ment, but of the most serious practical import in acute These are words of great weight and value. They cases; in which, amidst all the deceptious indications proceed from one who has lived in an asylum; has of superabundant strength, there is always a strong ten-watched the effects of different treatment in very nudency to death. A practitioner who is not content to merous cases from the hour of their admission to the have secured the patient by a strait waistcoat and end; and who knows all the details of the anxious, other means, because he has become "raving mad," but most instructive nights and days of those medical but who, having him carefully watched, is himself officers who, resident under the same roof with many among the watchers, will observe, in most of the cases lunatics, are zealous and vigilant, and depend more in which the invasion has been sudden and recent, that upon their own observation than on the vague reports amidst all the wild energy of the excited patient there of uneducated or slothful subordinates. I have alare intervals, often short, but perceptible to observa- ready remarked on the great amount of respectable tion, of sudden exhaustion; that the face becomes testimony to the same effect which is contained in the distressed in its expression, the loud voice ceases, the replies of the resident superintendents of our great skin becomes very moist, the face pale, and the patient, public asylums, metropolitan and provincial; and I although perhaps but for a few minutes, rests his weary need scarcely say how valueless, compared with it, head on his pillow. Fresh agitation succeeds; but must be even the most imposing denunciations of those these sinkings are important warnings; and when the who have never known such labours, and never propatient is forcibly restrained, either by the hands of fited by such observation. o B5 many persons, or by a strong strait-waistcoat, the repeated struggles will in all probability end fatally. I am encroaching too much on the pages of the Journal. But one reference more I must make, and with it I shall conclude. It is pleasant to cite the latest testimony of Mr. Gardiner Hill, who, after his experience in the Lincoln Asylum, has now for some years put the non-restraint system equally to the test in his private establishment of Eastgate House in that city. Mr.Gardiner Hill may have employed a few unguarded expressions in his celebrated lecture in 1838; but that lecture excited universal attention, in asylums. Many regretted, none more than myself, that Dr. Charlesworth's honoured name was too jealously regarded by Mr. Gardiner Hill's friends; that the venerable and eminent physician could not consistently grace the meeting to do Mr. Gardiner Hill honour; and that Mr. Gardiner Hill was not among those who inaugurated the statue of Dr. Charlesworth after his death. But when the memory of these, things has passed away, medical history will associate their names; and, doing justice to Dr. Charlesworth, will do no wrong to his most active pupil and most meritorious follower. I have now dwelt as long as seems necessary on the answers sent to the Commissioners in relation to the question of restraint or non-restraint; and if any remarks of mine have given pain to those mentioned, I can only say that such was far from my intention; and that I have said nothing except on the authority of those whose own words I have quoted. My intention has been to speak truly, and even freely, but still as to friends. It has been the peculiar happiness of my life to enjoy the friendship of most of the physicians of my time who were connected with asylums; and, as I have never had any object in view but the improvement of the condition of the insane in asylums, I have always given respectful consideration even to opinions most opposed to my own If I were convinced, even now, that mechanical restraints were more merciful to insane patients than non-restraint, I would abandon all my preconceptions. and confess my life to have been an error. But, seeing, after fifteen or sixteen years in which this controversy and this experiment have occupied the minds of mental physiologists, and of physicians especially devoted to mental disorders, that mechanical restraints are abolished in Mr. Gardiner Hill says: As I had occasion to re- nearly all the public asylums in England, Scotland, mark some years ago, does restraint prevent accidents? and Ireland, I have retired from public duties with a Experience proves the contrary. Does restraint pre- conviction that my limited labours have been directed vent, suicide? Experience proves the contrary. Can to an end that will surely be accomplished before a patient, insensible to the calls of nature, be restored many years more have passed away. As regards the to habits of cleanliness while under restraint ? He general impression left by a perusal of the various cannot. Does restraint contribute to the recovery of a evidence in the Eighth Report, cheering as it is, and patient? Experience