1847] Imprisonment of a Lunatic for Debt. 419 Lieut. F., who had been for many years confined in Haslar Hospital, had been brought to Winchester Gaol under an arrest for debt, he being both insane and blind! Dr. Anderson, the Deputy-Inspector of Haslar, and the creditor, were summoned before the Board. Dr. Anderson stated that the unfortunate Lieutenant had inhabited Haslar for twenty years, during all which time he continued insane. He was entitled to a pension of five or six shillings per diem half-pay, from which one and sixpence were deducted, and the remainder paid over to his wife. By one of these violations of common sense which law seems privileged to commit, it seems that, although this poor creature was not responsible for his own actions, he was for those of his wife; and she having got into debt, he was arrested, the Lords of the Admiralty having commanded, under the advice of their solicitor, Dr. Anderson, to refrain from preventing process being served on him. The creditor who caused the imprisonment was a dissenting clergyman (alas!) and schoolmaster, to whom the wife had become indebted for the education of her children. Upon the strong remonstrance of the Commissioners this man consented to the liberation of his victim, after an incarceration of some weeks, which would, without such interposition, have been prolonged for three months more, during an inclement winter, until the arrival of the Insolvent Commissioners. After examining the state of the law upon the subject, the Commissioners observe-" It appears, therefore, that Lunatic Debtors are deprived of the benefits which the Law extends even to criminals;" and add— "In reference to this case, we must observe, that attempts to proceed against lunatic patients are by no means infrequent, and that we have upon all occasions felt it our duty to interpose, as far as we are able, for the protection of the Insane. It appears to us that the person of a Lunatic should in every case be privileged from arrest and execution, and that some means should be taken (either by the appointment of a Guardian as Trustee or otherwise) to insure him sufficient means of defence to any suit or action that may be brought against him. Without some safeguard of this sort, any Lunatic Patient, however urgently he may require medical treatment, may be seized within the limits of an Asylum, and thrown, like Lieutenant F., into prison, to make good a debt for which he was never liable; and even where the person of a lunatic may not be taken, his property is liable to be distributed, for a debt to which he may have a valid legal defence." P. 150. It is to be hoped that humanity and common-sense will not be again violated before an enactment embodying this suggestion can be passed. That such a one should still be wanting seems incredible. The Asylum or Hospital for Lunatics at Lincoln is a strange place, and an account of an investigation of its condition entered into by the Commission is here given. It may be taken as proving by the experimentum crucis the utility of efficient and frequent inspection, for being a subscription asylum, it is not visited by the magistrates of the county, nor are its rules submitted to the Secretary of State, as is the case with County Asylums. The duties of inspection are self-performed by the body of persons who choose to constitute themselves Governors for Life by the payment of twenty guineas. And a despotic set they are, as may be judged of by the fact, that they pass decrees prohibiting their medical officers employing narcotics, and in various modes interfering with the other measures they may think fit to prescribe. There are three physicians attached to the place, each of whom successively takes the patients for a month. The same practice does or did prevail at the County Hospital: so that a patient might easily be prepared for an operation by one surgeon, undergo it at the hands of another, and have the after-treatment directed by a third! As in no town in the kingdom is the adage " Doctors differ" so completely verified as in this one, the patient has the full advantage or disadvantage of such a condition of things. The Governors seem to regard it as an excellent arrangement, and in their defence in answer to the criticisms of the Commissioners, observe: The effect of the rotation is that of a standing consultation. The pointed attention of each Physician is drawn to the case by his individual responsibility (?); successful modes of treatment are adopted and continued; a course of unsuccessful treatment is discontinued; points of doubtful practice are forced into discussion." The physicians have the most diametrically opposite opinions upon the treatment of insanity; and it seems too bad to place the patient in the way of this cross-fire. "One of them, Dr. Nicholson, advising classification; prescribing opiates occasionally to allay the restlessness of patients who are sleepless or in an excited state; and recommending the adoption of beer or wine as part of the ordinary diet, and frequently ordering them for particular patients; the other two (Dr. Charlesworth and Dr. Elmshirst) being adverse to classification; rejecting opiates in all cases; and ordering beer or wine very rarely, and then only as medicines in extreme cases when stimulants or tonics are imperatively required. It is worthy of remark that, there is a standing order of the Governors (who are not a medical body) by which the use of opiates to produce sleep, as also the use of beer and wine as parts of the diet, are prohibited. It appears by the Physician's Journal,' that Dr. Nicholson visited the hospital throughout the whole of August, and that he was succeeded by Dr. Charlesworth, 1st Sept. Dr. Nicholson on the 30th Aug. directed porter to be given daily to 16 patients and wine to one. On the 1st Sept. Dr. Charlesworth ordered 12 of these to discontinue the porter, and the one to discontinue the wine." P. 359. Other instances are added, but we need not cite them; the inherent