COX.

PRACTICAL OBSERVATIONS ON INSANITY, OGC.
By Joseph Mason Cox, M.D.
1306. Second edition.
24

STRONGLY recommends keeping a case-book, containing every symptom and peculiarity minutely detailed. Practitioner should first see that there are proper means of removing the patient, or, if under coercion, to determine the propriety of its continuance or removal ; next study cause, then peculiarities, as whether variations of temper, epilepsy, convulsions, headache, or hernia; is the subject of hallucination, and 25 whether it is to be combated or indulged; whether most disposed to injure himself or attendants; cautiously removing every weapon from his chamber, and furnishing him with every necessary comfort. If no alarming or prominent symptom, to remain without treatment for some hours. Some require no treatment, mental symptoms disappearing as general health is regained. Most of these been exposed to causes of disorder of the prima viæ ; hence emptying the stomach and bowels is the proper commencement of the cure. Though diet to be regulated by symptoms, yet regularity in meals essential.

I. Moral Treatment.-Management of highest importance. Sympathetic tenderness never to be forgotten by physician, though it should not diminish his steadiness and presence of mind. A system of rules impossible; our conduct must be governed by the character of the case. In some cases, extreme measures requisite for security and restraint ; in others, the opposite. Physician should be constantly on his guard against any sudden, wild measure in the maniac. The grand object is to procure his confidence or excite his fear. Confidence, from very varied means; seen it in the most furious, he observes, from being liberated from their shackles by my direction and in my sight, and so attached to me as never to require coercion. Fear, from firmness and menaces; confidence, often from soothing and gentleness : from opinion and experience, thinks more gained by the latter than their opposites. Harsher means never to be had recourse to except in extreme cases. Deception seldom admissible. No promise to be unfulfilled, no threat unexecuted. Besides fear, the whole range of the passions might be resorted to with advantage. Every object associated with delusions to be removed. Reasoning generally useless, but sometimes delusions may be combated by a few self-evident arguments, often repeated. Talking at found more efficacious than talking to a patient. If routine method fails, any remedy, if slightly plausible, justifiable, as pious frauds. If one erroneous idea stamps the disease, allowable to try certain deceptions, acting by unusual, unexpected, striking, or supernatural agents, as often waking him from sleep, either suddenly or gradually, by imitated thunder or soft music, according to the case; combating the erroneous, deranged notions by some pointed sentence written with phosphorus on the wall, or some tale, assertion, or reasoning by one in the character of an angel, prophet, or devil. In speaking of hypochondriacal cases, he says, much skill is necessary-an actor to be perfect in his part. Sometimes such expedients are absolutely necessary, as, if life be hazarded from a mistaken notion of a bone or stone impeding passage of food, or an imaginary frog, snake, or toad in the stomach induces him to refuse nourishment. We are warranted, in the first, to make a superficial wound across the throat, and exhibit a bloody bone as the result; in the last, one of the imaginary species to be conveyed into the receptacle; but the fraud to be concealed from the patient, even after recovery, lest a renewal of confidence be prevented, and the repetition in case of a relapse. Case.Æt. fifty; naturally cheerful, but easily acted on by trifles, and of melancholic temperament. Became melancholy, and thought he had sinned against the Holy Ghost. Removal, and moral and medical attempts of no avail. Observations on the subject acute, having studied it. Its impossibility often argued with a third person, and he was always extremely attentive, and sometimes very much interested. Sentiments in 26 writing handed from one person to another in his presence; expressed his desire to see them; acceded to on his promising to comply with certain requisitions: never deceived me. After repeated conversations such as the above, grew more open to conviction, and wavered; at last was convinced of his error. A long journey in an open carriage, light reading, avoidance of all abstract moral questions and disputed doctrines, completed the cure. Case.Æt. forty; spare habit and melancholic temperament; great general knowledge; injured his health by too close attention to mercantile concerns. Observed to attend to, and talk about, every feeling; thought himself universally diseased, and took all sorts of medicines ; all ideas at last concentrated in the one, that his sufferings arose from repelled itch. A formal consultation of medical men was held, who, having agreed on the propriety of humouring him, acknowledged him to be right, and a medical plan was adopted to cause successive crops of eruptions in different parts from time to time, which were washed with some simple preparation. After a few weeks' continuance, health and reason were restored. Case.Æt. twenty-five; of fair complexion, though hair and eyes dark; of exemplary morals and amiable manners. Had paid some little attention to medicine, though very desultory in his studies: in the constant habit of quacking himself. Though no apparent alteration in his countenance, yet constantly complained of his health, to which his whole attention was confined, until at length incapable of all exertion, bodily or mental. After repeated and anxious inquiries, found that he believed himself affected with syphilis, merely from sitting on a seat previously occupied by an infected person. No reasoning of avail. His case was referred to a medical man of his own proposing, and he being previously instructed, pronounced it venereal, and sent a prescription. This soon dissipated the absurd idea. Case.