the action of either system which may preponderate, so as to restore the lost balance.

When the cause evidently exists in a structural or functional lesion of some remote organ, affecting the brain by sympathy, it is obvious that attention must be first directed to the organ so affected.

When we have been made acquainted with the history of a case, and have had time to study and form our judgment on the nature of it, we shall have performed an essential preliminary. That history ought to inform us of the constitution, peculiarities or idiosyncrasies, age, habits, and every moral and physical cause that has occurred capable of intensely exciting or depressing the mind. Reflection will teach us, that the aged and the young, the vigorous and the debilitated, a recent and a long-standing malady of any kind, cannot be treated on the same principle. So especially is it with insanity; but this plain and wholesome maxim is too often forgotten.

In respect to mania and melancholia, the most common forms of insanity, it has been the practice to treat them as distinct affections; but a due consideration of their respective stages (Part II. Comment. V.) will shew, that in the incipient stage of both, the medical treatment can differ but little. It must be obvious, however, that this is the period for prompt measures, and that in the active or confirmed stage, while a chance of cure offers, those measures should not be relaxed, though they must be adapted to suit the various modifications which either form may assume in its progress. The declining or convalescent stage, though requiring great experience and tact, belongs more strictly to moral

treatment.

Obnoxious as insanity proves in all its relations to system, so likewise I believe is it in its curative treatment.

The several stages which it pursues in its course, testify that the brain, the organ of the mind, assumes different morbid conditions; first functional and then structural,-functional in the first three stages, structural or organic in the last.

This pathological view must be our guide in prescribing.

In the incipient stage, there is evidence of great vascular excitation and cerebral irritation, and this stage must be met by a correspondent treatment. Here are indicated repeated topical abstractions of blood from the head or contiguous to it, shaving the head and refrigeration so long as there is preternatural heat of the scalp, cautious general blood-letting even in the plethoric and robust, very moderate in the delicate though young, purging, vomiting after the vessels of the head are unloaded and the bowels evacuated, nauseating doses of tartarised antimony to moderate the circulation and excessive violence, the digitalis in gradually augmenting doses, till the pulse intimates reducing the dose, saline draughts, and moderate diet.

In the active or confirmed stage, the fury and violence of mania, or the despair of melancholia, with their concomitant mental delusions, may persist, yet the symptoms of physical excitation attending the incipient stage subside or intermit, and occasionally only return.

When the symptoms of excitation recur, they must be treated as in the first instance, except that neither depletion by local or general bleeding, nor by any evacuants, should be so active or copious. The system will not in this stage bear them so well; on the contrary, light tonics and the shower-bath are of great use, even when moderate topical bleeding and purging are indicated; and when the exacerbation of a paroxysm ceases, more powerful tonics, as chalybeates, cinchona, cold bathing, and a better diet, are admissible. It should also be observed,

that in melancholia the class of remedies which are designated anti-nervines are useful adjuvants.

In the convalescent stage, if symptoms still denote cerebral congestion, gastric irritation or uneasiness, or intestinal irregularities, they should be attended to until they are removed. In this stage, moral treatment besides is especially indicated.

I do not perceive that any particular advantage can accrue from giving specific formula of remedies in particular cases of insanity; for there are scarcely any two for which the same formula or dose would be suitable. Doses, like the remedies themselves, must be modified according to the constitution and peculiarities of the patient, and symptoms of the case.

It may be important to remark, that cases of evident derangement of the intellectual faculties are sometimes met with, which, perhaps, on a very rigid examination, All the present no symptoms of corporeal disorder. functions seem regular, and there is no alteration in the external appearance, except, perhaps, a little more vivacity in the look, and a slight peculiarity in the eyes. These are persons in whom, invariably, the hereditary predisposition is inherent. Moral perhaps rather than medical remedies in such cases appear to be indicated. Nevertheless, remedies which diminish inordinate cerebral action, provided they be not violent, will be found useful, and will often prevent a positive paroxysm of mania.

Presuming that no one will attempt the cure of a malady attended with such difficulties as insanity, without a previous knowledge of pathology and the practice of medicine, I shall proceed to comment on the different remedies recommended, interspersed with practical remarks on their application and effects.

Of the treatment of delirium specifically, little can be said. Where it assumes the form of a distinct affection, as in delirium tremens, I have described the treatment.

It is obvious, that we must first endeavour to ascertain whether it be idiopathic, as in acute cerebral inflammation; or symptomatic, as in ordinary fevers; or sympathetic, from narcotics or other noxious ingesta, intestinal worms, wounds, &c.; or from a remote diseased organ or texture; or from metastasis. In any of these cases, remedies must be applied to the cause, since the delirium is but the effect, and will generally cease when the cause is removed.

Such remedies as are commonly in use I shall discuss in the following order :

1. Abstractions of Blood; 2. Dry Cupping; 3. Refrigeration; 4. Gyration and Swinging; 5. Sleep; 6. Narcotics; 7. Blistering; 8. Setons and Issues; 9. Artificial Eruptions; 10. Bathing; 11. Purging; 12. Vomiting; 13. Nausea; 14. Salivation; 15. Digitalis; 16. Camphor ; 17. Turpentine; 18. Tonics; 19. Tobacco; 20. Diet.

COMMENTARY III.

1. ABSTRACTIONS OF BLOOD.

General Blood-letting.

COPIOUS abstractions of blood are almost universally adopted in cases of insanity attended with symptoms of violence, and sometimes where the patient is tranquil. The practice has received the sanction of ancient authority, and is at present very universal. Many of eminent character among the moderns, however, have doubted its efficacy; and experience has convinced me, that, except in a very restricted sense, it is a practice fraught generally with mischief.

Following example rather than experience, I tried depletion by blood-letting for several years; but discovering my error, I became more cautious; and, I believe, that I have scarcely ordered venesection in six cases of simple mania or melancholia in as many years. My conclusion is, that since I changed my practice more have recovered, and certainly the cases have been less tedious and intractable.

I have premised that three disordered conditions in the circulating system exist in mental derangement. 1st, There may be too great a quantity of blood flowing to the brain at the expense of other parts, which suffer a diminution of it, thus producing a real determination. 2d, There may be an excessive momentum in the vascular system, indicative rather of morbid action than of excess in quantity. And, 3rd, there may be a deficiency in quantity, by which sufficient blood is not propelled to the brain, to give the intellectual organs their wonted. energy. I may add, that mania, like gout, may be occa