Rib-Fracture in English Asylums. 
By W. LAUDER LINDSAY, M. D., F. R. S. E. 
Physician to the Murray Royal Institution 'for the Insane, 
Perth, Scotland. 
From the Amerzcaw Journal of Insanity for July, 1879. Rib-Fracture in English Asylums. 
BY W. LAUDER LINDSAY, M. D., F. R. S. E., 
Physician to the Murray Royal Institution for the Insane, 
Perth, Scotland. 
INTRODUCTION. 
The body of the following paper originally appeared 
in the Edinburgh Medical journal for November, 1870. 
It is reproduced here and now, in connection with various 
papers already published on restraint and non-rest/raint* 
because rib-fracture is one of the natural fruits of the 
non-use of mechanical restraint, in cases in which it 
should be applied. So far from its having become less, 
rib-fracture has become more and more common since 
1870 in the lunatic asylums of England. So common 
is it now-a days, that sensation articles regarding it, 
every now and then appear in the newspapers, in con- 
nection with the reports of coroner's inquests.f It is 
customary carefully to examine every entrant patient, in 
order to discover any broken bones that might be 
assigned to the period of the patient's treatment at 
home, or in a workhouse, or in a police cell; and even 
more careful examinations at each post mortem, in order 
to detect fractures that must or may have existed dur- 
*Vide the American Journal ok Insanity for April and October, 1878, 
pp. 517 and 272, and April, 1879, p. 543. 
f Important commentaries are also, however, occasionally to be met with 
in medical journals, as in the Cambewell House cases (London), of .1876, 
which formed the text of an instructive article on the " Alleged Ill-treat- 
ment" of lunatics, in the British Medical 19, 1876, 
p.247. 
19, 1876, 2 
ing life, whether or not they produced suffering or 
disease of any kind.* 
I should be very sorry to say that all rib-fractures 
or other bone fractures found in asylum patients, 
are necessarily the fruits of ill-usage by attendants. 
One main object of the present paper is (on the con- 
trary) to show how apt such injuries are to occur 
without anything approaching to violence or even 
to roughness on the part of attendants, or of fel- 
low-patients. But it is all the more necessary that 
certain classes of patients should be guarded against 
risk of accident, from falls, for instance, by the 
use of such appliances as the " protection-bed."f It 
can be no matter of surprise that certain general par- 
alytics and other restless and mischievous, but feeble 
patients, when left to knock themselves about "padded 
rooms," or subjected towhat is called "manualre- 
straint, the repressive force § of muscular attendants, 
should meet with serious " accidents " of divers kinds. 
It would be very strange if, under such favorable 
conditions, rib-fracture and numerous other injuries, 
major and minor, including death itself, should not, 
and too frequently occur. 
* The Twenty-third Report of the English Lunacy Commissioners, (for 
1869), regrets a number of cases of rib-fracture, whose origin or cause was 
never ascertained ; along with many other " accidents " that were obviously 
or apparently the result of non-restraint, literal or figurative. Such Blue- 
Books, indeed, furnish an eloquent commentary on the evils of non-restraint. 
f Vide the American Journal of Insanity, for April, 1878, p. 517. 
| Dr. Mortimer Granville, of London, in his evidence before the Dillwyn 
Committee of 1877, contrasts this form of restraint unfavorably with that 
which is " mechanical." [Report of said Committee, p. 400.] 
§" You wiustf have force in certain cases," says even Lord Shaftesbury, 
who admits that mechanical restraint has been replaced " by the personal 
force used by the keeper. * * * * To control a violent patient 
it requires three or four attendants. * * * * There is nothing on the 
face of the earth one-half so provoking as a madman when he chooses to be 
so!" [Report of the Dillwyn Committee, 1877, p. 543.] 3 
Nevertheless, it does not appear to occur to our lunacy 
authorities to connect preventable injury with the non- 
use in proper cases of mechanical restraint, or with the 
gross abuse of what they still complacently describe as 
"the non-restraint system."* The sense of moral re- 
sponsibility seems to sit lightly on their shoulders, for 
preventible accidents to their charges, as it does, 
for the "manufacture of insanity" itself-a subject 
sufficiently serious, however, to require an article to 
itself. 
And yet these authorities go on calmly reporting such 
injuries as the following: "The casualty was the death 
of a man from pleurisy, following broken ribs. The 
injury occurred in a struggle with an attendant, whom 
the patient had suddenly attacked."f "A woman was 
in bed with a fractured arm, which seems to have been 
caused by her violent resistance when required to take 
Well might an indignant critic exclaim: 
" Patients may have their ribs crushed, be boiled, or 
commit suicide, before a moderate and reasonable sum 
is expended upon sufficient and skillful attention ; " and 
he makes this comment apropos of the following state- 
ments of fact taken from the Twenty-fourth Report of 
English Lunacy Commissioners (for 1870). In the 
Witham Asylum, a patient was found by the Coinmis- 
* It may be carrying this benevolent " system " to its logical conclusion. 
