No. 1363.

OCTOBER 13, 1849.

The Croonian Lectures.Delivered at the Royal College of Physicians in 1849.

BY JOHN CONOLLY, M.D.,PHYSICIAN TO THE MIDDLESEX LUNATIC ASYLUM AT HANWELL.

LECTURE I.General Description of MaÍ1ia.

MR. PRESIDENT AND GENTLEMEN,-Encouraged by the atteu-tion with which I was honoured when I appeared before youas the Croonian lecturer last year, (1848,) I propose on thisoccasion, also, to offer you some remarks connected with thesubject of insanity.Having, at Hanwell, constantly before me the spectacle of a

crowd of spoiled and ruined minds, my thoughts are so habitu-ally turned to the various phenomena they present, and thevarious modifications of which they are susceptible, that Ishould find it difficult to direct them long enough to any otherprofessional subject to justify my addressing you upon it. Butthe interest that is naturally attached to a malady often mys-terious in its origin, most uncertain in its course, and fearfulin its results, will doubtless excuse my requesting your atten-tion to it again.Few, even of those whom I have now the honour of address-

ing, can have lived many years in the world without witnessingor hearing of some form of mental disorder falling suddenly,unexpectedly, fatally, on some one whom they have known orbeen familiar with. Its shortest attacks may have been reco.vered from; but the temper of the brain has been doubted forever afterward, and the position of the individual in society,won by previous exertions of his mind, has, you all know,seldom been regained and maintained. The young and pro-mising may become insane, and after some months of excite-ment, fall into hopeless imbecility; their elegance lost inmorbid negligence, and their talents extinguished. As lifedeclines, we observe too many for whom hope dies, and me-lancholy closes the scene with shadows of distress and terror.In the most vigorous period of life, men are also beset by ex-citements or anxieties, which rank among the most commoncauses of mental derangement; and, in persons of active intel-lect, and highly gifted, the balance of the mind is frequentlyseen to become disturbed and lost when most they thinkn their greatness is a ripening." The character is noticed tobe undergoing modifications for which, for a time, no one canaccount; unquestionable derangement, tending to mania, is atlength recognised; or, in the form of what is now usuallytermed generally paralysis, a slow destruction takes place inevery faculty of body and mind; and yet the cause of thislamentable wreck is shrouded in profound obscurity.Those who have had the most extensive opportunities of

making examinations of the brain after death, can but confesshow little information they have obtained as to the immediatecauses of the various forms of mental disorder; and how diffi-cult, or how impossible it is to say, during life, in a majority ofexamples of insanity, whether the state of the brain is such as lito admit of recovery, or actually to exclude the possibility of I,it. It may be well, therefore, now that the modern treatment Iof this class of disorders has, generally speaking, divested them ,of the aggravations and disguises resulting from violent ’;methods of control, and positively from all habitual exaspera- z,tion by violence, to survey the signs of some of the mostfrequent forms of these disorders, and to endeavour to gatherfrom such a survey some guidance as to their probable course, ’,some probable views of their nature and origin, and some helpas respects the principles of treatment. I

In most, or perhaps in all cases of incipient insanity, the ’,body is scarcely less disturbed than the mind; but the bodilydisturbance is no more uniform in its character than the mentaldisturbance. Perhaps the symptom which is most frequentlyamong the first, is an absence, or remarkable diminution, ofnatural sleep, and the patient is up nearly the whole of everynight, packing and unpacking; but with this there is soon co-existent a sensible excitement of the mind, more or less partial.The friends generally remember some previous peculiarities,indicating a change of habits or of character; but now therehas supervened an unusual quickness in all the movements;the steps in walking are hurried, and food is taken rapidly,with the air of one pre-occupied, or, sometimes, of one famished.A desire for stimulants is developed, and leads to further irri-tation.. Fits of vehement talking alternate with moods of

