HALLARAN.

PRACTICAL OBSERVATIONS ON THE CAUSES AND CURE OF INSANITY.
By William Saunders Hallaran, M.D.,
Physician to the Lunatic Asylum of Cork, &c.
1818. Second Edition.
97

Case.-A lieutenant in the East India service ; from hot climate and remorse, experienced maniacal symptoms. Placed under Dr. Hallaran. Attacks periodical, having tranquil intervals : both of these short. These attacks, the most regular he ever met with in males, continued for six years, about which time they were observed to grow longer, and there eventuated a recovery: from this instance, should never give up as hopeless any case, so long as the vigour of youth, or a disposition to a diverse form of the disease, continues.

Measures of treatment bear an intimate relation to the original exciting causes, and their peculiar effects ; thus, mania furibunda requires a different treatment from melancholia; in the former we could not commence favourably with moral means, nor in the latter with great depletion. Notwithstanding, similar remedies will frequently avail in the different forms, the period of using them only being different. And the ultimate treatment differs not widely ; thus the maniac is liable to be soothed and benefited by moral means ; and the melancholic often becomes violent and unmanageable, requiring evacuants, yet on the whole, the original exciting cause is generally found to appear, and to require a peculiar treatment throughout the disease. We must seek to anticipate the frequent contrivances of the ingenious maniac, and to counteract his constant imaginary supremacy. We only excite contempt by aiming at too much address. I have invariably conversed with each patient separately, on days of inspection, upon the subject most welcome to his humour ; mental exertion thus evinced among convalescents is very 98 advantageous. Think attempting to argue a patient out of his delusion hurtful and utterly useless. Agree with Dr. Cox, that it is better to talk at, than to talk to, delusions : have known friends impatiently pursuing the opposite course, thus bring back a host of absurdities. On the whole, the less notice be taken of even the most obstinate fantasies, the less disposed will they be to retain them. I never try to divert them from their favourite opinions, until they begin to show their surprise at their own credulity : I coincide with greatest extravagances, unless delirium of fever enjoins strictest silence, or disposition to injure prevents.

Venesection.-From theoretical principles, has refrained as much as possible from venesection. Another objection is the fact, that in public hospitals, are rarely received in that stage of the complaint when bleeding is thought admissible ; indeed, the disease has usually passed into the chronic form : venesection, therefore, little resorted to, and has not seen much of its effects. On the, other hand, in private practice, where, in some instances, had maniacal patients in the acute stage, induced to open temporal artery ; in those of essential service. In recent cases, this diminishes the excessive impetus of the heart, and thereby effects such a share of quiescence as gives immediate relief, as well as an opportunity of applying more speedily such other remedies as are best suited to subdue the violence of the paroxysm. Bloodletting, however, in mania, is not often called for, and unless under the most urgent circumstances, is not even admissible. In young persons, where pulse stands at from 96 to 100, with a white tongue, hot skin, and a suffused, protuberant eye, it will be undoubtedly found expedient, if not essential to the safety of the patient. But the great tendency, in all cases of insanity, to change from acute to chronic form, the marked inequality in the circulation, and the subsequent torpor, even of the arterial system, contribute to establish the propriety of looking carefully for the unequivocal appearances which denote the necessity of general bleeding. Scarcely ever find, on dissection, traces of inflammatory action, proving that bloodletting might have been a desideratum. On the whole, must necessarily look upon large evacuations by bloodletting, as, at best, but nugatory, in the ordinary cases of insanity; as inadmissible unless under strong emergencies at the commencement ; and as altogether mischievous, when anything like a protracted illness seems disposed to follow, from other circumstances of the case.

Local Bleeding.-In a great variety of instances, we have to observe, even in young robust. habits, where the inflammatory diathesis may be supposed principally to prevail, a peculiar turgescency of countenance, with a sense of heat throughout the scalp, tinnitus aurium, and not unfrequently the idea that loud voices are heard from afar, or as if the rolling of carriages was incessantly at hand. The lower extremities are disposed to grow cold ; insteps and toes, as well as hands, of a livid appearance. I have known apoplexy from this condition : and, in order to save life at the instant, have unwillingly been obliged to use the lancet. Advantage, however, never of long duration ; and too frequently a ascertained, that large bleedings had been originally practised ; though sanctioned by habit then, venesection, whenever possible, should be altogether dispensed with. There is here merely congestion. Where time will admit, relief from leeches to temples, of the first consequence ; and their repeated application, so long as superficial heat continues, to be fully relied on. By occasionally applying leeches to the back of the ears, on 99 a limited space, enough blood may be at once obtained, without making any sensible impression on the general circulation. I prefer this to scarifications, as appearing much less harsh; the latter has been very frequently insufficient.