Though this conclusion is fraught with serious social evils-when, for 
instance, it fails to regulate properly the moral relations of the sexes among 
the higher classes of asylum officers, or of their subordinates to their 
patients, when it permits patients to escape wholesale, so as to get them- 
selves into the gutters, or worse, of our large towns, or battered to pieces 
by railway trains, or drowned like rats in reservoirs, wells or streams ; or 
when it gives them license to write and to post numbers of the most mis- 
chievous letters. 
f Thirty-second Report of the English Lunacy Commissioners (1878, p. 258): 
Entry relating to the Sussex County Asylum. 
\Ibid., p. 235, entry relating to the Shropshire Asylum. 4 
sioners, " lying on a bench in an open rustic seat, re- 
strained by a strait-waistcoat, restlessly moving and 
moaning, and unattended by anyone;" while at Tice- 
burst, one of the highest-class private asylums in 
England, " The nurses had a practice of restraining the 
lady patients, at night time, by fastening them to the 
bedstead, tying their feet together ! "" 
The Pall Mall Gazette, of October, 1869, thus refers 
to a series of broken-rib cases that had occurred in the 
public asylums of Hanwell, Lancaster, and Carmar- 
then : f "One may say that there was hardly a rib in 
their bodies left unbroken. * * * There seems to 
be little doubt that this particular kind of injury is the 
consequence of the attendants kneeling on the chests of 
refractory patients, in order to make them submit to 
discipline. * * * Surely this kind of thing can not 
be endured much longer. For a strong, heavy man to 
kneel upon a helpless patient * * is, no doubt, an 
easy way of reducing him to order; yet it is clearly one 
which can not be practiced with impunity." Specially, 
in connection with the fatal cases of rib-fracture at Han- 
well, it is asserted: " Either * * the non-restraint 
system is a mere sham and delusion, or it yields results 
quite as horrible, and distinguished by the same monot- 
onous cruelty as existed under the old regime, when 
mechanical restraint was used."J Referring to " the 
*" A Social Blot," in British Medical Journal, October 22,1870, pp. 441-2, 
with commentary in the Journal of Mental Science, vol. xvii, 1872, p. 230. 
f The editor of the Journal of Mental Science tells us, (vol. xvi, 1871, p 65), 
of " The Public Asylums of England and Wales," that " in none of them is 
mechanical restraint used, and yet the accidents and injuries to patients 
might be counted by single figures ! " 
The editor of the Journal of Mental Science, in his own polished and 
charitable phraseology, accuses the writer of such a statement of " either 
gross and therefore incredible impertinence, or a singular contempt 
of truth," (vol. xvi, p. 64), a compliment similar to that paid to his fellow 
physicians by another " non-restraint apostle in the Dillwyn Report of 1877, 
p. 124. 5 
number of those who have been knelt upon, and 
literally crushed to death, in order to show the advan- 
tages of physical'"' over mechanical restraint, the public 
critic sums up that " the non-restraint system, as it is 
conducted in some asylums, seems to us worse than 
nothing."f 
To show that this critic, notwithstanding the abuse 
heaped upon him by the editor of the Journal of Men- 
tal Science, does not stand alone in his opinions, here 
are the remarks of another medical commentator-writ- 
ing this time in the Lancet, another of the leading 
English medical journals. His test is the Santi Nistri 
case, at Hanwell-a general paralytic, "who died there, 
after a fortnight, from the effects of frightful injuries 
received in the Asylum." These injuries were, " that 
the breast-bone was broken ; that the third, fourth, 
sixth and seventh right ribs, and the fourth, fifth, sixth 
and seventh left ribs were also broken; that the chest 
was bruised; and that the left eye was very black and 
lacerated. * * * It is sufficiently plain that, how- 
ever the event may have happened, the poor fellow was 
effectually crushed to death. .* * * We are driven, 
indeed, by a study of the evidence, to one of two 
equally painful conclusions: either that the supervision 
and care of patients in the Hanwell Asylum are so 
* The record of a suggestive inquiry by the English Lunacy Commissioners, 
into the causes of the death, in the Carmarthen Asylum, of Reed Price, is 
given at full length in their 84th Report, (1870, pp. 227-235). The evidence 
showed that the said patient died from pleurisy, associated with the fracture 
of eight ribs, these fatal injuries being caused in and by a struggle with an 
attendant. 
f The whole article is quoted in the Journal of Mental Science, vol. xvi, 
1871, pp. 60-70, on whose editor it produced the effect that a red rag is said 
to do upon a bull. He denounces the writer of the Pall Mall article as having 
" preferred seemingly to lend a willing ear to the malignant whisperings of 
some reactionary individual, who has failed to appreciate the spirit of the 
modern system of treating the insane, and who, if he be connected with an 
asylum, is manifestly most unfitted for the office which he holds." (P. 67). 6 
grossly defective that injuries such as Santi Nistri died 
of, may be inflicted without anyone knowing anything 
about the manner of their infliction, or that there has 
been a conspiracy of silence. * * * Santi Nistri's 
death is, unhappily, not a solitary instance;* other 
patients have died in the Hanwell Asylum from the 
effects of similar severe injuries. * * * 'We are 
aware that the Hanwell Asylum is not considered a 
good example of a public asylum, and that some even 
regard it as the opprobrium of our county asylums."! 
