It is an excellent rule to observe in local abstractions of blood, that as many glasses or leeches should be applied at once, if possible, as are capable of abstracting as much blood as may be desired. The effect will be more certain, and the length of the operation be curtailed, which is an object of no small importance with impetuous and unruly patients.

Among those who admit the utility of local abstrac tions of blood from the head, or contiguous to it, in this malady, there is much diversity of opinion as to the propriety of its repetition, or if repeated, how long the practice should be pursued.

Some conceive that the object is attained by a single emptying of the surcharged vessels of the brain; others repeat it through exacerbation and remission, even into the continuous form. The latter course I hold to be dangerous, as likely to produce a permanent state of collapse of the brain. My practice is to repeat cupping or leeches so long as symptoms of great cerebral excitation prevail, especially while a preternatural heat of the scalp is felt; but when they remit, to desist from drawing away blood, and repeat it only with the renewal of these symptoms. If premonitory symptoms announce an attack, local depletion will often prevent it. Mere raving and fury must not be mistaken for cerebral excitation consequent on vascular excitement. They are probably the effect of that cerebral irritation which is produced by an opposite condition of the brain, and would inevitably be exasperated by any kind of depletion.

Patients are often so sensible of the relief of topical bleeding, that they will frequently solicit it as a boon.

When insanity has been relieved, and sometimes cured, by spontaneous hæmorrhages from the nose, uterine and hæmorrhoidal vessels, or varicose veins, I question whether such an effect may not have been produced more by change of determination than by the sanguineous

evacuation.

It is certain that the degree of mental anguish and disturbance which impels suicide, finds relief in the sudden loss of blood.

In cases of nymphomania, all the distressing symptoms whence this affection derives its name have been removed by the application of leeches to the vulva. In like manner, improvement of the mental faculties, dependant on menstrual obstruction, follows cupping on the sacrum. Sympathetic delirium from an affection of the liver, has subsided by local abstraction of blood from the hepatic region.

Local determination and congestion of the brain in mania, with other symptoms of excitation, may take place without flushing of the face. On the contrary, in mania, as well as sometimes in the apoplectic diathesis, a singular palor exists. Nay, cases occur where topical blood-letting has been required to relieve local congestion, and at the same time stimulants to support the general tone of the system. I have no hesitation in continuing abstractions of blood from the cerebral vessels by cupping or leeches, so often as the symptoms denote fresh excitation. It is advisable to pursue this plan even when tonics are indicated to support the patient's strength; for local determination is as frequent in the weak as in the strong. Of course, the quantity of blood detracted in such cases will be smaller. Should faintness or marks of exhaustion come on during the abstraction, the patient must be supported by good broths or a little wine.

The melancholic certainly hold life by a more precarious tenure than the maniacal. It is the natural effect of depressing passions. But in the commencement of melancholia, accompanied by uniform despondency, the symptoms of determination, or of congestion of the cerebral vessels, are as manifest often as in incipient mania. Sometimes, on the explosion taking place in melancholia, it is attended with great fury and excitation. Whether,

however, accompanied by despondency or excitation, topical bleeding may be equally necessary and beneficial; and as the symptoms in this form of insanity persevere longer without remission, moderate local depletion may be repeated for a greater length of time than in an attack of mania. The ancients advised blood-letting in melancholia; and Willis says, Sanguinis emissio in omni ferè melancholiâ locum habet, et nonnunquam sæpiùs iteranda est." He advises bleeding from the vena salvatella; adopting probably the popular opinion, that bleeding from this vessel was particularly useful in melancholy. It is the fact, however, which I wish to record, not the vessel whence the blood was taken; since many are afraid to detract blood in any way from a patient in melancholia. There is nothing in such practice inconsistent with the received pathology of insanity, since more authorities support the pretension of melancholia to be the original disease, of which mania is but a variety.

The practice so frequent on the continent of applying leeches to the anus, is founded, I conceive, on the obsolete doctrine of revulsion, and as a general principle should be declined. But where insanity may be reasonably suspected to arise from sympathy with some abdominal viscus morbidly affected, the loss of blood from that part may do good; and more especially if the patient has been accustomed to hæmorrhoidal flux, and that has been suppressed.

2. Dry Cupping.

A few observations on this mode of operating may be here applicable as a corollary to the preceding. It is very desirable and useful in cases of insanity and transient delirium, where we have reason to suspect determination to the brain or congestion, to relieve the surcharged vessels; but the patient may be in such a state

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of emaciation and debility as to positively forbid the detracting of blood even in the smallest quantity. I have seen such cases; and have found sensible advantage, after shaving the scalp, from the repeated application of several glasses to the head, without scarification or loss of any blood. The blood is by this means derived from the surcharged internal vessels to those of the external, all of which will be seen greatly distended from the operation; and it is there retained awhile, without being absolutely withdrawn from the circulation, to the relief of the brain.

If a patient die soon after blood has been abstracted from the scalp by the usual process of cupping, and the head be immediately opened, all the exterior and interior anastamosing blood-vessels of the pericranium and the investing cerebral membranes, inclusive of those of the brain itself, will be found highly injected and distended with blood, to a circumference exactly correspondent with that of each glass which is applied on the surface. This appearance I saw remarkably displayed in the head of a patient who died in half an hour after he was bled by cupping, and whose head I examined six hours after he died. But where the examination takes place many hours after the operation, the internal evidence of this effect of cupping is nearly obliterated. This fact demonstrates the possibility of affording relief by simply attracting blood to the surface by the mere application of the glasses.

Friction on the pericranium after dry-cupping, and pediluvium, greatly tend to determine blood from the head to the general circulation.

3. Refrigeration.

The utility of refrigeration where there exists a preternatural heat of the head, is confessed in all cases of cerebral disorder.

Divesting the scalp of all the hair by shaving, is not

only a necessary preliminary to other applications, but deserves regard and adoption as in itself a refrigerating process. It is certain, that the simple denuding of the scalp produces a calming and even soporific effect, in violent mania.

Celsus sometimes advised clipping off the hair, sometimes shaving the head. In all diseases where the sensorium is affected, whether attended by pyrexia or without, the latter is an admirable auxiliary. Clipping the hair close does not suffice; for, besides that it does not produce the soothing effect of denuding, the process of evaporation, which abstracts caloric, never goes on so rapidly as when a naked surface like the shaven scalp presents itself; neither is the impression on the sensorium, the object desired by the operation, so effective. The abstraction of heat is much more rapid and complete by evaporation than by cold applications, such as ice, or any of the frigorific mixtures.

The head, when divested of the hair, should be kept so as long as symptoms of active cerebral excitation are manifested, and local applications to the surface are deemed necessary. When such symptoms subside, and the brain may be suspected to be in a state of collapse, refrigeration must cease, and the hair may be suffered to grow.

As a general rule, I recommend that the heads of all insane persons should be kept cool. For this reason, permitting them to have their heads covered when indoors is an injurious custom. In several public asylums I have visited, I observed this bad habit prevail, when, at the same time, the patients were crowded in apartments much too heated. This is very inconsiderate, and will produce in many cerebral excitement and sleepless nights, and consequent irritation to all the patients.

Insane persons disposed to determination to the head, should lie with their heads cool, and also raised. The blood may be invited to the head in adults, as it often