1. Cursory Remarks.-Visiting justices observe, that few things could have been suggested of greater value, or more efficacious in promoting good order among the patients, than the various occupations, however trifling and unprofitable in themselves, in which they are engaged. See no hopes of making their labour profitable to the county. Number of male patients being in September, 1811, 387 ; 154 were employed in gardening, agriculture, in various handicrafts, and in domestic offices. Of 531 females, 391 employed in gardening and agriculture, in handicrafts, and in various domestic offices. Additional expenditure of late years incurred by more liberal allowance of provision, and warmer clothing, both of which now considered valuable collateral curative aids. Number of the parish authorities at any time visiting patients should never be more than three or four, including the parish surgeon. Though employment been instituted by Sir William Ellis, until lately (1811) little recreation. Harmless amusements been found to produce a marked effect during continuance, and may be fairly presumed to contribute their full share to the comparative order and tranquillity which have of late distinguished the asylum. Has occurred more than once that a sullen and morose patient has cast off his unsocial humour, and ,joined the attendants and other patients in a game of cricket or of bowls, and while the game continued, has displayed something of the social spirit which characterizes the sane mind. The visiting justices remark, with respect to several occasions in which the evening was passed in festivity and merriment. by the patients, that. the physician, on subsequently going through the house, heard scarcely a sound in the apartments of the patients who bad retired-thus showing that such events were calculated to be sedative in their influence, rather than to exert any exciting effect.
Duties of Ward Attendants at the Hanwell. -At 6 o'clock patients' doors unlocked. Washed and combed, and state of skin examined, in order that any soreness or discoloration may be reported to the house surgeons at the morning visit. Sickness of any patient, state of evacuations, and any particular change observed, to be reported at same time. Half past 6. Female patients employed in laundry, taken thither by laundry-maids. 7. Attendants go for bread, butter, &c. Quarter to 8. Patients go to chapel. Quarter past 8. Patients breakfast. Half past 8. Attendants clean galleries, &c., and open windows. In warm weather windows to be opened at 6 o'clock ; and in hot and dry weather the gallery and day-room windows to be left open during the night. 9. Patients go out with out-door attendants, and females employed there, to the bazar. Infirmaries and sick in all the wards to be ready for morning visit of physician and house surgeons. 10. Cleaning to be completed. In fine weather all the patients who can walk, or who like to be out of doors, to be taken into the airing courts ; in each of which, when there are more than ten patients, there must be at least one attendant, or when any violent patients are taking exercise, at least two. Infirmary attendants to co to storeroom and kitchen for wine, porter, broth, &c., for the sick. 11. Wine, &c., to be given. Out-door workers have each half a pint of beer. Bowling, trap-ball, cricket, ball-playing, &c., in front 424 grounds of asylum, to be encouraged in the well-behaved patients taken thither. In hot weather to be taken thither as soon after 10 as possible, and to return to the wards at 12. In winter and in cold weather, time of being out between 11 and half past 12. At 12, attendants take trays and tins to kitchen. 1 P. M. Patients dine. Helpless to have their food divided into small pieces, and, if necessary, to be fed. Food and beer of patients in their rooms to be taken to them by the attendants, and not by other patients. At 2 P. M. One half of the attendants dine, and at half past two, the other. 3 P. M. All the attendants to be in their respective wards. Half past 3 P. M. In fine weather patients to be taken into the airing-courts, and those who are quiet and neat enough, into the grounds ; and to remain out, according to the season, from an hour to two hours ;-going out and coming in a little later in the summer ; and an hour later in very hot weather ; the object being to have the patients much in the open air. Shoemakers and tailors to go out every afternoon, in fine weather, at 4 o'clock. 4 P. M. Out-door workers have each half a pint of beer. 5 P. M. Out-door attendants return to wards, with the patients under their care. Patients take tea who are on the list for it. Attendants supply patients with books, papers, bagatelle and draught-boards, &c., for their amusement until hour of supper. 6. Evening service in chapel. 7 P. DI. Patients have supper. After each meal, dishes, trenches, &c., to be carefully washed, and every knife, fork, and spoon locked up. Quarter to 8 P. M. Patients go to bed. Clothes to be taken out of bedrooms, wrapped up, and placed on the outside of the door of each bedroom. Window shutters of each room to be closed, and all the windows carefully shut in cold weather. Each room door to be locked ; and gas to be turned off. 8 P. M. Night attendants enter on duty. 9 P. M. Male and female attendants sup. Night attendants to visit wards several times during the night, to administer the medicines and nourishment as directed, and to pay proper attention to such l..dtien:s as are restless, or who wish for water to drink, or who require nourishment, change of dress, &c. Night-clocks to be attended to every hour. Are to wear soft shoes. Must carefully attend to the proper clothing of any patient who refuses to lie in bed ; and see that the feet are protected by warm boots ; articles of this kind being left in care of night attendants. Patients disposed to suicide, or subject to severe epileptic attacks, or who have the habit of lying on the floor, must be watched with especial care. They call up the other attendants at the proper hour of rising, and when thus relieved send to the matron and house surgeons a report in writing respecting the state of the wards, and the patients attended to during the night. Sunday. Patients seized with fits at the chapel, and those who behave violently, are to be removed by the attendants with promptitude and quietness. Those whose conduct is the most doubtful should be seated near the attendants. No fewer than 8 female and 7 male attendants are expected to be present at the morning and afternoon service. About 300 patients usually at the chapel. After prayers attendants to collect hymn-books, prayer-books, &c., but in certain cases may allow them to be in possession of patients until bedtime, both on Sundays and other days. Monday. At 7 A. M. Attendants receive from storeroom soap, candles, &c., required for wards for the week. At 9. Clothing from male wards requiring repair, taken to general storeroom. At same hour female attendants take needlework done during the previous week in each ward to the female storeroom, and receive p425 from storekeeper a supply of work for the week commencing. At half past 9. Male and female attendants take their own clothes to the laundry. Monday being admission day, the male and female attendants appointed to that duty are to undress and give a warm bath to such patients as are admitted. Are carefully to examine the general state of the skin and person of such patients, and to report to the house surgeons any bruises, sores, &c., that may be. present. Books, ornaments, &c., to be taken care of, if found on them ; and if permitted by medical officers or matron, allowed to remain in the patient's possession. Tuesday. Friends of patients permitted to see them in the visiting rooms, unless an order to the contrary. In general, it is not. desirable that the friends of patients should remain with them more than half an hour. Several instances, however, will occur in which this indulgence may be extended to an hour ; and in a few cases the comfort of the patients may require that their friends and they should be permitted to walk in the grounds. During whole visit, some attendant must be observant of the patients, without unnecessarily interfering. No visiters (except visiting justices) at any time to go into the wards without leave from the physician, house surgeon, or matron. Wednesday. Male patients to be shaved by the attendants of their wards. Thursday. Clothes, &c., of female patients returned to attendants by superintendent of laundry. Friday. Visiting day ; linen returned to male wards, &c. Every male and female patient, with exceptions, to be ordered by the house surgeons or matron to have a warm bath. Its temperature not to be less than 90 degrees, nor more than 97 degrees, unless by special order. Patients to remain in the bath long enough for cleanliness. Saturday. Male patients to be shaved by attendants. Dirty clothes to be taken to laundry, &c. Attendants to see that none of the ward prayer-books, hymn-books, or Bibles are missing ; and if more are required, are to report the deficiency to the resident physician.
No ward is at any time, or under any pretext whatever, to be left with. out an attendant, until after the patients' bedtime. Whole time of attendants during the day is expected to be devoted to the patients : they are to pay constant attention to their food, dress, occupation, exercise, amusement, and general conduct, and to prevent every kind of impropriety of manners and language. Whenever the door of a ward is opened by an officer of the asylum, or by any of the visiting magistrates, one of the attendants is to advance and to attend such macistrate or officer through the ward, unless ordered to the contrary. :Must endeavour to be calm and forbearing, and not to be noisy in anything whatever. When a patient cannot be soothed or controlled, the attendant must, if necessary, summon other attendants, who are instantly to answer the call ; and the patient must be put as quietly as possible into a bedroom and locked up. Window shutters of room to be closed, and if the patient is destructive, the bedding must be removed. The seclusion is to be immediately reported to the house surgeon ; the state of the patient when in seclusion must be observed from time to time through the inspection-plate ; occasional attempts are to be made to soothe those who are distressed when in seclusion, &c. When necessary to seclude, remove, or give a bath to a refractory patient, or to dress or undress those who strongly resist, attendants should not be fewer than four, or even six. Must promptly render the violent patient unable to strike or kick, by seizing the hands or the feet. Patient may then be quickly and quietly p426 removed to the bath or in a single room, or dressed or undressed without injury to any party. Only signal allowed to be made on the whistle worn by the attendants is that which indicates that the aid of other attendants is instantly required. All in hearing must instantly attend. Strict attention to this rule essential to the protection both of attendants and patients. Attendants are to take pains to acquire a knowledge of the character of patients, to encourage them to good conduct, &c. Must endeavour to promote such habits in the dirty patients as may prevent their being negligent of cleanliness when in bed ; which may often be done by proper attention paid the last thing at night. Patients who assist attendants in ward duties must be treated kindly ; but must not be indulged in extra food or beer at the expense of other patients, nor permitted to exercise any austerity over the other patients. With regard to attendants Dr. Conolly observes, that whatever may be the ability, &c., of those at the head of the asylum, they must always so much depend on the fidelity and good conduct of the male and female attendants, that it is scarcely possible to be too considerate of whatever tends to keep them in bodily arid mental health. Unless cheerful and active, and well-disposed to officers of asylum, their services to the patients will be inefficiently performed. They are expected to exercise great vigilance for at least fourteen hours every day, and to take their turn at night-watching. No reasonable relaxation, therefore, should be withheld from them ; and their lodging, provisions, and every arrangement regarding them, should be calculated to preserve the habits and manners of respectable life, without which they are not likely to understand or execute some of the most important of the duties required of them. A mere change of attendants has been found, in several instances, to be followed with advantages greater than was expected. The character of a ward seems almost wholly to depend on the character of the attendants. Although number of ward attendants much smaller than in some other asylums, in proportion to number of patients, general appearance of wards and of patients sufficiently attests their efficiency as regards cleanliness and order ; an effect secured by accumulating attendants in wards containing patients who are violent or dirty.
In 1843, with an average of 970 patients, the number of males being to that of females rather less than the ratio of 4 to 5, the following officers and attendants were attached to the asylum :-1 superintendent, 1 matron, 1 chaplain, 1 steward, 1 deputy-steward, 1 house surgeon for the male department, and 1 for the female, 1 accountant, 2 assistant clerks, 1 engineer, 1 clerk to the visiting justices, 1 schoolmaster, i housekeeper, 1 assistant storekeeper and deputy-matron, 1 superintendent of needlework, 1 do. of knitting, 1 do. of laundry, 1 schoolmistress -19 officers. Male servants 37, viz., 26 attendants, 1 shoemaker, 1 tailor, 1 do. assistant, 1 gardener, 1 brewer, 1 cowman, 1 carter, 1 labourer, 1 house porter, 1 office messenger, 1 porter at lodge. Female servants, 52, viz., 34 attendants, 5 housemaids, 7 laundry-maids; 2 kitchen-maids, 1 scullery-maid, 1 dairy-maid, 1 bakeress, 1 cook. Servants then, 89. Servants and officers, 108. In 1841, there were 12 male wards, number of patients contained being 411. In No. 1, epileptic and imbecile, 52 beds and 3 keepers. No. 2, epileptic, 34 beds, 2 keepers. No. 3, quiet, 52 beds, 2 keepers. No. 4, refractory, 23 beds, 2 keepers. No. 5, do., 26 beds, 2 keepers. No. 6, do., 25 beds, 2 keepers. No. 7, do., 24 beds, 2 keepers. No. 8, quiet, 48 beds, 2 keepers.No. 9, convalescent, p427 40 beds, 2 keepers. No. 10, infirmary, 23 beds, 2 keepers. No. 11, quiet, reception ward, 44 beds, 1 keeper. No. 12, moderately quiet, 20 beds, 1 keeper. Female Wards, 15 in number, capable of accommodating 576 individuals. No. 1, quiet, 48 beds, 2 nurses. No. 2, elderly and infirm, 24 beds, 1 nurse. No. 3, noisy, 57 beds, 3 nurses. No. 4, quiet, 46 beds, 2 nurses. No. 5, epileptic and refractory, 23 beds, 2 nurses. No. 6, do., 26 beds, `2. nurses. No. 7, refractory, 26 beds, 2 nurses. No. 8, do., 24 beds, 2 nurses. No. 9, bazar ward. 47 beds, 2 nurses. No. 10, noisy, 56 beds, 2 nurses. No. 11, infirmary, 31 beds, 2 nurses. No. 12, convalescent, 44 beds, 2 nurses. No. 13, imbecile, 30 beds, 2 nurses. No. 14, moderately quiet, 52 beds, 2 nurses. No. 15, kitchen ward, 42 beds, 1 nurse. Garden nurses, 2. On the 30th Sept., 1843, of 412 male patients in the asylum, 168 were unemployed, 21 sick, and 223 employed. In garden and agriculture, 110 ; helpers in wards, 48 ; repicking coir, 8 ; storeroom, kitchen, and engine-house, 14 ; tailors, 10 ; shoemakers. 13 ; upholstery-room, 5 ; bricklayers, 2 ; painters, 2; carpenters, 10. Of 546 females in the asylum on the 30th of Sept., 1842, 113 were unemployed, 27 sick, and 406 employed. Garden, 17 ; laundry, 50 ; kitchen and dairy, 28 ; helpers in wards, 18 ; repicking coir, 59 ; needlework, 234.