Men are to be found in England who do not think 
broken ribs a very serious matter-who would, at least, 
rather submit to them-or, what is not quite the same 
thing, subject their patients to them-than have a ves- 
tige of mechanical restraint applied in prevention of 
such injuries. The editor of the Journal of Mental 
declares that, "were such injuries as broken 
ribs, in the proportion of cases in which they now 
occur, a necessary part of the non-restraint system, 
which we by no means believe them to be, we should 
still maintain that it would be better to accept them as 
an evil incidental to a good system than to return to the 
old system." 
Dr. Harrington Tuke, who is ostensibly like Dr. 
Lockhart Robertson, a staunch adherent of the " non- 
restraint system," confesses that "the only wonder is, 
that in public asylums, considering the savage nature 
of some of the half-educated victims of mental diseases, 
and the liberty which the non-restraint system allows 
* Further comments on the Han well and Carmarthen broken rib cases are 
to be found in vol. xvi, 1871, pp. 251-5. 
f Quoted in full in the Journal of Mental Science, vol. xv, 1870, pp. 
586-7. 
t Vol. xvi, 1871, p. 66. 7 
them, accidents do not more frequently happen. That, 
within the last few years, several superintendents, and 
many attendants, have been seriously hurt, would show 
there are two sides to this question. The fact is, that 
in the refractory wards of our public asylums, the 
attendants, too few in number, carry their lives in their 
hands."* In other words, as I understand Dr. Tuke, 
the "non-restraint system"-that is, the non-use of 
mechanical restraint, under any circumstances, is a 
dangerous system-dangerous equally to the lives of 
patients, officers and attendants! 
Dr. Tuke's views, however, concerning the "liberty 
of the subject," in the treatment of the insane, are 
peculiar; for he says: " I think that taking a patient, 
and locking him into a room, is simply committing an 
assault that you have no right to commit, unless on the 
very best possible reasons-reasons very grave; for if 
that remedy will do any good, he may be said not to be 
in a state fit to be sent to an asylum." Nevertheless, 
he would, under certain circumstances, " seclude the 
patient with the attendant. The seclusion, in that man- 
ner, is as curative, if properly carried out, as it well 
can be ! "f He holds, however, that facts warn us that 
all violence must be " avoided, and that, in addition to 
the care and gentleness required in the treatment of the 
insane, we have a new reason for caution in the danger 
that seems imminent of easily fracturing the more 
exposed bones." J 
Dr. Blandford, in his excellent manual of " Insanity, 
and its Treatment," (1871, p. 226), speaking of acute 
mania, says: " The patient will not lie quietly on a 
* Journal of Mental Science, vol. xvi, p. 141. 
f Journal of Mental Science, vol. xviii, 1873, p. 465. 
\lbid, vol. xix, 1874, p. 162. 8 
bedstead, and attempts to compel him to do so will end. 
in many bruises, if not in broken ribs."* 
I venture to offer the following cases, and the relative 
commentaries thereon, as a contribution towards a bet- 
ter knowledge of a subject that has lately attracted a 
good deal of attention, both public and professional, in 
England, in consequence of the animadversions of the 
press on various instances of rib-fracture among the in- 
mates of its county lunatic asylums. The subject to 
which I refer includes, on the one hand, a consideration 
of that unnatural fragility of bones, which renders 
them liable to fracture from the most trivial causes; 
and, on the other, of the frequency of rib-fracture that 
can not possibly be attributed to ill-usage by attendants. 
I do not offer my remarks apologetically; for I be- 
lieve that the animadversions above referred to are un- 
warranted either by evidence or legitimate inference- 
at least, in the majority of cases. Nor am I to be un- 
derstood as affirming that fragility of the bony system 
is peculiar to the insane; though I believe it is much 
more common among them than is usually supposed. 
Whether it is as common as, or commoner than it is 
among the sane, remains to be proved. This is a sub- 
ject that seems to me deserving of full and immediate 
inquiry. I have repeatedly statedf that I have never 
met with, or heard of, any lesion among the insane that 
* Instances of the frequency and readiness with which bone-fracture occurs 
in asylum patients, are to be found in (I.) A " Chapter on Broken Bones," by 
Dr. Rogers, of the Lancashire Asylum at Rainhill, and one of the ex-presidents 
of the Medico-Psychological Association, in the Journal of Mental Science, 
for 1875, (vol. xx, p. 81). (II.) A paper on " General Paralysis and Fragilitas 
Ossium " by the late Dr. Mercer, of the East Riding Asylum, Yorkshire, in 
the British Medical Journal, vol. l, 1874, p. 540. 
