“CHEMICAL RESTRAINT” IN THE MAN- 
AGEMENT OF THE INSANE 
BY 
H. B. WILBUR, M.D. 
[Reprinted from the Archives of Medicine, December, 1881] 
NEW YORK ' 
G. P. PUTNAM’S SONS 
27 & 29 West 23D Street 
1881 “CHEMICAL RESTRAINT” IN THE MANAGE- 
MENT OF THE INSANE. 
An impression prevails among the medical profession in the 
United States that in the British asylums for the insane the neces- 
sity for restraint by mechanical appliances, such as camisoles, muffs, 
straps, crib-bedsteads, etc., is obviated by the free use of stupe- 
fying drugs. The prevalence of the opinion is easily accounted 
for. In the United States the subject of the management of the 
insane, as well as the special study of insanity, has been left by 
the profession, in the main, to the superintendents of insane asy- 
lums. So when these gentlemen, in the annual meetings of their 
association and in their annual reports, have persistently asserted 
this substitution of “ chemical ” for mechanical restraint in British 
asylums, the medical profession have generally accepted the state- 
ment as a fact. 
It was a borrowed assertion at the start, but by long-continued 
iteration it has'become an article of faith with the superintendents of 
American asylums. It had its origin among the British opponents 
of “non-restraint” more than thirty years ago. These men, like 
their American brethren of the present day, believed that the only 
recourse for dealing with madmen was some form of restraint. 
With the disuse of mechanical restraint they could conceive of no 
alternative but resort to prostrating remedies, or of a superior 
physical force at the hands of muscular attendants. In a letter 
received from one of the oldest of our superintendents, under date 
Reprinted from the Archives of Medicine, Vol. vi, No. 3, December, 1881. 2 
H. B. WILBUR. 
of September 12th, in defending the use of restraining apparatus, 
he says : 
“ I believe that in many cases such means of control and care 
are alike more effective and humane than the opposite practice of 
attempting to control reckless, excited, and violent cases by the 
superior strength of one or several attendants, as the practice of 
some is, or of ‘ laying them out ’ by the use of strong drugs, as is 
said to be the resort of others.” 
Dr. Gray, the editor of the American Journal of Insanity, on 
his return from a late visit to Europe, informed his brethren of 
the New York State Medical Society that some of the English 
superintendents “used practically chemical or medicinal restraint, 
which, in the end, would prove more injurious than mechanical 
restraint.” 
As to the former alternative, it may be said that while one can 
hardly pass through any of our state asylums without seeing the 
various forms of mechanical restraint more or less used, yet I may 
say, after a quite extensive personal observation of the refractory 
wards of British asylums, that I have never happened to witness 
any patients struggling in the hands of attendants. And I also 
observed that the female patients were controlled by female at- 
tendants not of conspicuously muscular proportions. As to the 
other alternative, the statistics hereafter to be presented will throw 
some light. 
Happily the experience of the British alienists has not confirmed 
these and other theoretical objections to the principle of non-re- 
straint. For in the presidential address of Dr. D. Hack Tuke 
before the British Medico-Psychological Association, in August 
last, I find the following sentence : “ No one will call in question 
the statement, as a historical fact, that the commissioners of 
lunacy and the medical superintendents of asylums in this coun- 
try are, with few exceptions, in favor of ‘non-restraint.’ ” 
In the matter of professional communion the Straits of Dover 
is as wide as the Atlantic, and so we find that some of the French 
alienists, unaffected by the triumph of non-restraint in Great 
Britain, are urging the same objections to the doctrine common MANAGEMENT OF THE INSANE. 
3 
in this country, and especially the allegation that chemical re- 
straint is the substitute for mechanical restraint in the British 
asylums. 
It becomes, therefore, a question of some importance to deter- 
mine whether the statement is true. It occurred to me that I 
could, by some comparative statistics from the asylum registers of 
Great Britain and the United States, settle the question to the 
satisfaction of the medical profession in this country. 
It is hardly necessary to say that there is a legitimate use for 
chloral and the narcotic remedies in the treatment of insanity as 
in other diseases. Some of the more commonly manifested symp- 
toms of the disease obviously indicate their use. Nevertheless 
here, as in the domain of medicine generally, drugs are not to be 
given when other remedial agencies will avail. But I think that it 
will appear from the accompanying statistics that in some asylums 
soporifics and sedatives are administered so continuously and in 
view of such indications as to warrant the term “ chemical re- 
straint.” 
That chloral is given empirically no one can doubt. It is also 
evident that pathological considerations do not determine, al- 
ways if ever, in the employment of hyoscyamia. At all events, 
we find one superintendent of an asylum who has used it largely, 
internally and by hypodermic injection, commending its use in 
acute mania, chronic paroxysmal mania, melancholia, and paresis, 
besides finding it useful in hysteria and chorea. As he puts it, 
“ The cases of mania in which it was administered may be 
divided into those who are maniacal, raving, noisy, incoherent, 
and opposing necessary care, and destructive of clothing ; second, 
such as have occasional periods of maniacal excitement ; and 
third, such as are uneasy, talkative, restless, and sleepless. The 
cases of melancholia may be divided into three classes ; such as 
had periods of frenzy, sometimes endangering life ; such as per- 
sistently and determinately resisted care and food under delu- 
sions ; and such as would wear themselves out from restlessness 
and constant motion.” 
The modus operandi of a remedy is supposed to determine its 4 
H. B. WILBUR. 
application, and he therefore suggests the following principle for 
the guidance of others : “ I am inclined to think that it produces 
an effect upon the cerebral nerve tissue of a beneficent charac- 
ter, quieting the irritable and excited brain quite as markedly as 
preparations of opium, in their influence on nerve tissue, will re- 
lieve pain.” 