suspicions silence. The patient regards his- fiunily earnestly,and construes their commonest actions into signs and plotshaving reference to him alone. He thinks every familiarcountenance changed; he believes that sermons are especiallyaddressed to him; he imagines that he hears voices warninghim, or threatening him, or urging him to specific actions.He is sure that the popular authors of the day know all abouthim, and write at him. His senses become disturbed; he seeslights shining in the sky, or appearances in the heavens. Sén-tences are written there, condemning him for ever. He feelsheated, and thinks that the air is on fire, or that some mag-netic influences are exercised over him; what he touchesseems impure, and what he eats or drinks tastes of poison.He arms himself or barricades his room ; he cherishes secretplans of escape and distant travel; he suspects that his friendswill intercept him, and he arms himself, and meditates theirdestruction. There may be more vivacity from the first; adisposition to constant activity; the planning of perpetualschemes; the purchasing of books, clothes, furniture, carriages;ambitious designs to learn various languages, and acquirevarious accomplishments at once. He pays unexpected visits,and makes sudden offers of marriage, and displays an in-credible industry in writing letters; but more commonly someearly modifications of the senses, or some less marked depar-ture from ordinary habits preface the violent outbreak, which,however, generally succeeds. So much acuteness remains fora time, and so much self-control for any particular purpose,that the friends of the patient dangerously delay interference.They resolve and relent again and again. This delay leavestime and opportunity for the development of greater excite-ment, and hours precious to the cure are irredeemably lost.There are patients who, although even incurably insane as totheir actions, and as to delusions, continue to be so shrewd,acute, and witty in words and conversation, that no prudentmedical man can advise their being presented before a com-mission de lunatico inquirendo.Although in cases of insanity which have lasted some time,

there is often great violence with very little physical disturb-ance, such is not the case in recent or incipient attacks. Thewhole nervous system is disturbed, and the whole frame ofbody and mind is in commotion. The head is hot, the tongueis painted white, the pulse approaches or exceeds 100, therespiration is quickened, and the breath offensive; the diges-tion is deranged; the bowels and kidneys are inactive, or theexcretions are changed by disease; the skin is clammy andcold, and dry and hot, by turns, and the patient becomes rapidlyemaciated. The countenance grows haggard; the eyes havean unnatural brightness and prominence, and the pupil isdilated or contracted : even the hair seems to hang morewildly about the disordered head. The whole gait is altered;it is erect and boastful, or loose and swinging, and the dress isnegligent or fantastic. The desire for muscular exertion issometimes excessive; violent and destructive actions are per-formed with a rapidity scarcely to be eluded by any vigilance,and the patient utters wild and frantic cries. After a certaincontinuance of this state, symptoms of dangerous exhaustionmay ensue; although it is incredible for how long a time somepatients will remain in a state of agitation, noisy and sleeplessby night and by day, or very seldom sleeping, and not for anylong period, and taking food with little or no regularity, andsometimes scarcely any, and yet recover, and even recoverquickly, not appearing to have incurred fatigue or debility.In unfavourable cases, the violent symptoms are succeeded bydepression, silence, repugnance to taking food, with an appear-ance of general distress, restlessness, a dry and coated tongue,a rapid and feeble pulse, obstinately costive bowels, and othersymptoms, usually followed by death.

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In some cases the active imagination so predominates thatthe patient holds perpetual conversations with imaginary per-sons, and it is difficult to attract his attention to any real ob-jects or real words. If he does not speak, his lips continue tomove. Young men often fall into this state; and as they havebeen taught the value of intellect, some imagine that they are epreternaturally gifted; but many despond, and declare theirunfitness for any pursuit whatever.For various reasons it most unfortunately happens that the

treatment of insane patients in this most important period isconducted by practitioners who are unacquainted with insanity.The difficulty of acquiring a due knowledge of this subject inasylums was, until very recently, insuperable; and withoutmaking any illiberal reflection on the profession at large, itmay be said that a very general ignorance yet prevails as tothe treatment of this very serious form of malady. The pauperlunatic falls under the care of the medical officer of the parish

