As, however, was pointed out by Bernard and Barreswil, so long as the urea, or the products of its metamorphosis, are discharged by the stomach or intestines, uræmia does not take place, but that when these channels become closed, convulsions and coma are produced, and death soon follows.

"4th. That the introduction of urea or urine into the circulation of animals, the kidneys of which have been ablated, shortens the life of such animals, as Frerichs and others have already shown.

"5th. That there is reason to believe that the urine, as a whole, is more poisonous than a simple solution of urea; for in those cases in which urine was injected into the blood, the amount of urea thus introduced was much smaller than that previously thrown in, in a pure state, and yet symptoms of as great intensity followed.

6th. That urea, or the elements of the urine, as a whole, induce such a condition of the nervous system as strongly predisposes to congestion and inflammation of the viscera, especially of the lungs, pericardium, and spleen.

"7th. That urea, when directly injected into the blood, or suffered to accumulate in this fluid by extirpation of the kidneys, deranges, in some manner, the process of sanguification, so as to disturb the normal relation of proportion existing between the white and red corpuscles, and either to hasten the decomposition of the latter, or to interfere with the due removal from the blood of such as are broken down and effete.

"8th. That there is no reason to suppose that, under the circumstances specified, urea undergoes conversion into carbonate of ammonia, but that, on the contrary, there is sufficient evidence to warrant the conclusion that no such process ensues. The fact that in the foregoing experiments a larger amount of urea was generally found in the blood taken from the body after death than in that abstracted during life, is of itself conclusive against such an hypothesis."

We cannot, we think, do better in finishing our brief analysis of this able work than by offering another quotation, and by recommending the principle on which it was written, for the guidance of other inquirers in the noble and fruitful field of physiological research, with the addition of the excellent saying of the Abbé Fontana, that "Those only who observe and experiment make mistakes; those only who do neither never err." The author's words in harmony with this are:

We

"To say that I entered upon the inquiry without certain preconceived opinions would be far from correct. That such views as I had conceived have, however, blinded me to the truth, or warped my judgment of things as they actually were, I do not believe. Theories are true but for the time being, and physiological hypotheses are even more ephemeral than any others. should therefore be prepared to yield our convictions without regret, when they do not accord with the results of experiments better devised and more accurate than our own, for only by so doing can we entitle ourselves to be considered useful labourers in the fields of science."

REVIEW IV.

1. Seventeenth Report of the Commissioners in Lunacy to the Lord Chancellor. Ordered by the House of Commons to be printed, 9th June, 1863.—pp. 176.

2. Fifth Annual Report of the General Board of Commissioners in Lunacy for Scotland. Presented to both Houses of Parliament by command of her Majesty, 1863. pp. 226.

THESE annual blue-books present the usual particulars respecting the doings of the Commissioners, the condition of the asylums for the insane (public and private), and the statistics of lunacy. As on former occasions, we have again to remark on the greater value and completeness of the Report issued by the Scottish Commissioners. The English board appear wedded to their old style, and fail in presenting nearly so full an account of the state of lunacy in this country as their fellow-Commissioners do for Scotland. For example, we have no complete statistics of the number of the insane in this country prepared by the Lunacy Board—a fact that has been overlooked by some writers who have not been at the pains of accurately comparing the official returns made in each country respectively. To this the Scotch Commissioners allude in their last Report:

"An erroneous estimate," they say, "has been formed of the prevalence of insanity in Scotland, by instituting comparisons between the number of the insane in England and Scotland, founded on the official returns of the English and Scotch Boards of Lunacy. But, in making these comparisons, it has been overlooked that in the English returns no account is taken of private lunatics, resident with friends and boarded with strangers, who have not been reported to the Commissioners. In our former Reports, we estimated the number of this class in Scotland at 1887. We see no reason to doubt that if similar investigations were undertaken in England, a corresponding increase would take place in the known number of the insane of that country. In making such comparisons, it is likewise necessary to bear in mind that in Scotland the visits of the Commissioners are not limited to asylums and poorhouses, but extend to every house, wherever situated, in which a pauper lunatic is placed. Every parish in Scotland is thus visited, on an average, once a year, either by the Medical Commissioners or Deputy Commissioners; and there is, accordingly, good reason to think that the number of unreported pauper lunatics is much less in Scotland than in England, where no such parochial inspections are undertaken. We are of opinion, therefore, that any such seeming excess of lunacy in Scotland is not so much due to a larger proportion of insane in the population as to more copious and accurate returns." (p. 5.)