Æt. thirty; of full habit; melancholic temperament; extremely literary; and sometimes studied through whole days and nights, drinking only water, and taking no animal food. Friends remonstrated with him on account of the hazard of such conduct, and his housekeeper was urgent for him to adopt some plan principally for his health. He was struck with the idea that she intended poisoning him by a succession of poisoned shirts. Reasoning of no avail; hallucination humoured. A suspected shirt was exposed to some chemical experiments, simple, but pompous; and it was pretended that his suspicions were correct, and housekeeper hurried off as if under a warrant. A formal consultation was then held, certain antidotes prescribed, and he perfectly recovered in a few weeks, and remained so by a new plan of life and regimen. In similar cases, necessary to humour the idea, as where insane from idea that an ear-wig had entered the cranium; that insects were in the bones of the face from aroma of flowers; where they thought themselves bewitched, enchanted, a prey to spirits, devils, hobgoblins; under magical spells and vows. In the distressing cases where some absurd idea makes him refuse food, the most consummate art and address necessary; his reasoning to be fully entered into; fancies and wishes to be complied with as far as possible, keeping constantly in view the support of life: threats, promises, solicitations, indulgences, deprivations, and varied reasonings to be had recourse to, according to nature of the case. Case.Æt. fifty; melancholic temperament; spare diet; subject to bilious attacks; though having no bodily indisposition, had been taking all sorts of medicines. 27 After hearing his minute accounts, disease pronounced solemnly one of the bladder and kidneys, consisting of their universal ulceration; told that it was hoped this might be proved, but with much hazard. A bougie very formally passed up the urethra, and the mucus from the glands said to be pus. A course of remedies, consisting of simples, adopted, and a regimen for a length of time, which ultimately terminated in complete restoration. Similar deceptions, according to the circumstances of the case, only efficacious mode of combating hallucinations of the imagination, as where the patient suspects himself to have certain loathsome diseases, as itch, syphilis, &c. ; under the influence of secret poison from magic, witchcraft, and evil spirits. Such fancies not curable by common methods, as no obvious corporeal indisposition exists, and there are therefore no indications. In all such, deranged ideas to be humoured, contrary to the established rule in the more common. Case.Æt. fifty; illiterate; naturally gloomy; of melancholy temperament strongly marked; meagre habit; from infancy subject to inequality of spirits, and rigidly religious. Became, without apparent cause, very melancholy, without assigning any cause. Perfectly inactive and inattentive to domestic duties; only to be induced to read a certain description of books, whose meaning she strangely perverted. At length her ideas became perverted, and thought herself inevitably lost, which idea deprived her of all ease and rest, and led to several attempts at suicide. No change for months. Apartment decorated with portraits of burning martyrs, &c., surrounded with Bibles and Prayer-books, and constantly visited by some itinerant preachers, who tried diligently to cure her without success. I removed her books and pictures, and suffered no one to visit her but an attendant; allowed no reasoning on religious topics, and only a little light reading. Having been very irregular in diet, the tongue foul, and breath offensive, gave an active antimonial emetic; produced a vast quantity of bilious undigested sordes, and some very offensive evacuations from the bowels. A certain hour of rising and retiring, and exercise in the open air gradually increased, some days extended even to fatigue: still religion the subject of her musings and soliloquies; ideas confused and incoherent, but looks more natural, and could be diverted from her favourite topic. Various remedies, with very little relief, for several weeks; and then for two or three weeks all medicine suspended, and curative attempts confined to amusing and interesting the mind, to light, nutritious diet, and constant exercise. Improved, but grew thin and weak: more generous diet; two glasses of wine daily, with steel, and an occasional aperient to obviate costiveness. At length began to be rational on serious subjects. A plan for mind and body, calculated merely to restrain the propensity to inaction, and vary subject of pursuit: this finally succeeded. Case.Æt. forty; like last during first weeks of indisposition. At length all the symptoms suddenly changed into those of mania furibunda, elation, raving, &c. A varied antiphlogistic plan now adopted; all stimuli abstracted, and sometimes light excluded: recovered in a few weeks. Conversion of religious melancholy into furious madness frequent, and generally followed by recovery: in some cases which have resisted common methods, the idea thus suggested of producing a degree of excitement by various means, such as keeping the patient, for days in succession, in a state of intoxication, has often occasioned alleviation of symptoms, and sometimes restored. Though reasoning 28 seldom effectual, yet, when other means prove unsuccessful, should always be had recourse to, as there are instances where a single argument has convinced. Selecting mollia tempura fondi, we should preface by insisting on being heard uninterruptedly, and then suit the arguments to the patient's ideas. As generally tormented by too great remorse, and henpe fear of the wrath of the Almighty, should speak of the Saviour's atonement, and quote parts of Scripture inducing hope, as respecting the thief on the cross. If the unpardonable sin the delusive idea, should make him describe accurately his idea of this sin, and then confute his arguments by proving its impossibility. Perhaps most successful moral means consist in exciting new mental affections, tending to supplant or correct old morbid associations and feelings. Mental indications various as the forms and causes, but to be regulated by the prominent features of the disease: some require threats, others soothing, &c.; the eccentric of one class is to be humoured, of another the idea is to be combated. Where, in religious insanity, the patient has become deranged from speculations, or believes himself some supernatural. being, he should be deprived of his Bible and other books. In others, the idea may be calmly combated by a few mildly-opposing arguments often repeated; hopes to be elevated. Two classes of melancholics in religion, the self-conceited and the despondent. Against the first necessary to guard, for they are apt to consider those around them heretics. Against the latter, to prevent suicide. Case.-Asserted that he was the Holy Ghost. A gentleman asserted to him, "There is but one, and I am he; how can there be two?" Patient appeared surprised, and said, "But are you so indeed ?" The gentleman then answered, "Did you not know it?" The patient said, "No; and that he himself was not the Holy Ghost, as there could not be two."