f Vide " Illustrations of Pathology and Morbid Anatomy in the Insane,"' 
Journal of Mental Science, vol. xii. p. 522; and the following Reports of the; 
Murray Royal Institution -30th, pp. 15,16; 32d, p. 15 ; and 38th, p. 15. 9 
is to be considered quite peculiar to them, and in 
sense to be regarded as diagnostic of the existence of 
insanity. It is wonderful, however, how persistent and 
ingenious are the efforts of alienists to make out an es- 
sential or specific difference between sanity and insanity, 
the sane and insane, as regards their pathology and 
morbid anatomy, in the face of incessant and egregious 
failures. The "thin partitions" that are supposed to 
separate them, and that also "do the bounds divide" 
between great wit and madness, are not real or per- 
ceptible-not demonstrable or definable; and all efforts 
artificially to create specific distinctions where Nature 
has none, must end only in failure! 
I do not necessarily connect fragility of the bones in 
the insane with the accidents that have of late years 
been made the subject of sensational, and, I believe, 
most ungenerous and unjust outcry by the fourth 
estate. There may have been, in some cases, an essen- 
tial connexion between osseous fragility and rib-fracture, 
as cause and- effect; but the effort to prove or disprove 
such a connexion in the cases referred to, is no part of 
my present object, which is simply-so far as regards, 
I. Mollities ossium in the insane, to show that it 
sometimes exists in as marked a degree as among the 
sane; and as bearing on- 
II. Rib-fracture in the insane to point out (a) The 
frequency of self-injury. (3) The very slight violence 
sometimes required for rib-fracture, (c) The existence 
of serious or fatal surgical injury without external 
marks, or any relative symptoms, (fl) The importance 
of post-mortem examination in the detection of masked 
or unsuspected injury. (<?) The desirability of dis- 
tinguishing from each other* injuries that are-1, acci- 
*Vide 32d E eport of the Murray Institution, p. 11. 10 
dental; 2, self-inflicted; and 3, the result of maltreatment 
by attendants. (/) the injustice of attributing rib-frac- 
tures and similar injuries necessarily to attendants, (y) 
The frequency of such injuries as a necessary conse- 
quence of the non-use of mechanical restraint. (A) 
Those who are responsible for the frequency of such 
injuries are, therefore, those who have advocated the 
non-restraint dogma. (/) There are no pathological le- 
sions peculiar to insanity. 
I. Case of Molllties Ossium.-The patient was an 
unmarried lady, aged forty-nine, eminently nervous in 
temperament, of fine build of body, and of high deli- 
cacy of constitution, with a strumous tendency. For a 
long series of years she had been the subject of chronic 
insanity. In the last seven years of her life, during 
which she was under my observation, her general 
health was fair, till she began to complain of aching 
pains in the bones, of a character supposed to be rheu- 
matic. There gradually supervened a marked general 
debility, requiring rest in bed, to which she was con- 
fined for the remainder of her life-a very few weeks. 
While bedridden, boils appeared on different parts of 
the body; then acute tuberculosis suddenly showed 
itself, and rapidly proved fatal (in a fortnight.) A 
post-mortem examination was made, which revealed, 
besides infiltration of the lungs with miliary tubercle, 
and slight fatty degeneration of the kidneys, as well as 
other pathological lesions, the following condition of 
the bones. The walls of all bones were thin and soft, 
easily pierced by any steel or other hard instrument. 
The normal medullary (or cancellated) tissue was 
absent; the interior of the bones being occupied by a 
thickish fluid, which consisted apparently equally of 
blood and oil. Their surface was abnormally vascular 
and colored-usually a deep reddish-brown. The 11 
sternum was so flexible that it could be doubled on 
itself without much difficulty. The general condition 
of the whole bones of the system was that usually 
described as the earlier stage of mollities ossium; it 
was apparently essentially a hyperaemia, followed or 
accompanied \yy fatty degeneration, of their whole tex- 
ture and contents. 
For some time prior to her decease the urine had 
been highly phosphatic, but non-albuminous. It does 
not, however, follow that this apparent excessive excre- 
tion of phosphates stood directly related to the condi- 
tion of the bones. For, on the one hand, as Neubauer 
and Vogel point out, mere sediments of earthy phos- 
phates in the urine do not necessarily indicate excess of 
these salts-absolute excess being determinable only by 
quantitative analysis ;* and, on the other, as I have 
elsewhere shown, phosphatic urine is common among 
the while there is no reason to regard moUities 
ossium as otherwise than rare (comparatively) among 
either sane or insane. According to some writers the 
excretion of phosphates, as measured by the phosphatic 
character of the urine, bears a specific relation to cer- 
tain forms or phases of mental disease, (e. g. mania); 
but I long ago pointed out that this is a fallacy, and 
my experience has been confirmed (apparently) by the 
later researches of Dr. Adam Addison, sometime of 
Larbert. He writes: " The quantity of phosphoric 
acid excreted in states of mental excitement was less 
than after convalescence. * * * This perhaps is 
the most important fact elicited by the investigation, 
for a greater than the average secretion of the phos- 
*'- Guide to the Analysis of the Urine." Translated for the New Syden- 
ham Society, 1863, p. 331. 