The morning and evening services during the week are commenced by singing three verses of a hymn or psalm, accompanied by the organ ; a short portion of the second lesson for the day is read, and a few prayers from the church service are offered up in conclusion. On Sundays, the liturgy is used, omitting the first lesson ; and the service, when thus curtailed, occupies one hour, beyond which it is considered inexpedient to attempt to confine the attention of patients. A sermon is, therefore, preached only in the afternoon. An occasional service in the two infirmaries for the feeble patients unable to attend the chapel ; chaplain adhering to the order of the daily prayers ; adding, sometimes, a few words of exhortation upon the passage of Scripture that is read. The' quarterly administration of the Lord's Supper forms a part of the chaplain's duty. The chaplain, the Rev. S. T. Burt, observes that the number of communicants necessarily depends on the incidental state and religious character of the more convalescent patients. On the last occasion (1842), thirty-eight of the patients attended the administration of the sacred rite. Remarks that in 1841, at the first celebration of the sacred rite, that it was attended by no less than 50 patients, all of whom, after private and individual examination, appeared to him and the resident physician eligible communicants. The number in attendance on week days varies from 150 to 200. At least once a week, the chaplain accompanies the resident physician, or the matron, in their usual visits to the wards; on which occasions, he derives much benefit from their occasional remarks, tending to throw light upon the character of individual patients, attd to render him familiar with the general discipline of the establishment. Dr. Conolly speaks of the necessity and great advantages attending a full and constant co-operation between the resident physician and the chaplain ; they can thus determine, with more precision, the exact cases in which religious attentions and spiritual intercourse are likely to be prejudicial or the contrary. The resident physician furnishes the chaplain with a book describing the state of mind and peculiar delusions of the patient recommended to his care, and the latter endeavours to elicit their moral character before they became insane, inquires into their business and habits of life, and as to how their religious duties have been perfbrmed, &c. These considerations form a guide for his future instructions ; and he abstains from systematic religious instruction, unless physician thinks the patient a fit subject. In his sermons, endeavours to place all the important truths of Christianity before the hearers, in their most simple and encouraging form. Thinks the preacher should here present motives to piety, urged with moderation, as though calculated to excite, in a measure, the feelings-yet as being a wholesome excitation-while he should avoid sharp reproof and ideas tending to call up the individual delusion of a patient, and excite his morbid feelings. Besides, manifest necessity of abstaining from all alarming statements ; considers it desirable to avoid dwelling on miraculous and figurative passages of Scripture, excepting such as are at once simple and obvious in their application. Any idea requiring connected comment may be followed by injurious results, when it fixes itself upon a mind which does not possess sufficient power of p431 thought to embrace the explanation necessary to modify it. Entertains no doubt that there are some patients who join with true devotion in the prayers of the church. He describes the following cases : Case.-A female, an inmate of the asylum for eight years; suffered religious depression during whole period; at length began to express some degree of hope, and was persuaded, though with difficulty, to partake of -the Lord's Supper. Immediately after receiving the holy communion-her fears having completely yielded to more correct views of divine truth- she became happy, and even cheerful, and remained in that altered state of mind until seized with an illness which terminated her life. Case.- An aged male patient, long similarly affected, and from despondency, in vain entreated to attend the celebration of the holy sacrament. Becoming dangerously ill, was again visited by the chaplain, when he began expressing his usual fears ; but on the doctrines of the Gospel being presented to him, he gave them immediate assent, and maintained the most perfect composure during the remainder of his illness. Case.-A male patient, labouring under very wild delusions on secular subjects, having been frequently present during the intercourse of the chaplain with other patients, began to seek for conversation himself, and eventually stated that a great change had taken place in his mind on the subject of religion. His altered conduct gave unquestionable evidence of the sincerity of his profession, for he constantly showed the deepest emotion when speaking of his former neglect of his religious duties, and dwelling on his present hope of forgiveness. Case.-Would allude to this with great diffidence. A female patient, under the most distressing despair ; at first interview with her, shortly after her admission, she was persuaded to read a pas sage of Scripture, and having been supplied with a New Testament and hymn-book, she frequently perused them during the intervals of work. Her bodily sufferings were gradually relieved, without any change in her religious feelings, until, at length, the truths imperceptibly impressed upon her mind enabled her suddenly to overcome her despondency ; though, for a time, her hopes were modified by the nature of her former delusion. She has since been discharged from the asylum, and returned to her family in perfect health. Although services of chaplain may be thought chiefly useful in their general influence upon the inmates of an asylum, yet he cannot but regard these cases as important indications of the effect which Christian instruction is capable of producing upon the insane. It is seen that they who have previously been uninfluenced by religious truth, may become, for the first time, impressed with its importance during the period of mental derangement; and that the most delusive dreams of the imagination may allow a place among them for the Christian realities. It is seen, also, that religious melancholy is not the incurable disease which it is generally considered to be ; and that the remedy, so far as moral means are applicable, lies in the selection of those particular doctrines which are adapted to correct the erroneous views' of the patient. With such patients, his experience has not led him to think that a constant combating of the desponding fear-the course which might naturally be considered best adapted to their case-is calculated to be most efficacious. In the influence produced in the above cases by consolation, which had formerly been rejected, must be recognised an unseen Power acting upon those mental faculties, by the internal condition of which the mind is predisposed to understand and believe ; and it is the discovery of this divine agency working upon the susceptibilities of the p432 insane, that gives the greatest encouragement to their spiritual instructer, and the most confident expectation of success in his ministrations. There are some patients also, wbo, without having experienced a similar change in their religious character, appear to derive a temporary pleasure from conversation with the chaplain; a fact which leaves little doubt that the doctrines of the Gor pel may more or less penetrate the heart, while the mind is unequal to assent to their truth. Dr. Conolly observes, that frequently grateful expressions are addressed to him by the patients, in reference to the consolation they have received from the chaplain's attention to, and conversation with them.
II. Schools-Restraints. 1st. Schools.-In the report of the chaplain for 1842, he observes, that at an early period of his services in the asylum, he had felt it his duty to consider whether the peculiar condition of the patients did not require other than the usual means of religious instruction. The system of classes for reading and catechetical exercises appeared to him to promise the most important advantages. The visiting justices permitting the trial, his most sanguine expectations have been fully borne out. About 30 of the more intelligent patients were at first selected. They usually read the second morning lesson, and afterwards listened to a short explanation; evidently pleased with illustrations taken from a map or scriptural print. Subsequently, classes been increased in number, in day-rooms of respective wards ; and as many as 70 or 80 have taken part in them. Encouraged from experiment to suppose that those unable to read can be instructed in the alphabet and spelling. A boy, 14 years old, subject to epileptic fits, of very feeble intellect, unacquainted with the sounds of some of the letters, after ten short lessons was able to point them out and repeat them correctly. The collective system of teaching adopted in infant schools appears to be that best suited for patients, since it excites animation and imitation. A few of the better-instructed among them have assisted in teaching the rest, and showed some capacity for the office, under proper inspection. Thinks other information besides religious might, and should be imparted. In the report for 1843, the visiting justices observe, that at the suggestion of the chaplain, and with the approval of the resident physician, a schoolmaster and schoolmistress have been for a time engaged to give instruction to such of the patients as might be thought capable of deriving any benefit from it. They are instructed in reading the holy Scriptures, in writing, geography, arithmetic, and singing. Number of patients who, up to the 21st of September, have attended the schools, 115 males and 65 females. Number now in attendance (Oct. 18th), 70 males and 40 females. Average number of classes held during day, 5 of males and 4 of females. Average number who have attended the classes during the past week, 15 males and 9 females. Dr. Conolly observes, that no class is occupied more than one hour at a time. Among the readers may be seen some formerly the most troublesome patients; attend with gratification, and observe a remarkable order and decorum ; reading each a verse or portion of a page in turn, with attention and correctness. Articulation of some impaired by their malady. Greater number of the readers have been those who had learned to read in former years ; but of these several had lost the habit of reading, and have much improved by practice. Power of application, and memory of previous day's lesson, been observed to become strengthened by these daily but not long-continued habits of attention. Teachers have had the disadvantage of p433 endeavouring to teach those who are for the most part incapable of employment ; and, therefore, least capable of profiting by their instructions. Writing has been taught to some previously unable to hold a pen. Others, who had formerly learned to write, were found to have forgotten the art, and required to begin again. Often been observed that on the first day of going to the writing class, would scrawl irregularly ; on the second day, would try to imitate the copy ; and in a few days, write with care. Take particular pleasure in this, and exhibit copy-books with much satisfaction. Singular difficulty found in teaching these scholars to form each separate letter in cases where no previous instruction before, but this surmounted. Some variety imparted by occasional descriptions of different parts of the earth, aided by reference to maps and to a globe ; and in the classes for male patients, simple descriptions of various animals, with pictorial illustrations, have been found to excite a lively interest. Drawing and singing have agreeably occupied a few of them ; and a class of arithmetic has been formed on the male side. Patients appear to be pleased with these exercises, and in no instance compulsory. Chaplain thinks this attempt may place the patients-as respects. the capability of receiving and profiting by religious instruction-in a more advantageous state, by diminishing torpor of faculties. Dr. Conolly thinks particular rooms would be better than day-rooms, as less liable to interruption.
An elementary school was established at the Salpetriere, for insane female patients, in 1831, by M. Falret. Dr. Conolly has given an account of his visit to the schools at this institution and the Bicetre, in the number of the British and Foreign Medical Review for January, 1845. Found M. Falret, one of the physicians of the asylum, sitting in the schoolroom-a somewhat small but comfortable apartment-in which were collected about 100 of the patients, all perfectly orderly, all neatly dressed, and appearing to take as much pleasure in the occupations of the school as those who witnessed them. Some were engaged in needlework, which they chose to continue whilst attending to the singing, recitations, and other proceedings of the school. Almost every one was cheerful, &c. Patients at the Salpetriere have the advantage of a library, and several of them have read parts of the excellent books allowed for their perusal with so much attention as to be able, when requested, to recite them for the amusement of the other patients. Three or four of the women in the schoolroom were called upon, in succession, to do this. Each immediately stood up with much cheerfulness, and distinctly and pleasingly recited a short story or poem. This was done with great correctness, and it seemed as if the patients knew the whole of some long poems, which they went on reciting until stopped, when they sat down with an equal air of content. During the recitation, many of the other patients appeared to be attentive hearers. Several then invited to join in singing something, and they sung several verses, and in parts, very correctly and agreeably, and apparently without any sane leader. Afterward, an Italian patient sung a beautiful air with considerable skill, to the evident satisfaction of her companions. Saw various specimens of their writing, which were excellent ; it was, indeed, with regret that he left this part of the establishment, where, by innocent and improving recreations, the patients pass a portion of each day in tranquillity, and, it may even be said, happiness ; and it will be long before he loses the wish to see those cheerful groups again. MM. Leuret and Voisin established a system of instruction at the p434 Bicetre in 1839. Dr. Conolly found the schools here to exceed in interest, if possible, those of the Salpetriere. Male patients better prepared in general than females to derive benefit from such instruction ; also more attentive, and perhaps more able to receive various instruction. Never saw more exquisite penmanship than that of some of the male patients ; the drawings of some of them were most beautiful ; and he will not attempt to describe the effect of their singing, although he can never lose the impression of it. Here, too, as in the school at the Salpetriere, the most cheering thing of all was to see the evident comfort and happiness from the various and not fatiguing occupations of the schools ; to witness the satisfaction with which the afflicted, the paralyzed, the utterly incurable, exhibited the performances which they yet retained the power to accomplish. If no other end were answered by the formation of schools, they ought to be established, as recreative, palliative, remedial even, in every lunatic asylum.
The words of the choruses for the patients at the Bicetre have been printed in a little volume ; many of the best French poets have given their permission to have their poems inserted, and M. Elevart has adapted those having no music set to them expressly for the purpose intended. M. Leuret observes in an address to the patients on the subject - After allotted labours of day, whether in fields or workshops, no exercise can be more advantageous to you than singing. It assuages pain, and is a certain remedy for melancholy. Grief at separation from ordinary occupations and family becomes from music less acute, and those whose spirits are troubled and restless, will soon enjoy a mental calm highly favourable to recovery. Those tormented with haunting ideas leaving no repose, or fancied injuries or dread of danger from enemies, here soon see the falsity of their ideas, and are tranquil ; and amid course of labour and regimen, nothing conduces so much to their cure as the musical exercises. It behooves you, therefore, to sing as much and as well as you can. If the capable refuse, those learning and the melancholy will also be silent. This a great misfortune ; have seen patients who, after having been here for whole years absorbed by their malady,-have at length, from having heard you each day, learnt almost involuntarily the songs you sing, and have joined in the harmony. In some instances their reason has returned by slow degrees. Singing according to the systems of Wilhelm and Mainzer. M. Guerry has selected those pieces of poetry which express soothing thoughts and religious consolation. (We give here one of these songs which has been translated.)
