GUISLAIN

TRAITÉ SUR L'ALIENATION MENTALE, &C.
Par Joseph Gulslatn, Médecin à Gand.
A Prize Production. 1826.
137
I. Moral Means.

* Divulsion from Exercises of the Body.-Exercises of the body are not equally proper in the cure of all kinds of mental alienation taken indiscriminately. Unless the individual has a consciousness of his actions, and acts in virtue of such an impression, the exercise is merely hygienic ; it is so in idiocy and dementia. In the varieties of mania and monomania, these are powerful moral agents, at the same time that they act on the physique. Experience has demonstrated the great utility of exercises of the body in melancholy. In mania they are always of inappreciable advantage ; but it is in the intervals of the paroxysms and in convalescence that we obtain most success from these means. The advantages in procuring sleep may be here extended also to monomaniacs, with whom nothing is more frequent than sleeplessness. In dementia they should not be carried so far as to fatigue. In general they may be employed with advantage in most of the diseases which complicate madness, especially in epilepsy, and also in palsy. In the first, it is admissible to carry them even to fatigue : great care should be taken that they do not hurt themselves. An exercise which suits one lunatic will not agree with another. For very irritable persons, but a mild and moderate action is necessary ; for soft lymphatic constitutions, are necessary, on the other hand, more rough motions which should be borne even to fatigue. In general the exercise should be proportioned to the strength of the patient and his habitual manner of living. As is observed by Celsus, in changing the patient's ideas, by the things entering into his daily life, such a change should be gradual ; for if he perceives the purpose of these external objects, it will tend to make him distrust our efforts and cling more closely to his delusions. Travelling the best means of divulsion : a country should be chosen which would agreeably divert the patient, where the scenery is agreeable, picturesque, and varied, where the air is pure, and neither too cold nor too warm. Italy, the southern provinces of France, Sicily and Andalusia, are highly praised. The Belgic provinces offer all that could be wished here ; the environs of Spa, Aix-la-Chapelle, Liege, Brussels, and Ghent, are suitable. A great part of Holland in summer offers agreeable scenery, &c. A trip to some mineral spring is a means of divulsion not less efficacious ; the cessation from business, the country air, the varied society, &c., proving very useful. We cannot otherwise attribute, in general, salutary effects to the waters. But in some cases, where the derangement has resulted from the repercussion of a cutaneous disease, thermal waters become salutary auxiliary means. The itch is singularly apt to lead to madness, when treated by repercussives : in such cases, sulphureous waters are of acknowledged efficacy. Debility of the abdominal organs, and particularly that of the portal system, is sometimes a cause, and sometimes 138 a symptom in insanity. We are led to believe that ferruginous, bitter, and saline waters are auxiliary means sufficiently efficacious. The waters of Carlsbad and Ems are particularly praised in hypochondriasis. Mineral waters suit generally in insanity with debility of the solids. If the excursion is made by water, the patient should be engaged in directing the vessel. If the strength is good, he should be made to row, or be placed at the rudder : if in a carriage, nothing is more salutary than, as Sydenham remarks, to let him manage the horses ; he thus loses sight of his delusions for the time. Open carriages are preferable, as calashes, cabriolets, &c. Rough and uneven roads are suitable, as acting on the senses. Spring is the most proper season for all sorts of exercises, from the weather, long days, &c. The patient must be accompanied by some person ; whose choice is not unimportant : cheerful, gay, and well-informed men are preferable. Sea voyages are useful for the salutary air, and besides, the general effects of an excursion act well through the nausea and alvine evacuations to which they give rise. Excursions require discrimination as to the character of the patients. It is evident that we cannot thus expose the furious maniac, nor him who exacts much care and overlooking. The patient ought, more or less, to be pleased with the measure ; he should be docile, and have no desire to escape the vigilance of his guardians by deception or by force. In general, whatever be the nature of the mental alteration in convalescence, travelling is a great resource. In monomania it is very useful. In hypochondriasis, in misanthropy, in erotic and fantastic monomania, it is of inappreciable value. If the patient is not habitually noisy and turbulent, even in mania, it is salutary. In dementia it is purely hygienic. Walking, &c.-In general, nothing can be worse or more irrational than to keep a patient shut up in a close apartment. Suitable places should be chosen for walks ; both crowded spots, and those where reign silence and gloom, should be shunned. These promenades should be made at the dawn in summer or in spring ; as nature is then grand, imposing, and beautiful, and therefore likely to exert a strong impression on the patient. Sailing is very efficacious ; and here we may advantageously procure agreeable company. Riding on Horseback.-This has long been a hygienic precept : the patient should shun gloomy and monotonous situations, and ought to be in agreeable company. From its peril, this exercise ought to be limited. Some varieties of monomania, of which hypochondriasis is the most essential, call for it almost alone. Hunting.-The divulsion here procured is most powerful, but the case must be appropriate. In this, and all sorts of exercise calling for a dangerous weapon, great circumspection is necessary. Games.-They do not suit in general, but inasmuch as they arouse the attention and other intellectual faculties. Dancing, the course, tennis, battledore, billiards, bowls, mall, are preferable amongst a great number. Those which require much calculation and thought are rarely salutary, and almost always hurtful. Games of address are specially indicated with patients of high grade, or with those unaccustomed to labour. As to dancing, waltzes are very good revulsives. They act upon an important passion. The alluring attitudes, the liberties; the frequent, almost continual touchings, invite to sentimental pleasure and voluptuousness, and are correspondently arousing ; on the other hand, the activity given to the circulation, the excretions and secretions which are favoured, are consequences which give to this exercise the rank of a precious means 139 in mental derangement. From the agreeable sensations, this dance would be particularly useful in hypochondriasis ; such patients being very sad and depressed. It is not less salutary in erotomania, owing its origin to faithlessness, or to the loss of a beloved object ; it is thus that new ties are often produced. Billiards, battledore, tentus, and the course, suit on the same principles as the dance ; the exercise and divulsion being the salutary results. Horn had, at Berlin, a cart to contain four lunatics, drawn by thirty others, which, according to him, is a very efficacious means of divulsion. Labour is indicated in almost all kinds of madness. In monomania and mania it procures a salutary divulsion, and it is in the intervals of the paroxysms of the latter that it is most suitable to employ it, as far as the thing is possible. It should not be borne to fatigue ; it is only necessary to produce a divulsion, to procure tranquil nights, and repose of the intellectual functions. In dementia its use is more limited. The kinds of labour suitable are numerous ; gardening, household duties, the care of domestic animals, principally of horses and cattle, with all sorts of hard labour, hold the first rank. Reil gives too great an extension to bodily exercises ; he proposes combats and tumultuous exercises of all kinds : these would be pernicious from the too violent passions which they would excite. A Scotch farmer was very successful by working lunatics as beasts of burden.

Divulsion from Mental Labour.-We, are able to employ mental occupation with less hope of success than bodily, with respect to all lunatics ; because a taste and inclination are here necessary. Music, amongst the fine arts, occupies an eminent place. It is useful in mental alienation, 1st, as exercising the mind of the patient who executes ; and 2d, when executed by another, it excites agreeable sensations through the hearing. The different emotions which music excites indicates the precautions necessary in its use. Skilful persons can alone decide on the employment of such an agent ; for when the choice is not applicable to the case, music is not only of little efficacy, but it may become even hurtful. On this subject, Frank relates that Dr. Herberski was called to a young insane person, affected periodically with mania, who, every time that he heard the sound of any music, was seized with a furious paroxysm of the disease. I have seen, says Esquirol, patients whom music rendered furious ; one because the tones were false, and the other because he imagined his misfortunes to be sported with. It would be irrational to make use of all sorts of music without distinction. Experience teaches that that composed of a small number of instruments, quick, light, and agreeable, is the most suitable ; such are warlike marches, waltzes, village dances, and others of this sort. Cases with sadness, hypochondriasis, misanthropy, and demonomania, gall, more than any other species of madness, for the use of music. The effects are rarely salutary, according to some authors, when the disease has its source in an amorous passion. It is an excellent means in madness accompanied by transports of fury and rage. Many authors report under this head astonishing cures : Frank, amongst others, says that in like cases, he has drawn from it the best effects. The influence of music will be the more salutary if the patient applies himself to this as a science ; as exercising mental faculties. The following is a case, although from love, showing the salutary effects of music. Case.-A young girl of very nervous temperament, gay and pretty, goes to stay at the house of a friend, for whom she soon takes up an affection. Suddenly she became 140 maniacal, quitted the house, spoke much of her love, and committed a thousand absurdities. Reconducted home, she placed herself at the piano, of which she was very fond. The first tones were incoherent, but in a few moments she observed the measure, followed rigorously the rules of music, and from that moment not the least error in her intellectual functions could be observed. She had regained her reason ; she always found her' reason return from the harmony of this instrument, the same paroxysm having reappeared many times. After singing, the choice of the musical instrument is not indifferent altogether : all stringed instruments appear to me particularly suitable. The harp, the lyre, the guitar, the mandolin, and the piano, are peculiarly fit. The flute, the clarionet, and the bagpipe, are equally suitable ; the last instrument should, however, be proscribed with nostalgics from Scotland. Theatricals.-It has been proposed as a means of divulsion, to make the insane act comedies. It appears even that this practice is in vogue in some of the German institutions : Klose thinks that a patient should not support any part which has connexion with the character of his delirium. We cannot conceive how a troupe of comedians of this kind can be obtained. The patient might, I think, be present, in some instances, as a spectator, in well-selected pieces, but it is not at all suitable to make of these patients dramatic artists. The maniac is here excluded : it does not suit except in some kinds of monomania and in convalescence. Painting and the other Fine Arts.-None of the means demanding an application of the mind are more engaging than painting and music. They should choose preferably landscapes and sea views, rather than historical subjects, as they are more easily executed, and the imagination receives a greater diversity of impressions ; this means of divulsion also leads to country walks, which divert the mind. It is not universal, being almost exclusively applicable to the different varieties of monomania. If an organic cause be at the bottom of the evil, in vain will be the moral measures which we have recommended : it is to cures from moral causes, as loss of fortune, &c., that they apply. Moral means are more powerful in the commencement of the malady than when it has become chronic. The same remarks apply to sculpture, architecture, &c., as to painting ; the attention and the imagination are chiefly concerned. Science and Belle-Lettres.Their cultivation is a means not to be neglected in the moral cure of insanity. But prudence is here necessary ; as their too assiduous cultivation, to the neglect of the body, has given rise to the disease. Mental application is not usually advantageous, but in some varieties of monomania ; in mania the attention is too disordered. In erotic monomania we should act with great reserve ; shunning all reading that disposes to strong passions, such as poetry. For the same reasons, music, the theatre, dancing, and the sight of lascivious images and pictures, demand here such strong precautions. All mental application relative to computation is decidedly more hurtful than useful in all kinds of madness. Mathematics, logic, and metaphysics, are included in this category. Sciences which furnish novelty and recreation are requisite here. We may give the first rank to botany, chemistry, experimental philosophy, physical astronomy, and the natural history of minerals and animals. I repeat, mental application is only really useful in some varieties of monomania: It is thus that misanthropy, nostalgia, suicide, and hypochondriasis, call for its employment more than all other species of madness : it is especially suitable in the 141 convalescence of such patients. Belle-lettres offer a vast extent of divulsion ; they are oftener attractive than scientific labours ; a good choice is necessary, however. All works exciting violent transports of the soul should be rejected. The choice of the works should be based on the character of the disease, the literary education, and the ruling ideas of the patient : the physician must be governed by the circumstances of the case. In general, voyages, books of a moral and historical kind, are preferable. Sandttnann counsels that the patient should read in a loud tone ; the attention, says he, becomes, by this, more intense and sustained.

Means acting upon the Imagination, &c.-Numerous examples of success have tested the curative powers of the means in this section. In their use prudence and strict discretion are demanded. The circumstances of the case must altogether determine the nature of the means. We here coincide with the patient in his delusions. The use of these means is very limited ; it is only adapted to some varieties of monomania ; it is when the intellectual functions as to other things are in a good state, when we know the source of the disease, and when we seek by a stratagem to dissipate the delirium : then these means offer the greatest hopes of success. In nostalgia they are but hurtful ; the misanthrope receives from them a fatal blow, and the suicide only sees reasons for accomplishing his unhappy design : bad effects are not less to be feared in hypochondriasis, and in erotic monomania. Lemnius reports the case of a patient who, believing himself dead, refused to eat ; after trying various expedients for many days, persons at last entered his room dressed in white, and asked him toy dine with them, saying that they too were dead, and had come to visit him ; he was astonished, and said that he did not know that the dead were able to eat; but finally he placed himself at the table, ate with a voracious appetite, and after a long sleep, was delivered from bis delusion on finding himself alive. Tulp, a celebrated physician of Amsterdam, mentions a painter who thought his bones made of wax ; he told this patient that his disease was well known, and could be cured, provided proper directions were followed. He agreed to this, and got well in seven days, the time predicted for his recovery. Gatianar cured a female imagining frogs to be in her abdomen, by administering a purge, and having them placed unawares in her dejections. Case.-A patient is mentioned, who became sad and morose, and refused to eat., under the persuasion that his enemies had stripped him of his fortune, and that he had not wherewith to procure sustenance. By M. Esquirol's advice, he was advised to consult a lawyer, in order to know the situation of his affairs. After some days' hesitation, he commenced a long account, which necessitated much travelling. After a month, his cure was advancing. Everybody knows the anecdote of the patient who feared to pass water lest he should deluge the world, and was made to do so, by being told that the city was on fire, and that he could thus quench the flames. Cox mentions a patient cured, who fancied he had the venereal, by the physician's pretending to use the mercurial treatment. Sauvages reports a case in which the patient. fancied himself unworthy of divine pity, and who was cured by a man's entering his room, dressed as an angel, and in the name of the. Trinity offering pardon to him for his pretended sins. Case.-A lady imagining her bones lucent and ready to inflame ; and fearful of being exhausted by her alvine and menstrual secretions, and endeavouring to retard these, Frank relieved by rubbing with a solution of phosphorus in oil ; as if to 142 draw out the light ; he also gave her some astringents, and employed recreation. She was attacked, however, afterwards by mania, from which she was restored. This means of cure presents a vast extent all great physicians have confirmed the sentence of Celsus- " We are oftener to assent with than oppose." A number of cases of mental alienation exact that we should lend ourselves to the false ideas. It is, above all, in madness accompanied by sad emotions, that it is most requisite to partake in the feelings of the patients. Nothing could be more absurd than the endeavour to give happiness to a sad soul by gay pleasures. It is in speaking to the patient of the subject of his delusion, in exciting his tenderness and confidence, that we may lead him by degrees, and imperceptibly, towards another end. But, as may says, the most essential point in the art of directing minds is to conceal from them whither we lead them. We should take care that stratagems which we place in use should not subsequently be discovered by the patient. a Michel Wagner relates that a military man imagined himself to have irk his head five grasshoppers ; a surgeon performed a fancied operation of extraction, and five of the insects previously procured were shown him as the product. He was cured. A number of years passed, when his comrades made known to him the means by which he had been restored : from that moment he had no repose ; his fantastic delusion reappeared, and changed itself to furious mania, by which he perished. Maas speaks of a man who believed that he had a bird in his head ; he was cured also by a stratagem, which was afterwards communicated to him, and he relapsed into his old delusion. Pinel speaks of an individual believing himself destined for the guillotine; he was cured by a simulated tribunal, and relapsed on the means being discovered to him.

Means acting on the Senses and Judgment.-Philotinus cured a man fancying himself headless, by placing on his head a leaden hat. Van Swieten speaks of a man of letters, who fancied his legs made of glass ; having reprimanded a servant for carelessness with fire-wood, she, provoked with his importunateness, struck him a blow on the leg. Angrily, hasty he jumped up to avenge the insult, and soon rejoiced in being able to stand on his legs. He was cured. Case.-A lunatic believed himself to be God the Father ; and stretched upon the earth, he fancied that be reclined on a rainbow and watched the globe. By placing him in different situations, causing him to feel his error, and by reasoning, he was convinced of the falsity of his ideas. Falret relates an instance in which air adopted daughter seeing him whom she had supposed to be her father, became insane, and also the mother and sister of her husband, through the fear of being herself insane, at last became actually so. She recovered from having discovered, in a lucid interval, that. the person who had adopted her was not her real father. Another similar instance, respecting suicidal madness, is given in the Journal of Sciences. A tailor, imagining himself surrounded by all sorts of phantasms, was restored by the constant reasoning of two of his companions. Cox speaks of a man who became melancholic and believed himself damned, and who was cured by placing in his hands a treatise on mental alienation. A young man causelessly fancied that he had syphilis ; and after consulting many physicians, he at last imagined that he could not walk a step, and did not dare to venture in the streets. One of my friends to whose care he was intrusted, seeing that all moral measures had been 143 spent, determined to convince the patient of his error. He commenced by proposing to him walks. After some persuasion the patient consented, provided that he should be accompanied, and necessary means should be furnished, in case of syncope or other accidents. The first questions in these excursions turned upon his disease, but insensibly the conversation was directed to other points, which engaged his curiosity ; by degrees he forgot his pretended feebleness and his pains, he walked with ease, and lost sight for the moment of his malady. This moment was seized to make him feel, by all possible reasoning, the change operated in him. He was astonished at himself, he wavered, and at last yielded to the advice given him : some promenades have been sufficient to cure him. It may be easily perceived that the application of such means as those just detailed is confined to some forms of mental alienation : in hypochondriasis, for example, it may be of great benefit ; it is the same in fanciful monomania. There are some cases in which the patient, wholly conscious of his situation, agrees to the disorder of his imagination ; it is with pain that he acknowledges it ; incessantly governed by a fatal passion, it is impossible to call reason to his succour. This condition belongs to mania without delirium ; it is equally present also ip the commencement of monomania. It is necessary, in cases of this description, to inspire the patient with a firm will against the ascendency of the passions, in order to cure the disturbance of his intelligence.


Means specially drawn front the Passions.-The three preceding sections have furnished us with the operations of the understanding, or of locomotion, attention, memory, &c. These cannot be exercised apart from the passions. It is thus that all the divulsive influences cannot be really efficacious, but inasmuch as they are accompanied by the agreeable feelings of the heart. The passions, then, although capable of being directly excited in mental alienation, accompany, in a number of cases, the moral means which we have discussed.