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for the time being, and the case of the richer patient is care-fully concealed until an increase of the disorder makes con-cealment impossible. Thus, in all classes of society, a patientjust attacked with insanity, and exhibiting some of the signsof extensive cerebral disturbance just mentioned, may be sub-jected to erroneous medical treatment, and to most injudiciousgeneral management. Ignorance and fear combine to heaprestraints upon him, and to suggest resort to measures for re-ducing his supposed excess of bodily power; and all his ex-citing fancies, all his restlessness, all his suspicions, and all hisfears, are violently exaggerated; whilst from loss of blood, orthe administration of very active medicines, his strength isdangerously reduced, and the chance of sudden prostration onthe decline of the excitement is very much increased.To be entirely divested of dress seems a favourite fancy of

many lunatics when first attacked; and it probably arises froma morbid sense of heat, or from some uneasiness in the skin.Exposure to cold, lying on the cold stones, and even puttingice or snow next to the skin, seems to give some of themmuch pleasure, although the temperature of the surface maynot be sensibly elevated. Entire neglect of cleanliness isanother peculiarity seen very often in recent cases, returningwith each attack, and becoming permanent in chronic cases.Young and delicate persons, in a recent attack of insanity,will sometimes resist all efforts towards emptying the bowelsand bladder, until both can be done in the most inconvenientplaces and at the most inconvenient times.

It is, indeed, most curious to contemplate the entire changeof character which an attack of insanity at once en*ects;—men of diffident nature, modest and retiring, or learned andpious, becoming rude and swaggering, and " full of strangeoaths;" honest and generous persons becoming avaricious andfraudulent; and prudent persons extravagant. A quiet, pen-sive, industrious woman becomes full of mischievous tricks,abounds in the lowest jokes and comicalities, is delighted tobe slovenly or dirty, and makes impudent grimaces. A re-served, middle-aged lady, of gentle manners, and usuallydressed as becomes her time of life, assumes a lightness andeven a grace of deportment not noticed before; her eyesbecome bright and animated, her face acquires a livelier ex-pression, she cultivates ringlets, wears a profusion of orna-ments and ribbons, talks eloquently, sings tastefully andarchly, and declares her partialities without reserve. Another,young, lady-like, tranquil and modest when well, and movingin good society, becomes vain and pretending when the attackcomes on, swears, and affects a vulgarity of speech, and aboundsin scandalous and not over-delicate stories. A few, and happilybut a few, even of the gentler sex, to whom such expressions,one would think, could never have been uttered, become, as itwere, inspired with the whole vocabulary of blasphemy andndecency.Some become very dangerous to certain persons whilst the

attack lasts. An inexplicable reversal of all the attachmentsand affections takes place; children revile their parents, andparents wrongly accuse their children, although loving them,when well, with the utmost affection. I have known in-stances in which the receiving of abusive letters from aparent or relative, when at a distance, has been among thefirst symptoms exciting suspicion. Insane married personsvery commonly conceive much jealousy and hatred for theirwives or husbands. A sudden and short attack of insanity in,one case produced very perplexing effects. A gentleman,twenty-eight years of age, had been attached to a young ladyfor two years, and at length made her an offer, and was ac-cepted. HQ had been living irregularly, and his brain ap-reared to have become just sufficiently excited to disable himfrom bearing his good fortune with rational joy. Some days-of slight maniacal disturbance were followed by a deepmelancholy, accompanied with a dislike to the lady, yet witha disinclination to break off the engagement. I entertainedtt hope, after many inquiries, that this dislike would disappear Ion recovery, which happily proved to be true. The attack

Iwent off, the patient was delighted to find himself still en- I- gaged, and his marriage soon followed. (He recovered fromthe attack in about two months.) Even the officers of theasylums find that some patients who, when well, are singularlyattached to them, become, when insane, suddenly dangerousto approach. In transient attacks, the daily alternations ofavour and dislike are only amusing; but in longer paroxysms

:ib.e dislike remains, and uniformly manifests itself until the’attack subsides, and then all at once disappears.

