Forms of Disease

We have thought it expedient in this place to distinguish the principal forms of Insanity which are usually met with in lunatic asylums, in order to render more clear and intelligible the statements which we are about to make respecting the classification and treatment of their inmates. They may also be useful in illustrating the Statistical Tables which will be found in the Appendix.

The principal forms are comprehended, in the Tables which accompany this report, under the following heads:_

I. Mania, which is thus divided:

1. Acute Mania, or Raving Madness.
2. Ordinary Mania, or Chronic Madness of a less acute form.
3. Periodical, or Remittent Mania, with comparatively lucid intervals.

II. Dementia, or decay and obliteration of the intellectual faculties

III. Melancholia

IV. Monomania

V. Moral Insanity.

The three last mentioned forms are sometimes comprehended under the term Partial Insanity.

VI. Congenital Idiocy

VII. Congenital Imbecility

VIII. General Paralysis of the Insane.

IX. Epilepsy

To these heads may perhaps be added "Delirium Tremens", since it is mentioned, as a form of Insanity, in the Reports of some lunatic asylums.

A few brief descriptions of the disorders to which these terms are appropriated, may be deemed requisite by way of explanation.

I. Mania - This term is used to designate a particular kind of madness, as affecting all the operations of the mind. Hence the term Total or General Insanity is used as synonymous with Mania. Maniacs are incapable of carrying on, in a calm and collected manner, any process of thought; their disorder for the most, part betraying itself whenever they attempt to enter into conversation. It likewise affects their conduct, gesture, and behaviour, which are absurd and irrational; their actions being characterised by great restlessness, appearing to be the result of momentary impulses and without obvious motives. Mania is also accompanied by hurry and confusion of ideas, and by more or less excitement and vehemence of feeling and expression. When these last symptoms exist in an excessive degree, the disorder is termed Acute Mania or Raving Madness.

1. Acute Mania or Raving Madness is the first stage of the disease, which often becomes gradually milder in its character, and is then termed Chronic Mania or simply Mania. lu other cases, the disposition to high excitement or raving continues through the whole course of the disease, which sometimes becomes fatal through the exhaustion occasioned by perpetual agitation and want of rest. It is also generally attended with considerable disturbance of the vital functions.

2. The Chronic Form of Madness is attended with less excitement of the passions, less rapidity of utterance, and less violence of action. In this stage, the disorder of the mind is not always immediately perceptible; but it soon becomes apparent that the patient is incapable of continued rational conversation or self-control, and that his acts are the results of momentary caprice, and not governed by rational motives. A great proportion of Maniacs labour under Illusions and Hallucinations, or false impressions as to matters of fact, but in these illusive notions there is no consistency or permanence. Patients labouring under this chronic form of Mania are often tolerably tranquil and harmless. Many of them are capable of being employed in agricultural and other active pursuits, and of amusing themselves by reading, music, and various entertaining games. A great proportion of the inmates of lunatic asylums belong to this class. However quiet and manageable they may appear to be under the authority and supervision to which they are subjected in an asylum, they are quite unfit to be at large and to mix with ordinary society.

3. Intermittent Mania or Madness attended with lucid intervals is by no means so frequent as might be inferred from the writings of authors on medical jurisprudence. Some medical writers, of considerable note, have denied the existence of lucid intervals altogether. The fact is, that in all large asylums, there are patients subject to occasional paroxysms of raving madness, but who have intervals of comparative tranquillity and rest. It generally happens that after the alternations of raving fits and periods of tranquillity have continued for some time, the intervals become less clearly marked, and the mind is found to be weakened, the temper more irritable, and both; the feelings and the intellectual faculties more and more disordered.

Recurrent Insanity differs from Intermittent Mania, though often confounded with it. In Intermittent Mania paroxysms occur either after regular or irregular periods, and this is the ordinary character of the disease. Recurrent Insanity is a name applied to any form of mental disorder, when the patient recovers perfectly, but suffers from relapses after considerable periods of time.