Pleasant Feelings, Consolations, Friendship, Hope, the Succour of Religion.-To induce calm and serenity in the soul of the unhappy, nothing surpasses consolations in efficacy. Our first endeavours should be to gain the confidence of our patients ; to attain an end so desirable, it is necessary to share in the troubles of him whom we console. In the first instance, indeed, we should direct our efforts to excite the courage, and to renew hope: in the first moment of grief, says Darwin, the consolatory method of my Uncle Toby, in Tristram Shandy, is doubtless the best : " he sat himself in a chair at the side of his unhappy friend, and ...... said nothing !" The mere presence of a friend is very sweet ; friendship also becomes of inappreciable value in the cure ; all who have had the care of the insane have felt the good from the confidence of a sympathizing friendship : there are none so ferocious as not to be sensible of this. Willis insists especially upon the truth of this principle : small gifts of flowers, or of some ornament, pleasant diet, good garments, much liberty, are equally, says he, tokens of good-will, and means by which we gain the esteem of the insane. It is always necessary that the conversation held with them should be as agreeable as persuasive ; and there is nothing, as respects this matter, which surpasses in efficacy the society of females. Moral sengibility, assiduous care, and the art of speaking to the heart, appear to belong, par excellence, to them. In order to apply consolations with success, we 144 must descend to the source of the evil. It is here, above all things, that we should appreciate how important is the knowledge of the moral causes. The death of a parent, of a friend, or of a mistress, of a spouse, or a child ; the loss of a considerable fortune, withered hopes, disap pointed love, faithlessness, jealousy, domestic dissensions, fear, terror, and separation from the natal land, are the principal causes of disordered mind ; these are they which exact most imperiously consolations. In all cases in which the disease is accompanied by grief or gloomy feelings, consolations are indispensable. In nostalgia especially, the physician should nourish his patient with hope, and by feigned consolatory circumstances. In this case, more than in any other, we must make the time pass in promises, and in well-concerted fictions. At the military hospital at Ghent, a Swiss soldier, already attacked by a slow fever, with whom a number of means had beer. in vain employed, was cured by promising him his discharge, upon the condition that he should not obtain it until he was entirely restored. A militiaman, named Hoogstoel, a nostalgic at the same hospital was in an almost complete state of marasmus when he was discharged. He returned to his friends, and in a few days had made astonishing progress towards being cured. We flatter the imagination of the patient, by letting him see in the future a return to his country ; we repeat the stratagem according to circumstances ; and in this manner, if it is impossible to destroy the mental alienation, we at least sustain the health, which would deteriorate so quickly, if these persons were abandoned to their sad ideas. We cannot employ too much care, affability, and attention : when the madness proceeds from the loss of a beloved object, this method is equally indispensable. Pine] has cured in this manner a young man who became insane from the loss of his parents. When from unhappy love, in our own consolations, the greatest prudence is necessary : we commence by agreeing with the patient. respecting his complaints. Frank says, justly, that it is pleasing to the lover to listen to his complaints, and to receive them as real and genuine. On this account, we should listen with interest to all which the patient relates respecting his disappointed affection ; we should question him, we should recall to him the charms of the beloved object. If loss of fortune be the cause, the patient should be made to feel in what true happiness consists ; he should be made to perceive that health and a moderate fortune have more of true pleasure connected with them than immense wealth, which is calculated but to render our existence uneasy or insupportable to ourselves and to society. Consolations not less efficacious may be drawn from religion : in prayer, the patient feels to revive tranquillity in his sad heart: it is sometimes from this measure that greater consolation is derived than from any other means. The ancients well knew the influence of religious ideas upon the moral portion of man. Amongst the Greeks and Romans temples were devoted to the cure of these maladies, and antiquity has left us many proofs of their astonishing effects. Even in our time we see religion invoked for the cure of diseases in general, and of disorders of the mind in particular. At Bensanqon, religious ceremonies are conducted for the insane for nine days. The same is practised at the village of Bonnet. At Gheel they pretend to cure thus demonomaniacs. Religious aid is not a means generally admissible in insanity. We must have in view the cause, character of the disease &c. We ought to act with great prudence, if the derangement be characterized by religious symptoms, and not have religion for 145 its cause, as may be the case. This means should not be confided but to fit hands. From the moment in which the delirium assumes a super stitious character, it would be more than imprudent to use a like measure. It is not so, where the patient is a prey to violent grief, in consequence of disappointed love, of a loss of fortune, or from the death of a beloved person : then religion becomes the source bf the most touching consola tion. In all insane hospitals, religious worship is indispensable ; at least that some person capable of inculcating this should be attached to them. This individual should always remember that his duty is not to make proselytes, but to calm the sufferings of the spirit. It is here that we must. observe that the success of the moral treatment cannot be obtained by any one isolated means : there is necessary a concurrence of various agents, all of which lend a mutual assistance. After having gained the confidence of the patient, and having procured for him all possible consolations, we withdraw him insensibly from his ruling passion, and by a course of conduct wisely directed, we attach his attention to other ob jects ; we remove everything which may give room for sad feelings ; we cause him to seek company, the society of females, and gay conversa tion ; and if, by these means, we do not always cure, at least, says Esquirol, we do not aggravate the disease, and we always tranquillize, we console and animate the mind. Joy.-Relaxation and hilarity are highly necessary, says Lorry, in the cure of melancholy. Gayety is a feeling which should be joined with almost all sorts of divulsion. Nothing ful fils this end better than the conversation of beloved persons ; parties of pleasure; sudden joy; music ; the theatre ; Moliere's plays ; the operas of Rossini : but in all these a gradual progress is necessary. Great pru dence is, above all, required, when we act by means of sudden joy ; for even death has been the result of such feelings. It is useless to observe that joy and gayety are not. indicated in all kinds of mental alienation, indiscriminately. Noisy pleasures are hurtful to maniacs ; and in joyous monomania they would but aggravate the disease. In all cases, moder ate enjoyments are preferable in hypochondriasis, in misanthropy, in nostalgia, and in erotic monomania. We may always try to procure agreeable sensations in dementia. It is a general rule to place a patient in contact with persons who please him. Love-Coition-Gestation.-In dependently of cases arising from loss of property, of a friend, of a rela tive, or of high station, and many other cases of this nature, love would be principally useful, when the mental affection originates from this passion as a cause. If a man has become insane in consequence of disap pointed affection or from other causes of the kind, and travelling, consolations, and all sorts of divulsion have been unsuccessfully employed, there remains no other resource than to lead him to new connexions : by provoking a new passion, the old is obscured. If this is unsuccessful, nothing remains but possession of the beloved object, which may not always be easy. Circumspection is requisite here. If the mental aliena tion really depends on disappointed love, marriage is the means, par excellence; but if erotomania is but a symptom of the disordered mind, it is to be avoided. Frank mentions a case in which the patient was said to be deranged from love : the physician recommended marriage, which was celebrated, and the patient imperceptibly recovered her reason ; but it was but to abhor him, whom she had not loved save in her disordered imagination. I thinly I may abstain from speaking of the cure, when the disease proceeds from a premature widowhood, and from celibacy. Arnold 146 nold de Villanova, Bartholinus, and Alexander Benedictus Veroninen sis have given instances in which coition acted favourably. The privation of enjoyments ordained by the nature itself of our organs, is sometimes the cause of mental alienation. In this case it promises to be advantageous. As to the utility of conception and gestation, opinions are strongly divided. I know well that these acts do not always produce the happy results which ought to attend them. Suckling, however, almost always operates a happy change in insanity. Darwin assures us that he has seen the most astonishing cures of this nature. It happens sometimes that young children, in consequence of jealousy with regard to the preference of a mother, become melancholic : maternal love can alone work here an efficacious cure. The most brilliant success is said to have been obtained from extirpation of the ovaries and from castration. But what would be the situation of a man thus restored to reason ? would it not produce insanity on reflection? Is the preservation of the life of relation more in nature than the preservation of the species ? There are some cases in which these operations are indicated without restriction ; it is when the testicles or ovaries are attacked by some incurable organic disease, and to which the patient must inevitably succumb. Such cases are rare. Frank speaks of castration and the extirpation of the ovaries as an operation which has produced the most salutary effects in confirmed epileptic mania, and in that arising from organic disease of the testicles or ovaries, and resisting all curative means : it has also proved to be of utility in mania accompanied by frequent pollutions.

Disagreeable Emotions--Sadness.-Pinel relates the instance of a melancholic at the Bicêtre, who, after having improved, relapsed from seeing a female who was dressed in ornaments which formerly were his property. This example shows the necessity of separation from all old painful associations. Frank thinks that the patient should be in permanent contact with all which may develop in him disagreeable recollections ; for he is thus habituated to impressions which otherwise, on recovery, might endanger a relapse. Such a curative method meets with numerous indications in mental alienation arising from separation, from absence, or from the loss of a beloved object. Travelling and other modes of divulsion cannot prove here really efficacious, until the patient has been previously rendered insensible to all which recalls to him the source of his misfortune. It is true that the presence of an object to which the cause is attached ought infallibly to excite sad reminiscences ; such, for instance, as the home or garments of a beloved person, &c. ; but the patient, by the law of habit, becomes gradually habituated to these things. In this manner the most violent despair soon changes into a chronic sadness. Patients suffer at first, but they soon get accustomed to it ; and, after having experienced deep anguish, the soul falls into a silent. repose. It should not be until after this calmness of the spirit, that we have recourse to means of divulsion, to consolations, and that the patient should be placed in contact with objects which may give a salutary direction to the vicious chain of ideas. Very great prudence is, however, required in like circumstances. It is to particular cases that this means of cure should be applied ; certainly, if we perceive that the condition of the patient becomes daily more and more alarming by this practice, we ought not to employ it. Fear.-Fear has been aroused in some cases of madness as 147 a curative means ; but in having recourse to such a feeling, we cannot use too much precaution. In exciting such emotions, says Lorry, there is need of the greatest prudence, lest we increase the melancholy instead of diminishing it. An important rule here is, that the physician ought, as much as possible, to abstain from himself inspiring the fear of the patient ; he renders himself odious by it, and loses the confidence of the individual. Some other person should fulfil this purpose. In order to render solid and durable the effects of this passion, it is necessary that fear should be allied to the sentiment of esteem. It is in suicide, and principally when the patient refuses to eat, that such a practice is useful. Pinel has related the case of a patient who refused, during twelve consecutive days, to take nourishment, and in whom fear produced salutary effects. From the moment in which we obtain by fear the desired moral effect, it is necessary, as far as practicable, to cause this feeling to be replaced by one of a pleasant nature ; by this we gain the friendship of the individual, and render him docile to our views. The choice of the means to arouse fear is not indifferent. An idea, which skilful physicians of the present day have converted into a law, is, never to permit the least act of violence towards the insane. Haslam, Pinel, Willis, Esquirol, and others, all state that violence only aggravates the disease. We find in Van Swieten, that a Dutch physician treated lunatics by every means which might inspire fear or terror; blows, chains, and affusions of cold water were, in turn, employed by him ; but so soon as the patient became docile, he had recourse to caresses and consolations. Lichtenberg professes to be of the same opinion. This inhuman practice cannot, under any pretext, be put in execution. A cold severity on the part of those having the direction of the insane, an imposing array of repression, magical apparitions, seclusion, privations, and other means of this kind, fulfil far better the desired end. It is in the excess of maniacal fury that we obtain the greatest success by an array exciting fear. Experience teaches that the maniac will not moderate his fury but at the sight of a great number of persons ; this means is the most simple, at the same time that it is less hurtful than any other. Pinel mentions a patient who had refused to eat under all sorts of remonstrances, who was induced to do so by a number of persons coming to his door, clashing chains, and threatening the most cruel treatment if he persisted in his obstinacy. Onanism being a cause or symptom; it is necessary to inspire the patient with anxiety concerning his corporeal condition. It is by depicting the destruction to which ho exposes himself, and by invoking the precepts of religion and morality, that we sometimes succeed in turning away a patient from his vicious habits. Langerman furnishes a case cured by fear. A female became insane, and fancied that she had killed her only son. Neither the presence of the young man nor any other means could convince her of her error. They announced to her that her son, in despair at his mother's riot being restored to reason, had become seriously ill, and that there was no safety for him but a change in her conduct. This news was so powerful, that she was only occupied with the means of saving her child. She recovered perfectly. Terror.-Everybody knows the history of the man of letters, who being melancholy, and about to cast himself into the Thames, was cured by an attack of robbers. Haindorf says that a lady seeking, by advice, travelling as a means of cure, recovered her reason from the vehicle being overturned. Resembling in many respects fear, 148 and not differing from it but in the degree of its intensity, terror should be placed amongst the curative means which medicine borrows from the feelings, in order to obviate the disturbance of the understanding. Sudden terror, says Celsus, avails in this disease, and almost any vehement mental perturbation. Amongst the agents to which recourse has been had for arousing terror, the principal is the bath of immersion. This was made known by accident. At Anvers a carpenter became insane and threw himself in a pond ; he was taken out nearly drowned, but with returning consciousness he was restored to sanity. Alibert gives a similar case of an insane lady, who was cured thus, remaining so for more than seven years. Perfect says, that on the occurrence of an inundation at Glasgow, the water elevated itself in the cells of the insane hospital the most furious patients, on the sight of this, became extremely docile, but the moment the water retired their fury and indocility regained its habitual course. Hufeland reports a melancholic female who was thrown into water, and recovered at the same instant. A patient at Ghent, aged sixty, born of insane parents, had been insane for some time. After escaping from his keepers about seven o'clock, and wandering about in a state of agitation at not knowing where he was, he at last fell into a river: being a goad swimmer he got out, and his reason had returned. He remained well a year, and about this period experienced some relapses, but he died sane three years after the accident. I can allege other facts of this nature, all going to prove the salutary effects of immersion in mental alienation. In England, especially, many are furnished. All the great practitioners agree in saying that immersion is particularly useful in mania. It is practised by Frank, when the disease proceeds from the indiscreet use of spirituous liquors. Pinel restricts the employment of this means to extreme circumstances ; he recommends it in the case of a violent paroxysm of mania; in continuous mania, and especially in that which is inveterate. According to Esquirol, immersion is useful in mania without delirium. It may also be advantageously employed in suicide. It has been proposed in confirmed mania, combined with epilepsy. It is to be supposed that this means is more hurtful than useful, in the greater number of cases of this nature. To avoid all strong feelings, arid to shun all which may excite strongly the intellectual functions, appears to me, in this terrible affection, the only rational and curative treatment : all moral or physical excitants can but lead to epileptic convulsions. The employment of the bath of immersion exacts strong precautions by its connexion with asphyxia. It is a means always dangerous, because we cannot measure the extent and value of the effects which it will produce on an insane person. The constitution, more or less robust, of the patient, the duration of the disease, &c., are important objects for consideration, when we employ immersion. If there are symptoms of inflammation, baths of immersion can only be fatal. The manner of plunging the patient in the water is a subject requiring great prudence. We find in the Dictionary of Medical Sciences, that Dr. Willis has constructed a reservoir, with an apparatus by which the patient can be plunged in at will ; this means, as all others in which we are master of the person of the patient, is preferable to every other. To throw the patient in the water in order afterwards to draw him out, is a practice which should never be permitted. To plunge in water suspended by a cord, as is done in England, is a method which, though preferable to the preceding, is equally defective. It is only to produce a salutary terror that we should 149 exclusively have recourse to the bath of immersion; similar emotions, but more feeble, may be produced by a magical appearance, or by the sight of some hideous objects, as serpents, frogs, &c. It is necessary, in all cases, to consult the sensibility of the individual whom we submit to similar trials. Reil thinks that the patient should be suspended by means of ropes fitted conveniently to his body, at a height more or less considerable, in order to let him thus float between heaven and earth. He thinks also that fire-arms should be discharged very near him ; and that we should affright him by feigning to wish to burn his body with flames, and that fireworks should be set off at his sides. Langerman caused a red-hot iron to be brought to a female who refused to take medicines. lie created by this so salutary a terror, that the patient, believing that she was about to be burned, took with facility all that was offered her. Most of these agents may be replaced by the douche and the rotary machine. Extreme prudence is necessary in their administration. Donatus, says Schneider, reports the case of a man who believed himself so large that he durst not pass through the opening of an ordinary door ; a physician ordered him to be taken through by force. The order was executed ; but the patient experienced such a fright that he died. This example is sufficient to render us circumspect in the employment of this means. More than once we have seen the maniacal insane, when treated by fright, pass into a state of incurable dementia. Hatred and Aversion.-Erotic monomania alone admits of these passions as curative means. To exaggerate and enumerate the vices of the beloved object, is a dangerous practice. If real faults exist, we may paint them as they in fact exist, but they will not always be such to the lover; through love's glowing prism vices themselves take up a charming aspect. And I do not know how far the precept of Ovid, quoted by Sauvages, is true, to the effect that we should exaggerate and enumerate the faults of the beloved object. The physician should take care never to administer these means himself : the patient may suppose him to be influenced by personal interests. Pride and Vanity.-When a patient of high rank or superior condition is presented to our care, we should acknowledge the honours which are due to him, and gratify his pride as much as possible. Nothing could be worse than to follow an opposite plan, although different German psychologists, amongst others Schneider, have counselled it; this would irritate the patient, and he would become more indocile to our precepts. Anger.-It has been observed, with justice, that anger always aggravates mania, by rendering the patient more furious. We have seen monomania pass into mania by provoking this passion. We should not excite anger but to a feeble degree ; that of impatience, for instance, or slight ill-humour. It should be employed only in some varieties of monomania. A fact, reported by Reil,.proves the success of anger in a case of madness. Case.-A young man fancied himself dead; he refused to eat, and exacted that he should be buried. He was placed in a coffin, and some young persons were invited to come and abuse him. This was done : they met the funeral procession, and commenced speaking of the scandalous life which he had led, &c. : the patient, lifting himself up, leaped from the coffin, and ran to avenge his wounded self-love. This paroxysm of anger had upon him so good an effect that he was delivered from his delirium. Reil reports other examples of this nature. 150

II. Physical Means.

Means acting upon the Brain and Nerves.-It is when mental affections offer great alteration in the nervous system, when the lesion of the functions of this system forms a part of the intellectual derangement, that the means of which we are about to speak are urgently indicated. The cause of the malady should be seriously taken into consideration. Sometimes sedatives, sometimes excitants of the nervous sensibility, produce madness, and the curative means must be directed accordingly. The character of the delirium does not merit less study ; the complication of mental derangement with a neurosis, properly so called, such as epilepsy, hysteria, &c., is a circumstance which always indicates the nervous state. The periodicity of the delirium confirms us in this opinion. In all these cases, the means acting specially upon the nerves are indicated as really useful. The symptoms denote often a special and prominent lesion of the nerves in some of the insane ; here we must apply our curative attempts to the nervous system. These patients are extremely susceptible ; the most simple and ordinary objects are exaggerated in their imagination ; the least variation in the temperature of the air, the slightest noise, unexpected news, however unimportant, agitates them. The brain being in continual action, is incapable of repose ; it absorbs in itself alone the energy of all the other organs ; if even the patients sleep, their slumber is agitated; frightful dreams come to overwhelm them when they believe themselves delivered to repose, and these dreams are often so terrible that many patients, as Esquirol says, fear the hour of sleep. These phenomena are especially remarkable in the commencement of monomania, in religious monomania, and in hypochondriasis. We should, however, be careful not to take the disorder of the nerves as primitive, when it is but secondarv to another disease.

