KNIGHT

192
OBSERVATIONS ON THE CAUSES, &C., OF DERANGEMENT OF THE MIND,
FOUNDED ON AN EXTENSIVE MORAL AND MEDICAL PRACTICE IN THE TREATMENT OF LUNATICS.
By Paul Slade Knight, M.D.,
many years Surgeon of the Lunatic Asylum for the County of Lancaster, &c.
1827.

A PATIENT Who had recovered, said that when they were about to cup him, he fancied they were trying to kill him with a pistol. To avoid conveying an idea so terrifying, Knight advises a method of Baron Larrey; instead of employing a scarificator, he burned tow under a glass, and then used an instrument like a horse fleam. Dr. F. Willis observes that bleeding is sometimes very inconsiderately and indiscriminately employed. Dr. Hallaran says that it does not often seem desirable, and except in recent cases does not even appear admissible, &c. Dr. Haslam thinks it, in strong plethoric and recent cases, the most beneficial remedy; but that in later stages it will not answer, &c. Dr. Mayo says that depletion directly weakens, and may exhaust, by being carried too far; but also prevents weakness by lessening excitation; it is, then, requisite to aim at a medium point. Hill says that it is an undoubted truth, that in fifty maniacs of the highest degree of the sthenic form, not more than from seven to ten will require bleeding, and when sudden and profuse it is always highly dangerous, and never necessary. Pinel says, if without bounds, it changes curable mania to dementia. Georget observes this stage does not require violent treatment ; when abused, it has produced the worst effects. The writer is more copious on this point, from having had many occasions to lament the use of the lancet by the inexperienced. He adopts, and earnestly recommends to practitioners, the observations of Dr. Willis; these, in full, are as follows :-Remedies powerfully weakening the body are sometimes, in the worst cases of delirium, unskilfully resorted to, whether the patient be old or young, strong or weak; whether labouring under the high or low state, blood is copiously drawn. The advice of some authors here is very inconsistent: they extol bloodletting as most beneficial, nay, even essential, but, at the same time, very forcibly demonstrate its impropriety, showing that the nature of the complaint forbids its use. Dr. Knight adds, in the high state, as described by Dr. Alexander Crichton, I never saw bleeding lessen the violence of the paroxysm, but, on the contrary, have seen the excitement augmented by it. Puerperal insanity is of the same description, and admits same remarks. Idiopathic insanity often connected with epilepsy. Medicine has appeared here of very little use, especially if epilepsy be conjoined ; has found small quantities of blood 193 from leeching or cupping, or from jugular vein or arm, to have a constant good effect in mitigating the severity, and shortening the duration of the epileptic fits. But these bleedings should precede the fits, and as near as possible to the accession. When unaccompanied by epilepsy, or any marked bodily disorder, is unaware of any rational mode of proceeding that has not moral treatment and the regulation of diet for its basis. Moral treatment should be commenced by a mild and firm discipline, and however unruly the patient, by availing himself of the authority generally accorded to a stranger in a superior station, has never failed to enforce such a degree of subordination, as to preserve the patient in a tranquil and decorous course of demeanour, so as to make him appear calm and rational to a visiter. Case.-Idoipathic insanity ; &aetlig;. 19 ; a very small head ; three different times under my care in as many years. At home, occasionally violent, and always very irascible, not submitting to any authority, and dangerous to relatives. By a treatment uniformly mild, and uniformly firm, to enforce the rules for his conduct, I succeeded, in a few weeks after his first admission, to make him obedient and well behaved. Plan was this:-periods of rest, meals, exercise, and study, fixed and immutable; when refractory, admonished; if he persisted, instantly compelled to obey ; for instance, if required to take exercise in the grounds, and he refused through mere captiousness, was conveyed thither by an irresistible number of persons ; if when there he would not stand, was speedily conveyed to a dark room ; if he kicked the door, or was guilty of any extraordinary violence, was secured to a proper place prepared in this room ; and if he then screamed, was either suffered to do so until weary, or another habitually noisy though harmless lunatic was put in the same room; this has silenced him in a very short time, and he has come from coercion tranquil and obliging. This is the utmost coercion or punishment I ever inflicted on any lunatic. His study was voluntary, or only enforced by example and persuasion. On the subsequent times of being placed under my care, he immediately conformed to the rules, so that it was extremely difficult to detect any insanity in him.

