3. Dr. Godding lays stress upon the doctrine, taught by Butler, that an insane person requires individual treatment, just as an individual sick from any other disease. In carrying out this idea, he believes that he has served the best interests of certain of his patients by mechanically restraining them in a proper apparatus at certain times.

The burden of my argument will be an endeavor to show that, of these three views and methods of practice that of Dr. Godding is the correct one. Between the views of Dr. Bryce and those of Dr. Pilgrim, neither of whom restrains patients, there is a great and vital difference. Both these gentlemen admit that patients might be placed under their care whose interests would be better served if they were mechanically restrained than if they were not so restrained. Dr. Bryce would not, but Dr. Pilgrim would restrain such patients, the former giving as the reason for his views that the few ought to suffer for the good of the many.

There is also a difference between the views and practice of Dr. Pilgrim and those of Dr. Godding. The first-named gentleman, as a matter of practice, has not used restraint; the last-named gentleman applies mechanical restraint to certain of his patients. Each of these gentlemen believes he is best serving the interests of each and of all his patients with regard to his course of procedure in this matter of mechanical restraint.

From this review I think it must be apparent to all that, although Dr. Pilgrim's practice is substantially in accord with that of Dr. Bryce, yet there is far more harmony in views as to the principles involved, between Dr. Pilgrim, who does not restrain, and Dr. Godding, who does restrain, than there is between Dr. Pilgrim and Dr. Bryce.

I am glad that Dr. Bryce has expressed himself so clearly. Certainly we know just where he stands. His views, I am glad to find, are shared by no one who has been heard to-night. I must say that I regard these views not only as extreme, but as containing in them great possibilities of danger; and I cannot help feeling that Dr. Bryce is moved to hold them largely for sentimental reasons. Evidently he takes a great pride in the showing his asylum has made in the past ten years. Even if an extraordinary number of difficult and trying cases were to be brought to him for treatment he would still carry out his non-restraint policy. Why? Because, I fear, “non-restraint" has become a watch-word or a dogma with him; because he would not care to have a blot on his unbroken record of "absolute non-restraint."

There is in London (and, if I mistake not, in Chicago also,) a so-called "temperance hospital," which was founded and is maintained by those who believe that alcohol should never be used as a therapeutic agent; that its use is always wrong; that it is an evil per se; that it should never be given to any person, sick or well. In short, they contend that any disease is better treated without than with alcohol. This hospital is, I believe, well conducted generally. Its annual report makes a seemingly excellent showing, yet, without knowing anything as to the details of its workings, I make bold to opine that certain of the patients treated within its walls would have been better treated had they received appropriate amounts of alcohol. It seems to me that this boycotting of a certain means of treatment by this temperance hospital which is sanctioned by the over-whelm

ing sanction of the medical profession, is quite analagous to Dr. Bryce's boycott of another measure of treatment in the hospital of which he has charge. In each of these hospitals a certain means of treatment which is sanctioned by an overwhelming consensus of opinion of the profession is proscribed, largely or wholly for sentimental reasons.

Aside from Dr. Bryce's views, the expressions of opinion which we have heard seem to me to be pretty evenly divided between those who share Dr. Pilgrim's views and those who share Dr. Godding's views. This difference I believe is not irreconcilable-for it is a difference of measure or amount only, and not of kind or principle. I am quite willing to subscribe to Dr. Chapin's view that it should be the endeavor of all physicians who have charge of insane patients to constantly endeavor to use less and less restraint, but never to accept "non-restraint" as a dogma.

It has often been said that restraint is a dangerous thing; that it is too powerful and dangerous a measure to be placed even in the hands of asylum superintendents-much less in the hands of assistant physicians, supervisors, or attendants; that there is constant danger of its over-use, i. e., abuse; that in spite of all that can be done to prevent, attendants will fall into the way of using it without orders from physicians; that restrained patients exert a pernicious moral influence upon other patients about them; that a restrained patient feels a terrible sense of degradation; that almost always other measures of treatment are better or at least just as good.