Comparisons are proverbially odious, and in the above quotation the comparison thus officially drawn of the manner in which the duties of a lunacy board, when rightly apprehended, are performed in England as compared with Scotland, is unfavourable to the Commissioners in the former division of the kingdom.

Indeed, it is a fact that cannot be ignored, that the interests and

welfare of the insane are in England not watched over for nearly the whole number known to exist. The attention of the English Commissioners is pretty nearly absorbed in the supervision of those lunatics whose position is the most favourable. Their visitations of public and private asylums leave nothing perhaps to be desired, except in frequency; but the poor lunatics who are detained in workhouses are only visited by them at intervals of uncertain length, of from one to two or three years, whilst that large number referred to by the Scottish board in the quotation above, as distributed singly in cottages and private houses, are not (except when found lunatic by inquisition and inspected by the Chancery physicians) visited at all by any inspectors or commissioners. And yet every Report gives details of unfit lodging and improper treatment, and of illegal detention in workhouse wards and in private houses, which in the course of the year have been brought under their notice by others.

At

The official Reports themselves may therefore be adduced to prove the necessity for the visitation of all lunatics wherever and however situated, and of a like thorough investigation into their existence as that which brought to light so many as 1887 scattered cases in the comparatively small population of Scotland. The desirability of a general supervision will doubtless be conceded by the Lunacy Commissioners, but they are unable to undertake so extensive a charge. the present time they are pressed by work at their central office, and, as we have seen, cannot make an annual visit to the various workhouses which contain insane inmates, notwithstanding the extended provision of the Lunacy Act, enabling any one of the honorary or of the paid Commissioners to visit alone. The obvious remedy is to increase the number of Commissioners, or, as a more economical proceeding, to appoint Assistant-Commissioners, as has been done in Scotland, to whom a very large portion of provincial inspection might be allotted, and great facilities be thereby afforded for the performance of the functions invested in the Commissioners themselves as members of a central board, occupied in liceusing, in a heavy correspondence, in making investigations, and in some degree in acting as a judicial body. But, oddly as it sounds, the Commissioners, according to the statements of some of their members examined before the Committee of the House of Commons in 1859-1860, are averse to any additions to their number in any shape, whether of compeers or assistants. We were told they are such a happy family that they could not avoid quarrelling with any intruder, because as a novice unacquainted with their traditions and usages, he would probably interrupt their harmony, and, what was still more to be deplored, might prove an innovator. We commend this sagacious argument against rendering a board efficient to the consideration of our readers whose mental vision is not obfuscated by the cobwebs of office.

There is not much of interest to the general medical reader in the English Commissioners' Report. Several sad cases of violent death in asylums are fully reported, and were investigated with the greatest care. One case, happening in a private house, would furnish a valu

able and impressive text for any one who may not go to the full extent of the non-restraint principle in treatment. From the account given, it appears that the patient was a tall, powerful man, labouring under acute mania, with symptoms of general paralysis. "Three, four, and even five men had great difficulty in controlling him. In the course of the four days of his residence in the asylum several desperate conflicts took place between him and his attendants, during which they frequently fell down together, and over the bedstead which was in his room. At four o'clock in the morning of the day upon which he died . . . a most violent struggle took place between him and the attendants, by whom he was then fastened to the bed with a sheet and towels." Death took place between ten and eleven o'clock that same morning, and on examination of the body, various bruises and abrasions were found, and three ribs "fractured on the right side and six on the left. The heart was also extensively diseased." In the inquiry before a jury no undue violence could be proved to have been used, but "the Commissioners could come to no satisfactory conclusion with regard to" the conduct of the attendants, although the two senior of them were requested to resign. The Commissioners' conclusion was, that the treatment "had not been judicious, and that there had been a want of proper care and supervision;" for it appears that the superintendent did not see the case until making his ordinary round at half-past ten in the morning.