f " On the Chemistry and Microscopy of the Urine in the Insane," Journal 
of Psychological Medicine, July, 1856, pp. 492,496; and 30th Annual Report 
of the Murray Royal Institution, p. 16. 12 
pliates has come to be regarded as a pathognomonic 
phenomenon of maniacal excitement." (P. 15.) * * * 
"I consider it sufficiently proved that the quantity of 
phosphoric acid excreted during the course of a mani- 
acal attack, is less than that voided in an equal time 
after recovery." (P. 16.) * * * " I believe that the 
excretion of phosphoric acid is regulated more by the 
condition and weight of the body than by the action of 
the brainy (P. 27).* 
In the foregoing case (I.) there was no fracture of any 
of the affected bones; but it is obvious that they were 
in a condition in which some very trivial cause might 
have caused fracture. Druitt tells us, in his admirable 
"Surgeon's Vade-Mecum," in mollities ossium, 
"from a fall or some other slight injury" the bones are 
liable to break ; or that " bone after bone breaks from 
the slightest cause" (1851, p. 217). Even in the earlier 
stages of the degeneration, and still more so in the later 
ones-slight stumbles in one's own bedroom-falls 
against the edges of beds, chairs, or tables during the 
night-or even ordinary, and still more so inordinate 
or unusual, muscular effort-may suffice to produce 
rib-fracture! 
The morbid condition of the whole bony skeleton in 
this case was quite unsuspected during life; it was 
detected, and could only have been detected, by post- 
mortem examination. Such cases furnish one of many 
sorts of argument that might be adduced in favor of 
such examinations in every death from I 
have elsewhere pointed out that autopsy frequently 
reveals the most unexpected pathological lesions of the 
most interesting kind-though not necessarily interest- 
*"Onthe Urine of the Insane." Reprint from the British and Foreign 
Medico-Chirurgical Review, April, 1865. 
f Vide 39th Report of the Murray Royal Institution, p. 13. 13 
ing as throwing light on, or essentially connected with, 
the mental or cerebral disease. Autopsy in the insane 
is, however, one of these subjects, on the other hand, 
regarding which it may prove that "ignorance is bliss," 
and "'tis folly to be wise;" for it, and it alone, may 
bring to light injuries or lesions, the origin or cause of 
which may become subject of judicial inquiry, news- 
paper outcry, and public condemnation 1 The frequency 
with which previously unsuspected rib-fracture is de- 
tected by post-mortem examination may be illustrated 
by the following: 
II. Cases of Rib-Fracture detected only on Post- 
mortem Examination, which occurred in the practice of 
Dr. Workman, formerly of the Provincial Lunatic 
Asylum for Upper Canada, at Toronto-a gentleman 
who is distinguished among American alienists for the 
attention he has devoted to morbid anatomy, as well as 
for the manly frankness with which he expresses his 
opinions. 
A. A male, set. 52, "of large size," suffering from 
general paralysis, his insanity being characterized by 
" great restlessness and violence." During life he 
"neither admitted that he suffered any pain, nor gave 
any indication of so doing." Death arose apparently 
from " cerebral compression." At the post-mortem ex- 
amination attention was, therefore, directed mainly to 
the brain. "After I left the dead-room, believing I had 
seen all that the case afforded, my assistants proceeded 
to examine the rest of the body. * * * They were 
surprised to find pus diffused beneath the muscles on 
the left side '(of the thorax),' and fractures of five ribs 
running in a vertical straight line a short distance from 
the junctions with the cartilaginous portions. No 
reunion had taken place. * * * There was no rea- 14 
son to doubt that the fractures of the ribs had taken 
place before the patient's arrival at the asylum. The 
rectilinear course of the fractures appeared to indicate 
that they had resulted from a fall forward on some 
hard, narrow surface, such as the edge of a board or 
plank. The account given as to his violence and rest- 
lessness corroborated the supposition. This patient not 
only appeared perfectly free from pain or muscular im- 
pairment up to the period when symptoms of cerebral 
or cerebro-spinal compression showed themselves, * * 
but he preached and shouted perpetually."* 
1>. A male, set. 33, "furious and dangerous; * * 
restless, noisy and destructive " on admission, but sub- 
sequently became quiet and harmless. During life he 
complained of no pain, and had no cough. Immediate 
cause of death was, nevertheless, hydrothorax. Post- 
mortem examination revealed the fracture of seven ribs, 
the appearances proving that the fractures here also 
had occurred prior to admission. 
In neither of these cases was any lesion of the ribs 
either diagnosed or suspected during life. " Neither 
of the two would have been known without post-mor- 
tem examination." These and similar cases also illus- 
trate the fact that- 
1. Surgical injuries sometimes occur among the 
insane without external marks of violence and that- 
2. Serious organic lesions frequently exist without 
relative symptoms during life.% 
* Report of the Provincial Lunatic Asylum, Toronto, for 1862, pp. 13-15. 