Opium.-This is a means to which the ancients had frequent recourse in madness, and which has been the subject of lively discussion amongst the moderns. Some fear the action of opium, others see but salutary results for the cure of these sorts of maladies : certainly, in skilful hands, it may perhaps be crowned with brilliant success ; but it does not demand the less discretion on the part of him who employs it. This means, as is known, does not produce calmness, insensibleness, morosity, and sleep ; but after having called forth in the circulatory apparatus and the intellectual functions a state of exaltation which, without being absolutely the same as that from spirituous liquors, is much like it. Hence, in proportion as the subject is plethoric and robust, when the mental disease is united with vital turgescence of the encephalon, or other organs, opium may cause sad results. Examples may be given in which the patients, although sufficiently tranquil, have become furious from the use of this remedy. Constipation and a retardation of the exhalations and secretions, by its employment, ought with not less care to be taken into consideration : in administering this remedy to a constipated patient affected with organic diseases, abdominal obstructions, we would only aggravate the disease. The cause, too, must also be attended to. An arthrictic diathesis, a repulsed tetter, suppressed evacuations, acting caus. atively, opium, independently of its doing no good, is a means whose action is in opposition with the curative end which we propose in these affections. Such obstacles should not form, however, general contraindications against the use of the medicine. When the case is well 151 chosen, when everything is removed which might counteract the salutary action of the remedy, when the strength is consulted, the organs affected, the age, the temperament of the patient, and the cause of the disease, it may be employed with confidence. Thus, if opium cause constipation, we should make use of a moistening regimen, united with mild purgatives and enemata ; if there be plethora, if the subject is young and robust, if there is a suppression of a sanguineous evacuation, it is necessary to precede its employment by a sanguineous evacuation, general or local, according to the case. Opium is particularly indicated in mental alienation with sleeplessness. Cullen and Bernard Huet say that this remedy is very advantageous in mania, by producing sleep. A number of the insane sleep very little towards the period of their convalescence, or remain awake through fear, jealousy, or distrust: opium in this case, when there is no contra-indication, becomes an indispensable means. We may have recourse preferably to the preparation which Dr. Majendie makes known under the title of syrup of morphine. It has, according to him, the power of exciting sleep without previous excitement. The formula is, clarified sugar, lb. i. ; acetate of morphia, gr. iv. -the dose a spoonful in coffee, every hour or so. Lorry is very much in favour of the employment of opium in periodical derangement, when, in other respects, the functions are in good condition. Frank asserts that it is particularly suitable when the disease has arisen in consequence of some passion ; this is being too general, as some passions demand sedatives, others the opposite. Van Swieten approved of the use of this means in mania occurring from the suppression of the lochia, and he justly observes, that the antiphlogistic regimen should always precede its employment in similar affections. Esquirol makes use of it in mania with great nervous tension, in that. in which the subjects are very sensitive, and with those in whom the nervous system appears essentially affected. Other things being equal, as Dr. Schneider observes, opium is very advantageous in monomania characterized by continual weeping, a state of sadness, sighs, &c. ; he directs it, after the example of Nord, in strong doses. The state of acute inflammation is rare in mental alienation. It is present, as Hufeland well observes, where the face is red and injected, the constitution strong and robust, the pulse hard and full, and where we are forced to put in use the antiphlogistic regimen, before having recourse to opium. Experience has taught that general bleedings are sometimes necessary, and more frequently leeches to the head; mild purgatives, and epispastics. This inflammatory state may, how. ever, be even here secondary to a nervous alteration. If the subject be feeble, aged, pale and thin, and after a frequent and small pulse, opium becomes an excellent means. Kriebel thought opium acted by producing sleep: he gave a grain every hour, until the manifestation of complete sleep. Twenty-six grains in twelve hours are the maximum dose employed by this physician. We find in Darwin's Zoonomia, that Dr. Binns cured a patient by a dose of two scruples of opium, and twenty grains four hours after. Dr. Brandreth gave 400 drops of laudanum with similar success to a furious maniac. This practice should be made known to those believing madness to be an inflammatory state ; but it would be unsafe as a general thing. If the malady is of long duration, if the sanguineous system loses energy from day to day, and when the cause is neither repulsed tetter nor suppressed hemorrhage, or when there are only nervous symptoms to combat, T would not hesitate in having recourse to opium. 152 The quantity given to the insane should always be greater than that which a sane person could bear. It is not always suitable to give it in one strong dose ; it is better to proceed gradually in its administration, in order to study its effects ; we commence with two grains, and the dose is augmented even to ten, to fifteen, or to twenty, according to the nature of the case. Cullen has always given large doses : Van Swietcn never went beyond fifteen grains. Opium is not. always administered alone. Ferriar made great use, in monomania, with a depression of the muscular energy, of a combination of opium and bark. Opium combined with vinegar appears endued with much efficacy in both mania and monomania. Van Swieten reports that this became known from a maniacal girl being cured by accidentally swallowing a scruple : it is doubtful to which we may attribute this cure. Sydenham has made great use of the Theriaca Andromachi (a farrago of 61 ingredients, G.) combined with bitters, in dementia ensuing in consequence of protracted intermittent fevers. It has been proposed to employ opium as a fumigation. Frankenstein says that, administered in this manner, it produces a state of drowsiness and slumber. Etmuller employed fumigations of opium in madness with convulsions, and with melancholics, to produce sleep, and in the furious to calm their excessive muscular mobility. Such means would always be dangerous. Dr. Donne proposes, in order to increase the efficacy of opium, that it should be united with camphor. Opium has even been added to errhines. I cannot determine how far this mode of treatment is efficacious.

Hyoscyamus Niger.-- Willis maintains that opium may be advantageously replaced, in mental alienation, by hyoscyamus. In some respects its mode of action resembles that of opium ; in others it differs from it. Previous excitement always precedes the subsequent sedation caused by opium. Hyoscyamus does not excite, nor does it arrest the secretions and exhalations, and does not constipate ; but it leaves always a feebleness far greater than that from opium; it causes, in like manner, a sadness and depression of spirits : opium, as we know, disposes to gay feelings. Science possesses few facts which attest the efficacy of henbane in mental alienation. It is praised exclusively in mental affections connected with derangements of the nervous system. Should we not try it in joyous madness ? A turbulent patient, whom Dr. Müller, of Würtzburg, caused to take hyoscyamus, became more tranquil under its influence.

Camphor has been frequently used in mental alienation, and a great number of physicians have not ceased to vaunt the advantages which they have obtained from it in maladies of this description. Dr. Consbruch thinks it should be given in large doses; one scruple, and even two drachms. Dobson has given to a furious maniac three drachms of camphor in twenty-four hours (a scruple each time) ; the following day, the same quantity was consumed, and the patient was entirely restored. Avenbrugger has particularly employed camphor in mental alienation, with retraction of the membrum virile; where the scrotum appears empty and the testes are drawn back towards the pubis ; and where the whole genital apparatus is cold. In females, says Avenbrugger, camphor is indicated in mental alienation, when the hands are cold, contracted, and trembling ; symptoms which are equally met with in the male sex. Hufeland cured an insane female by injecting in her veins a mixture of four grains of camphor, and as much tartar emetic, with two drachms of the mucilage of gum-arabic ; he augmented the dose gradually. 153 Viborg, Schonheyde, and Schneider have equally made known the success of camphor in mental alienation ; but Perfect may be cited as having made most use of it in this sort of maladies ; he prescribed it to almost all lunatics indiscriminately. However, of 108 cases of mental alienation which this author reports, and nearly all of whom were cured, it is impossible to recognise whether the reason had been recalled by the use of camphor, or by some other means ; since bleeding, camphor, the seton, vesicatories, and vomits, are always employed in the same individual ; Perfect has also but little distinguished the cases in which camphor suits, from those in which it is but hurtful. The difficulty of telling to which portion of the treatment the cure is due, is evident in the cases which follow.-Two scruples of camphor, with fifteen drops of the camphorated tincture of opium, were prescribed to a female attacked with melancholy connected with amenorrhoea. She had made use of many other means, but without success. By the employment of opium and camphor, she recovered her reason, and her courses also appeared. Case.-A married female, of leucophlegmatic temperament, became melancholy. Her colour was pale ; the urine reddish ;the tongue dry ; the pulse contracted, hard, and unequal. After bleeding and administering an emetic, Perfect prescribed two scruples of camphor, morning and evening. There was manifested, on the whole superficies of the body, an eruption, and the menses, which had been suppressed during the whole course of the malady, regained their healthy flow. Nitre was added to the camphor, and the patient recovered perfectly. Case.-A female, after having been cured of contagious catarrh, which pervaded England, suffered a periodical relapse with it. She was given bark, and from that time she lost her spirits, and complained of continual anxiety. The pupils were dilated ; the exterior of the patient was pale and wan; she spoke in a low voice and without coherence ; her respiration was difficult, and on many parts of the skin eruptions appeared. Perfect made the patient take camphor and musk also, and applied a vesicatory to the epigastrium. After four weeks' use of these means, she recovered. Case.-A man, aged 45, of tall stature and relaxed fibre, after having committed an excess in drink, was attacked with palpitation of the heart, difficulty of breathing, vertigo, and want of appetite. His intellect wavered ; he experienced an epileptic paroxysm, and felt a pain in the right hvpochondrium. When Perfect saw, for the first time, this individual, he observed that the pupils were strongly dilated, and that the eyes were remarkable for an excessive mobility. He had not slept for seven days consecutively. His face was red, and the pulse frequent and full. There was constipation. He had been bled, given emetics and purged, but the. mental disease did not the less persist. A volatile liniment was first prescribed, and afterwards a vesicatory for a species of paralysis with which the patient was affected in the right leg. He experienced also frequent spasmodic pains in the arm. A seton was placed between the shoulders ; but he did not regain his reason until after having made use of a bolus composed of camphor, valerian, and mustard. Perfect has cured many lunatics ; but no person has been more empirical. The success of camphor is not generally testified by practitioners. Cox says that he has seen melancholy pass into furious mania from the employment of this medicine in a small quantity, and that in a large dose it has sometimes produced death. He never saw the good effects which have been attributed to it. Müller, of Wurzburg, has given it in a large 154 dose, and obtained no other effect but an augmentation of the caloric on the cutaneous surface, as also a greater energy in the pulsations of the heart. I have made, in the lunatic asylum at Ghent, some trials with camphor, and I cannot report any case in which it has produced marked advantageous effects. A case of dementia from onanism took it for a long time without the least benefit. A case of mania was given it six weeks, without any moral change. I gave it, in large dose, to a melancholic who offered all the indications given by Avenbrugger and Burserius for its employment, such as paleness of the face, coldness of the extremities and of the genital parts, and slowness of the pulse ; but after taking the remedy during forty days, there did not appear the least remarkable change. Camphor has been combined with vinegar, nitre, opium, and musk.

Musk.-As a great excitant, musk demands circumspection. It never is suitable when excitement of the vascular system is feared. It seems that it has been given with advantage in disorders of the mind proceeding from the retrocession of some exantheme, and in those accompanied by convulsive motions. Van Swieten has given it with success to a young maniac. Locher said he had calmed the furious transports of a maniac by from fifteen to twenty grains of musk per day : having given it to six other maniacs, he obtained no success from its use.

Digitalis.-According to the report of various respectable writers, digitalis may be employed very advantageously in mental alienation. Cox praises it extravagantly. Fanzago reports also facts respecting the cure of the disease from digitalis. Madness, he says, with an exaltation of the sensibility, particularly demands its use ; and a state of debility is a contra-indication to its employment. According to Frank, it is particularly indicated in recent mania which has not its origin in organic disease. On account of the nausea which it creates, it may be advantageous : Willis affirms that he has seen good effects from this. Digitalis has been recommended in mental alienation with scrofula. Dr. Müller, of Würtzburg, has made many trials with this plant. He has given it in large and in small doses in furious mania ; from his experience, he concludes that it is a means which cannot be rejected here. I gave it to a maniac in whom all the symptoms demanded its employment. The pulse was remarkably quick, and the patient presented at intervals a red and swelled appearance. He took five grains of digitalis in a day ; but with no moral or physical change ; the pulse preserved ever its frequency. It does not follow that I call in question the success of Cox , Nord, &c. I like to believe, with Muller, that being adapted to the case, it may give advantageous results ; and the following fact decided me as to its salutary properties. Case.-A female, aged 33, of the sanguineolymphatic temperament, of colossal stature, the mother of many children, had at each pregnancy a swelling of the lower extremities, which disappeared after delivery. In 1823 she was delivered of a dead infant. In 1824, the ædema appeared in the seventh month, and, as the year before, with difficult respiration; she moreover felt intolerable pains in the feet, was sleepless and extremely agitated; vesicatories to the legs proved unavailing ; she passed thirty days without sleep. About the eighth month she was delivered of a dead child; the difficulty of respiration immediately diminished, and the swelling decreased rapidly. She was tormented by a violent and continued cough. The fifth day after delivery, mania was exhibited. 155 The patient sung, laughed, and committed a thousand extravagances. The pulse was remarkably quick ; the cutaneous temperature was not increased, and there was not the least sign of abdominal inflammation. The cough ceased with the appearance of the derangement. There was no sign of milk. The eyes were dull, and the patient presented a very wandering aspect. There was no redness of the face. To watch the symptoms, I had abandoned the whole to nature, but after waiting eight days, and the madness becoming more and more intense, being guided by the quick pulse without fever, I gave half a grain of digitalis in the morning, and as much in the evening. After taking two powders, she experienced nausea, followed by vomiting, and passed a very restless night. The next morning she took, at an early hour, a third similar dose, and the symptoms of poisoning immediately declared themselves ; continual vomiting, inextinguishable thirst, &c. ; insomuch, that she was thought to be dying. The next day there was a diminution in the symptoms, but the thirst was always extreme. She was somewhat comatose for thirty-six hours ; and she became perfectly reasonable the fifth day after taking the first dose. The symptoms of poisoning from so small a quantity was owing, probably, to the extreme susceptibility of this female.

Stranaonium.-Storck is the first who made use of stramonium in madness. He has employed it in two cases of mania, and he asserts that he obtained success. According to Engelhart, Smaltz has cured with stramoniUm a girl alternately affected with mania and melancholia. Bergius cites cures operated by this means upon various mania; s. Grandidier speaks also of a case in which stramonium has produced the most advantageous results. We read, in the Journal of Nasse, the following case :-A married woman, aged fifty, of the choleric temperament, atrabilious, healthy in both body and mind, had experienced many misfortunes, and was attacked in 1821 by cholera morbus. She was thus debilitated for some time. The critical period came on, and insensibly demonomania declared itself. Dr. Schneider found her extremely sad ; she uttered cries and shed continual tears ; her eyes were red, her skin cold and moist, and she sustained with indifference hunger, thirst, and cold. She was excessively fearful, believed demons were about her, and said she was unworthy of divine pity. All her conversation referred to the torments of the other world ; she was affrighted at everything ; desired drink, but refused all aliment. Constipation soon obstinate ; tongue always clean, pulse regular, urine copious, and pains in abdomen from time to time. Depletion, evacuation, tonics, belladonna, were in turn employed, but without success. Dr. Schneider had finally recourse to the tincture of stramonium of Hufeland, and made the patient take twenty drops four times daily. With the intention of getting well, she swallowed thirty or forty drops at a time : immediately she experienced an extreme prostration of strength. The dose was reduced to twenty drops, and the progress towards recovery was striking ; she insensibly recovered the free exercise of her reason. Dr. Schneider reports also a case of puerperal mania cured by the tincture of stramonium : he gave from fifteen to twenty-five drops, two or three times daily. The patient had made use of all sorts of means, without. the least advantage. The disease had existed from March, 1821, to February, 1822. The following is the tincture referred to :Rx Pulv. sem. stramonii, Ounces ij. ; vin. hispani, Ounces viij. ; spirit. vini, Ounces i. Digest for some days with a gentle heat and filter. The dose is six, ten, or twenty drops. Read makes this 156 preparation in another manner-Rx Pulv. semin. datur. stramon. Ounces ij. ; alcohol vini diluti, ibi. Digest with a gentle heat for some days, and filter. Dose ten to twenty drops. Reil gives the stramonium in extract, in the dose of a grain daily, augmenting it gradually to 5 dr. in twenty-four hours. Would stramonium suit in mania with epilepsy ? Storck has made great use of this means, and Rasoux, Adhel, and Widenburg, have equally confirmed its success in epilepsy. Stramonium is a remedy which exacts in its administration much precaution on account of its poisonous properties.

Belladonna.-Belladonna has been vaunted in treating mental alienation. Murray has given it in the dose of five grains, with as much rhubarb, in a case of madness, and he thinks that he has obtained good effects front it. Müller, of Würtzburg, has seen satisfactory results from it. Case.A female, forty years old, had been for a year affected with furious mania; he gave her belladonna, and she was cured by making use of the powdered root of the plant : he augmented the dose to thirty-six grains per day, and diminished it afterwards, or ceased its use, when the symptoms of poisoning were declared, such as blindness, vertigo, &c. Munch speaks of belladonna as an excellent remedy in melancholia and mania. Frank recommends it in mental alienation with fantastic visions, and in that accompanied by epilepsy. We must say, however, that its success in the latter instance is little known ; for this disease is almost always incurable. Good air, continual occupation, labour, walking, healthy nourishment, easy digestion, vigilance on the part of those who have charge of such patients, sustaining the forces in a just equilibrium, are almost in all cases the only means to which we can have recourse, when this fatal complication exists.