Emetics.-By reason of action on system, their application to the maniac deserves particular attention. If the practitioner could meet the incipient form of insanity, at all times, its progress might be interrupted, or at least it might be deprived of its extreme severity, by the timely interposition of an emetic, But if in its maturity, caution requisite as to the general opinion of the indiscriminate utility of emetics in all its stages. Readily agrees to the propriety of relieving the primae vine from indigestible impurities, or of altering their action by the effort of vomiting; though cannot too forcibly resist administering them, in such doses as suddenly to excite the violent action of the stomach, when the vessels of the head may be surcharged with blood, and when the danger of overdistension is to be apprehended. Has witnessed very disagreeable consequences from want of precaution on this head, which have deterred him from directing full emetics, in any cases of this description. To obviate such danger, has invariably directed previously a strong purge, or combined with it the emetic. Also, equally cautious to direct such combinations in divided portions, at regular intervals, in order to maintain a state of nausea, until such a portion of the purgative be taken as might eventually secure a copious discharge from the intestines. With such precautions, will not be any ground for alarm, from free operation of emetic ; as most commonly, the action of the bowels quickly succeeds, so as to satisfy all anxiety as to partial determination. The tardiness with which emetics act on some lunatics, contrary to Dr. Haslam's opinion, only to be overcome by an extra portion equal to that requisite for three ordinary persons. In several instances, portions of four times the usual quantity have been given before the effect was produced, and without any remarkable inconvenience. A friend, Dr. Bennett, and himself had to give a lady, a recent case, of delicate form, 16 grains of tartarized antimony, before nausea or vomiting ; this proved neither excessive nor troublesome in its action. A purgative with the emetic seems to be beneficial, by directing a portion of the mucus (here present) downwards, and thereby expelling it ; thus exposing the surface of the stomach to the emetic, by which an immediate discharge of feculent sordes is accomplished. Tartarized antimony best emetic, as tasteless, most soluble in water, and most certain. Usually directs 4 grains, with four ounces of the sulphate of magnesia, in a pint of hot water. Two ounces every hour until vomiting or purging. Great utility in acute stage, cannot be too highly estimated. Where bloodletting cannot, from turbulency, be attempted, or through other prudential motives be thought admissible, free use of tartarized antimony, in two-grain doses, at moderate intervals, seldom fails to reduce the most stubborn maniac to a state of relative quiescence, at most after the third portion of the medicine. In this state, sleep, which had been for some days interrupted, very frequently follows : and with it, those happy consequences succeeding a relaxation from inexpressible misery. By persisting in this mode of treatment, has frequently, without any other remedy, completely reduced the maniacal hallucinations, within ten or fourteen days from the commencement ; so as to be enabled to follow up the plan of cure in the most satisfactory manner. Emetics continued until discharges natural. 100

Purgatives.-Purgation almost constantly of primary importance during the progress of an insane paroxysm. At the conclusion of fever, and even at the more advanced period of convalescence from mania, purging invariably indispensable ; not only to subdue the frequent dispositions to a recurrence of symptoms, but also to confirm the prospect of recovery by a moderate continuance of aperient medicines, long after the disorder has ceased to make its appearance. Whenever cause denotes organic lesion, or this state can be sufficiently ascertained, the purgative plan is to be rigidly adhered to in preference to any other. Where the patient can be induced to take medicines freely, prefer the submuriate of mercury, united with antimonial powder and jalap in the form of bolus, in such proportion as will secure its direct passage through the bowels. Relief from this plan continues 24 hours at the least ; after which feverish symptoms more marked, delirium changes from sadness to gayety, obstinate constipation, acute pains in the head and sleeplessness succeed, and the patient scarcely knows a respite from the most wearisome exertions. Under this reaction, slow introduction of emetic solution, singly, or combined with the neutral salt, diminishes pain and gives sleep. Where the patient obstinately refuses all medicine, but will occasionally take drinks, tartarized antimony is very capable of being imposed on him without exciting suspicion, thus largely diluted. Having had its effect on the stomach and bowels, or either, it need not, for obvious reasons, be persisted in ; unless where frequent exacerbations should make it advisable; yet, where previous symptoms remain partially in force, and where necessity for continued purging still urgent, combined solution, with a diminished portion of the emetic tartar, given at longer intervals, will, by preserving its influence in a more gentle manner, materially contribute to promote a farther amendment. Indication for perseverance in purgative plan, must be determined by nature of discharges. So long as dark, broken-down matter, with scybala, but slightly marked by yellow bile, no hesitation in continuing evacuants. If faeces moderately consistent, and coloured with recently secreted bile, of the florid aspect; if a remission of more urgent symptoms ; if region of liver be to touch free from pain and tension,-and if appearance of debility be at hand, it will be full time to desist, and to look to the support of the patient by suitable nourishment. Patients refusing medicine will often be deceived into compliance with the directions of physician ; his assumed authority will rarely be insufficient for purpose, and if careful not to overact part, will in most cases succeed. A determined conduct once or twice repeated, so as to subdue opposition by dexterity, rather than by force, will tend to overawe, and to establish a tacit acquiescence, where an obstinate resistance would otherwise prevail.