“ Dr. Kempster, of the Wisconsin Asylum,” according to the 
statement of Dr. Squibb, who is engaged in the manufacture of 
hyoscyamia, “ has used this remedy quite largely, and considers it 
as a most admirable substitute for physical restraint. He says 
that with the proper use of hyoscyamia he thinks it may never 
be necessary to use the straight-jacket or other means of re- 
straint, and that the maniacal patients who cannot be controlled 
by its use he believes are very rare. He uses it hypoder- 
.mically.” 
In this case it is not an improper use of language to speak of 
it as chemical restraint. 
Some fifteen months after the introduction of chloral at the 
Utica Asylum Dr. Andrews described the mode of its use. 
“ The whole amount used is 90 lbs., which has been prescribed 
in 370 cases, as follows : 
FORM OF DISEASE. MEN. WOMEN. TOTAL. 
Mania ... 69 119 188 
Melancholia . . 30 59 89 
Dementia 18 50 68 
Paresis ... 12 1 13 
Epilepsy . . 2 2 4 
Employes ... 3 5 8 
134 236 370” 
It is further related that 15 of the number took it nightly, on 
an average, for some 200 successive days. The average dose em- 
ployed 30 grains. It can hardly be questioned, then, that in 
that particular institution this remedy was used in a somewhat 
routine way. 
Some five years since a fatal accident happened in a Western MANAGEMENT OF THE INSANE. 
5 
asylum. An investigation followed by the Board of State Chari- 
ties. In their report to the Governor occurs the following para- 
graph : “ The use of chloral hydrate to produce sleep at night, 
common, as we are informed, in the majority of hospitals, is car- 
ried to a considerable extent at this asylum. The night-list of 
medicines administered shows that about sixty patients (ten per 
cent.), on an average, take chloral every night, the average dose 
being from 30 to 35 grains, in combination with whiskey, opium, 
or fluid extract of hyoscyamus/’ 
It may be well at the outset to say that it would be easy to 
furnish competent general statements from British authori- 
ties in denial of the assertion that “ chemical restraint ” is the 
substitute for mechanical restraint in British asylums. One will 
suffice. 
The Lunacy Commissioners of Scotland remark in their annual 
report for 1877 : “Mechanical restraints and seclusion are prob- 
ably as little used in the treatment of the insane in the asylums 
of Scotland as in those of any part of the world.” And again, 
“ Stimulants appear to be decreasingly consumed in Scotch asy- 
lums. * * * Even more than in the case of stimulants, the 
use of narcotics appears to be diminishing. In some large asy- 
lums sleeping draughts are rarely given. Increasing attention, 
however, is bestowed on all those arrangements which tend to 
secure sound and refreshing natural sleep.” 
But to come to comparative statistics, it may be remarked, then, 
first, in a general way, that the cost of medical supplies in British 
asylums for the insane is very much less than in those of the 
United States. The average annual cost, per patient, for such sup- 
plies in Great Britain is about one dollar. (See Lunacy Reports 
for 1880.) The cost in American asylums, from two to six times as 
much. 
Secondly, to attain more precise results, the following circular 
was sent to the superintendents of some 20 British asylums : 
“ Dear Sir : 
“ It is alleged in this country by the opponents of the doctrine 
of ‘ Non-Restraint ’ that in the British asylums, where restraining 6 
H. B. WILBUR. 
apparatus is least used, resort is had in large degree to the use 
of the so-called chemical restraints. I have prepared the accom- 
panying circular of questions, to be sent to a dozen or more Brit- 
ish asylums, where restraint is least used, that I may learn the ex- 
tent to which sedatives and narcotics are used as substitutes for 
mechanical restraint. 
“ Will you kindly fill out the enclosed blank and return it to 
me.” 
“ Name of Institution .... Number of Patients . . . . 
Males .... Females .... 
“Average number of patients to whom chloral is administered 
each day .... 
“Average number of patients to whom hyoscyamia or other nar- 
cotic is administered to allay excitement .... 
“ Number of instances of seclusion for a month past .... 
“Number of occasions for the use of mechanical restraint for a 
month past .... 
“ Remarks.” 
I am now able to give the returns from 15 British asylums. I 
have also, by correspondence, obtained similar statistics from 
some American institutions. These are embodied in the following 
tables. 
With reference to the first two tables, namely, those relating to 
British and Canadian asylums, it should be remarked that the 
statistics were taken from the registers of the several asylums for 
the month preceding the receipt of my request. 
It is hardly necessary to say that these statistics relate to insti- 
tutions that are recognized as among the best in Great Britain, 
that the medical superintendents who are in charge of them are 
conspicuous for ability and success, and, further, that the ratio 
of recoveries in these asylums will compare favorably with that 
of similar institutions in the United States. 
To these tables should be appended some of the remarks that 
have accompanied the returned circulars. 
Thus, the patient restrained at West Riding was so restrained 
for surgical reasons. Patients there, especially epileptics, are 
frequently kept in bed, for excitement, the door not being fastened. 
Only one patient has been restrained since 1877. MANAGEMENT OF THE INSANE. 
TABLE NO. I. BRITISH ASYLUMS. 
Name. 
No. 
Number of Pa- 
tients. 
Monthly occasions 
of restraint. 
Monthly number 
restrained. 
Monthly occasions 
of seclusion. 
Monthly number 
secluded. 
Average number to 
whom chloral is 
daily administered. 
Average number to whom 
hyoscyamia or other nar- 
cotic is administered to 
allay excitement. 
West Riding 
Asylum . . . 
I 
1,410 
I 
I 
2 
2 
31 
38 
County Asylum, 
Chester . . . 
Hull Borough 
2 
533 
none 
none 
none 
none 
none 
4 
Morphia used occasionally 
Asylum . . . 
