reason restored.-26th. Medicines and regimen to recruit her strength were prescribed. For several days she was affected with occasional fits of anxiety and distress, such as had occurred during the recurrence of her original complaints, after the first interval. These paroxysms were always troublesome about 2 P.M., when there was an increase of heat and pulse. She gradually amended; on the 7th of September returned to her friends, and several months afterwards continued well.

"She was conscious, she said, of her nakedness, and of several other circumstances during the insanity; that she felt something like wind rising from her stomach to her head, and that her heat of body was so intolerable that she could not endure the least clothing. Soon after she recovered, her feet were affected with such a burning sensation that she was often obliged to put them into cold water; and she was much annoyed with frequent flushings over the whole surface of the body for several days."*

A case of apoplexy ending in mania is related by Ferriar, where recovery commenced on ulceration of the gums taking place consequent on a course of calomel; and the cure was completed by supporting a gentle ptyalism.

The frequent resistance of the absorbent system to the action of mercury in mania is remarkable. Perhaps it may be accounted for on the well-known principle in the animal economy, that when any irritation is already existing, the system is less susceptible of another irritative process. Hence the cerebral irritation in mania proves a bar to the mercurial irritation.

In Dr. Smith's case of mania, the strength of the patient was a good deal reduced before mercury was

*New York Med. Repos. vol. i. p. 174.

+ Med. Inq. vol. ii. p. 72.

exhibited; for which reason, possibly, it was so readily imbibed.

Mania resists the action of mercury more obstinately than melancholia, as it does of all remedies that are supposed to influence through the medium of the circulation.

Notwithstanding the ill success which has attended my attempts, where other means fail, I shall not hesitate making trial again, in obstinate cases, of mercurial salivation, always first prescribing evacuants.

As an alterative, in cases of insanity attended with glandular or cutaneous affections, or where the chylopoietic functions are deranged, mercury is of undisputed utility.

15. Digitalis.

Possibly, the testimonies of British practitioners are more at present in favour of the powers of digitalis in mania and melancholia than of any other remedy. Indeed, some ascribe to it a specific antimaniacal virtue.

Its power in influencing the action of the heart and arteries is acknowledged; and as the pathology of insanity which I advocate refers mental derangement in the first instance to derangement of the circulating system, it may hence be inferred that I entertain a high opinion of the qualities of digitalis.

Dr. Cox* ranks it next to emetics as a remedy in madness; and thinks that its efficacy is as much to be attributed to the nausea it creates as to its direct power over the circulation; and that its effect is not transient, as the nausea produced by other medicines, but will remain a long while after the use of it is discontinued.

Dr. Hallaran† is a still warmer admirer of the virtues of this plant as an antimaniacal remedy, and strongly recommends it "as a medicine peculiar in its effects, and,

* Pract. Obs. on Insanity, ed. 2. + Prac. Obs. on Insanity, ed. 2.

under proper limitations, admirably calculated to the present intention." He conceives that much discredit has attached to it from not observing certain preliminaries before its exhibition; and he thinks he has had satisfactory proof" that the digitalis is not eligible in any case, unless where the system is previously reduced by proper evacuants; and although its sedative quality, as far as regards the circulation, will not be questioned, yet, that this cannot be usefully exerted under the pressure of high arterial action."

Such is Dr. Hallaran's confidence in the effect of this medicine, when judiciously administered in real maniacal cases, that he as firmly expects recovery from it as he does from mercury in syphilis. He farther remarks of its properties, that besides its capability of restraining within due bounds the action of the heart and arteries, it possesses remarkable anodyne and soporific qualities, and none of the formidable objections which attach to opium in maniacal cases.

He cautions against carrying the use of it too far, lest, by producing paralysis or extreme debility, the existence of the patient should be endangered; and advises its suspension when there is pallor, inability of retaining food, vertigo, dilated pupils, and slow intermitting pulse, with cold extremities, which condition should be met by volatile stimuli and cordials. Moderate purging during the interval of suspension secures a safe return to its exhibition.

He recommends beginning with five or ten drops of what he calls the saturated tincture thrice a day, and gradually increasing the dose. When arrived at one hundred and fifty drops daily, in three doses, he stops at that quantity for ten or twelve days; he then proceeds, he says, to increase it to one hundred drops at a time, with safety and advantage. But when there has been occasion to suspend it, he always recommences with ten or twenty drops, adding one drop to each successive dose daily.

I have never carried the dose beyond fifty drops of the tincture of digitalis of the London Pharmacopoeia. Even in that quantity, by gradual increment, I have seen effects produced that have alarmed me for the safety of my patient; and therefore, if it has not answered in that dose, I have desisted from carrying it further, or suspended it altogether.

Besides premising depletion, and purgation with calomel, Dr. Hallaran advises mercury to be given internally, so as to produce moderate salivation, as preparatory to the exhibition of the digitalis.

Without any of the enthusiastic admiration and confidence in the virtues of the foxglove as an antimaniacal remedy which this respectable physician professes, I perfectly concur with him in considering it as having a very powerful influence, when properly administered, in all stages of insanity accompanied with great vascular excitement and a rapid pulse.

I believe, also, that if the general rule he lays down, of previously depleting, and evacuating the bowels by calomel purges, be adhered to, the operation of digitalis will be found much more uniform, not only in insanity, but in many active diseases where it now often proves ineffectual.

Where mercury has been pushed to ptyalism preparatory to the exhibition of digitalis, and recovery as soon supervened as Dr. Hallaran mentions, it may be doubtful to which remedy to ascribe the cure.

The preliminary course of lowering the general system by depleting and purging, before the sedative and calming power of digitalis will have effect, exactly corresponds with my own experience. This plan, as I have stated, applies also to opium and other narcotics, given to procure composure and sleep in maniacal delirium.

In fact, it is obvious that none of the most efficacious internal remedies recommended in mania are admissible,

unless anticipated by evacuants. It would seem, indeed, that the vascular system in this malady is at first so excited, that it resists the powers of all remedies which act on that system, till it be lowered, so as to be capable of producing re-action.

In reference to the use and effect of digitalis in mania, it will be seen that I have drawn copiously from the observations of Dr. Hallaran. I confess, however, that I have not had such surprising success with it in the cure of insanity as he and his correspondents describe. I may not always have observed so strictly the essential and preliminary rules. At the same time, I have seen sufficient of its powers to have much confidence in them.

Dr. Ferriar has remarked, that when digitalis, camphor, and opium alone, have been found ineffective, each has proved serviceable when combined with cinchona. This is contrary to my experience.

In closing my remarks on the utility of this plant as a remedy in insanity, and the causes of its failing so frequently to produce the desired effect, we must not altogether impute such failure either to idiosyncrasy in the patient, or the unfitness of his system for its reception. For digitalis is peculiarly open to the objection justly charged upon the whole tribe of vegetable narcotics, in whatever form they are presented for our use; viz. that their qualities are affected by such a variety of circumstances, that the same preparations at two different seasons or periods rarely accord in their properties; hence, such diversity in their effects.

Whenever remedies so active and dangerous are prescribed, the case must be proportionably important. It behoves those, therefore, who are actuated by proper zeal for their profession, and regard for their own reputation, not only to remember this objection, but, by a strict attention to the directions in the Pharmacopoeia for the preparation of vegetable remedies, to obviate it.