Sad is my troubled soul, My happiest days are o'er, Like waves that onward roll To death's eternal shore Hope never cheers my heart, Tears seldom bring relief; Deserted, lone, apart ; My doom is silent grief. But hark! what greets my ear? 'Tis music's softest strain, p435 Sent my lone heart to cheer, And lessen sorrow's pain. As the sweet chords arise, Emotions new I feel, Joy's tears suffuse my eyes, My wounded soul to heal.
The patients at the Lunatic Asylum of Rouen attend singing schools and lectures.
In the report of the Lancaster Asylum, dated June 30th, 1843, very favourable testimony is afforded of the effects of a plan of teaching there, comprehending spelling, writing, arithmetic, and singing.
In the New-York State Asylum at Utica, schools for the instruction of patients of both sexes were established soon after the opening of the institution in 1843. In extracts from the Utica report of that year we have given elsewhere an account of these. In the report for 1844, Dr. Brigham observes, that they have been continued, and his confidence in their utility, and even their necessity, for the improvement of many of the insane, has increased.-Find recovered patients to look back to school as greatest enjoyment, and to often allude to it in letters. Believe schools in asylums may be rendered still more useful than even we have found them, by having more perfect arrangements as regards schoolrooms and school apparatus, than we have yet had. In the April number of the Journal of Insanity (1845) Dr. Brigham writes as follows : We have three schools for the men, one of which has been managed for the past six months wholly by a patient, the others by a teacher hired for the purpose. One school for the women, conducted by a hired instructress. The schools commence at 10 in the morning, and at 3 in the afternoon, and continue about one hour. They are opened and closed by singing a hymn by the pupils. To enable all to unite in singing, have hymns printed on cards, which each pupil holds in his hand. Patients then read, spell, answer questions in arithmetic, geography, history, &c., assisted by black-boards and a globe. A majority commit pieces to memory, and once in two weeks have a meeting of all the schools in the chapel, when they unite in singing. Then follow declamations and the reading of compositions. In all the schools good order prevails, and many of the patients have made great proficiency. Some have here first learned to read and to write. Several inclined to be discontented, have been made far less so by attending school, and a considerable number already in a demented state, or fast approaching it, have improved in mind and become interested in learning. Occasionally have an exhibition, when original plays are exhibited.
Dr. Pliny Earle, who succeeded Dr. Wilson as physician of the Bloomingdale Asylum in 1844, observes in his report for that year-During last few months a supply of newspapers and books been constantly kept upon the tables in some of the halls occupied by those patients whose disease is of the most aggravated form, and benefit derived there-from been astonishing to ourselves. Books are of descriptions adapted to all capacities, and there are few of the patients who have not made use of them. Hence some of the halls formerly the most noisy and disorderly, have become as strongly characterized for their general stillness and good order. Another remarkable feature of experiment, p436 that destruction of books is probably not half what would occur among same number of children. But one book been seriously injured. Writing-books, arithmetics, and slates been placed in hands of some. Delivers lectures to them on miscellaneous subjects, illustrated by large diagrams arid pictures. These frequented by from 60 to 70 patients, whose conduct is marked by order, decorum, and attention. Lectures, sketches in Greece, national and local peculiarities, physiology of the muscular system, &c.
In the Report of the Frankford Asylum, dated March 10th, 1845, it is observed-A course of lectures, as in previous years, on subjects capable of easy and entertaining illustration, with proper apparatus, as anatomy of heart, electricity, &c. Many of the inmates have attended, appear much interested, and some have been decidedly benefited. Managers remark that the females receive daily instruction from a young woman connected with the institution, in reading interesting books, the use of the black-board, &c., with as complete a school organization as circumstances of case and character of pupils will admit. Latter arrangement, which is of recent date, will, they hope, prove advantageous to some of the patients, by arresting their attention, bringing back associations of early life, and agreeably occupying many leisure hours. The physicians observe --- The demented compose a large class of our patients, for whom suitable occupation has always been an object highly desirable, but difficult to attain. Some are able to perform domestic duties, but greater part are apparently too sluggish and inanimate to engage in anything requiring much bodily exertion. For this class among the females, it was concluded to try the experiment of keeping a school, which has been regularly attended by them, and some of those afflicted with chronic mania. Reading the most common exercise, but geography and lessons in the first rules of arithmetic also learned by some, with a readiness which evinces a degree of mental effort of which they had long been considered incapable. Order and decorum generally prevail during school hours, and in several ways result. so far been satisfactory. Experience, then, encourages continuance of experiment, and its extension to other classes. Effect of school in improving condition of those attending it, unequivocal. Less listlessness and inanity which characterize the demented, greater care of the dress and appearance, and more cheerfulness manifested. When collected, the noisy impose upon themselves a restraint, to which they have for a long time been almost strangers, and which is now observed to influence them at other times. One imbecile patient, long in the habit of walking throughout night at intervals, since becoming interested in the school, is reported by the watchwoman as regularly in bed and quiet.
In the Report for 1844 of the Pennsylvania Hospital for the insane, Dr. Kirkbride makes the following remarks :-Among different means of direct mental treatment, likely to be extensively used in insane hospitals, instruction of certain classes of patients will probably hold a prominent place. Now well ascertained, by direct experiment, that. a certain amount of information may be imparted even to the demented, and that their regular attendance upon lessons of an instructer, and devotion to such an object, even where little direct effect is produced, adds to their comfort and to the good order of the wards. Here seems necessary a limited number of attendants of a higher order, released from all ordinary ward duties. Should be men with true Christian feelings, courteous p437 manners, intelligent and cultivated, and possessed of a peculiar tact. Good to some patients by regular and systematic instruction-to some by reading-to most by judicious conversation. Constant presence of these in the wards will supply a prominent want. Has made arrangements for a short series of lectures by an enthusiastic naturalist. Good effects in hospital, by persuading patients to engage in particular branches of study ; and cures of some in instruction of others, referred to in a previous report. Constant endeavours towards same end, and often with considerable success.
Dr. Win. Stokes, physician to Mount Hope Hospital (late Mount St. Vincent's), makes the following observations :-Institution has derived great. advantage from the formation of reading classes, and music, and French classes. Plan, to commit one or more whom we may succeed in awakening a desire to learn to perform on the piano, or the guitar, the harp, &c., to the instruction of another patient acquainted with the instrument; and in like manner in regard to French. Thus, several have been taught to play quite skilfully on the piano, &c., who had never touched a key before ; and one lady assures us that she must remain indebted to another patient for renewing that acquaintance with the French which had escaped her through years of neglect. The reading classes, too, have exerted a much more wholesome effect than we could have anticipated. A certain number forms a class around a sister, and each in rotation takes her turn in reading aloud for the edification of the company.
2. Restraints.-Visiting justices at Hanwell think non-restraint system as secure against accidents as one of partial restraints, which has now taken the place universally of the constant restraint of former times. Non-restraint requires constant watchfulness, and the kindest treatment of patients, and forbearance on part of keepers and nurses, under circumstances however irritating. Must be obvious to every one, that whatever means can be applied to cheer and divert the minds of the patients (such as entertainments, &c.), must, at the same time, tend to awaken their susceptibility to kindness-increase the moral control of officers who contribute to their enjoyment-and, in same proportion, diminish necessity of governing them by brute force, and by mechanical restraints.
The disuse of bodily restraints commenced at Hartwell in 1839. On account of want of union of purpose amongst the officers, there were at first many difficulties and much confusion, which afterwards, under au opposite state of things, disappeared. Extracts from Dr. Conolly's Re. port of 1841.-General results strengthen conviction that by abolishing restraints many other evils, considered inseparable from asylums, are at the same time swept away. A prolonged maniacal attack not unfrequently characterized by continual activity, and a most ingenious disposition to mischief. Such patients formerly often injured or ruined by restraints, as saving trouble. Now they are seldom violent, easily amused, and when amused as playful as children ; but become uncertain in temper under annoyance of bodily restraints. In commencement of attack, often evident bodily disorder, and one of the most serious evils of bodily restraints, that patients so treated do not receive requisite share of medical treatment. A cherished error of the advocates of restraint is, that it can at least do no harm to the incurable. No patients more permanently injured by it in temper, feelings, and habits. In cases in which no p438 hope of cure, mitigation of violence, from long absence of any avoidable irritation, extraordinary. Case.-A female, admitted in June, 1839. Long insane, and of a violent temper. For some time daily committing or threatening some violence. Restraint freely employed; shower baths and the douche often resorted to, to calm her paroxysms. Baths apparently useful, but restraints seemed only to exasperate her more. At length, every exciting application, mechanical or verbal, being found hurtful, she was spoken to with invariable calmness, and scarcely ever interfered with. Violent fits of passion continue, but seldom uncivil, and ceremoniously polite to visiters. Previous to September, 1839, there were 41 females, almost all of whom were in constant restraint ; 14 in restraint chairs, and 20 in a kind of strait waistcoat, called sleeves ; several in complicated restraints, and some in a chair ; and at the same time in sleeves, or the muff, or in leg-locks. All these were liberated before the end of Sept., 1839. Not one has been in restraint since. 37 yet in the asylum, and riot one who may not be pointed out as an instance of the improvement of the mental faculties, or of the habits, in consequence of never having been subjected to restraints during two years. Some considered formerly dangerous at all times, are now occasionally seen at the work-table, smiling, and pointing out what they- have done. Some who were sinking into dementia, or imbecility, are now lively and talkative. Some, who were said to pursue visiters through the ward, are now never known to do so. A ease which greatly roused him to evils of restraints, was a young woman in a chronic dementia following attacks of mania six or seven years back. At his first visit, found her fastened in bed by a strap round her neck, one around her waist, and straps to her Feet. The sleeves enveloped her hands in hard leather cases, and her hands were fastened by short straps connected with the strap round her waist. Extremely feeble and emaciated ; skin in a very irritable state. Could not get out of bed, or raise herself up, or turn, or lift her hand to her mouth. Been kept thus for some weeks. No cause assigned, except that she was troublesome-that she would undress herself-that she was always in mischief. Day by day, with due caution, one restraint after another removed. For a short time, mischievous and troublesome. Would take off her clothes, and stood up instead of lying down on the bed. One day, being locked up in her room, she broke a pane of glass, and stuffed her superfluous wardrobe through it. This discontinued -hen permitted to come in the gallery. There appropriating viands which she found, the nurse, who disapproved of the improved treatment, was contented to secure her by a long strap to a bench. & c. This being also forbidden, she gradually became less troublesome ; and being removed to another ward, slowly recovered strength, and even became fat. Is now incapable of employment and imbecile but seldom mischievous or troublesome. From altered habits of attendants, they would at present look with a general feeling of horror upon restraint placed upon her. The impression on his mind from this case, that there must be something inherently wrong in a system of treatment, the grossest misapplication of which-witnessed daily by those whose general kindness to the patients was never called in question-appeared to excite no surprise. Impressions made by his experience, as follows :-1. Much difficulty will always attend the discontinuance of restraints, from indifference and indolence of attendants accustomed to avoid trouble, by imposing them on every occasion in which a patient is irritable or mischievous. 2. p439 Some patients, long accustomed to severe mechanical restraints. are troublesome for some time after freedom of muscular action. 3. This disposition evinced in a proneness to quarrel or fight, or to break windows, or to knock at the door of their bedrooms, during a part of the night. 4. Conduct of thp most troublesome of these eventually improves, and attendants gradually learn that they can manage the patients better without restraint than with it. 5. General tranquillity will be conspicuous in wards previously distinguished for excitability and noise ; this particularly the case in the epileptic wards, as being more subject to restraint, and more capable of appreciating their treatment. 6. Abusive language, assaults, and acts of violence, will gradually become of less frequent occurrence. 7. A disposition to meditate mischief or revenge will be seldom observed. 8. The patients will be quieter at night, from being more comfortable. 9. The general aspect of the patients throughout the house will become more cheerful and confiding. 10. They will be less liable to manifest irritability during divine service. 11. Cases of obstinate refusal to comply with rules and directions, as well as instances of persevering refusal of food, and attempts to commit suicide, will become less frequent. 12. Improvement will be more readily effected in patients recently admitted, who will be less alarmed and less excited on admission, and sooner acquire confidence in those about them. 13. The abolition of restraints cannot be successful without a vigilant and constant superintendence exercised by a competent number of attendants, under officers zealously united to meet every variety of difficulty, and by every possible resource. 14. Attendants most attached to restraints will be least alert in carrying these resources into practice, and the most prone to use secret violence ; and to abuse seclusion until it becomes as objectionable as restraint itself. 15. In a properly-arranged asylum, with efficient officers and attendants, acting under one uniform system, scarcely any conceivable case can occur in which the security, cleanliness, and comfort of the patient may not be provided for, and the safety of all the patients secured, without mechanical or bodily restraint, and with fewer troublesome consequences than when restraints are employed. 16. To effect these objects, number of attendants need not be extravagantly great. At Hanwell, it is only in the proportion of one attendant to 18 patients ; but the patients must never be left unattended during the day. By no means indispensable for attend. ants to possess unusual bodily strength. First requisite, to be humane, to gain good opinion and confidence of patients. Must be capable of acting with great patience, and also with firmness and courage. Their business to prevent mischief, and not to punish it. When required to seclude a dangerous patient, must assemble quickly and quietly ; must avoid harassing the patient by controversy and useless contradiction ; and, having accomplished their purpose, must disperse quietly. These directions continually acted upon at Hanwell, and the plan has a considerable effect on the patients, who are perfectly aware that they will not be unnecessarily interfered with ; but that when interference is necessary, it is sure to be effectual. With regard to religious services in this connexion, observes-Like every other part of a system that appeals to what remains of the reason and the feelings, a perfect trial of what could be effected by spiritual means was incompatible with modes of treatment which produced gloom, discontent, or ferocity. Ordinary public services at Hanwell were much more liable to interruption-before the disuse of p440 mechanical restraints ; and those interrupting the services were always such as had been the especial subjects of mechanical restraint. Then Sunday a day of more than usual anxiety ; whereas now, no day in which aspect of whole asylum is more comfortable and tranquil. The management which a careful superintendent will be continually learning in an asylum, is forbearance. Scenes presenting at first sight an aspect of confusion and violence, will generally resolve themselves into simple elements, if calmly surveyed for a few minutes. Furious gestures, threatening language, and abusive epithets, if not met by irritable arid angry measures, commonly subside in a short time. Calm persuasion often efficacious against apparently determined disobedience. Firmness and determination may be often required, but anger or passion always leave an uncomfortable impression that they have been at least superfluous. Since disuse of restraints, has observed a considerable improvement here in the ward attendants-the very imposition of restraints in itself inducing bad feelings between the attendants and the patients, and making them speak illy of each other. Now, patients in refractory male wards not unfrequently to be seen grouped around an attendant, who plays some instrument for their amusement ; and patients, violent at other times, afford essential occasional protection to tire attendant, when suddenly taken at disadvantage by some other violent patient. In female refractory wards, patients usually found either assembled round a work-table with the nurses, or sitting by them on benches in the airing-court, or riding with them on the rocking-horses. In both male and female wards, an appearance of good feeling between patients and attendants ; and, when necessary to use some force, either to ensure seclusion, or to administer a bath, it is done after long attempts at persuasion, with a quietness, promptness, and efficacy, by which the patient is taken by surprise, and obedience ensured, without anything being done to give offence. 