proves the contrary. It ex-gratifying to all who feel earnestly on the principal asperates the sufferer, excites in him a spirit of revenge against the attendants, and thus is the fertile cause of accidents or injuries in an asylumsort peber o U "I further observe, non-restraint is practicable, for it has been well tested: it is humane, as all must acknowledge; it contributes to the comfort, the cheerfulness, and the recovery of the insane. It is also safe, for no serious or fatal accident has occurred in consequence of it. Constant surveillance has prevented this, It soothes the patient, keeps his angry and revengeful passions at rest, gives him the power to assist himself, and thereby prevents his falling into habits of hopeless filth and misery; and I venture to pronounce of it. that it is the system which must and will ultimately prevail in every asylum." subject of them, I shall say no more; adding merely the well-weighed testimony of the able and indefatigable Commissioners themselves. “As the general result which may fairly be deduced from a careful examination and review of the whole body of information thus collected, we feel ourselves fully warranted in stating that the disuse of instrumental restraint, as unnecessary and injurions to the patients, is practically the rule in nearly all the public institutions in the kingdom, and generally also in the best conducted private asylums, even those where the "non-restraint system," as an abstract principle, admitting of no deviation or exception, has not in terms been adopted. “For ourselves, we have long been convinced, and wants and complaints, and he sometimes pointed to his neck, the muscles of which no doubt suffered from the convulsive spasms of the epileptic attack. He was observed generally to be short breathed. have steadily acted on the conviction, that the possi-arms and by expression of countenance his various bility of dispensing, with mechanical coercion in the management of the insane is, in a vast majority of cases, a mere question of expense, and that its continued or systematic use in the asylums and licensed houses where it still prevails, must in a great measure be ascribed to their want of suitable space and accommodations, their defective structural arrangements, or their not possessing an adequate staff of properly qualified attendants, and frequently to all these causes combined. "Our matured views upon this subject will be best understood by stating the course we have followed in the discharge of our functions as Visitors. In that capacity we have made it a principle to discourage, to the utmost, the employment of instrumental restraint in any form. Wherever we have found it in use, our uniform practice has been to inquire minutely into the circumstances and reasons alleged for its necessity, and to insist on recourse being had to those various other means which experience has proved in other Houses to be effective substitutes for it. Qo97 "In numerous instances in which the employment of constant or frequent restraint was represented to be indispensable, the patient has upon our recommendation been removed to another establishment, where a different system is adopted; and the removal has frequently been found to be attended with the happiest effects." 1 It only remains for me to apologise to you, and to the members of our Association, for having said so much, perhaps to the exclusion of more valuable On the 11th of October, about 10 o'clock, a.m., under the influence of epileptic excitement, he suddenly became excessively violent and made a murderous attack upon one of the attendants with a chair; with some difficulty, and with the assistance of a second attendant, he was removed to his bed room. On my attention being called to him, I found him lying down in an uneasy posture with a cadaverous aspect; the respiration being laboured; the skin cold and clammy with distinct emphysematous, crepitation in the cellular structures about the thorax; and he was evidently moribund. Without making any painful examination I inferred that fracture of the ribs, with punctured lung and effusion of blood into the thorax, had occurred. In about one hour-and-a-half he died. A post-mortem examination was made twenty-two hours after death, and the following were the appearances, taken chiefly from Mr. Rose's description. There was well marked cadaveric rigidity and much static congestion of the integuments, and dark fluid blood oozed from the incised scalp. The surface of the brain was pale, the convolutions packed and flattened as if hypertrophied and compressed. Moderate opacity of arachnoid with no serous effusion. Brain substance of good consistence with gray matter dark coloured. Ventricles considerably enlarged and ocI cannot conclude without congratulating cupied with clear fluid. Soft commissure absent. the members on possessing a common ground of libe- | Brain weighed forty-four ounces. ral practical discussion, as well as so convenient a medium as the Journal offers for the communication