3 
163 
u 
41 
1 
2 
Montrose Royal 
Lunatic Asylum 
4 
4S5 
a 
a 
19 
1 
3 
I 
Brookwood Asy- 
lum, Surrey . 
5 
1,050 
it 
a 
none 
none 
10 
I 
East Riding Asy- 
lum .... 
6 
286 
u 
a 
» 
“ 
i 
none 
Hanwell Asylum 
7 
750 
a 
a 
ti 
tt 
none 
“ 
Burntwood Asy- 
lum, Litchfield 
8 
600 
a 
ti 
>4 
tt 
44 
tt 
Royal Edinbur’h 
Asylum. . . . 
9 
832 
u 
a 
20 
1 
44 
North Riding 
Asylum . . . 
IO 
546 
2 
1 
3 
4. 
7 
9 
Royal Asylum, 
Gartnavel . . 
II 
483 
none 
none 
none 
none 
6 
14 
Richmond Dist. 
Asylum, Dublin 
12 
1,013 
4. 
<4 
3 
1 
II 
2 
Dr. W. C. Hill’s, 
Norfolk County 
13 
620 
it 
it 
none 
none 
none 
20 
Kent Co. Asy- 
lum 
14 
1,200 
>4 
it 
ti 
4. 
it 
none 
Woodilee (near 
Glasgow . . . 
15 
448 
“ 
it 
it 
» 
10,419 
3 
2 
47 
4 
7°i 
91 
TABLE NO 2. CANADIAN ASYLUMS. 
Name. 
No. 
Number of Patients. 
Monthly occasions 
of restraint 
Number restrained. 
Monthly occasions 
of seclusion. 
Number secluded. 
Average number to 
whom chloral is 
daily administered. 
Average number to whom 
hyoscyamia or other nar- 
cotic is administered to 
allay excitement. 
Nova Scotia Hos- 
pital for Insane 
London, Ont., 
Asy’m for I’sane 
Toronto, Ont., 
Asy’m for I’sane 
Hamilton, Ont., 
Asy’m for I’sane 
Kingston, Ont., 
Asy’m for I’sane 
1 
2 
3 
4 
5 
380 
851 
673 
537 
43° 
117 
61 
' 10 
6 
4 
XI 
8 
3 
17 
13 
4 
4 
13 
5 
9 
2 
none 
u 
2 
5 
occa- 
sional 
none 
3 
5 
occasional 
2,871 
198 8 
II. B. WILBUR. 
TABLE NO 3.—ASYLUMS IN UNITED STATES.1 
Name of Asylum. 
No. 
Number of pati’nts. 
Monthly occasions 
of restraint. 
Number restrained. 
Monthly occasions 
of seclusion. 
Number secluded. 
Average number to 
whom chloral is 
administered daily. 
Average number to 
whom hyoscyamia 
or other narcotic is 
administered to al- 
lay excitement. 
Northern Hospital, Wisconsin 
I 
54i 
48 
— 
I 
I 
24 
8 daily 
Cook County Asylum, Illinois 
2 
440 
480 
- 
60 
- 
33 
- 
Kings County Asylum, N. Y. 
3 
868 
none 
none 
- 
8 daily 
5i 
6 a month 
Worcester Hospital, Mass. 
4 
594 
69 
- 
71 
- 
22 
no record 
Retreat for Insane, Hartford, 
Conn 
5 
121 
2 
2 
4 
i daily 
Willard Asylum, New York . 
6 
1,727 
— 
6 daily 
7 
27 
10 u 
Athens Asylum, Ohio 
7 
586 
none 
none 
Il6 
58 
20 
none 
Longview Asylum, Ohio 
8 
661 
8 
- 
II 
- 
8 
1 daily 
Dayton Asylum, Ohio 
9 
591 
118 
6 daily 
309 
- 
29 
- 
Northern Asylum, Elgin, 111. 
IO 
526 
483 
- 
25 
- 
26 
5 daily 
Insane Criminal Asy’um, N. Y. 
II 
J3i 
I 
I 
5 
- 
15 
5 a month 
Middletown, Connecticut 
12 
582 
l6 
3 
43 
15 
21 
1 daily 
Minn. Hospital for Insane 
13 
53° 
67 
43 
24 
17 
6 
2 
Southern Asylum, Anna, 111. . 
14 
486 
35° 
- 
129 
- 
12 
3 
Eastern Illinois Asylum . 
15 
175 
12 
22 
- 
- 
3 
Homoeopathic, New York 
l6 
244 
5 
3 daily 
- 
- 
none 
none 
Central Hospital, Illinois 
17 
641 
483 
32 
2 
- 
73 
48 
Western Asylum, Kentucky . 
18 
473 
16 
- 
12 
- 
9 
8 
Hudson River Hospital . 
*9 
250 
- 
6 
none 
- 
29 
12 
State Insane Hospital, Wis. 
20 
548 
2,547 
- 
13 
- 
4 
IO 
Danvers, Massachusetts . 
21 
643 
138 
- 
161 
- 
5 
3 
Northampton, Massachusetts . 
22 
47i 
25 
IO 
26 
- 
none 
none 
S. Lunatic Hospital, Harris- 
burg, Pa. .... 
23 
353 
3 
21 
18 
3 
Taunton Lunatic Hospital 
24 
574 
14 
— 
6 
— 
20 
N. J. S. Lunatic Asylum . 
25 
586 
180 
- 
150 
- 
n8 
none 
Newburg, Ohio 
26 
625 
24 
- 
38 
- 
47 
21 
(see postscript) 
i3<967 
1,254 
561 
139 
1 This table is incomplete in some of its columns because the reports upon 
which it is based were imperfect. MANAGEMENT OF THE INSANE. 