I have collected the Digitalis purpurea so late as the end of August, long after the plant has ceased to blossom ;and, by selecting those plants which were vigorous, and the leaves downy, and which had not blossom ed that year, I found that they possessed the sedative power of the plant in great perfection. Digitalis is, in the majority of cases, on its first administration, as decided a stimulus as brandy or geneva. It never fails, after a few drops, at least, to reduce the pulse either in force or number, and, in a few instances, both in force and number. Sometimes, however, the pulse loses in power, but gains in velocity, and here, unless we are very cautious and watchful, instead of the pulse descending from a hundred and twenty, the patient sinks into oblivion. Dr. Withering was the first to suggest its use. I have uniformly found it to exert a beneficia effect in allaying the maniacal paroxysm, and reducing irritability, exactly in proportion as it reduced the pulse, whatever the mental, action, whether gay or melancholy. Case.-May 20th. Æt. 35: a compact, strong-made little man ; generally cheerful and obliging ; a lunatic for some time; eyes bright, quick, and prominent; countenance animated and sarcastic ; pulse greatly accelerated ; very talkative, with great volubility ; inquisitive, quid:, and sarcastic in reply ; bowels costive. Purgat. 21st. Boisterous, impudent, noisy; countenance expressive of great excitement; spits at people, and then abuses them ; pulse quick 194 and full, carotids beating powerfully. Rx Tinct. Digit. drops xxv., ter die s. 22d. More noisy and talkative ; offensive as before in conduct ; talking deliriously. Last night began to destroy everything around him ; then confined to his bed, from which exertions to get loose powerful and incessant for last twelve hours. Rx Tinct. D., drops xxx., ter die s. 23d. No alteration. Continuantur. 24th. No amendment ; pulse quick and full. Rx Tinct. D., drops xl., ter die s. Hitherto, digitalis only stimulative. 25th, 9 A.M. Not quite so violent; says "he perceives the medicine does him good;" pulse quick. Rx Tinct. D., drops l., ter die s. 7 P.M. Pulse still quick, and he is more noisy. Rx Tinct. D., 3i., vespers capiend. 26th. Much less excited ; pulse sharp, and 90. Rx Tinct. D., drops lxx., ter die s. 27th. Digit. continued. 28th. Been sick with nausea; this morning more rational and tranquil; liberated from coercion ; pulse soft, and 60. Omitt. digit. 29th. Much more calm and manageable ; passed the night without confinement to his bed ; pulse 42, and rather irregular ; languid ; appetite good, and permitted to eat heartily. From this time forward continued to improve. Has found it necessary, in most instances, to give digitalis for two or three months successively, generally in small doses of mv. to viij. thrice daily. Pulse thus kept steady, and patients been enabled to enjoy amusements, exercise, or labour, and to mingle peaceably with the other lunatics. Have repeatedly omitted it, and insubordination, restlessness, and a slight acceleration of the pulse have always followed. On resuming the medicine, the patient has peacefully and cheerfully returned to his avocations-generally labour, and, under this treatment, has very much improved in health, and been ultimately restored to sanity. The two Misses L- laboured under melancholia religiosa, with a quick pulse. After attending to the stomach and bowels, I put them on a course of digitalis, and they improved us the pulse was reduced, became manageable, and, by the powerful aid of a moral treatment, judiciously planned, and faithfully executed, they recovered, though long, I think some years, had been considered hopeless. I frequently combine camphor with digitalis, and have found its effects rendered more certain and uniform. M. Esquirol is wrong in saying that opium and other sedatives are now rejected by unanimous consent. Dr. Hallaran, for instance, speaks of its being, under certain data, of infinite utility, although opium is the most objectionable of anodynes. Dr. F. Willis uses the henbane, hemlock, and foxglove, to allay irritability. Case.-Symptoms precisely analogous to the one last detailed. April, 1817. Excitement combated with small doses of camphor and &ealig;ther, and by taking a half a pound of blood from the neck. On the third and fourth days, camphor gr. x. ; opii p. gr. l. ; nitr. gr. v. Ft. Bol. vel Haust. 6 q. q. hora s. Continued this till the fifth day, without amendment. At night, on fifth day, Rx Extr. Hyoscyami, gr. xxv., hora somni s. Next morning slept well, and more tranquil during the night. At 5 P.M., out of bed, loosed from restraint; pulse quick and feeble; tongue parched, and covered with fur; very weak ; drink, common water, acidulated with muriatic acid. Next day better; tepid bath. Although he took his food well, I found it necessary to support him. Rx Decoct. Cinchonæ. Ounce vi. ; Extract. Cinchonas, Scruple ij. ;Conf. Arom. 3i. Ft. mist., de qua cap. coch. ii j. quart. quaque hora. Continued this about three weeks, when his bodily health was quite restored ; bark had a decidedly good effect. I have frequently given the Ext. Hyoscyami; in doses of gr. v., every fourth or sixth hour, with 195 the effect of tranquillizing very restless lunatics; and I have, for years, been in the frequent practice of giving it in doses of 20 and 30 grains, at bedtime, with the most complete success, as to procuring rest ; nor have I ever witnessed any ill effect from its use.