of practical observations. Much benefit must be the result, to all of us. matter. Thorax. Old adhesion at apex of left lung, with some minute aborted tubercle in the cicatrix. Lungs of violet mottled colour, apparently healthy and crepitant. In raising the sternum and cartilages of the ribs, serous fluid escaped, apparently from the pericardium, which membrane was attached to the sternum, and on turning the bones fully back, the areolur tissue lining the sternum was seen to be distended with air, (from the roots of the lungs,) and the pericardium was found occupied by a thin watery blood, in which were suspended some long ropy masses of fibrinous bloodcoagulum. A large collapsed sac, the size of an orange, was found in the situation of, and attached by a reflection of the pericardium to the right auricle, and occupied by a spongy areolur tissue, in places consisting of wide broken up meshes, and in this tissue an innumerable congeries of minute hard fibro-cartiliginous and bony masses, from the size of a pin point to that of a pea. There was a fissure of an half-an-inch extent in the walls of this sac, from which rent, the blood had gradually flowed filling and distending the pericardium. It was probably supplied with blood from the coronary vein. There were very peculiar appearances in the anterior and posterior surfaces of the liver: small blood ecchymoses, with adjacent loss of tissue or broken tissue, resembling minute lacerations, and of various dates as to origin, some apparently recent, others of long existence, and similar to old fibrous cicatrices. There were small follicular ulcerations of the mucous mem brane of the stomach; the other abdominal organs On the Employment of Seclusion in the Treatment of were free from disease. Case 2. Rare Tumour of the Brain. General Paralysis T. H., æt. 26, a male patient, unmarried, by trade a shoemaker, was admitted December 6th, 1853, with marked symptoms of "general paralysis;" the intelligence limited, the articulation confused and stammering, the under lip being drawn to the left side in speaking, the gait very unsteady and tottering, surface pale, and general health much impaired. He had probably experienced epileptic convulsions. During the period of his residence, (15 months,) the general and spinal paralysis advanced progressively, and the patient was prone to fall suddenly, as if the spinal nervous energy had altogether failed, and in attempting to walk he would attempt to support himself with his arms. He was not, during this period, subject to epilepsy, nor was he prone to excitement; an amiable placid disposition being evinced. At the commencement of March, 1855, he suffered a mild febrile attack, which was relieved by akaline alteratives. On the 8th of the month he was wholly unable to leave his bed, and the respiration becoming accelerated, he was removed to the infirmary, and on the following day he died. An examination of the body was made twenty-two hours and a-half after death, and the following were the appearances, chiefly described by Mr. Rose, who conducted the examination. the Insane, by J. C. BUCKNILL, M.D., &C. The witty Brillat Savarin wrote: "Quand j'écris et parle de moi au singulier, cela suppose une confabulation avec la lecteur; il peut examiner, discuter, douter et même rire; mais quand je m'armedu redout. able Nouz je professe, il faut se soumettre." Physiologie du Gout. On this principle we descend from the editorial stool to reply to an article in the last number of the Psychological Journal, on the use of Seclusion in the treatment of insanity as practised in the Devon County Asylum; feeling that the subject has an individual reference to myself, and that it is one upon which the most free discussion is permissable, and even desirable. The writer of the article referred to has very fairly set my use of seclusion before his readers; and I might well be satisfied to leave my opinions and practice in this respect as by him stated, "did I not learn from other reviews, that they are liable to great misrepresentation. The use and the abuse of seclusion is, certainly, a subject of sufficient importance to justify a full enquiry into its characteristics. It is one in which the greatest diversity of opinion and practice appears to exist. Some SuperintendentsTM“repudiate seclusion altogether, and some plead specially in its favour." Among the latter, I am "prominent." I accept the responsibility, and plead justification; premising, however, that my views are not so fixed, as that their modification or abandonment, upon sufficient reason, will occasion either annoyance or regret. On the subject of seclusion I profess myself to be in that happy state of receptability for facts or arguments, which is the necessary condition of a man capable of conversion. Body well nourished, with well marked cadaveric rigidity. Calvarium thin and diaphanous, pitted by pacchionian bodies. Surface of brain much congested. Slight changes only in the arachnoid and very little effusion underneath. Brain