Circulating Swing.-Fortunately for practitioners, Dr. Cox's swing is a safe and very effectual remedy for description of maniacs last adverted to. From want of subduing means in such cases, he soon followed idea of Cox, and thinks advantages of first consideration, and to extent alleged by him. In the above inflexible maniacs, generally after swinging has found them willing to take medicine, and has given a calomel purge at bedtime ; and when necessary, the purgative solution before adverted on the following morning. Has also been in habit of using swing with evident success, for those recently attacked, and who, previous to its application, were sufficiently evacuated by purgative medicines ; also with others, who, after repeated attacks at short intervals, were subjected to its 101 influence immediately on the accession of a paroxysm. Not to be inferred that it is always to be employed, even where violence of symptoms seemed to justify it. Has never used it, where introduction of other remedies sufficiently in power; or, unless they had failed of the desired effect. Sometimes useful, on failure of other means, in procuring sleep here an unusual length of time under slow action of swing, without vomiting ; repetition according to circumstances, but dread of it will invite a disposition to sleep. Advantages, in intermittent insanity, cannot be too highly estimated. Has known symptoms of an approaching paroxysm, nearly subside on first effort. Strongly objects to it where inordinate determination of blood to head, especially in young plethoric habits, in whom every sudden emotion should be carefully avoided. Seems inapplicable at commencement of insanity, or until violence of paroxysm has abated, or been previous evacuations. Horizontal position to be preferred as long as desired effect can be obtained. When this cannot be accomplished, great care, especially with the tall, in erect position, to prevent ecchymosis from hanging over of head. For evacuation, erect posture preferable. Careful superintendence proper. Has in some instances, as a remedy, entirely failed ; cannot recommend more than two or three well-directed efforts. By indiscretion may produce most painful apprehensions in patient, and remove at a greater distance benefits already in possession. Swing, in Cork Asylum, appears to be an improvement on Cox's. Worked by a windlass, and capable of being revolved a hundred times in a minute ; but can with ease be regulated to degree best suited to intent. Now adapted for one person only, instead of four, as had been at first contrived ; to body of machine affixed apparatus for horizontal position, (a sort of hammock merely). In several cases of continued insanity, excellent effects after a few trials. In some who, from disposition to violence, and necessity, were closely confined to solitary apartments, rendered them easy of access, of kind and gentle manners ; and doing most willing service in daily occupation of cleansing, and attendance on sick. Previously, invariably affected from swing, with a smart fever of eight or ten days' duration, the apparent cause of this change. Cannot mention a case of chronic insanity cured, but from established utility, thinks every insane institution should be provided with one. In a few cases of private practice, where not at hand, as well as in public, in which it could not be repeated, has contrived to confine his patients in close hammocks, slung by two parallel ropes from ceiling, and supported at angles by cords, with eyes hooked to the upright ropes. A gentle oscillatory motion thus readily obtained, applicable particularly after effects of swing, where continuance of sleep of importance. If nausea or vomiting desirable in first instance, oscillatory motion should be held in reserve; and by twisting parallel ropes to full extent, so as to let them return, by retexation, to former position, action of stomach powerfully excited : this followed by refreshing sleep. Attendant, on continuing rocking motion of hammock, in a darkened room, has continued to prolong it, for eight or ten hours, without intermission. This method of subduing furious maniacs has succeeded in an admirable manner. Deprives them of all power to resist, and prevents the possibility of injury to themselves, by beating against a wall or bedpost. Thus, too, completely enveloped, and kept sufficiently warm, and by silence of attendant, violence may be again thus restrained. A string to side of hammock, and passed through aperture in door of apartment, avoids 102 necessity of attendant being constantly in room. Has known swing of especial advantage, where hæmoptysis had taken place of mania, and where it succeeded in stopping the mania.

