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he was noisy and dirty at night, but harmless; that he was reported ill to the governor on the 18th ult.; that he knocked his bedstead about at night; and that, on one occasion, it was taken out of his room on this account by an attendant.

Mr. Firth said,—I am the visiting medical officer to this asylum. I have occasionally seen Sizer, but my attention was not called to him till last Friday, when I found him to be labouring under a fracture of the ribs; on further examination I discovered a fracture of the breast-bone, between the second and third ribs; I considered him then in a very precarious condition. The patient was in such a state of mind that I could not make out how the injuries came. I saw him again on Sunday, at which time I considered his condition as hopeless. I saw no more of him when living. I have this day made a post-mortem examination, the result of which leads me to think he died from the injury on the chest, which must have been done with great violence; on the right side four ribs were broken, and four on the left. There were marks of inflammation on both sides of the chest; on the right a large quantity of matter was found. These were quite sufficient to account for his death. I think these injuries could not have occurred more than ten or twelve days ago. I think he might have been able to get into bed as usual after he received this injury; but I consider he could not make quick movements. There are no external bruises. I think, if Sizer received the injury on Tuesday, the appearances I discovered to-day might appear; but I think he received the injury be

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made to me, that Sizer was not able to get out of bed. I went to him, and discovered a tumour on his chest. I discovered nothing more at that time. I visited him afterwards: he remained much the same. I attended him again the next morning: I then found his ribs were badly broken. I attended him afterwards, as often as was necessary. I was never able to discover in what way he received the injury. He died this morning, and I have assisted Mr. Firth in making the post-mortem examination. We found four ribs fractured on each side, and considerable inflammation, which was quite sufficient to account for death. I could get no information from Sizer how these injuries occurred. I think if Sizer had the bedstead up end ways, and it fell on his chest, it might have caused the injuries we discovered. I think Sizer could not have received the injury more than eight or ten days. I considered him in great danger when I saw him on Thursday morning. I also discovered the breast-bone was broken.

The coroner having briefly summed up, the jury, after a short deliberation, returned the following verdict: "That the said William Sizer died from the effect of a serious injury he received, but how or by what means the same was inflicted, there is no evidence to prove; and the jury consider there is some mystery in the case."

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No. 10.

Published by Authority of

The Association of Medical Officers of Asylums and
Hospitals for the Ensane.

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M.D., Medical Superintendent of the Warwick County
Asyl um

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ON PROLONGED FASTING, with reference to a Particular Class
of Insane Persons, by JOHN MANLEY, M.D., Medical
Superintendent of the Hants County Asylum, late As-
sistant Medical Officer of the Devon County Asylum
HILL, ESQ, of Eastgate House, Lincoln

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Second Notice of the EIGHTH REPORT OF THE COM-tients and attendants, in consequence of the adoption
of the "expensive" system of non-restraint.
The next in order of the communications published

I have been reminded that in my first notice, when I spoke of Dr. Davey, Dr. Nesbitt, and Dr. Hitchman, by the Commissioners is from Mr. Wilkes, of the as having respectively introduced the Non-Restraint Stafford County Lunatic Asylum, who has so conSystem into the asylums of Colney Hatch, Northamp-ducted that fine institution during the last thirteen ton, and Derby, it would appear that I overlooked years as to make it a model worthy of general imita.. the fact of that system having been adopted at North- tion. As Mr. Wilkes is a gentleman of great profesampton by Dr. Nesbitt's predecessor, the late Dr. Thomas Prichard. Although my meaning was merely that the three physicians named had each left Hanwell convinced of the practicability and safety of the nonrestraint system, and had steadily maintained it on their removal; I ought, perhaps, to have added, that at Northampton it had already been acted upon, and zealously and ably defended in the successive annual reports of the superintending physician. One or two occasional instances of the abandonment of the principle deprived this early and laudable example of full effect.

sional attainment and experience, as well as now long familiar with all the management of a large asylum; and as all who know him, know that with an excellent judgment he possesses the most candid mind and the sincerest love of truth, all his observations are valuable. He says:

"Previous to the year 1841, when I was appointed to the office I now hold in this institution, mechanical restraint was part of the system of treatment habitually employed, and its disuse was looked upon as absurd and chimerical. Although the registers certainly show a gradual diminution of restraint for some previous years, its amount at the time referred to was consider

"The means of restraint employed were the leather

Of the sixteen county asylums alluded to in my former paper, the only one in which the use of me-able, and probably more than was recorded. chanical restraints is advocated or employed is that of Bedfordshire. At the time when I proceed with a muff and wriststraps, iron handcuffs, long leather notice of the views expressed by the superintendents of other asylums, I have the satisfaction of believing that the Bedford asylum no longer forms an exception to the rest; Mr. Denne having now commenced his residence there. From his reports we may expect hereafter to learn whether or not more bedding is destroyed, and more injuries are inflicted on the pa

sleeves, hobbles for the legs, the restraint chair, and various devices, specially adapted to the peculiar propensities and habits of the patients. Many of these were employed both by day and night, and, in addition, many of the patients were confined to the bedsteads by means of straps passing through iron loops.

"The evil of this system was not simply confined to

tinuing restraints in the chronic cases, and that the recent and acute cases always proved the most embarassing; and consequently that the large institutions crowded with chronic cases hardly afford fair opportunities for testing the practice. This must be admitted: but the embarrassment attending the manage

the coercion of the patients, but the same principle pervaded the whole establishment, and the high win dows partly or wholly protected by iron guards and wirework, the numerous staples in the walls of the galleries and rooms for confining patients to their seats, and the strongly guarded fireplaces, gave a gloomy prison-like aspect to the interior of the build-ment of recent and acute cases was, as Mr. Wilkes no ing, which was still perpetuated externally by the cheerless, high-walled airing courts, mostly destitute of either trees or flowers. Above all, it was evident that the system adopted had a natural and inevitable tendency to demoralise, if not to brutalize, the attendants; and, perhaps, one of the not least important results of the disuse of restraint is, the marked effect it has had upon the feelings and conduct of the attendants themselves.

doubt remembers, greatly increased when chronic patients were to be seen in restraint in most of the wards of an asylum. Mr. Wilkes is also inclined to admit some apparently exceptional cases in which even in a large asylum the temporary employment of restraint would be both necessary and justifiable. Two cases, admitted to be extreme, are adduced as illustrative of this; one, in which food was refused, under the impression that it was poisoned, and the patient struggled so violently that no food could be adminstered to him; and another, in which no dress

"In an old asylum, and with deep-rooted prejudices to contend against, many difficulties and much anxiety necessarily accompany the first efforts to abolish re-ings could be kept on the patient's head. On these straint. Many patients, who had been habitually in restraint for years, were at once set at liberty; in others, the process was gradual; but, ultimately, all instruments of restraint were collected together out of the different galleries; restraint chairs were brokeu up; and, at the same time, windows were unblocked, guards removed, airing courts planted and improved; and, in a variety of ways, more humanising influences were brought into operation.

cases it may be remarked, that the temporary confinement of a patient's hands during the introduction of the tube of the stomach pump into the œsophagus may be as necessary as in the case of a surgical operation. Continued refusal of food is however so rare in any well conducted asylum that resort to the stomach pump is, I believe, seldom necessary. I have witnessed horrible instances of its misemployment; and have known patient persuasion succeed in some of the most unpromising cases. I have seen it used recklessly and needlessly; and have known years pass without being once called upon to sanction recourse to it. Apparently the necessity for it is more frequent in patients of a class far above pauperism; and no doubt life has often been preserved by its timely use. As regards keeping dressings on the head or elsewhere, the secured covers or cases of ticken with small locks are generally efficacious; but if they do not prove so, the confinement of the hands comes within the surgical category, and is of course allowable. Every superintendent should look upon such a means, however temporary, as the last he wishes to have recourse

"The effect of this upon the old inmates of the asylum was decidedly beneficial. One patient especially, who had been for some time wearing the muff and hobbles, and appeared to be falling into a state of fatuity, rapidly improved upon being set at liberty, and ultimately recovered. The excitement of the patients generally was decidedly diminished; they were less noisy at night, and, though many had become inveterately dirty in their habits, a gradual improvement took place also in this respect. With greater opportunities of doing mischief, less absolutely occurred; and now, without a window in the asylum in any way protected, there is probably less breakage of glass than there formerly was. The experience of to. more than twelve years, during which upwards of 1,300 cases have been admitted, only tends to strengthen and confirm the opinion that, as a general rule, restraint is unnecessary and injurious in the treatment of the insane.