II. Dementia. - Chronic and protracted mania is frequently the prelude to a decay and final obliteration of the mental faculties, which is termed Dementia.

Dementia differs from all other forms of insanity. It differs from Mania, in which the intellectual powers still exist, though they are exercised in a confused and disordered manner. It differs from Idiocy, in which the powers of the mind have never been developed, while in Dementia they have been lost.

Dementia is, in some instances, the primary form of mental derangement, and its phenomena make their appearance in the first onset of the disease. Cases of this kind are chiefly from causes of a depressing nature, such as deep and overwhelming grief, extreme poverty, destitution, and old age. In those instances in which dementia is the sequel of protracted mania, it is not easy to determine the point at which mania ends, and dementia begins. It is sometimes, also, the sequel of epilepsy, apoplexy, paralysis, and other affections of the brain.

Mania and Dementia prevailing forms of Insanity in large asylums

In most large asylums the prevailing forms of insanity are Mania and Dementia. In the collective numbers of Patients in the Lancastcr County asylum, the Superintendent has furnished the following statement, viz., Out of 619, reduced to 580 by the omission of 30 doubtful cases, there were labouring under mania 235, and dementia 183=418, which is about two-thirds of the whole number of the Patients.

III. Melancholia. - A considerable proportion of the inmates of all extensive lunatic asylums, are the Melancholies; among whom there are several degrees and varieties. Some patients display merely lowness of spirits, with s. distaste for the pleasures of life, and a total indifference to its concerns._These have no disorder of the understanding, or defect in the intellectual powers, and, however closely examined, manifest no delusion or hallucination. This state often alternates with an opposite condition of the mind, namely, one of buoyancy of spirits, and morbid activity, It is thus frequently very difficult to determine in what degree Melancholy, when it exists without delusions, constitutes insanity. A great number of persons whose disorder is precisely that which is above described, and who betray no particular error of judgment or hallucination, are confined in lunatic asylums as a precaution against suicide, to which they are prone, in many instances, from a disgust of life.

Another class of Melancholies derive their grief and despondency from some unreal misfortune, which they imagine to have befallen them. Many are convinced that they have committed unpardonable sins, and are doomed to eternal perdition. Others believe themselves to be accused or suspected of some heinous crime., of which they are destined to undergo the punishment; and of this they live in continual dread. Some fancy that they have sustained great pecuniary losses, and are utterly and irretrievably ruined. A numerous class of melancholy patients live under the impression that they labour under some terrible bodily disease. Many of them have, in reality, sonic complaint of which they magnify the symptoms: they fancy every trifling sensation of n painful kind to bo certain indications of their incurable distemper, which they often attribute to some fantastical cause.

Particular care required by melancholy patients to prevent suicide

Melancholy patients require particular care and constant inspection, on account of the frequency of suicides among persons of this class. In the Report of the Patients admitted into the Northampton Asylum from August 1838, to November 1843, out of 118 cases of Melancholia, a suicidal propensity had been discovered in sixty-four.*

The suicidal propensity is not, however, restricted to this class of patients. In a late annual Report of the Lancaster County Asylum , there are only forty-five cases of Melancholia mentioned, while it is stated that a suicidal propensity had been manifested by 105 out of the total number of 619.

IV. Monomania. - Monomania, properly so termed, is a form of Insanity, which, from the attention given to it, might be supposed to be of more frequent occurrence than it really is. The term is professedly given to cases in which the intellectual faculties are unimpaired, except with relation to some particular topic. Instances, indeed, are continually occurring in which some particular impression of a delusive and insane kind, occupies the attention of the patient and is uppermost in his mind, but unless the power of reasoning correctly on subjects unconnected with the illusion, is retained, the disorder is not a case of Monomania, or "Partial Insanity."

A frequent illusion of Monomaniacs is, that they hold conversation with supernatural beings.