The same case is also reported in the American Journal of Insanity, for 
April, 1862, and Journal of Mental Science, vol. viii, p. 585. It is there 
stated, in addition, that the patient was " tall and powerful," and that the 
" fractures ranged in a straight line, as if all caused by one blow ; or, most 
probably, by a fall on some hard-edged substance." 
f Vide 34th Report of the Murray Royal Institution, p. 33. 
| Vide 31st Report, p. 13; and 34th Report, p. 36, of the Murray Royal 
Institution. 15 
None but those habitually engaged in the manage- 
ment of lunatics can be aware of the extent to which 
accidental or self-inflicted injuries occur, or of the excep- 
tional character of these injuries. They are exceptional 
in so far as it is (1) frequently difficult to understand 
how they could have been inflicted (I refer to cases in 
which ill usage by attendants has been impossible); 
and (2) in so far as serious structural lesions may be 
developed without the usual accompanying or propor- 
tionate physical indication, or without vital symptoms 
of any kind. Thus, I have known almost all the ribs 
of a young man's side broken without a single outward 
indication, or the exhibition of any kind of symptom. 
No complaint ever emanated from the patient; there 
was no bruise-mark, no lung-symptom, no indication of 
the slightest suffering from first to last. Nor was it 
ever discovered how the injury was inflicted. The frac- 
tures were detected accidentally by manual palpation. 
The patient was confined to bed for some days, his 
thorax tightly swathed in flannel merely as a precau- 
tionary measure ; but no chest or other symptoms were 
ever developed, and the patient never could comprehend 
why he was confined to bed and swathed in flannel! 
It is not surprising that, from ignorance of such facts, 
mere surgical experts, unacquainted with the peculiar- 
ities of injury or disease in the insane, should occasion- 
ally express, in courts of law, opinions that are calcu- 
lated to do great injustice to the attendants of lunatic 
asylums. Dr. Workman is very severe, though not too 
severe, on certain recent exhibitions of this kind in Lon- 
don. Thus, he says, " It has been incontestably proved 
that lunatics afflicted with general paralysis, or with other 
forms of intense cerebral disease, may sustain severe 
and extensive osseous or other lesions, without mani- 
festing the slightest perception of pain or impairment 16 
of muscular activity." Nevertheless, "in one of the 
English cases, * * * * two surgeons gave testi- 
mony to the effect that no person having two or more 
fractured ribs could be free from pain, or freely use the 
eostal or other respiratory muscles! Ne sutor ultra 
crepidam! Before delivering opinion on any question 
relating to insanity, or to the insane, medical practi- 
tioners would do well to acquaint themselves with the 
subject on which they are to testify."* * * * * 
" Eminent medical gentlemen who have not spent their 
lives in the practical study of insanity, would act very 
prudently in abstaining from rash deliverances in all 
questions (relating to the malady) in which they find 
themselves in antagonism with those better qualified to 
give a correct opinion." Until the peculiarities of 
accident and disease, among the insane, are generally 
recognized, and until juries cease to be guided by the 
opinions of experts, who are not qualified to give opin- 
ions of any real value, " how can we hope (as alienists) 
to protect ourselves from the fallacies of their testimony, 
whether before the tribunals of justice, or the more 
terrible ordeal of public judgment-a court whose re- 
visions of error hardly ever come in time to reinstate 
its victims in the position of innocent, much less of 
meritorious men ? I quite agree with Dr. Workman 
as to the little value to be attached to the opinions, as 
applied to the insane, of surgeons in ordinary practice, 
who are unacquainted, by personal experience, with 
the peculiarities of surgical injuries in lunatics. Hav- 
ing myself had frequent occasion to hold consult- 
ations with surgical practitioners, in cases presenting 
surgical difficulty in my own practice, I have found 
their opinions too often not only useless, but absurd; 
* Toronto Asylum Report, 1862, pp. 14, 15. 
f Journal of Mental Science, vol. viii, pp. 582-584. 17 
because the procedure or appliances that are proper in 
the case of a quiet, sane patient, who co-operates with 
his surgeon in the efforts made for his recovery, are not 
equally applicable-indeed, are sometimes singularly 
in that of a violent, restless, destructive 
maniac, who applies all his strength, perseverance and 
ingenuity to thwart the procedure intended for his 
benefit! 
The two preceding classes of cases refer to the non- 
detection, during life, of rib-fracture, or of the osseous 
fragility on which such fracture may depend; but there 
is another interesting group of- 
III. Cases of Rib-Fracture detected on admission 
into Lunatic Asylums, in which the discovery of such 
injuries is due to the medical examination of entrant 
patients that is now generally made in lunatic asylums 
in all parts of the world. There are few asylum phy- 
sicians, of any experience, who have not met with in- 
structive cases of this kind,* and who are not quite 
alive to the policy of making such entrance examina- 
tions, in order to guard themselves or their subordinates 
against the accusations that are sure to be made in the 
event of the discovery, subsequent to admission, of such 
injuries as rib-fracture. Some instructive instances of 
rib-fracture, so detected, are given in the Annual Re- 
ports of the New York State Lunatic Asylum, at Utica. 