"Not only has no accident or injury occurred which could have been attributed to the disuse of restraint, but amongst the large proportion of suicidal cases which have, from time to time, been admitted since 1841, only one suicide has taken place, and that was in 1842. This is much below the average of former years; and I only mention the fact to prove that they were not rendered more frequent by the disuse of restraint, being fully aware that these unfortunate occurrences will baffle every vigilance aud precaution, and happen in spite of any system."

This testimony is of the highest importance, and certainly conclusive as to the superiority of the new system over the old. But Mr. Wilkes's evident anxiety not to overstate anything has led him to make additional observations, which must not be passed over. He says that no great difficulty was met with in discon

When the attempts were first made to dispense with mechanical restraints the difficulties which they were said to prevent were met by a great variety of new contrivances and adaptations, and generally with complete success. Slovenly and unfaithful officers and attendants neglected these means or despised them; allowed all kinds of accidents to happen, and zealously recorded them. But these accidents happened no more when the total and unqualified abolition of restraints became the rule. Every kind of exceptional case then became rare or almost unknown.

Dr. Kirkman, of the Suffolk Asylum, says that all instruments of mechanical restraint were destroyed in that asylum more than twenty years ago, and that they have neither been used nor required since that time. If so, the Suffolk Asylum seems to have been prior to that of Lincoln in this movement; which has certainly been overlooked. Dr. Kirkman's reply to the Commissioners is very brief; but his reports for several years past have contained interesting details as to the employment and general management of his patients. His sentiments as to restraint are, however, not always

stated with the positiveness required to give them been remedial; or, as an example, unproductive of force. bad effects of various kinds. Dr. Parsey says, that "no protecting guards have been found necessary for windows."

Dr. Thurnam, of the Wilts County Asylum, so well

Mr. Snape, of the Surrey asylum (male side), leads us to conclude that he never employs mechanical restraint, which he says he considers quite superfluous in a properly constructed asylum. He considers tem-known for his valuable work on the Statistics of Inporary seclusion to be absolutely necessary in some cases of maniacal excitement, and justly observes that a mild persuasive manner, constant superintendence institution." One exception is, however, mentioned,


and care, and a never-failing attention to the clothing, food, personal cleanliness, occupation and amusements of the patients, are but so many different ways from which the best results are expected to arise."

Dr. Diamond, who is the superintendent of the female division of the same asylum, expresses himself very strongly, fully concurring in Mr. Gardiner Hill's opinion, that in a suitable building, with a sufficient number of suitable attendants, restraint is never necessary, never justifiable, and always injurious, in all cases of lunacy whatever: adding his belief, "that any person who would now use personal restraint or coercion is unfit to have the superintendence of an asylum." During the past five years, more than 800 female patients have been admitted into the Surrey asylum, and Dr. Diamond has usually about 520 under his immediate charge: so that his opportunities of testing the facility of dispensing with restraints have been very great. He thinks that cases are even very rare in which seclusion is requisite and beneficial, and appears successfully to substitute employment; he does not appear to think that there are cases in which temporary seclusion is required, and where tranquillity and the absence of all causes of cerebral excitement are the remedial objects proposed; and consequently, in which employment could scarcely be resorted to with propriety. It is impossible to avoid a doubt as to Dr. Diamond's proper estimation of the value of quiet seclusion, or of the use of padded rooms, which last he pronounces "obsolete." The number of attendants employed in the Surrey asylum does not exceed one to twenty-one patients. With such a limited staff, it must be difficult to ensure to all classes of the patients all the care which both Dr. Diamond and Mr. Snape appear ardently to desire.