In most instances of Partial Insanity Melancholy connects itself with the subject of delusion. These cases properly belong to Melancholia.

V. Moral Insanity. - This term is used to designate a form of mental disease in which the affections, sentiments, habits, and, generally speaking, the moral feelings of the mind, rather than the intellectual faculties, are in an unsound and disordered state. The common distinctive character of all these cases is of a negative kind, viz. - that the faculties of the understanding remain apparently unimpaired, and that no delusive impression can be detected in the mind of the patient, which may account for the perversion of his moral dispositions, affections, and inclinations. Cases of this description were formerly looked upon as unaccountable phenomena. They are, however, now recognised as a distinct form of mental disorder in nearly all the public asylums. They arc characterized by a total want of self- control, with., an inordinate propensity to excesses of various kinds, among others habitual intoxication. This is often followed by an attack of Mania, which, however, speedily subsides when the patient is confined, but is generally reproduced, by the same exciting cause, soon after he is discharged.

Among the Female Inmates of asylums, there are many whose disorder principally consists in a moral perversion connected with hysterical or sexual excitement.

VI. & VII. Congenital Idiocy, and Congenital Imbecility.

Congenital Idiots are persons whose intellectual faculties have never been developed.

Congenital Imbecility is the result of some original defect, which renders the mind feeble in all its operations, though not altogether incapable of exercising them within a limited sphere. There are many degrees of Imbecility, but the examples chiefly found in lunatic asylums are persons labouring under this weakness in an extreme degree. It is evident that more discrimination ought to be used than has hitherto been practised in selecting from persons of this class proper objects for confinement.

VIII. General Paralysis of the Insane, and other forms of Paralysis complicated with Insanity.

Paralysis is not unfrequently complicated with Insanity, and is almost an invariable indication that the case is incurable and hopeless [compare 1989], marking the existence of organic disease in the brain.

In some instances, Insanity is the consequence of an attack of apoplexy, or of hemiplegia. This happens more especially in aged persons. In others, apoplexy or paralysis supervenes on protracted mania or dementia.

The most strongly marked case of the complication of paralytic symptoms with those of mental disorder, is the disease termed General Paralysis of the Insane. This is more properly to be considered as an affection distinct both from ordinary paralysis and from insanity. The paralytic symptoms in this affection are sometimes observed to precede those of mental disturbance; and others they follow. General paralysis of the Insane seldom occurs in females, but mostly in men, and is the result almost uniformly of a debauched and intemperate life. Its duration is scarcely ever longer than two or at most three years, when it generally brings its victim to the grave. The onset of the disease is distinguished by an impediment in the articulation, an effort is required in speaking and the words are uttered with a sort of mumbling, and stammering. At this period, there is no other perceptible sign of paralysis, and the mobility of the limbs is not at all impaired. In a second stage, the patient is observed to have a tottering gait: the limbs are weaker than in health, especially the lower extremities, while the functions of the organs of sense are likewise enfeebled. In the progress of time, a third stage appear*, during which the victim of the malady loses not only the power of locomotion, but can neither feed himself nor answer the calls of nature. He becomes more and more weak and emaciated, but generally perishes under some secondary disease, such as gangrene, sloughing of the surface of the foody, or diarrhoea, unless he be cut off at an earlier period by an apoplectic or epileptic attack, to which iou these patients are very liable. The disorder of the mind is peculiar in this affection. It is generally a species of monomania, in which the individual affected fancies himself possessed of vast riches, and power.

This specific form of Insanity has been known for some time in France, by the Physicians of which country it was first described: its existence has been more recently recognised in the English hospitals, and some instances of it are reported in the enumeration of cases transmitted from most of the County Asylums. The proportions which these cases bear to the whole number of admissions is very different in different asylums; as will appear by reference to the following Table:

IX. Epilepsy. - In most of the lunatic asylums there are some, and in the large asylums many persons confined among the insane who are subject to epilepsy. For this disease, unfortunately, is often complicated with insanity. There are, however, some epileptics in these asylums who are not insane, or in any way disordered in mind during the intervals of their paroxysms.

