Mechanical Restraint In the Management or Treatment of the Insane
112 Art. VIII.?. :Author: F. Murchison, M.A., JI.B. Edin. Assistant Physician, Cricliton Royal Institution, Dumfries, N.B.
Road to Scotch Branch Psychological Association, Edinburgh, November 14, 1875. A medical superintendent related to me the following anecdote : A determined suicide was brought to him by her father, a bluff country practitioner, who said: ” I place this patient in your hands. She will cut her throat, hang, drown, or destroy herself, if she can. I care nothing about your restraint or non-restraint, but I shall require her from you safe and sound, whether sane or not.”
The extreme opinions at one time prevalent in Britain, adverse to restraint, have never obtained the same countenance or favour in France, America, &c., where mechanical contrivances still form a part of treatment. Even in this country the conflict between the dictates of professional duty and humanitarian sentimentalism is less keen than it was some years ago. The bugbear dread of public criticism has faded in cases where life or limb is known to be in danger; but would it now be prudent and justifiable to employ such coercion, where the danger is merely suspected, inferred, or verbally threatened by the patient ?
The following cases may illustrate this difficulty. They have all occurred since the reign of the non-restraint creed became absolute, and are all derived either from my own practice, or the experience of a medical friend in a Public Asylum.
1. M. C., a healthy robust maniac, had been permitted to retire to bed, on the recommendation of the Medical Superin- tendent, that rest and horizontality should be encouraged. He was almost immediately afterwards called to see her, in conse- quence of her having wounded herself; and found her in bed,, laughing and joking, with a large deep wound extending from about the middle of Poupart’s ligament for about four or five inches towards the umbilicus. A triangular flap was folded, laterally towards the ileum, the lower edge of the omentum loaded with fat, and several folds of the intestine were exposed. She had detached a pair of scissors from the waistband of the attendant, and inflicted the injury with this instrument. There was inconsiderable haemorrhage, as neither the epigastric nor any large artery had been divided. The patient recovered com- pletely from the effects of the wound, and from her mental derangement.
2. A clergyman, labouring under suicidal mania and the delusion that he was suffering from a syphilitic sore-throat, was requested by the attendant to say grace at a t able where ten other persons were standing around. The attendant had (as is common in Scotland) shut his eyes during the benediction, and had laid his carving-knife for a moment on the table. The clergyman, seeing the opportunity, seized the knife and inflicted a frightful gash on his throat, dividing the trachea and the surrounding tissues, without, however, severing the large blood- vessels. After being sustained for some time by artificial alimentation, he died.
3. A robust mischievous imbecile, known to be disposed to injure his skin, but not suspected of eroticism, retired to bed in good health. Pie was found in the morning with a frightful mutilation of the penis, scrotum, and testes. He had inflicted the wounds with a sharp portion of the chamber- utensil, which he had broken. The haemorrhage was excessive ; but he seemed to enjoy the consternation of the attendants, and made a joke of the whole affair. Castration was complete, but the eunuch lived for many years after this event. 4. A religious melancholic, with a suspected but not well- marked tendency to self-mutilation or suicide, slept in a dormi- tory with other patients in M Asylum. It was discovered one morning that lie had, in the night, quietly gouged out his right eye, and left it hanging by a few injured tissues outside its socket. The eyeball was removed, and the patient made an excellent recovery.