Digitalis.-After frequent trials, at a loss to account for its total failure formerly, patients becoming sickened by merely five drops of tincture ; accident taught him reason and true mode of administration. Case.-Being called upon some years back to renew attendance on a gentleman with whom had made previously several fruitless attempts to introduce the digitalis, in various forms, now, after an interval of fifteen months, found circumstances of case very different, and opposed to principles of treatment which former symptoms required. Tendency to dementia, violerice, and sleeplessness. Directed generous diet and repeated use of opium in small quantities. Ordered ten drops of tincture every two hours until sleep. Next day had enjoyed eight hours sleep, and was much relieved. Pulse from 120 to 96, with some intermission ; none of heat or confusion from laudanum, and in every respect evidently improved. Suspected some mistake, and found he had taken tincture of digitalis instead of laudanum. Thinks failure formerly, and success now, proves that the digitalis is not eligible, in any case, unless system previously reduced by proper evacuants, and sedative effect cannot be usefully exerted under pressure of high arterial action. Digitalis then kept up by repeating it every six hours only. On following day, had spent the night with great tranquillity, had slept several hours ; somewhat conscious of late eccentricities, and raved much less ; pulse still a good deal affected : continued six days in same manner, and at length, finding circulation firm, and general appearance much improved, directed an additional drop to each dose. Progressively able to go as far as sixty drops, three times a day. Pushing farther, disposition to late violence succeeded ; medicine, therefore, omitted for two days. During interval, smartly purged, by the bolus of calomel, jalap, and antimonial powder, assisted by the purgative solution, as previously mentioned. Again returned to digitalis, at twenty drops three times a day ; gradually increased as before. Persisted in up to one hundred drops at a dose, not only with impunity, but evident advantage. This plan, with certain modifications, uniformly adhered to for several weeks after; and though occasional disposition to relapse, it was finally overcome, and lie has remained in perfect health for last seven years, in active exercise of an important branch of business. Dr. Longfield, Dr. John Milner Barry, Dr. Baldwin, and Dr. Daly of Cork, agree with him in opinion as to merits of digitalis. As soon as injurious effects of either digitalis or opium apparent, they cannot with safety be persisted in Where proper maniacal cases occur, as confident of their recovery from digitalis, as cure of lees by mercury. As in above case, showed its capability of restraining within due bounds action of heart and arteries, so has it, in a remarkable manner, evinced its anodyne and soporific qualities. Since result of that case, has continued to direct it with the same confidence of procuring sound and refreshing sleep, as would prescribe opium on other ordinary occasions. Special advantages over opium cannot be too highly valued; and it may be very readily admitted, that it possesses them free from disadvantages of opium. Insane persons have repeatedly assured him, on approaching recovery, that they, within a very few minutes, have had a consciousness of relief, both as to mental and corporeal sensations, from the digitalis. In worst state, when no other drink would be received, 103 have eagerly accepted that in which odour of digitalis perceptible. One, in particular, who for a time had been intent on self-destruction, declared, that propensity was never present so long as its efficacy had remained. Sedative power on circulation to be carefully attended to, lest it be carried too far, and endanger existence of patient, by producing paralysis or extreme debility. On first appearance of pallor, accompanied with inability to retain food, vertigo, dilated pupils, slow intermitting pulse, with cold extremities,-should be instantly laid aside, and volatile alkali, and other cordials, liberally substituted. Those symptoms, however, though requiring every attention at the instant, are, by proper care, of short duration. By withholding medicine, for a few days only, and by employing interval in moderate purging, a further opportunity of returning to it without difficulty or danger will be effectually restored. Very few can bear 40 drops at a dose, on recommencing, without nausea, and some vertigo : this should be at all times signal for pausing, and recurring to purgative plan ; after which may again be had recourse to, by reverting to 10 or 20 drops : then, on adding one drop daily, or to each successive dose, number can with propriety he extended to 50, as circumstances may direct. Remains regularly at 50 drops thrice a day, for eight or ten days. Then proceeds with facility in increase to 100, with safety and advantage. Do not often experience the good qualities of this medicine, in small doses: chiefly where carried to a large amount, that it manifests the most decided and permanent proofs of a superiority. Negative quality-, in some rare instances, has appeared very remarkable in these discontinued for fear of consequences. Case.-A young lady; six months under care ; took digitalis without effect to an extraordinary extent ; suspended it; mercurialized her. Then took 10, 20, and 30 drops, when a listlessness and languor, with unusual disposition to sleep ; suspended, and aperients substituted; then resumed, and at end of fortnight up to 40 ; quiescence and complete recovery in six weeks. Wholly well for last six years. Tendency to constipate calls for purgatives ; inconveniences met with mostly at commencement, as pallor, nausea, vomiting, &c., also immediately give way, as soon as bowels operated on. No diuretic effect in mania, though in largest quantities. Yet it is effectually ascertained to assist in reducing the maniacal furor,-in subduing arterial action,-in promoting the most refreshing sleep,-and ultimately, in restoring sensorial functions, without uneasy sensations. By almost insensible action only, can expect to meet best effects ; and injurious administration may be generally rated according to sudden and decided evidence of power, over vital organs. Cannot with advantage or safety be ventured on, where the inflammatory diathesis presents itself. In all cases of relaxed fibre, exerts its excellent qualities with peculiar efficacy ; it is therefore that in mania, unless by preparatory measures of depletion, it is ever inapplicable, if not decidedly mischievous. Saturated tincture preferable preparation. From greater odour, ascribes more of soporific quality to the green tincture, than to that from digitalis pulverized, after drying. Former well adapted at commencement, from greater mildness; latter, more to be relied on, in necessity of immediate rigorous measures. Advantages seldom to be obtained unless by determined patience and vigilant observation. Case.-Æt. 21 ; had been exposed to much bodily fatigue, loss of rest, and great anxiety of mind, during illness and subsequent death of a near friend. Generally cheerful, spoke a great deal, and very clamorous, particularly at night. Pulse sharp and quick, and much throbbing 104 of carotid arteries. Leeches to temples; subsequently bled from arm twice ; second bleeding being so copious as to induce considerable debility,-bowels moved repeatedly by calomel, followed by a solution of epsom salts and tartarized antimony. Had taken camphor, hyoscyamus, compound tincture of castor, in order named, without producing refreshing sleep, or any amendment of symptoms. After a week, digitalis in dose of gtt. xv. every third hour,-slept sound first night, and much calmer and collected succeeding day. Continued in doses gradually increased, for four or five days, and in a short time recovered her intellects and bodily strength.

Opium.-Inferiority of other means led to use in asylums formerly but of late years, seldom employed in Cork Asylum ; nor need its advantages be sought, when digitalis and swing supersede it. Notwithstanding, in certain cases found to subdue first approaches of paroxysm, and even cut it short, where it had already assumed a positive character. Still a question, therefore, whether, in generality of instances, a full and timely dose of opium will not make way for gradual return of rational perceptions. Has known this to take place in the most decided manner, where sleep had been absent for 48 hours in succession ; and where disease would have been confirmed but for intervention of an opiate, to extent of 240 drops of tincture, at three short intervals. Sleep, approaching to apoplexy, finally succeeded, in consequence, for nearly 24 hours ; evidently the means of effecting an entire and lasting return of mental faculty case alluded to one from ebriety, where loss of sleep extreme. In perfectly quiescent state, where all febrile heat and turgescency of countenance been subdued, will be found, separately or combined, of infinite utility; particularly where mind remains defective, through debility, and is prone to dwell on real or imaginary misfortunes ; or where corporeal functions, exhausted by weight of mental power, become inert and feeble. Under such circumstances, cardiac principle of opium, in small quantities, at regular intervals for a few days only, will not fail to promote convalescence by progressive means. Opium also leads way to more permanent use of digitalis; for where former productive of any benefit, latter to be fully relied on subsequently. Same applies to wine, as well as to animal food.

