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connected behind by another strap so as to keep the elbows near the hips and
prevent the abuse of the upper arm in striking persons, the forearms being free
and allowing the patient to feed himself, &c. I am indebted to Mr. Robert Gor-
don for an ingenious contrivance to keep the armlets secure: it consists of two
screws screwing one into the other as sketched. The
brass screw (A) is a right-handed one and is intended
to be screwed into the leather or strap and remain there;
the hole should therefore be cut a little less in size and
the brass be driven with a screw-driver; then the steel
screw (B) is a left-handed one, that is, it drives the oppo-
site way and thus does not loosen the brass; they are of
enormous strength.
The object of the restraint was to provide for the general security against
personal injury inflicted by the patients and as a means of protecting persons
from his propensity to attack and injure them, less objectionable for the patient
himself than very frequent seclusion would be, which very frequent seclusion
would be otherwise necessary.
Until the occurrence of this case I had always believed and held restraint
worn on the person could only be necessary in a case of surgical injury putting
on an unfavourable appearance from neglect or for a strictly medical purpose, e. g.,
to obtain the recumbent position when, as in a few particular instances, the
choice lies between securing that or accepting death from exhaustion, or in
a certain small number of cases demanding unusual precautions to frustrate
attempts at self-injury. But the very exceptional nature of this case (to my
experience) compelled me to disregard preconceptions never designed to embrace
such and to treat it strictly upon its own merits, thus causing me for the first
time to apply restraint for the prevention of violence offered by one patient to
others.
The history of this man's conduct ever since his admission is an almost
unbroken series, daily repeated, of violent assaults, knockings-down, kicking,
&c, of attendants and fellow-patients. After enduring or permitting this for
a long period he was placed in seclusion. I became convinced that as my duty
extended to the protection of the patients at large equally with that of each indi-
vidual one, I was bound to limit this man's power of doing bodily mischief not
less for his own than the general good. I therefore adopted the restraint I have
described; and in applying it felt I was not acting inconsistently with that other
duty of avoiding uncalled for expedients in the management of particular cases.
I ought not to omit to mention in terms of praise the forbearing conduct of the
various attendants who had the immediate charge of this case and who sustained
many hurts in the course of their duties.
Previous to the imposition of the restraint he was the terror and complaint
of the patients in his ward: with one blow he shattered the ribs of an unfortunate
patient. His build is admirable; he is light and of great muscular development
and agility, seems to have the skill of a practical fighter, and under the impulse
of his disease has no sense of fear.
Judged by non-restraint as a principle permitting of no deviation in practice
this case is of importance. I believe I am justified in deeming the case a rare
one, not simply because of the violence displayed, that being a common feature
in insanity amongst Burmans, but because the homicidal propensity was a ruling
and unvarying passion, pursued without delirium, but in a cool, calculating way,
and independently of provocation from without. In these respects it will be seen
to differ widely from the irritable and transitory explosions of mania, with the
shifting of the attention from object to object in that disease, as also from the
perhaps still more dangerous blind but passing fury of the paroxysms of delirium
which sometimes attend epilepsy.
Statement No. VII.—The causes of insanity are as follows : to physical causes
chiefly are set down 3 to ganja, 2 opium, 1 ardent spirits, 1 disease of the brain,
and 5 fever; while among the moral causes 2 were from loss of property, 3 grief,
2 domestic troubles, 6 poverty, 2 religion, and 1 fright.
In 28 cases no cause is assignable.