I have rarely found that lunatics require more powerful purgatives than other persons ; sometimes, however, they labour under very obstinate constipation, when the most active purgatives may be dangerous, or rendered abortive, and enemas useless, being stopped by hardened, compacted fæces in the rectum. In this state, the following suppository will be available and effective. Rx Extract. Elaterii, gr. i. ad il. ; Submur. Hydr., gr. v. ; G. Gamboge, gr. v. ; Sapo dur, g. s. Ft. in ano imponantur.

Does not recollect ever giving an unusually powerful emetic. Has found Pulv. Ipecac. scruple i. ; Antim. Tart., gr. i., sufficient.

In a great number of instances in which I have used the pilulæ hydrargyri (as an alterative) in old cases, I have never once witnessed a bad effect ; and there is not a single instance where the medicine has not been of some benefit, and many cases in which recovery was chiefly, if not wholly, attributable to it. I have generally combined with it either the carbonate of soda, digitalis, or columbo, according as the corporeal ailments seemed to require these remedies. I should, however, apprehend mischief from its use in most, perhaps in all recent cases, attended with excitement, except as an ingredient in an active purgative. To the insane we should administer no medicines with the use of which we are not familiar, and that, too, after being well versed in the peculiarities of the insane. The inexperienced should never venture on medicines of extraordinary power, as hydrocyanic acid and colchicum ; this is only justified by much previous study, weary experiment, and cautious in. duction. In giving digitalis, if the suggestion of Dr. Withering-to refrain from diminishing or suspending it, until nausea and vomiting occur-has been followed, I have no doubt that death has frequently been the consequence ; pulse the sure index here. The shower bath frequently relieves the headache and irritability in old cases. It may also be advantageously used to allay the irritability and restlessness of some epileptics; by it I have frequently seen the fits postponed. I think it is not in any other cases peculiarly beneficial. The tepid bath, about 96 F., is very grateful to almost all lunatics, and there are very few cases in which it may not be very advantageously used, at least once or twice weekly. Besides promoting a healthy state of skin, on account of cleanliness, it is of much value. The cold, plunging bath, or otherwise, does not appear so useful as the shower bath. The circular swing is a means of cure, possessing immense power; I have found it extremely useful in obstinate constipation, and in dyspeptic complaints with much acid. A fine young woman said to me (1823), "The circular swing did me more good than aught else ; it threw all the sour stuff off my stomach." Shortly after, she recovered. When patients are very unruly, and, at the same time, have either of these ailments, it never fails to be physically and morally beneficial. I do not believe that apoplexy can ever occur here, if the patient be not in a furious state when put in the swing; with this single exception, I consider the circular swing perfectly safe. It should be easily accessible in every asylum, but never be used, except under the direction of an experienced physician. Best time, a little before retiring, as its physical effects predispose 196 dispose to sound and refreshing sleep; it lowers the pulse, unloads the alimentary canal, and relaxes the skin. Giddiness and sickness are speedily produced; sometimes the patient vomits, and passes faces in rapid succession and great abundance along with his urine.