Camphor.-Has had a character which still gives it place in the estimation of many of the most respectable practitioners. Does not deny efficacy in first stage of mania, as an anodyne ; also admits it possesses a soporific quality : yet obliged to declare, that neither of these effects ever so manifest, as to induce repetition for more than six or eight days, with additional confidence. Has used it to a great extent, on many occasions of acute madness. On some has apparently assisted in the gradual reduction of the febrile symptoms : but has more frequently failed. Has not met any case indebted to it principally, where recovery had taken place; nor has it proved so effectual, as when combined with opium, with antimonial powder, or the nitrate of potash, though in proportions exceeding their usual quantities when given separately. Might point out some few cases, where pertinaciously adhered to, and eventually succeeded by the deplorable state of idiotism: no medicine of the class so suddenly loses its influence on maniacs. As a palliative, may be entitled to some credit, but treating by a continued course of camphor and opium, an egregious loss of time, and particularly liable to ultimate disappointment.

Restraint.-Persons in acute madness suffer much from coldness of 105 lower extremities: gangrenous sores have arisen, and death has ultimately succeeded. Has known danger of life particularly, from supposed expediency of confinement without interruption on ground floors in the depth of winter. Those here alluded to remained in first instance closely confined, and were kept an unreasonable time under influence of camphor, to subdue violence. In order to meet first approach of lividity from cold extremities, and consequent gangrene, patient should at once be encouraged to take such daily exercise, within doors, as strength will allow, and to persevere, if possible, until warmth shall succeed. Of importance to bear in mind, that maniacs, on complete reduction of acute symptoms, do not admit of a greater degree of coercion than is requisite merely to act as a check on their present propensities. When this is prolonged, a vicious disposition is acquired. Then additional restraint; and mischiefs from muscular contractions and muscular inactivity. Term of confinement determined by prevalence of fever, and not by force of hallucinavions. To obviate inexpediency of freeing maniacal patients from close confinement, and to provide against possibility of unrestrained violence, during this indulgence, a broad strap of leather has been provided, which embraces the body directly under the axillæ,-at the sides of which are fixed other narrower straps, fitted to hold each arm, so as to be buckled behind, and by which means they are effectually secured. Main strap closed behind with loopholes and rings, through which a small iron pin passes, stayed at top, and fitted at bottom for a padlock. To prevent body strap from slipping down, a loose circular band of leather extends from front edge over head, and lodges broadly on shoulders, which is also secured behind by a loophole and small strap, attached to one of the rings, through which the pin is directed. By this method, the whole is preserved from being shifted; and it most completely prevents the use of either hand, for any injurious purpose. Object of exercise is; however, sufficiently attained, for which open galleries of institution very well adapted ; till at length patients permitted, under the same restrictions, to pass into the open air.* A determined perseverance in this plan, sometimes under very remarkable circumstances, has had its full reward. Gangrene of lower extremities no longer known in asylum. No patient allowed to remain confined to bed during absence of fever; or to his apartment, unless on principle of occasional punishment. Hence a confidence and tacit acquiescence in the measures of regular discipline; prospect of recovery upheld; and dread of perpetual confinement entirely effaced: order of dismissal therefore made public, and hope of obtaining a similar one, by all in turn, never lost sight of. Of two hundred and fifty patients in asylum, not more than twelve under restriction; others either at large in their particular galleries and dayrooms, in the courtyards, or in the garden, employed in horticulture, and exercising, for recreation and amusement, in a more open atmosphere. Pleasing result, that uproar from uninterrupted confinement nearly done away, &c.

Blisters.-Use been indiscriminate. Inadmissible, as only irritating, whilst fever lasts. In more advanced stages, where a want of energy, and an incapacity to participate in usual objects of volition, succeed to previous activity, occasional repetition round lower part of neck often beneficial, by stimulating property. Has learned from convalescents, that applied too early, they renewed previous acute sensations of head.


* Plate also represents irons on ankles connected by a small chain G.


106 Precaution of applying them some distance from head, seems justifiable; efficacy may, in certain cases, be more complete by placing them on calves of legs, or feet. Apt, unless watched, to rub them off, and have even chewed them, producing desperate inflammation of mouth and fauces : their ingenuity in eluding vigilance have deterred him from use of blisters. But, in truth, seldom requires their aid before the advanced state of convalescence, and until they may be employed, not only without constraint, but also with the concurrent approbation of the patients.

Mercury.-Cases rare admitting its employment ; those admitting it, strongly connected with retrocedent gout ; and so clearly dependant on inactivity and over-distension of entire mass of liver, that there could be no hesitation in giving the credit of the relief obtained to the deobstruent power of mercurial frictions. From observation, entertains a high opinion of mercury as a preparative to digitalis. Calomel seems most eligible preparation-as relieving bowels from retention, and altering previous action of system, and thereby modifying it for the more effectual admission of other remedies. Cases like those already referred to, may still require the more direct introduction of mercury by friction or otherwise ; but where calomel has been previously used and frequently resorted to, as a purge, such necessity will not long continue ; nor can a compliance with it in any other form of the medicine be admissible, under pressure of strong pyrexia, or active maniacal emotion.