1842-Resident physician has now but the agreeable task of recording that time and patience, and the zealous co-operation of all the officers of the asylum, have enabled him to overcome many obstacles, and confirm. ed the belief-now established beyond likelihood of ever being overthrown -that the management of a large asylum is not only practicable without the application of bodily coercion to the patients, but that, after the total disuse of such a method of control, the whole character of an asylum undergoes a gradual and beneficial change. Case.-A middle-aged woman ; spirits greatly depressed ; had attempted to destroy herself, but was perfectly tranquil, and spoke rationally. When strait waistcoat was removed, talked more cheerfully. In a few days busily employed and content, and gradually got quite well. Case.-A young woman, insane one month ; brought in a strait waistcoat ; wrists and ankles ulcerated, which she said was done by 11 those infernal irons." Expressed great satisfaction when the waistcoat was removed, and evinced a feeling of still more comfort when put into a warm bath. Lively and noisv, talked loud, sung, and laughed ; face flushed, eyes animated, and had all the usual symptoms of acute mania. IAlere removal of restraint evidently prepared way for recovery. Kind and rational management soon completed it. In two days, engaged in sewing. A few weeks afterward, employed in matron's kitchen ; and in two months from time of admission, left asylum perfectly well. Patients sometimes brought to the asylum with ulcerations and impaired power of lower limbs, from restraints and straw beds, who put on an improving appearance so soon as they are p441 allowed to get up and walk about. Case.-A poor German ; in lying down observed to adopt the most singular positions to relieve back from pressure. On being allowed pertect liberty of movement, and good food and porter, ulcerations healed, and physical state improved. For a few days always in motion, and seemed not to understand any word or sign ; but within a week, played several airs on the flute, with considerable skill. State of mind of a patient of ordinary sensibility, on arriving at lunatic asylum, usually somewhat agitated. Confidence then to be gained, and first steps of successful treatment to be taken. Manner in which addressed, attendants to whom confided, personal interest taken in them by the officers, wards in which they are placed, ernployments,assigned to them, all matters of great consequence-not only by allayipg immediate anguish in many cases, but as exercising an influence over every curable patient throughout stay in asylum. 1843-Impression confirmed by experience of last twelve months that, by the abolition of physical restraints, the general management of the insane has been freed from many difficulties, and their recovery in various degrees greatly promoted. Effeet of principles, as expressed in former reports, are to remove, as far as possible, all causes of irritation and excitement from the irritable; to soothe, encourage, and comfort the depressed ; to repress the violent, by methods which leave no ill effect on the temper, and leave no painful recollections in the memory; and in all cases, to seize all opportunities of promoting a return of mental health. Every separate article of treatment, every prescription, every direction, has these objects more or less immediately in view. In proportion as, by these means, all the accidental aggravations of insanity are avoided or removed. and general tranquillity and contentment produced in communities of the insane, opportunities are presented of trying to what possible extent faculties which have been neglected, or misdirected, or ungoverned, may be brought to healthy, orderly, pleasurable, or u.,eful exercise, and the mind be restored. To this great end of all treatment, has always looked upon the abolition of restraints as merely a means, and ineffectual except in combination with a uniform system of kindness and consideration-prevalent throughout establishments for the insane-and maintained by zealous and humane officers and attendants, under an appropriate and undivided direction. Exactly in relation to the combination of these influences, and to their undeviating and steady application, will be progress of the insane to that state in which important resources, yet untried, or tried very partially, may be applied to the remedy, or to the relief of their malady. Capacities of feeling, and of intellectual action, and of pure, varied, and elevated enjoyments, preserved to the insane in many forms and stages of their affliction-and even when it is incurable-are becoming developed beyond expectation in many institutions directed by persons of intelligence and humanity ; and will doubtless become more manifest as the delicacy required in the management of infirm minds becomes more generally appreciated.
When the use of restraints has been done away with, the means employed in their stead have been summed up as follows :-11 Moral suasion ; garments made of strong materials ; the holding, by an attendant, of the, body or limbs; padded rooms; windows shielded by wire screens; seclusion arid the shower bath." This summary we proceed to illustrate, by reference to the Hanwell and other asylums. Dr. Conolly states that the douche is now seldom resorted to at Hanwell, producing no good effect 442 feet beyond that of the shower bath, and distressing the patient much more. He finds the shower bath the most effectual means of subduing violent excitement : the patient being placed up to the middle in warm water. It should be suspended, says he. when patient appears overcome, and instantly renewed when symptoms of violence occur. A strong shower, even for a minute, has sometimes considerable effect; and it is never many minutes prolonged without careful observation of patient's state. After four or five applications of this kind, the patient becomes entirely subdued ; and should then be taken out of the bath, rapidly dried, warmly covered up, and put into bed, with every possible demonstration of kind attention. Calmness and sleep are the usual results; and more permanent effects frequently follow. A bath of this kind seems to produce a moral, as well as physical, impression ; being succeeded, in recent cases, by tranquillity- for a few days ; and in chronic cases, by quietness and improved behaviour for many weeks, and even for months. In his report for 1839, he remarks- "For patients who take off or destroy their clothes, strong dresses are provided, secured round the waist by a leathern belt, fastened by a small lock. For some who destroy the collar and cuffs of their dresses with their teeth, a leathern binding to those parts of the dress is found convenient. Varied contrivances are adopted, with variable results, for keeping clothing on those who would otherwise expose themselves to cold at night ; and warrn boots fastened round the ankles by a small lock, instead of a button or buckle, are sometimes the means of protecting the feet of those who will not lie down. Those who are in the habit of striking suddenly, tearing the bedclothes, &;c., sometimes wear a dress of which the sleeves terminate in a stuffed glove, without a division for the thumb and fingers. But no form of strait waistcoat, no hand-straps, no leg-locks, nor any contrivance confining the trunk or limbs, or any of the muscles, is now in use. The coercion chairs, about 40 in number, have been altoether removed from the wards." As in a measure qualifying the preceding remark relative to varied contrivances, &c., we here insert a paragraph in Dr. Conolly's report for 1842:-"Wildness and irregularities of patients entering the asylum often rapidly subside, and their habits conform to the general order and decorous routine so remarkable in majority of the inmates. Continued operation of a tranquillizing system has produced effects even on the character and manners ; and, as it would seem, on the disposition of not a few of the old and incurable patients ; several of whom, formerly accustomed to meet the officers with endless complaints, seem now to have lost their fretfulness, and to be satisfied and content. Accidents, anxieties, and agitations must always be incidental to any house in which all forms and varieties of mental disturbance and disease are accumulated ; but the resident physician believes that all the officers of asylums who are experienced in both methods of treatment, have found, or will find, that the liberation of their patients from restraints has lessened the frequency- of accidents, and diminished the agitations and anxieties of those having charge of them ; so that even the various contrivances at first required for the prevention of evils and inconveniences formerly opposed by restraints, as strong dresses, seclusions, and window guards, become less required." In illustration of these remarks of Dr. Conolly, it may be stated, that at the Lincoln Asylum, where the non-restraint system first originated, they have attempted to disuse even seclusion, trusting altogether to holding the patient through the hands of 443 attendants. But to proceed, the visiting justices of the Hanwell observe, that where, as in the case of the violent lunatic, the above-mentioned means (vigilance, kindness, forbearance, comforts, employment, amusements) would not be found sufficient to guard against a paroxysm of fury, then, as a last resort-and, as it has proved, an effectual one-the patient is placed, with the least possible violence, in seclusion. In some instances, it is true, the shower bath may be required as a medical remedy ; but seclusion in a room in ordinary cases has been found, and usually in a short time, to produce the desired effect. Here, the sources of irritation, whether fancied or real, are removed from sight ; the pa. tient has no painful instrument of restraint to torment him ; and thus left to himself, without the means of injury within his reach, he soon recovers his usual temper and condition of mind. In addition to these safeguards, carefully-padded rooms have been provided for the epileptic liable to injury from falls; low bedsteads, and beds covering the rooms, for those patients formerly kept strapped to prevent their rolling out of their beds, peculiarly-constructed dresses for those who would otherwise destroy them ; these, and other minor contrivances, are designed to meet the various contingencies as they arise, and to ensure, so far as human contrivances can ensure, the safety of the patients by other means than those which at once torture the body and exasperate the mind. When those most prone to mischief were left unrestrained, they indulged their propensities freely by breaking the glass of their rooms and wards. Breakage of glass in 1840 doubled that in 1839. Remedied by wirework guards fixed to the windows. They are convinced that less cruelty in this system than old ; for being accustomed to examine discharged patients as to their treatment, only one ever complained. Dr. Conolly says that it is especially necessary to be guarded against extravagant notions of seclusion set forth by opponents of non-restraint system : it is a simple exclusion from the irritable brain of all external causes of additional irritation ; secures without irritating bindings ; is better than restraints with respect to other patients; very seldom fails to tranquillize in a short time ; is easily effected, whilst restraint often involved a severe and irritating struggle ; and does not tend to excite revengeful feelings. But to secure these advantages, must be remembered, that the term is applied to the temporary confinement of a lunatic in his own bedroom ;sometimes with the light partially excluded, sometimes almost entirely ; that it must not be hastily resorted to ; not carried into effect with anger, but steadily accomplished, when persuasion fails, by a sufficient number of attendants ; that it must not be accompanied with irritating expressions, nor applied as a punishment, nor unreasonably prolonged. All instances of seclusion should be promptly reported to the medical officer or matron ; state of patient in seclusion should be ascertained, from time to time, through the inspection plate; and any appearance of contrition should be met with kindness. After half an hour, or one hour, or two hours, in different cases, the practicability of putting an end to the seclusion should be tried, except in instances where a longer repose of the brain is plainly required. Seclusion so carried into effect at Hanwell ; and although many days in the year in which there is not a single patient in seclusion any part of the day, frequent opportunities of witnessing its remarkable quieting influence. Attention frequently directed in visiters to this. He does not think that restraint ever exerts this salutary moral effect. Speaks of indignation of those on whom restraints were forcibly 444 imposed, their fierceness in running about the wards in a strait waistcoat, &c. When the angriness, ferocity, and sullenness characteristic of some of the wards in which restraints were habitually employed (as in the epileptic wards) are contrasted with the present indications of confidence and general good temper, firmly impressed that general bad effects of restraint, and its liability to abuse, are immeasurably more pernicious than anything that can be occasioned by its discontinuance. After the trial already made at Hanwell, and a frequent revision of every kind of troublesome case, the resident physician can only concede that there would be some convenience in putting certain patients in restraint, who have the inconvenient habit of suddenly striking those about them ; but even this convenience would be only temporary, for it cannot be continually applied. Seclusion, therefore, although it does not wholly remove the difficulty of such cases, is a better temporary resource, as it neither leaves the patient offended, nor aggravates his combative propensity, which restraint always seemed to do in exact proportion to its severity and duration. No patients in the asylum were more dangerous to approach than those who were fastened every day in restraint-chairs ; and no patients have improved more signally since their entire liberation. He never presumed to say that no possible case could ever occur in which a resort to restraints might be found convenient : but he has not yet met with one related case-with one imaginary combination of danger and difficultyof which he does not know, from actual observation, that the management is practicable, and the evils avoidable, without having recourse to such measures. Incidents exemplifying the success attending the persevering application of diversified means to all kinds of cases, instead of restraint, are too frequent and too numerous to be repeated. Case.--Acute mania ; very troublesome at night from restlessness ; various medicinal applications tried without success, and room and dress so ar. ranged, that his restless nights could be followed by no bad consequences on his health, but never fastened to his bed. At length occurred to house surgeon, that malt liquor sometimes proved an agreeable sedative. A bottle of Scotch ale was given to the patient at night with the most satisfactory effects, and continued for some weeks; quantity then gradually reduced, but its omission for a single night was still followed by bad effects. During this time patient, who had been reduced to the state of a skeleton, and was generally excessively noisy, has become fat, and in all respects greatly improved. Less striking cases, however, among the more unhappy victims of restraints ; restless, helpless creatures, seldom speaking, and seeming almost wholly stupid, and scarcely exciting attention. In a case of this kind, a poor, feeble man, could not be always induced to lie down on his bed ; he sometimes remained a great part of the night, or the whole of it, standing at the door, as if ready to come out. Slept much by day, seemed well nourished, seldom spoke, and never complained, but ankles began to swell. Continued attention from the night attendants and the keeper of the infirmary, together with a frame. bed, at length habituated him to lie on his bed at night ; and lie may now often be seen by day no longer sleeping, or stupid, or silent, but cleaning the knives and forks, polishing the fire-irons, and pointing to and telling result of exertions, and appears in perfectly good health. If he had been fastened in his bed, by hand or foot, lie would have become less and less capable of exertion, lost his health, and remained in restraint every night until he died. Dr. Conolly has found opium of utility, sometimes giving 445 it only at night, and at others in repeated doses in the day. Grain doses of the acetate of morphia at night, and smaller portions in the day. Upon the whole, he prefers, as a sedative, hyoscyamus, giving 3ij of the tincture at night. But he adds, it should never be forgotten in a lunatic asylum, when a patient is noisy at night, that a copious draught of cold water is often a better sedative than any medicine. By this means, and by allowing the patient to wash his hands and face, and by a quarter of an hour's quiet conversation with him, and by causing his bed to be re-adjusted, a patient may occasionally be tranquillized, who would otherwise disturb his neighbours for hours. In other cases, the unexpected offer of a little bread and meat, or bread and cheese and beer, is very successful, although it has not been thought expedient very often to resort to it. These trifles important, not merely because they give the patient a quiet night, but because they also interrupt the habit of being noisy in the dark. He speaks highly, in cases of excessive excitement, of shaving the head, and applying the ung. ant. tart. freely to the scalp.