In epileptic insanity, I have freely used the spirit. terebinth. rect., as recommended by Dr. Edward Percival, frequently with much benefit, the fits being often suspended from their usual accession, and when returning, being less violent. Added to this, I have checked the circulation, when necessary, with the foxglove, and aided the stomach and liver with carbo. soda, pil. hydr. and columbo, according as these medicines would be indicated in ordinary practice. Nor have I hesitated to give all these in conjunction, or variously combined ; for I have been long quite satisfied, that much more can be effected by a skilful combination of various remedial means, than by the most judicious exhibition of an isolated remedy. Simplicity in prescription is a good way to learn the practice of physic, but it does not appear to me the most certain method to attain our object. I have seen no benefit from the use of various other means advocated by distinguished physicians: as the cuprum ammoniatum, argent. nitrat. valerian, &c. General health and appearance not forbidding, I have taken blood in small quantities, from ounce iv.-vi., from the arm, or better, from the jugular vein; uniformly shortening the fit, and rendering it much less violent ; this should immediately precede the fit. In these as in all other cases attended by derangement of the mind, the bowels should be always kept in an active state, but not purged. Straightening the hands and limbs has very frequently appeared to put a stop to the progress of the fit ; and where no hurt or violence occurs, I have always permitted, and sometimes advised it. I have frequently known the epileptic fit checked by various means, as by surprising a patient, or sudden!y shaking him ; but cannot recommend the practice, as great irritability has uniformly succeeded, or a state approaching dementia, and the general health has not been so good for a week or more afterwards, or till a regular fit has intervened : so as to checking the aura epileptica. Case.1820 ; Thomas Halliwell, an epileptic lunatic, recovered during the use of spirit. terb. rect. ounce iij. ; Tinct. digitalis, drops viij., ter die s.

He has restored at the Lancaster Asylum 8 out of 58, or I in 7 epileptic lunatics.