Warm and Cold Bath.-In first stage of mania, warm bath, at any temperature, altogether unsafe : there being from it increased fulness and velocity of pulse, instantly on immersion ; and then additional turgescency of countenance, with thirst and an acute sense of pain throughout the head, but particularly at the occiput ; in no way refreshed, but lassitude and debility; rigours ensue, followed by arid heat on surface,restlessness and wild delirium. During second or improved stage, equally inadmissible ; and where stimuli in general forbidden, rule will hold good. In third or convalescent stage of mania, advantages cannot be too highly estimated-stimulating bilious and other secretions, and soothing. Also useful in diminishing peculiar foetor. Bath at 96 highest for beginning : continuance regulated by immediate state and strength of patient. To obviate faintness, napkins wrung out of cold vinegar and water, and applied entirely round the head in the form of a turban, and frequently renewed whilst in the bath, will sufficiently answer-preventing heat and turgescency. By regular repetitions, at length becomes a source of recreation and enjoyment : capability of remaining in it prolonged to an hour and upwards ; a confidence acquired from a consciousness of its good effects, and with those, the other measurtis of more permanent relief, are without difficulty put in force. Does not urge necessity of going to bed immediately after bath of 96. On the contrary, recommends moderate exercise in a dry, open atmosphere.

Shower Bath.-Cold to surface under immediate febrile action, very generally admitted, and in no disease more deservedly than in maniacal fever. Cold affusion recommended by Dr. Currie, in this instance applicable in its fullest sense, but maniacal paroxysm, as far as Dr. H.'s experience, has never been found to yield to it. Shower bath inadmissible, if reaction imperfect. Should ascertain, at the instant, the force and frequency of the circulation, as well as -degree of superficial heat. A maniac, whose "heat stands steadily above temperature of health," 107 and is as high as 100, with a pulse from 96 to 110, may with perfect security be placed under a cold shower bath, and with the expectation of receiving very important benefit. In certain urgent cases, may with propriety be repeated three times a day ; in the morning, especially after a restless night ; at noon, on the approach of the evening exacerbation ; and at night, when at its height. Though no permanent effect, seldom fails to limit, in a great degree, the exhaustion which would arise from uninterrupted violence. Patients, after leaving the bath, and being carefully rubbed and dried, should be placed in bed and encouraged to take rest ; sound sleep generally the consequence, attended with a mild diaphoresis. Such frequent repetitions must be directed according to the urgent circumstances of the case ; morning recurrence has ever proved eminently salutary, and the evening also, where a turbulent night might otherwise be expected. Cold affuston, during prevalence of diaphoresis, or in the absence of fever heat, under existence of pallor or appearance of emaciation, should not be attempted. lit melancholia, where a suspension of every active principle of life forbids all evacuant measures, save as to bowels merely, exhilarating quality of warm bath, from commencement, evidently advantageous. As use of warm bath in melancholia is occasionally interrupted by symptoms tending to acute mania, the cold bath, on cessation of fever, is frequently interdicted by a disposition to inveterate melancholia ; each requiring in succession all the measures necessary for the other, on a primary consideration.

Melancholia.-In sanguineous temperament, immediately at commencement, symptoms assume somewhat of the acute aspect, admitting of topical bleedings from the head, together with active measures of depletion from bowels ; in melancholic temperament, torpid action of bowels singularly urgent, and frequent necessity of unloading them, principal indication. Melancholia calls for remedies at outset, for which mania needs preparation : thus with digitalis only moderate attention necessary in former. In melancholia, cold affusion would tend to extinguish life. Wine, with animal food, under certain limitations, with other stimuli, admissible in melancholia in its earliest stages. In this form also every measure of recreation or amusement, consistent with capability of advantage ; whilst mania calls for immediate seclusion and restraint. When latter terminates in former, it is for the most part accompanied with jaundice, and other proofs of hepatic derangement. Here mercurial action immediately called for. Calomel preferable ; if indisposed to take medicine, mercurial frictions. This form apt to run into oedema of lower extremities, and unless checked by mercury, assuming serious character of anasarca or ascites. Such terminations not common, where digitalis been allowed to exert influence, combined with or immediately after mercury, and mischiefs arising from a dropsical tendency will be effectttally prevented.

Convalescence.-On judicious regulation of convalescence, on its first appearance, will depend hopes of recovery, or danger of a fixed complaint. No measure so decidedly tends to retard convalescence, or to defeat its end, as close confinement continued too long. In melancholia, on approach of convalescence, little more of urgent concern than to regulate and keep within certain limits disposition to extraordinary vivacity, which for a time exists, and which finally resolves itself into a state of natural tranquillity. In aid of this, dietetic restriction seems to be the chief indication - with it, however, such means as may meet first appearance 108 of febrile action indispensable ; those should be persisted in on a scale not much inferior to plan laid down for treatment of maniacal fever. Next care to effect a gradual relaxation of all impediments that stand in the way of the patient and those indulgences, privation of which, however essential, was an unremitting source of painful irritation. Will not answer to remove restrictions abruptly. As to utility of restraint, if a slight degree of personal restriction, such as that of strait waistcoat, the strap, or a light chain round the ankle can impose, be found sufficient to prevent commission of suicide, in the one case, or murder in the other,-are they not in strict justice to be permitted, and conformable with kindness, &c. In Cork institution, certain modes of personal restraint and coercion often unavoidable ; and in order to subdue turbulency and confine patients to their beds, ankle-chain frequently called for, and used with best effect, where all other measures would prove of no avail.

