and can indorse all that Dr. Anstie has urged in its favor as a special anodyne to the female pelvic organs. Conium I have also used, and, though it is strongly recommended by French authorities, I have not found any great benefit from it. Henbane is better (5 to 8 grs. of the extract), and morphia (to gr. of the acetate) are exceedingly valuable. By any of these, used in the way I have suggested, we may easily, if we wish, affect the whole system.

As resolvents, alteratives, deobstruents, or by what other name we may please to call them, iodine, iodide, bromide of potassium, iodide of lead (though I must say that the insolubility of the latter is a great objection to its use, in my judgment.) and the preparations of mercury, may be used, and will be found very efficacious in the chronic congestions and enlargements of the uterus or ovaries and in local syphilitic affections.

I have already alluded to some other remedies, such as astringents, or tonics, and disinfectants, which will be found of great value in cases requiring their use; and though I have not yet used the ergot of rye as a local application, I intend doing so, under the belief that it will prove a good uterine tonic; and as the action required is local, it seems well adapted for local use.

3. In conclusion, I would offer a few considerations for and against the adoption of the method here recommended. To take the latter first, it may be said that suppositories applied to the rectum are better than pessaries to the vagina. I can only reply by a contrary opinion. If we are to have local treatment, I think the more dircct it is the better; and I believe the patients themselves would prefer the one to the other as a matter of delicacy; besides, some of the remedies could not be used per rectum. Again, it may be urged that it is undesirable that women should be taught to introduce such things; my answer is, that it is far less objectionable, and much more efficacious, than the old and too common practice of introducing a syringe twice a day, or oftener, for the use of a lotion, which is, and has long been, so empirically recommended. Lastly, it may be urged that this practice is very unpleasant, not to say unclean. My answer is, that the same objection may be made to the introduction of any nauseous, unpalatable, or disagreeable medicines into the stomach.

On the other hand, in favor of the practice I would

urge, the advantage of the immediate and direct action of the agents employed to the parts affected; their gradual and continuous effect pari passu with the uniform solution of the mass; the avoidance of any stomach derangement which the use of the same remedies might, and not unfrequently does, occasion; the saving of any injurious constitutional effect, which is less likely to happen when the drug is used in this way; and, lastly, the opportunity thus offered of enabling the patient, in many cases, to treat herself, and thus to avoid the attendance by a medical man where local treatment is thought to be really necessary; a point which, I own I regard as one of great importance.

It is quite possible that this mode of therapeutics admits of improvement in the means employed, but this will best be attained, I think, by a more extended trial of those we now possess.-[The Practitioner.

ART. III.-ON OPIUM IN THE TREATMENT OF INSANITY. By HENRY MAUDSLEY, M.D.

Although opium has been long and largely used in the treatment of insanity, there is still a great want of exact information as to the cases in which it really does good. No clear discrimination has been made of the varieties of insanity in which its use is sanctioned by experience, nor of the drug which it is best to give when opium is inad missible. Systematic writers on mental diseases are apt, in their chapters on treatment, to speak of the drug rather than of the disease; they vaguely praise its virtues, and specify the doses in which it should be given; but they do not supply the elements of a definite answer to the questions which press on the practitioner who has to do with a particular case of insanity-whether he shall prescribe drugs, and if so, what drug, and in what doses? This unsatisfactory vagueness is owing mainly to the psychological classification of insanity, by which forms of disease sufficiently distinct to demand a separate description are included in the same class. What profit is there, for example, in reading generally of the treatment of mania by opium, when there are included under this class such distinct varieties of disease as puerperal mania, the mania of general paralysis, syphilitic, epileptic, or hysterical mania, each presenting features and re

quiring treatment in some degree special? Then, again, much mischief springs from the neglect of the individual constitution or habit of body, as determined by hereditary influence and the conditions of life. There is hardly a disease in which opposite remedies may not be useful under the different circumstances which are denoted by such words as "diathesis" and "idiosyncrasy;" and there can be little doubt that future progress in therapeutics will lie in directing the means of treatment more definitely to the diathesis, and in less random attacks on the particular disease which may have been engrafted upon it. An attack of melancholia occurring in a gouty subject, and, perhaps, taking the place of an attack of gout, is sometimes cured by the treatment proper for gout; and there are cases on record in which acute mental derangement has affected persons living in a malarious district in regular tertian or quartan attacks, and has been cured by quinine. We might, in relation to this matter, profitably apply to the body, corporeal ideas derived from the study of the body, social or political. No statesman with a gleam of philosophy in his mind would dream of using the same measures for the radical cure of rebellion in differently constituted states, simply because it was rebellion; he would have regard to the fundamental causes of the disorder, to the evils in the political system whence it had sprung, and would in each case apply his measures differently, adapting them with special reference to the particular defects of each constitution. On the other hand, a foolish ruler, like an ignorant empiric in medicine, would immediately apply the same measures to rebellion, under whatever conditions it had arisen, because from time immemorial such measures had been thought good for rebellion. So he would do no good, or would do great harm.