Cherry-laurel Water.-It is said that this medicine is of great efficacy in many varieties of monomania, and particularly in hypochondriasis. Like digitalis, it requires great prudence in its administration, as diminishing considerably the action of the heart. Many other medicines acting upon the nervous system have been employed in mental alienation ; such are aconite, hemlock, sulphuric and nitric æther, valerian, serpentaria virginica, the oxide of zinc, the oxide of bismuth, saffron, spirits of ammonia, the oil of dippel, castor, prussic acid, arsenic, nitrate of silver, &c. ; but what these means have produced in madness has not yet been published. I ought, however, to recommend to the attention of practitioners borax ; a remedy employed by Dr. Monro in large doses in sleeplessness, or in order to provoke sleep and repose of the organs. Dr. Müller, of Würtzburg, has made trial of this means, but with no success. I ought, also, to repeat an observation already made by Van Swieten concerning the employment of vomits as narcotic means in mental alienation. This author observes, that the most profound sleep often succeeds the administration of tartar emetic. Such a medication is uncertain, since we possess means more efficaciously given for a like purpose. Kramer proposes phosphorus, and Muller, of Wurtzburg, has made experiments with it upon a demented patient. He continued its use until symptoms of inflammation manifested themselves in the throat ; but the intellect was not ameliorated.

Electricity, &c.-According to various writers, electricity and galvanism have been employed with success in madness, and in the different varieties of monomania. Esquirol especially recommends its use in chronic dementia. We possess some facts which demonstrate the efficacy 157 of this means. Perfect relates three cases of mental alienation cured by electricity. Hufeland speaks of a girl, aged eighteen, become melancholic, and who was cured by galvanism. Dr. Most also cured a hypochondriac by galvanism. As to animal magnetism, the results obtained from it are little satisfactory ; it is a means with which we ought to be on our guard ; more than once it has produced disorder of mind. Electricity and galvanism have been much employed in mental alienation with paralysis ; but this affection is often rebellious to all curative means. We may say generally, that the chief point in treating this complication should be almost entirely confined to a wise direction of hygienic means: such are good air, a dwelling in a spacious place, in the country, moderate exercise, substantial nourishment, agreeable company, and great observation on the part of those to whom is confided the care of these patients.

Rotation, &c.-Darwin has proposed rotation as a means of treatment. He was preceded by Caelius Aurelianus in the conception of this idea. Cox put it in practice. Von Hirsch believed that he had perfected the apparatus of Darwin and Cox, by suspending the patient in a sort of hammock ; this had already been proposed by Hallaran. A piece of cloth receives the body of the patient, forming a sort of hammock, by being in a state of suspension, and is so fixed that it may be turned round. Above the part which corresponds to the head of the patient is constructed a bath of affusion, that. is made to communicate with this apparatus by an opening in the ceiling. Dr. Von Hirsch asserts that the effect of this hammock is not so violent as that of other apparatus of the sort, but thinks it possesses the advantage of being more durable in its action. At Berlin in the Charity Hospital, two rotary machines have been constructed, the one for horizontal, and the other perpendicular motion. The latter is the chair of Cox perfected, and which appears to me to be very ingeniously constructed. (The change seems to lie nearly in the being moved by a set of pullies, and in a sort of cage taking the place of the chair.) This may be much improved by suspending a rotary chair instead of the heavy cage in which the patient finds himself, the ordinary chair of Cox (with this difference, that the cords are not fixed in conjunction with the hook above, but they slide through a moveable ring of iron) : the desired purpose is much better fulfilled ; for then we may give the chair sometimes a horizontal position, and sometimes a perpendicular, and we have thus united in a very simple manner the apparatus of Darwin, that of Cox, and also the hammock of Von Hirsch. Hayner has given a design of a chair like that of Horn, but it is more simplified ; it is, as the chair of Horn, of wood, but this is provided only at its superior part with a piece of iron which is received in a moveable hook. An assistant turns the machine by shaking it, whilst that of Horn is turned by mechanical means. Hallaran has invented two rotary machines ; the apparatus is simple, but is replaced by that which I have proposed. Navigation by sea for him who is not accustomed to it, may give analogous results to those of rotation. I have made use, at Ghent, of the chair of Cox. He assures us that he has never observed this means to be followed by any bad result. He has obtained from it in mental alienation the greatest success, and the most favourable indication to him appeared to be an alteration in the pulse, without fever. Case.-A strong and sanguineous man, aged thirty-seven ; on hearing of his father's sudden death, he became maniacal, and remained so a year. 158 After seven months he again became rational : subsequent to this period, he experienced a maniacal paroxysm, which changed into tranquil mania. There was then not the slightest moral change for six consecutive months. He then became more agitated ; his eyes more open ; he spoke more than usual, and his pulse was of an extraordinary frequency ; from time to time there was redness of the face. The chair was tried from fifteen to twenty-five minutes, for six days in succession, without any good eff&ct, and furious mania appeared: there being no influence exerted, Cox is wrong as to his idea of a constant effect. Another individual, exposed for half an hour each time, suffered no change. Horn asserts that the machine cannot be borne beyond two or three minutes : patients differ in this respect. All those who have employed this means have recog. nised its utility in periodical mania. They have observed that. in this case, the paroxysm is much mitigated ; that the lucid intervals are longer, and that in some rare circumstances, rotation causes the paroxysm to cease. I have not had occasion to remark this great success ; but I can certify that it is the best means I know of to diminish the violence of the maniacal exacerbations, or to retard an explosion. Case.-Aged fifty, meagre, tall, eyes large and moveable ; since twenty years of age, attacked with furious periodical mania ; at each exacerbation, compelled to be shut up in his chamber for seven or eight days ; after the paroxysm, calm and wan. The 25th Feb., 1824, announced a new exacerbation ; rotation for six minutes. He became pale : he was carried to bed, and slept peaceably. The pulse was a little slower than ordinary. The next day the patient was agitated, turbulent, and indocile : rotation for five minutes : prostration, &c. The 27th, refused to eat; rotation for four minutes. Abundant vomiting ; he ate, and was more calm than ever. The same experiment has been repeated upon this individual many times, and always with the same success. Case.-Aged thirtyseven, maniacal many years ; the paroxysms return periodically every eleven or twelve days. In the intervals he is as though in a state of dementia, and during the paroxysm is insupportably agitated and restless. After five minutes' rotation, he exhibited signs of fainting ; the maniacal access impending, did not take place. By repeating this many times, an interval of six months was gained, but eventually the rotation became ineffectual, and the malady regained its habitual course. Case.-Aged twenty-five years, of a nervous temperament, pale skin, regular scull, a patient at the hospital of Ghent. He was subject to periodical attacks of mania; the attack was preceded by a disagreeable sensation in the epigastrium, which mounted upwards; he then became very furious and destructive, and seemed to talk with evil spirits ; he usually announced the approaching paroxysm, and solicited seclusion. The access lasted generally a few hours, and alternated with calmness : its return was very irregular: sometimes during four months there was no intellectual aberration, at others it returned every month. He recollected clearly what had happened. On the 22d Dec., 1825, according to his announcement, the paroxysm came on, lasting three hours. I saw him next morning; he was rational, and assured me that a new paroxysm impended. The pectoral anxiety manifesting itself, he was placed in the rotary chair. The usual symptoms, vomiting, &c., soon followed ; the intellect was wholly sane, and since that time -for four weeks, there has been no aberration. Case.-Aged thirty-four years ; of nervous temperament ; forehead prominent, head in other respects regular; attacked every 159 month, on a fixed day, with mania sine delirio, preceded by abdominal pains tending towards the bead ; is inclined to sing and to commit acts of violence in the paroxysm, but possesses a consciousness of his situation at the time ; this state continues six or seven days before a return of reason. For three years at the hospital, this delirium had not ceased to appear. I seized the moment when he began to complain of his abdominal pain, to place him in the arm-chair, at the same time giving him a drastic. Rotation was tried twice with the usual physical symptoms, but no mental amelioration. By reason of its disagreeable effects, rotation may be considered one of the most efficacious means of coercion. Cox has particularly recognised its advantages with patients refusing to eat. Case.-Steens, a maniac, aged thirty, refused to eat during six consecutive days. I had him placed in the arm-chair, and he was turned during eleven minutes : he vomited abundantly : from this moment he took nourishment with the greatest docility. Case.-Souplet, aged fifty, with a regular scull, except the occiput, which is very little developed ; of a nervous temperament ; had been a patient two years in the hospital at Ghent, when he was, in 1824, exposed to the action of the rotary chair. At his entrance, he was affected with a tranquil mania and an almost complete blindness,. lie remained in this condition nearly two years, and did not offer the least sign of amelioration, either physical or moral. About that time he refused to take nourishment, and for some days rejected all aliment that. was presented to him: rotation for ten minutes ; he begged its discontinuance ; paleness, &c., occurring. He was taken from the chair, placed in bed, and reposed some hours ; from that time he took aliments with the greatest docility. A sensible moral amelioration took place equally ; and in two months he became completely cured. He had a perfect recollection of all his actions whilst deranged, and said that though exceedingly frightened at the time, yet this alarm had not made him eat, but that his taste for aliments returned some hours after the experiment. This change is not always so sensible. Case.-Von Lacr, aged fifty, and affected with periodical mania, refused to eat ; he was exposed to rotation during twenty minutes, without the least alteration, physical or moral. He remained obstinate in his refusal : for four days after the same attempt. was fruitlessly made the sixth day he was fed with a spout. As a means of repression, properly so called, rotation would be very advantageous. I have seen a curious example of this. Case.-A monomaniac for two years; from time to time his ill-humour became so insupportable that he embroiled himself with all around him. On the 17th June, 1824, he quarrelled with everybody : he was turned in the arm-chair nine minutes, with the usual symptoms. After this, he seemed completely changed ; from being the most gloomy, passionate, and obstinate patient in the institution, he became very pleasant and affable ; and whilst previously he had been careless, he now did not cease to seek the good graces of his keepers, by continual attentions and obligingness. The ruling delusive idea always remained, but I think that if circumstances independent of my will had not prevented farther trials upon this man, he would have recovered his reason through this means. Schneider supposes, in order to augment the efficacy of this measure, when employed repressively, that it is very advantageous to submit the patient to its operation in a gloomy place, retired, and deprived of the light of day, the terror of the individual being thus increased. Case.-Joseph de Jonghe, aged thirty, of the sanguineo-lymphatic 160 temperament, having a regular scull, had been for three years at the hospital at Ghent. He was affected with mental alienation, which partook of the character of mania and that of dementia. He was in some sort without ideas, but turbulent, and sometimes dangerous, from his brutal manners, so that it was necessary oftentimes to keep him shut up during two or three consecutive months. In 1824, he was exposed to the action of the chair during twelve minutes, with the usual immediate effects. The moral change was marked; he became peaceable ; he occupied himself with household labours, and obtained in a short time a complete recovery; this patient had begged off from farther trials after the first. In one case I have seen the patient become worse. Case.Scrofulous ; of the lymphatic temperament; has a badly-formed head ; had been a year at the Hospital of Ghent. He was paralytic on the right, side, and had a considerable encysted humour on the right cheek. He was affected with mania, and offered in his disease, as a dominant character, an obstinacy in not wishing to answer questions made to him. In 1824, he was placed in the rotary chair, and after having been exposed during sixteen minutes, vomiting took place, and he experienced a considerable muscular prostration. The next morning he was more sluggish than was his wont to be ; but they observed, at the same time, that the intelligence had decreased considerably. He has remained up to this moment in a condition bordering on dementia. Cox asserts this means useful in epileptic mania. I have not observed its beneficial influence. I quote the results which Cox obtained from it in intellectual disorders. &c. Horn reports the case of a patient cured by it. A preacher born of insane parents, aged fifty-two, having lost his reason for a number of years, offered all the symptoms of a furious maniac. All sorts of means were used, but without success. Horn exposed the patient to the action of the rotary machine, and his mind recovered its natural exercise. The conclusions to be derived from what I have said on this subject are as follows:-- 1st. The rotary motion is a means which promises advantages in mental disorders. 2. Its debility is but momentary, and not productive of bad results : I have observed only one exception to this rule. 3. It is an efficacious means of coercion. 4. It is useful to excite vomiting in cases where emetics prove ineffectual. 5. It is useless in madness from organic disease, and in that with great sensibility. 6. It should be avoided in mental alienation with a propensity to apoplexy. 7. It calls for prudence in delirium with plethora. 8. Great circumspection is necessary in madness complicated with phthisis. 9. It should never be permitted but in the presence of a physician. 10. It appears to be principally useful before the explosion of a maniacal paroxysm, and in periodical mania. 11. It promises advantages in monomania with sluggishness and nonchalance. 12. It suits equally in mental alienation with a suicidal propensity. 13. It is said to be a good measure in mania with epilepsy.

Means acting principally on the Intestinal Tube.-The ancients as well as the moderns have acknowledged their efficacy.

I. Emetics -They are particularly useful in the commencement of mania, and in that of different species of monomania. Perfect commences his curative method, with almost all lunatics, by emetics. Esquirol approves highly of their employment in the commencement of madness. Dunne says that they are often capable of arresting or preventing 161 a paroxysm of mania. Ile thinks that their use should be frequently repeated, and at close intervals. Daudebertières reports a case of madness from a fit of anger, which was cured by emetics. Hufeland furnishes art example, proving how efficacious these means are in commencement of mania. A man, says he, was taken in the night with a violent paroxysm of mania ; he was given an emetic and became well. Prost reports that Billerey, a physician of Grenoble, cured a very furious mania by an emetic administered many times. Müller, of Würtzburg, found an emetic very useful in mental alienation with fixity of ideas ; when the patient is fearful, when he believes in an evil future, when lie is taciturn, or does nothing but weep. In all the varieties of monomania which approach the fantastic, in suicide and misanthropy, emetics are capable of being very useful. The effects which they exert in nostalgia and erotomania, are less satisfactory. Advantage is obtained from them in insanity accompanied by nonchalance and an indisposition for locomotion ; for the patient is thus made to move himself. If there be a state of languor in the system of the vena porta, and a want of energy in the biliary secretion, vomits, by reanimating the vigour of this set of organs, may suit in mental alienation. Their utility is not less great, when the derangement has for its cause or its effect the suppression of the menstrual flux or of hemorrhoids. They are dernanded in different varieties of monomania, by reason of the sweating which they favour, as this excretion is often here diminished or absent ; it is particularly when the delirium assumes the form of sadness, that the effect. is very marked, and their vomiting may be an advantageous means. The foregoing are the principal indications for emetics. They should be used with great caution. They are contra-indicated in mania, where the cerebral excitement is vascular and not nervous, as apt to lead, as Haslam has seen, to apoplexy, &c. We should fear their use in cases of pregnancy, where there is great oppression of the chest, a disposition to hemoptysis, considerable hernia, &c. Debility would be also an obstacle to their employment, as tending to enfeeble still farther. Most lunatics resist ordinary doses of emetics. Nevertheless, we should be circumspect in giving tartar emetic in enormous quantities. It will be always preferable to test, by an ordinary dose, the sensibility of the digestive organs ; by acting otherwise, we risk the production of considerable vomiting, hypercatharsis, and even death. Amongst the substances which medicine possesses to provoke vomiting, there is none more suitable than tartar emetic, from its being taken in pure water, &c. The dose varies with different individuals. In most cases, we may resort to ton grains. We may equally resort to emetine, as being destitute of colour and odour, and by reason of its small dose 1/16 gr. suffices for a sane man. It would be imprudent, as Celsus and others counsel, to place the medicine in his food, because the patient might fear poison, and refuse aliments. The best method of administration is in distilled water, seeing that the patient took nothing acid or astringent.

We have described the utility of vomits in different cases of mental alienation. In order to obtain from these means the same advantages with less general disorder, vomits in small doses, so as merely to nauseate, have been proposed. Dr. De Vos, of Berlin, who has made much use of tartar emetic in this mode, assures us that he has thus cured a number of lunatics. He recommends its use in fantastic monomania; and in mental alienation with torpor of the muscular and circulatory 162 systems. I think with Cox, that nausea would be useful in mental alienation with orgasm of the circulatory system. In suppression of therrienses (depletion having been previously made), in torpor of the system of the vena porta, in suppression of the hemorrhoids, &c., nausea may prove serviceable by the concussion which is given to the abdominal viscera. In general, the curative indications for emetics in broken doses are in many respects almost the same as those which we have already seen for vomits. This means would be, other things being equal, more to be preferred in the commencement of mental alienation, than when the affection has been existing some time. It would be useful in all cases in which the attention of the patient is strongly concentrated upon the same object, by turning the thoughts of the person from the subject of his delusion. It is in these sorts of cases that Müller, of Würtzburg, has made great use of tartar emetic in broken doses. With a maniac, this treatment would be equally useful, by its diminishing the energy of the intellectual faculties. My experience has not realized that which many authors assert of the efficacy of this means in mental alienation. I have given at the hospital for male patients, at Ghent, during fifteen days, tartar emetic to many melancholics and maniacs, without observing any sensible moral relief. Dr. De Vos takes a grain of tartar emetic, in three ounces of distilled water, and gives it by spoonfuls, until nausea ensues, augmenting the dose according to the susceptibility of the subject. In some cases, he takes eight grains of tartar emetic and four ounces of distilled water, giving, from time to time, a spoonful.