Superintendents of a great number of lunatics should soothe the irritable, check the forward, encourage the timid, resist the importunate and petulant, but carefully attend to all reasonable requests. So he must be just in judging between two lunatips. He must neither coincide with a lunatic in his delusions, nor attempt to reason him out of them; best to let them go unheeded, and fix his attention to a very different subject, as much as possible unlike the subject of delusion. Insolence, and even the grossest insults, must be borne with patience, and even good temper, rather than inflict the slightest restraint on a patient unconscious of the nature of his offence. A judicious discrimination, the fruit of experience, here necessary; for when conscious, it is proper, and conduces to recovery to resist him, but with a mild and firm manner, and calm dignity; irascibility of attendants wholly inadmissible. Case.-Intriguing, unruly, and vicious, and detected him contriving a dagger with a piece of iron; on removing it immediately, excessively abusive; muffs then put on; the most revolting imprecations, saying, "I'll murder you yet: I am a mad 197 man, and they cannot hang me for it." Muffs on for three weeks; then strictly watched for a short period ; then, as not violent, no restraint at all. Was studiously reserved to him, till I saw that he was ashamed of his conduct, then treated him with the same cheerful freedom as other patients ; soon good friends, and premeditated assassination forgotten. A patient on no account to be beaten ; strict coercion in a dark room generally sufficient for very unruly lunatics, if done in a mild and determined manner; in all cases of coercion and punishment, this is to be our guiding axiom-mildness and firmness ; and the demeanour of the attendants should indicate regret for its necessity. At the same time, the patient should be taught by the powerful means used, the uselessness of resistance ; this last is of the utmost consequence, since inefficiency be. gets a spirit of resistance, tending directly to excite furious mania. By these methods, few of the insane who cannot be made cheerful and tranquil-the most favourable state for bodily health and mental recovery. Should be a law that all restraint is improper which is not imposed either to prevent the patient from injuring himself or others; and the moral treatment preceding coercion should be inquired into, for necessity of coercion may arise from some prior mismanagement. Occasions, however, when strict coercion contributes much to tranquillity and comfort of patient, and lunatics have earnestly sought it: but these are generally in the early, the delirious stage, when excitement and suspicion of a novel superintendence not yet lulled. On the first manifestation of deranged symptoms, those around the patient should be extremely circumspect, so as not to confirm him, by any conduct of theirs, in his suspicions of his own insanity, for this augments the disease. Every portion of the con. duct and manner, indeed, of those approaching an individual in this condition, must be strictly guarded, as the least things are noticed by him, and delusions built upon them. Case.-A young woman, a nurse in a large public hospital, who after a slight fever became timid and hesitating, and after giving an account of ailments would suddenly insist that nothing was the matter with her; knew every one, and conversed rationally except as to health and duty. Opinions never combated ; if actions required any interference, which they frequently did, was diverted from her object as indirectly as possible : no appetite, thirsty, and exceedingly weak. Gradually recovered strength with the aid of bark : for two or three years after, however, irascibility instead of previous mild manners ; however, discharged same duties as before. Thinks a high case would have been produced by the strait waistcoat, &c.

Drafts is a very suitable game in weather unfavourable for outdoor exercise ; is a gentle stimulus, without exciting the passions ; many lunatics play an excellent game. Mentions one never beaten, who wrote games out; his health unfitted him for labour, and he was thus relieved from hopeless ennui. Ninepins is also well adapted : pins and bowl to be made of strong leather stuffed with horsehair; he introduced this eleven years since, and yet it is noticed by a periodical as a recent invention in Berlin ; it is greatly preferable to drafts, as being a fine exercise ; calculating the score also disciplines the mind to accuracy. The insane should never be encouraged to write. If anxious to do so, may be per. mitted to write a short letter to their friends, provided they are sedate, and not easily excited or depressed ; but even then bad effects frequently conspicuous. This is because they introduce their insane notions, the exertion excites vivid emotions, confirms them in their imaginary characters, 198 and they finish writing much more restless lunatics than when they sat down. I never, in any one solitary instance, witnessed any benefit from permitting lunatics to write on any subject, where their own insane notions could be introduced. Walking is so obvious, that I only notice it to say that lunatics should never stroll alone, because, if excited, they will take too much exercise ; if depressed, not enough ; and they seem here peculiarly prone to indulge in their insane reveries.