Epilepsy is complicated with defects or disorders of the mind, in various ways.

1. Epileptic Idiots. - Persons whose intellectual faculties have never been developed. They are not materially different, as regards their mental deficiency, from idiots not subject to epilepsy; but they require greater care, on account of the accidents to which this disease renders them liable.

2. Epileptics who are imbecile or demented. - When paroxysms of epilepsy are very frequent and severe, and the disease is of long duration, it generally impairs the intellectual faculties. Torpor, weakness and imbecility come on, which, if the patient survives under his disease for many years, terminate in fatuity, similar in every respect to the fatuity which ensues in protracted mania.

3. Epileptic Mania. - Some persons subject to severe paroxysms of epilepsy without suffering obliteration of their intellectual faculties, and even without obvious disorder of the mind during the intervals of their paroxysms, are nevertheless subject to occasional fits of a maniacal character. It is an observation frequently made by the attendants of asylums, that when the epileptic fits are coming on, such persons are irritable, morose, malicious, and sometimes exceedingly dangerous. During these periods, epileptics are prone to violence, and sometimes perpetrate the most atrocious acts. Many instances are upon record of such persons, at a time when their disorder had been in abeyance, or even supposed to have ceased altogether, having been seized with a sudden impulse, to commit homicide, infanticide, suicide, or to set fire to houses.*

In other instances, the mental disorder of epileptics has the form of acute mania, or rather of raving delirium. The patient, generally a day or two. after the attack of epilepsy, sometimes immediately after it has ceased, is seized with a sudden fury, during which he sings, roars, shrieks, or resembles a man in a violent fit of intoxication. The species of madness which is complicated with epilepsy is one of the most mischievous and dangerous forms of the disease. But the instances of this affection bear a very small proportion to the cases of epilepsy in general.

A great number of instances of epilepsy, however, are all known to exist without any considerable disorder of the mind. Persons subject to occasional paroxysms, or those of infrequent occurrence only, are, during the intervals, in a tolerably perfect possession of their intellectual faculties, and are capable of following their ordinary pursuits.

Adult persons of this description are scarcely to be found in lunatic asylums, but we have been informed that boys and girls, when they have become a source of anxiety and trouble to their parents, as well as dangerous to themselves, have sometimes been sent by Boards of Guardians to asylums for protection. We do not, however, consider this a sufficient reason for associating this class of epileptics with the Insane. Where a proper classification exists, the epileptics are placed in wards by themselves, or are separated from the insane; but there are many lunatic asylums where this regulation is entirely neglected.

The proportion of epileptics to the other inmates is very considerable in some asylums, as may be seen by the following statement.

	Numbers in house	Male epileptics	Female epileptics		%
Hanwell	975	80	63		14.6 %
Bethnal Green	562	40	19		10.5 %
Hoxton House	396	24	20		11 %
Lancaster	611	40	23		10.3 %
York W. Riding	433	23	16		9 %
Kent	249	15	14		11.6 %
Chester	164	12	6		11 %

% column not in the original

X. Delirium Tremens - Instances of Delirium Tremens are occasionally, though not often, seen among inmates of lunatic asylums. The disorder is well known. It is the result of intemperance, and frequently supervenes on a fit of intoxication. It is named from the muscular tremor and agitation which accompanies it, and the peculiar affection of the mind, resembling the delirium of fever rather than the phenomena of , Insanity. It is not a disease of long duration, but terminates, for the most part, in a short period, either in death or in recovery. Hence, there are comparatively few cases of this description in lunatic asylums.

MEDICAL TREATMENT

Medical treatment in asylums considered

Having thus described the different forms in which Insanity manifests itself, we now proceed to consider the Medical Treatment to which the Patients confined in lunatic asylums are subjected.