In a great variety of them, medicine either improper or impracticable, and here to depend on management, which is often valuable in the cure. Strong coercive measures seldom necessary in early stage; much address to secure tranquillity and obedience, but more effected by firmness and tenderness than harshness. Certainly some cases where bodily restraint is necessary. In mania of a high character, strait waistcoat best means of coercion; being secured, all stimuli to be abstracted. Doubtful about light; if you wish to excite fear, apprehension, and dread by darkness, then use it; but not in some cases, lest these feelings aggravate the complaint. In most cases, a quiet, airy apartment, free from missiles, all that is necessary. Physician to see the coercion executed. Corporeal punishment never necessary or admissible. Liberation to be gradual, as promises seldom to be depended upon. Generally thought that the patient should be talked with as to hallucination; but this is often hurtful and rarely admissible, except to gain some important object, or where a part of the curative system. Agrees with a reviewer of his work, that cases in which the main idea may be humoured are hypochondriasis in an extreme degree; in other words, originating from some obscure corporeal sensation; while, if from a strong and repeated impression on the mind, as in religious insanity, then no allusion ever to be made to it. Still, Cox has met with a few cases of religious melancholy, in which the most obvious advantage resulted from reasoning when other means had failed. Doctor Lorry says that you should endeavour to divert the mind of the patient from any insane action, not by blows or stripes, but by praises of the opposite vir 29 tues, and by turning it away from all things increasing such feelings; and this operation should be concealed from him. In every case, as much liberty and exercise in the open air as is safe, and coercion to be always proportionate to the disease. Management of melancholics to turn on prevention of injury to themselves; otherwise, coercion seldom necessary. Utmost sympathy and feeling to be observed towards them by physician and attendants, who are to employ all their exertions to amuse the mind, and divert the gloomy tendency by interesting, and exciting new and pleasing ideas. Combating his errors to a third person in his presence sometimes succeeds when unsuccessful as addressed directly to himself. Should never mind their insults, &c. A firm, resolute demeanour; stern aspect, and assumption of authority; giving orders, and seeing them executed; uniformly decided measures; a scrutinizing look, fixed on the patient's eye, will, in general, excite dread or confidence, respect or compliance. This is a material point, and never lost but by mismanagement. His promises, if he can reason at all, may sometimes be attended to; and his word of honour is seldom broken, if solemnly given, when more violent and dangerous symptoms have subsided. Deception not to be admitted, unless part of our attempts to relieve, lest confidence be lost, and with it, very frequently, hopes of cure. No point to be abandoned which our judgment approves: an effect once produced generally lasting, and repetition of disagreeable means seldom necessary. Artfully inducing some pursuit or occupation requiring attention, and yet not fatiguing, often a great assistance, as attaching importance to weaving bobbin, knotting thread, knitting, netting, &c. Music of great efficacy sometimes. Case.-A military maniac. Though he had not left his bed for weeks, nor spoken a single word, and was supported entirely by force, yet, from hearing a few tunes on the fife, he returned to his former rational habits, and with the aid of a few gentle tonics he recovered. Music has hushed contending passions, allayed irritation, collected the wandering thoughts, and induced sleep. Where the patient has been a performer, should be allowed his instrument, as it employs; where partiality to music is considerable, may form a part of rewards and punishments. Thinks both concords and discords might be usefully employed. The study of thorough-bass and counter-point well calculated for the amusement and employment of the musically mad. Some practitioners recommend total abstinence from liquid: he does not approve of this, though allowable where there is an obvious determination of the fluids to the brain. Effect on the stomach, arrests the attention from morbid idea. Antiphlo. gistic plan usual as long as symptoms of irritation exist; but if these proceed from stony or debility, to be removed only by generous diet, port wine, &c. Very improper, as is almost universal, to deluge the stomach with cau dles and broth" teas and ptisans. In the majority, diet ,ld ost mi itio in m U, ti , ft Lg_ hou be in t' all q tie' and - e mes improper, and fermented liquors ; best beverage, pure water, with the occasional mixture of distilled spirit. When they refuse food, rich soups, jellies, and the like indispensably necessary, to be introduced by force; but new milk alone, with other nutritious substances, or loaded with animal gluten, has been found to preserve life longest: either by the mouth, or clyster-wise. Always advantage from regularity: rising and retiring, meals and exercise, always at identical hour. Trifling means constantly acting, often very advantageous; and we should ever 30 persevere while the shadow of a hope is left. Where we have reason to suppose a topical, mechanical cause in the brain, and common means have failed, are we not warranted in desperate ones, as the trephine, by allowing expansion, being applied to various parts of cranium? Here complaints of fulness, flying, painful affections about it, occasional squinting, dilated pupil; and it is periodical. Cases frequently where acuteness of sensibility and extreme delicacy so great that common means contra-indicated; here, relief often through the medium of the senses. Music, either discordant or otherwise. Thus, Æolian sounds in an airy room, surrounded with flowers of sweetest breath, walls and furniture of green; or sounds discordant, where screeches and yells are made in a black, or red, or glaring white apartment. Case.Æt. 19 ; rather choleric in temperament; fair skin; dark eyes; accomplished manners; literary acquirements; amiable. Seduced. A painful and protracted parturition, reducing her frame; ideas became confused; constantly raving; vociferous and incoherent; eyes insanely brilliant. A regimen of nutritious soups, vegetable and animal jellies, gradually changed to a full and generous diet. A slight infusion of bark, succeeded by a strong decoction; change of scenery and varied pursuits; sympathy of friends; consolations of religion. Gradually recovered. Case.-Æt. 30 ; sanguineous ; of a delicate, irritable habit; subject to transient headaches, and slight febrile attacks; four children; always suffered much in parturition; milk at first copious, generally disappeared second or third day, and then insanity occurred. Ideas extremely incoherent, as usual in puerperal mania. Vital functions almost exhausted by volubility, exertions, and want of rest. Cured in same way as last case. Case.-Æt. 22 ; sanguineous ; very delicate; seldom robust health; cultivated drawing and botany ; in rambles, often regardless of weather and food; sometimes debilitated and exhausted to faint. ing. At the end of one of the hottest days in July, found on a hillock in North Wales in a state of furious madness, surrounded by fragments of plants and drawings, making most furious gesticulations, and spouting parts of Shakspeare ; then for some time at home in the wildest phrensy, except fever. Bled, purged, and vomited; deluged with saline juleps, broths, and ptisans, but no alleviation. Dr. Cox consulted. Adopted gradually a more nutritious diet; a change speedily observed. With assistance of port wine, gentle exercise, and without any other medicine besides bark, recovered perfectly in a month. Could detail a number of similar cases with different remote causes: where from debility and exhaustion, as incessant action of passion, study, &c., accompanied sometimes with audacity, fury, and impatience of control, evacuating medicines and a debilitating plan frequently fail; and the regulation of the mind, by removing strongly impressive things, and a tonic, invigorating plan, as often succeed. Dr. Gregory mentions a case in which periodical alienation was cured by trepanning. Case.-For years insane; fell backward down stairs; seemed lifeless; restored by opening the jugular and by other means; scull fractured; trepanned; insensible for weeks; looked more intelligent; more rationality ; exercise in open air, improved diet, and interesting amusements now adopted. Gradually recovered.