It will be vain, however, to look for exact knowledge respecting the medical treatment of insanity until its manifold forms have been systematically subjected to the same exact method of positive inquiry as is applied to other bodily diseases. We must cease to give the mental symptoms the only place in our consideration, and to classify the varieties by them, and must set ourselves to work to study the bodily disorder which in most cases will be found to have caused, or to be associated with, the mental derangement. Why, Dr. Skae boldly asks, should we attempt to group and classify the varieties of

insanity by the mental symptoms, and not, as we do in other diseases, by the bodily diseases of which these mental perversions are but the signs? What we want now is an exact clinical observation of the causes, the symptoms, bodily as well as mental, and the course of the different forms of insanity, and the accumulation of such observations. In this way we may hope to arrive at a natural history of the disease, and to be able ultimately to arrange its manifold varieties in groups or families, having real relations and characteristic features, a knowledge of which will instruct us as to the causation, course, probable termination, and suitable treatment of a particular case which we are able to refer to the group or family. It will then be possible to test the action of drugs with something like precision, and, having made our experiments, to give something like exact information concerning their effects. Meanwhile we are working almost in the dark; and all that the most experienced physician can do is to state generally his empirical conclusions. No wonder then that there is a great want of agreement among men who have no agreement as to the conditions of their inquiries.

These preliminary remarks, while indicating the difficulties of the inquiry, and the direction which our future. efforts must take, will serve to prevent an undue value from being attached to opinions given in this paper. They represent the results of personal experience rather than universally accepted rules of practice.

Among the drugs on which we rely in the treatment of insanity, opium undoubtedly occupies the foremost place. And my experience would lead me to say that the most beneficial action of opium is witnessed in the incipient stages of insanity-at that early period of mental depression which so often precedes actual derangement of thought. This is, indeed, the time when judicious treatment will do most, for it will truly sometimes ward off a threatened attack. Unhappily it too often happens that this critical stage is passed through, and a worse stage has supervened, before the physician is applied to; friends make light of it, if they hear of it at all, think it a hypochondriacal fancy, or a little temporary depression, out of which the patient only needs to be rallied or roused, and the sufferer himself, strangely changed and miserable as he feels, is almost ashamed to mention feelings for which there appears so little reason

in his bodily state. He is unaccountably depressed, fearfully apprehensive of some undefined evil; cannot sleep soundly, but frequently wakes up frightened, or dreams terrible dreams; can take no interest in, and has no energy for, his usual occupations and amusements; everything appears changed, nothing looking as it used to look. These distressing feelings are worse in the morning, but often pass off towards evening; and the patient may for a time be delighted to feel quite himself again. It is in this stage of depression and vague apprehension, which is truly a fore-feeling of the threatening calamity, that the systematic administration of opium produces the best effect. In some cases a grain of opium every night at bedtime, combined with extr. aloes gr. ij. and tonics, with a moderate allowance of stimulants in the day, almost immediately dispel all troubles. In other cases the use of morphia in or grain doses three times a day is more suitable, and should be persevered with, notwithstanding an apparent want of success at first, and notwithstanding the ignorant horror which the patient's friends may express on discovering that he is taking morphia regularly.

A more advanced stage of melancholic depression, which may be called actual melancholia, although there is no definite delusion, is that in which the patient is in a permanent state of acute fear and misery. His feeling of external objects and events is strangely and unnaturally changed; impressions which should be agreeable or indifferent are painful, and he is miserable because he believes that he has lost all his natural affections; there is a constant fearful apprehension of something dreadful being about to happen, and whatever he does he fancies to be wrong. He is incapacitated from all healthy exertion, and his mental suffering is so great that he asserts that he cannot bear it, and he dreads that he may do some injury to himself. Paroxysms of acute anguish and despair come on at times, when he hardly knows what he does. Here again is a class of cases in which the systematic use of opium or morphia is most useful. In two cases of this kind in women, in each of which there had been a vague and abortive suicidal attempt, entire recovery was brought about in a short time by the administration of a dose containing aloine gr. j. and morph. gr., every night and morning. Even in those more obstinate and distressing cases, where there is persistent