Case. -Hypochondriasis : an intelligent young man ; was convinced of successive incurable disease in the lungs, brain, liver, bowels, and kidneys. One day said he was quite black, and about to die : but slept well, appetite and digestion good, and no corporeal disease. After lasting a year, aperients, change of scene, horse exercise, and reasoning being all in vain, I at last successfully combated disease, by representing how ridiculous it was for one who ate, drank, and looked well, &c., to imagine he was about to die ; and that even if apprehensions were well founded, pusillanimity was disgraceful. Case.-Chomel mentions a physician who, after examining the bodies of some persons bitten by a rabid wolf, conceived himself inoculated. Sleep and appetite were lost ; and for three days he wandered through the streets in despair, till his friends persuaded him that he was under the influence of the imagination. In cases of decided mania, Tuke, Burrows, Cox, Haslam, Willis, Foville, Georget, and Pinel are in favour of seclusion. As surrounding an insane person with the sane is hardly practicable, the next best thing is to separate the violent from those otherwise-the raving mad from the convalescent. Considered best not to bring together those labouring under similar delusions. A great change in the moral treatment at present strait waistcoats, padded iron collars, cumbrous leather muff's, belts with manacles, handcuffs, iron wrist and leg locks were resorted to. At Bethlem up to 1815, handcuffing, besides chaining closely to the wall, in force. At Palermo, in the asylum founded by Baron Pisani, in 1824, corporeal punishment or undue restraint is unheard of; the patients manage the affairs of the establishment, cultivate their own gardens, perform in a theatre built by themselves, and have balls once a week. At Siegberg, Jacobi states regulations similarly humane. At Lancaster, the magic lantern, music and dancing, weekly and daily newspapers. In the Belfast establishment under Dr. Stewart, I witnessed with much interest the patients dancing and enjoying themselves, to the sound of their own music ; industrial occupations here instead of harshness. At Hanwell, since 1839, 900 patients, of every gradation of insanity, are entirely exempt from personal coercion ; solitary confinement, and that in extreme cases, is the only resort. Prior to 1839, 41 in constant restraint ; fourteen almost always fastened in chairs, twenty in strait waistcoats. Some strapped to chairs, leg-locked, and in strait waistcoats at the same time. These were all liberated ; thirty-seven are yet in the asylum, in all of whom the faculties and habits are improved. Some considered dangerous at all times might be seen smiling at their work ; others sinking into dementia, have rallied. This system, continued by Dr. Conolly, was commenced by Dr. Ellis, under whom the apartments were rendered warm, light, airy, and comfortable, &c. Mr. Hill has discontinued personal violence at Lincoln, for three years, without a single accident, substituting kindness and unceasing watchfulness day and night ; in the Lancaster asylum, the condition of the patients was, in 402 every case, ameliorated by the removal of instruments of coercion. Dr. Prichard, of Northampton, having received a person in the asylum chained and manacled, removed the instruments. A little after he begged that they might be replaced, as he was going to be furious. Was received with a smile, and told to begin as soon as he pleased ; he was afterwards quite manageable. A lunatic threatening violence, should be made to know that he is not his master; and for this purpose an imposing force should be at hand, if needs be, to pounce upon and restrain him. When such a one has made himself possessor of a knife or other weapon, trying to disarm him by address is best ; the superintendent fixing his eye so as to arrest his attention, may advance steadily forward, while assistants coming up behind, secure the patient. An envelope, as auxiliary to this purpose, is sometimes thrown over the head. Esquirol has more than once seen patients long deprived of srtflicient nourishment, lean and wretched, whom sound regular nourishment, baths and bitters, in a short time restored to a surprising degree of health and reason. At the Salpétrière, the nurse even carried bread around at night ; as a refusal induced anger. Calmeil mentions a girl completely exhausted by repeated leeching and prolonged low diet. Her voice was extinct, her eyes dull and stupid, urine passed involuntarily, and her moral and intellectual faculties reduced to a nullity. A few months' succulent food, with care and attention, restored her to health and reason. A few conceive that they have received a divine command not to eat. Here the stomach-pump, through one of the nostrils, enables us to introduce milk, wine, and soup ; a procedure certainly preferable to the shocking practice of knocking out the front teeth. Patients finding that they can be made to live, sometimes yield ; others have been persuaded by an imaginary voice, as if from on high. Pinel has found the cold shower bath or douche, the patient being seated in a warm bath, to subdue the most obstinate and render them controllable. Used principally, however, by Pinel and Esquirol, as a remedial measure, &c. Foville, with whom it succeeded beyond his expectations, sometimes used it twice or thrice daily ; but, in place of the douche, preferred a cold sponge, or bladder filled with ice, to the head. Patients whose violence nothing else sufficed to calm, and whose obstinate sleeplessness no other means contributed to allay, not only became tranquil, but slept five or six hours after the first day of this treatment He has thus removed, perhaps in three or four weeks, acute and sometimes violent mania, monomania, and dementia ; and thinks it the best resort in recent cases. Busser, of Wohlau, applied pounded ice in a bladder several times a day to the shaven head of a puerperal maniac with success. Rotary chair of Darwin and Cox is now rarely resorted to. Music often proves useful, although I should hardly countenance the recent experiment of taking a crowd of patients to a public theatre. A subject in the Salpetriere plunged in the deepest melancholy, was so excited by lively music, as to dance and waltz till completely exhausted. Placed in bed, perspiration, followed by deep sleep, ensued, and the patient was cured. Of all the different means, however, commend me to constant, moderate, steady employments of the intellectual, and, so far as may be, of the effective powers, with regular daily muscular effort, so as to induce slight fatigue. Ellis has warmly advocated industrial occupation. Mr. Fletcher, consulting surgeon to the Gloucester Asylum, conceives that literary-composition, when available, exercises a most benignant influence. 