II. Purgatives.-As derivatives, purgatives are indicated in monomania and in mania. For a long time the efficacy of purgatives in mental alienation has been recognised, and there are few writers on the subject of insanity who have not mentioned them ; all have proclaimed their beneficial effects. Their employment, however, exacts prudence : if an energetic purgative is given, by prolonging the excessive alvine evacuations, we risk the passage of the disease, whether mania or monomania, into dementia : the state of the vital forces should decide us here. They would be hurtful in dementia, on account of there being debility of the intellectual organs. For the same reasons they are only admissible in the commencement of mania, or in that of monomania. They may be indicated in mental alienation with constipation, sluggishness, and aversion for muscular motion. We should, however, have always in view the state of the vital forces. They act in sluggish cases by necessarily making the patient move about somewhat. This symptom is an attendant of melancholy. They are indicated in mental alienation from sup. pression of the lochia, of the menstrual flow, and of hemorrhoids. The ancients frequently solicited alvine evacuations in mental alienation. They employed drastics ; the moderns eceoprotics. Hellebore, their great remedy, was aided by the divulsion in making the voyage to Anticyra to take it, &c. It has. been particularly used in mental alienation with sadness. Hoffman, Vogel, and Ludwig have renewed the ideas which the ancients attached to the virtues of this remedy. These authors think it specially indicated in partial insanity ; this would result merely from its irritating the intestinal tube, as monomania is often the result of abdominal obstruction. We, at present, when purgative substances are better studied and better known, prefer those whose action is less energetic. The saline purgatives, rhubarb, aloes, and the root of jalap are used the most frequently. Clysters.-These are little used in mental alienation ; 163 there is no want, however, of useful indications : they may perhaps give great relief, but the obstinacy of the patient, his great restlessness, and the perversity of his conceptions, cause these means to be almost always rejected by him. They would be of great service in constipation, and in cases of mental alienation having their origin in abdominal obstruction. Kampf has written largely upon the efficacy of clysters in obstruction of the abdominal organs, and gives all praise to them: his injections are composed as follows :-The root of the dandelion, of the saponaria, the leaves of the carduus benedictus, of fumitory, and of white marrubium,the tops of yarrow, the flowers of chamomile and of verbascum, and bran. The whole boiled in water composes the clyster. Buchan counsels stimulating clysters in furious mania. I am not able to determine how far this opinion is admissible. It is, however, extremely difficult, or even impossible, to administer such a means to a furious maniac. The ascending douche has been equally counselled to overcome constipation, to unload the large intestines, and to change the spasmodic condition of the intestinal tube.

Means acting on the Skin.

Warm Baths.-If we may believe Cullen, the warm bath is of little use in mental disorders. In mania, says he, it is rather hurtful than advantageous ; but he thinks there are sufficiently favourable indications for its use in some of the varieties of monomania. Cullen adds, that, in order to obtain advantage from the warm bath, it is necessary, at the same time, to employ the cold douche upon the head. Pinel confesses, in all his writings, a decided aversion for warm baths employed as curative means in insanity. He attributes the incurability of a great number of the insane to the debility ensuing from this means. The idea of Pinel is too exclusive. Experience, according to the report of Tuke, has taught, in the Quakers' Retreat, near York, that the warm bath is a good means of cure, and that it is particularly useful in melancholia. Dr. Müller, of Würtzburg, makes an equally great employment of this means, and assures us that he has not observed marked hurtful effects. Cox has employed, with much success, warm baths in mania, and has often infused in them rosemary and other aromatic plants, in order to dispose the patient to submit easily to this means. The warm bath may be rendered more stimulant. by the addition of soap, of flowers of sulphur, and of alkaline and saline substances. Müller employs warm baths rendered stimulant by the addition of mustard or hydrochlorate of soda. A lunatic for a long time demented, was placed in the salt bath many different times, and recovered, by this means, from his disease. The temperature at which we should commonly employ the warm bath is from 86 to 96 degrees Fahrenheit. This subject admits of the following heads :- 1. The warm bath is hurtful in mental alienation with feebleness of the functions in general. 2. In a subject in whom the functions are not feeble, and where the malady is but recent (an important point), it is useful, acting derivatively. 3. It is advantageous to prevent the explosion of a maniacal paroxysm, either in the interval of the same attack, or in convalescence, paying always due regard to the condition of the vital forces. 4. Experience has demonstrated that warm baths are of great utility, when the mental alienation has the character of the neuroses. This condition is very familiar in the commencement of monomania. It is to be recognised by an extreme nervous susceptibility, by agitated movements, 164 and irregularities in the animal heat. 5. Esquirol asserts that it is very useful in mental alienation with refusal of nourishment. 6. Frank makes use of this means where there is want of sleep, and great excitement of the intellectual functions. 7. The same author recommends its employment equally in mental alienation with a rough and foul skin ; to that which is' the result of a suppression of the cutaneous secretion, or of a repelled tetter, or, from an erysipelas, or transient exantheme, and any other diseases of the skin in which we have to re-establish the perspiration. 8. Warm baths are also useful to re-establish a suppressed evacuation, as the menstrual, hemorrhoidal, lochial, &c. 9. Ferriar employed with great success the warm bath with a maniac. He thus produced, during the maniacal paroxysm, a great diminution in the muscular energy. Cold fomentations upon the head, and other means, completed the cure. 10. Warm baths rendered stimulant by salt, soap, or mustard, are particularly useful to gloomy, taciturn, and sluggish monomaniacs, in order to excite them to an aptitude of corporeal motions. The most suitable method of employing warm baths, is to gradually augment the degree of heat. Commencing at sixty degrees, the temperature is augmented to 96 Fahr. We must. be cautious when tile patient is inclined to suicide. In all cases, it is prudent to be on our guard against fainting and convulsions, which may supervene. Our remarks, with respect to warm baths, apply also to pediluvia and hip-baths. Schneider says that Lucett employed with success upon the head warm water of 90 and 108 Fahr. This would always be dangerous, because it exposes to scalding, the face, eyes, or other parts.

Cold Baths.-As productive of apoplexy, &c., cold baths are imperiously prohibited in madness with plethora; they are also in that with great feebleness ; a medium is requisite. If the derangement proceeds from organic disease, they will be equally useless. They are much in vogua in England for the cure of madness. There are few practitioners of that country who do not attach to this means great value, but, as I have said, its employment is not applicable but to some cases. 1. They are recommended when the cause is a debilitating one. In this category are, excessive coition, abuse of drinks, and all the sad and unpleasant emotions. Feebleness of the pulse, and diminution in the cutaneous heat, are symptoms which speak most in favour of this means. I cannot partake in the opinion of Schneider, who says that the cold bath may be useful in madness with great sanguineous congestion of the head in such a case it would but aggravate the disease. 2. They are equally indicated when feebleness of intellect enters into the nature of the mental alienation, from their tonic nature being capable of rendering great service. It is thus that Esquirol, if the debility is not too much advanced, recommends them in dementia; he then prefers river baths. 3. Ferriar has made great use of the cold bath in melancholia. 4. Dr. Richard, of Osnabruck, gives us the relation of a case of puerperal mania cured by cold baths, after having resisted a number of means. 5. They are of acknowledged utility in many maladies which accompany madness ; such are paralysis and scrofula. We cannot leave the patient in the cold bath longer than some minutes ; ten minutes is the minimum; half an hour the maximum. Schneider speaks of the bath of snow, and says that Mellin has cured a monomaniac by placing him in a vessel filled with snow. We may easily conceive that this means can be applicable but little, from the excessive cold. 165

Douches.-The douche consists of a column of water let fall on the head. The pipes may be of copper or leather ; the latter are preferable, on account of the inflections which may be made in them. The douche is descending, lateral, or ascending. The column of water (managed by a cock) is ordinarily from six to twelve lines in diameter. The water is simply cold water, sulphurated water, or mineral. The douches are either cold or warm, and the patient may receive them either in or out of a bath : in the latter case, he is fixed upon alt arm-chair by fastenings ; in the former, the bath should have a lid, the patient's head being out. (On the plate given, the reservoir of water is 10 to 15 feet above the patient's head. G.) The cold douches are preferable to the warm, on account of the shock. In feeble subjects the douche acts as a sedative, in the robust it is excitant. The part to which the douche is usually directed is the vertex ; sometimes it is made to act on the hypochondria. Schneider speaks of a kind of douche of small drops, such as was employed formerly to torture criminals. The head is shaved, and the water falls upon it from the height of from ten to twenty feet. This means is too painful, and should be banished from the medical art. Little importance is attached, in France, to the usefulness of the douche in insanity. Georget says that these measures are hurtful to lunatics : in Germany it is used more extensively, nor does it appear so hurtful. According to Müller, of Würtzburg, a man aged about twenty-eight, is admitted in a furious condition to his hospital ; they give him the cold douche upon the belly, and in an instant he becomes docile. C. Schwik, says Horn, lost his mind insensibly without known cause : he was given the cold douche upon the head, whilst he was in the warm bath, and having repeated this means three weeks, he recovered his reason. Case.-A woman, according to Hufeland, became insane, in consequence of an unexpected change of fortune ; she showed a suicidal disposition ; she was placed in the warm bath, cold douches on the head were administered, and she recovered her reason. Subsequently she broke her thigh and relapsed. Case.--He mentions another female, deranged from pride, who was restored by the same means, repeated twice daily. After the first trial, sleep was more tranquil, and she was less irrational. A slight relapse took place, but reason was restored. The employment of the cold douche is particularly useful in mania : it demands, however, a boundless precaution. If mania occurs in a robust individual, plethoric, with red face, and sparkling eyes, affusions of water, unless preceded by bleeding; might produce fatal consequences. The douche would be very useful if the symptoms in mania seemed in a measure concentrated on the nervous system ; by a sort of strong revulsive action, both moral and physical. It would be efficacious, for the same reasons, in many varieties of monomania, especially in the chimerical, and hypochondriasis. Van Swieten asserts that the cold douche is eminently salutary in mental alienation with sleeplessness, and that in this case it produces almost always good sleep. Douches of thermal sulphureous waters may be useful in madness proceeding from cutaneous diseases, itch or tetter.

Baths of Afusion.-Another kind of douche is the bath of affusion. This consists in turning some buckets full of water from a height, more or less great, upon the head or other part of the body of the patient. A machine for the same consists in a box or reservoir turned on two pivots, so that the upper part may become the lower. It is placed at a convenient height (four feet above the patient's head, in plate. G.), and is 166 turned over by a cord attached to a hook fixed to one of the superior edges. Its effect is more violent than that of the douche. The curative indications are the same as those of the douche in general. We may make use of either cold or warm water ; the first is preferable in connexion with the disagreeable sensation which it excites.

Aspersions.-Aspersions of cold water are in a small, what the douche and bath of affusion are in a great way. They are made on the face, and are particularly useful for indolent patients, and those who are plunged in stupor. Lotions of cold water upon the head have been especially recommended in dementia. But discretion is necessary in the employment of these means, as with all those having connexion with them; and we should never lose sight of the fact, that applications of cold are considered amongst the causes of dementia. If, however, their application is not too much prolonged, they may produce a salutary reaction in this affection. Van Swieten and others think that lotions of cold water upon the head would be particularly suitable in mental alienation arising from strong heat, from coup de soleil, and in that from the abuse of wine or other spirituous liquors; but we should keep in view the state of the sanguineous system. Cold is a means as dangerous in the exaltation of the forces as in a state of feebleness. It is a practice sufficiently general, that of employing applications of cold water and pounded ice upon the head, in mania with exaltation of the sanguineous system; but do good effects really result from it ? Does it not tend to concentrate the blood in the encephalic vessels ? Heinroth proposes to cover the head, in cases of this character, with a vessel of mercury ; but this is impossible. Some physicians have obtained advantages from the application of cold water to the genital parts in mania.

Bath of Immersion.-This is more violent than the douche, the bath of affusion, or the application of cold water; it considerably affects the patient, and its utility is based upon the fear which it inspires of impending suffocation. I have spoken of its utility : it is sufficient here to describe an apparatus for putting it in execution. Willis has imagined an apparatus for the purpose, a sort of swingate ; but his invention is imperfect, and the apparatus which I give (in the plate) appears to me better qualified to fulfil our purpose. To render ourselves master of the patient, and to shun suffocation, are the two important measures which we must take in a bath of surprise. In the centre of a bridge across a pool or stream of water is a small Chinese temple, which encloses a cage of iron ; the latter moves up and down by grooves ; to this is attached a cord reaching to the opposite side of the water from that on which the patient comes into the temple ; this is moved by a wheel provided by a trigger; and there are such arrangements of pullies, &c., connected with the cage, that it can be lowered and raised at pleasure ; the patient, when let down, being immersed to his neck. A servant on one side shuts the door on the patient, whilst a second on the other loosens the trigger connected with the wheel. The construction of such machines cannot be too much varied ; a stratagem, commonly, not being capable of answering but for one application with the same patient. We may place upon a pool or canal a little bridge, which may be made to give way ; and the patient, after falling into the water, may be recovered by a rope. This means, however, would be more or less dangerous. Facts cited by Dr. Richard, of Osnabruck, prove the efficacy of cold water, especially in insanity. He reports three cases of puerperal mania in 167 which cold water has produced the most salutary effects. He employed affusions upon the body, the bath of immersion, and cold water internally-, in the first case. The second, a case of furious mania, was rendered calm by aspersions of cold water on the body, and by the immersion of the head in the same liquid. The third was a case in which had been tried without success a number of means, which was cured by the bath of immersion and ablutions of cold water.

Epispastics.-Of these, cantharides are most in use. We have recourse to these means with different intentions. If the insanity succeeds the suppression of a cutaneous disease, of a fetter, an erysipelas, or any other repelled eruption, vesicatories are the means, par excellence : they are preferably applied upon the place where the disease at first existed. The obstinacy of the patient, &c., limits the use of these means in mania; they here suit most as derivatives. The calves of the legs are the best place. Some practitioners advise the neck or top of the head. Dr. Willis observes, that applied in this manner they are more hurtful than useful. Hufeland gives us, however, the case of a patient whom he cured by a vesicatory to the top of the head. The day after taking it off the patient recovered his reason ; but he was irrational on the third day. The vesicatory was made to suppurate, and the patient, recovered. Vesicatories are employed in monomania, but particularly as derivatives. The end proposed in these sorts of cases is to act upon the cerebrum by the pain which they excite. Being applied upon the sensible surface of the skin, they force the patient to direct his attention towa-ds this painful sensation, and make him abandon, for the moment, the vicious chain of his ideas. It is in fantastic and joyous monomania that vesicatories are particularly- indicated ; but to be really advantageous, their application must be reiterated. Dr. Schneider very well observes, that their use should be prohibited in erotomania, nymphomania, and in madness accompanied by satyriasis and priapism ; the action of cantharides might have a fatal effect in these affections. In dementia it is not as derivatives that vesicatories are indicated ; the irritation of the brain is here indicated in a curative manner ; consequently, the application of these agents should be made upon tissues which promptly transmit their irritation to the organs of the understanding. They are placed with this view upon the top of the head, to the nucha, or behind the ears. Mental alienation accompanied by paralysis may exact the employment of vesicatories. Sinapisms, although they act less violently than vesicatories, suit, in many respects, where the latter are indicated.

Artificial Wounds.-Lofler cites the case of a lunatic who was cured by incising the skin of the scull. The wounds were kept open, and the patient recovered perfectly. Vering, according to Schneider, has made use of this means with success. Hailer speaks of a demented patient who recovered his reason by a wound of the scull. Cox mentions a case of cure from this cause, and proposed the trepan, &c.

Exutories.-Issues are principally indicated in cases from suppression of a cutaneous malady. Casper knew at the Salpétrière a female, aged thirty-eight years, who had an issue on the arm for four years. She let it dry up, and became maniacal. An epispastic was placed on her arm, and the whole limb was covered with a phlegmonons erysipelas. The issue reopened itself, and the patient was from that time cured. She let the issue dry up a second time, and mania again manifested itself. Case.-A man became furious, in consequence of the suppression of a 168 habitual ulcer on the foot, he was restored to reason by the application of an issue upon the cicatrized place. A patient attacked with periodical insanity, after seven or eight years, was improved by a cautery on each leg. We should take care that we are not restricted in our practice to the employment of exutories ; these are not useful but when they accompany other agents, physical or moral. In their application, the purpose is almost always derivative. This action differs from that of vesicatories in being more permanent. The mental alienation which develops itself towards the change of life, and which is connected in its development with anomalies of menstruation, calls strongly for their employment. Frank recommends them particularly in insanity with the arthritic or scrofulous diathesis. The place of application varies. If it is desired to recall a cutaneous malady, an exutory is placed near the spot where the primitive affection existed, and, if possible, even upon the cicatrice. We apply them, derivatively, to the extremities, to the hypochondria, or to the epigastric region. All things being equal, we choose, always, a place which renders the application of the extrtory as little inconvenient as possible, that the patient should not be much irritated.

Inoculation of the Itch.-This has principally been proposed, in order to arouse those too much abandoned to inactivity. But would not powdering the garments of the patients with towage fulfil the same purpose ? Would not vesication suit equally as well ? This inoculation has been recommended when insanity arose from repulsion of this eruption. We find, in the Journal of Hufeland, a case of melancholy, arising from suppressed itch, which was cured by the inoculation. Chiaruggi asserts, that he has cured dementia by the inoculation ; and Metzel, according to Reil, has cured by the same means a demented patient who was in a state of complete immobility, having no desire to drink or eat, and with whom various means had been employed without success ; his insensibility was such, that twenty-five grains of tartar emetic produced upon him but a slight vomiting. Ile was inoculated with the itch, and three days after this operation an inflammatory fever declared itself; on the seventh, the itch became manifested, and the fever appeared no more ; on the ninth, the patient bean to reason with sufficient exactness, and in a short time the understanding regained its ordinary vigour.

Seton.-The seton is very analogous with the means which we have seen. Perfect has made great use of it, and Ferriar reports tire case of a patient become insane from a suppressed eruption, whose recovery was due to a scion to the nucha. It has been much employed in insanity, but the observations attesting its success are not numerous. Everything leads us to believe, that applied to the nucha, or between the shoulders, it can but be useful in dementia.

Moxa and tire Actual Cautery.-Moxa, to the top of the tread, has been proposed in the different species of mental alienation. Larrey has frequent recourse in nostalgia to moxa applied to the shoulder. Georget thinks this means particularly useful in madness with stupor and insensibility. Müller, of Würtzburg, has not seen any advantageous effect from this means. Reil has employed, as a curative means in madness, burning sealing-wax, let fall in the hand of the patient. Valentin has employed in madness the actual cautery upon the crown of the head. Müller, of Würtzburg, has repeated these experiments, obtaining no marked success from there. Gondret, according to Schneider, has cured a demented epileptic by the application of the actual cautery upon the bones 169 of the scull, after having made an incision through the aponeurotic covering. Dr. Groos, of Pfortzheim, said he had made use, with much success, of the actual cautery, applied to the cranium, in two furious maniacs ; one was radically cured ; the other had a relapse. The success of these means belongs but to some rare cases. and we do not know how to decide upon their virtue in madness. Moreover, the actual cautery may lead to the most deplorable consequences, when its application is made upon a denuded portion of the scull.