I have read the report of Dr. Parsey of the Warwick county asylum with peculiar interest; having had the honour of being consulted on the plan of the building, together with Mr. Gaskell. Dr. Parsey says, "Mechanical restraint has never yet been used in this asylum, nor are there any special means for applying it. My opinion, drawn from personal observation, is, that its application may always be done without." Still, Dr. Parsey thinks there are rare cases in which, "if used at all, it should be in the mildest possible form:" an admission really difficult to understand. Dr. Parsey thinks it might have been useful in one case of 258 cases which have been under treatment. I occasionally hear such statements in other asylums into which no instruments of restraint have been introduced; but when the nature of such exceptional cases is described, all that is proved is, that restraint would have met some temporary inconvenience, or would have saved somebody some temporary trouble. It is never pretended that its imposition would have

sanity, says, "Personal restraint is never resorted to, and there is literally no instrument of coercion in the

in which an epileptic patient, having broken his leg, required, during his maniacal accessions, to be restrained from interfering with the surgical apparatus. "In cases of great violence," Dr. Thurnam adds, "where efforts to check or soothe the excitement of the patient are unsuccessful, temporary seclusion in a sleeping room is prescribed; or, for those requiring it, in a room the walls and floors of which are padded, in order to prevent bodily injury." The means of preventing patients from undressing themselves, or destroying clothes and bedding, as well as meeting various other difficulties, are explained in a manner shewing that Dr. Thurnam is practically acquainted with the various exigencies of a lunatic asylum by night and by day. As respects suicidal cases, in which mechanical restraint used to be considered as indispensable, he says, "there is no doubt the propensity is generally aggravated by the adoption of personal restraint; and many instances in the experience of asylums might be quoted, where suicide has been committed under the use of such means, and even by the aid of the instruments of coercion themselves." But Dr. Thurnam still thinks there are possible cases in which it is justifiable to have recourse to personal restraint. These are, first, surgical cases, about which there is no controversy; and secondly, cases of "perverted instinct," where a patient would "gnaw his flesh," &c. I only once saw a case of this kind in fourteen years observation of 1000 patients; and that occurred when restraints were used, and when the craving appetite of patients in some forms of mental malady led to this and other revolting practices, apparently the results of hunger, and permitted by the gross neglect of the attendants.

My notice of the COUNTY asylums, from which answers had been sent to the Commissioners, began with the unpromising instance of Bedford. It must end with the more lamentable example of the asylum for the North and East Ridings of Yorkshire. It is the opinion of Mr. Samuel Hill, the Medical Superintendent, that, "in order to treat the most violent lunatics with the greatest mercy, as well as safety, personal restraint is now and then necessary. To dispense with such auxiliary and remedial measures, would be to incur risk, prolong the paroxysm, and probably reduce the patient to a state of danger, if not of helpless exhaustion. A spencer, made of thick linen, to button or lace behind, with sleeves ending in pockets (which latter are sewn to the lower and front part of the body of the spencer), answers very generally, and is in use in this asylum for both sexes, when all other means have failed to tranquillise dangerous, destructive, or suicidal patients."

Twenty years since, such a passage as this would' have occasioned no surprise; but that such galling

exertions of petty tyranny. I cannot but partake of the apprehension expressed in the Editorial remarks on this subject in No. 6 of the Asylum Journal, that, in the North and East Ridings Asylum, the duties of the physician are rather lost sight of amidst the duties of the steward and farm-bailiff. The non-medical officers of asylums are too generally anxious to convert them into mere workhouses, and the Committee of an asylum has always some active members upon it, who look on the medical officers as inconvenient, if not superfluous. We have only the Commissioners in Lunacy to look to for the protection of the lunatic in these circumstances. If they, deluded by the perpetual cry of "work,” abandon those who cannot work to tying of hands or the cheap guardianship of the spencer, all their other labours will be in vain, and