Thus, Dr. Gray, who is Physician-in-chief of the said 
Asylum, as well as Editor-in-chief of the American 
Journal of Insanity, reports, among the admissions of 
a single year, one case of fractured clavicle; one of 
fractured ribs and sternum; and one of fracture of the 
arm-all in acute mania. He adds the important par- 
ticulars that, in no case, were these injuries produced 
*Vide 32d Report of the Murray Royal Institution, p. 10. 18 
by intentional violence; or, in other words, they were 
not attributable to mal-usage by attendants, but to 
accident or self-inflicted injury. In no case did the 
patient complain of pain or injury; the fact of bone- 
fracture existing at all being unsuspected, either by 
patients or friends, till the medical examination was 
made by the asylum physicians. " The person who had 
fractured clavicle was very wild and boisterous, and 
moved his arm in every direction; complained of no 
pain, and challenged those about him to fight. The 
first day we were unable to bandage him; and, even 
after we succeeded in this, he tore off the bandages, 
and tore up his clothing and bedding; notwithstanding 
which, the bone united in the usual period, and with- 
out any unfavorable symptoms."* 
In another year, he describes the following two 
cases:-"One had, in jumping from a window at home, 
under delusions, fractured his sternum and clavicle, and 
driven down his neck into his chest, pushing out the 
upper portion of chest and vertebral column so as to 
shorten himself about two inches."! The other was a 
male, set. 53, admitted in a state of high maniacal ex- 
citement (restless and noisy). There were bruise- 
marks on the chest, and emphysema was rapidly 
developed. Rib-fracture was suspected, but proper 
examination of the thorax was rendered impossible on 
account of his restlessness. He died from hydrothorax. 
The post-mortem examination proved the correctness of 
the diagnosis as to rib-fracture, there being five ribs 
fractured on one side and four on the other-the sternum 
also being fractured. J 
Such cases as the foregoing show how unjust and 
absurd it is to ascribe all rib-fracture, in the inmates of 
*20th Report (for 1862), p. 15. 
f 27th Utica Asylum Reports, (for 1869), p. 15. 
127th, (for 1869), ibid, p. 77. 19 
lunatic asylums, to deliberate violence by attendants. I 
believe that, as a body, asylum attendants lie under 
most unmerited opprobrium for supposed brutality or 
roughness in the management of their charges-espec- 
ially of such as are unusually troublesome, by reason 
of filthy habits, insubordination, assault, destructive- 
ness, mischief or otherwise. Attendants would not be 
human, did they not occasionally lose their temper or 
self-command, and allow themselves to be irritated into 
acts which they very speedily regret, and for which 
they have frequently most inadequately to atone. But, 
even in the exceptional cases in which faults of com- 
mission do occur, far too little allowance is made for 
the provocations to which attendants are subjected. 
My own experience has led me, on the whole, to be 
equally surprised and gratified at the forbearance and 
kindliness they exhibit-a forbearance and self-control 
infinitely greater than that which is sometimes exhib- 
ited by their superiors in office, notwithstanding the 
profession by the latter-usque ad nauseam sometimes- 
that their rule of practice in dealing with lunatics is 
that combination of all the virtues embraced in the 
" Law of Kindness " as embodied in the " Non-Re- 
straint System." 
Ribfracture may legitimately be regarded as one of 
the many fruits of the non-use of mechanical restraint 
in cases where it is really required. There can be no 
doubt that many cases of rib-fracture would never have 
occurred had the "camisole" or the old "strait-waist- 
coat" been timeously employed, or had any other 
efficient means been used to confine the arms, legs or 
body.* Since, however, the Conollyan era in the 
history of Han well, it has been deemed culpable in this 
country to make use of this or other simple mechanical 
* Vide 37th Report of the Murray Royal Institution, p. 13. 20 
means of preventing self-injury, or injury to others.* 
There is, and there has long reigned in England a tyr- 
anny of public opinion on the subject of non-restraint 
in the treatment of the insane-a tyranny which, among 
other bad effects, prevents the Superintendents of its 
asylums from acting upon their individual judgment, in 
individual cases, as regards the imposition of mechani- 
cal restraint.f The substitution of personal for me- 
chanical restraint-restraint by attendants instead of by 
mechanical appliances-has led to incessant personal 
struggles, during which it would have been strange 
had rib-fracture not occasionally occurred in common 
with other injuries of even a more serious character. 