In 1834, Dr. E. P. Charlesworth, the attending physician at the Lincoln Asylum, observes, that as the disposition of some of the patients to tear their blankets is occasionally a cause of their being confined by the wrists at night, he recommends in such cases that the blankets should be enclosed within strong Russia sheeting, quilted ; and it was made a regulation in 1835, that strong dresses of barragon, or sacking, be procured for the patients who tear their clothes, to prevent necessity of restraints. A visiter to the lunatic asylum at Northampton, in England, observes -- Eighty-three per cent. of all the patients are employed, and 94 per cent. of the male patient. The non-restraining principle is applied here in its ultra form. In one instance, the day 1 was there, the bed and bedclothes of a patient were completely changed four times between 8 and 12 o'clock -- a warm bath prepared each time -- and the patient washed, and her clothes changed throughout, rather than use severe measures for correcting or counteracting her propensities. In violent cases, the patient is placed alone in a room well aired and lighted, where there is nothing destructible, and treated with all the kindness which he is capable of receiving. It is observed in the report for 1841 of the Lancaster Asylum, that some changes have been made in the clothing of the patients. Many, who destroyed or refused to wear shoes, have been supplied with cloth boots, which, causing no uneasiness to the feet, and not being readily cast off, they have allowed to remain on. Unsightly appearance of barefooted patients thus obviated, and warmth given to the extremities -- a matter of no small moment as a remedial measure. Such patients as are of destructive habits are supplied with clothing of strong materials, and constructed in such a manner that it requires considerable force and ingenuity to destroy the fabric ; and in every instance where male patients have exhibited a strong propensity to take off their clothing, they have been supplied with a jacket and trowsers both in one, and made to button up the back-an ingenious contrivance, that has admirably effected the desired object. In all cases of violent excitement; if gentle persuasion fails in subduing the irritability of the patient's mind, he is removed as carefully and mildly as possible to his own room, where he is left alone ; or, if circumstances require it, to a room into which is admitted a subdued light, and so constructed and prepared that he cannot injure himself. Every precaution taken to avoid substituting physical force for physical restraint. A regulation of asylum, that when the 446 shower bath is used with a view to correction, the patient must be brought to it mildly, &c. After being under it a sufficient length of time, he must be gently wiped, and soothed by kind language ; and when he is placed in bed, clean sheets and a clean shirt must be provided. In report of 1842, it is stated that decided advantage has been experienced among a restless class of patients, who were liable to get up at night, or who perversely threw off their bedclothes, by simply attaching a piece of tape to each corner of the quilt, and fastening it to the bed-stock, so as to form no impediment to the free motion of the body or limbs. In almost all such cases, a quiet night's rest has been secured, and the propensity has ultimately been overcome. A visiter to Bethlem observes -- Bethlem contains patients of every description. On the day of our visit there were 360 within its walls, of whom 90 were convicts, sent thither from their prisons by government. The others were of all classes and stations, nearly equal of both sexes, and suffering all the varieties of insanity. But except one man in a padded dress, like a carter's frock, within which the mischievous hands were confined to his sides, there was no constraint visible.
The asylums in Great Britain which have discarded restraints entirely cannot be said to be numerous. The testimony, however, of these is, we believe, altogether in favour of the plan ; or, rather, the superintendents of such asylums give it as their opinion, after a trial of the new system, that it is preferable to the old. A remark of Dr. Conolly should also be given here- "It is, moreover, an important fact that in the only asylums in England in which attempts are known to have been made to abolish restraints, the experiment is known to have been successful." The experience at the Gloucester Asylum was, that "all the patients are as securely managed, and are governed with much less difficulty and dig. turbance without, than with mechanical assistance." The physician of the Edinburgh Lunatic Asylum says-"For 18 months I have not considered it necessary to use personal restraints on any occasion during the day. In one case (a suicidal patient), I have been reluctantly compelled to make use of it during the night; but with a larger staff of attendants, or a building on the plan of the new establishment, I would have been enabled to dispense with it even in this instance."Dr. Hutcheson, of the Glasgow Asylum, observes- "I have been enabled to carry out the system completely, without increasing the number of the attendants, and with the happiest effects. Not only are the patients quieter and more orderly, but a great saving of glass, furniture, bedding, &c., has been effected, the amount of seclusion has been diminished, and the habits of the patients much improved. Greater attention, forbearance, tact, and kindness required in the attendants; but much less struggling, and less physical force used, than under the old system ; infinitely less seclusion also." Is of opinion, that personal mechanical restraint in no case necessary for the mere treatment of insanity in an asylum : and that in all cases it is prejudicial. The Lancaster Asylum is next in size to the Hanwell, of all the British asylums. Dr. De Vitre and Mr. Gaskell state, in the report of 1841, the year in which restraints were abolished, that on taking charge of the institution they found 29 persons wearing either handcuffs, leg-locks, or strait waistcoats -exclusive of between 30 and 40 patients who were chained down during the daytime on seats like water-closets ; moreover, during the night-time all the epileptic and violent patients were chained or otherwise secured in bed. An established 447 custom to place every case on admission under restraint during the night-time, for a longer or shorter period, as might appear expedient. Patients nearly always were much improved after the removal of restraints. Dancing and other amusements of importance at all times, but still more so in an institution where the patients are undergoing a change from a system of coercion to one of cornparative freedom. In report for 1842, it is observed, that with a view of diminishing, as much as possible, all harshness of treatment, attempts have been made with great success to induce patients requiring the shower bath to submit to it voluntarily ; but in some few instances it has still been found necessary to use coercive means during its administration. In report for 1844-System of moral management and control, in contradistinction to mechanical restraint and coercion, strictly adhered to; and since first adopted, only once been found necessary to depart from it, in the case of a very violent and un controllable epileptic patient, who had got an impression that the medical officers durst not have recourse to any coercive measures-such as were formerly in constant use-no matter how outrageous his conduct. This patient was placed under restraint for six hours, with the best effects as regarded himself, and with great advantage to several patients in his gallery, who had, through his instrumentality, shown symptoms of great insubordination. It was with some reluctance that such a nneasure was had recourse to, and it was not adopted until all ordinary palliative means had failed in producing the desired effect.
The eminent Mr. Samuel Tuke, who must be placed in the first rank of those whose benevolent exertions have raised the insane from darkness and chains to light and kindness, has the following observations in his introduction to Dr. Jacobi's work on Hospitals :-It may be observed, that the degree in which personal restraint is required towards the patients depends very much upon the character of the attendants. Many fits of excitement, or acts of violence. which appear to justify coercion, would be prevented by a little kind consideration and judgment. Restriction of the power of attendants, and the not allowing them to impose personal restraint, without the consent of the superintendent, has a tendency to lead them to cultivate the arts of prevention ; and it may now (1841), I believe, be said to be established that, under fair management, the num. her of patients subjected to any kind of mechanical restraint, either by day or by night, will rarely exceed five out of a hundred, and sometimes no one out of this number will be found to require it. I freely acknowledge the conviction that there are cases in which, under the most favourable management, we should best consult the feelings of the patient, as well as the comfort of his companions, by the application of mechanical means of restraint. Have seen the patient ask for restraint ; have witnessed this in connexion with a strong disposition to strike others, as well as with an occasional rushing impulse to a particular means of self-injury. I apprehend that some restraint upon the free action of the body must be imposed, either by the passive resistance of mechanical applications, or by the active coercion of human force. If not restrain. ed by a strap, are there no other means for attendant to overawe ? I fear and believe there are ; and that in the struggles which cannot fail occa sionally to take place, fear may be excited, sufferings be inflicted, far more distressing than those from the right application of mechanical restraint ; with this additional disadvantage, that they are less open to public notice. Nothing more to be deprecated than protracted struggles 448 between the insane and their care-takers. In our large institutions, at. tendants must be left, to a very great extent, to carry out the directions of the superintendent in their own way and spirit ; and this, our knowledge of attendants as a class, hardly justifies us in expecting, will ever generally be the best. Liability to abuse and perversion, even under enlightened management, deserves consideration ; but if the system has to be carried out by a reluctant or inefficient officer, or is left mainly to the ordinary attendants, there can be hardly a doubt of its inexpediency. In meantime, consideration which the proceedings at Lincoln and Hanwell have induced, as to whether, in our respective asylums, we may not safely and advantageously, at least, still farther diminish the amount of personal restraint, is operating, and will continue to operate, very beneficially.
The Commissioners of Lunacy, whose duty it is to visit all licensed asylums in England and Wales, in their report to the Lord Chancellor (1844), give no decided opinion as to the respective merits of these systems, but they rather incline to doubt the propriety of the total disuse of mechanical restraint, and cite several cases to show the danger of this course. They say the care of violent patients is more expensive where no mechanical restraint is used ; the safety of attendants and others is sometimes endangered, and in some instances the patients are much more calm and disposed to sleep when confined by a proper apparatus, than when held by attendants. They remark- "In some asylums, both public and private, the superintendents and proprietors state that they manage their patients without having recourse to any kind of restraint whatever. In other asylums, it is affirmed that the disuse of restraint is their rule and system ; and that its use, in cases of necessity or experience, forms the exception to the rule. Those who profess the entire disuse of restraints, employ manual force and seclusion as parts of their method of management, maintaining that such measures are consistent with a system of non-restraint. It is said by these persons, that when any of the limbs (as the legs or hands of 'a patient) are confined by the strait jacket, the belt, or by straps or gloves, he is under restraint ; but in cases where he is held by the hands of attendants, or when, for any excitement or violence, forced by manual strength into a small chamber or cell, and left there, it is said that restraint is not employed, and the method here adopted is called the 'non-restraint system.' In those cases where patient is overpowered by a number of keepers holding his hands or arms during a paroxysm of violence, it is said there is no mechanical restraint. Here restraint of some sort or other is manifest; and even in those cases where the patient is forced into a cell by manual strength, and prevented from leaving it until his fit of excitement shall have passed, it is difficult to understand how this also can be reconciled with the profession of abstaining from all restraint whatever, so as to be correctly termed 'non-restraint.' It seems to us that these measures are only particular modes of restraint, the relative advantages of which must depend altogether on the results. "With respect to seclusion, they observe- "As a temporary remedy for very short periods, in cases of paroxysms of high excitement, we believe seclusion is a very valuable remedy. We are convinced, however, that it ought to be used only for very short periods ; and that it should not be permitted as a means of managing and treating those persons who are permanently violent and dangerous."
