COMMENTARY V.

RESTRAINT.

RESTRAINT is apt to be confounded with coercion. Nothing can be more dissimilar. The one is an efficacious remedy, the other an aggravating torment. There is just as much difference between them as there is between morality and immorality.

He says,

Cælius Aurelianus, whose treatment of the insane. does as much credit to his heart as to his head, accuses the sect of medical philosophers designated methodists, with treating lunatics with great barbarity. they ordered them to be fed like wild beasts, covered with chains without any discretion, and to be whipped. It must be confessed, that the incomparable Celsus is open to this reproach; for he expressly orders for his third species of insanity, when a patient says or does any thing amiss, "fame, vinculis, plagis coërcendus est;" and, as if this were not harsh enough, terror, fear, and mental perturbation, are to be added.* It is to be suspected that the Celsean rather than the Aurelian plan prevailed even to our own age; and although happily fast exploding, yet that it is not quite extinct in every part of Europe. We find Thomas Willist advising, as the first indications in the curative process of mania, manacles, fetters, and stripes, to be equally as necessary as medical remedies. He further recommends that the food should be slender and not over delicate, clothing rough, bed hard, and

Lib. iii. cap. 18.

+ Omnia Opera.

treatment severe and rigid. Those labouring under obstinate madness were rarely submitted to curative means, but were placed in lunatic hospitals, that they might not do mischief to themselves or others. Prescriptions, deceptions, allurements, rewards, and punishments, were to be frequently varied.

Such is the picture presented of the treatment of those afflicted with mania by the "inventor of the nervous system," (as Friend calls Willis), and the most distinguished anatomist and physician of the seventeenth century. It is evident that this coercive system descended to Willis from the ancients, and had been adopted without reflection or trial of more humane means. Yet in melancholia his moral instructions become the most enlightened period. In that malady he recommends cheerful society, music, singing, dancing, hunting, fishing, pleasant exercise, sights, any light occupation, studying mathematics or chemistry, also travelling, changing the scene, and to abstract the mind by artificial means. In this mild course, however, he was equally an imitator of the ancients as in the severer.

His medical advice, too, considering his astrological and chemical pathology, was appropriate, with the exception of depleting too much, and periodically.

In the course of another century all the good points in Willis's practice appear to have been forgotten, while the objectionable ones were too faithfully retained.*

* We collect from Morgagni two facts that maniacs in Italy, a hundred and fifty years ago, were very inhumanly treated, and that he was less acquainted with the nature of the disease than his contemporary, Willis. Although Morgagni did not follow them, yet he could admire and commend the humane precepts of Valsalva in respect to the treatment of the insane. It is curious, but the former eminent Italian physician and pathologist suspected that persons could not be insane because they died of acute disorders during the rigors of winter!-Epist. Art. 4 and 5.

In the worst species of lunacy, or even of congenital idiocy, the mind is never so degraded and obtuse as to be incapable of distinguishing between kindness and rigour. Rewards and punishments, as with children, have each responsive effects.

The rotatory chair, the douche, a dark room, and personal confinement, are often used as means of repression. These, and other expedients, so far as mere restraint of violence or malignancy extends, are justifiable and imperative on many occasions. Deprivation of an accustomed indulgence, also, will often check the repetition of a wilful offence. But in employing repression, or constraint, or deprivations, we must always remember the constitution and condition of the patient, and act accordingly.

All these expedients are apt to be construed by the patient into punishments; and if enforced when there is no actual necessity, beget a dread and resistance to them when necessary as remedies, and thus counteract any benefit from them.

Except when the safety of the patient or others demands the immediate interposition of restraint, it should not be hastily adopted; nor should any measure that can be interpreted as a punishment be imposed but by the direction of the physician or superintendent. Most lunatics readily discriminate between the medical character and those in real authority, and the servant or keeper. The lunatic who respects the command of the former, spurns indignantly constraint from the latter.

Every thing pertaining to medicine is ever in extremes. From excessive coercion and neglect of the insane, the opposite extreme is to be dreaded, and thus wholesome restraint be withheld when really required.

The philanthropist alleges that too much coercion is generally used towards the insane. If coercion imply the practice which Celsus and Willis recommend, it ought

not to be endured; but if it mean no more than simple restraint, to prevent a patient from doing injury to himself or others, or to enable his attendants to control him, I maintain that such restraint is frequently called for, is generally highly useful, and, notwithstanding all that is alleged of lunatics being managed without, cannot altogether be dispensed with.

I have frequently been told, that no restraint is ever used, that is, a strait waistcoat, &c., in the Quakers' Retreat, at York. This is an error, which a perusal of Tuke's " Description," &c. will refute. That excellent man himself shewed me a patient under the strictest restraint I ever saw; but it was a case of most desperate propensity to suicide, and the confinement was no more than the safety of the patient, and the reputation of the asylum, required.

Those who are unacquainted with the extreme violence of maniacs, and the amazing muscular strength which they are capable of exerting, cannot conceive the contention, struggles, and personal injuries which the patient himself consequently suffers, when prejudice or a false humanity interferes and prevents a proper control being exercised. I have known the patient in these personal conflicts to sustain such serious bruises and lacerations, that, in more than one instance, mortification of the parts, and death, have followed.

To obviate the necessity of bodily restraint by the ordinary means, Dr. Autenrieth constructed a strong room, padded all round, in which he conceived that the most furious lunatic might be let loose, like a beast in a den, without doing harm to himself or any one.* The absurdity and uselessness of such a plan must be apparent

Those who wish to read Autenrieth's description of this room, and how to manage violent and obstinate lunatics, must consult the Clinical Annals of Tubingen, vol. i. part 1. 1807. But I fear the perusal will scarcely compensate the trouble.

Y Y

to the experienced, who know that some maniacs unrestrained, and so situated, would tear away all padding, and beat their brains out, or soon become beasts in reality.

Solitary confinement is certainly best for the turbulent and vicious. Irritation is thus avoided; and if the patient have any dangerous propensities, proper precautions must be taken.

As light is often a source of great irritation, so darkness is a powerful auxiliary in obtaining quiet, and preventing the renewal of raving. But we should as speedily as possible ascertain that darkness does not beget real terror. Many, besides the ignorant and superstitious, have an unaccountable dread of being left in the dark, and the worst consequences might follow their being so treated.

Shading the eyes, by merely placing a temporary bandage over them, has, while it was on, banished ocular illusions; but if by so doing it is found that its effect is to substitute one illusion for another, no advantage is gained.

I can easily credit that more restraint is often exercised than is absolutely necessary. It is the ready resource of idle keepers; and frequently the subterfuge of parsimony, both in public and private practice, to save the expense of adequate attendance.

Unnecessary restraint has often a very injurious effect, both morally and physically, on the insane. Some minds are of that free and elevated cast, that except alienation be complete, forced control begets a deep sense of degradation. The pride of birth, too, ill brooks control, and will not yield obedience where accustomed to command. A nobleman, or man of fortune, when insane, therefore, is always infinitely more difficult to manage than one of inferior degree.

With such persons we should be particularly circumspect that no control is attempted that can possibly be