In our visits to these asylums, both public and private, we have been careful to make inquiries as to the methods of medical treatment adopted by the proprietors or superintendents, or by those persons to whom the medical care of the patients has been confided. We have occasionally found some difficulty in obtaining information on this subject. In some instances, we have not seen the medical officers, and we have derived our information, in such instances, from the proprietors, superintendents, and the inmates of the respective asylums. Yet, on the whole, we have obtained a tolerably correct knowledge of the state of these establishments, with regard to the manner and degrees in which the resources of medicine are applied in them to the cure and alleviation of mental diseases.

Difference prevailing in different Asylums

A great difference prevails, in this respect, in the different classes of lunatic asylums. The licensed houses, containing fewer than 100 patients, in which the residence of a Medical Officer is not required, by the Act 2+3 William 4 cap 107, within the walls of each Establishment, and which, in some instances, are under the management of persons entirely without medical education, are visited generally by medical practitioners in the neighbourhood. These visits to the asylums are usually made twice in a week, and in some instances more frequently.

In some asylums, the whole system of management appears to have been constituted less with regard to the cure of insanity, and to the restoration of lunatics to health and society, than to their seclusion and safe custody. Occasional doses of medicine are administered, when incidental deviations from bodily health or any contingency calls for their use but the application of medicine and other restorative means, on any determined plan, with a view to promote recovery, and to restore the mental faculties to a sound state, appears in some asylums never to have been contemplated. To accomplish this object; the residence of a Medical man on the spot, or in the immediate vicinity, is very essential; and here we cannot but notice the following extract from a Report of the Commissioners who visited the Norfolk Asylum in August, 1843, which will point out the evils likely to be contingent on this arrangement.

"The most serious defect in this Institution, and one which may be attended with the most mischievous, if not fatal, consequences, is the want of a Resident Medical Officer. On this subject, we cannot but notice, as a singular anomaly in the law, that, whilst it is required in every Licensed House, containing 100 Patients, that there shall be a Resident Physician, Surgeon, or Apothecary, there is no similar provision as to County or Subscription Asylums, or public Hospitals. The liability to apoplexy, and the possible occurrence of cases of suspended animation from strangling may be mentioned as among the many reasons calling for the constant attendance or immediate vicinity of a Medical man. We put some questions to the Superintendent, as to what ho would do in cases such as we have described. His answer was that he would not venture upon the responsibility of acting or applying remedies, that he could not bleed, and had no knowledge or experience, medical or surgical. Upon asking, then, what steps he would take in such cases, we were told that he would immediately send to Norwich, the nearest place, three miles distant, for one of the Medical visitors. He subsequently directed our attention to a pony on the lawn, which he informed us was constantly ready to be saddled as occasion required."

Character of Medical men attached to Asylums

It must be observed, that of several private asylums the proprietors are physicians, who reside within their own establishments. Many of them are able and well-informed men in their profession, and appear to treat their patients with judgment and skill. Many of the Superintendents of County Asylums, and some of the Medical Officers in those licensed houses which, from their containing one hundred patients require the residence of such an attendant, are men intelligent, and active in doing all that is practicable towards the restoration of their patients.

Causes of Insanity in Paupers

The Medical Officers residing in the asylums have been led by personal observation and experience, nearly to the same conclusions, as to the most efficacious treatment of Insanity; or, to speak more precisely, of administering the aids of medicine and regimen to those classes and descriptions of persons who are principally the inmates of public lunatic asylums. Amongst the most frequent causes of Insanity in Paupers, are habitual intemperance, poverty and destitution, grief, disappointment; and, we fear, in some instances want of sufficient sustenance. These causes act with different degrees of influence on different individuals, according to the various states of their constitution, but they have all tendency to bring the body into a state of weakness and exhaustion. This is greatly aggravated by the insane poor being very generally sent in the first place to workhouses and other improper receptacles, instead of to asylums, where they might be immediately subjected to medical treatment, at a time when the disease is known to be curable in a large proportion of cases.