Seclusion from Light.-Some patients look at sun with indifference ; here has remarked remedies to be useless. Abstraction of light in earliest stages of complaint indispensable. Not total darkness, as by contrast endangering optic nerve on convalescence. A moderate and equable light is at all times necessary, so that surrounding objects may be distinctly viewed, without adding to danger of misconception or of visual deformities. Apartments, then, in acute mania, should receive light indirectly, or from a northerly aspect, in order the more effectually to guard against its glare ; also should be admitted from the highest elevation which the room will afford, so as to avoid all intercourse from without, and to prevent irritation, even from inanimate objects, which may otherwise happen to be within observation. From want of precautions, seen persons far advanctd in convalesence suddenly thrown back, from inability to resist unusual impulse of light, and impressions and associations to which unguarded conduct of officious people had exposed them. Therefore of great importance that a gradual admission of light be permitted for some days previously to the patient being allowed to change his apartment ; and that no objects be left in the way of observation, which may revive former associations, either of a grateful or of au offen. sive nature. In effort to familiarize convalescent insane with a more free exposure to light as well as still objects at a distance, those con. nected with rural scenery have ever proved the most acceptable. Scenes of busy life, from which a quick succession of ideas is forced upon the imagination, have invariably produced serious mischief. Mentions an instance in which a convalescent, from witnessing the ascent of a balloon, relapsed, fancying that it contained his wife and infant child.

Exercise, as forming a material department of regimen, and as inti. mately connected with treatment of convalescents, requires to be conducted with much precaution and address. As unused to open air and light, and therefore peculiarly susceptible of impressions, of the first im. portance that a free and constant circulation of pure air should be established at all times, but particularly before any efforts be made to exercise the patient. Even then, range of exercising should be limited to pre. cincts of dormitory, shaded from direct rays of sun. Already shown that proper regulation of exercise ought to commence as early as circumstances will admit. Insane, during a tedious confinement, if not kept warmly covered, and made to extend limbs in bed, will acquire habit of 109 huddling them together, for sake of warmth ; in consequence of which, on restoration of faculties, often cripples for life. Hence require very closest attention. A safe and ready mode of preventing this, in asylum under his care. bricks, properly heated and placed near lower extremities, so that their warmth may induce the patient to extend his feet in their direction. Thus heated and covered up in a woollen cloth, retain heat for several hours ; also afford less opportunity of being applied to injurious purposes than hot water. Erect position of walking appears preferable to convalescents amongst modes of gestation, and has immediately obviated coldness of extremities when present. Horticulture best mode of employment. Good effects which have already resulted from regular employment of chronic insane and convalescents in horticulture cannot be too forcibly remarked. To all classes been a source of enjoyment and of ultimate benefit, well worth purchasing at any price. Easy labour of garden at once a recreation and amusement ; an indulgence of good conduct and contrary. Land had been lately added to Cork institution. Not possible to be present at the busy occupation of 30 or 40 of them, in earnest application of their remaining faculties, and each intent on immediate task so as to ensure approbation, without wonder and satisfaction. If not silent on any sudden occurrence, for some time difficult to reduce them again to order. Quantum of work almost incredible ; seldom inferior to one-fourth that of ordinary day labourers, and execution not deficient. Whole directed by one man, who has charge of garden ; and although every individual has the unrestrained use of the implements, no instance yet of mischief. Such avidity for this, that in a few days the apparent novice has become so familiar with garden tools, as to set an example to others. When unwilling, a small portion of tobacco the sovereign remedy. In convalescents, propensity to ill-temper, immediately after most refreshing sleep ;therefore eligible, with few exceptions, that they shall not be trusted with offensive weapons for any purpose till after hour of breakfast : attributes this to flow of blood to head. Important result as compared with vociferations formerly pervading house at night, the stillness from the uninterrupted sleep invariably succeeding habitual labour. By a systematic arrangement of daily occupation, all descriptions of the insane, capable of corporeal exertion, however set down as incurable, may still acquire habit of rendering themselves useful. Case.-A young man apparently convalescent, who had fallen into a state of imbecility in spite of means used to encourage him in some light work ; nearly been ranked among incurable idiots, when discovered by accident amusing himself in drawing, with rude colouring, on walls of his apartment-first intimation of his possessing the talent. By giving him better colours and encouraging him in this occupation, he was cured in two months.