The asylum superintendent has power over his patients, down to the smallest details of their lives. He must necessarily come in comflict with their wishes or inclinations many times and in many respects. He must, at times, refuse one patient his jewelry; another, his shoes; another, linen table cloths and china plates: another, he keeps in-doors; another, he holds firmly on a mattress and forcibly injects poisonous drugs into his tissues or pumps fluid nourishment into his stomach against the patient's earnest protest; he may cause another to be bathed against his will or secluded in a room. Any or all of the above measures may be used by the superintendent or assistant physicians. They are all measures of restraint, if you please. Certainly they may be called means of treatment (or therapeutic measures). No one gainsays the propriety of their use in appropriate cases. But, mark you, one other measure of restraint, one other means of treatment-mechanical restraint-is wrong per se; it is such a dangerous thing in itself that it cannot be trusted in the hands of the superintendent, who presumably is strong enough and wise enough and humane enough to rightly use all these other measures of restraint or means of treatment I have mentioned and many others. Surely this is a reductio ad absurdum. The correct position seems to me to be this: That mechanical restraint is a measure of treatment, a remedy of peculiar value-one which, in certain cases, cannot be supplanted by any other from which an equally good result can be obtained. It is a dangerous remedy; the appliances for administering it should be locked up as safely as the hyoscine or chloral, and no one, other than the physician, should administer it any more than he should these other two dangerous remedies. Like all other powerful remedies, such as morphia, chloral, and alcohol, restraint has been too

much used and abused by some physicians. The abuse of opium in physicians' hands has wrought far greater harm than has the abuse of mechanical restraint. Yet, in spite of this fact, the use of opium should not fall into complete desuetude-no more should mechanical restraint.

In treating his patient, a physician who has charge of the insane ought to use therapeutic measures as a skilled mechanic uses special tools-use the right remedies for any given disease and be ever ready to withdraw any measures and add others, as may be called for by the varying manifestations of the disease. At one time it will be a duck dress; at another, 1-100 grain of hyoscene; at another, seclusion; at another, piano-music or dramatic entertainment; at another, restraint; at another, open-air walks; at another, farm work. What would be thought of the carpenter who had a confessedly useful and effective tool and yet would not trust himself to use it? Yet this is the position of those who hold to "absolute non-restraint" as a dogma.

It has been said that the presence of a restrained patient has a baneful effect upon the other patients about him. It must be admitted that there is some truth in this statement. Yet, after all, there is no very great force to this objection, for a restrained patient would, of course, not be in the same ward with mild patients or convalescents, but would naturally be placed in a ward containing the violent or the chronic insane by whom the niceties are little or not at all appreciated; and in these wards other sights may be witnessed (epileptic fits, e. g.), which would have quite as much or more deleterious effect upon the patients in the ward than the sight of a restrained patient.

Now, as to the sense of degradation which restrained patients themselves experience. In some patients (e. g. dements), this feeling is nil. In others, where the feeling is experienced, likely the patients do not rebel against restraint as a personal indignity nearly so much as being compelled to receive forced feedings or hypodermic injections.

Very often, perhaps generally, it is better to seclude a patient than to restrain him. But in some cases seclusion cannot be used in lieu of restraint, if the best interests of the patient would be served. will mention a few illustrative hypothetical cases. A chronic maniac suffers from a fracture of the humerus, and will not permit the surgical dressing to remain on his arm. A paranoic, under delusive promptings, makes persistent efforts to pull out his rectum or castrate himself; an epileptic, while in the post-epileptic state constantly picks his arms, producing horrible raw surfaces; a violently suicidal patient makes not only persistent attempts to take his life, but also constantly tries to injure or mutilate himself; a patient suffering from acute delirious mania (typhomania), would use up his little remaining strength, all of which is precious to him, in order to carry him through the crisis, by unceasing muscular activity. In such cases as these I think Drs. Meredith, Chapin, Hill, Trowbridge, or Godding would use mechanical restraint. In such cases I, myself, have used it.

One matter more, and I have done. Dr. Blumer (the successor of the honored Gray, of Utica, who used restraint as needed), says that he does not restrain patients, and immediately adds, with almost a "therefore,' that this is a closed question; that my letter is simply useless verbiage;

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that what I have said has been said very, very often. These are indeed strange views, especially coming from the source whence they do. I think Dr. Blumer's views will find no responsive echo among the members of the Medico-Legal Society, composed of men and women who recognize the great principal that no question is a closed question upon which men honestly differ.. I am quite as well aware as Dr. Blumer that the question has been many, many times discussed. I also know-perhaps better than he-that it will be many times yet discussed before it will, in truth, become a closed question." If I am not endowed with but little eloquence as compared with Dr. Blumer, I feel sure that my honest attempt to express my opinion upon this subject will at least be respected, while Dr. Blumer's attempt to dispose of me and of my views with a sneer will be held in just and merited contempt, and, I trust, their author charitably pitied. This would be true, even if I were in a hopeless minority. But it is all the more true when you consider the large number and the great eminence of the men who hold the views for which I have contended in this discussion. These views, it was found, were held by nearly every man who attended the large meeting of British alienists held in Edinburgh so recently as 1899. The men whose views are essentially the same as my own are too numerous to mention, nor could I call to mind a tenth of them just at this time. But among them are the great Yellowlees, Savage, Godding, Trowbridge, Chapin, Meredith, Hughes, Prince, Curwen, Hill, Talcott, Lyon, Parker, Moncure, and Dewey.