Medical Treatment.-Where the mind is intensely occupied, the body, by sympathy, becomes equally steeled against impressions. Lest we should accumulate remedies, and do harm, as has occurred in 31 these cases, our curative attempts should be confined to external carporeal agents, blisters, sinapisms, heat, cold, swinging, &c., drastics particularly being suspended until new indications.

Tbough some, from theory, have condemned emetics, he thinks them rarely dangerous. When obvious and unusual plethora, and vomiting indicated, venesection and other evacuating means to precede it. Of all remedies, they have stood the test of ages, having been employed almost constantly from the days of Hippocrates to the present. In almost every species of derangement, proved a most valuable and efficacious remedy. Saburra in the stomach and bowels often seems the whole cause of disease, and removal of it relieves permanently. Never witnessed anything like paralysis from them, and thinks them almost indispensable in almost every case. In many instances a single emetic has removed every symptom. Case.Æt. 46 ; dark eyes and hair, though fair skin; very sedentary profession; gay and cheerful disposition, but subject to dyspepsia and headache. Without obvious cause, neglected his business, though his family's support; became irritable and quarrelsome; sobriety and industry changed to tippling and idleness, though would occasionally exhaust himself with fatigue; being unconscious of indisposition, refused remedies. Being in his neighbourhood, saw him leaping through the doors of my carriage with the utmost velocity. Gave him an antimonial emetic; restored. Have a servant whose disease was wholly removed by an emetic: still subject to aberrations, uniformly corrected by a few grains of emetic tartar. Recollect several cases in which state of intellect seemed regulated by that of stomach; in many of these, an unnatural tendency to the accumulation of viscid, indigested matter in the stomach. In all similar cases, emetics indispensable, and generally relieve. Have under care a relapsed patient: a few days since, mind strangely affected; but from a single emetic, became, and continues clear. In some cases, emetics for several days in succession; but by giving a common dose of opium on going to bed the night previous, a diminished quantity of an emetic will produce very considerable effects. Though sometimes no obvious curative indication, will seldom err by evacuating the stomach and bowels by an emetic. Of highest value in melancholia, as rousing the system. Preparations of antimony to be preferred: antimonium tartarizatum best; vinum antimonii very valuable; may be put in other fluids, particularly cider. In athletic and more robust patients, vitrurn antimonii, finely levigated, and in form of a bolus, most powerful, and often very, efficacious, especially if given on going to bed with a grain of opium, or at an early hour before getting up, and left in the stomach as long as nausea allows, before tepid fluids: cleanses completely. With a similar intention, calomel with ant. tart.; one of first, and two of last, in the more delicate cases. These supersede necessity of frequent repetition by milder means. Majority of emetics inadmissible or inefficacious. Ipecac. too bulky.; asarabacca much esteemed by some, but I have not found it so. Mustard and squills too mild and uncertain. Sometimes cannot be administered internally, then external; strong solutions of tartar emetic in boiling water, when cooled, rubbed on the stomach, or tobacco cataplasms applied. Per anum rarely succeeds, on account of maniac's power over sphincter. Not to be used when the subject of apoplectic make; where inflammation in any of more noble viscera; particularly if hernia. In addition to physical effects, 32 they often lessen number of deranged ideas, and in some change them entirely. In doses only to excite nausea, concentrate mind on stomach from hallucination. Vitriolated zinc been very successfully employed; found to allay irritability, without debilitating; and generally indicated in all cases which have undergone unmerciful evacuation.