Amusements are generally the first occupations which patients can be induced to adopt. Useful labour should succeed as soon as possible to amusement, if the prior habits of the patient will permit; and many are susceptible of benefit from labour, whose intellects unfit them for amusements. The mind seems always more or less active. excursive, and consequently restless, if unemployed; and therefore should be exercised and carried out of itself, either by manual labour or some favourite amusements. Some stated task should be imposed on all. It is disgraceful and reprehensive to permit them to idle away months and years. Safest labour as to means, and best as respects moderate and wholesome exercise, the wheelbarrow. Utmost advantage to his patients, rich and poor. Case.-A wretched hypochondriac, in such a state of apathy as to be considered an idiot : he would be constantly turning about in one place, pulling in pieces a particular part of his dress, and tying it in knots; heaving deep sighs ; snatching a glance at the bystander. Used various means to arouse hire, and after a considerable time resolved to try the wheelbarrow. Persuasion, &c., unavailing. Then made him grasp the handles of a barrow, and two assistants held his hands there. Then, after one or two days farther efforts, with persuasion, &c., tied his hands to the handles of the barrow with handkerchiefs, and putting him in the midst of a line of five or six barrows, he was constantly urged by the other patients. He demurred at first, but shortly set to work. furiously. This victory was followed closely up, and in a few days he was an excellent workman without compulsion, and in about a week from choice. Other moral measures were used also, such as communicating stirring news, &c. ; and after six or seven years' total silence be began to converse, proved to be an acute and well-informed man, and recovered. Subsequently, however, he was grossly ungrateful. From the pleasure derived from useful occupation, permission to labour with the barrow maybe made a source of indulgence, and its restriction, of punishment. Outdoor labour of every kind is much better for corporeal health, and consequent sanity of mind, than any other; especially in those numerous cases where the stomach is obviously much disordered, and its cure is generally, perhaps always, followed by the restoration of sanity. It is therefore of the utmost importance that simple means be provided for every gradation of exercise and labour. To the women, cooking, washing, ironing, mangling, cleaning, making and mending clothing, &c., are healthful, and answer well the main objects. No experience as to agriculture in women; doubts whether it would make them more tranquil; but in his practice, in the same species of insanity, their number of the unruly as compared with the male insane, is at least 2 to 1. Women, too, will not amuse themselves with drafts ; it seems too great an exertion of intellect. They enter readily and gayly into the dance ; sometimes they will play battledoor or romp; but, in general, they take much less interest in mere amusement than the men, and those too indolent, or not well enough to be employed in some useful occupation, will rarely attend, 199 even for a short time, to anything requiring exertion of body or mind, unless strongly prompted ; whereas, on the contrary, the majority of men of the sarne class will always be found playing drafts, ninepins, or, if permitted, plaiting straw, and making of it hats and bonnets, baskets and table-mats. In the straw manufacture the whole affair is left to themselves; and they have a regular systematic division of labour, although a novel occupation to every one of them. One picks and sorts, another plaits, another cuts the ends of the straw with his thumb-nail, knives and scissors being prohibited. Pecuniary gains small. This evinces, incontestably, that the spirit of industry is incomparably stronger in the insane man than in the insane woman.

There seems an innate devotional feeling in every human soul, and this dim longing is gratified in religious worship. From numerous complaints as to the want of this observance on the part of patients, which proceeded, in some cases, from those who undoubtedly felt a longing desire, he had it instituted. He is opposed to a daily visiting clergyman, as there should be no clashing authority, &c. Of sixteen letters to the committee of the New Bethlehem, in London, for 1817, from various physicians and superintendents of lunatic asylums, fifteen speak favour. ably of the effects of religious instruction in their respective establishments, and in the other none had been resorted to. Dr. Monro, one of the physicians to the Bethlehem Hospital, states, "A general augmentation of comfort amongst a considerable class of the older and more orderly patients. Danger, lest such instructions alarm and dishearten a mind already enfeebled by disease; and more than one instance of a similar result has fallen under my observation, where, so far from advancing the cure, it has even retarded recoverv. I (Dr. M.) cannot with a safe judgment recommend its exercise in recent cases; but, assuredly, I both can and do approve of the frequent exercise of religious instruction and consolation amongst many of the incurable." Dr. K. appears to oppose instruction or worship on week-days, but approves of Sunday exercises. Result of his observations: 1st. Chief advantage of services on Sunday, the satisfaction from having performed a sacred duty; though the majority incapable of appreciating the merits or importance of the service Insane notions have sometimes been called into action by the service. 2d. Orderly conduct depends on management. If properly regulated, few will behave improperly in the presence of their physician and his servants. 3d. When performed on Sunday, nine out of ten recognise the pleasing solemnity of the day. 4th. Even recent cases, if not excited, or very prone to be so, may advantageously attend. 5th. Never saw any injury to convalescents, but much benefit. 6th. No permanent effect, beyond immediate advantage of allaying the importunity and restlessness, resulting from absence of Divine worship, rendering Sunday (instead of a day of idleness, gloom, and discontent) the most cheerful and pleasing day in the whole week. It is the duty of the physician to ascertain whether religious misconceptions are.making injurious impression on the intellect, and it is also his duty to yield to the religious desires of his patients in every degree, that will not endanger their intellect, or impair their health ; this has been the rule of his own conduct.