In closing I wish to thank Mr. Clark Bell for opening this discussion on so broad a scale, and to express my firm belief that distinct good will come from it. It will be better known hereafter than it ever was before, that the overwhelming consensus of opinion of alienists in the United States is that inflexible adhesion to the rule of absolute non-restraint as a dogma is a short-sighted, illogical, and unscientific policy-one which ought not and cannot be maintained.

Dr. ALEX. ROBERTSON, M. D., F. F. P. P. and S., physician to the Royal Infirmary and City Parochial Asylum at Glasgow, to whom I lately wrote for his views upon the subject, but who had not seen the prior discussion, responded as follows:

I have pleasure in complying with your invitation to express my views on the use of mechanical restraint in the treatment of the insane. You mention that there has been a correspondence on the subject in the MEDICOLEGAL JOURNAL, and that you had posted a copy of the JOURNAL containing it to my address. I regret, however, that it has not come to hand, and I therefore write without knowledge of what has been stated by those gentlemen who have already taken part in the discussion.

I more willingly accede to your wish from the fact that in the year 1868 I visited a large number of asylums in the United States and Canada, and then became acquainted both with their merits and demerits. The "notes of my observations were published in the English Journal of Mental

Science for April, 1869, and I added to them as an appendix a short abstract of the late Dr Willard's report on the condition of the insane poor in the workhouses of the State of New York. At that time their care and treatment in all respects, in most cases, were very bad in these establishments. Since my visit of that year I know that great improvements have been made in the provisions for that unfortunate section of the community, both by the transference of many of them to new and well appointed asylums, and also by the adoption of more kindly and humane methods of treatment.

Among the reforms which have brought the asylums of America to the front rank of such institutions throughout the world-at least in my opinion—is the almost complete disuse in many of them of the instruments of restraint. However, I gather from your letter that in some they are still largely used, and that those medical superintendents who employ them fortify their position by quoting the opinions recorded in favor of re-traint by certain British physicians, notably Dr. Savage in England and Dr. Yellowlees in Scotland.

It was with a mixed feeling of surprise and regret that about three years ago I learned that these gentlemen, physicians in the land of Tuke and Connolly, advocated so retrograde a measure and carried it out in their practice. Their action has, I believe, been prejudicial to the best interests of the insane in this country, and, as they might have anticipated, has so far, but I trust only temporarily, checked the movement for the further amelioration of their condition in the New World.

My own acquaintance with the fact that mechanical restraint was somewhat freely used in some of the asylums of this country was derived from a report of a meeting of Scotch asylum Superintendents in November 1888, which was published in the Journal of Mental Science. Dr. Yellowlees, of the Glasgow Royal Asylum, took the leading part in the discussion and spoke strongly in favor of the use of mechanical restraint, defining four classes of patients to whom he considered its application was proper and legitimate. Though there was a general theoretical concurrence in these views by other speakers, I was glad to find that some of the more experienced in their practice really exceeded only by a very little the sanction of Connolly, the great apostle of the non-restraint system. Thus Dr. Clouston, who has charge of the most important of our Scotch Asylums, stated that he used restraint only in surgical cases and where the suicidal disposition is exceptionally pronounced. I was not present at the meeting, but on perusing the report of it I felt that the practice commended by Dr. Yellowlees more especially, was so opposed to my own, and was so calculated to affect injuriously the treatment of the insane that it was incumbent on me to record the result of my long experience and the conclusions at which I had arrived. Accordingly I drew out a statement in detail, which was published in the Journal of Mental Science for April, 1889.

In the exposition of my position on the question I cannot do better than give a short résumé of that paper. It appeared to me that in estimating the value of mechanical restraint the most exact and convincing test was that of results. Therefore, in the form of question and answer, I submitted all my experience as physician-superintendent of an asylum extending over