Purging necessary, and generally indispensable. Their uniform costive tendency to be obviated by it; and, first, the more gentle aperients, being governed in the selection by the indication. A favourite remedy among the ancients, whose practice was very simple, though successful, consisting, in the most part, of evacuations from the stomach and bowels by the most drastic medicines, more particularly the different species of hellebore. He prefers salines; cremor tartar best. Calomel best, if a more active one required; but where uterine suppression or hæmorrhoids the cause or consequence of insanity, aloetics preferable. As a spontaneous diarrhoea is often useful in the cure, where there is florid health, and more regular natural functions, a system of purging may be instituted; generally mitigates, if not relieves the symptoms of violence and irritation: no more powerful or convenient mode of emptying the vessels; a part of the antiphlogistic system. This system too indiscriminate, and sometimes ends excitement only with life. Purging improper, if debility, or tendency to anasarca, or delicacy of system, with irritability of bowels, and where there is emaciation.

Bathing.-Cold to head, a very rational remedy, and been often employed to advantage to appease irritability and fury, and induce sleep. Modes of application differ, according to the degree of cold required, or the effect intended. In some cases only a partial application of cold required; simple ablution of the head with cold water, or wrapping wet cloths around it, frequently renewed as they get warm, most convenient methods. In others, where intended to be general, common cold or shower baths preferable. French physicians said to employ with much advantage a small stream of cold water falling from a great height on the shaved head: he never tried it, but can conceive its efficacy. Clay cap, in some instances, very convenient and efficacious. Where an intense degree of cold required, may be easily procured by Eether poured on bald or shaved head; and evaporation may be increased by a stream of air from a pair of bellows. General cold immersion one of the most powerful means, and never with hazard, unless system too reduced by previous evacuation, or violent ravings and exertions, or some structural lesion. Best effects have followed severest, even where pulse much reduced in force, and heat below natural standard. Often indicated in opposite conditions; as a sedative to diminish violence of reaction, and as a tonic to remove debility. Effects depend on degree of cold and its duration. Where an obvious state of local plethora, cold bathing, after evacuation, has instantly restored rationality, and paleness of the superficies has succeeded the redness. By its great sedative action on the heart and arteries, particularly indicated where much external heat, particularly about the head, and when patient refuses to take remedies. A favourite remedy with the ancients, who sometimes carried it to a dangerous extent: even in the days of Boerhaave, most vague directions as to its employment, such as keeping the patient immersed until almost drowned, or while attendants 33 could repeat the Miserere. May be resorted to safely in.every desperate case. Dr. Currie's method is very far preferable, and very successful with him; suddenly immersing the patient in the very acme of his paroxysm : to be easily accomplished if secured by a straitwaistcoat, and fixed in a common Windsor chair by strong, broad straps of leather, or a web girth. Common shower bath answers every intention when he will submit to its application; or where, from violence, this is impracticable, same advantages from pouring on the water from a common watering-pot, securing him in a chair fastened to the floor: not to be indiscriminate. Warm and cold bathing often produce very analogous effects; former more general in action, and patient may be exposed to it for hours, not only with impunity, but with obvious advantage. Where rigidity of fibre, any degree of spasmodic stricture, exhaustion and debility, with mental irritability, no remedy promises more than the warm bath: often very successfully employed while a stream of cold water is directed on the head. At 90 F. one of the most valuable remedies : particularly opposed to that unnatural dryness of the surface, those bilious and dyspeptic symptoms which frequently accompany the lower degrees of mental indisposition. Often more willingly submitted to than the cold bath, and equally invigorating and tonic. If a relaxing and debilitating effect intended, a few more degrees of heat, and its longer continuance. In a delicate female whose system is much reduced, when violence and fury threaten death, and internal remedies obstinately refused, it is admirably calculated to appease. Where unusual heat, partial or general, has been known to reduce it more speedily and effectually than the cold bath. Where, with suicidal intent, food obstinately refused, after every method was in vain, the warm bath, either of water, or water gruel, or milk and water, has contributed to support life for a considerable time, being more practicable than clysters. Vapour bath of similar nature to warm; but pediluvium most frequently used, and may be very beneficial in various ways : sometimes impregnated the water with aromatic herbs, as rosemary; to which they attributed good effects of bath, were pleased by it, and willingly submitted to its repeated employment.

Blisters have been often employed, and sometimes with obvious advantage, whether for a discharge or for temporary inflammation. Has proved the truth of Dr. Monro's observation, that they are never useful to the head itself; but to the calves of the legs and feet, in the form of sinapisms, are frequently a powerful and efficacious means. There are cases where they are inadmissible on any part, as where salacity exists.

Camphor, uncertain in dose and indication; as other sedatives, often excites and stimulates. Has seen no permanent good effects from it in any shape. Seen small quantities convert mild melancholia to mania furibunda, and seen it often produce no other effect than the common terebintbinate preparations. Never saw it quell the passions or curb the venereal propensities, as it is reputed to do. As other antispasmodics, more calculated to obviate unpleasant symptoms than effect a cure. In small doses, generally inert; in larger, prejudicial; in enormous ones, tends to increase the disease, and has been known to extinguish life.

Bleeding would seem to be indicated in most cases; but unless obvious plethora, or evident determination and congestion about the head, 34 may rather increase than diminish the disease: when determined on, to be effected either by leeches, cupping, venesection in the foot, arm, or neck, or by arteriotomy' : in performing the last on the temples, artery not to be divided, but a longitudinal incision with a lancet or scalpel, from whence requisite quantity of blood may be taken: invariably to secure the vessel by a ligature; and, indeed, never safe to trust even a wounded vein to a common bandage with maniacs.