It is the general opinion of the best-informed medical attendants on lunatic asylums that the most successful method of attempting the cure of pauper lunatics in public hospitals, exhausted and destitute as they often are, is to obviate the state of body which poverty and distress have a tendency to induce. This is best effected by a restorative plan, and by means calculated to reproduce a vigorous state of bodily health. For this purpose a nutritive and tolerably full diet is allowed, consisting of a considerable proportion of animal food, wholesome digestible bread, milk porridge, or milk thickened with various farinaceous substances, and good broth. To these a moderate quantity of malt liquor, ale, or porter, is added in most cases, and in some extreme instances, wine and other stimulants. Warm clothing and bedding, and a moderately warm and dry atmosphere, are indispensable auxiliaries for promoting the comfort and cure of lunatics, in whom the circulation is languid, and who for the most part, are chilly, and suffer much from exposure to cold and damp air. Exercise in the open air in cheerful airing-grounds; baths, either warm or cold, according to the state of the circulation and the habitual temperature of the skin; frictions promoting cleanliness and dryness of the surface of the body, and tending to keep up the action of the blood-vessels to a certain healthy standard, are generally found to promote the restoration of patients whose cases are of a curable description.

The whole of this plan is said to prove beneficial only in those cases which are free from the ordinary signs of congestion in the brain, and from tendencies to epilepsy and paralysis. When these exist, they must be treated by appropriate remedies, such as topical bleedings and counter-irritations. In the cases before alluded to, tonic and stimulant medicines, and all the remedies which promote healthy digestion and a due circulation of blood to the extremities, are said to be productive of beneficial results. The tonic remedies most in use are carbonate of iron, cinchona, sulphate of quina., gentian, combined with aloetics when required by the state of the natural functions, or with astringents, when, in cases of great debility and exhaustion, there is a tendency to diarrhoea, or dysentery. A moist or relaxed state of the skin, with cold extremities; a shrunk and shrivelled surface, with a livid and blotchy, or pale and yellow complexion and feeble circulation, are well known to frequently co-exist with insanity, and are especially noted in those cases which are the result of depressing agencies. In this state of the system, great advantages are said to arise from the use of carbonate of ammonia, given in frequent doses, and continued for a considerable time. Emetics and powerful purgatives are said to be rather injurious than useful, in the forms of disease now described, except where any temporary complaint indicates the necessity of having recourse to them. It is the testimony of the best-informed among the Medical Superintendents of asylums, that the restoration of bodily health is frequently accompanied by a marked improvement in the state of the mental faculties. We must not omit the fact, that although a very general agreement exists among the intelligent Medical Officers of lunatic asylums, as to the most efficient method of treatment fur the cure or relief of the class of patients above described, there arc some remarkable exceptions, and that the regulations of some asylums are quite at variance with the general opinion.

Occupation, amusements, and exercise

By the Acts 2+3 William cap 107, section 37, and 5+6 Victoria cap 87, sections 10 and 34, we are directed to inquire what occupations and amusements are provided for Insane Patients; and (by the latter Act) to state the effect thereof, in-door and out-door respectively.

The answers which we have received to our inquiries have been generally, that occupations and amusements, especially such as take place in the open air, are beneficial to the bodies as well as to the minds of the patients. Indeed, all intelligent persons who are well acquainted with the disease of lunacy, by having seen it in its different stages and varieties, and can. therefore form some opinion as to the chance of its relief or ultimate cure, are strenuous in advising that insane patients should bo employed as much as possible. From the observations which we have been enabled to make on the subject, in the course of our visits through the several public and private asylums of this country, we are disposed to concur fully in this opinion.