substance of putty-like The general views I entertain at the present time, consistence. The ventricles greatly enlarged and and pending the production of arguments sufficiently filled with blood. Fine amylaceous bodies on floor of weighty to justify my changing them for others, are fourth ventricle. On turning up base of brain, there stated in the Eighth Report of the Commissioners in was observed a large mass of yellowish granular sub- Lunacy. They are, however, there stated in a brief stance, evidently composed of distinct cells, the mass official manner, shorn of all decoration and superfluous readily falling in masses distantly resembling masses illustration, as becomes the gravity of the document of of ants' eggs, the whole amounting to about ten drams which they form part. It would have been satisfactory in weight, and contained in a soft brittle cyst of white to me, and perfectly fair, to have treated the question squamous glistening appearance. A portion was for- of seclusion on its own merits, and without introducing warded by Mr. Hedger to Dr. Willis, of Guy's Hospital, that of restraint; since it shares the liability of being who, on placing it under the microscope, found it a called a substitute for restraint with every part of the tumour, “composed of fat and cholesterine, (cho-modern system of treatment. When restraint is not lesteatoma,) its physical characters like broken up suet, and the cyst compound of layers of a mother of pearl appearance. Under the microscope it exhibited a beautiful arrangement of polygonal cells, with faintly marked nuclei, and among them an immense quantity of cholesterine " in oblong tabular crystals. This tumour rested on the right half of the pons Varolii, and was in contact with the medulla oblongata, pushing the pons to the left side, and insinuating itself into the right fissura Sylvii, thus making a bed for itself in the side of the middle lobe and adjacent parts of the brain. Spinal cord in its upper dorsal portion, and in its inferior enlargement, much softened and disorganized, its tissue altogether having a dark muddy aspect. Colney Hatch, March 16, 1855.. employed, everything which is employed is liable to be called a substitute for it. Instead of the periodical bleedings and vomitings which were formerly used, aperients, hypnotics, and stimulants are now employed pro renatâ; and these are pointed at as substitutes for restraint. Instead of the torture of the cold douche, now happily obsolete in this country, moderate shower baths are used to cool hot heads or give tone to hysterical nerves, and they become, in their turn, the scape goats of restraint. Since all means of treatment are liable to this imputation, it is scarcely necessary to defend from it a single one of them. This, however, I may state in broad terms, that I do not consider that I use seclusion as a substitute for restraint; and, that were I to discontinue the use of seclusion, in consequence an order from the authorities, or for any other of differing enormously from each other, as they do, in the intensity and character of their symptoms. Having secluded the inmates of asylums from the excitements of society at large, on what principle can it be maintained that none of them can ever need, for a time, to be withdrawn from the excitements of that society to be found in the asylum itself, and that one exact measure of seclusion is the proper dose in all cases? In China, where all things are done by exact rule, or at least used to be so done before the rebellion, the government lays down the most stringent regulations for the practitioners of physic and surgery; the exact kind and quantity of medicines to be given in all cases of disease are a part of the law; and, in the event of any deviation therefrom, if the patient suffers loss of life or limb, the doctor is punished in conformity to the lex talionis, the legal hue and cry is raised, and he is duly hunted down in the crown court of Pekin. A man daring to treat diseases under such restrictions must be a man-darin indeed, and deserving of the most distinguished button. Perhaps, in some bye-gone cycle of ages, the Chinese suffered from an epidemic of pathys, not dissimilar to the one which disgraces and devastates this country at the present time, and the beneficient and paternal government thought the best way to impede the progress of quackery was, to put the infant feet of medicine into little shoes. But are we to imitate the Celestials, and suffer it to be laid down as a dogma, that in the disease which most of all presents striking diversities in its symptoms and its intensity, the remedy which is most necessary and most universally beneficial shall be administered to all cases in exactly the same amount? Any one who would seriously maintain that this is reasonable, ought to imitate these interesting Orientals in one other thing, and without delay to get his head shaved. But a truce to banter, which, after all, is but the Cossack ingredient of argument. reason, I have