9 
Dr. Major also remarks : “ I believe it to be a great mistake to 
consider that with us non-restraint depends in any degree upon 
our use of sedatives. Were sedatives taken from us entirely I am 
sure we should not use more than we do now. Here, also, I have 
cases who have most destructive tendencies and habits, and who, I 
feel sure, if restraint were in use would be restrained ; but they 
are not restrained and are not habitually on sedatives. I still be- 
lieve that in rare instances restraint (other than surgical) is of 
advantage to the patient, and, therefore, should be resorted to ; 
but I think those cases so rare as to be quite an event in pro- 
cedure.” 
The case of seclusion at the Montrose Asylum was a homicidal 
epileptic, who, after a series of fits, voluntarily remains in bed ; at 
other times works on the farm on parole. 
Dr. Whitcombe, of the East Riding Asylum, remarks : “ At the 
present time not a single patient is under treatment to allay ex-' 
citement. The chief means used here are employment, out-door 
exercises, and in- and out-door amusemements. Restraint and 
seclusion are rarely, if ever, needed. I look upon chemical as one 
of the most pernicious forms of restraint,” 
Dr. Brushfield, of the Brookwood Asylum, says “ that mechani- 
cal restraint has not been used in the asylum since its opening in 
1867. Seclusion (that is, shutting up a patient by himself) has 
not been practised since the year 1875. The numbers given are 
beyond the usual average ; and such remedies are never used con- 
tinuously with any patient for any period.” 
Dr. Rayner, of the male department of Hanwell Asylum, adds : 
“ In the nine years I have been here I have never used mechani- 
cal restraint, although I should not hesitate to do so if the necessity 
arose. I never use sedatives to allay excitement, and narcotics to 
procure sleep very rarely ; no patient has sleeping draughts as a 
habit, and probably not more than two or three such draughts are 
given in a month. My rule is, ‘ Better no sleep than a stupor 
from drugs,’ of whose action we only know that they gravely affect 
the processes of nutritional repair ; that the most protracted cases of 
mania are those in which narcotics have been used ; the most in- H. B. WILBUR. 
tractable cases of insanity, those which have been most freely 
treated with sedatives and narcotics.” 
Dr. Davis, of the Burntwood Asylum, says : “ I have just left 
the asylum, but during the 17 years that I was there I had no re- 
course to seclusion or restraint. I always found that plenty of 
food and extras, such as stimulants in arrow-root, quieted the 
most turbulent cases.” 
Dr. Nicholson, of the North Riding Asylum, says “that the two 
occasions for restraint mentioned were in the case of one indi- 
vidual for surgical reasons. Hyoscyamia is only given in two 
cases at present, the principal other sedatives being opium and its 
preparations.” 
Dr. Yellowlees, of the Gartnavel Asylum, referring to his fig- 
ures, says : “ Chloral is given at bedtime and usually with bro- 
mide of potassium. It is very rarely given by day, and at night 
only if required. Two (2) melancholics are taking regular doses 
of liquid extract of opium, and about 12 patients, including epi- 
leptics, are taking bromide of potassium regularly. This is the 
whole sedative drug treatment for the month. Hyoscyamine has 
never been used here, as I am satisfied it is dangerous, and greatly 
doubt if it is really beneficial. The two patients secluded were 
each secluded on two occasions. One of them is an epileptic. 
Last month there was but one patient in seclusion, and only on 
two occasions, for epileptic mania. I do not hesitate about using 
restraint if I think it necessary for the patient’s welfare, but have 
had no case requiring it for a long time. Such a case may not 
occur once in a whole year. Of course I exclude cases where 
some surgical necessity may demand it. I do not consider the 
use of padded gloves, enveloping the whole hand, to be “ restraint ” 
at all, and occasionally employ them in cases of determined suici- 
dal attempts or of extreme destructive violence, but only with 
express medical sanction. ***** Mechanical restraint 
tends in the vast majority of cases to the injury of the patient 
instead of to his benefit, and therefore—and only therefore—it 
should be dispensed with as far as possible,—which means, practi- 
cally, that it is all but completely disused. I hold a similar MANAGEMENT OF THE INSANE. 
opinion about the so-called ‘ chemical restraint,’ as my practice 
proves.” 
Dr. Davies, of the Kent County Asylum, said in a letter to the 
Journal of Mental Science, Jan., 1881 : “Chemical restraint has 
long since ceased to be practised here. I did not make the 
change suddenly ; it has been a gradual transition. I used to 
give large doses of morphia, chloral, etc. ; then less, and now 
none.” 
Dr. Hill, of the Norfolk Asylum, “while not an advocate for 
the routine use of sedative drugs, thinks his practice of adminis- 
tering them to about three per cent, of his patients beneficial.” 
Dr. Merson, of the Kingston Asylum, says : “ The returns I 
send you represent perhaps more than the usual average of 
patients taking medicine to allay excitement. Chloral I never 
use to allay excitement, except in the case of epileptics subject to 
outbursts of fury before or after fits, and in these cases its action 
is simply marvellous. I never give it for prolonged periods in 
cases of chronic excitement. My experience here is of course 
limited to small numbers, but so far as it goes I am inclined to 
think that, as with mechanical restraint so with chemical restraint, 
the less they are used the less need we shall have to use them.” 
Dr. Rutherford, of the Woodilee Asylum, says in his last annual 
report, after describing the thoroughness of his system of occupa- 
tion of patients : “ This full employment of the patients renders 
it possible to give greatly extended liberty, and to do away with 
all remaining forms of mechanical or chemical restraint, such as 
walled courts, locked doors, stimulants, narcotics, and sedatives.” 