The editor of the Medico-Chirurgical Review, in the number of 449 that admirable journal for Jan., 1845, has some remarks on the subjects of restraints, and particularly with reference to the testimony of the commissioners. He says, the practicability of totally abolishing all mechanical restraint in asylums chiefly destined for the reception of chronic cases of insanity, has been completely demonstrated at Lincoln, Hanwell, and Lancaster. That, however, whether as regards the lunatic himself, his attendants, or his fellow-patients, its indiscriminate proscription, especially in establishgnents where only recent and often violent cases are received, would be most injudicious, we have often stated in this journal; and we are glad to find that the dispassionate inquiries of the commis. sioners have led them to the adoption of a similar view. They state that the opinion is unanimous, upon the part of the superintendents of insane establishments, that the condition of the insane has improved in proportion as mechanical restraint has been disused. In point of fact, it is nearly practically abolished in public receptacles. In 17 of these, containing 2868 patients when visited, there were but 24 persons under moderate restraint ; and while weekly average at Bethlem was 11 in 1839, it was only 3 in 1843. But few medical officers, however, approved of the power of using it being totally withdrawn; and the commissioners relate several examples of serious accidents resulting from its total disuse. Upon the score of humanity, Mr. Tuke, and numerous other well-qualified observers, prefer its mild employment, as subduing impetuosity with least suffering to the patient. Its universal abandonment would be attended with great expense in additional attendants, without corresponding advantage. Its abuse must be guarded against by its infliction requiring sanction of physician, and its duration being faithfully recorded. The same precautions are required when seclusion in dark cells is employed.
With respect to the asylums on the Continent of Europe, the principles of the non-restraint system appear to have exerted but little influence. Kohl, in his work on Russia, gives, however, an account of an asylum at St. Petersburg, in which it seems these ideas are put in practice. Behaviour of attendants polite and courteous; every fresh patient received very respectfully, and first taken into the society of the most rational of the lunatics, who have some politeness. Here shown interesting collections and productions of art; refreshments brought to him; is invited to a game of billiards or backgammon, or may converse ; indulged in everything, as far as possible, and thwarted only in that which might be hurtful to him. Employment, the beauties of nature, pleasant society, and recreation ; and, on the other hand, darkness, solitary confinement, and ennui, are the principal engines employed to excite and to encourage, to soothe and to tame. Next day, a new-comer is conducted to the workrooms of the patients, where they are engaged in carpenter's and pasteboard work, spinning, knitting, sewing, embroidery, &c. If he fancies one of these, pains are taken to teach him, as it were, in play ; but if' aversion continuous to all bodily exertion (reading in the library being allowed to only convalescing), he is taken to a solitary apartment. If' complains of ennui, is led back to workrooms and again begged to work, being promised permission to join the tea-parties. If insusceptible of ennui in the light room, and persists in apathy, or begins to be violent, is shut up in the cushioned room, from which even the most outrageous; soon wish to be released, because maddest persons fqel the need of light in their wildest undertakings, and darkness seems intolerable, even to the 450 most phrenzied imagination. The asylum at Palermo, in Sicily, has been classed amongst those employing the non-restraint system ; but if it be an institution commendable in some respects, it is certainly not so ill others. We give an account of it, taken from a traveller in Sicily, during the year 1844- "We saw nothing in this house or its arrangements to make us think it superior, or very difFerent from others we had visited elsewhere. Cleanliness, good fare, a garden, and the suppression of all violence-these have become immutable canons for the conduct of such institutions, and fortunately demand little more than ordinary good feeling and intelligence in the superintendent. But could not fail to observe a sad want of inducement to occupation apparent throughout the asylum. Not one woman in four could be induced to dress according to her sex; they figured away in men's coats and hats! Dining-room filing with portraits of some merit by one of the lunatics. Have a dance every Sunday evening."
We proceed to give the latest opinions of superintendents of insane asylums in the United States, as expressed in the reports of these institutions for the year 1844. 1)r. 1tay, of the Maine Insane Hospital, writes as follows :-Thinks that an unwarrantable prejudice has been excited in England against restraints, from the unfortunate errors previously exist. ing in the opposite extreme ; as for instance, at Lancaster. From such practices never having been allowed in our asylums, we cannot sympathize in this strong feeling. Nobody doubts that an asylum could be conducted without them. Question at issue, whether welfare of patients promoted by disuse, and this not settled by the fact that some hospitals are conducted without them. To authorize disuse, must be proved either positively injurious to patient, or that their intended object can be better obtained in some other way. First consideration attending disuse, increased number of attendants-thus increased expense-which in many parts of our country would forbid any establishment at all. This not the ground of his defence, however, of mechanical restraints. In most cases where now used in American hospitals, has no hesitation in saying that they are far preferable to the vigilance or force of attendants. Tire object is gained more surely, more effectually, and with far less annoyance to the patient. The one arouses feelings of various kinds, the idea of eluding vigilance or overpowering strength of attendant, or anger, as the author of the patient's sufferings ; the other is inert matter, and excites no feelings. For instance, when a patient continually converts abrasions of the skin into ulcers by scratching, or a suicidal patient is bent on tearing open a wound on his neck, the attempt to prevent these is very difficult and irksome ; whereas a simple strap answers the end in view, at the sarne time leaving considerable freedom of motion. Another case is that of a highly excited, restless, and strongly suicidal patient. In the one case, the night is spent in a series of irritating struggles with the attendant; while in the other the patient is left to comparative quiet. Another, exhausted by sickness, and needing repose, is constantly endeavouring to rise from his bed ; conversation and movements of attendant only excite his attention, and maintain the morbid activity of his brain. The bed-strap of Dr. Wyman holds him gently upon the bed, and he falls to sleep. Often, to prevent a patient from doing some improper thing, two or three attendants must use such force as to exhaust and irritate him ; whilst the muff or mittens would be far less annoying. Very often, as to the same patient in the same condition, mechanical restraints are substituted 451 for the personal efforts of an attendant ; and the superiority of the former shown by the superior calmness and comfort of the patient while under their application. To the objection that they leave unpleasant impressions in recovered patients, he says lie never rknew this in cases really restored. To the objection of their liability to abuse, to save trouble or gratify spite of attendants, says, in Maine Hospital, and he presumes in all others in this country, no restraint can be applied, except by order of an officer. His rule to use no more, and continue no longer than necessary to effect object in view; and in all cases, comfort of patient, not attendant, is consulted. In well-regulated establishments, number under restraint is always very small. While writing this, not a single patient in the institution under restraint; this often the case fomany days together. Occasionally may amount to 4 or 5, but probably would not average more than 2 or 3 (average of patients 70). To objection that they chafe the skin and produce sores. says this doubtless occasionally happens ; but if restraint is discontinued as soon as it is observed, the evil is not a very serious one. The above objections iuav be urged with far more propriety against the substitute than the original. An attendant is very apt to use more force than he intended, and tire patient is apt to imagine himself hardly dealt with ; this impression ever) remaining after recovery. Patient often believes his path beset by eilemies ; and constant presence of attendants at his side would confirm this impression, and also prevent sleep at night. Still, whether this disuse of mechanical restraints in some foreign establishments be persisted in or not, I am willing to admit that the experiment thus far has strengthened the important truth--that kind words and interesting employment will be found, much oftener than we have been in the habit of believing, a successful substitute for their use. Considering proneness of times to ultraism of every form and hue, we can hardly be surprised that seclusion, or solitary confinement of the patient to his own room, should have been included with mechanical restraints, in the same category of condemnation. The experiment of dispensing entirely with seclusion was lately tried at the Lincoln Asylum, England, very much to the satisfaction of the medical officers. That seclusion is liable to great abuse, and that it may be entirely dispensed with, are points that may be admitted without touching the true question at issue-whether corntort and recovery would be promoted by abandoning its use in every case and in every stage of the disease. The idea of introducing a furious, raving maniac-vociferating in the loudest tones and using the most revolting language-into the company of patients tolerably quiet, is preposterous. But evil would be scarcely less, if such were associated only with others somewhat like themselves ; for result would be that they would increase one another's excitement, and effectually prevent even its temporary remission. His way of treating such cases is by seclusion in strong, comfortable rooms, so furnished that they cannot injure themselves, and so ventilated and warmed that they may divest themselves of all clothing, and still be sufficiently warm. Here they can expend their fury without let or hindrance, neither disturbing nor being disturbed by others, until the excitement passes away, when they are gradually introduced into the company of others. This change must be very cautiously made ; for if premature, or effected too suddenly, nothing more common than to see the excitement rekindled by the looks, and acts, and voices of others. In cases, too, of more moderate excitement, occasional seclusion for an hour or two at a 452 time is a most salutary measure ; and does not see how it could be dispensed with, without risk of great injury to the patient. Occasional seclusion also valuable, as a means of moral discipline. Patient understands that so long as he does not annoy his fellow-boarders he can associate with them ; but otherwise, he will be subjected to temporary seclusion. This an impressive lesson of self-control, which would be absent if no seclusion was used. It may be carried too far, and must be necessarily, in hospitals poorly provided with means of classification. In such, a little superfluous noise, merely because it disturbs others, leads to seclusion in the solitary, with bad effects. Condition of patient should be only test of its propriety, while the comfort of others should be pro. vided for by suitable architectural arrangements. Deeply to be deplored that a measure of so much importance as seclusion is too often used, in consequence of defective construction, for patients to whom it is quite inappropriate ; and but very imperfectly applied to those on whom it would have a salutary effect.
Dr. Bell, of ythe McLean Asylum-Been an object constantly kept in view, to reduce the restraints upon the volition and the feelings, as well as the actual personal restraints, to the lowest degree compatible with the patient's welfare. Have, as intimated in former reports, no ultra or exclusive views as to entire disuse of apparatus to abridge the muscular movements of the highly excited. During last three quarters of the year (a memorandum enables him to state the fact), it has been judged proper to use, on the male side of the house, a single restraining measure -that of the muff to the hands of a patient disposed to destroy his eyesand some form of restraint, in a few instances, on the other side of the house, for reasons deemed imperative. That "restraints" in these few cases might have been avoided by the substitution of hands, is probable ; but it is difficult to appreciate the advantage of such painful, irritating, and less secure substitutes, as a universal rule. No reason is yet seen for cutting an institution off from the proper employment of measures occasionally valuable, by a dogmatic adherence to any ultra or exclusive rules, such as may, in other countries, have become popular, if not expedient, in consequence of an honestly generated popular prejudice against "restraints." In all cases, except a few of the kind above referred to, ability of an institution safely to dispense with restraints of all kinds will depend principally upon its means of employing and educating an adequate number of good attendants. His reliance been mainly upon the aid of as many assistants as could be well employed. Having a carte blanche as to these from the trustees, intention is, that the substitution of mechanical for human guarding shall be a rare exception to the general rule. Present number of competent assistants in immediate care and constant presence of the patients, not less than 25, exclusive, of course, of the number otherwise engaged (asylum accommodating 150 patients). With such a force, doubts not that in some years its register may show a clear page as regards the use of restraining apparatus, or coercive administration of food ; in other years, it is equally believed that the highest exercise of skill and humanity might sanction occasional departures from the general rule.
Dr. Earle, of the Bloomingdale Asylum-Means of bodily restraint "tranquillizing chairs," straps, muffs, wristbands, mittens, and other appliances for the confinement of the body and limbs, have been considered as necessary evils, or perhaps, by some, as necessary promoters of good, 453 in establishments devoted to the accommodation of the insane. Hence they have been employed, even to a very recent time, to a much greater extent than was necessary. In his individual experience, has fbund that in proportion as fie has become acquainted with the insane, with their tempers, dispositions, habits, powers of self-control, and capabilities of appreciating the ordinary motives which influence the conduct of mankind, has his opinion of the degree to which these means are necessary, diminished. His practice has corresponded with this change of opinion, and the results have been eminently satisfactory. At present no patient upon whose body or limbs there is any apparatus of restraint. In the men's department none during last six weeks ; and in but a single instance during last three months. A patient, whose ordinary conduct is unexceptionable, but who is subject to sudden and uncontrollable impulses to destructiveness, acting under the influence of one of his paroxysms, broke a chair and some windows, and wristbands were employed two days. So-called "tranquillizing chairs," for many years used here, were taken from halls in April last, and neither of them has since been used. Heretofore customary to keep a supply of the other kinds of restraining apparatus in each hall throughout the establishment. About the 20th of November, evervthing of the kind was removed from the men's department, and deposited in the physician's office, where it has since remained undisturbed. (Average, 55 males ; date, end of year.) And yet, during the period that he has been connected with asylum, has been no equal extent of time in which there was so general a prevalence of quiet, order, good feeling, contentment, and reasonable conduct, as during last six weeks, and appeals for confirmation of this statement to officers, at. tendants, and visiting committee. It is not asserted, for it is not his opinion, that restraints upon the limbs are never necessary ; on the contrary, he believes there are cases in which the application of them is the most judicious course that can be pursued. Once heard a patient beg most earnestly to have her hands confined, lest she might injure herself. Now a female in the asylum, who is subject to frequent and very violent spasmodic paroxysms, or "fits," in which there is an uncontrollable propensity to bite herself. If her hands be unconfined, she immediately plunges her teeth into the flesh of the forefinger, the upper portion of the thumb, or the arm. Has no hesitation in regard to the propriety of confining the hands in a case like this. One of the means of restraint among the most simple, effectual, and least offensive to the patient, is the camisole, only distinguishing peculiarity of which is, that the sleeves are about twice the length of those of ordinary garments. This being on, the patient's arms are folded, in the manner frequently adopted by persons in health, and the two sleeves are tied together behind. Thus there is no pressure upon the body or limbs, no liability to abrasion of the skin, as with the wristbands and muffs, and the limbs are in a position as easy and agreeable as any in which they can be placed. Says he believes attendants are fully disposed to carry out his views as to the use of mechanical restraints; but that if, when deprived of resort to means of bodily restraint, under the obstinacy, perverseness, &c., of patients, they still succeed in their duties without cause for censure, they must have achieved a victory over themselves, such as is attained by comparatively few of their fellow-men, and have reached a degree of moral excellence that would be meritorious in the more conspicuous walks of life.