no doubt whatever, that I should be enabled to treat my patients without having recourse to the employment of mechanical restraint. The great majority of those for whom I order seclusion are patients for whom restraint would never even in the olden times have been thought requisite. Still, a small number of the patients who are now occasionally secluded would, in by gone years, have been placed in restraint; and conversely, some of those who would formerly have been restrained are now sometimes put into seclusion. But even in these cases the one could rarely be substituted for the other. Restraint was formerly used either for patients for whom seclusion would be inappropriate, or it was used in addition to seclusion. Let us, as Lord Eldon used to say, "clothe the case in circumstances," and suppose a patient in whom the destructive and combative propensities are in a high state of excitement. He rushes forward in headlong career, striking kicking, biting, pushing, striving, rending, tearing, smashing, crashing; of what use would it be to restrain the arms of such an individual, unless you also limit his powers of locomotion? Unless you tie him to a stake or a staple, or shut him up in a box where he cannot move, you must, in addition to the strait-waistcoat, put him into seclusion: and therefore, the use of seclusion alone in such a case, would not be a substitute for restraint alone, but a substitute for restraint and seclusion in combination. Again, suppose another case of violence, and of far more frequent occurrence than the above. Suppose a patient apt to strike, kick, or commit other acts of violence on the slightest provocation, but not under the dominion of the blind objectless excitement of the other. Such an one would formerly have been considered the most legitimate of all objects for the strait-waistcoat and the hobbles. But would he, in the present day, be frequently placed in seclusion? Certainly not, because sudden violence of this kind could only be prevented by seclusion, on the condition that it was constant, which it never is. There- The act of compelling a patient to reside in a special fore, seclusion is not used for violent patients as a sub-house or institution has been referred to as the first stitute for restraint alone, although it may sometimes step towards the imposition of mechanical restraint; be used as a substitute for restraint combined with seclusion. A comparison, therefore, made between the merits of seclusion and those of restraint, is destitute of the foundation which has been assumed for it, in their supposed power of mutual substitution. I may now, I think, fairly claim the right to state the grounds upon which I found my opinion of the value of seclusion in the treatment of the insane, not as a substitue for any other means, but for itself, and on account of its intrinsic merits. but this comparison is rickety and unsound. There is no resemblance between the locked gates and the boundaries of an asylum demesne, and ligatures applied to the arms and legs: while on the other hand, compulsory residence in such a locality is obviously the first step, the lowest grade of seclusion. In my reply to the Commissioners, I have strongly expressed my disapproval of seclusion used in the old fashioned manner, by harsh and negligent attendants; and I have been careful to specify that I advocate The general principle on which seclusion is employed its use only as a means in the treatment of inmay be thus stated. Assuming, that which will scarcely sanity, to be prescribed solely and strictly for that be denied, that seclusion from society at large is ne- purpose by the physician, at the same time that cessary for the protection and welfare of the insane; I admit the existence of a few exceptional cases, when this step has been taken, and large communities in which it is sometimes needful, for short periods, for have been secluded in asylums from the excitement of the protection and security of other patients, rather than the outer world, it cannot reasonably be maintained that for the medical treatment of the individual secluded. I one and the same amount of seclusion is all that is apprehend that this latter is the form of seclusion which requisite for every variety of case. The principle of is condemned by Dr. Diamond. I expressed my opinion seclusion being recognised in the very existence of that this form of seclusion "used as a means of coercion asylums; it is inconceivable upon what grounds it can ought to be reduced to a minimum." Dr. Diamond be denied, that more or less of seclusion may be has succeeded in doing without it altogether. Of needful in the treatment of various cases of insanity, this I am fully assured. I leave it to him to ex plain the favourable circumstances under which he are willing to pay a reasonable sum for it; and, as far has obtained this success, and whether it has been as my personal knowledge of the medical proprietors altogether unattended by disadvantages counteract- of private asylums