In the Montrose Asylum for the whole year 1877, with 549 
patients, only three men and twenty-two women had draughts 
given to induce sleep, most of them only occasionally, some only 
once. In only four instances were the draughts given continu- 
ously. 
In the English as in the American asylums the Irish are 
regarded as the most turbulent patients ; yet it will be seen by 
the returns from the Richmond Asylum, Dublin, that with r,oi3 
patients there was no mechanical restraint, and only one patient 12 
H. B. WILBUR. 
secluded, on three occasions and for a total period of four days 
and four hours. 
Dr. Lalor also kindly sends me his record of seclusion for the 
prior six months. From this I learn that thirteen patients were 
secluded on one occasion each, one patient on two occasions, and 
one on five. The total aggregate period of seclusion of the fifteen 
was 205 hours. 
Accompanying the Canadian tables were the following remarks : 
“The cases of seclusion at the Nova Scotia Asylum were for 
brief periods, usually from one to three hours. Under restraint: 
two male patients muffed, nightly, and two females, one for four 
nights and the other for twelve, constitute the most of the occa- 
sions.” 
Dr. Bucke, of the London Asylum writes, that the average dura- 
tion of each instance of seclusion was less than two hours ; of 
each instance of restraint about nine hours. He adds : “ I use no 
sedatives here, and no alcohol in any form. I find that my patients 
rest better at night and need sedatives less, since I ceased to use 
alcohol. I never give medicine except for bodily ailments. Re- 
straint of all kinds has been much reduced at this asylum during 
the last few years. I hope to do without it altogether, after a 
time.” 
Dr. Clarke, of the Toronto Asylum writes that to no patients 
is either chloral or any other drug given habitually or contin- 
uously. In the male department only three have been restrained 
in thirty-two months. 
Dr. Wallace, of the Hamilton Asylum writes that the figures for 
the past month, are in all respects higher than usual ; chloral is 
never given except in cases of extreme excitement. Merck’s hyos- 
cyamine is used, and is in many respects superior to chloral, 
though the after-effects are more disagreeable. The only forms of 
restraint used are the camisole, muff, and restraint-bed. In cases 
of extreme excitement and continued insomnia the restraint-bed 
is used with the best results to the patient. It enforces rest with- 
out the use of sedatives, which must always be more or less inju- 
rious when frequently repeated. The patient cannot injure him- MANAGEMENT OE THE INSANE. 
13 
self or others, and the position almost always induces sleep and 
prevents fatal exhaustion in violent maniacal cases. Muffs are 
sometimes used, but the camisole preferred, being less uncom- 
fortable and quite as effective. Alcohol has not been used in any 
form unless in tinctures for the past two years. 
Dr. Metcalf, of the Kingston Asylum writes : “ None of our 
patients regularly or constantly receive sedatives or narcotics. 
We administer an occasional dose whenever we think benefit will 
be derived. Sometimes we give half a dozen doses to the same 
patient, but rarely more than one or two consecutively. Seclu- 
sion simply means putting the patient, for as short time as possi- 
ble, into an ordinary single bedroom. We use for restraint the 
leather muff, or simply the wristlets belonging to the muff.” 
Remarks accompanying and explanatory of the statistics of 
asylums in the United States : 
In the table relating to asylums in the United States I have 
purposely omitted the names, designating them only by numbers 
to avoid offence. Two of the asylums, Nos. 2 and 3, are county 
institutions ; the others, with one exception, state institutions. 
In some of the States where there were several asylums my ap- 
plication for the statistics was made through the Boards of State 
Charities. In others it was made direct to the medical superin- 
tendents. In a few cases the record was made for the month 
succeeding the date of application, and, therefore, possibly may 
not represent the average monthly record for the year. In inter- 
preting the term “ occasions ” of restraint or seclusion, it may be 
well to state that the reporter, as a rule, has called a week or 
month of continuous restraint as seven or thirty occasions, as the 
case may be. 
The superintendent of No. 1 remarks that the numbers do not 
refer to the same individuals ; in other words, that the patients 
are not necessarily taking the remedies continuously. Of the 
patients in No. 4 it is remarked that “ fifteen are convicts.” The 
total number of hours that patients were secluded was 1,601. This 
number was swelled by the fact that three persons were in seclu- 
sion for the whole twenty-four hours during the entire month. 14 
//. B. WILBUR. 
The superintendent of No. 5 says : “The cases of mechanical 
restraint were two females, and only for short periods ; and con- 
sisted of a linen waist with closed sleeves. In one case the pa- 
tient was persistently suicidal, and in the other destructive of 
clothing.” 
No. 6 is doubtless improperly stated in the table. The return 
states that, on an average, three by day and three by night are re- 
strained for suicidal propensities. 
The return from No. 8, under instances of seclusion, reads : 
six regularly ; eleven, total. 
The return from No. 9 states that “the number 29 includes all 
who take any kind of sleeping draught ” ; also, “ average number 
of instances of seclusion for each day of the month, 2-f, males, 
and 7-f, females ; of restraint for each day, males, two ; females, 
four.” 
The superintendent of No. 10 remarks—and the remark will 
doubtless apply to other American asylums—“that during the 
summer months there is greater need of restraint on account of 
greater irritability of patients.” 
The superintendent of No. 11 reports that only three of the 
cases secluded were on account of mental excitement. 
The superintendent of No. 13 writes: “I wish to say that if 
the number under restraint appears large, it is made so, to a con- 
siderable extent, on account of our crowded condition. It is not 
quite proper to compare our list with a hospital where each pa- 
tient can have a separate room, when we are obliged to keep two 
and three in single rooms and apply restraint to prevent assaults 
and homicides.” 
The superintendent of No. 15 gives the average duration of 
the periods of seclusion as nine hours. 