Dry Frictions.-Dry frictions and liniments were frequently used in the infancy of medicine ; the utility which the ancients derived from them, in disorders of the mind, has been confirmed in our own times. Irritation of the cutaneous system, made by friction, is suitable in almost all kinds of mental alienation ; these means excite the sensibility of the skin, and render perspiration mere active. Frictions are made with the hand alone, with a brush, or with rough linen. Dry frictions are needed in those kinds of madness where there is a diminution in the perspiration. Monomania calls for their use more than any other mental alienation. In similar cases, they are not only useful to excite the cutaneous secretion but, made upon the abdominal parietes, they lead to satisfactory results when the derangement is complicated with inertia of the organs contained in this cavity. They may then advantageously replace, according to Tissot, various exercises of the body, as equitation, riding in a coach, and others, which it may not always be in our power to employ. Boerhaave says that frictions, made with more or less gentleness, upon the crown of the head, are sometimes capable of calming the transports of furious maniacs.

Tartar Emetic Ointment, &c.-Case.-A farmer's wife, remarkable for the exactness of her mind, suddenly became insane ; it took many men to restrain her ; she then fell into an intense state of stupor. Bleeding, a laxative, and a vesicatory to the neck were unavailing. The pulse was full and frequent, and the respiration natural. Dr. Müller, of Pfortzheirn heard that she had, just before the attack, had a suppression of the itch from mercurial ointment, having been from that time more gloomy. Müller placed an her the shift and gloves of a person affected with psora, made frictions with the pommade of Autenrieth upon the breast, legs, and about the neck, and internally gave sulphur with calomel. Large pustules appeared, and the patient had some stools. The chronic eruption gradually appeared, and in a little time she recovered. Case. A country girl coming to Ghent on a visit, after being there fifteen days, her mind became suddenly troubled. My colleague, Dr. Hulin, was called, and ordered a bleeding of ten ounces, and a purgative. The pulse was sufficiently full, and she was regular. This state remained five days, and I was called in consultation. I found a tranquil mania ; she scarcely recobmised her parents and best friends. I remembered Dr. Müller's case, and learned on inquiry, that she had an eruption of pimples on the back, and that she had been several times affected with psora. Her head was shaved, and frictions of tartar emetic ointment made, formed in the proportion of a drachm of tartar emetic to an ounce of hog's lard. She took sulphurated baths, and internally the milk of sulphur. She then went home, pustules appeared, and she regained her reason: footbaths were also used ; whilst at home she would not suffer any one to approach her, and did not wish to eat or drink. Four months after mania declared itself anew; she laughed and wept without motive. Antimonial 170 frictions on the crown of the head were used, and in a few days mental alienation vanished. Case.-A female, aged sixty-eight, an inhabitant of the country, who had always led a sober and regular life, experienced an attack of apoplexy, attended by stupor and paralysis. Suddenly the paralysis disappeared, mental disorder came on, and in a few hours she was-in a complete state of mania. Leeches were applied to the head, sinapisms to the feet, and vesicatories to the legs, with little or no amelioration. Dr. Houdet and myself then saw her: we gave her digitalis internally, and used antimonial frictions on the crown of the head. In proportion as the pustules developed themselves, the change in the intellectual functions was greater and greater, until, within fifteen days, there was no symptom of -mania. The intellect, however, yet vacillated in its ideas. The frictions were repeated, and, in two months, the patient recovered completely. [He gives, moreover, two cases, in which there was great amelioration, but no cure ; the first a female, arising after cephalalgia, somnolence, and then fever, the fever continuing to be complicated with it ; and the second a male, periodical case, arising after suppression of a cutaneous disease.] A great partisan of the frictions with the ointment of Autenrieth (unguentum antimonii tartarizati) is Dr. Müller, of Würtzburg, who employs this means, almost indiscriminately, in all kinds of mental alienation. Lotions made with a solution of tartar emetic, on different parts of the body, have not appeared so efficacious to this physician as the pommade. He concludes, from his observations, that this means is more efficacious than all those which the art possesses for the cure of mental disorder Case.-Moral Insanity.-Verplactse, aged 37, had been, for six months, affected with madness. He was cunning and rebellious ; he had been three months at the hospital of Ghent. Ile took the tartar emetic fifteen days, without success. Dec. 17th, 1823.-Tartar emetic ointment was rubbed oil the whole of the shaved head. The pommade was composed of a drachm of tartar emetic to an ounce of lard. A piece as large as a hazelnut was employed at each friction. One was made daily. 21st. Pimples in suppuration; pale ; feels feeble. 25th. Agitation ; less docile. 30th. Active suppuration ; pustules ; diarrhoea. Jan. 5th, 1824. Tongue dry, thirst ; refusal to eat. 13th. Very meagre ; scarcely able to rise from his bed ; complains bitterly of the pain from the pustules. 20th. Diarrhoea persists ; frictions to this time had been daily from the 30th Dec. ; they were now ceased. 7th Feb. The diarrhoea is diminished ; the pustules have passed away. The patient is always very feeble : the mind has not experienced the least favourable change. 15th. He regains his strength. 20th. In the same condition, physical and moral, as before the frictions. Case.-Fantastic Monomania.-Wevers, aged 35, has been attacked, for a month, with fantastic mental alienation. He fancies himself to have the head of another person. The cause appears to be the abandonment of himself and three children by his wife. He entered the institution the 25th Dec., 1823. Frictions with the antimonial pommade upon the head. 30th. Pustules. Jan. 10th, 1824. No moral amelioration. 20th. Frictions ceased. 25th. No moral amelioration. 30th. Same state. 10th Feb. This means abandoned. Case.-Last degree of dementia; aged sixty ; he lost his intelligence and memory immediately after having a syncope. He forgets everything, not even recognising his bed or chamber ; neglects to eat and drink, and shows great difficulty in collecting his ideas; he is pale. The disease has existed two months. 171 The frictions were made from the 15th Dec. (1823) to the 15th Jan. (1824), with no mental amelioration. Case.-Melancholy. Goossens, aged 42, since 18 months at the hospital; accuses his wife of having wished to destroy their children. The frictions were commenced on the 15th Dec., 1824. They caused obstinate fury in the patient, who resisted the attempt to make them. They were continued to the 5th Jan., 1825, when they were stopped, an oedematous swelling of the eyelids manifesting itself. There was not the least moral amelioration. Case.-Mania without Delirium.-Aged 36 ; robust; deranged 17 months; in a state of continual fury ; scull very prominent towards the ears; reasons well on a number of subjects. 15th Dec., 1823. Frictions. 25th. Suppuration of pustules. Jan. 15th, 1824. Stopped. 30th. No moral amelioration. Case.-Mania changed into Dementia.-Æt. 28; in the institution since four years back; grief was the cause of the disease. Not the slightest moral amelioration from frictions. Case.-Dementia. Aged 24 ; pale ; feeble; fair; tall; beardless; taciturn ; has been a year in the hospital; onanism the assigned cause. Not the least amelioration from frictions, and he remained always saddened. Case.-Dementia following Mania.-Aged 45 ; deranged three years; his delirium was at first intermittent mania, which soon passed into dementia. Domestic griefs appeared to be the cause. After frequent attacks of epilepsy, he had a stroke of apoplexy, to which succeeded paralysis of the left side. Dec. 5th, 1823. Fractions. Jan. 10th. Pustules. 20th. Suppuration of pustules. 25th. Whole scullcap in suppuration. 27th. Frightful apoplexy. 26th. Death. Case.-Tranquil Mania.-Aged about 40 years; an old soldier; since five years at the hospital. Not the least moral change resulted from the frictions. An intense ophthalmia was caused, which was treated by an emollient cataplasm to the head and eyes, and was dissipated. Case.-Dementia.-Aged about 40 ; since five years at the institution. At first he was maniacal. Not the least moral change resulted from the frictions. Deep ulceration was produced, which was treated by an emollient cataplasm: these were healed. Case.-Dementia. -Aged 36; he was at first maniacal but later the disease passed into dementia. The frictions caused swelling of the eyelids, so as to prevent their being opened ; this was merely temporary. He remained in the same state of imbecility. These observations were made at the Hospital for men at Ghent. I am able to report others, but only negative in their import. More than thirty individuals were submitted to the frictions; and I was not able to remark the least favourable change. Many of these have suffered from inflammation of the conjunctiva, &c. That which is worse is, that I became an object of horror to the unfortunates submitted to my experiments, since they saw in my person the source of their sufferings. The conclusions to be derived on this subject, from the preceding observations, are as follows :-That this means has produced advantageous results, in the cure of mental affections, is incontestable that, in a number of cases, on the other hand, it has not produced the slightest moral amelioration : that we do not possess any certain rules for its application : that, however, amongst all the different species of mental alienation, most success is promised in that proceeding from a repelled eruption, especially psoriasis: and that experience has hitherto decided that this means is particularly suitable an recent mental alienation. Frictions with the Pommade of Kopp.-Kopp has made frictions with an ointment composed of calomel, digitalis, and lard. It is less violent in its 172 action than that of the tartar emetic alone. It is more prompt, but less durable in its action than the pommade of Autenrieth. Frictions with this appear to have less virtue than those appertaining to the tartar emetic ointment. Stimulating Liniments.-I have made upon the head trials in dementia and melancholy, with liniments composed of the tincture of cantharides, Hoffinan's Balsam of Life (a tincture of ambergris and essential oils), camphorated alcohol, wther, and others ; but I have not obtain. ad the least success from these means. An individual was rubbed upon the head and spine, for three weeks, with a liniment composed of treacle and oil of rosemary, but not the least moral amelioration was manifested. This patient became insane from onanism, and addicted himself daily to this fatal habit. Esquirol, according to Casper, employed the same means in a similar case.

Bleeding.

The remarks which I here make, and those on tonics, are intended to demonstrate that the exaltation of the sanguineous system often exacts the use of sanguineous depletion, but that tonics and excitants may also find not less useful indications. As to the indications of bleeding, authors have rarely followed a proper medium. Haslam, Perfect, Joseph Frank, and especially the Mayos, have not ceased to proclaim the signal advantages of bleeding in disordered mind ; and Celsus, Hildanus, and Paul Ægineta, and others of the ancients, have spoken of this curative method. The augmentation in action of the circulatory system is an index which invites the employment of bleeding. The general exaltation of this system, which is announced by the force and fulness of the pulse, the redness of the face, the general heat, the thirst, &c., belong particularly to mania. This sanguineous excitement is frequently, not to say always, consecutive from a phlegmasia, whose seat is in the brain. It is recognised in the fury and violent actions of the lunatic; the carotid and temporal arteries beat with force ; the face is often red, sometimes livid ; there is either a comatose state, or a want of sleep. The symptoms of phrenzy, says Reil, are those which the physician should take for his guide. He should then have regard, ay in other maladies, to the temperament, cause of the disease, and other concomitant circumstances. Case.-Aged 36 ; of an athletic, bilious temperament ; became insane without apparent cause. Being attacked with a furious maniacal delirium, he was conveyed to the hospital at Ghent: ten persons could scarcely restrain him. His face was red and his pulse beat with violence ; the carotid arteries could be seen to pulsate ; he struck and misused all whom he met. He was without sleep and constipated. Twenty leeches were placed on the neck, and the next day he was more tranquil. Application of the same number of leeches was repeated, and amelioration became sensible. During, four months' stay in the hospital, two hundred leeches were applied. From time to time, ten, fifteen, or twenty were applied ; and, each time, a striking amelioration, became evident. He was cured after five months' stay at the hospital. Case.-Of ordinary stature, but rather delicate than strong. He is attacked every year, towards midsummer and midwinter, with a furious maniacal delirium. When the first symptoms appear, he is abundantly bled, and in a few days the disease is dissipated. If the sanguineous evacuations are neglected, the delirium makes terrible progress. Case.-A man, according to Perfect, strong and robust, becomes maniacal, and commits many acts of violence ; he is bled 173 to fainting, the operation being repeated many times, and is cured in a short period. Case.-An opulent gentleman, says the same author, became insane ; he offered extraordinary pulsations of the carotid arteries, and experienced severe pains in the head and left hypochondrium, and also praecordial anxieties; he complained of depraved appetite, and of a feeling of constriction at the scrobiculum cordis ; the abdomen was tense. Exutories were placed on him, and he took baths, but without the least effect. Perfect drew eight ounces of blood from the arm, and a seton was placed between the shoulders. He took internally nitre and the tartrate of potash ; he was bled nine times, and the violence disappeared. He was perfectly cured. The abdominal viscera are sometimes in insanity in a diseased condition, and merit attention; the menstrual and hemorrhoidal flow. Case.-Two years before, at the critical age. Her menses flowed no more; religious fanaticism produced her derangement; she committed a thousand extravagances. Bleeding was repeated three times, and she recovered perfectly.-(Perfect.) Case.-Aged 30; of vigorous constitution ; had her menses suppressed from violent anger ; lost her mind, and furious rage characterized her derangement. Voluminous hemorrhoids appeared, the pulse was hard and strong, the skin hot and dry. A bleeding of ten ounces was made, which was covered with the inflammatory coat ; a seton was placed between the shoulders, and she was given a slight purge. The bleeding was repeated, and she took the warm pediluvium. During this treatment her progress towards health was rapid. She was cured, although her menstruation was irregular during a certain time.-(Perfect.) Case.-A gentleman, long addicted to intemperance, felt, on a sudden, pain in expelling foecal matters, and other symptoms of hemorrhoids occurred, at the same time that mania declared itself. He had pains in the head; the eyelids were swelled, and there were convulsive movements in the muscles of the face and in the fingers; the pulse was strong, full, and hard, and the abdomen tender. A bleeding of twelve ounces was made, and showed the inflammatory crust. Camphor and soluble tartar were also administered ; the bleeding was repeated, and the patient was shortly delivered from his delirium and his hemorrhoids.-(Perfect.) Here abdominal plethora was a cause. Cases also reported by Perfect demonstrate that bleeding is not exclusively useful in mania, and that it may find not less favourable indications in melancholia. Case.-Aged 45; had been attacked by blind piles and acute rheumatism ; suddenly, without apparent cause, he became insane, and his delirium took the form of melancholy. After taking vomits, purgatives, and employing other means, Perfect drew six ounces of blood, ordered an antiphlogistic regimen, and in a little time the patient was entirely restored. Case.-Aged 44 ; melancholic ; of plethoric constitution; she recovered her reason by sanguineous depletions. Case.-A young girl, aged 14; delirium assumed the character of religious melancholy; she had a fixed look ; she could not repose at night; she was extremely fearful. Different means were employed without success. Perfect ordered a bleeding of six ounces from the arm: she took also camphor, nitre, and castor, and was cured after the second bleeding. Case.-A young man had been attacked, some time, with erysipelas of the face, and to relieve the pain, he made it disappear with a wash : mental alienation immediately declared itself; he was bled to syncope, and a sefon was placed between his shoulders. His re-establishment was complete in a Case.-A man affected with a scabby eruption, caused it to 174 disappear by a repellent. He was bled to fainting; a vesicatory was placed between the shoulders, and an emetic was given internally. The patient became more calm ; the bleeding and the emetic were repeated, but the last did not cause vomiting : reason soon returned.-(Perfect.) After this, we see that Perfect had recourse always to general bleeding. Temporal arteriotomy, leeches to the head, anus, vulva, and other places, cups, simple scarifications, and opening the vena saphena of the foot, are, however, in many cases, to be preferred to general depletion. It is thus that we draw most advantage from temporal arteriotomy, when there is cerebral congestion, as in the disposition to apoplexy, and the application of leeches to the vulva or anus ought to be made preferably, if suppres. sion of either hemorrhoids or menses have occurred. But bleeding, in whatsoever manner it be made, demands great precautions : more than once, fatal accidents have ensued, when the patient was not watched. It is an efficient means in mania with epilepsy, in order to prevent or diminish the cerebral congestions so frequent in this affection. Since the discoveries of Gall, it has been hoped that topical applications to the head would have a doubly efficacious effect, when the application was made upon such and such a part, corresponding to the original cerebral malady. This remark we principally apply to erotomania. Formerly, here applications were made to the genitalia ; now, to the region of the cerebellum. Gall gives a case. [See Combe, G.] Ferrand assures us, according to Georget, that physicians have drawn advantage from the application of leeches to the nucha, and behind the ears, to individuals attacked by this affection. After having made known the utility of bleeding in mental disorders, and established the indications favourable to it, it is my purpose to add some words to prove the non-existence of increased sanguineous action, and the inutility of sanguineous depletions in insanity. A number of physicians, Perfect amongst others, as we have seen, have proved, by facts, the good results of bleeding in mental alienation. How. ever, all those who have studied these sorts of maladies, in a great num. her of individuals, rarely praise bleeding. Pinel scarcely ever saw any good results from it, &c. Müller, of Würtzburg, shares in the same opinion : he has rarely seen satisfactory effects from this means ; he does not except even maniacal fury. Most of the patients who arrive at my hospital, says he, have been bled copiously, and dementia, in a great number, has become the sad result. Georget gives a similar testimony. Dr. Willis had already observed this evil effect, and Mr. Simmons, the physician to the Hospital of St. Luke, at London, makes the remark, reported by Lorry, that a patient became more irritable after more or less repeated bleedings. There are various reasons, too, for believing a nervous instead of vascular state to exist in insanity, and that, therefore, bleeding is not indicated ; this is the case, even where strong vascular symptoms exist. Conclusions :-I. Bleeding may be, perhaps, useful in disordered mind. 1. If the cause of the disease reside permanently in the circulatory system, in plethora, in suppression of the menses, or hemor. rhoids, or epistaxis. 2. If the cause is an inflammation of an abdominal or thoracic organ, which sympathetically affects the brain. 3. If the intellectual disorder proceeds from a strong external irritation ; blows, falls on the head, and insolation. In these cases everything denotes inflammation and sanguineous depletion. II. If the cause be unknown, inflammatory symptoms may mislead, and the success of depletions will be doubtful. III. A case purely from a moral cause may produce inflammation 175 of the cerebral, thoracic, and abdominal organs. Depletions might in these sorts of phlegmasia render useful service, as to the diseased condition, but would rarely benefit the mental alienatian. IV. A moral cause, as Georget says, may trouble the intellect, and, at the same time, other organs. Fright may render a female insane, whilst it suppresses the menses. Depletions and the antiphlogistic regimen would here render great service. V. If the cause is moral, and, immediately after the development of the disease, abdominal inflammation occur, bleedings on this region would but calm a symptom of madness. VI. If a moral cause produce excitement of the cerebral system to a considerable degree, bleeding becomes an indispensable means. VII. It is a difficult but essential point to discover whether the vascular action is due to local inflammation or is purely nervous. The latter is very frequent in mania and monomania: bleeding in all these sorts of cases is almost always hurtful.

Tonics and Stimulants.