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In less violent cases, the patients merely become spitefuland malicious, and delight in creating misunderstandings, dis-comfort, and quarrels, by which they become intolerable atliome, and, after creating extreme discomfort, are sent to an

asylum. In general, the character of insane ladies and gentle-men becomes false. Their professions of comfort, satisfaction,and gratitude, are not to be fully depended upon, and themore they retain of intellect, with some exceptions, the moremischievous they become in a family.Amiable and gentle persons not unfrequently become coarse,

abusive, and pugnacious, when the malady is coming on orreturning; but in one instance, in a lady subject to very violentattacks of mania, warning was always given of the recurrenceof an attack by jàvou1’able changes in her character; from beingpenurious she became generous, her temper became unusuallyamiable, and instead of being discontented with everybody andeverything, she admired all that she saw, and all that was saidand done. But this preceded a long and violent attack of mania.

Generally speaking, human nature is seen to great dis-advantage in mental disorders; the social feeling is lost, andsympathy with others seems extinct. One of our greatmoralists has observed, that in the chamber of disease allthe delusions of life are laid open," and that we there find" Vanity divested of her robe, Power deprived of her sceptre,and Hypocrisy without her mask." But insanity tears awayall the conventionalities of life even more rudely, levels allranks more completely, and is the most terrible part of thattouch of Nature which " makes the whole world kin." Yet,against the cruel error of condemning all the insane as de-praved, and abandoned to evil influences, those will alwaysbest be guarded whose familiarity with insane persons showsthem that kind feelings and many virtues yet exist in a greatnumber of them-buried and obscured, but not lost. Tothese feelings we apply, and with success. ’ For a time, thereason is not capable of being exerted, but the patient, eventhen, may be calmed and assured of the kindness of otherstowards him, and thus a preparation made for favourable re-covery. Their attachment to their children and to other re-latives is often strikingly displayed, especially among the in-sane of the poorer class; they feel their own helplessness, andmourn over their destitute and unprotected house, or cherish,in long years of absence, the strongest and tenderest attach-ments. They are grateful to those who are kind to them intheir illness, and acknowledge their obligations to them inways not to be mistaken, and with expressions that comedirect from the heart. Very lately, an elderly woman, sub-ject to-recnrrent paroxysms of mania, and who had beenmany years in the asylum, was suddenly told’of her husband’sdeath. At that time she was calm and well, but she returnedfrom the visiting-room to the wards in a state of high maniacalexcitement; hemiplegia followed, and she never recovered.Although the patients may be often violent, and prone to

make fierce attacks on others, any display of severity on thepart of the attendants revolts them, and they evince muchsympathy both with attendants and patients who are sulferingor dying; and I am quite sure, that in asylums where thewhole treatment is uniformly kind and compassionate, the in-stances of a continued disposition to hurt the attendants orofficers, or to meditate revenge, become extremely rare. Thefew patients who cannot be fully conciliated become, for themost part, passive when not interfered with, and the restbecome more or less attached to those who never approachthem but as friends. There are days in which patients whoare generally friendly and confiding are passionate, abusive,and full of accusations; but if the sane persons about themreceive all calmly, they will find the patient, in a day or two,smiling and friendly again.

In cases of recovery, nothing is more interesting than towatch the revival of all the decent habits of life, and of allthe old feelings, and the departure of cruel delu&ions; andthe return of the fondest affections. It is gratifying to notethe signs of recovery from bodily illness, and to see strengthreturning and hope reviving in the sick man; but to seerational sentiments restored to one long deranged, and reasononce more calmly exercised, is, as it were, to see life itselfrestored as to one long dead; and constitutes one of the mostgratifying rewards of those devoted to this department ofpractice.Amidst the crowd of what would seem almost undistin-guishable shapes of malady in a large asylum, three forms arechiefly found, both in recent and chronic cases :-

1. Cases of continued excitement or continued depression,or of alternate excitement and depression, lasting for weeksor months.

2. Occasional excitement or depression; with delusions recur-rent with these paroxysms, or even persisting in the intervals.

