1847]

Objections to the Non-restraint System.

349

insane and in those verging on insanity, by the recital in the newspapers of the various circumstances alluded to, should long since have secured the interference of the State.

While praising the great cleanliness (indeed he passes great encomia on this important item of management, as manifested by the utter absence of bad smells, in all our establishments) and the general good management at St. Luke's, M. Brierre properly maintains that, in so limited a space and so confined a situation, it is impossible for the patients to profit by the progress of improvements in this branch of medical science to the extent they otherwise might do. He also much objects to patients being allowed to sleep in separate rooms, being persuaded that efficiency of supervision and inspection is best secured by dormitories containing from eleven to twelve beds.

After describing Dr. Philp's private asylum at Kensington, he observes→→ "I have examined Dr. Philp's house with much attention, and in regard to arrangement, cleanliness, and comfort, it calls for, in my opinion, nothing but praise; but I must avow that my sympathies are enlisted with that system in which we live continuously with our patients. It is my conviction that the physician and his family should reside in the midst of the insane, so as to have them incessantly under the eye, and receive into his intimate society the convalescent, the monomaniacal, and especially the melancholic. This is my system, in which I am so ably seconded by the devotion of my wife, who keeps those poor suffering souls in her apartments for ten hours together, and it appears to me the means which, united with reading, music, diversions, exercise, and employment, furnishes the most incontestable results."

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Hanwell. This establishment M. Brierre visited with much curiosity and interest, as the great scene of the development of the non-restraint system. To this he has always shown himself an enlightened opponent; believing, in common with many other observers in this and other countries, that however infrequently it may be required, there are cases in which its mild application becomes the greater kindness to the unfortunate lunatic. There can be no doubt that the experience of Hanwell has been attempted to be prematurely generalized in respect to establishments receiving a different description of patients.

"The aspect of the inmates of Hanwell, the information I have obtained in England, and that which was furnished me in the establishment itself, have left me in no kind of doubt as to the description of patients which this asylum is filled with. It is not to be dissimulated that Hanwell is a true hospital of incurables. Almost all the patients brought to it have already been treated elsewhere, and are consequently in a very favourable disposition for the non-restraint system. To convince ourselves of this, it suffices to observe what takes place in our own establishments. At what epoch do paroxysms of fury, cries, agitation, suicidal ideas, the desire to injure others, refusal to eat, or attempts at escape, take place? At the commencement of the disease. It is then only that we are obliged to place the insane in the baths by force, to apply the strait-waistcoat, to fix them in their chairs, or to imprison them in their cells. But this condition lasts a very short time: and never does the excitement of acute mania resist seven or eight prolonged baths. Soon all this effervescence and fury subside; and patients, who seem determined to brave all measures, become tranquil, and follow the customs of the establishment. When new paroxysms occur, they

NEW SERIES, NO. XII.--VI.

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are, most commonly, but transitory: a bath, or a seclusion for a few hours, or the privation of some favourite dish, sufficing to restore order.

"The conditions here are quite different to those observed in insanity at its commencement. Moreover, we should take into consideration the characters of the English people. In England people are brought up with a respect to the laws, a deference for the upper classes, and a submission to custom. There they are slaves to the letter, and individuality, controlled by religion and patriotism, is not incessantly opposing itself to the slightest obstacle. Do not these national differences, joined to the chronic or incurable condition of the patient, suffice to a certain extent to explain the success of the non-restrain system at Hanwell?

"It has been said, and not without foundation, that solitary confinement in a padded cell, and the subjection of a patient by a greater or less number of atten dants are truly coercive measures, the name of which has alone been changed. But even such means are not always applicable. For those who know the insane,' says M. Falret, non-restraint is a fiction, a simple substitution of one means for another;' and I may add my profound conviction, that solitary confinement is a mode of repression a thousand times more painful and more restrictive of liberty than the strait-waistcoat; and that it is contrary to the first principles which should prevail in the treatment of the violent insane, which consist in placing them in conditions the most favourable for taking that exercise in the open air, which Nature so imperiously demands for them."

M. Brierre de Boismont thus concludes his papers :

"In summing up my impressions it will be seen-1. That the English establishments I visited are remarkable for their size, cleanliness, and the care bestowed upon the patients; but that they differ from those of France in their construction, classification, and mode of treatment. In our comparative exami nation we should not lose sight of the serious, methodical, puritanical, matter of fact, but comfort-loving character of the English nation. 2. Some of these are defective in space, and consequently in the means for those agricultural labours, which form an indispensable portion of all effectual treatment. Their position in the midst of towns is also an obstacle to their amelioration. 3. The separation of the Criminal Insane is useful, and I sincerely desire to see it adopted in France with certain modifications. 4. The crowding together of patients, so as to assemble 1000 in one establishment, as at Hanwell, is contrary to the objects of Asylums. 5. The increase of incurable patients which threatens the invasion of the best institutions, should induce measures for the separation of such from those who have yet a chance of cure. 6. The non-restraint system has rendered good service by forcibly directing attention to barbarous systems of treatment in complete disaccordance with the manners of our times, but it is not always applicable."

