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MECHANICAL RESTRAINT IN THE TREATMENT OF THE INSANE
W. L. Worcester
Am J Psychiatry 1892;48:476-489.
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Since the foregoing was written, a report of the discussions, in the Scotch meeting of the Medico-Psychological Society, of a paper by Dr. Carlyle Johnson on "Time Use of Sulphonal," has come under my notice, a few extracts from which may, it seems to me, be instructive in this connection. Time observations were made in the Morningside Asylum, conducted by Dr. Clouston, who is one of the most eminent and uncompromising advocates of absolute non-restraint. It appears from the paper that it is customary, at that institution, to give this drug, not only as a hypnotic, but for its sedative effect during the day, for considerable periods of time. Dr. Johnson gives time following account of the effects of its continuous administration:

"In every case where continuous doses were given for periods of more than a few days' duration certain motor symptoms became apparent. These ranged from mild feelings of languor and fatigue to a condition of complete muscular collapse in which time patient could neither walk nor stand erect, nor help himself in any way."

In the discussion, Dr. Clouston said that "There were very few medicines that they would allow even an intelligent nurse to give to patients without special medical orders for each dose. Now, they could allow an intelligent nurse to give twenty-five grains of sulphonal to a patient as time case required."

Dr. Clark, agreeing substantially with Dr. Johnson as to the beneficial effects of sulphonal, said: * * * "It would be difficult to say whether sulphonal shortened the life of paralytic patients. At almost any cost, however, they must save broken bones and obviate other risks."

I do not know Dr. Clark's position on the subject of restraint, and it may not be fair to assume that he would not consider it a possible alternative to a measure that he suspects to be capable of shortening the lives of his patients.

"Dr. Robertson gave an account of a case at Morningside Asylum, to which Dr. Clouston had referred. He said that it was impossible to describe how very troublesome and dangerous that woman was. She was homicidal and very suicidal. These attacks came on quite suddenly, and it was necessary to bring her very quickly under the influence of sulphonal of sulphonal. They sometimes gave sixty grains in the morning and sixty in the evening."

Now, I consider sulphonal a very valuable drug, but I have never pushed it to such an extent as to produce any more noticeable after-effects than a slight drowsiness on the following day. I will not say that it may not be justifiable to produce with it such symptoms as Dr. Johnson describes, but I have no hesitation in saying that, so far as my own feelings are concerned, I would much rather be restrained with wristlets or muff than be reduced to such a condition of imbecility and helplessness. If a drug that is capable of producing such effects is placed in the hands of attendants, with permission to use it according to their own judgment, I cannot see there is less danger than in the case of mechanical restraint that they may sometimes use it to save themselves trouble, without benefit to their patients.

The impression has got abroad, in some quarters, that the insane are so much more reasonable than the sane, that nothing but an appeal to their higher and nobler feelings is necessary for their successful management.

"There was an old man who said " How Shall I flee from this horrible cow? I will sit on the stile And continue to smile, Which will soften the heart of this cow.'"

The truth is, as every one who has had much experience with the insane knows, that there are cases in which, if mechanical restraint is not used, it is necessary to oppose some other equally insuperable obstacle to time insane impulses of our patients. Granting the truth of all that has been said about the liability to abuse of restraints, there is nothing that can be substituted for them which is not liable to abuse. I confess that I cannot quite comprehend the mental attitude of a physician who does not believe that he can control his attendants in the use of a measure that can only be applied with his knowledge and under his direction, and yet has no misgivings as to their discretion and trustworthiness in the use of other means of coercion, the exercise of which must be mostly left to their judgment, and carried on with only occasional supervision.—W. L. W.

State Lunatic Asylum, Little Rock, Arkansas

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