The per cent. of recoveries of recent cases is very large in the American Institutions, which speaks well for the correctness of the moral and medical management. The treatment of the insane in all the American Hospitals is on the same principles and the appliances very nearly alike in each, Some depend upon medicine more than others, but when it is prescribed, it is nearly the same in all.

BLEEDING. All agree that depletion, by which I would be understood general bleeding and active cathartics, is not favorable in insanity, as it rarely affords more than temporary relief, and frequently produces marked injurious effects. When blood-letting has been employed freely and frequently in active mania, the only form of insanity in which it is commonly used to excess, if the excitement, for a short period, an hour or two, and sometimes a day or two, abates, it is generally renewed with increased violence, and under circumstances far less favorable for the benefit of other remedies. The indications for active depletion are usually the effect and not the cause of excitement, they grow out of the perpetual activity of the physical and mental powers, and are not the cause of it. By this course of remedies the strength and energy of the system is reduced, the nervous system is rendered more susceptible, and the actual violence of the symptoms is increased. The effect of great loss of blood is often to produce pain in the head, a sense of stricture, as if a fillet were tied around it tightly, ringing in the ears, and noises in the head which lead to false perceptions of sound, and illusions liable to result in permanent insanity. It is said that animals which are bled to death have congestion of blood in the vessels of the head; the last rush of blood seems to be to this citadel of life. It is a fact also that I have noticed for many years, that affections of the heart are produced by excessive loss of blood in any way. An eminent practitioner of medicine once informed me, that when he had bled cases of severe and painful neuralgia, he had repeatedly found palsy of the side affected with the disease on his next visit.

Free general bleeding is only useful in cases of entonic inflammation, such as pneumonia and phrenitis, with symptoms very unlike those attendant on insanity in any form.

CUPPING AND Leeching. The effect of local bleeding is more favorable, and may sometimes procure relief from distressing symptoms and afford an abatement of excitement that may give other remedies a

better opportunity to produce good effects. But even local bleeding can rarely be relied upon to cure insanity. It is usually prescribed to procure present relief rather than with the expectation of permanent benefit. Where there is a redness of the eyes, great head-ache, and much heat and throbbing of the carotid and temporal arteries, it may not be amiss to use local depletion, while at the same time every effort should be made to promote the circulation of blood in the extremities, and the quantity of blood abstracted at one time should not be very great.

In some cases I have seen great excitement followed by a state of apparent dementia, almost immediately on free blood letting. Some time ago, a female, aged about 50, came under my care in the most violent mania. The remedies prescribed for her had but little effect, and it was resolved to bleed her freely. Sixteen or eighteen ounces of blood were taken from her arm, she became dull almost immediately, and remained so for a long time before she gained activity of mind, after which her excitement became as bad as ever and other remedies finally relieved her.

A vigorous, athletic man, aged 55, was subject to the most violent paroxysms of periodical insanity. He had been under my care repeatedly, and remedies had little effect in diminishing his excitement or abridging the length of his paroxysms. One day in the extreme of one of his excitements, he urged me to bleed him, and presented his arm for the purpose, held by the other hand so as to swell the veins to an inordinate size. I had him bled freely, principally to see what would be the effect of copious depletion in such a state of excitement. Within a few hours he seemed like an idiot, but the excitement was not essentially diminished. His mind was entirely chaotic for a number of days, the paroxysm was prolonged to an unusual extent, and its violence, on the whole, was not lessened.

Some years ago, a ship-master came under my care, who had been bled about sixteen ounces, from twenty to thirty times in the course of five or six weeks. He looked pale and bloodless, was tremulous and weak, but his excitement was not essentially abated. He afterwards recovered under different treatment, and has had no return of disease.

A patient is now under my care who was bled in the outset of disease, four or five pounds, at as many different times. His body appeared bloodless, and his mind chaotic in the extreme; he has become more quiet, but all our efforts have failed in removing his insanity.

CATHARTICS. Drastic purging is often even worse than bleeding. The effect of this remedy as a depletion, is probably less disastrous than blood-letting, but it produces other effects often very injurious. The digestive organs of the insane are peculiarly liable to disturbances. Dyspepsia, vomiting and costiveness or diarrhoea, are often troublesome symptoms with them. Drastic cathartics generally aggravate these symptoms when they exist, and sometimes produce them when they do not. Costiveness is generally easily obviated by mild cathartics, it is far less troublesome than diarrhoea, which is often obstinate, and too frequently a dangerous symptom when attendant on insanity. If the secretions of the liver are unhealthy or deficient, or if other conditions of the digestive organs require a change, the blue pill or small doses of calomel may be indicated. These remedies often produce very favorable impressions and prepare the system for others which may be needed to remove the symptoms of insanity itself.

In short, cathartics, as such, rarely do good in cases of insanity, but alterative remedies and laxatives are often necessary, and in many cases cannot be dispensed with. Tincture of Rhubarb and Senna with aromatics, Aloetics, Colocynth and Guaiacum are valuable remedies of this class.

