will the principle of management be the equalization of the expenses of removal, &c., and requiring of each county that it shall take charge of the lunatics, who fall into the custody of its police? In most counties the State Asylum will be inappropriate, and inconvenient for their ordinary needs in lunacy. The lunatic, who awaits his trial, or has recently manifested insanity, needs to be in an asylum or hospital, easily accessible to the County Magistracy and Constabulary. The patient, who has been treated in the County Asylum, and has passed the most dangerous crisis of his lunacy in its charge, will not ordinarily need that great expense shall be incurred for his subsequent removal to the State Asylum. If a criminal manifests insanity subsequently to his conviction, he, being insane, needs the care of the most easily accessible hospital for the insane. The punishment awarded to the criminal is inapplicable to the man of unsound mind. He should, on recovery, be transferred to the State Asylum, before punishment can be resumed towards him. It will often happen that dangerous lunatics will be found in asylums or licensed houses, who have, by the care of their friends, never been allowed to bring themselves to the cognizance of the police. Will all these insane persons be admissible to the State Asylum because the commission of a criminal act cannot be imputed to them? The term and treatment "Criminal" should be inapplicable to the insane; and the official Visitors of any asylum should be allowed to recommend the removal of a lunatic to the State Asylum, whenever it appears to them that the asylum, in which he is placed, is inadequate to his proper charge. The County Asylum refuses to be classed as a place of safe custody. It no longer receives inmates for detention; the order for the admission of a patient now requires his reception for care and treatment; neither does it allow to its inmates two classes of care and treatment; the "Lunatic, not being a pauper, shall have the same accommodation in all respects as the pauper the pauper lunatic." The state lunatic may be of high rank, and dangerous; or he may be a vagrant, accustomed to a life of vice and demoralised. Will the insane gentleman be allowed to provide, at his own cost, accommodation and observances suitable to his education, or will the plea of insanity debase him and elevate his uneducated fellow misfortunate to the same level?

Littlemore, Dec. 1857.

WILLIAM LEY.

To the Editor of the Asylum Journal.

Sir, It is impossible to read Dr. Huxley's Report upon the introduction of "special night watching," without feeling that he has scarcely given the system a fair trial; and I cannot help thinking that he has been somewhat hasty in characterizing as reckless, cruel, and harsh a system which has been found of signal service in many large county Asylums.

It is some four years since I had my attention directed to the advantages of special night watching, by the same Commissioner in Lunacy, Mr. Gaskell, whose recommendations at the Kent Asylum have been received with so much disfavour by Dr. Huxley. Before that period, the night watching in the Leicester County Asylum was performed by the attendants in rotation; and, subsequent to Mr, Gaskell's recommendations, some experiments of similar character to those made by Dr. Huxley, were instituted by me, to test their value, the results of which were not unlike those which he has so particularly detailed.

The novelty of the plan, and the difficulty of obtaining suitable persons for the duties of continuous night watching, made me view with apprehension so great a change in our internal arrangements; but some experience of the inefficiency of the old plan of night watching, which I derived in the latter part of 1853, clearly shewed the necessity of greater attention being paid at night to the wants of those afflicted with paralysis; so that I came to the conclusion that it would be better to give to one person the charge by night of those incapable persons designated in Asylum nomenclature "wet and dirty" cases, rather than let that important duty be divided amongst 12 or 14 persons, who, by the long interruption of their night duties, could only have very imperfect acquaintance with these afflicted cases.

We have now at the Leicester County Asylum, a special night attendant, who enters upon his duty at ten o'clock at night, and gives up his charge at six o'clock in the morning. This attendant has special charge over the wet and dirty cases, and while he expects to receive these patients in a cleanly state on his entrance upon his duties, it is expected of him that he shall deliver them up to the day attendants in similar condition; and that condition is regularly recorded in the ward Reports.

This system of night attendance has been in operation with us nearly three years, and I have found it a valuable means, not only of enforcing cleanliness and order, where previously only dirt and neglect had prevailed, but also of great moral effect in the governance of the Asylum. I confess I was somewhat startled at hearing this system of special night watching, characterised as a reckless project by a gentleman of Dr. Huxley's experience. In order to ascertain the difficulties which beset the system, especially as regards the time occupied in attending to the wants of the wet VOL. IV. NO. 24.