Digitalis.-Next to emetics: no case to be deemed incurable until submitted to its action. Few instances in which contra-indicated most frequently succeeds where derangement accompanied, and in a degree regulated by an accelerated circulation, without any other symptom of pyrexia. Begin with a few drops of the tincture, or half a grain of the powder, and gradually increase; thus all danger obviated, though some cases resist its action to a wonderful degree. Had a patient whose system was kept saturated for weeks, and whose mind seemed regulated by the rate of the circulation. With the pulse at 90, constantly furious; at 70, rational; at 50, melancholic; and at 40, half dead: at length, cured by such a dose as kept the pulse pretty uniformly at 70 ; and yet had sometimes taken three drachms of excellent tincture of digitalis three or four days following. Injudiciously given, may lower the pulse to extinction of life. It arrests the action of the heart, and nauseates, without impairing the vigour of the system. A greater or smaller dose of any active medicine is required as the mind deviates more or less from rationality. Thinks digitalis sometimes inefficacious, from faulty preparation.

Opium.-Alone, has tried to an almost incredible extent, without any advantage whatever from it. Often increases heat and irritation, constipates, and increases determination to the head. With digitalis, has been useful in maniacal cases, especially where there is a tendency in the latter to run off by the bowels. With antimony, in small repeated doses, has been productive of good effects, but only by relieving more obvious symptoms. Been beneficial with bark, in hysteric. melancholy insanity, where universal laxity of fibre. With concentrated vegetable acid, has produced a soothing, tranquillizing effect, easily kept up by small repetitions for a length of time; and in some instances with considerable advantage. Dissolved in strong tincture of tobacco, and applied externally to stomach, has allayed the violent nauseating effect of other remedies, particularly digitalis; and applied to the shaved head, has removed pain, and checked wanderings of mind. With a æther and alcohol, similar good effects; as also in a plaster.

Hyoscyamus, aconitum, datura, cicuta, and such like articles, been employed, but seldom with success. First, from testimony of Storck, Home, A. Fothergill, Monro, and others, been used with advantage. Preferable to opium in some cases, as considerably narcotic, and rather relaxing than constipating: as powerful, to be administered cautiously, beginning with small doses, gradually increased until obvious effects, the first of which is generally a stupor or dizziness. Soothes and calms: used when opium disagrees or constipates. Aconite has been extolled by some, but too uncertain and apt to constipate : with antimonials, has occasioned profuse perspirations, and where evacuation by the skin is intended, such a combination may produce this effect. Hemlock, gradually introduced, has certainly been of service in some 35 cases, oy diminishing irritation and excitement, and causing sleep; but some systems resist its influence for a length of time, and others are not affected unless administered in enormous doses. When opium has disagreed, cicuta has often been conjoined, or substituted with advantage. Antispasmodics seem often indicated in maniacal affections, from their analogy to convulsive ones. Will often subdue certain prominent symptoms, as pains in the head, constipation, irregular spirits, &c., frequently accompanying some of the milder forms; but often heat and irritate. Accompanied by epilepsy, cuprum ammoniacum and zinc have been beneficial, mitigating the epileptic paroxysms, and diminishing the affection of the intellect. Some of the preparations of iron have certainly advanced convalescence; and where accompanied by debility and relaxation, have proved eminently useful. Here the continued use of Fowler's solution might contribute to recruit the system and restore reason. Musk, though highly extolled, he never saw relieve by removing the characteristic symptoms, though, combined with some other powerful antispasmodic, it has contributed to diminish the hallucination. In cases where are insensibility to all agents, torpor, and inattention, stimulants of various kinds have been found beneficial, but to be used with great caution and judgment, particularly as applied to the head, such as volatiles, errhines, and sternutatories. Medicines of this class, more usually applied externally, have been directed internally with advantage, as mercury, squills, mustard, horseradish, and cantharides. First doubtful, though useful in some cases, either to act on the bowels or produce ptyalism. Diuretic stimulants have been very advantageously employed in mental affections. Cantharides has occasionally been very beneficial, when the system seemed steeled against all other remedies : dose at first to be small, then gradually increased, watching carefully the effects as they arise, in order to suspend the medicine if unfavourable, it being dangerous. As paralysis of the bladder sometimes, from inattention to the stimulus of urine, and hence over-distention, it should be frequently examined, lest irreparable mischief ensue. Haemorrhoids a frequent accompaniment, and should be particularly attended to, as troublesome sinuses, scirrhus, and even sphacelus have succeeded neglected piles. When combined with paralytic affections, among the stimulants used has been electricity, but never seen any lasting benefit from its use, except in cases from uterine obstruction.