mischievousness of such an arrangement being apparent enough. The Commissioners also object to the absence of due classification; to indecencies which have arisen from insufficient separation of the sexes: to the noise, turbulence, and frequent casualties; the allowing troops of strangers (311 in one month) to visit the wards; to the time of the House-surgeon being occupied by attending these idlers through the wards, and various other duties foreign to his proper province, which he is prevented fulfilling by an order of the Governors, that prohibits him from prescribing for the patients; to the insufficiency of the diet, &c. &c. &c. The Governors have made a most flippant reply, ill-suited to the gravity of the subject, and the courtesy with which the original strictures were delivered. We hope the time is not distant when an establishment possessed of such fine capabilities as this asylum, will not be permitted to waste them in the reckless manner it has hitherto done. That the non-restraint system ever succeeded under such a management speaks volumes for its power of universal application. 1847] Treatment of Insanity in the English Asylums. 421 Present System of Medical and Moral Treatment of Lunatics in the English Asylums.-This forms the last part of the Report; and is unquestionably a document of great importance, as exhibiting the practice pursued at the chief asylums of this country, obtained by means of a circular letter containing queries addressed by the Commissioners to the various Medical Superintendents. To these, answers have been returned by upwards of fifty of these gentlemen, including in the number nearly every name of eminence in this department of medical science. The substance of these replies is analytically distributed for the purposes of reference, and some of them extend to a considerable length. We can here only indicate the general tenor of their statements, referring our readers to the Report itself, as containing the only authentic account of the opinions and practice prevailing among those whose opportunities constitute our authorities upon this important subject. The queries related to four principal topics: viz. the treatment adopted in Mania; in Epilepsy complicated with Insanity; in Paralysis connected with Insanity: and in Melancholia; and, upon consulting the various replies given at length in the Appendix, we find far less discrepancy of opinion than we were prepared for; and less we think than will be found to prevail upon most other medical topics. 1. Treatment of Mania—(1.) General Bleeding.—The replies are nearly unanimous in condemnation of this, and even the few physicians who approve of its employment under peculiar circumstances, just as strongly disapprove of it as an ordinary remedy in mania. The Drs. Fox of Brislington House make an important observation. Previously to admission, most of our patients have been under medical treatment, and we have often had reason to suspect that the general bleeding to which they had been subjected has been detrimental, and that it has in some cases induced permanent fatuity;" and Drs. Miller and Shapter of St. Thomas's Hospital, Exeter, in like manner state that "the experience of its employment derived from those cases admitted after it had been freely practised, shows it to be evidently injurious, by breaking down the constitution, and conducing to an incontrollable mania, very apt to settle down into Dementia." Dr. A. Sutherland" considers the violent paroxysms of the acute stage as depending not on inflammation, but irritation. He thinks the arterial congestion which is found in cases p. m. the result not of inflammation but of irritation-an effort to repair the mischief sustained in some cases, and in others the effect of anæmia, which venesection would aggravate. Dr. Conolly considers it as " rarely admissible and generally dangerous in insanity." Those physicians who countenance it at all restrict its use to cases in which great plethora, threatening apoplexy, exists-never employing it as a mere means of quieting a paroxysm of excitement. (2.) Local Bleeding, although condemned by some experienced practitioners, is, by the great majority, spoken well of. (3.) Emetics and Purgatives.—The former of these, once so constantly employed in the treatment of mania, are now laid aside by nearly all experienced practitioners, the endeavouring to diminish excitement by smaller doses of antimony finding, however, favour in the eyes of several. “I am not in the habit of prescribing emetics," Dr. Sutherland observes, "for two reasons, 1, because in these cases, where there is a tendency to congestion in the capillary vessels of the head, they are known to increase it: 2, because the nerves of the stomach in insanity, as those of the intestines, are often less sensitive to impressions than in a state of health, owing to the disordered state of the functions of the brain, and it is sometimes necessary to give a large dose before the stomach will act." The beneficial effect of Purgatives, on the other hand, seems to be everywhere acknowledged, as indeed the frequency of the existence of constipation might have, à priori, led us to anticipate. Those of a strong character are generally preferred, and several practitioners speak very highly of the preferability of Croton oil. (4.) Anodynes.-A prejudice long and generally prevailed against the use of this class of medicines in Insanity; but they are now looked upon by our most experienced physicians as very efficacious remedies in several forms of the disease-and especially so in cases of extreme violence and maniacal excitement. The different preparations of opium and henbane, but especially of the former, are those generally preferred: while, as to the efficacy of the Indian hemp, much difference of opinion seems to prevail, due, doubtless in some degree, to the difficulty of obtaining the substance genuine. Dr. A. Sutherland has some very interesting observations upon this class of remedies, a few of which we extract. 