Diet.-Patients in the Cork Asylum, being chiefly paupers of the city and county : it was wisely resolved, that their ordinary diet should consist of the farinaceous fare, to which, from previous habits, been chiefly accustomed. In addition to a plentiful meal of oatmeal porridge, and new milk for breakfast, a dinner allowance of vegetable soup, the product of their own cultivation, with oatmeal boiled down, is served out ; to which beef is added three days in each week, so long as price within certain limits ; potatoes also in dinner meal. To aged and infirm, and convalescents particularly, animal food, whenever circumstances may seem to demand it. At certain seasons of the year, they were allowed 110 to participate in the general festivity, by a few generous meals of animal food ; a scene of uproar was sure to follow from the unusual stimulus thus given : may be inferred, however, that if more frequently permitted, such consequences would not have resulted. This may be so in part ; but even in such cases, has found that animal food tends strongly to aggravation of insanity. And this an additional argument in favour of a farinaceous diet, in preference to admixture of animal matter, so long as any remains of acute appearances which denote insane orgasm. On the first establishment of asylum, regular allowance of animal food once a week, produced similar effects. At more advanced period of convalescence, and under appearances of debility, owing either to age or to the protraction of aparoxysm, necessity of a gradual indulgence in animal food must be abundantly obvious. Where this has continued to be admissible, it has afforded one of the best securities of a permanent recovery. Wine but seldom an article of diet in any stage of insanity ; at least so long as prospect of cure can with propriety be depended on. Wine and all fermented liquors equally injurious, unless in the most urgent cases. In the higher classes of society, however, where wine was daily an indispensable source of indulgence, and where at the eve of recovery it could not be altogether withheld, has found it, in strict moderation, to answer a good purpose ; by adding strength to patient, and serving, during term of probation, to confirm opinion of his safety. Yet, even in such cases, should not be taken undiluted ; and those who have been prevailed upon to abstain from it altogether, have been also the most fortunate in escaping a return of the malady. Temperance, in its widest sense, chief security to persons predisposed to insanity ; this doubly applies to those recently afflicted with an insane paroxysm. As appears to exist an opinion that a regimen approaching to starvation is essential, would wish to enjoin the more justifiable principle of temperance, by a middle course between over-distension on the one hand, and inanition on the other. Digestive power being suspended through disease, animal food provokes it into premature exertions ; to this succeeds a collapse of the entire system, with all the horrors of indigestion, followed by increased determination of blood to vessels of head, and ending in congestion, apoplexy, and sudden death. Therefore of importance to ascertain that the liver and its appendages be subservient to the process of digestion, in the secretion and copious supply of yellow bile, previous to admission of solid animal matter as an article of diet for the convalescent insane.

Chronic insanity has still its modifications and periodical excitements, which demand the most rigid abstinence ; they are of frequent occurrence, and should be provided against by a generally governing principle of moderation and frugality. Its treatment, in the generality of instances, bears a strong reference to that which had been pursued in its primary state : it varies little more than in degree, and requires to be regulated in strict conformity with the force and continuance of the paroxysms.

Fowler's Solution.-Where chronic insanity has decidedly assumed the periodical type, and also, notwithstanding the intervals, together with the paroxysms, has obtained the most desirable balance without terminating in health, the object of recovery may be greatly promoted, by the cautious introduction of the solution. Will not undertake to say that such instances have been numerous, as the proper opportunities for using 111 this powerful medicine are not of frequent occurrence ; neither does necessity of employing it appear to be justifiable, where other remedies of sufficient efficacy and of less hazard have a decided claim to our preference. As a last resource, may conditionally apply it as a tonic medicine, where fever and local determination are no longer in question ; or, during the intervals, where congestion especially does not appear, and is not suspected as a close attendant.

Spirits of Turpentine.-Selected eight men and four women affected with epileptic mania, and, following Dr. Percival, commenced with a teaspoonful in a glass of water thrice daily, for three days, when dose was doubled. At end of week, fits of each less frequent and of shorter duration. All were conscious of having slept better, and of having felt more comfortably. In general, took it from conviction that it merely contained a dram ! During first fortnight an evident advantage, but from that to end of second, effect had ceased, although increased to half an ounce three times a day ; it at length became painful to the bowels, and seemed to create a distaste for food. Again put on trial with others of the same class, and precisely with similar results, and must agree with Dr. Percival, that "not able, in a single instance, to banish permanently the epileptic attacks ; but in every instance they became considerably milder, less frequent, and remarkably disengaged from the maniacal excitement which had formerly attended them." In a case of chronic insanity, arising out of acute mania from habitual intoxication, found that two teaspoonfuls of the spirit three times a day satisfied eager anxiety for ardent spirits, with great mental amelioration ; at the time, on probation in asylum ; æt. 30 ; sallow ; two years back under similar confinement, from whence dismissed cured.

All parties, speaking dispassionately, seem to be of one opinion as to strict propriety and necessity of early removal and non-intercourse of the insane with their intimate friends and relatives ; but friendship and affection often induce contrary action. Has not been so fortunate as to meet more than three cases of confirmed mania, in which a perfect recovery was effected under regulations of home management. It therefore cannot otherwise be supposed, than that his first care is to recommend immediate removal, as the only means by which can reasonably hope for an effectual termination of disease. Many, however, partially insane, yet who are not the proper objects for confinement. A few of these, conscious of their infirmities, have personally consulted him, whether they stood in need of retirement or otherwise. Some have voluntarily complied with the opinion, that a temporary seclusion from the busy scenes of life would be productive of utility : others, on the contrary, have been encouraged rather to partake of the moderate intercourse of friends, and to join in such recreations as may best tend to relaxation and hilarity. Tenderness, perseverance with decision, are qualities which cannot be dispensed with in those who would aspire to the effectual treatment of the insane : those, if well bestowed in such a service, must ever ensure their own reward. They afford a confidence which inspires hope ; they unquestionably subdue asperities, which severity cannot conquer. Convalescents, properly regulated, should be allowed to associate only with those of their own class ; the incurable insane should also be apart ; the idiots should never, if possible, be permitted to come within view of either. The indiscriminate mixture of all cannot fail to be an endless source of riot, and of serious disappointment 112 Daily intercourse of convalescents in particular, by serving as a check to extravagant emotion, is highly expedient as a moral means, and materially conducive to final recovery.