Of the power of music, even in a very imperfect state, to tranquillize the insane, and induce an unusual degree of cheerfulness, I have had instances far too numerous to specify ; nor have I witnessed from it a bad effect in any one individual. At the same time, I do not think it 200 proper, or even safe, to permit all lunatics, indiscriminately, to hear music. Never ventured to try it in excited and recent cases. Psalms and hymns peculiarly fitted for the devotional exercises of the insane: they always appeared to afford much gratification to all classes of lunatics ; and am satisfied have, in many cases, contributed to recovery. Though less experience as to effects of music on the females than the males, have seen enough to conclude that, properly conducted, it may be made more efficient in the former than in the latter ; but will require more caution in its use, as acting more powerfully. Case.-Married ; young; melancholic; remained in her room gloomily brooding, and would not come near the music, though repeatedly urged. At length, one evenin?, when eight or ten couples were merrily dancing, she slowly and cautiously peeped out of her room, seeming afraid and ashamed of being seen. In a day or two became less reserved, and ventured from the door of her room ; had her brought among the dancers, resisting, though evidently "nothing loth :" she paused a minute, then suddenly turning round, drew her shawl off, and began dancing gayly. From that moment ceased to labour under melancholia, and shortly after was discharged, well. M. Esquirol says, that "music well managed acts with considerable power, both on the moral and physical frame." Dr. K. feels no hesitation strongly to recommend vocal and instrumental music, as an important means of cure.

As to classification, reprobates the idea of dividing according to the theory of the name, as the dirty, the noisy, epileptic; for one epileptic, and so on, may be quiet and inoffensive, another violent arid dirty, &c. With regard, indeed, to the epileptic in particular, the peaceable lunatic is often a very useful companion to the former; and, vice versâ, many epileptics, at intervals of weeks and months, are very rational, and excellent companions to the convalescents. Placed together in considerable numbers, they would embitter each other's lucid moments. I have found that in classing lunatics, only very general rules can be adopted. The vicious and violent, curable and incurable, form one class ; tile very noisy are rarely long so, and can be scarcely said to form a class. When females annoy their companions (for this is far more frequent among the women than the men), if but one, she should be secluded in a dark room ; if more than one, they should be put together ; mutual uproar makes one or both eventually become quiet. They may then be quietly restored to the class they came from. The peaceable and decently behaved, whether curable or incurable, and the convalescent, should form a class. The sometimes unrulv, and the very talkative and obtrusive, and the more slovenly and negligent as to person than the generality, should form another class ; those with offensive habits another. In each of these may be several grades; arid translations from one to the other may frequently be necessary. If patients are permitted to associate with the person immediately in charge of them, they will of themselves form very useful subdivisions. The more rational and industrious will court the society of the keeper or servant; and the latter will employ them in many little confidential duties ; this, from the consequent good understanding, I have found very conducive to the comfort and recovery of the patients.