66 These remedies are, according to my experience, of essential service in those cases of insanity which border closely upon delirium tremens, in cases of puerperal mania, in the acute stage, and particularly in the paroxysms and sleeplessness of mania, in cases where there is great nervous irritability from poverty of blood, and in cases combined with cachexia, from starvation and other causes. They seem to be contra-indicated when there are symptoms of incomplete general paralysis and congestion of the head. Prescribed merely because the case is one of insanity, without taking into consideration physical symptoms accompanying it, or not in proper doses, or not given sufficiently often during the day as well as during the night, these remedies disappoint the practitioner: they keep up irritation, and add to the excitement instead of allaying it. I have sometimes seen a very simple case_converted into a very complicated one by the excessive use of anodynes. At St. Luke's I have been in the habit of prescribing the Acetate of Morphia in solution with distilled water-in private practice I often combine it with distilled vinegar (a very old remedy in insanity). The hydrochlorate is combined with advantage with dilute hydrochloric acid. I have found the meconiate of morphia very serviceable in cases where the two former preparations have not agreed with the patient. Hyosciamus and Conium are also very serviceable in the treatment of insanity. I am in the habit often of prescribing the former in those cases where it is essential that the bowels should not become constipated; and as it also acts upon the kidneys and skin, it is likewise useful when we wish the increase of the secretions of these organs. Combined with potassio-tartrate of Antimony, henbane is useful also in paroxysms of furor. I have seen considerable lassitude follow the administration of træ. hyoscy. 3j. with gr. of the former ter die. This is, of course, in some cases, not to be desired. Combined with camphor, opium allays the irritability of those suffering under mania complicated with delirium tremens, and in the incipient paralysis of the insane, tartar emetic is the remedy I place most confidence in. Conium is 1847] Treatment of Insanity in the English Asylums. 423 very useful, either given alone, or in combination with hyosciamus and opium. The boasted effects of Camphor have not been realized to the extent, at least, which some of its advocates have insisted upon. I think, however, its effects in allaying uterine irritation cannot be doubted. The combination of hop, camphor, and henbane, is valuable in such cases. Stramonium is a remedy which has not succeded in my hands, although I have tried it in large doses." P. 391. (5). Baths of various kinds, especially the tepid and shower, are well reported of in almost all the answers: many physicians have derived great advantage from the simultaneous application of cold to the head. Still, baths are seldomer resorted to in this country than is desirable; and far less often and for very much shorter periods than in France. (6). Diet and Stimuli.-Medical practitioners connected with Asylums are nearly unanimous in recommending a generous diet, most of them advising the use of beer, wine, and other stimuli. As patients will oftentimes refuse food, Mr. Philipps observes they should at all times be well supplied with it, so that they may have access to it in the sudden fits and starts during which they will consent to take it. Dr. A. Sutherland frequently finds the various tonics of great use in the cases met with at St. Luke's, in some of which the insanity has indeed been induced by poverty and wretchedness. 2. Treatment of Melancholia.-There is, perhaps, less diversity of opinion as to the treatment of Melancholia than with respect to that of Mania. Most of the medical officers, who have given us an account of their practice in this form of mental disorder, seem to agree in directing their attention to the state of the alimentary canal, and the organs subservient to the digestive functions; and to be of opinion that, in cases of Melancholia the primary disease is often to be sought in some derangement there seated, and that great benefit may be derived from the means which tend to correct disorders of this class. Such are the use of purgatives, tonics, and stimulants of various descriptions. There is, however, likewise a prevalent opinion, expressed or implied, that the vascular system of the brain is in some manner oppressed and disordered in Melancholia either secondarily or primarily. Many of the remedies resorted to, seem to be prescribed upon this hypothesis, and if they are really efficacious and of benefit, which may be supposed from the fact that so many judicious and experienced persons agree and persevere in their use, this must be considered as affording evidence that the hypothesis in question is well founded. "There is a greater amount of testimony for the beneficial effect of counterirritation acting on the head in this disorder than in Mania; and even bloodletting, both general and topical, seems to have been in some instances fouud more useful in Melancholia than in maniacal affections. All the Medical Superintendents who have entered into the nature and purport of our enquiries, are unanimous in advising, as indispensable for the cure of melancholia, a regimen calculated to promote health and vigour of body and mind, viz., much exercise in the open air, cheerful society, abstracting the thoughts as much as possible from gloomy impressions, and some advise the use of wine and other stimulant drinks. Most are of opinion that if sleep does not follow a day spent in exercise of body, it should be procured by the use of some narcotic remedy, such as opium or henbane." P. 205-210. Dr. A. Sutherland has known prolonged courses of mercury of great avail, and believes that medical treatment is frequently prematurely abandoned. Dr. Willis of Shillingthorpe considers the preliminary action of |