It appears to us that employment should be afforded to all patients whether pauper or private; and that they should be induced to occupy themselves as much as is consistent with their bodily health: not, however, with the view of deriving any profit from their labour, but solely for the purpose of relief or cure. There can be little doubt butt that by amusing the mind of a patient, and diverting his attention from any idea, either painful or delusive, which occupies it, that much good may be effected. The longer a delusion is dwelt upon, the stronger and more inveterate it becomes. It is important, therefore that it should be displaced (though only for a time) as soon as possible, by a fresh and healthy train of thought, and by occupations which may improve the patient's bodily condition, with which his state of mind is often connected, especially in the early stages of insanity. Employment, therefore, in cases of long standing, tends to the tranquillity, and in recent cases contributes materially to the recovery, of the patient.

In most instances, it is desirable to place at the disposal of the patient, the same species of occupation that he has been accustomed to follow, previously to his entering the asylum; and if he has not been brought up to any profession or trade, it may be even proper that he should bo instructed in some regular pursuit, in order fully to engage his attention. It is at all times important, that as much exercise and employment as possible, in the open air, should be afforded, and that for this purpose, gardening and agricultural labour should be provided.

Without reference, however, to any pecuniary advantage that may result to the rate-payer, or to the proprietor of the asylum, we deem it most necessary that employment should be provided for the lunatic. In fact, the labour of a patient neither can, nor ought to, be reckoned upon as a regular source of profit. In the first place, it is uncertain; depending upon his health, temper, raid disposition. A lunatic, moreover, is a person afflicted with a positive malady, which frequently circumscribes his physical powers, and at other times exhibits itself in the shape of dangerous or violent excitement, suspending for a time, the capability of making himself useful. The object of employing a patient is not that he should make a return in value for the money expended upon him, but that his tranquillity and comfort should be promoted, and the disease with which he is inflicted, consequently mitigated or even remedied. For this purpose, moderate labour only should be resorted to, and that as much as possible in the open air, in order to strengthen without fatiguing the body; and it should he of such a nature as will afford amusement, without any risk of harassing the mind. With a view to these objects, spacious and cheerful yards, and also pleasure-grounds, should be provided, for the purposes of exercise, and of yielding the patient opportunities, at all seasonable times, of occupation and amusement in keeping them in order. But as, by these means only, sufficient employment cannot at all times be afforded to any considerable number of persons, it seems necessary that a farm, or extensive gardens, (proportioned to the number of patients), should bo attached to every large Asylum, and that a variety of in-door employments should also be provided. In order to promote exercise and occupation, it is also advisable that some trifling indulgences should be given to such patients as are willing to perform a moderate quantity of labour.

Music, dancing, and various games (as many as possible in the open air) may be resorted to with advantage, in most cases, except where the patient is too excitable. No Asylum should be without a library. Books, judiciously chosen, especially such as will not encourage any morbid ideas already existing, are an important help in promoting a happy and serene stats of mind. In cases of great depression, and particularly of religious melancholy, books of a cheerful character should be placed, to a much greater extent than is generally done, at the disposal of the patients. In most of the Asylums that we have visited, we have found an abundance of religious publications, and in some few of them little else. However useful such works may bo, we have frequently urged upon the various proprietors and superintendents, the duty of their also procuring books and publications of au entertaining character, adapted to the capacity of the patients under their care.

In the better-conducted asylums, these views are apparently acted upon to a considerable extent. Books are procured and placed at the disposal of the patients ; the exercise of trades and other in-door employments is encouraged, in some cases rewarded; and out-of-door occupation is provided by means of large gardens or farms, in which patients regularly labour in the proper seasons.

In the Wakefield Lunatic Asylum, to which are attached a garden of three acres, and a farm of forty acres of land, we were informed (on our visit in September, 1842) that 120, out of 208, male patients, and 135, out of 190, female patients, were employed in various ways. These patients belonged to a manufacturing district, and occupied themselves in woollen and cotton weaving, and all the clothes, including the shoes, used throughout the establishment were made by the inmates. They made fancy articles also for sale, and performed all the gardening and agricultural labour. A variety of amusements was provided for them, and the effect both of occupation and amusement was considered to be highly beneficial.

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