The report of No. 16 in the table is doubtless improperly stated. 
The return reads : “ Restraint of a mild form is used on between 
one and two per cent., on the average.” 
The superintendent of No. 17 gives the following explanation 
of his use of restraint : MANAGEMENT OF THE INSANE. 
15 
4 wore wristlets during month, for violence. 
4 “ “ “ the day, for the month, for violence. 
2 “ “ “21 days 
2 “ muff “ 14 “ for general destructiveness. 
3 “ “ “ 21 “ “ “ • “ of 
bedding. 
1 “ “ “ 26 nights, violence to self. 
1 “ “ “ 8 days “ “ and others. 
J << << << U (( u 
1 “ “ “ “ destructiveness. 
2 “ “ “ 1 day 
3 wore camisole “ 7 days “ 
j. it it U 2 it it 
2 “ “ “ 1 day 
1 “ “ “ 4 “ 
1 confined to bed to economize strength. 
1 restrained to bed 3 nights. 
The superintendent of No. 20 remarks : “ The restraint has 
been for short periods, averaging one hour and a half. The oc- 
casions for restraint are often, with a few patients, four or five times 
daily of one hour each, during periods when they cannot be 
watched by attendants, and generally consist of a belt passed 
around the patient and through metal loop on chair. The construc- 
tion of the building and its crowded condition renders seclusion 
almost impossible. The large number (46 to 50) in a ward makes 
mechanical restraint necessary in a much greater number of cases 
than would otherwise be useful.” 
The asylum, No. 20, is in the same state with No. 1. The 
State official whose duty it is to inspect these institutions, and 
who sends me these returns, writes as follows : “ Notwithstanding 
the large discrepancy which appears on the face of the answers 
to the questions, I am satisfied, from a somewhat careful inquiry, 
that if any, there is no substantial difference in the amount of 
restraint practised in our hospitals. The difference is in the 
manner of reporting.” 
The superintendent of No. 25 gives chloral only as a hypnotic ; 
the dose usually given 15 grains, seldom more. Narcotics are 
never given to allay excitement. No bad effects have resulted 16 
H. B. WILBUR. 
from his mode of administering chloral. No cases are ever 
kept under constant seclusion or restraint. Restraint not 
applied, except by the authority of the physician. Patients from 
the state prison are sent to this asylum,—many of them homicidal 
cases ; hence, in part, the amount of mechanical restraint. 
Some half a dozen of the superintendents of asylums in the 
United States have failed to respond to my inquiries, evidently 
unwilling to furnish the desired statistics. With reference to one 
of these, I learn from an authentic source that about ten per cent, 
of the patients are daily taking either chloral, hyoscyamia, or a 
combination of the two remedies. 
Dr. Tuke, in the inaugural address from which I have already 
quoted, in comparing the old system of management of the fnsane 
with the new, remarks : “ The old system desired secrecy ; the 
new is not afraid of publicity.” It is evident that some of the in- 
stitutions of the United States have not fully come out from under 
the influence of the older system. 
My space would not allow me to give all the explanatory re- 
marks accompanying the statistics of the several asylums. I have 
meant to give enough to avoid doing injustice to any. I may, 
therefore, now proceed to make a few comments on the above 
tables. 
First, the use of sedatives and narcotics, the so-called “ chem- 
ical restraint,” is not the substitute or alternative for mechanical 
restraint either in British asylums or in the two or three American 
asylums where the principle of non-restraint has been lately on 
trial. On the contrary, the general rule seems to be: the more 
mechanical restraint, the more chemical restraint. 
On reflection, this need not surprise any one. For if, as one 
American superintendent states it, “ rest is vital to successful 
treatment of acute mania,” mechanical restraint will not suffice, as 
it merely limits the range of muscular action, neither fully con- 
trolling the patient’s efforts nor quieting the violent and exhaust- 
ing action of his vocal organs. Till some ingenious superinten- 
dent shall invent a protective gag and still more efficient appliances 
of restraint, resort must be had to sedative drugs to secure the MANAGEMENT OF THE INSANE. 
17 
vital rest. And so one superintendent writes that the narcotics he 
gives are not as substitutes for restraint, but in some cases associ- 
ated with restraining apparatus. 
Secondly, it appears that the British superintendents who have 
furnished these statistics not only do not regard such remedies as 
proper substitutes for mechanical restraint, but rather look upon 
their general use as unnecessary and even pernicious. Some of 
them even assert that such use protracts or perhaps prevents the 
recovery of the patients. 
Thirdly, it will be seen from the opinions of the British super- 
intendents, given in connection with the tables, that non-restraint, 
as held and practised by them, is no inflexible dogma. It is 
simply the practical disuse of restraining apparatus, because they 
have found by experience that other means and resources are 
better for the patient, except in very rare instances, in which 
event they would unhesitatingly accept the alternative. Of course, 
it will be seen that, besides the actual condition of the patient, 
the knowledge, tact, and skill of the physician will be factors in 
determining the application of the dernier ressort. 
As has been already stated, the purpose of the present inquiry 
was merely to bring out the facts as to the comparative use of 
chemical restraint in British and American asylums. Incidentally 
another has been served. It is this. Although during the last 
four or five years there has been a great diminution in the use of 
restraining apparatus in the insane asylums of the United States, 
yet it is obvious from the table that mechanical restraint is now 
used in some to a degree that will surprise most British alienists. 
Some of their number have visited a few of our institutions when 
in this country. They have been told by the superintendents that 
little resort was had to restraining apparatus, and with the known 
non-restraint opinions of such visitors, such apparatus has, not un- 
naturally, been kept out of sight and out of use for the time being. 