The terrorism which is in England exerted on asylum 
authorities by the bugbear of public opinion, the 
anathemas of the fourth estate, and the censorship of 
the Board of Lunacyr is a very real onej-in the eyes, 
* Vide 39th Report (1865-8,) p. 15. 
f Vide Dr. Kellogg, of the New York State Asylum, at Utica, in his Notes 
of a Visit to the Asylums of Europe: American Journal of Insanity, for 
January, 1869. 
| That it is real, is admitted by those of the English alienists themselves 
who are manly enough to speak out-on a subject on which I have found 
them more given to whisper with bated breath, as if it were treason even to 
harbor aspirations or opinions contrary to that worst of all tyrants or despots 
-public opinion ! One English asylum physician, writing me in 1869, says: 
"I quite agree with your remarks about the terrorism that the Lunacy Com- 
missioners exercise in England. All independence is really extinct now in 
this department" (lunacy practice). Another, in 1870, remarks:-" In the 
present state of feeling on the subject of restraint and cruelty in asylums, 
one can scarcely be too much of a coward if he would avoid imputations, 
whose groundlessness is only equaled by their ridiculousness. * * * * 
On the head of what might be called the restraint system as applied to medi- 
cal men," (engaged in lunacy practice) " see the correspondence between Dr. 
Sheppard and the Commissioners in Lunacy, and you will easily understand 
how difficult it is when there is so much spurious sentiment abroad, to avail 
one's self of a useful means of treatment, or of the exercise of a little 
native discretion!" 21 
especially of strangers, who can contrast it with the 
manly independence that exists on the same subject, as 
regards both action and opinion, in America! Eng- 
land boasts of being fas regards the treatment of its 
insane) the country of non-restraint; but it will 
repudiate, I do not doubt, the addition, that it is 
equally entitled to the designation of the country of 
fractured ribs; and it will, I dare say, indignantly deny 
that there can be any proper connection between the 
non-use of mechanical contrivances against self-injury, 
or against the provocation of attendants beyond the 
bounds of their self-command, and the frequency of rib- 
fracture, in common with many minor or major injuries. 
Nevertheless, I believe that, in relation to the causa- 
tion of such injuries, we must regard, as the real offend- 
ers, not the poor defenseless attendants, who are at 
present saddled with the whole of the guilt; but the 
following categories of persons or institutions, viz:- 
1. Such men as Conolly and Gardiner Hill, who 
have promulgated the absurd and mischievous dogma, 
that in all cases mechanical restraint is unnecessary and 
improper.* 
2. All who have adopted this dogma of non-restraint; 
all who have imbibed the extreme views of Conolly 
and Hill, constituting these views their creed quoad 
the management of the insane; including especially- 
(A.) The general public. 
* " The Entire Abolition of Mechanical Restraint in the Treatment of the 
Insane," is the title of a volume published, by Dr. Gardiner Hill in 1857 
(London), which contains the following enunciation of his views:-" Restraint 
is never necessary, never justifiable, and always injurious in all cases of lunacy 
whatever!" (p. 52.) Now Conolly professes to have followed Hill, and the 
school which Conolly may be said to have founded thus adopts as its creed a 
proposition, -which is (to say the least of it) much too sweeping and dogmatic. 22 
(6.) The general newspaper press, with certain ex- 
ceptions. 
(c.) A section, at least of the medical press, such as 
the Journal of Mental Science* and the Lancet:f 
The Boards of Lunacy. 
I do not, however, further enter at present upon this 
subject, referring simply to what has been already said 
on "The Theory and Practice of Non-restraint in the 
treatment of the Insane,"J in the American Journal 
of Insanity for October, 1878. 
* The narrow views of the latter on this subject are in marked contrast to 
the more liberal and enlightened ideas of its predecessor and rival,-the 
Journal of Psychological Medicine, as edited by the late Dr. Forbes Winslow, 
j- In favorable contrast are the views of the Medical Times and Gazette, 
as expressed (e.g.) in vol. ii, for 1868, p. 365 ; and in vol. i, for 1869, p. 254." 
| Meanwhile my views regarding the Disuse of Mechanical Restraint, and the 
substitution for it of Restraint by Attendants, may be found expressed in (1.) 
the 11th Report of the Board of Lunacy for Scotland, Appendix, pp. 270 and 
272. (2.) The following Reports of the Murray Royal Institution: 39th, p. 
15; 37th, p. 12; 32d, p. 13. (3.) The following separate papers: (a.) on 
" Temporary Insanity," Edin. Medical Journal, vol. xi, (1865), p. 449. (6.) 
On " Typhomania," Edin. Medical Journal, vol. xiv, (1868), p. 333. THE 
AMERICAN JOURNAL OF INSANITY. 
♦ 
The American Journal of Insanity is published quarterly, at the 
State Lunatic Asylum, Utica, N. Y. The first number of each volume 
is issued in July. 
Editor, 
JOHN P. GRAY, M. D., LL. Medical Superintendent. 
Associate Editors, 
JUDSON B. ANDREWS, M. D., ] 
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The Journal now enters upon its thirty-sixth volume. It was es- 
tablished by the late Dr. Brigham, the first Superintendent of the New 
York State Lunatic Asylum, and after his death edited by Dr. T. Ro- 
meyn Beck, author of " Beck's Medical Jurisprudence;" and since 1854, 
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