3. Strong delusions, remaining for months, or for years, orfor life, without violence.Thus the terms mania and melancholia comprehend nearly

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- 1111 the cases in which there are active symptoms. Long ex-isting delusions are generally associated with a partial im-

’becility of the mind ; but in many forms of imbecilityparoxysms of violence occur. The extremity of imbecilityis that state of inactivity of all the faculties to which the- term dementia is now generally applied.

These few forms, or the three particularly mentioned, in-’elude as many varieties as we can conceive combinations offaculties, and of faculties all, or nearly all, impaired.Much difficulty exists in assigning a locality to various

- deceptions of sense, which are yet very common in the in-’sane. The idea of all objects being impure or dirty wouldseem to depend on some disorder in the peripheral termina-tions of the nerves of the surface; the idea of being galvanizedor poisoned often arises from a coppery taste connected withdisordered digestion: from an analogous condition of thenerves of different internal organs many delusions perhapstake their origin, especially those of the hypochondriac. Asregards the special senses, insane persons not only see imagi-nary objects, hear imaginary sounds, smell bad smells, tastepoison in food, and feel phosphorus on chairs and sofas, but oftenmistake persons not known to them for those to whom theyare attached, or whom they dislike; and treat them accord-ingly. They also point out houses and buildings as placesfamiliar to them, although really before unknown to them;-and this for years together.We have, in the Hanwell asylum, a young Irish woman,

who, in her paroxysms of excitement, mistakes me for a cer-tain Pat Murphy, and would, if not prevented, violently at-tack me. A clergyman whom I attended in consultation witha physician holding a high office in the college, told us, whenrecovering, that for a long time he always thought, when Dr.P- visited him, that the Archbishop of Canterbury wasdoing him that honour. An old man in the asylum alwaysinsists upon it that I am a Mr. -, from Hitchin, in Hert-fordshire, although in telling me so he generally also addressesme by my own name. It is not easy to determine the share’which the nerves or the brain respectively have in these de-ceptions.

Patients can seldom clearly describe what they feel.E. V——, a female patient, long affected with mania in its Imost active form, but now well, used to say, that when ill ishe felt sensations in the stomach and bowels as of somethingturning round and round like a mill. A feeble man, whoselower limbs were partially paralyzed, always complained of afeeling of giddiness, not in the head, but in the left side of the-abdomen. A consumptive patient referred certain sensations-in his chest to " Bramah’s people and machinery." Com-plaints of a feeling of turning and twisting in the brain are notvery uncommon; and some patients have described a suddensensation, as if one side of the head, or some one portion of it,had lost all feeling. The expressive description of an Irishfemale patient, when a paroxysm was coming on, was, that "herhead was boiling."Of their own shape, of their stoutness or leanness, or even

- of the composition of their limbs or noses, it is well knownthat they sometimes entertain the most erroneous notions.Some imagine that they have lost the power of speaking, andwill only write their thoughts; or of walking, and will lie inbed for months; or of swallowing, and will almost starve them-selves ; or that the bowels are hermetically closed, being proof

against all evidence to the contrary.A woman of forty-eight, a nurse in a public institution,without any previous incoherence of mind, or manifestation offolly, began all at once to think that, for her, time was de-stroyed, so that she could no more read or write, or occupyherself in any way. She said her thoughts were all going;she was afraid to sleep, lest on awaking her mind should begone. She sate up all night in bed, tearing her nails and fingers.When dressed, said she always felt as if some one wasdragging her out of her clothes, and when undressed, feltas if she were flying to pieces. When walking, felt some onewas always dragging her backward. Days and nights seemedconfounded; everything wore a dark line; all was agony: shemoans with every breath she draws. Such were her expres-sions. This case, dreadful as the sufferings of the patientwere, appeared curable; depending on some temporary mor-bid condition of the nerves or brain, capable of removal.From some irregular nervous excitement, productive of

morbid impulses, we find certain patients, in acute attacks ofmania, delighting, like boys in the streets, not only in singingscraps of songs and choruses, but in making every kind of dis-cordant sound of which the human voice is capable. Thatvoice, qualified by Nature to form sounds sweeter and moretouching than any instrument can produce, becomes a real

instrument of torture, sending forth hoarse shouts and piercingshrieks and yells more fearful and repelling than any othersounds on earth. Patients will delight in this exercise in thesilent hours of the night; but sometimes by night or day, forweeks. Still these and all other extreme phenomena seemto me to be rare, except in those formerly, or at present, sub-jected to severe restraints. -