Permanent artificial drains, as caustics, issues, and setons, among valuable remedies; last best, as being managed with great facility, and least liable to be injured or destroyed. Few cases of mania in which they cannot be usefully employed, except where there is considerable debility. Have been eminently useful in various instances where disease arose from painful, unnatural parturition, with retrocession of the milk. If from repelled eruptions, drying up of old ulcers, curing hæmorrhoids, and the like, setons seem more particularly indicated : immaterial where they are inserted, if being placed between the shoulders did not prevent patients from getting at them : always advisable to enclose at least an inch of skin between the two orifices, and the extremities of the riband or cord should be fastened or sewed together. His swing formed by suspending a Windsor chair to a hook in the ceiling, by two ropes to hind legs and two to fore, joined by a sliding knot to regulate the elevation : patient in a strait waistcoat, and a leathern strap 36 around his waist, buckled to the bars behind; legs fastened by straps to the front ones of the chair : then turned around. Dr. Darwin describes one more nearly approaching to completeness : a perpendicular shaft with iron gudgeons, and a horizontal beam, on which may be a bed or a chair: an improvement, says Cox, is a rod of iron fixed to upper end of shaft and horizontal beam, contrived to regulate the elevation of the bed. It renders the system more susceptible to the action of agents previously resisted. It is a valuable anodyne, being succeeded by the most refreshing slumbers. Combined with unusual noises, smells, &c., in the dark, might avail much. Found very beneficial in patients of delicate habit, with previous pulmonic and consumptive predisposition. Has seen a patient, requiring several persons to manago him, rendered by it almost helpless; succeeded by profound sleep, convalescence, and recovery. In some cases in which insanity seemed intimately connected with the state of the circulation, rationality varying with its slowness or quickness, most beneficial effects from it. Often succeeded in bringing from the stomach accumulated sordes and tenacious phlegm, which other emetics, however drastic, have failed in doing. As a "mode of discipline, no species of punishment more harmless or efficacious. Case-Æt. 34 ; of a gloomy, morose, reserved disposition; had always been indulged. Became suspicious, revengeful, and impatient of control ; had been in business occupying his thoughts, with scarcely any bodily exercise. At length deranged from a series of disasters, and confided to my care. Peculiarities of temperament increased : saturnine blackness of countenance ; eyes suffused with bile, immovably fixed on the ground; limbs seemed deprived of locomotion; action of lungs and circulation retarded; tongue parched; like an automaton, except heaving the deepest sighs. All most common means had failed. Placed to the swing two hours after eating a pint of thick water gruel and milk pulse 80 ; 20 inspirations in 60 seconds; no passage for six days; no urination for 24 hours; skin dry, but cool; eyelids half closed; face vacant, and of a murky hue; some resistance, but secured in chair. Struggled violently after a few gentle revolutions ; increasing, begged discontinuance; promising compliance as to medicine, &c., liberated. Nausea, giddiness, exhausted, and nearly fainting: on a bed, pulse 60, inspirations 15 ; expression of features changed, and whole superficies cold. Soon a profound sleep fbr three hours. On awakening, body and mind unchanged, and promises forgotten. Next day, swing as before, and similar effects; but on increasing velocity, vomiting stopped suddenly. Aroused and alarmed, begged and promised; taken out exceedingly helpless, and put to bed; slept six hours. Then reluctantly consented to a mercurial purge, a very small quantity of which acted copiously, though before, in disguise, three times the quantity had no effect. A light, nutritious diet, and gentle exercise. Mental peculiarities returned, but submitted entirely sooner than be swung. Gradually recovered. Case-Æt. 40 ; florid complexion; very muscular: became gradually depressed, then unusually gay and flighty. Previously eccentric, ingenious, and good tempered; remarkable for a retentive memory, and feats in the palestra. Love supposed cause, though not chief train of thought. For six weeks had resisted all attempts at medicine; appetite voracious; always in alternate struggles from coercion and violent vociferation. A strong party to place him in 37 the swing : no change for first five minutes; motion increasing, features altered, countenance became pallid, urine passed; complained of sickness, begged release ; vomiting succeeded; became perfectly relaxed, and was taken out and carried to bed by a single attendant, where he immediately fell asleep, awakening after nine hours calm and refreshed. Out-door exercise, an occasional purge, and a light, nutritious diet; soon convalesced permanently. Case-Æt. 26 ; led an active life ; occasionally violent exercise in field-sports; prone to excessive drinking and other intemperance; attacked by an inflammatory fever, in which he was delirious. Recovered perfectly; ut a small quantity of spirits now affected his reason, and while drunk he exhibited peculiarities unnoticed previously : very grotesque ideas ; sometimes reasoned acutely on the most absurd principles. When sober, he was elevated and depressed by the merest trifles, and in many things bordered on insanity. At length some legerdemain tricks, seen by him, baffled his comprehension: he continually thought on this one thing until he became wholly deranged. Six months so in spite of all remedies. Tried swing: fear, unpleasant sensation, and vertigo; and sometimes the stomach was violently affected, and the secretions of the kidneys and intestines increased, but no other permanent advantage, except rendering him more orderly and quiet. Case.