extends, I believe there are few of ing or diminishing its value. The difference which them who would not, if they could, assign the use of exists between Dr. Diamond and myself, in the use of a separate sitting-room to any patient, on account of seclusion as a means of treatment, is not very wonder- the requirements of his malady, with at least as much ful, perhaps not very important. It is well known that readiness as they would do so on account of the physicians differ greatly in their modes of treating other solicitude and liberality of his friends. Yet the emdiseases; that one physician, for instance, treats pneu-ployment of a separate sitting-room fordan insane monia with calomel, another with tartar emetic, and patient must be considered as the use of seclusion. another with ptisans; and diversities in the treat-In public asylums each ward generally contains from ment of a disease, the pathology of which is far more obscure than that of pneumonia, need excite little surprise, even if they exist to the amount which is apparent between myself and Dr. Diamond. This diversity perhaps may be more apparent than real, and depend upon a wide difference in the employment of the term. The reviewer in the Psychological Journal moots the question:⠀⠀ “whether the seclusion practised by Dr. Buckmill, was wholly necessary?" I willingly reply in the negative; that it was by no means wholly necessary; that indeed only a small proportion of it was necessary. I only maintain that it was wholly beneficial, or at least that the whole amount of it was prescribed under the belief that it would be beneficial. 41 thirty to forty patients, and in many of the new asy- 9 What is the advantage of doing without that which you believe will do good? And that the temporary separation of an insane patient from the throng of his insane associates will frequently do good, I cannot myself, at the present time, entertain a doubt. Do not even the sane feel that there are times when it is good to be alone, and shall the repose of solitude never be permitted to the insane, every fibre of whose nervous system is in a state of intense irritability? Educated sane persons who, in adult life, have for the first time been condemned, by circumstances, to uninterrupted association with their fellow men, have frequently expressed the acute moral suffering they have experienced There is a state of mind frequents in insanity for from the impossibility of secluding themselves. School which we have no word but which the Germans teachers sentenced to have their lives gradually rubbed recognize and name angstgefuhl we may call it away like a slate pencil by constant educational friction; passionate anxiety. Patients suffering from this state and assistant surgeons, of literary and scientific ten-are intensely anxious, sometimes about one thing, dencies, condemned to dwell in the midshipman's berth sometimes about another, the object of anxiety often of a man-of-war, afford good examples of this truth. changes; it is generally some real existence: the husIt may be true that as a general rule for the insane, band, or the children, or the property, or the return perpetual association may be preferable to prolonged to home, or the bodily health, or the interests of the seclusion. But there can be little doubt, I think, that future state. It is usually accompanied by sleeplessness, unnecessary and prejudicial distress of mind is not weak digestion, and general want of tone of the nerunfrequently occasioned by the totals denial of retire-vous system. Occupation is undoubtedly the best mentam Aspatient, whose mental disease may have been produced by exaltede sensibility, is admitted into an asylum, and from that time che must eat, drink, sleep, wash, dress, pray, and do everything else under the eyes of a throng of fellow patients. Or if for a few hours he or she obtains the luxury of retirement, the fact must be noted in an official book, under penalty for neglect, and the treatment of that patient is liable to be considered as so far objectionable and unsuccessful.my. Private asylums have great advantages in the employment of seclusion over public ones. Many of them profess to provide separate sitting rooms for any patients whose friends may desire such a luxury, and moral means of treating such patients. But sometimes this anxiety is so intense that all attempts to occupy the patient are futile, and sometimes the state of physical health discourages the employment of this means. Upon such patients, according to my experience, the refusal of seclusion inflicts great suffering 18 while two or three days spent in bed, aided by the use of small doses of morphia, or of tincture of opium with sulphuric ether, rarely fail to afford great relief. A supplied by the mental state occasioned by intense fearfulness. This state, however, is seldom so demonstrative as that characterized by intense anxiety, and more frequently resembles the melancholie avec stupidité of the French, few cases of a similar character areo |