Case.-Æt. 35 ; fasted fourteen days ; told me he had not experienced any benefit from eating ; that it had frequently made him ill ; on asking it, said he would take any medicine; I told him, then, that it would be 201 necessary- to take it in beef tea. A pint was sent, and he took it; and it was repeated, until his appetite returned, when he again ate his food as usual : lie was finally- discharged, well. I have frequently known food r,fused when otlcred at stated periods, and yet taken readily enough when the patient iN as permitted to eat %% hen he thought proper. The lunatic was shut up in his rooiu, and his food as taken to him and left without comment: the dinner was always made peculiarly grateful to the palate. I cannot recollect more than one instance where I thought it expedient to force a lunatic to take food, and I believe that in that case I acted wrong. Proper management will render forcing very generally, if not always, unnecessary; patience arid address seem all that are necessary. Means of compulsion should he constantly, nevertheless, in the hand, of a physician, as it may be sometimes required to administer medicine instanter. Case.-Æt. 45 : seized a vial, containing a drachm of lunar caustic in solution, and at once drank it off. Within a few minutes I saw him ; he had been vomiting, looked excessively pale, and appeared very weak. Beef tea being at hand, dissolved two ounces of common salt in it, and desired him immediatelv to drink it off. He obstinately refused. Instantly had him secured in a reclining posture; introduced the key into his mouth, and had no difficulty in making him swallow the basin full, nearly as speedily as though he had voluntarily drank it. Purged afterward, and a short time allowed broths, &c., and sustained no very serious injury, though lie never recovered a healthy appearance. Mr. Charles Newington has invented an instrument, consisting of a syringe with a tube, covered at the end, to pass behind the last masticating or jaw tooth, when the teeth are pertinaciously closed. It seems to answer, but perhaps might be made more efficient if another tube were fitted with valves similar to the stomach-pump, so that, on being introduced, it might be kept there until feeding was finished. The key consists of a handle and stem pretty much like a corkscrew, and instead of the screw at the end, an oval part, being a plate of iron about a quarter of an inch thick (the edges being rounded and polished), and of a size to fill the cavity of the mouth whetl tile jaws are extended : in the centre is a hole about an inch in diameter. In using it it is to be introduced edgewise, and then turned, so that it will fill the whole space, or nearly so, behind the upper arid lower fore-teeth, and then the food is introduced by the hole. By a pump on principle of the stomach-pump, and this key, either food or medicine may be injected into the stomach in any quantity, without resorting to the harassing and very offensive operation of compressing the patient's nostrils, so as to force him to swallow before he is enabled to breathe.

Means of restraint, source of much difference of opinion : several years since, procured from various places, particularly recommended for their humane methods, their apparatus; avoiding injury seemed the leading object, bbt its execution was singularly deficient. Objects to the straps, strong, carefully padded, and covered with soft wash leather, the means he found used to secure the arms and legs, as pressing too much, if tight enough, and from perspiration caused by the padding, producing friction straps in Dublin asylum round arms, much better than padded wrist straps ; but this also preventing free circulation, was, like the last, inferior to the strait waistcoast, but many powerful objections to latter. After trying various methods, thinks best, 1st, muffs; 2d, hand-muffs, or, as now called, mittens. It will frequently please a patient to 202 give him his choice between the muff and the pocket-muff. 3d, sleeves these are by far the best way he can imagine of securing a lunatic. Consist of two large strong leather sleeves, closed at the bottom, and fastened across the shoulders by a strap, and staple and lock, and again the same means across the back by the elbows; the sleeves being attached in front by a broad short belt across the upper part of the breast. In extreme cases, where the patient makes violent exertions to break the strap across the back, also adds another strap, passing round the thigh, and through a loop sewed to the bottom of the sleeves, and then he stands with his arms, as it were, loosely by his sides; in this position he can make but feeble efforts with them. If the common leg-locks be added, the patient will be rendered almost powerless, without any injurious pressure what. ever, although his exertions should be the most violent and incessant. Patients have worn these sleeves for months, without the slightest injury from them. If, at any time, they or the muffs are found too warm, small holes may be easily punched in them so as to admit of ventilation.