-Eccentric, volatile, and gay. Without obvious cause, became furiously insane. In spite of all means, mind became wild and confused. Swinging tried :little affected; rather amused playing with the cords; if he observed it, however, seemed to have some unpleasant sensation: on these days, more easily affected by exercise, food, and remedies. Under swinging and physic, improved at first, but afterward grew worse. Case-Æt. 25 ; delicate and nervous; sanguineous temperament; characteristics of ulcerated lungs. Without obvious cause, became unusually talkative; had some strange ideas, and finally was wholly deranged. Pulmonary affection disappeared. Stimulating and debilitating remedies tried in vain ; then swing every other day for ten minutes, with gratification to her, but no effect : at length used daily for fifteen minutes, with gradually increased velocity, when nausea, pallor, and exhaustion supervening, it was suspended for a day, and she dreaded its repetition; then every other day; and vomiting and slumbers,,denied her for weeks before, and other consequences, ensued. On intermediate days, a more generous diet, tonic plan, and constant out-door exercise, with amusements. Delusions gradually diminished in number until mind and body perfectly restored. Case-Æt. 22 ; choleric temperament, partaking of both the sanguineous and melancholy, the marks of the latter predominating; naturally retiring and gloomy. Classical education; plodding mind; very moral and religious, but had a few peculiar tenets; Bible his daily study. An unguarded expression of a conceited, rash teacher depressed him nearly to suicide, being only restrained by a sense of its criminality. After reading that part of the New Testament which mentions plucking out an eye or cutting off a hand, the idea of castration rushed into his mind, which he performed with a pair of scissors : protected from any bad effects by treatment of a surgeon, but mind the same, and was perfectly torpid, fearing perdition; inatten, tive to the calls of nature; and would neither eat, move, or drink. Forced, with great resistance, by experienced attendants, to take some food for six weeks. At the end of a two months' struggle, a slightly 38 less vacant expression of countenance, and resistance to food somewhat less. Wrote sentences expressive of miserable fears respecting perdition, &c., and read only Leviticus in the Bible; wrote that he wished to attend to some of the ceremonies there enjoined ; promised to eat if allowed daily plunging in a cold bath, and a spare diet adopted voluntarily-so spare as to be evident that intentions of self-destruction were unabated-forcing or spouting again necessary; but determined to resort to swinging beforehand. After a few revolutions, eyes always kept nearly closed, were observed to open, alarm next, then nausea and retching; then stopped, and asked if he would eat; on refusing, motion renewed to vomiting; begged liberation, and promised compliance. When out, put to bed, and slept for some hours; food offered and refused, as usual; threatening swinging succeeded, and ate for some days. Reluctance returned, and swinging again used two or three times, till at length he yielded entirely; and gradually, from this plan, wholly recovered. Case-Æt. 25 ; plethoric, sanguineous temperament. He became suddenly insane without obvious cause; mania furibunda; abstraction of stimuli. Very obstinate; but by means of the swing, which exerted its full effects, made to do anything necessary. Could mention other cases showing its good effects; in a few instances, action resisted entirely; in no case any unpleasant consequence ; no advantage in some. Case.-Miss -. Case-Æt. 18; sanguineous temperament; subject to catarrh and slight pulmonary affections fi-om the most trifling causes, as handling anything damp; hectic habit; pulse seldom below 80 ; health never robust; subject to irregularities both of the menses and alvine evacuations. Without obvious cause spirits depressed, expression of countenance unnatural, and from being amiable, she became peevish, rude, and morose. Gradually alienation of mind succeeded. At first lucid intervals; at length no intermissions for days and weeks. Sometimes one idea, constantly repeated, and at others the most grotesque imagery. All means ineffectual. Swinging-first in the upright position, between breakfast and dinner: eyes brilliant, slight flush, moist skin, pulse 84, inspirations 18 in 60 seconds; all these increased by resistance. After ten minutes, took some notice of Surrounding objects, for the first time for weeks, though talking absurdly of them; pale and alarmed; placed on the bed; the inspirations were reduced to 16, and the pulse to 65. Slept for some hours; skin dry and cool, but no improvement on awakening. Similar changes, though in some measure as to immediate effects, in a greater degree followed the repetition week after week. At length had to be continued longer and with greater velocity to produce the effects; and almost constantly impressed with dread and nausea, she would resist violently and implore release. Uterine obstruction in some degree removed, but extreme prostration of strength, pains in the back, and livid countenance. More orderly and accommodating, but perpetually talking on the delusive subjects of her imagination. Swing used only once in five days, though compliance often procured by threatening it. A new system of diet and exercise adopted, with the pediluvium and aloetics, calumbo and aromatics: previously to the next period of the catamenia, warm fomentation: of the lower extremities and uterine region daily, which succeeded. Gradually recovered in both mind and body. The swing always promises very considerable relief where the wanderings of the intellect are attended with increased arterial action, unaccompanied by 39 any other symptoms of fever. In some instances little or no effect, though violent, repeated, and long-continued: here should be applied in different positions of the patient, different times of the day, and states of the stomach as to fulness or emptiness : never known it fail when some nausea had been excited by a grain or two of vitriol, of zinc, or emetic tartar, or when a moderate dose of opium had been given on going to bed the night before, swinging before breakfast. Essential relief from it in those maniacs who strive against every shackle and means of coercion ; gesticulate violently, and rend the air with vociferations. Also for those bent on suicide from starvation, being induced to eat by the fear of its repetition. Efficacious morally and medically, where the disease is owing to mechanical causes within the cranium, where symptoms are aggravated by indulging in improper habits and resisting other remedies. Says, in this edition, that the above opinions favourable to the swing, in the first edition, had been confirmed by his own experience and that of others ; had failed in some dreadful cases, but succeeded in others almost hopeless. Case.-Swinging in a perpendicular position produced a most complete revolution of the mind, changed the whole train of ideas, induced the catamenia, long before obstructed, and altered the state of the circulation and the expression of the countenance. Removal of uterine obstructions a frequent effect, especially if used at the expected period, and if assisted by the more common emmenagogues. Finds that the perpendicular position is best calculated for violent cases, and the horizontal for the opposite ; and in both the motion should be communicated in the most gradual way, and be progressively increased to the degree of velocity required.

From smallpox having dissipated very obstinate melancholia in cases resisting other remedies, we should place great hopes in inoculation: in some cases, also, we should have no scruples in communicating itch. When from dried-up old sores, repelled eruptions, &c., tartar emetic ointment to the shaved scalp. Blisters, setons, and issues also proper substitutes here.