Patients brought from their own houses, or the houses of theirparents, to asylums, have commonly been subjected for someweeks, or for a longer period, to all the severities of mecha-nical restraint. When the patient is sent for, the whole houseis found in a state of dismay; the patient’s room is filled with! people called in to hold the patient down; and the patientlies, bound hand and foot, the hair in disorder, the body un-washed, and if struggling, is knelt upon and almost choked;and at length becomes limited to frantic shouts and curses.All this time the windows are left insecure, and no provisionis made against accidents, except mechanical force. Onarriving at the asylum, a bath is prepared, the bonds aretaken off, refreshment is given, the hair is thinned or cut off,the heated scalp is relieved by cold applications, and othermeans are applied; and yet it requires similar care for manydays, and sometimes for many weeks, to bring back thepatient to a natural state of malady, freed from the aggrava-tions created by bad treatment, and offering some opportunityof pursuing a remedial plan with success.The same observation is generally applicable to other cases

in which all instinctive or acquired love of comfort and ofease seems lost; and the patients will sit in one position untilthey become deformed, or clench their hands until the nailsof the fingers penetrate the palms, or walk only on their toes,or lie only in painful positions, or sit only in the coldestcorners, refusing to be comforted. Among the milder ofthese peculiarities, is that of patients who will walk in onespot or circle only, for days and years, until the earth is wornwith their footsteps. An old man at Hanwell used for someyears to walk about six yards forward and backward, seldomuttering articulate sounds; he now makes rather longer ex-cursions, but when spoken to, almost always says, " Excuseme," with which words he has answered almost every questionthat I have put to him for ten years past.Some patients will repeat a few words all the day long, or

for days together; some create a kind of composite language,of English, French, Italian, or Irish, and talk long and rapidlyand vehemently, or utter everything in a kind of recitative;others address you in precisely similar words and phrasesevery time you see them, asking some particular question ormaking some particular request, the mind seeming, in suchcases, to have acquired a fixedness and immobility analogousto that of the muscular system in other cases in which thepatients preserve one attitude every day, from morning tonight, and sometimes until they die.

Altogether, the use of words and the faculty of speech ismuch troubled in a majority of the insane. They often seemto employ words which they do not mean to employ. Theyplace emphasis on wrong words, or on every word, so thatwhen they are heard from another apartment, the voice re-sembles the noise made by beating a drum, or sometimes thevoices of two persons. Some alter the terminations of words,or have a pleasure in talking with a foreign accent, or inspeaking like children learning to talk. The violent acces-sions of mania in one of our patients were always known tobe approaching when he began to speak Welch. In a deafand dumb patient, mentioned by Sir Alexander Morrison," during the prevalence of her disorder, her sister was unableto understand the signs she made use of."In all the forms of insanity, as perhaps in all the varieties

of human character, the voice affords some indication of thestate of the mind. Loud, fierce, and long-exerted in mania;low, and scarcely audible in melancholia; it is painfully mo-notonous, only varied by bursts of sound, in many forms ofchronic mental disorder, where it is exerted from sunriseuntil night, constituting no small trial for those exposed toit; and in the various degrees of imbecility it is singularlyinefficient, most of the words of a sentence being only halfuttered, or lost in hollow sounds in the fauces, or blown outwith a kind of effort.When the first violence of an attack of acute mania has

passed away, but the mind still remains excited, we find thepatient, in an extraordinary number of cases, suddenly affect-ing high rank. I think this is most common in the poorestclass of patients; and it is to be remarked, that among our

. crowd of lunatics at Hanwell, although we have several, queens of England, our male patients do not at present. assume the title of king, although several assert that they