5. M.E.B., an attenuated religious melancholic, and a most determined suicide, with marks of injuries inflicted with a view to self-destruction, very recently admitted into the G Asylum, was given in charge of a trustworthy attendant, who was instructed to watch her carefully. An hour and a half after her admission, I was hurriedly sent for, to attend to an injury which she had inflicted on her right eye. I found the organ removed from its place, and lying on the cheek, bleeding, and totally disorganised and collapsed. After some little hesitation as to the propriety of severing the lacerated tissues that still suspended the alleged offending and now sufficiently punished eyeball, I returned it to its place, where it lias ever since remained, sightless, and much reduced in size ; and if not ” a thing of beauty,” at any rate a credit to the vis medicatrix naturcc, or to a weak solution of carbolic acid, with which it and the surrounding injured structures were daily dressed. A consideration of these cases, which a more extended ex- perience than mine could doubtless easily supplement, entitles me to question the propriety of the total abolition of mechanical restraint, and of the means which have, from humane but I think erroneous considerations, been substituted; and emboldens me to advocate its use for securing the safety of such patients as are bent upon self-mutilation or destruction. Extremes are known to be hurtful in every line of life, but, strange to say, the utmost amount of liberty is, if not already granted, strenuously advocated for our asylums; and the cry, emanating chiefly from those who are ignorant of the difficulties to be encountered in the discipline and management of the insane, against locked doors, strait-waistcoats, bolts, bars, in short, prohibitory means of any kind, even if the patient goes to the extent of tearing himself or his neighbours to shreds, is now almost universal, although patients themselves sometimes petition for restraint. Indeed, in some places, where accidents are not unfrequent, and suicides not quite unknown, all similar provisions are ignored. To those who, by experience, understand the many and great difficulties of managing a class of people with intractable and wantonly destructive propensities, this method of ” non-restraint” treatment appears inadequate to cope with a morbid determination to injure or kill. Notwithstanding the general appeal for forbearance, freedom, and do-nothingism, it will ever remain evident, that in cases apparently requiring restraint, a moderate and harm- less use of mechanical contrivances to secure that end will be less hurtful to the patient, and more likely to guide him in safety through a war of mental elements, than a living force that may become too lax or too harsh in its exercise. It is next to impossible to watch some patients with sufficient assiduity to prevent their carrying out their dangerous designs upon themselves or others. Their intention is so fixed, their determination so strong, and their vigilance for ” opportunities ” so sleepless, that whenever an attendant’s eye or hand is removed from them, they injure or destroy whatever may excite their anger. I knew a lady so determined upon self- destruction, and so totally regardless of all moral suasion, that she tried to swallow pins, nails, and such other hurtful articles, and to set fire to her clothes ; nor could she resist the tempta- tion of asking me for a knife to cut her throat. A moderate use of innocent restraint saved her life, as doubtless its absence would have led to new attempts at destruction. A second lady, to my knowledge, set herself on fire in a house where she had all the freedom that the enthusiasts for ” non-restraint” would have heartily admired, and had burned her body so frightfully that she lived only for a few hours. Numerous examples could be adduced to show that death and other serious evils have frequently resulted from the non-adoption of gentle and humane mechanical con- trivances to prevent a patient from executing his wild designs.
Even the ” camisole ” and similar instrumental expedients have failed to secure safety, a result demonstrating at once the des- perate character of the cases to he dealt with, how dangerous the struggles which must ensue when manual restraint is trusted to, and how ineffectual must often prove even the humanely directed exertions of a trustworthy attendant. When such means are resorted to in private houses, difficulties must be greatly multiplied. Unenlightened henevolence may pro- bably blame me when I suggest a linen inanimate strait- waistcoat as being preferable to the muscular force of two or three strong, rough, and certainly not passionless attend- ants, in cases similar to those cited, or when a patient, surgically treated, is restless and refractory; when for an ex- cited and dangerous lunatic I prefer a padded room to one in which he can injure himself or break my head. Liberty to a person not entirely delirious or demented is, no doubt, dear, and should never be denied when experience has proved its advantages; but when it tends to the patient’s or his neigh- bour’s injury or destruction, it assuredly becomes a duty to curtail it to the extent and in the manner that can be pioved to be the most desirable.
It is my firm conviction that the absence of mechanical restraint is the cause of the great majority of accidents, and of many of the suicides that take place in asylums; and that at the present day a diminution of the freedom of the patient, by restraint or seclusion, would minimise, and per- haps abolish, these undesirable items in the statistics of asylums. Coercion from the very beginning, in suicidal cases of grave import, would doubtless save life, and much anxiety to those in charge. In such cases it should, I think, be unhesitatingly adopted, and continued as long as the morbid state of the patient necessitates such a measure. The cases requiring its continued adoption form only a small per- centage of mental ailments, and they usually improve under judicious treatment. The great object is to save the patient from his own excitement and violence; and any course that secures this, in a harmless way, seems justifiable and right, however much it may be against the dictates of those whose sympathies will not allow them to see any virtue in it. Enter- taining the opinions I express, I should not hesitate to lecom- mend mechanical restraint in cases of acute mania, when the patient is not merely incited to destroy all around, but may exhaust his strength, engender disease, and thus precipitate that fatuity which so frequently follows such paroxysms. In addition, it might conveniently be resorted to, as an instru- ment of harmless reproof, in cases where ” temper and original wickedness, plus insanity, disregard moral discipline, and defy constituted authority. u 2
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.