Death is attributed to the heart-disease and the fractured ribs consequent on the struggle in the early morning of the day on which the patient died; and the Commissioners evidently disapprove even the final expedient of confining him to his bed. He must be a thoroughgoing partisan of non-restraint, and willing to sacrifice everything to it as a universal principle of action, who will not regret that some means of mechanical coercion had not sooner been resorted to-supposing always that seclusion was found inapplicable or ineffectual, rather than that such a terrible struggle for mastery, and indeed for life, should have gone on from day to day in a room between the infuriated maniac and his attendants. It will be generally admitted as unfair to attendants to be so exposed to maniacal violence, and to have their passions so tried by prolonged resistance and desperate assaults; while it must be also granted that such conflicts are necessarily attended with danger to the life and limbs of the unfortunate patient. In hinting at mechanical restraint as expedient in the case, we necessarily assume that all other means of calming excitement had been tried in vain, and that seclusion, drugs, baths, and moral influence had failed.

This was just one of those cases which foreign physicians, in their criticisms on non-restraint as a universal expedient, represent as inevitable, and therefore a sufficient reason against such an extreme principle. To this objection it has generally been replied by our English advocates of non-restraint, that such cases were purely problematical, and that in the experience of the many asylums of this country in which that principle is fully acted upou, no maniacs not amenable to firmness and kindness-in short, to moral treatment as 65-XXXIII.

3

understood and practised in England—were met with, and that if such did occur in foreign countries, it was because coercion was not wholly laid aside, and because the true system of non-restraint was not comprehended. There is much truth in this reply, for none can deny the extraordinary extent to which the non-restraint principle can be carried out in well-ordered asylums; but that struggles between patients and attendants are comparatively frequent, the annual reports issued attest by the yearly catalogue of patients whose ribs have been found fractured before or after death, not to speak of slighter injuries. We must, however, not be understood to imply that such struggles are the consequence solely of restraint not being used; on the contrary, we are perfectly persuaded that they will unavoidably happen, for insane patients are prone to violence, and attendants have not always moral control, and that in almost all cases where maniacal violence does occur, mechanical coercion should not be employed to control it. We argue therefore on the same side with foreign objectors to non-restraint as a universal principle, only so far as the recognition of very exceptional cases of maniacal violence is concerned, believing that humanity will be best served in such supposed instances by a departure from so inexorable a rule of management.

The State Criminal Lunatic Asylum is ready to receive patients, but the Commissioners find that a removal of all the registered criminal lunatics to it is unnecessary and undesirable. The number to be removed bears a small proportion to the aggregate, on account of the trivial nature of the offences of the majority, and other circumstances with regard to them mentioned. The Commissioners indeed

"Have been forcibly impressed with the impropriety and absurdity of treating a large number of the patients confined under Secretary of State's warrants as of the criminal class, or otherwise than as ordinary lunatics, from whom they cannot, on any sound principle, be distinguished. We think it most desirable that the Secretary of State be empowered to transfer such patients from the criminal to the ordinary pauper class."

Eight hundred and seventy-seven criminal lunatics are enumerated as detained in asylums, hospitals, and licensed houses in England; but the number of those confined in convict prisons and gaols, the Commissioners are unable "to state, even approximatively." This last is a remarkable admission on the part of a Board which, if properly constituted and empowered, should, from its single special function in the State, be charged with the supervision of all lunatics in the kingdom.

In Scotland the only criminal lunatics alluded to by the Commissioners are those confined in the general prison at Perth, and only thirty in number. We cannot, in face of the large number enumerated in England, suppose those thirty to be the whole of the criminal lunatics in Scotland, yet no notice is given of any such inmates in the very complete lists of patients in asylums of all sorts, and we presume therefore that their existence is either not taken into account, or else that the Scotch criminal law operates in a different manner on the destiny of those guilty of crime who are at the same time of unsound mind. The English Commissioners have arrived at the conviction,