403 Rush had a patient who, by transcribing notes, got well. At the Dumfries Asylum the occupation of amanuensis, Dr. Brown states, has been followed with considerable advantage. The gentle, conciliatorv language to be employed not inconsistent with the requisite firmness and decision. Burrows justly esteems tact the principal moral measure. Haslam correctly observes that different pursuits engage attention and minister to enjoyment, varying with the culture of the intellect. When no access to such, indifference and stupor are too apt to ensue ; and it cannot be doubted that, as regular habitudes of thought and moral discipline are good for the healthy mind, so the same, with sufficient amusement, under proper management, will benefit the insane. Religious instruction, in the Glasgow Asylum and elsewhere, has carried consolation and comfort to the minds of the patients. Lectures on amusing and interesting subjects even, as chemistry, natural philosophy, astronomy, might in some instances prove useful. They should be treated with consideration and respect ; they do not because insane, if in that class, cease to be and have the feelings of ladies and gentlemen. Manual labour, gardening, and, in fine, every species of physical exertion, without doubt, says Foville, are among the best means of soothing the insane. Agricultural pursuits, I think, cause serenity of mind, and few tillers experience insanity, except from drink, &c. A sufficiently large garden, with lathes, forges, carpenter's benches, and so forth, in doors, should be attached to every asylum. Ladies and gentlemen, under pretence of horticulture or floriculture, might be induced to dig a little, so that with cricket, bowls, ball-playing, gymnastics, perhaps riding and rowing, pursuits might be adapted to every grade of life and form of disease. Quotes Georget's three rules of moral management. The medical treatment, irrespective of collateral disease, is matter of chance medley ; we may sometimes succeed, but much oftener fail. The perturbation from a particular remedy may sometimes remove the complaint, but we cannot calculate on the recurrence. Acute and chronic concomitant affections to be treated as in other cases, only seeing that the patient does not undo bandages, &c. Bleeding, says Cox, may be esteemed an important remedy, but the lips of the orifice must be secured by adhesive plaster. Rush and Haslam are tardy in favour of bloodletting; Esquirol, however, not to speak of Haslam and Foville, while he admits, with Pinel, its occasional ill effects, would confine it to plethoric cases, and those which involve suppression of some accustomed discharge. Excitement of insanity, flushed countenance, &c., cannot be relied on as an exclusive indication. Like other perturbating remedies, however, venesection has occasionally been found to answer. Joseph Frank obtained a cure in a case of mania, by drawing four pounds of blood. Venesection in delirium tremens, or mania from drink, would of course prove destructive. Cox relates two instances in which emetics removed the disease. Burrows found nauseating remedies useful in furious mania; in melancholic cases, emetics. Tuke derived advantage from the latter ; but Haslam knew them to induce paralysis. Prichard avers that nauseating doses of antimony and ipecacuanha are always safe. Purgatives in great vogue with some, used in hoary antiquity. Hippocrates speaks of hellebore ay employed by the oldest practitioners. Themison administered two drachms, his successors four. Esquirol, apart from their efficacy in relieving gastric or internal derangements, avers the utility of purgatives in puerperal mania, and Foville suggests aperients, such as 404 croton oil, which prove active in a small compass. Digitalis found advantageous by many: some wonderfully resist its influence, but always best to begin with a small dose. Case.-A young man, recent mania with hallucination; found him about two in the morning in a heated apartment, with candles burning, and anxious relatives pacing about. I ordered out the lights and fire, regulated the crowd, and speaking a few soothing words to the restless and greatly excited youth, induced him, the first time for several nights, to lie down. Administered an aperient, and next day, every two hours a spoonful of saline draught, containing a notable proportion of tartrate of antimony and tincture of digitalis, keeping him, with the best effects, for some time under its influence ; was subdued in a few weeks. These means, with change of air and scene, mildness, and sedulous attention, I found similarly useful in two cases of acute mania in the opposite sex. Sander, a German practitioner, adverts to a young man who was freed from mania of two months' standing, in a few days, by large doses of the infusion of digitalis ; the brain and bowels were greatly disordered. Opium is not generally approved of; but I can conceive cases of maniacal delirium with sleeplessness and exhaustion, in which it might prove expedient. Mercury pushed to salivation, has been occasionally known to produce recoveries. Percival found turpentine useful ; and camphor, in forty-grain doses, has been alleged successful. Burrows, who tried it with henbane, does not speak encouragingly. Finally, it is stated by Willis, that tonics formed the basis of his uncle's and grandfather's treatment. In a case of mania, the subject being stout, the disease was aggravated by a stimulating diet; but venesection and cold lotions to the head having suppressed the excitement, abundant nourishment and tonics effected a cure. Foville has found the tartar emetic ointment useful, applied behind the ears, or on the hairy scalp, in cases tending to chronicity. In several cases in Esquirol's practice, Foville saw reason return by degrees, from the date of the suppuration-produced by the actual cautery. In the following, however, we would refer the improvement to moral causes. Case.-A young girl who paid no attention to anything ;the preparations, however, greatly frightened her : and when she felt the hot iron, was so terrified as to escape from the hands of those that held her. For five minutes enjoyed all her reason, and entreated that she might be spared. Esquirol consented, provided she conducted herself properly, and was willing to work. She promised, and kept her word (Hill says maniacs rarely fail in this respect), was forthwith transferred to the convalescent ward, and became shortly after well. Two women who had been in a state of stupor for a year, and on whom this operation was performed by Esquirol, assured Georget, they had felt as if a torrent of fire were running through their frames, and from that time reason returned.