restraint, including every evil of the strait-waistcoat, patient is ill-tempered, or whenever the attendant is personal irritation, unavoidable uncleanliness, and ill-tempered, is really very unnecessary and unjustimental degradation, should not only be used in a fiable cruelty, and must always lead to numerous other county asylum in these days, but spoken of with satisfaction by a medical superintendent ;-that fifteen years after the total abolition of restraint from the largest asylums in this country, this ancient restraint should be resorted to in every difficulty; to prevent suicide, which it cannot prevent; to control destructive tendencies, which it cannot remove; and, above all, to tranquillise the dangerous, is a matter of astonishment and sorrow. In these appliances, on these ancient principles, Mr. Samuel Hill's asylum stands nearly alone among county asylums. But Mr. Hill has, in other respects, such sensible ideas relative to the treatment of the insane, that even his views of the necessity for restraints demand respectful consideration. It is to be observed, that mechanical restraint is recommend ed by him as a means of the "greatest mercy," as well as "safety." Mr. Hill should explain the terrible alter-even their eloquent reports a tinkling cymbal." natives he evidently has in his mind; the dangers Two great evils incidental to the competition thus avoided ; the cruelties inevitable in his asylum but encouraged in the heads of different departments of for the use of restraints; and why dangers averted, labour call for especial vigilance: one is the forced and cruelties unknown in Middlesex, and Derbyshire, employment of those unfit for continuous bodily exerand Wiltshire, should be so certain of occurrence in a tion; and another, the unjust detention in asylums of Yorkshire asylum, as to justify the buttoning and patients whose mental malady has left them, but who lacing up of men and women like bales of insensible are too useful to be conveniently parted with. My goods. It would also be desirable to know what all recollections assure me that such evils are not hypothose "other means" are, on the failure of which, in│thetical; but, under the mere workhouse system, imthe North and East Ridings Asylum, the use of the minent, and scarcely avoidable. linen spencer "answers" so very generally. Never having had an opportunity of visiting the North and East Ridings Asylum, it would be presumptuous in me to suggest a probable explanation of this unhappy anomaly; but, unless all my experience of asylums deceives me, I do not doubt that the reasons for using restraint depend on something defective in the constitution of the asylum itself. Whether the explanation is to be found in a deficient number of attendants, or in their character and qualifications, or on undue attention being demanded in connection with the labour of the patients, to the overlooking of other attentions more important-so that those who are able and willing to work are chiefly regarded, and the few The first case mentioned is merely a surgical case, troublesome ones who will not work are merely in- and calls for no comment. The second is that of an vested with the spencer-can only be determined by aged woman, melancholic, and who refused to lie those whose duty it is to inspect the asylum. But down; and, as there was swelling of the extremities, that there is something wrong cannot be questioned. the recumbent position was enforced by restraint. The tendency, moreover, in any asylum in which a Sleep was obtained, with partial improvement, food spencer or strait-waistcoat is employed, to extend was taken voluntarily, which had not been the case restraints to every case of even trifling difficulty, is before; and the patient lived a fortnight afterward. curiously enough shewn in a Report made at the Dr. Huxley thinks restraint should have been emNorth and East Ridings Asylum in March last, by | ployed earlier, and deplores the disfavour attached to two of the Commissioners in Lunacy; who mention it. I think I have known nmmerous cases of this that a patient's hands were tied behind her by means kind in which the difficulties were overcome without of a handkerchief, because, "under paroxysms of ex-restraints being applied. A blister applied behind the citement," she was "apt to seize and shake her fellow-neck, a tepid shower bath, not too violent, sedative patients very violently." For such frivolous reasons, medicines, variously prepared food, and very patient some years ago, scores of patients were put into restraints, in large asylums, every week. It is not creditable to any asylum, when such trifling difficulties cannot be obviated by different methods. To place even this kind of restraint in the power of any attendant, to be used at any time, or whenever a

Although the Commissioners' Eighth Report con tains no reply to their enquiries from the Kent asylum, the Annual Reports of that institution inform us that there also mechanical restraints are habitually employed. The high character of the asylum, and of its superintendent, Dr. Huxley, whose late communication in the Asylum Journal was characterized by great good sense and very careful observation, give importance to this additional example of an adherence to the old ways. 1

Dr. Huxley's cases must speak for themselves. Six are mentioned in which during the past year restraints have been used.

persuasion, have certainly often succeeded at Hanwell; but there may be exceptional cases, and gentle compulsion may become necessary in some of them. Yet the great danger of these exceptions growing into a rule must not be forgotten.

To the imposition of gloves in the case in which a

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