These gentlemen have gone away deceived, as Dr. Bucknill was, 
as to the amount of restraint used. He spent several days at the 
Utica Asylum, and also travelled with Dr. Gray, its superinten- 
dent ; and yet he wrote of his visit in his Notes on American 18 
H. B. WILBUR. 
Asylums : “ That he saw none in restraint or seclusion at Utica, 
and that Dr. Gray differed from his A merican brethren in not using 
restraint." 
It will not be out of place, in connection with these tables, to 
give a summary of the facts relating to the use of restraint and se- 
clusion in British asylums. 
It is the more desirable, because these facts are not always 
fairly represented. Thus, Dr. Gray, the editor of the Journal of 
Insanity, has lately returned from a visit to Europe, where, as he 
says, “ he gave particular attention ” to the subject of restraint. 
Since his return, at the suggestion of his Board of Managers that 
he should give them “ a full presentation of the present status of 
professional opinion and practice on the question of restraint, 
whatever it be, fortified by such facts of experience as may throw 
light upon it and furnish its justification,” he has come out with 
an elaborate defence of the use of mechanical restraint. 
His own opinions given in the paper will have no more influence 
with thoughtful men, because he insists that, upon this subject, as 
well as the intimately correlated topic of employment for the in- 
sane, they have undergone no change during the last twenty years. 
Certainly, the light that has been thrown upon these subjects by 
British experience during that period, ought to have modified the 
views of every intelligent alienist. 
He lays down three rules for the use of restraining apparatus. 
“ ist. Cases of suicidal disposition where it is so determined and 
persistent that watchfulness will not secure the necessary safety. 
“ 2d. Where there is determined and persistent disposition to 
self-maiming or injury, or denuding the person, or debasing self- 
abuse. 
“3d, Where there is great destructiveness or violence toward 
others.” 
With the known characteristics of insanity we have in the above 
rules a warrant for a quite liberal use of mechanical restraint. 
Dr. Gray uses the camisole, wristlets, the waist-belt, buckskin 
mittens, and, in rare instances, the leather muff. He makes no 
mention of the crib-bed, of which he has some thirty in number; MANAGEMENT OF THE INSANE. 
19 
though in other asylums they are certainly used as means of re- 
straint, if not at Utica. 
The general conclusion of his paper is, that there is no real dif- 
ference in principle among experienced professional men who 
have devoted their lives to this specialty ; that the English Com- 
missioners of Lunacy and the superintendents recognize the 
necessity of some mode of protective restraint; but having no 
settled convictions in favor of any particular method, they use 
coercive measures in the form of seclusion, the use of padded 
rooms, wet and dry packing, showering, and manual force Gf 
attendants. 
The chaplain of the Utica Asylum has also, in a late number of 
the Journal of Insanity, attempted to show that non-restraint is a 
failure in England. The point upon which he lays most stress, 
perhaps, is the following : 
“ The report (referring to the Annual Lunacy Report) gives 
considerable attention to a review of cases of suicide in various 
institutions, in some of which deficiency of attendants is men- 
tioned, but no reference is made, in connection with the circum- 
stances related, to the practicability of limiting these casualties by the 
judicious use of restraint.” The thought is, that the English su- 
perintendents do not make what he calls a judicious use of re- 
straint ; that if they did, some of these suicides might have been 
avoided. The English statistics of restraint are as follows, taken 
from the Lunacy Report of 1880 : 
The county and borough asylums of England, which corre- 
spond in the main to our state asylums, are 59 in number. 
They contained 38,209 patients. 
Twenty-nine of these, including an insane population of 17,756, 
or 46 per cent, of the whole number, used no mechanical 
restraint. 
Eight with 5,057 inmates used neither restraint nor seclusion. 
Eight with a population of 5,446 had, during the year, each but 
one occasion to use restraint, and that usually for surgical 
reasons. 
In six others, with a population of 3,437, 27 patients were re- 20 
H. B. WILBUR. 
strained by what is known as the “ wet-pack” or “ dry-pack.” In 
these cases medical considerations prompted their use, as well as 
the purpose of restraint. 
Of two asylums with 1,470 patients, the Commissioners cf 
Lunacy make no mention of the use of restraint. 
In fifteen asylums, with a population of 12,651 restraint, was 
used in the case of 115 persons. In a large number of these cases 
it is expressly stated that restraint was used for surgical reasons. 
But for any reason, in these fifteen asylums less than one per 
cent, of the persons were subjected to mechanical restraint. 
Taking the aggregate population of all the county and borough 
asylums, less than four in a thousand ever had applied to them 
any form of mechanical restraint. 
If we compare these statistics with the report of No. 17 asylum 
in Table 3, it will be seen that there is more restraint used in that 
single institution than in all the county and borough asylums of 
England. 
And as the managers of the Utica Asylum have expressed a de- 
sire for light upon this question of restraint, we may add that 
counting the crib-bed as a form of mechanical restraint—and it 
most certainly is—there is more mechanical restraint used in their 
institution than in all the borough and county asylums of Eng- 
land. For, regarding all the 38,000 patients in such asylums as 
in one institution, the average number of persons under mechan- 
ical restraint, at any one time, would be but three. 
As to seclusion, which means, according to the definition of the 
Lunacy Commissioners, putting the patient in a room by himself, 
usually with the door unlocked, out of 38,209 patients, only 911 
were secluded. Of these, 47 were so secluded for bodily illness 
and not for excitement. 
Deducting these and fourteen others, who for special reasons 
were secluded for protracted periods, the remaining 850 patients 
were each secluded, on an average, less than two days. 
Following on the heels of this disuse of mechanical restraint 
have been other improvements in the same direction, which I have 
not space to describe. MANAGEMENT OF THE INSANE. 