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are married to the queen. We have also noblemen and lord-#tnayors at all times, and a few baronets, but scarcely a generalor an admiral, and not on bishop or dean. In the form ofinsanity combined with general paralysis, the patient willsometimes assume the highest rank in the navy, army, andstate, altogether. In all asylums there are patients who con"sider themselves divine persons.A very elevated idea of their talents and powers is ex-

tremely common among those who have recently becomeinsane. They detail the vast plans which they were about toexecute, and deplore the loss of time and money to whichthey are subjected. Their demands for writing or drawingmaterials are extensive, and they make ambitious, but frag-mentary efforts to sketch designs for railways, palaces, oreven asylums; or to write poems such as the world has neverseen. One of our most intelligent patients has spent monthsin painting on the walls of three sides of his bedroom innu-merable faces,and figures, and forms, representing the defectivestate of the social and political world; and has exercised inthis work what may almost be called an eloquent ingenuity.As the three walls set forth "what is," the fourth is destinedto indicate " what ought to be;" but at present these wordsalone are painted on it, and a mysterious blank remains to befilled up.These voluntary mental efforts of the patients are ordinarily

harmless; but I question the propriety of stimulating themby the prospect of publication; and I observe in the paperswritten and printed periodically in some asylums in Europeand in America, a disposition to dilate on vague metaphysicaltopics, which cannot, I think, be usefully encouraged. Apraiseworthy zeal has, in other instances, carried good princi-ples of treatment to excess. When mechanical restraintshad become disused in several asylums, the temporary seclu-sion of a violent patient in his room, which was substitutedfor it, was also in some institutions declared to be needless,and one of the plainest principles of treatment in cases ofcerebral disturbance repudiated. The next step would havebeen to declare asylums useless, and to set all the insane atliberty. And thus, also, although occupation and amusement,kept within the bounds of hurtful excitement, are found to beboth agreeable and serviceable to insane persons, who enjoyan evening party, and music and dancing, and looking atdrawings, or at pleasing representations in the magic lantern,and even occasional instruction by elementary and illustratedlectures on simple subjects, I can by no means persuademyself that it is good for them to take parts in theatricalrepresentations. The constant aim should be to occupy andamuse, and gently to draw away the mind from its besettinginfirmity; but never to produce violent impressions or excite-ment. As these amusements, however, receive encourage-ment in some asylums superintended by physicians of greatability, I acknowledge that my impression of the evil of themmay be partly imaginary. The experiment has, rather oddly,been hitherto confined to Scotland-a country in whichtheatrical performances have never found much favour withthe public. In France the trial signally failed, but it wasmade during the most exciting period of the last sixty yearsof excitement in that country.There is scarcely anything connected with recent cases of

insanity more important for the practitioner to know thanthat in no form of it is the suicidal impulse stronger than inacute mania,-not in the deepest despondency-not in theprofoundest melancholia. It is often a wild, mad, ungovern-able impulse, without melancholy; and seeks its ends with adetermination, a quickness, and an acute perception of thereadiest means of death, demanding constant watchfulness.No dread of pain, no shrinking from suffering, seems toremain. Driven thus by mere impulse, or by some supposedorder which they have received, the most violent and terribleforms of self-destruction become attractive to them,-deathby strangulation, starvation, drowning, leaping down a preci.pice, or burning.Nothing can prevent the success of these attempts but con-

stant superintendence. Binding the limbs is no security-the very bonds become converted into means of mischief; andthe imposition of restraints has been confessed, in the greathospital of Bethlem, to increase the disposition to suicide. IfI were to describe the anxieties occasioned to us in large asy-lums by suicidal patients, the perseverance and ingenuity oftheir attempts, the providential discoveries of such attemptsin time to baffle them, and the various resources adopted fromtime to time to prevent accidents, which are most affiictingwhen they occur, to attendants and officers, my descriptionwould seem to take the colouring of romance, although com-prehending no more than serious realities. Yet, in ten years,

we have had but two suioidesat Hanwell, the average numberof patients being all the time about 900; and one of theseaccidents occurred before superintendence had become esta-bliShed in-place of restraints.Amidst these, and all the other violent symptoms of an