1847]

Scudamore and Deshon on Consumption.

351

I. ON PULMONARY CONSUMPTION, AND ON BRONCHIAL AND LARYNGEAL DISEASE, WITH REMARKS ON PLACES OF RESIDENCE CHIEFLY RESORTED TO BY THE CONSUMPTIVE INVALID. By Sir Charles Scudamore, M.D., F.R.S., &c. &c. 8vo, pp. 259. London, Churchill, 1847.

II. COLD AND CONSUMPTION; OR, CONSUMPTION, ITS PREVENTION AND CURE BY COLD AS A CONSTITUTIONAL, AND INHALATION AS A LOCAL, AGENT, &c. &c. By Henry C. Deshon, Member of the Royal Colleges of Physicians and Surgeons of London, &c. 8vo, pp. 153. London, Renshaw, 1847.

It is now ten or twelve years-it may be more since Sir Charles Scudamore published a work on the treatment of Phthisis by the inhalation of Iodine. It was not well received by the profession at the time, in consequence of an air of mystery that was cast around the use of the remedy, in a manner which was rightly deemed not altogether consistent with the usage of an honourable profession. Sir Charles thereupon promptly made public his mode of practice; but we have never understood that it has been used with any satisfactory results by other medical men to warrant its general adoption, and it may therefore be fairly presumed that it, like too many other vaunted remedies for pulmonary consumption, has been found inefficacious, if not positively hurtful. We have seen it tried under Sir Charles' own superintendance; but the results of the trial most assuredly did not encourage us to repeat it in our own practice.

It may be as well here to specify Sir Charles' formula, and the directions he gives for using it.

B. Iodinii puri,

Potasii iodid. āā gr. vj.

Aquæ destillat. 3v. 3vj.

Alcoholis 3ij. M. fiat mistura, in inhalationem adhibenda.

"But invariably I direct the addition of a saturated tincture of the dried leaves of conium, which in the most favorable manner softens the action of the iodine solution, and tends to soothe the bronchial mucous membrane. Of the iodine solution I commence with the dose of 30 minims, and increase it by 5 or 10 at a time, in a gradual manner, according to its effects and the nature of the case, till I may perhaps carry it to 240 minims; but, in the majority of instances, I confine my range to 180 minims. Whatever may be the quantity I use for each inhalation, I constantly direct that two-thirds of it be put at first, the other third when half of the time for inhaling has expired; otherwise it would be too strong at first and too weak at last; 30 minims of the tincture is the ordinary dose which I prescribe, and this need not be divided, nor does it in general require increase, as it is so much less volatile than the iodine, and enough of strength remains; but, if much of its soothing influence be wanted, either to allay irritable cough, or to act as a soporific, a drachm, or even a drachm and a half, may be employed; but in such case, it is better to use it in divided portions. The water, to which these preparations are to be added, should be of a temperature of from 115° to 125° Farenheit ;-as a medium, 120°; a little more or less is not material. The whole should be well blended by shaking the inhaler. This

* BB

should be constructed of glass, for a metallic one instantly decomposes the iodine. Its tubes should be capacious, and the inhaler should never be quite half-filled; for if these two last circumstances are not carefully attended to, much inconvenience would arise, the inhaling would be rendered difficult, and which by proper attention is so perfectly easy a process, that an invalid with the weakest respiratory powers does not experience any difficulty.

"The last part of these preparatory steps, for the purpose of keeping up the proper temperature of the contents of the inhaler, is to place it in an open vessel, large enough to allow of the inhaler being a little removed from its sides. Water, of a temperature from 120° to 130°, is to be put into it, enough to rise to about two-thirds of the inhaler; and, to prevent any inconvenience from the vapour which issues, the vessel should be covered over with a piece of thick paste-board, neatly fitted.

At

"Now desire the patient to inhale by making a rather deep inspiration, then to relax, or take off, the lips from the mouth-piece; and to inhale again immediately, carrying on the process effectively, so that the medicated vapour shall pass into the deep air-passages, but not in a quick and fatiguing manner. the first time of using it, five or six minutes will be sufficient; but in the progress of the treatment it may be extended to twenty, twenty-five, or thirty; but I seldom in my direction exceed twenty. The frequency of repetition is from twice to thrice in the day; commonly thrice, for the first four or six weeks." P. 110.