There is sometimes a real, sometimes an apparent feebleness merely in insanity. The system of the two Mayos, father and son, looks upon insanity as being always an inflammatory condition, and never admitting of tonics. But in all time the success of stimulants and tonics, in some cases, has demonstrated the existence of asthenic cases of insanity. For merly, in England, vanilla was famous for the cure of melancholy : vanilla is, however, a substance very stimulating. Pargeter has made great use of it, and cites the cure of four melancholics from its employment. Ferriar obtained the most happy success, in madness with depression, from Peruvian bark. He often united this tonic with opium and aromatics; and cured, radically, by this combination, an insane female. Perfect cites different cases in which bark was given with success. Reil has proved the excellent effects of bark in dementia with the intermittent type. Georget assures us that he has employed with success bark and other tonics in remittent insanity. Dr. Castel utters, amongst others, these remarkable words: "More than once I have seen insanity yield to bark." Case.-A girl, aged 24 ; of highly nervous temperament ; thin; black movable eyes; fair, clear skin; looks lively and piercing; black hair, &c. ; was frightened at night, and exposed herself to cold. The next morning she complained of rheumatism in the arm, which disappeared from frictions made with the volatile liniment ; but the mind showed symptoms of being disturbed. This augmented from day to day, and, after six weeks, she was transported to the hospital at Ghent. She was, at her entrance, inexhaustibly loquacious; she spoke upon various subjects, but without the least judgment; she knew, however, her neighbours, and recollected all that had passed before her disease. The evening of her entrance a bleeding was practised by a pupil. The next morning she became furious. From that moment she exhibited symptoms of amorous mental alienation ; her mobility was so great as to re. quire means of repression. The blood drawn had the inflammatory crust. The second day she was ordered twelve leeches to the head. She became insupportably gay and loquacious. The professor of clinique, M. Van Rotterdam, thought he saw a state of debility with excess of sensibility. He ordered a decoction of bark, in which was infused serpentaria virginica. Next morning the delirium had almost disappeared. In four weeks she was perfectly cured, always taking the same remedies, joined with red wine and good broth. Case.-A negro, driven from home for a 176 domestic robbery, after wandering about, without means of subsistence, was at last taken home by an Englishman, but showed. almost immediately, signs of mental alienation. His body was wan; his eyes dull; pulse very frequent, but weak ; cxtrernities and nose cold ; paleness of tongue remarkable; loquacity continual, confused, and incoherent. He constantly turned his head to the contiguous wall, as if attending to some voice. In ten days the delirium was complete, and he spoke riot a reasonable word. I prescribed good broth and a decoction of bark. During the first days reason made little progress: the tongue, however, became redder, the pulse stronger, and the nights more tranquil. After fifteen days' perseverance in tire same means, there was manifest amelioration in the intellectual functions, and, in about a rnonth, he became perfectly reasonable. In a few months after lie died of phthisis. Case.-A young theologian abandoned himself to study with a sort of fury. He became maniacal, and was transported to the hospital at Ghent. Various means were employed by Dr. Hulin, but without success; he remained maniacal. His father, a physician, proposed bark, and, in a short time, amelioration followed, and he was cured. These cases are opposed to the exclusiveness of the Mayos. Perhaps there is more prudence required with regard to tonics, in intellectual disorder, than in any other. I can cite cases in which all the indications appeared united for the employment of Peruvian bark, and yet no advantage resulted from it. There is a periodical case at Ghent, approaching mania without delirium, and attacked on a fixed day, the delirium lasting six days, and succeeded by perfect sanity. Dr. Hulin and myself had given him, at various times, bark, but without the least success. Still these are riot reasons for ban. ishing tonics from our treatment of mental disorders. Tire cases in which they suit are not numerous, but there are facts showing that they exist ; and, moreover, in directing our attention towards the numerous causes of mental alienation, it is impossible not to find agents weakening the natural energy of the system, such as sedentary life, disappointed love, &c. This feebleness being very common in dementia, it in general demands the employment of tonic means. The system of the vena porta, especially, and the abdominal viscera in general, often are affected with feebleness. The means raising up the energy of the system are indicated when insanity depends on such a cause. Tonics are also indicated as useful, when the digestive organs are in a true state of feebleness. Loss of appetite, paleness of the tongue, slow digestion, sometimes being absent, are phenomena which, when they occur from want of tone in the organs of digestion, invite to the employment of tonic means. But, as I have often observed, we ought to be circumspect in not taking the diminution or cessation of the functions of the priæ vi%aelig; for atony when it depends on irritation of the viscera which compose this apparatus of the organs. Tonics are also advantageous when the mental alienation is accompanied by feebleness, paralysis, scrofula, and scurvy. Whatsoever be the cause and the complication of mental alienation, true feebleness is a cause which calls for the use of tonics. The choice of these means should be based upon the difference in the cases which we treat. Amongst tonics, tire most efficacious is, without doubt, bark. It is particularly useful in periodical mental alienation, and in those cases which arise from onanism, or are complicated with it; in dementia, and especially in that which arises from intermittent fevers, protracted or treated by too debilitating a method, and upon which Sebastian fixes the attention 177 of practitioners. We often see mental alienation after typhoid fevers, which exacts imperiously the employment of tonics, acrd, above all, of bark. The use of the last is not advantageous in madness accompanied by scurvy, or some other affection from debility. Iron is indicated in insanity with atony of the digestive system, and in that which has for its cause an asthenia in the menstrual flow. Esquirol makes use of it in chronic dementia. Long, Frank, and others, employ it preferably in hypochondriasis. The bitter extracts, as those of dog's grass, duck.bean, chamomile, and gentian, may be used in mental alienations with cachexy, atony of the abdominal viscera, and obstruction of these organs. We may place in the same class stomachic and visceral elixirs. Soap and all plants which contain it, as lettuce, saponaria, and others, are of great utility in insanity complicated with visceral obstructions. Dr. Hunter, of York, makes great use of it in such circumstances.

Anthelmintics.

Professor Gilbert, a physician at Lyons, cured a young man of violent mania, by the evacuation of an abundant quantity of lumbricoides, caused by anthelmintics. Prost reports, also, that Dr. Cowade has communicated to him a similar observation. In such cases anthelmintics may be of service.

Mercury.

Dr. Palmer has found all the indications of inflammation of the convex surface of the liver, in a melancholic who made great abuse of spirituous liquors. After having tried, without success, bleedings, epispastics, and other means, he had recourse to mercury, and in a little time the patient was cured by the combination of this means with mild purgatives and a light diet. He experienced a relapse: he again took mercury, and scarcely was salivation established, when the madness disappeared. The convalescent exposed himself to cold ; ptyalism was arrested, and at the same time the delirium reappeared. Mercury was then given, and at the moment in which the saliva began to flow, reason regained its natural energy. This flow was kept up a long time, and the patient was cured. Dr. Palmer reports that he has cured a melancholic young man by the use of mercurial frictions carried to salivation, adding to this means the use of bark internally. Burrows reports a case of suicidal melancholy cured by salivation. He also gives two others, similar to it, thus restored. We find in the journal of Nasse the description of cases of mental alienation cured by calomel and affusions of cold water on the head. The first is a female, who became melancholic in consequence of severe fright. Heinroth prescribed calomel, and she recovered. At the same time cold affusions on the head were employed to prevent too abundant a salivation. The other case is that of a furious maniac, with whom they had employed, without success, various means, and who recovered his reason by the use of calomel. Dr. Groos has made many experiments with this means. He says that the use of calomel, continued a long time and given even to salivation, appears to produce, in some young female maniacs, salutary effects : but for this moral change it was necessary that the patients should first be attacked by typhus, in which the spirit suffered as much as the body : a general stupor was required before the re-establishment of reason was perceived. Many male subjects, little robust and aged, were victims of his experiments; and a dysentery which then prevailed 178 was almost always mortal. They were made at the hospital of Pfortzheim. Müller, of Würtzburg, has not obtained any success from mercury in mental alienation. The following are the experiments which I have made: Case.-Aged 43 ; a man of short stature with abdominal embonpoint, jaundiced skin, and black eyes; had been melancholic nine months. In fifteen days I produced ptyalism, by calomel given internally. This flow was kept up three weeks, and the patient experienced no moral change. Case.-Aged 48; little robust; of a bilious temperament; had hard stools, and complained of a feeling of weight in the right hypochon. drium. He was attacked with fantastic mental alienation. Salivation made no alteration in his condition. Case.-Melancholic; salivated for two weeks with not the least benefit. Case.-A maniac; salivated with calomel ; not the least benefit. Case.-A tranquil maniac ; took calomel during five weeks with not the least benefit : salivation lasted only a few days. Case.-A monomaniac ; bilious temperament ; took calomel thirty days without salivation ; but the remedy had to be suppressed on account of the abundance of the stools. Case.-Aged 48 ; servant to a farmer; had not been regular for five years ; meagre ; of a nervous temperament; eyes black and movable; skin yellow ; became insane without manifest cause. She believed herself pursued by phantoms, and was found one day about to commit suicide with a knife. Her ideas were extravagant ; she wept incessantly. This state continued eight months. Eight grains of calomel were given her in twenty-four hours, and every day; they produced diarrhoea and salivation in two weeks. She was salivated abundantly ; her whole face was swelled, and her teeth came from their sockets. After adopting this treatment, I could not arrest the flow, and soon she fell into an extreme prostration of strength; her skin became dry; her tongue was black; the parotids remained tumefied ; and she was shortly affected with a profound stupor. I observed, not precisely the phenomena traced by Groos, but a great cerebral congestion. She convalesced from this accidental disease ; the mental alienation, however, existed always ; but it was changed in character. A dementia bad replaced the melancholia. This reverse made me renounce farther trials of mercury. This patient, viewed now as incurable, shows symptoms like general dropsy, and at present takes bitters. If I judge by my own experience, mercury is little salutary to the insane. Some facts, as we have seen, demonstrate that it has been useful to them, and I am far from wishing to call this in doubt. I presume, however, that we are yet far from knowing the circumstances which indicate the cases in which this means is really useful, and those in which it is hurtful. We cannot doubt but that more than once it has provoked enfeeblement of the intellectual faculties and the motive force of the muscles.

Oil of Turpentine.-Percival and others have spoken of the efficacy of oil of turpentine in the maladies here treated of. The following are cases from Percival. Case.-Aged 45 ; has experienced attacks of epilepsy since twelve years of age ; in 1816, they occurred regularly every eight hours, alternating with a paroxysm of mania ; at first little intense, the returns of the epilepsy became daily more violent. Percival gave an ounce of white sugar with as much oil of turpentine, making the patient drink a small quantity of water; this was repeated thrice daily. After four days, there was diarrhoea; but the epileptic paroxysms were less violent ; the maniacal fury had equally diminished in intensity. 179 They then gave three times daily, half an ounce of sugared turpentine. The attacks diminished much in intensity, and the intervals between them became longer. The intellect had gained in energy, and soon the patient experienced no more, during a month, than one paroxysm of epilepsy, which was, however, violent. An ounce of turpentine was then given thrice daily again. A month having elapsed, a convulsion only, of little violence, occurred : this was the 9th of January, 1817, and up to February there was not the least spasmodic movement. The medicine was then stopped. Case.-Aged 50 ; robust, sanguineous ; had been for a number of years attacked with mania with epilepsy, and had made great abuse of spirituous liquors. The epileptic paroxysm was repeated regularly every two, three, or four weeks. The mental alienation then assumed a character very intense, and to such an extent, that the patient had to be shut up. The 11th October, 1816, an ounce of the oil of turpentine sugared was administered thrice daily : diarrhoea supervened. The dose was reduced to half an ounce, three times daily. The 29th, a paroxysm of epilepsy with a slight maniacal exacerbation. Up to the 9th December, no paroxysm : the physical and moral forces were increased in their energy. The 17th, epilepsy without mania: increase of the dose of turpentine. The 3d of January, a paroxysm of epilepsy. Up to the 12th February, the time at which the patient ceased to take the remedy, no epilepsy appeared. Case.-Aged 38 : affected with mania, with epilepsy, for seven years. The paroxysm returned regularly every month, with exacerbations of furious mania. He took (the 11th October, 1816) the oil of turpentine sugared, three ounces daily. Diarrhoea. Dose diminished. Manifest amelioration. Two epileptic attacks towards the 7th December, without exacerbation of the mania. The 19th of December, a violent paroxysm of mania, which was not, however, of long duration. The 7th January, a mild attack; it was exempt from convulsions and from mania. The 12th February he ceased to take the medicine. Case.-Aged 30 ; subject to paroxysms of mania, which are renewed every eight days, twice in twenty-four hours ; deranged. On the 11th October, he was given the oil of turpentine, and from that moment there was a sensible diminution in the violence of the convulsions. From the 12th November, up to the 23d of the same month, there was a complete cessation of the paroxysms. This time being passed, they were renewed at night, and he experienced no more during the day up to the 19th December. At this period he had convulsions, four days successively, but only a paroxysm in the day, without mania. During the month of January, the paroxysms occurred only at night, although with less intensity than ever. In the day he was well. Case.-Aged 30 ; cause and origin of the'disease unknown. The 17th September, he experienced an attack of epilepsy with mania, which succeeded each other alternately during seven days consecutively. He commenced the oil of turpentine the 11th October. The stools from it were copious, and a diminution took place in the intensity of the epileptic paroxysm. The 15th November, he experienced a violent paroxysm without mania ; the 18th, he had one with mania, and was very well until the 27th, when he was taken with an epileptic paroxysm. From this time, there was so sensible a physical and moral amelioration, that the patient was soon cured. In reading these observations, it is impossible not to remark a great want. In all these patients, Dr. Percival commenced his treatment the 11th October, and finished the following February, 180 without mentioning whether the patient experienced a relapse. I administered this medicine for a very long time to all the epileptic maniacs at the Hospital of Ghent for males, but obtained no advantage ; and what is more, some of the individuals submitted to my trials have experienced ill consequences thereby. I go on to report some of these cases. Case.-Aged 36 ; two years at the institution ; paroxysms every two or three days. After taking, during four days, the oil of turpentine sugared, in doses of three ounces a day, there occurred a continual vomiting ; the dose was diminished, but he could not bear it at all. Case.Slight mania with the epileptic paroxysm, which announces itself very irregularly. The patient had been at the institution two years. He took the turpentine for eight days ; but the medicine had to be stopped on account of its producing copious diarrhoea. Case.-Aged 30; had been eight years at the institution ; attacked by dementia with epilepsy. The paroxysms are very irregular. He took the oil of turpentine : considerable diarrhoea ; the medicine had to be stopped. Case.-Dementia with an epileptic paroxysm which declared itself irregularly twice weekly, asthmatic ; at the institution twelve years. He took the turpentine, but it had to be stopped, from the excessive difficulty of breathing which resulted. In some of the patients submitted to it, I observed a retardation in the return of the epileptic paroxysm ; but I am far from at. tributing this effect to the turpentine. I have often remarked this in individuals not employing it ; it belongs to the nature of the malady. Dr. Horn has repeated the trials of Percival, and has not observed the happy success of the latter. In some patients, he has obtained a retardation in the appearance of the epileptic paroxysm ; in others, the returns were less violent. Some liked it and asked its continuance, others bad a borror of it. Horn concludes from his trials, that what Percival has said of its efficacy is exaggerated. I have tried it in the different species of mental alienation without epilepsy, but fruitlessly. Twelve persons attacked with partial insanity, and as many demented, were submitted to its use for three months, without the least advantage. Means of Repression.-It is not an indifferent matter to establish, when we should have recourse to these means. However violent, unless the patient compromise his own, or the safety of others, they should not be applied : for he thus becomes irritated, our curative efforts are obstructed, and sometimes he will even refuse nourishment, and suicide may be a consequence. A repression wisely directed is, however, in a number of cases, of the first necessity. Independently of being a safeguard, it produces salutary impressions, and, as a href="p70.html">Haslam says, disposes the patient to reflection. But the success of our treatment depends here upon the choice which is made of agents, and the cases which exact their employment. It would be useless to report here all the inhuman means which have been employed. It is sufficient to say, that blows, chains, &c., have more than once rendered a patient obstinate, distrustful, and often imbecile. Retention in a chamber is the most simple means, and perhaps the most generally efficacious. It may be modified in different ways : the patient may be shut up simply in an ordinary chamber, or he may be deprived, at the same time, of all light. Dr. Müller, of Würtzburg, said he had often remarked, that the most furious patients became peaceable and tranquil, when they were shut up in a gloomy chamber, isolated and deprived of all light. He had one constructed for this purpose in his hospital, a chamber painted black and deprived 181 of light. The same practice occurs at the Retreat, near York, and we meet with examples of it with us. This means is sometimes excellent in insanity ; we have experienced advantageous effects from it in furious mania.