21 
Comparing the above statistics with those of the asylums in 
the United States, as seen in Table No. 3, and making allowance 
for the fact that the statistics in the one case are for a month, with 
an insane population of but 13,342, while in the other they are for 
a year, with a population of 38,209,—it will be seen that the differ- 
ence in practice between the British and American superinten- 
dents, in the matter of restraint, is broader than the Atlantic. 
But the alleged casualties are one of the bugbears of the non- 
restraint system! We have, unfortunately, no grounds for compar- 
ative statistics, for there is no public record of such events in 
American asylums. The English Lunacy Reports give publicity 
to all occurring in their asylums. The record for last year was as 
follows : With the 38,209 patients in county and borough asylums, 
more or less of them epileptics, paretics, and cases of senile de- 
mentia, 2 were scalded, 1 killed by another patient, 3 cases of 
broken ribs, one of which was through his own violence. I ob- 
serve that these occurred principally in asylums where restraint 
was not wholly abandoned. I also observe that the list of such 
casualties is annually diminishing, in spite of the progress of the 
non-restraint principle. 
There were eight suicides in these asylums. Here com- 
parison is not entirely at fault. Thus, during the year 1875, 
I made some investigations and published the results, which have 
never been questioned. In the year 1875, in all the insane asy- 
lums of England, with a population of some 43,000 patients, 
there were but 21 suicides, or one to every 2,000 patients. During 
the same period, in 40 American asylums, containing 17,000 pa- 
tients, there were 35 suicides, or one to every 500 patients. In 
other words, suicides were four times as common in American 
asylums as in those of England. 
I may venture another comparison The most pronounced 
opponents of the principle of non-restraint in this country are the 
superintendents of the asylums at Utica, and at Newburgh, Ohio. 
In the county and borough asylums of England there were dur- 
ing the last year 4,291 deaths, and one suicide to every 536 deaths. 
During the last 17 years, or as far back as my file of the Utica 22 
H. B. WILBUR. 
Reports extends, there have been 951 deaths and 17 suicides, that 
is, one suicide to every 56 deaths ! ! 
At the Newburgh Asylum since its opening there have been 418 
deaths and 15 suicides, or one suicide to every 28 deaths ! ! ! 
In conclusion, I think that it may be said—carrying the convic- 
tions of the reader—primarily, that “ chemical restraint ” is not 
the substitute for mechanical restraint in British asylums ; inci- 
dentally, that the principle of non-restraint is not a failure in 
England ; that casualties are not confined to non-restraint asy- 
lums ; and lastly, that some of the advocates of mechanical 
restraint seem to be reluctant to have their methods made known 
to the profession generally. H. B. Wilbur. 
Postscript.—The author of the above editorial article had in- 
tended not to name the various American asylums set down in his 
table, but had referred to them simply by numbers. I consider 
the subject one of such great importance to the medical profes- 
sion, and to the public generally, that I have assumed the respon- 
sibility of re-inserting those names. This being done, persons in- 
terested in the more humane and intelligent care of the insane will 
know where to look for remnants of barbarous measures, for over- 
drugging, and for excessive suicide. E. C. Seguin. ARCHIVES OF MEDICINE FOR 1881, 
A BI-MONTHLY JOURNAL, 
Edited by Dr. E. C. Seguin, with the assistance of many prominent physicians in this 
country and abroad, enters upon the third year of its existence. 
The Archives of Medicine will continue to be published every two months. 
Each number is handsomely printed in large octavo form on heavy paper, and contains from 
104 to 112 pages. The articles are illustrated by means of lithographs or wood-cuts wherever 
necessary. 
It is intended to devote the whole of each number to original matter, consisting of original 
communications or editorial articles, reviews of books, and a record of important cases. 
The Abstract Department has already been omitted in two numbers. The principal reason 
for this change is that the editor believes that the profession are ready to support a journal devoted 
to original communications and bona Jide reviews. 
Especial attention is given to the review department, and while every pains is taken to secure 
the services of unprejudiced reviewers, they are asked to criticise or praise without fear or favor 
and to assume the responsibility of their statements by appending their initials to the reviews. 
The following Editorial Articles have appeared during the year 1880 : Mr. Lister’s Antiseptic 
Method, by Dr. Lewis A. Stimson ; Our Asylums as seen by a Competent Foreign Visitor, by 
Dr. von den Steinen ; Observations on the Insane Asylums of California and Nevada, by 
Dr. R. W. Birdsali. ; The Right of the Insane to Liberty, by the Editor. 
Among the Original Articles may be mentioned the extensive papers by Dr. N. M. 
Shaffer, On the Hysterical Element in Orthopaedic Surgery ; by Dr. Mary Putnam Jacobi, 
On the Use of the Cold Pack, followed by Massage, in the Treatment of Anaemia; and Dr. 
Amidon’s Prize Essay on the Temperature of the Head. 
COLLABORATORS. 
London.—Drs. J. Hughlings Jackson, J. Burdon-Sanderson, and Sydney Ringer. 
Paris.—Profs. J. M. Charcot, J. Marey, and A. Ollivier. 
Germany.—Prof. Dr. W. Erb, of Leipzig. 
Philadelphia.—Profs. D. Hayes Agnew, M.D., J. M. Da Costa, M.D., William Goodell, M.D., Roberts Bar- 
tholow, M.D., S. W. Gross, M.D., and Drs. Tiros. G. Morton, E. O. Sharespeare, and J. C. Wilson. 
Boston.—Drs. James R. Chadwick, Charles P. Putnam, James J. Putnam, and Samuel R. Webber. 
Baltimore,—Prof. E. T. Miles, M.D., Dr. I. E. Atkinson. 
Hartford, Conn.—Dr. Samuel B. St. John, Dr. M. D. Mann. 
Albany, N. Y.—Prof. Samuel B. Ward, M.D. 
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