X

and dirty cases, and also as regards the disturbing effects on other patients, I accompanied the night attendant last night on his first round (which I did without giving him previous notice), and found that he had twenty-five patients of the class who were the objects of his peculiar attention. In two cases the sheets were found wet, by soakage of urine, and they were, of course, replaced by clean ones, in fifteen cases the patients got up and performed the act of micturition; six of them owing to the great amount of paralysis, with which they were afflicted, were assisted in and out of bed, by the attendant; twenty-three of the patients so visited, were in single rooms, two only were placed in associated bed-rooms. The whole period of getting out these twenty-five patients, and performing those acts necessary to leave them in a state of comfort and cleanliness occupied forty-six minutes, and by the simple contrivance of list-slippers, and a little India rubber round the frames of the passage-doors, these visits were so noiselessly made, that not half-a-dozen patients, besides those specially visited, were at all disturbed.

Upon re-visiting those patients who had been subjected to what Dr. Huxley terms the "turning-out system," I was gratified to find that the "disturbing influences," to which they had recently been subjected, were at all events of a very fleeting character, and I am clearly of opinion, that all these and similar cases, are better off with their rest so disturbed four times every night, with cleanliness, than if they had been permitted to have "sound sleep and plenty of it," with wet and dirty sheets next their skins.

Moreover it will be found that enforced cleanliness by night, leads to habits of cleanliness by day, for the ordinary day attendants knowing that they must give up their patients at night in a cleanly state, do not find it any particular advantage to hurry their patients off to bed at improperly early hours. In the patients themselves, that irritability which long neglect of personal cleanliness engenders diminishes, and with it diminishes the necessity for those early hours of retiring to rest, which seem habitual to Dr. Huxley's patients; at all events to those six who were the subjects of his personal investigation, four of whom were found wet or dirty, so early as seven p.m.

"In conclusion, while I agree with you, that the subject of special night-watching is too important not to invite free discussion, I may remark that any observation respecting the internal economy, and management of Asylums, should be received with great respect, when falling from so experienced and successful a cultivator of the science of mental medicine, as Mr. Gaskell, whose accession to the Commission of Lunacy, ought to be a source of gratification to all professional men.

Leicester County Asylum,

JOHN BUCK.

December 15th, 1357

Case: Extensive Disorganization of the Brain, with Paralysis, Epilepsy, Gout, and Albuminaria; Recovery from Mental Alienation and Paralysis; Eventual Death from Congestion of the Lungs, Hypertrophy of the Heart, Paralysis of the Pneumogastric Nerves, and Albuminuria; Autopsy. By D. F. TYERMAN, M.R.C.S., &c.

J— P——, æt. 42, marble-mason, a married man, was admitted on the 26th January, 1855, supposed to have been insane for fifteen weeks, the cause not accurately stated, and described as having manifested great defect of memory, incoherency, restlessness, and a tendency to wander, "recollecting neither persons or places," and "muttering to himself." Upon his admission he was pallid and debilitated, generally incoherent in conversation, but capable of giving a few rational replies. He said, "They gave me cross breath; I never smelt them in my life before;" but stated that he suffered a fit three months previously. The articulation was confused, a fact of which he was himself conscious, and to which he alluded. The right pupil was more dilated than

the left.

My diagnosis was "brain disease, in association with convulsions, and consequent general paralysis."

A fortnight after his admission, he suffered an acute attack of gout, affecting various parts of the body, especially the hands, in the joints of which concretions had long formed, and the urine was highly charged with albumen. Alkaline medicines, with colchicum, afforded relief; and on the subsidence of the attack, he remained in a debilitated, infirm condition, and was associated with the paralytics, his deficiency of intelligence being apparently persistent and confirmed.

In the course of a few months, however-namely, by November of the same year-great general and mental improvement was manifest; he had not recently suffered from gout-to which, by-the-bye, he stated his father had been subject; the symptoms of paralysis were far less evident, and he was usefully employed in assisting the attendants in their ward duties.

In December this improvement continued; his time was fully and willingly occupied, chiefly in scullery work; and his conversation was rational, and disposition amiable. He had, however, suffered one epileptic fit, which was not succeeded by maniacal excitement, or more than very temporary mental disturbance.