Case.-A maniacal patient at Ghent was shut up in a dark chamber ; he was only permitted to go out to take the air in a court, every fifteen days ; he was not accorded this liberty but three days at most : if this time was prolonged, the patient became terribly furious ; but from the moment that he was shut up, he became mild, and by no means dangerous. Heinroth has cured a monomaniac, by giving him as his abode an apartment gloomy, sad, and shut out from all bustle. This means would be pernicious in mental alienation with sadness, in melancholy, properly so called. It would be equally of little use, and even hurtful, in dementia. It should be, then, almost exclusively confined to mania. Staying in a grated court belongs to the same kind of coercion. Cells formed of slips of wood have been constructed by Autenrieth, and used in different institutions in Germany and Netherlands; these are bad ; as Heinroth well observes, the patient is liable to bruise himself. At Charenton, was employed a sort of osier cage, the length of a man, in which the patient lies down upon a mattress placed at the bottom ; a lid is provided at the extremity corresponding to the patient's head ; and this being shut, he is condemned to a complete immobility, without being exposed to the least injury. Casper has seen this applied with full success. Heinroth speaks of an agent of coercion employed in some institutions of Germany, which is unworthy of imitation. It is a press the length of a man : the patient is placed on his feet, the press shutting him up by a little panel. This would look ridiculous in a hospital. A means less ridiculous, but more dangerous, is the bag of oil cloth, yet employed in some institutions. It is a bag of the ordinary form, made of simple cloth, of the size of the individual for whom it is intended. It is covered with oil cloth, to intercept all light. It is tied at the top to the head of the patient, being made to descend so as to cover him entirely. Such a means is bad, because liable to frightful accidents. Experience has taught, says Heinroth, that it has led to suffocation, convulsions, and apoplexy. Horn placed it upon a patient at the Charity of Berlin, and she was found dead. In some institutions for the insane in Germany, a means of repression is employed, less dangerous than the preceding, but more odd. The patient is placed upright against a cord stretched perpendicularly from ceiling to floor ; he is fixed to it by a band which surrounds his body, and which is provided behind with a ring, through which passes the cord. His arms are restrained in the sleeves of the camisole ; they are extended and fixed by bands to cramps in the sides of the chamber; to the same place is extended a cord from each side of the body, attached to a ring in the bandage. The feet are also fixed to the perpendicular cord. Horn thinks he has obtained much success from this means. The turbulent and obstinate have been reduced to order, after having passed, at most, from eight to twelve hours in this attitude. Autenrieth has invented a kind of mask made of leather, which turns under the chin, hindering the falling down of the lower jaw, leaving openings for the eyes and nostrils ; straps fix the mask upon the head. He proposed thus to prevent hollowing ; but we may easily perceive that this means, like the preceding, merits but little confidence. Another means of repression is the Tranquillizer of Rush. It is a chair of strong wood, upon which the patient is fixed by strong bands of leather, which hold his arms, body, and legs. A rest for the feet and for the hands, of wood, is provided. Much may be said both for and against this means ; but whatever be the difference of opinion, there will always be the great inconvenience of producing cedema of the lower extremities, chaps, inflammation, suppuration, and even gangrene of the parts upon which pass the leathern bands; it has also the disadvantage of strongly impeding the circulation of the blood, and disposing to descent of the rectum. I will add, 1. That it may render eminent service, when the patient is placed on it but for a time extremely short. 2. That when he is attached for a long time, independently of the accidents mentioned, he often acquires an incapability of moving the lower limbs. 3. That almost always patients who have been placed in it a long time, preserve the habit of sitting down continually, and become unfit for manly exercises. At Ghent, there are a large number of these ; they walk with their knees bent, and sit down almost continually. 4. It is bad, as taking all physical liberty from the patient. Heinroth gives it great praise. In the asylum of lunatics at Glasgow, it is placed upon springs, so that the least contortion of the patient's body causes a motion analogous to that of a carriage. This has one useful effect, but we do not think it exempt from the inconveniences attending the ordinary chair. Reil has invented a kind of moveable wheel, in which is placed a furious patient, in order to force him to repose ; this is like the moveable cages in which squirrels are shut up. The least motion of the individual makes him toss about, and he is thus forced to repose. Different inconveniences naturally attend this. A means of repression far more efficacious, is the belt of Haslam. This, at the same time that it controls the arms, holds them in such a position as not to deprive them of all motion. Casper has had occasion to observe the efficacy of this means, and has given it great praise ; it is easy to assure ourselves, says he, that the patient does not feel the inconvenience of those who have on the camisole. The strait waistcoat has, in some institutions, the sleeves in one piece : this is bad, as it gives a patient some use of his hands, and he can free himself with his teeth. Three men are necessary to place it on a patient ; one goes directly to him ; he has his arms in the sleeves of the camisole, and seizes him by the hands ; a second throws over his head an apron, whilst a third draws the camisole upon his arms, and closes it behind. This means, like the belt of Haslam, possesses the advantage over every other agent of repression. 1. In not causing any pain. 2. In not arresting in any manner the course of the fluids ; and 3. In leaving to the body great liberty. Haslam gives, however, no praise to the camisole, &c. Some of his observations are just ; but others do not merit the least attention : but however this is, the belt and the strait waistcoat are the best means of repression which we know. In a number of cases, the strait waistcoat is of great utility ; but it is equally true, that it is insufficient for furious maniacs, who well know how to untie it. Haslam would re. place the camisole by bands of metal, which encircle the fore-arms, and attach them together, so that the patient may exercise his arms, although his hands are joined. We are of Horn's opinion, that these might be more efficaciously replaced by bands of leather lined internally with fur. Different means have been imagined to restrain a patient in his bed when furious and turbulent ; they are less efficacious than the first, because they force the patient to hold a position which is not absolutely to his taste. They even render many worse, and less docile The most simple apparatus is that of Heinroth. The strait waistcoat is placed on a patient, and by the upper part of his body strong girths go to be fixed into the bedstead. The same writer describes another means, more complicated. The patient lies down on a bed pierced with holes to give vent to the excrements ; a large girth of leather surrounds his body ; it is provided, on its lateral parts, with rings of leather, through which pass bands, intended to fix the patient to the lateral parts of the bedstead ; it is also provided with strings and eyes on its lateral parts, to fix the hands. Two girths united surround the legs, and are provided at their lateral parts with rings, also intended to give passage to bands, which are fixed to the bedstead. At the York Retreat another mode of proceeding is followed, more complicated than the previous one. A girth of strong cloth, five feet and a half long, by three inches and a half broad, is placed at length upon the bed. At each of its extremities is attached a leather band, one foot long, one inch wide. Where this strap is fixed to the girth, there is a buckle. Staples are fixed in the foot and head of the bedstead, through which the straps go, and the patient being placed on the bed under the girth, this is, by the straps, buckles, and staples, fixed to the bedstead. By a set of buckles and straps, similar to the girth, answering to the upper portion of the body, and attached transversely to the girth, and the same arrangement as to the feet, the patient is held stationary, the straps passing round the shoulders and legs. This means may be efficacious for lunatics who are disposed to strike. In malicious monomania, and in suicide, the employment of it would be particularly useful during the night. It is advantageous in giving great freedom to the movements of the body, to such a degree that the patient is not forced to hold himself permanently in a disagreeable position. Other agents may serve as means of repression ; such are the rotary machine, cold douches, and all that may produce a considerable degree of terror.

It is sometimes necessary to force a patient to take nourishment which he refuses. When ne is obstinate in this respect, two men hold him upon his back; a third holds his nose: the mouth opens itself, and a liquid aliment is poured in. This is done without the least rudeness, and without offensive words. In the York Retreat, they place the patient in a chair-the back of which is moveable, by means of springs this is turned back, in order that the head of the patient may be bent in this direction. The mouth is opened with the aid of a little key; whilst another person introduces, by means of a spoon of strong metal, liquid nourishment. A metal spout, or a cow's horn, serves for this purpose. At Bedlam is used an elastic bottle, furnished with a tube equally elastic. However, before having recourse to this means, it is necessary to exhort the patient, in all possible ways ; often, by placing nourishment near him, and without making the least remonstrance, we will see him eat that which he has refused with the greatest obstinacy. The maladies which most frequently afflict the insane are those which proceed from cold and humidity. The gangrene of the lower extremities, at the Bicetre and at Bedlam ; the diarrhoea, at the institution of Amsterdam ; the scurvy, at the Salpetriere ; the scrofula and pulmonary affections of other institutions, recognise, almost always, these two agents as their primary cause. Observation' has manifestly demonstrated that. the insane, considered generally, although apparently physically insensible to a cold and humid atmosphere, are not protected from the maladies which it produces in persons of sane mind. They do not feel them, 184 precisely as they do not feel the vesicatory which is applied, and which, nevertheless, produces a suppurating wound. I have been able, even this year (1823), to assure myself of this truth, at the hospital for males at Ghent. At the commencement of winter, more than half of the lunatics were attacked by a dysenteric diarrhoea ; others offered symptoms of pleurisy and pulmonary catarrh, and these maladies exhibited themselves immediately after the first cold days which we had this year. We gave warm shoes and stockings ; we redoubled our care in protecting them against the cold, and in a few days the disease ceased to make progress. This establishment is a representation of all which is frightful to humanity. We should say, in visiting this sad abode, that the typhus of prisons, scurvy and intermittent fevers, would reign there permanently ; this is, however, not the case. Let its imagine a vault, tire or six feet below the level of the ground, which is not forty feet broad, in which are crammed, pellmell, more than one hundred persons, where does not penetrate a ray of light, and we may judge of the unfortunates in so sad a dwelling-place. We do not, however, see there the prevailing diseases, although everything concurs to render the air infected. One stove alone heats this dungeon ; all the linen is dried on this ; the beds, impregnated with the odour of the night, are also carried thither ; twenty of the insane, affected with epilepsy and other diseases, lie here ; also, in entering, we are stifled with a mephitic air ; add to this, that this cave opens on a moist court, surrounded by high and vast walls, being but fifteen feet broad by fifty long, and where no sunlight penetrates, but in the longest days of the year. The mortality, however, is not considerable in this hospital. According to my observation, the changes in the temperature of the air; from warm to cold, cause almost the only maladies which reign there ; such are catarrhs, pleurisies, and diarrhoea. This last affection, which is sufficiently frequent here, does not depend upon the inspiration of mephitic air, since it is only manifested towards the equinoxes, when the changes of the atmosphere, from cold to warm, and vice versa, are frequent. The maniacs, and especially the furious, appear the most sensible to these influences. At the Hospital of Ghent, many of the insane were attacked by diarrhma, at the approach of the winter of 1823, and without prompt relief it would have made great ravages. In all those attacked, there was redness of the tongue, loss of appetite, and nausea. Foot-baths, mucilages, warm garments, above all, warm stockings, arrested this affection, when it was on the point of assuming an intense character.

An observation, which dates from the time of Hippocrates, affirms that intermittent fevers have great influence in nervous maladies, and that they are proportionally efficacious, as the duration of the febrile paroxysm is long and violent. Quartan fevers have been generally recognised as the most favourable.

Aliments.-Abstinence, as to food, has been counselled and put. m practice by some physicians, in order to subdue the furious transports of maniacs. This practice has especially prevailed during the last years in Germany. But besides want of nourishment being a cause of madness, it has been, in more than one case, followed by the most deplorable results. In all cases, we would here do less injury by too much, than too little : such is the opinion of Lorry and others. Pine] experienced the baleful results, at the Bicetre, of a want of food. In the cure of mental alienation, the use of stimulating, salt, spicy aliments has 185 been proscribed, and, with one accord, has been insisted on a diet light and vegetable-pot-herbs, fruits, and the flesh of young animals, and of easy digestion, and all substances which contain in abundance the mucoso-saccharine principle. This practice should be regulated according to the varying nature of mental alienation. Such alimentation suits one lunatic, whilst it is hurtful to another. In general, the regimen should be little nourishing, when we observe a considerable excitement in the functions of the understanding; when the pulse is active, full and frequent; when the patient is furious, &c. There are many exceptions to this. If the disease has existed a long time; if the forces have begun to decline, we should prefer a regimen more restorative. Violent exercise, watchings, and loss of the humours, cause always enfeeblement of the organs, and exact prudence in the prescription of nourishment. Aliments nourishing in the smallest volume should be preferred. If the patient is endued with exquisite sensibility, if his structure is delicate, the pulse quick and frequent, we should, above all, insist on a nourishment which may little fatigue the digestive organs. All that contains stimulating principles should be studiously shunned, and the aliments should be given often, but in small quantities at a time. A diet too restorative, with these individuals, carries into the circulatory system a fatal irritation ; it accelerates the pulse ; it causes redness of the face, disquietude and anxiety, and other accidents, more or less formidable. I say, then, that a restorative diet is particularly indicated when the forces decline, and when the insanity draws its source from a debilitating cause. This remark is, above all, useful in the disposition to suicide, &c. In the last extreme of refusing food, soup may be introduced through a strong sound of silver put into the throat, &c. Mental alienation, from an abdominal phlegmasia, requires the proscription of all stimulating regimen, or which is highly nutritive. In dementia, the nourishment should be substantial. We should equally insist on good regimen, when the madness is complicated with paralysis, with scurvy, or with scrofula. It is a fact, that. deviations from dietetic rules have the most pernicious influence on these maladies. Scurvy, especially, exacts the use of the most substantial aliments.

Drinks.-Under this report, pure water is a drink which is very suitable to the insane. It renders digestion easy ; it prevents the cerebral orgasm, so frequent in mania after the ingestion of warm aliments, and the patient prefers it often to all other drinks. This has been proposed in mental alienation as a curative means. Lorry and others have recommended it, particularly in mania and melancholia. In the most modern times it has been proposed as a beverage in suicide. Theden dissipated a hypochondriasis, with which he had been affected for many years, by the abundant use of cold water. At the age of forty, he was upon the point of committing suicide, and to dispel the anxieties which tormented him, he drank cold water in abundance. All the symptoms of hypochondriasis were dissipated insensibly, and he no more felt the least self-destructive desire ; no relapse took place, and he drank, in his old age, even thirty livres of water per day, adding a good dose of wine, to prevent feebleness of stomach. Case.-A female, aged twenty-six, strong, robust, addicted, since infancy, to masturbation, complained of anxiety and extreme fearfulness ; there was a feeling of constriction in the whole abdomen ; the stools were hard; the genitalia swollen, very sensible, and covered with eruptions; menstruation regular, and mind disturbed. 186 All sorts of measures were used ; acids, valerian, extract of hyoscyamus, &c., but without the least effect ; finally, by Hufeland's advice, she took from sixteen to twenty pounds of water per day. The progress towards cure was rapid. In three months she had recovered. Her mind had become tranquil, anxiety had disappeared, and also the erethism of the genitalia. Hufeland then added to this drink an infusion of valerian, and also the tincture of Peruvian bark, with the milk of sulphur. We cannot attribute the cure to the last-mentioned remedy, for the patient had previously taken it, without the least success ; but to having drunk the cold water. Case.-A female, says Hufeland, became melancholic, after having experienced severe anguish. She believed herself affected with a concealed organic disease ; she was sad and gloomy, and was found ever bathed in tears. Her mind experienced, front time to time, a true alienation. This condition had already existed some years before Hufeland saw her. She was constipated ; the menses flowed with difficulty, and the evacuation of the urine was abundant. A tumour extended obliquely from the right hypochondrium to the pelvis. She felt not the least pain from it. They supposed it a disease of the spleen, or of the left ovary, and, after having vainly tried a number of means, she made use of cold water, and took even eighteen pounds a day. In less than three months she was completely cured ; her mind regained its ordinary energy, and no intellectual alienation could be remarked. The tumour on the left hypochondrium dissipated itself insensibly, and became half its primitive size ; the stools, urine, and menses regained their ordinary course, and the patient was delivered from her anxieties and from her delirium.

In the cases given, and those treated by the ancients, some phlegmasia of the abdominal organs probably existed, and hence cold water would prove an admirable antiphlogistic. The use of cold water, taken as drink, forms part of the curative method of Avenbrugger for suicide. This author wishes that in this species of delirium the patient should take a litre* (* A litre is nearly two pints, five drachms.) of cold water every hour. If he remains pensive and taciturn, he says his forehead should be sprinkled, his temples and eves, with the same liquid, and a vesicatory should be applied upon that hypochondrium which feels most warm. Cold water is not successful in suicide in reality but in some rare cases. Falret made a melancholic, with a propensity to suicide, drink of it, during three weeks, at least twenty litres daily, without the least benefit. He adds, that he has seen a lady, confided to the care of M. Esquirol, who had made all sorts of attempts at self-destruction, arid with whom the treatment of Avenbrugger had been employed, with this difference, that the vesicatory had been replaced by a seton on the right hypochondrium : this treatment continued during three months, without the least satisfactory effect. I do not believe it useful to follow the precept of Dr. Schonheyde, to make patients eat of stimulating meats, as salt herrings, and other things of this nature, in order to provoke thirst. 1 witnessed a case, who, after a propensity to suicide for three years, threw himself from a window, and fractured his left thigh ; he then refused to eat, and starved to death. In the first part of his illness he took, of his own accord, twenty litres of cold water per day. In the Transactions of the Academy of Medicine of Berlin a similar case is reported. Great virtue has been attached to whey in the 187 cure of mental alienation. Lorry says that it has worked marvels, and he cites as an instance the following case : A woman, seeing a maidservant drown herself in a well, fell into the same madness ; she was cured by drinking, for months, pounds of whey, without any other medicine. Whey is a drink very suitable for the insane, and in many respects it resembles water in its medicinal virtues. Where there is great excitement of the brain or of the digestive tube, its use will not but be advantageous. This drink is not, however, without bad effects : if it is taken too abundantly, it leads often to colicky pains, or cardialgia-disadvantages in which it partakes with all aqueous drinks; in such a case it could but be hurtful. It may be advantageously replaced by water of rice, barley, or bread, orgeat, or other emulsions which have the property of diminishing the great sensibility of the primtT vise, and are, at the same time, more or less nutritive. The vegetable acids, especially vinegar, have been often employed in insanity ; I think Dr. Locher, of Vienna, first proposed it. Bosquillon says that it re-establishes the perspiration and other excretions, and that it restores suppressed menses or hemorrhoids. Lorry also makes much of this liquor. The acids are rarely given pure : they are mixed, usually, in an aqueous, mucilaginous, or syrupy vehicle ; and it is with this view that we may advantageously form syrups of vinegar, of the juice of oranges, lemons, citrons, &c. The acids are of acknowledged efficacy in scurvy ; they ire particularly indicated when the mental alienation is complicated with this affection. Mineral waters are divided into cold, warm, acidulous, saline, ferruginous, sulphureous, and gaseous. The sulphureous are particularly recommended in cases of mental alienation complicated with cutaneous affections the principal are those of Bareges, Aix-la-Chapelle, Harrowgate, and d'Enghien, near Paris. The acidulous, of which the most remarkable are those of Seltzer, suit, principally, in cases of mental alienation with stony of the digestive system: they are taken with advantage in the morning. The acidulous, ferruginous waters are preferably indicated in cases of mental alienation which proceed from masturbation, from chlorosis, from passive hemorrhage, or from those which are complicated with paralysis, or other affections of this nature. The cold, mineral waters, in general, tend to excite the digestive forces. Administered in favourable circumstances, wine may be of efficacious use in mental alienation ; but its employment exacts much prudence. As a general rule, it ought not to be so given as to produce drunkenness ; but simply as a tonic. Its use is particularly indicated in monomania with depression and sadness, in panic-terror, and in that with debility and trembling of the limbs. Its use is, in some sort, prohibited in mania. However, we must never lose sight of the vital forces, the duration of the malady, the habits of the subject, and the cause of the disease. It is thus that, in convalescence, whatever be the kind of madness, wine finds numerous indications with reference to the weakness of the forces. In those habituated to this drink, its utility will be greater. In dementia, wine agrees very well, through the alcoholic portion which it contains. It is a diffusible stimulant: by its astringent part (I speak of red wine) it is a permanent tonic par excellence. Would it not be suitable to permit, to a certain point, the use of spirits in dementia ?