Dr. Brigham, of the New York State Asylum, at Utica-Treatment of 454 violent maniacs.-Many of this class brought to us in chains, or with their limbs confined by strong cords. These, in all cases, immediately removed; and the patient is kindly addressed, and assured that he is among friends who will use him well. Is also told the truth, in the presence of those who accompany him, respecting the asylum, and the object for which he is brought to it. He is then taken to the apartment which he is to occupy, and permitted to have his liberty ; but his attendants are directed to watch him carefully, and if he is disposed to be violent, to strike, to break the windows or furniture, to put him in his room. Most of the rooms for patients of the same size, none smaller than 10 by 9 feet ; but those for the violent class are, in some respects, more comfortable. They are well ceiled with boards, handsomely painted, which makes them warmer, safer, and better for patients than those with plastered walls. Upper part of the door opening into the hall from each room is open lattice-work ; so that the patient, can look into the hall, and be constantly seen from it. Window which lights each room is well se. cured by a strong lattice shutter, so open, that the patient can look into the yard or garden. If disposed to tear his bed or bedding, they are removed from the room during the day ; and if we find, from our own observation, that he tears his clothes, and that no persuasion or watchfulness can prevent it, we usually enclose his hands in leather muffs, or in mittens of leather or strong cloth, or apply soft leather or cloth wristbands. These the only methods of restraint for the most violent patients. In no case use ropes or chains, or the strait jacket. Occasionally have a patient who would exhaust himself by walking, jumping, or standing up continually, that we fasten in a gentle manner to a chair or bed, for a short time. But none of these methods of restraint are long continued, without giving the patient an opportunity of showing that they may safely be dispensed with. Much prefer that a patient should occasionally break a pane of glass, or tear some of his clothing, than to keep him constantly confined. Give him, therefore, frequent opportunities, and place before him inducements, to exercise self-control. As we have said, no part of establishment made so comfortable. Assign to this class a greater num. ber of experienced and discreet attendants than to any other, some of whom remain constantly with the patients, and two of them sleep in the same apartment. This class now at the end of the first or basement story of each wing, which is easy of access. Have no detached or outbuildings for patients, nor do we intend to have, as we deem it important for the welfare of the insane, especially the violently deranged, that they should be placed where they can be readily and frequently visited by the physicians, the matron, and other officers. Utmost care to ensure com. fort of this class, by properly ventilating and warming their apartments. Some are disposed to destroy their bedding, or to remove it from them, and thus liable to suffer from cold at night. These give much anxiety, and resort to various methods to ensure their comfort. To prevent their suffering from cold during the night, find nothing better than a dress of woollen blankets, open behind, and with the sleeves and legs extending below the hands and feet, and sewed up at the extremities. Covering the whole body, and fastened behind, it will usually be kept on during the night ; though, in some cases, have to enclose the hands in mittens. Effectually secures from cold, especially the feet, which is most difficult, yet very essential to guard against during the night. During the day, a few patients wear strong loose gowns ; which, in cold weather, for those 455 that are feeble, are padded. Never allow a patient to be punished. Sometimes withhold some little favour, or promise some additional gratification, such as visiting museum, if lie will refrain from hallooing, &c. Rarely shower patients with cold water, except in warm weather, and when they request it for their comfort. Sometimes do not use it when we think it might be useful for fear of its being considered a punishment. More frequently apply cold water directly to the head, without wetting any part of the body ; and this we find very useful in cases of great excitement. But never allow attendants to do this without an order from one of the physicians, and do not permit a large quantity ; a little is sufficient in cases where any is required. Find the warm bath, especially if long continued, with cold water gently applied to the head at the same time, often very effectual in quieting excited patients, and disposing them to sleep. But this a very changeable class ; often those whom we are obliged thus to treat, become better in a few days, and are placed with the most quiet. To no one object are our efforts more constantly directed, than to diminish the number of this class, and to dispense with all kinds of restraining apparatus ; although we most firmly believe, after much reflection and inquiry, and repeated attempts to entirely dispense with it, that some restraining apparatus such as we have mentioned, is not only essential for the comfort of patients, but, in some instances, preserves their lives. Most of the recovered under above treatment are conscious of this, and grateful. Some few never appear to comprehend necessity of any kind of previous restraint, even being sent to the asylum ;they generally complain, in such instances, of the cruelty of friends, &c., telling long stories of it. Every one who has had much to do with the insane, soon learns that by kind treatment and attention they are far more easily managed, and much less troublesome, than when they are neglected, or in any manner abused. Rarely admit visiters into apartments of easily-excited patients, though most frequently visited by officers and managers.
In the report of the Frankford Asylum, it is observed-As a necessary result of this system (kindness, candour, and forbearance), when carried out by efficient and intelligent officers and assistants, is the removal of all mechanical means of restraint, except in those rare instances where, in its simpler forms, it produces no excitement, and prevents the sacrifice of important curative means.
Dr. Kirkbride, of the Pennsylvania Hospital for the insane-Gross abuse of restraining apparatus in European institutions has produced a reaction, bidding fair to place some of the same in the first rank of those where there is a general absence of restraint. Although well understood that in the hospitals of the United States, with perhaps a few exceptions, restraint has been resorted to to a much smaller extent, it will scarcely be denied that, until within a few years, much more was employed than was either proper or justifiable. From information from nearly all the regularly-organized institutions for the insane in this coun. try, has no doubt that less real restraint is employed in them than in the same number of asylums in any part of the world. In this country, cruelty, immoderate restraint, and ingenious but barbarous contrivances to control the insane, are rarely, if ever, found in properly-organized hospitals. When they do exist, it is in the almshouses and jails, and in the private dwellings of the inhabitants. Non-restraint system, meaning the disuse of mechanical restraint, must, of course, be substituted by less 456 objectionable forms. A properly-constructed building-an efficient organization--a more numerous body of more active and intelligent attendants-all the means to prevent excitement, kindness and tact, and temporary seclusion-are part of the substitutes. Few familiar with insanity will now assert that restraining apparatus is frequently required, or that many patients can be benefited by its use. The question appears to be, whether it is ever justifiable, or ever employed, without injury to the patient. Believing firmly that the improper use of restraining apparatus, combined with long -continued seclusion, has been, and ever will be, productive of the worst effects, and go far to render intractable curable cases of disease, is still of opinion, that a few of the simpler means may occasionally be employed with advantage to a patient. Judging from his own experience, the percentage in any hospital for whom these means are indicated, is exceedingly small ; and for considerable intervals, none will be required. Rule should be, that no apparatus was in use-its employment should be the exception-while, at same time, long periods of seclusion are not to take its place, as being still more injurious. One advantage in disuse of restraints, that should never be overlooked, is, that it brings into activity in attendants, watchfulness, &c., and shows great power of kindness and firmness, which otherwise would have been dormant. Although probable cases do exist, yet never saw a patient that required any other form of apparatus than the bed-strap, mittens, or wristbands, with a belt around the waist, or still simpler substitutes for the mittens. Of the 592 cases which have been in the hospital, does not hesitate to say, that all might have been treated without any mechanical restraint, had there been such a determination, or any pride in the declaration. Feels equally confident, however, that in the few cases in which the mild means already referred to have been employed, effect in some has been to prolong, if not to preserve, life ; in others, to diminish violence and serious danger ; and in scarce a single one, to have been productive of the slightest injury of any kind. Restraining apparatus kept in office of physician ; and, like medicine, never prescribed unless a decided indication for its use. Never applied but by express direction of physician; and when applied, never kept on longer than he believes it likely to obviate a great danger, or to promote the comfort and benefit of the patient. In 1844, 285 patients under care, and average number 151. Have embraced nearly every variety of insanity, and the usual proportion of violent and otherwise dangerous patients, several being brought strongly ironed. Five males and four females have been kept on their beds, one male and three females have had on the connected sleeves, and one male has had a strait common buckskin mitten attached to an undercoat sleeve. Bed apparatus never used for more than a few consecutive nights, on any patient, and on some for only a single one. In every instance applied to break up the habit of standing during entire rights, and to prevent the exhaustion which a determined refusal to assume a recumbent position seemed likely to induce ; and these objects were attained, in a great measure, in every instance. Connected sleeves are large enough to allow ample motion of the arms on each other, and make no pressure on any part; were used, in one instance, to prevent an uncontrollable inclination to rub an abraded surface ; and in the other cases, to control peculiarly disagreeable habits. Buckskin mittens were sufficient to prevent certain injuries to his dress, in a patient determinedly addicted to it. Amount of seclusion has been small, and of short duration. 457
Dr. John R. Allen, who, under the new organization of March, 1844, took charge of the Kentucky Asylum, observes in his report- "A leather belt, with wristbands, or leather muffs, for the violent or mischievous, and a few hours' confinement in a dark room, have generally been sufficient for the worst cases; and a cold bath, judiciously administered, always successful in controlling the most vicious."
Amongst the rules of the Western Asylum of Virginia, published with the report for 1844, we observe the following :- "The muffs, mittens, or wristbands, are never to be put on, unless by order of the superior officers." With regard to the remaining asylums in the United States, that is, those from whose reports we make no extracts, we have not noticed any remarks in those documents, for the year 1844, bearing upon the subject of restraints. We presume, therefore, that in their management no material change has taken place in this respect. Doubtless, however, as is evidently in a measure the case with respect to those asylums whose reports we have quoted, the voice from over the seas has reached most of our institutions for the insane, and tended to reduce still further the small amount of restraint which is found in them. We venture to state, however, that the superintendents of American asyla are, in a body, distinctly opposed to the exclusiveness of an entire and total disuse of mechanical restraint.
Suicide.-Dr. Conolly. Report of 1841.-During year, 8 patients (5 men and 3 women) admitted, after manifesting suicidal intentions. Others also in the asylum. Difficult to ensure here proper degree of attention. As often cases of melancholia, restraint seems by no means desirable ; and the effects of a kind and confiding system of treatment are often immediately seen. Whenever disposition remains long, vigilance of attendants must be great ; and whatever tends to make this apparently unnecessary, adds to the danger. Before restraints were abolished at Hanwell, were occasional attempts by patients to convert the instruments of restraint into the means of suicide. Case.-A woman, æt. 45; a few days before admission attempted to cut her throat. An injury of the head, by a fall, had predisposed her to unusual excitement at particular periods. Leeches to head, aperients freely given ; and suicidal disposition never returned. Soon got well. In other cases, low spirits seem connected with a state of the brain, removed as the patient gains strength. This in men and women between 50 and 60 ; and perhaps earlier in men than in women. Are carefully watched, but increased bulk causes cheerfulness to return, and suicidal tendency to vanish. The most conciliating treatment being indispensable in all cases of this kind, they are quite unfit fer restraints. Among numerous patients at Hanwell, are sometimes three or four supposed to meditate self-destruction at the same time. They are watched during the day, and frequently visited during the night; and either placed in rooms affording no facilities for their object-the beds being, in some cases, placed on the flooror, more generally, put into rooms where other patients sleep-a measure always advisable, if the patient is not noisy or violent. Sheets are always removed, shutters properly secured, and rooms carefully searched. Patients, in general, seem much impressed with these precautions, the intention of which is not always concealed from them, and the impression seems to militate against continuance of the suicidal disposition. There are always, however, some cases against which scarcely any prudence can guard ; as patients who have been long in the asylum, and with long 458 periods of tranquillity, have paroxysms in which suicidal ideas revive, and sometimes with very little warning. Gives such a case, the patient cutting his throat, and requiring constant watching to prevent the wound from being torn open. Paroxysm subsided in a few weeks, and now trusted as an excellent helper. May eventually accomplish his object. But if restraint were used, it must be constant ; and this would cause suicide, by rendering life intolerable. Instances of occasional refusal of food been rather numerous during last year. In some difficulty been overcome by varying the food; in others, by very patient endeavours; and in a few, the stomach-pump has been used. This been only necessary in cases in which the refusal was from obstinacy or delusion, and its frequent repetition has not been found requisite in any case. Physician avows that he consented to give it to one case-a patient dying of chronic disease, after being long epileptic and maniacal-from the apprehension that his refusal would be cited as cause of patient's death. Futility of attempt was proved by the low fever in last days of his life, and the general disease evident after death. 1842-Four cases during last year in which food has been obstinately refused for a time ; and in two of these stomach-pump was deemed requisite-in no case more than twice. A male patient, admitted in a very miserable state ; at first refused food, and seemed obstinate. Assistant steward, Mr. Clift, long used to the ways of the insane, took some cake into the infirmary where patient was, and sitting down opposite to him, began to eat it. Patient looked on for a short tune in silence, but finding himself apparently unnoticed, begged to be allowed to have some, and ate it with much satisfaction. After that time, took his ordinary food. Upon the whole, all additional experience strengthens the resident physician's unfavourable opinion of instrumental means in such cases. Advantage is limited to a small number of them; they have an unfavourable influence on the patient's mind when often resorted to ; and their employment is by no means free from danger in weak and violent patients. Eleven of the admissions suicidal. Attempts made by 9 ; 6 females. One female made 3 ; another tried twice to accomplish the same end ; and a male patient made 4 attempts in a few days, by four different methods. None were successful. Eight of nine patients still in asylum, and seem free from the impulse. Several tnelancholics have an almost constant impulse to suicide, but without the will to commit it. Every attention that anxiety can suggest, is continually paid to such patients ; and prevention of so many attempts has been wholly due to vigilance and attention to directions of officers and attendants, without having recourse to any bodily restraints. From number of suicidal, all precautions in a large asylum liabje to be baffled ; and the severest restraints have been fully proved to_ be useless, as means of prevention. There are, however, several ptients in the asylum, in whom a long-continued course of kindness, and a life free from all avoidable discomforts, have seemed entirely to overcome the propensity. The chief' security against suicide would seem to be, even in the insane, removing all mental and physical uneasiness from them.