acute attack of mania, the hope of the patient’s entire 1’000-very is so far from being extinguished in the mind of thepractitioner acquainted with such cases, that it is peculiarlyin such that he looks, ordinarily speaking, with the most con-fidence towards a cure. The physician to any large asylummust, among the recollections of any one year, have that ofpatients brought to the asylum a few days, or a week or two,after the mania appeared, and of having seen them wild, andbewildered, and impulsive, and scarcely conscious, and pre-senting many or all of the phenomena which have been eilu-merated, and yet who, in a few months, and sometimes in afew weeks, and sometimes in a few days, have been transformedso entirely by advancing convalescence, as scarcely to be reoo-gnised ; their whole appearance and manner, their very fea-tures, having become so calm and tranquil, that to recal thedistracted objects seen on their admission requires an effort ofthe memory. These recoveries, which are the chief materialsof a probable proportion of cures, in recent cases amountingto at least fifty per cent., afford encouragement in the treat-ment of a class of maladies wherein too often the first signs ofmental disorder are but the indications of death beginning atthe brain. How much they show the importance of the earlytransmission of cases to asylums, or, at least, of their early andjudicious treatment, whether in or out of asylums, I needscarcely observe. In by far the greater number of cases, how-ever, especially among the poor, the early treatment is,neces-sarily conducted by those who cannot have had the advantageof much observation of such cases; and I look to the continuedefforts of the eminent physicians of Bethlem and St. Luke’shospitals, to impart clinical instruction to medical pupils-and I wish I could add to law students,-with what aid wecan give at Hanwell, and to similar exertions making, or likelyto be made, in the county asylums generally, and the asylumsof Scotland and Ireland, for the superintendence of whichthere are now always numerous highly educated candidates, asbeing likely to effect such improvements as may even yet in-crease the number of recoveries from insanity.

I cherish this pleasing expectation, not because I look forany striking novelties in the treatment of these disorders, orexpect wonders from heroic remedies, or look for miraclesfrom specifics yet undiscovered, or have confidence in hiddenmethods; but because I am convinced, that many of the errors,and all the brutalities, which formerly disgraced the manage-ment of the insane, arose from the unhappy custom of consign-ing them to the rude care of coarse and ignorant persons. Veryfew physicians of education were to be found, until a recentperiod, devoting themselves to mental disorders. Those occupiedin asylums were chiefly distinguished by an eccentricity and aroughness which, unfitting them for other professional avo-cations, made them willing to undertake to treat mad people.By such persons, ill-educated, prejudiced, and without anyresources but methods of violence, and who had never studiedthe forms and treatment of mental disorders, all attempts toameliorate the condition of the insane were bitterly and un-scrupulously opposed, with every effort and every contrivanceof vulgar minds. Meantime, the outside walls of an asylumwere regarded with awe; the shrieks issuing from it madenight hideous; the frantic creatures, inclosed in their dens,furnished appalling subjects for the artist or the novelist;squalor and dirt, and famine and ferocity, were everywhere tobe met with. Now, all is changed, or all is changing.Asylums are hospitals for disordered minds, places of rest andrefuge for those unfit to struggle in the world. Highly edu-cated young men leave the medical schools every year, pre-pared to study and to treat the insane as well as the sick.Public efforts are still making to throw additional protectionround the lunatic. The commissioners in lunacy, gatheringexperience with every year, are indefatigable. Asylums, ad-mirably constructed, are rising up in every county; and thenobility, clergy, and gentry of numerous districts are found tobe devoting much time and attention to the construction andorganization of these new establishments, where the mostdestitute pauper lunatic will have good food, decent clothing,a comfortable bed; where occupation or amusement will befurnished; and where perfect cleanliness will show how

generous a care is extended to those whose malady wouldotherwise drive them to misery. When these establishmentsare completed, it is to be hoped that every pauper lunatic mayreceive early treatment in them, and thus the number of r4,-coveries may be increased.