1856, February. In the second week of the following February, he was again severely attacked with gout, and soon afterwards suffered two violent epileptic fits during the night, one arm being much bruised in his violent movements. Torpor, somewhat hurried respiration, and indisposition to converse, succeeded these occurrences.

On February 23rd, it was manifest that the lungs were fatally congested, and that the heart and kidneys participated in disease. The left side of the chest was almost motionless from paralysis of the respiratory nerves. Nevertheless, the patient was rational, the aspect of his countenance was intelligent, and he was perfectly conscious of his critical position, as proved by his observations to that effect. Wine and ammonia were administered. The respiration became more and more accelerated-very little air entering the gorged and paralysed lungs; and death resulted on the 25th, no impairment of the intelligence, beyond the ordinary comatose state just before dissolution, having beeu manifest.

Autopsy, on the following morning. Calvarium and bones of the head, pale and anemic; the arachnoid membrane, translucent, entirely free from opacity the subarachnoid cellular tissue (pia mater) infiltrated with a considerable amount of clear fluid raising up the arachnoid, in places, from the brain surface. The brain substance generally very pale and anæmic, very minute quantities of light-coloured serous blood flowed from the vessels on section, and the tissue was firm and somewhat tongh. Near the outer surface of the middle lobe of

the right hemisphere, there was much old rusty degeneration, evidently the effect of a coagulum. There was much more extensive degeneration of the substance of the left lobe, the entire corpus striatum and thalamus of that side, with much of the surrounding tissue being destroyed; an extensive dark brown, rusty and irregular cicatrix, shewing the magnitude of the coagulum, which had been thrown out. The lateral ventricles were enlarged and contained about two ounces of clear fluid, and stretched across the left, was a tough band the residue of some powerful inflammatory action. There was a considerable amount of fluid at the basis cranii. The arteries of the brain were extensively degenerated by atheromatous deposit. Weight of the brain without the effused fluid, 45 oz. Both lungs and the bronchi intensely congested and gorged, blood aud frothy mucus flowing freely on section. Heart greatly hypertrophied, weighing with the roots of the large vessels, 22 oz.; the left venticle being 1 inch in thickness. There was no valvular disease. Both kidneys granular and atrophied, the parenchyma having almost disappeared, the right weighing 2 oz. 3 dr., the left 2 oz. 4 dr. There was much congestion of the stomach. The bladder was full, but not distended, and the urine was loaded with albumen and gave an acid reaction. Observations. Subsequent to the decease of the patient, the friends have stated that, eighteen months before admission he suffered apoplexy, with convulsions, which stated antecedents fully receive their corroboration by the post mortem appearances.

In No. 13 of the Asylum Journal, page 201, I gave a short history of a case in which marked symptoms of general paralysis subsided on localization of phthsical disease in the lungs. In this case, however, not only paralysis (with the exception, I should say, of a right dilated pupil), but the mental alienation were recovered from, notwithstanding extensive structural brain changes. The absence of opacity of the membranes and comparative freedom of the cortex from disease, may be significant facts. This so-called insanity was evidently traceable to apoplexy, from degeneration of brain vessels, &c.; causes which probably produce a very different type of physical symptoms from such as result from the hereditary transmission of psychopathies, and other causes, which have been much longer and more gradual in their operations. The restoration of the locomotive, and other muscular powers, after the destruction of the left central ganglia is an additional fact to many already known and recorded, and which tend to throw doubt upon the received physiology of the brain, or, possibly, to prove that one portion of the organ may be complementary of another, whose functions are in abeyance from the encroachments of disease. D. F. TYERMAN. Colney Hatch, March 6th, 1856.

The Medical Certificates of Admission Papers.

Many of our readers are aware that the Commissioners in Lunacy assume the right to determine whether the documents, upon which patients are admitted into Asylums, are formal and correct, or otherwise; and that of late they have required many medical certificates to be amended in consequence of the facts upon which the opinion of Insanity was founded, having appeared to them vague and insufficient. This authority appears to be exercised in default of any sanction given by Act of Parliament, even in cases where the informality of the papers is obvious and unquestionable.