Such is the remedy, from the use of which Sir Charles assures us that he has often derived the most surprising and truly gratifying results in the treatment of even aggravated cases of tubercular Phthisis. He does not indeed trust to it alone; but it is abundantly obvious that the other remedies employed are regarded by him but as adjuvants, and that it is to this one in particular that the credit of his succsss is believed to belong. As might be expected, he gives minute details of some of the wonderful cures that he has effected. The question is, can we place sufficient reliance upon Sir Charles' diagnostic skill to warrant us in recognising the curative efficacy of his practice? It is most unfortunate that he has not adduced any cases from the experience of other medical men, or, at all events, where their concurrent testimony might have been had, in confirmation of his own very favourable statements. In Case VIII., indeed, we learn that another medical gentleman was in attendance; but, alas! his testimony is one of the most damaging things in the world to the credit of our author's sagacity; for the ignorance displayed by this witness of the subject on which he gives his opinion is so transparent, that one might almost suspect that he is not an educated member of the profession. What will our readers say of the information contained in the following passage?

"The left lung gave strong puerperal resonance; the right lung was pectoriloquous, from the root to the mamma; there was much gurgling, and percussion was dull over the greater part of the right side; it was also much smaller than the left, and hollow at the clavicle. The body was much reduced; he had profuse hectic sweats, and the expectoration was copious, puriform, and very offensive; the pulse rapid. His debility was so great, that, to use his own words, he felt to be dying from day to day. The night perspirations were most profuse, and he was often sleepless. On the first inhalation, he expressed himself very sensibly relieved; afterwards, his breathing was never oppressed in going up stairs, as it was before using the inhalation; and, with a little more interval, he was able to walk two miles without fatigue." P. 140.

1847]

Treatment with the Inhalation of Iodine.

353

The report of the case, to which these remarks apply, may be fairly taken as a specimen of the evidence which Sir Charles adduces in favour of his method of treatment. It is headed—“ Tubercular Phthisis; the existence of a large cavity unquestionable. Symptoms of the case highly alarming; recovery, which lasted for a long period." The patient was believed to be in a most confirmed consumption; the right lung being supposed to contain a large tuberculous excavation, and the left one to be infiltrated with tubercles in a crude state. Great emaciation, afternoon hectic, and night sweats, had existed for a considerable time. Now for the treatment that was adopted, and its declared results:

"The patient inhaled the mixture of iodine and conium regularly three times a day, at first for ten minutes, afterwards gradually increased to twenty; small blisters were applied to the chest from time to time; the lotion of tannin infusion, with acetic acid and eau de Cologne, was applied night and morning to the skin, followed by the use of the flesh-brush. Internally, pills composed of pilula. hydrarg, camphor. and c. colocynth. extract, were given at night, occasionally followed by a morning aperient draught; a strong infusion of the cortical part of sarsaparilla, with alkali and gentian, was used twice in the day; and, to procure comfortable sleep at night, he took a soothing morphine syrup, acidulated with diluted sulphuric acid. The plan of diet was changed to one highly nutritious; and such were the languor and debility, that wine, the best port and sherry, was allowed with more than usual freedom. He usually took three or four glasses in the course of the day, in addition to a pint of sound draught porter, not only without disagreement, but with every sense of benefit. He had sometimes alarming attacks of exhaustion, at the commencement of my attendance. His diet had been too much restricted, and he had indeed said that he was 'dying from starvation.' After a few weeks, iron and quinine were administered in conjunction, instead of the other medicines." P. 140.

Within three weeks, "the specific symptoms were most materially relieved;" and in three weeks more, he was on the high road to recovery. Sir Charles saw his patient two or three months afterwards, and then he found" a remarkable diminution in the extent of the pectoriloquism, with an evident amelioration in the condition of each lung. The râles had ceased; and by auscultation there was satisfactory evidence of a very improved respiration. The expectoration continued, but was much lessened in quantity, and almost free from its former offensive odour. It appeared to me that the tuberculous cavity was in a favourable progress of healing; and certainly the whole aspect of the patient was promising a fair recovery; for to regain perfect health could not be expected, when so much disorganisation of lungs had been produced, existing in conjunction with an unhealthy liver." It would appear that this patient recovered his health and strength so much that he was able to return to the West Indies, where he remained for nearly a twelvemonth, that he then returned to this country, "passed the winter in a cold wet part of the North of Scotland, and there took cold very seriously, and had an attack of acute symptoms which terminated fatally."

All that we shall say respecting this case is, that we feel it our duty to caution our less experienced brethren against expecting any thing at all like the success which Sir Charles considers to have been the result of his method of treatment; else they will assuredly be most grievously disappointed.