttended to only in the daytime ; and if this attendance could be given also in the night, cleanliness and self-control would speedily intervene.

In the Lincoln Asylum the greatest attention to personal cleanliness. Warm bath on admission : afterwards once in three weeks, and oftener if necessary: feet washed and heads dry-cleansed once a week, and hands and faces daily;-bed linen once in three weeks; ventilation, &c.

Extracts from the proceedings of this asylum, 1830, Nov. 29. List shoes ordered for any patient, injuring with his feet.

1832. Dr. Charlesworth, senior physician, suggested quarter boots (of ticking), with rings to the soles, as a night restraint to those requiring them, instead of hobbles. 1833. Mr. Bakewell, of Springvale, has suggested instead of the stomach-pump or speculum, a troublesome, and sometimes dangerous method, a tin vessel so contrived that the patient, in the mere act of breathing, without having the teeth forced open, cannot resist the introduction of fluid nutriment. Physician recommends 348 for patients tearing blankets, that these should be enclosed within strong Russia sheeting, quilted. 1834. In the tenth annual report, abolish use of fermented liquors, as more mischievous than the good is worth derived from the temporary tone produced.