Report of Bloomingdale Asylum for 1844.-Dr. Earle- "Entire prevention of suicides in asylums seems impossible. A patient, being disposed to destroy himself, was placed, with his hands muffed, in a room from which every article of furniture had been removed. Succeeded in his object, by getting into the window, and throwing himself head foremost 459 upon the floor. A female, deprived of other means, strangled herself with her hair. Should every patient suicidally disposed be placed constantly under corporeal restraints asylums would be odious in appearance. Moreover, as above, this method not only affords no perfect security, but appears to increase number of attempts, by rendering the patient more strongly determined to execute his fatal purpose. At the Bethlehem Hospital, from 1750 to 1770, when every patient was under restraint, suicides were as 1 to 202 ; whereas, during the last twenty years (when restraints have. been but little used), proportion has been only 1 to 963."
In the report of the Frankford Asylum, dated March 1st, 1845, it is observed-The use of severe mechanical restraint was formerly deemed imperative in most cases of suicidal insanity ; but while it fostered uneasiness and discontent, it too often proved useless as a means of prevention. We have had several cases of this description under care, and have reason to believe that the systematic course of kindness and sympathy pursued towards them, and the watchful care to avoid everything calculated to produce mental distress or physical discomfort, have been eminently conducive to overcoming the propensity.
Dr. Kirkbride, after enumerating the restraints employed in the P. H. for the Insane, says- "In no single instance have the means referred to been employed on account of violence or suicidal propensities."
Dr. Brigham - So frequent in society are suicides, that it is surprising the friends of such persons do not secure them from this fatal consequence of disease. Whenever illness, or circumstances in a man's social, domestic, or other affairs, is followed by a striking change in character or conduct, there is reason for the apprehension of dangerous results. If he becomes reserved and melancholy, loses his affection for his family and his business, prefers to be alone, is undecided in his purposes, and restless and sleepless at night, there is indication that immediate action in his behalf may be necessary to his safety. He is fast approaching that point where reason is overwhelmed, or is exercised but to justify the act of self-destruction. Only security for such persons, the constant care of a judicious friend; or still better for their recovery, a residence in a well-directed asylum. Removed from objects of solicitude, new thoughts and feelings are excited; suitable medical treatment is applied ; and, in most cases, they are restored. The important truth to be inculcated is, that persons who have exhibited the above symptoms are insane ; and for their own personal safety, and that of others, need restraint and appropriate treatment. Case.-$AElig;t. 38 ; a farmer, in good circumstances, with small family. Poor health for some time from dyspepsia, but gradually became melancholy, lost his interests in business, his energy and decision of character, and passed much of his time in useless regrets about his unhappy condition. On admission to Utica Asylum, had been melancholy about 8 months. During that time, had twice attempted to commit suicide, and had frequently secreted knives with this object. At other times, thought he might procure death by killing another person ; but relinquished this, from idea of acquittal as insane being mentioned to him. Calm and rational in his general conversation, and at times cheerful and even mirthful. Again would give way to melancholy feelings, when idea of self-destruction was constantly before his mind. Conversed freely on his condition, but had no belief in possibility of his recovery. Gradually, by a combination of laxatives 460 and tonics, and remedies tending to restore the tone of the digestive organs-the use of the warm bath, and the change of circumstances attending removal from home-his health improved, gloom passed off, and in about two months returned home in usual health. In a letter soon after, says : "I feel it my duty to say to you, that no one disposed to suicide ought to be allowed to carry a silk handkerchief, for I know it is a great temptation to commit the act." Case.-Æt. 27 ; amiable, and a kind mother ; insane from continued religious excitement of Millerism. Thought she had committed the unpardonable sin, became very melancholy, restless, sleepless, manifested tendency to suicide, and endeavoured to cut her throat. At this time, conversed intelligently on many subjects ; but husband becoming alarmed at her condition, brought her to asylum, and she soon returned home perfectly well. Medicines used, extract of conium and carbonate of iron, with sulphate of morphine-in sufficient doses for sleep Morphine appeared, in fact, to cure her, as for a short time it was omitted, and she became worse. Case.-Æt. 34 ; single. Insane but a few days when admitted. A very worthy man, a Methodist. Had poor health for some time, became very nervous, sleepless, and finally insane, without any very obvious cause. Had refused to take food, with view of starving himself; and was otherwise inclined to suicide. Declared to his friends, when they left him, that although thus far prevented, he was resolved to destroy his life if possible. Warm bath several times, laxatives, as he was costive, and put on sulphate of morphine, to procure sleep. Soon began to improve, and left asylum in about three months entirely well. Prominent symptoms in this, as in the preceding cases, was extreme depression of the feelings, without manifest delusion of the intellect. Change of scene and associates, together with quieting remedies, the means of his restoration. Case.-Miss ----, æt. 40 ; had been a housekeeper, and by hard labour for several years, accumulated $150, which she sent to a sister in England. Sister did not receive it, and from supposition that it was lost, became deranged. At times appeared quite rational, and then would again relapse into an anxious, timid state of mind. Thought that murderers were pursuing her; that she was to be burned or cut in pieces ; to avoid which, she attempted to destroy her own life by cutting her throat. So strong this determination, that she afterwards repeatedly tore open the wound, and was received before it was healed. By great caution, prevented from injuring herself, and returned home in about four months entirely well. After she began to convalesce, money was returned from London. Warm bath, laxatives and tonics, compound tincture of bark, and wine, the only remedies used. Case.-Æt. 40 ; a farmer; married ; a very worthy, intelligent, and industrious man; became much disturbed in mind while attending a protracted religious meeting. For a short time quite happy, but soon became melancholy, and despaired of his salvation. Thus four or five months before entering asylum, much of the time melancholy, with no disposition to attend to business, or to labour, and said that all feeling and affection for his family and friends had left him. At times disposed to suicide ; and his friends becoming fearful in this respect, placed him in asylum. Appeared to be dyspeptic, and to have some biliary derangement, and was put upon a slight mercurial course for a short time, with laxatives and warm bathing. This was followed by the extract of conium and iron, with elixir proprietatis, and he soon began to recover, and left asylum in perfect health in about three months. 461 Case..-Miss ------, æt. 20 ;single. From much attention to religion during a revival, became nervous and sleepless. Complained of a heavy pressure on her head, and had disturbed dreams. Though accustomed to labour, ceased to be industrious, and to take any interest in her usual domestic duties. Also, lost flesh, became melancholy, said she should never be any better, that the effort of thinking distressed her head. Bled and blistered, and took cathartics at home, but without any relief. Her melancholy increasing, friends became apprehensive of her committing suicide, as she said she did not wish to live ; therefore brought to asylum. Soon began to amend, on the use of the warm bath, laxatives, and the extract of conium and iron, with morphine at night for sleep. In about two months, regained health and spirits, and soon after left asylum wholly well. Might adduce many more instances ; friends here took the alarm in time, and prevented dangerous results. Course pursued at the Utica, with those disposed to suicide, consists in constant watchfulness both night and day, the removal from the apartments of everything likely to tempt them, or to make them think of committing the act. (A rule being that the clothes of suicidal patients, and every dangerous article, are to be removed from their rooms at night.) No patient is allowed a razor, knives and forks are counted after each meal, and at night those believed strongly suicidal are either placed in rooms where there are no means by which they can accomplish their object, and the watchman is directed to give especial attention to them, or several are placed is one large room in which an attendant sleeps. We also exert ourselves to divert their minds by exercise, labour, or amusements, and to remove any bodily disorder that may exist.
By referring to the treatment of Dr. Brigham, given elsewhere in the present work, it will be found that his treatment of suicidal insanity is based upon the same general principles which he employs in other forms of the disease. And the same remark applies to the treatise of M. Falret on suicide, published in 1822, and that of Mr. Winslow in 1840. Both of these works are now before us, and we discover that the treatment recommended in them is pretty much that in vogue for insanity generally, at the time these works were published. Indeed, M. Falret observes, that the medicines most esteemed for efficacy in mental alienation, are those which succeed best in the suicidal tendency. It may be observed, that neither of these writers have much to say about restraints, though they strongly advise watchfulness. Mr. Winslow, however, somewhat inveighs against the outcry against restraint, saying many lives have been lost from want of proper security when desire had been exhibited.* (* For further remarks on restraints and also on schools, see Appendix.) We add a few remarks from each. Falret-Recommends exercise and manual labour ; games for the rich, and travelling. Although agrees with Pinel as to ill effects resulting sometimes from bleeding, yet thinks it necessary to avoid opposite extreme ; and to have recourse more frequently, though with reserve, to evacuations of blood ; principally in neighbourhood of affected organ. Warm baths, prolonged many hours, often successful. Cold water to be applied by a sponge or by linen, during time of bathing. These means should be seconded by cooling remedies internally, mild sedatives, and sometimes even mild purgatives. Vomits frequently useful in course of malady ; especially and incontestably useful in preventing relapses. External derivatives have appeared 462 to him in general to have good effects. Antispasmodics and narcotics, rarely useful in mental alienation, may, however, do good, if indicated especially. Tonics often indicated towards close of malady ; bark may produce happy effects in intermittent suicide. Mentions an instance, in which development of disease was arrested by leeches to the neck, and Seidlitz water, the individual being subject to attacks of it. In general, does not suit to reason with them ; long conversations are little calculated to cure. Physician should assume towards them the most kind and tender air. In cases of resolute propensity to starve, speaks of pressing behind lower jaw, and introducing the sound, and also secretly leaving food near them. Case.-A female of the Salpétrière on the 20th of December, 1815, kept the most complete silence, and refused all aliments. This obstinacy persisted until the 1st Jan., 1816, although all ordinary means had been employed. This day, Professor Pinel offered her a cornet de bonbons, and pressed her to accept this New Year's gift. By a sudden motion she seized it, and began to eat, covering her head under the bedclothes. From this moment, took nourishment without difficulty. Refusal of food often depends, especially in commencement of insanity, on disorder of stomach, and is transient. Not requisite here to use compulsory means ; an emetic frequently dissipates this condition. It is necessary to be cautious in suspecting all the insane who refuse aliment, to aim at suicide, for we may thus originate such ideas. Winslow --- Case.-A young lady, passionately fond of music, manifested an inclination to. kill herself; sent to a hospital, and carefully watched. Idea of suicide not removed, until allowed favourite instrument. the harp. When disposition to suicide is present, presence or not of cerebral congestion should be carefully ascertained. Loss of a small quantity of blood has frequently been known to remove propensity. If general bleeding inadmissible, cold shower bath often productive of much good. Case.-A young lady- ; suicidal disposition ; communicated particulars of malady to an eminent living physician, bitterly lamenting the unfortunate feeling. After various remedies, without much relief, cold shower bath every morning recommended. In 10 days, desire entirely removed, and never afterwards returned. If cerebral irritation present, bleeding injurious here friction on spine, antispasmodics, gentle aperients, and alteratives. A timely-administered purge has been known to dispel the desire. Disease of stomach and liver frequently incite to suicide ; hepatic affections notoriously affect. equilibrium of mind. Many a case exhibiting an inclination to suicide, has been cured by a few doses of blue pill. Irregularity of uterine organ may cause disposition : emmenagogues here. In some cases, a blister kept open in neighbourhood of head has effected much good. In others, issues been beneficial, particularly if cerebral congestion. Says it should be recollected by physicians, that patients have often disposition for one means of destruction, passing by others, and committing suicide long after inception of disease by the especial method. Sufficient attention not paid to precursory symptoms of disposition. In two-thirds of cases, act preceded by premonitory signs ; which, if attended to, prevent development of propensity.