I often combine compound extract of Colocynth with Ens veneris or Martial flowers, in torpid states of the intestinal canal with constipation. My favorite remedy in such cases, is the tincture or powder of Guaiacum. No remedy in my hands has a more favorable effect in those cases of melancholy attended by dyspepsia, costiveness, and gastric distress after taking food, than the aromatic tincture of Guaiacum prescribed so as to insure a laxative effect. It invigorates the stomach, acts favorably upon the bowels, proves diaphoretic, and, when necessary, emenagogue. It may be prescribed in doses of from one drachm three or four times a day, to half an ounce. Milk and sugar are altogether the best medicine in which it can be taken. The powder of Guaiacum is the better form of this remedy, if needed as a simple laxative, it rarely nauseates, and is useful in flatulency, giving tone to the whole alimentary canal, and effectively obviating constipation.

Oil of Croton in combination, given in minute doses, often proves favorable to remove costiveness. It is almost the only active purgative which can be prescribed favorably in small quantities. In combination with tonics, alteratives and narcotics, it can be used without swelling the bulk of the medicine, often in very small doses counteracting the constipating effects of other remedies.

EMETICS. Emetics have never been extensively used in my practice with the insane. Many practitioners think well of their effects, and I have occasionally prescribed them to obviate particular symptoms, but have not seen much good from them to relieve the symptoms of insanity. In certain conditions of the stomach, they are indicated in this, as well as other diseases. Ipecacuanha and sulphate of zinc and copper are generally preferable to antimony. Antimony in small doses, combined with narcotics to determine to the surface and obviate their constipating effects, may be prescribed for a short time in the commencement of the disease, but is not useful when it has progressed for some time, especially when tonics and generous diet become necessary. Antimony in small doses often destroys appetite and relaxes the tone of the stomach and bowels, so as to retard the progress of recovery. The patient requiring more tonics to restore strength to the system generally, and to the digestive organs particularly, than if it had not been used. It is not always a safe medicine, and generally does less good than it has credit for, yet I doubt not there are cases in which it may be useful.

NARCOTICS. By far the most useful remedies in active mania, after the system is prepared for their use, are narcotics.

It is generally conceded at the present day, that the condition of the brain in mania, is not inflammation, but rather a high state of irritation, increasing its activity and that of the nervous system generally. The symptoms are sometimes equivocal, and are calculated to mislead, but close observation and the effect of remedies conspire to show that the brain is not in a state of inflammation. For this state of the brain narcotics would seem to be the most natural remedies, and experience shows that such is the fact. In many cases, this state of excitement will, after a time, give place to more healthy and natural actions, and the disease will be cured without the use of remedies; but in a majority of cases the symptoms yield more readily and favorably where narcotics are prescribed.

MORPHINE. The remedies of this class most extensively useful are the Sulphate of Morphine and other similar preparations. The exact time, circumstances, and cases when these remedies can be applied with the greatest benefit, must depend upon the judgment and experience of the medical adviser. On this, doubtless, depends their greater utility in the hands of some men than of others, though many more cases, suitable for their use, may have fallen under the care of one

man than of others who have management of institutions. Other practitioners have generally but a limited experience with them, as insanity, at the present day, is but little treated by medicine except in the institutions especially devoted to this class of patients.

The Morphine should usually be administered in solution, beginning with greater or less doses, according to the nature of the case, and the urgency of the symptoms. Moderate doses should generally be first tried, and they may be cautiously enlarged till the system is under their influence, and the excitement is controlled. The effects should be carefully watched, and if any unpleasant or unfavorable symptoms occur, the remedy must be changed, modified or combined, so that these effects may be obviated. In a large majority of the cases no such effects will occur. When its effect is favorable, it exercises a controlling influence over the symptoms, and the patient becomes more quiet, rational and natural in every respect. These effects, once gained, can in most cases be maintained till the recovery is complete. Sometimes symptoms occur which require that the remedy be increased, but more generally it can be cautiously diminished, and after a time be withdrawn, and the system suffer no inconvenience, and the insanity proved to be cured. The time that this remedy should be used varies, in different cases, from a few weeks to many months.

In the few cases in which it is necessary to administer narcotics, in large doses to produce the most decided impressions, the tincture of opium is better than the salts, but generally the salts are more safe and agreeable in their effects.

In some cases, the Dover's powder is the best form in which this remedy can be administered, especially in the early periods of disease, when the skin is inclined to increased temperature and unnatural dry

ness.

For twelve years this remedy has been extensively used in this institution, with the most marked success.

The manner in which the Morphine has been used in this and other Hospitals in this country, continuing it till the symptoms have subsided, then omitting and seeing them return, then again and again removed by the renewal of the medicine, affords unequivocal evidence of its power to subdue maniacal excitements, relieve the delusions of the insane, and restore the brain and nervous system to a sound and healthy

state.

Most English writers speak of the extraordinary effects of this remedy in isolated cases, but caution against its general use. But the