Such a patient is, without exception, the most troublesome class of inmate of an asylum.

Summary.-1. The preceding observations consist of three parts. 1st. Experiments to determine the effect on maniacal excitement of single doses of certain medicines, stimulants, and food. 2nd. Experiments to determine the effect on maniacal excitement of prolonged courses of certain neurotic medicines. 3rd. An account of clinical observations and experience of the effects of the same medicines in all kinds of insanity.

2. To compare the effect of opium on maniacal excitement, with that of bromide of potassium, with that of cannabis Indica, and with that of a mixture of bromide of potassium and cannabis Indica, and to compare the effect of these with that of a pure stimulant in large quantity, and with that of a nutritive food, eleven maniacal patients were treated with drachm doses of each of the medicines, and with four ounces of whisky, and the beef tea made from a pound of beef on successive days, and the results noted. The experiments were repeated from fourteen to twenty-nine times.

3. A mixture of one drachm of bromide of potassium with one drachm of the tincture of cannabis Indica is more powerful to allay such excitement than any of the other drugs or stimulants tried. It is more uniform and certain in its effects, more lasting, interferes less with the appetite; and to produce the same effect the dose does not require to be increased after long-continued use.

4. Single doses of opium tended to raise the temperature and to lower the pulse; single doses of the mixture above-mentioned to lower the temperature and quicken and weaken the pulse, of bromide of potassium alone to raise the temperature and lower the pulse, of cannabis Indica alone to raise the temperature and quicken the pulse, of whisky to lower the temperature very much and slightly to quicken the pulse, and of beef tea to lower the temperature in the least degree and to lower and strengthen the pulse.

5. By giving bromide of potassium and cannabis Indica together, not only is the effect of either given separately immensely increased, but the combination has an essentially different action from either of them given alone.

6. Bromide of potassium alone can subdue the most violent maniacal excitement, but only when given in immense and dangerous quantities, and its effects are so cumulative while so given, that after they have once begun to appear they increase for days after the medicine has been stopped, almost paralysing the cerebrum and sympathetic.

7. To produce sleep in mild excitement, one drachm of the bromide of potassium is about equal to half a drachm of laudanum. To allay maniacal excitement, forty-five grains of the bromide and

forty-five minims of the tincture cannabis are rather more than equivalent to a drachm of laudanum.

8. Seven cases of chronic mania were treated for twelve weeks with opium, in doses rising gradually from twenty-five minims of the tincture up to ninety minims three times a day, and the results noted. After getting no medicine for several months the same cases were treated with a mixture of bromide of potassium and cannabis Indica in gradually increasing doses, and the results noted and compared with those of the opium treatment.

9. Under the opium treatment the patients all lost in weight continuously; their morning temperature was lowered and also their evening temperature, but the latter (which was too high, and its being high was a bad sign) very slightly, and their pulse was decreased in frequency. The opium allayed the excitement in the larger doses, but it soon lost its effect.

10. Under the bromide of potassium and cannabis Indica treatment the patients only lost in weight very slightly for the first six weeks, and after that they gained, their weight being more at the end of eight months' treatment than it was to begin with. Their appetites were not interfered with. Their temperature fell, especially their evening temperature, and the pulse was slightly increased in frequency and weakened in force, while the excitement was subdued, and the medicine showed no signs of losing its effect, even after being thus used for eight months. The maximum of good effects and the minimum of the ill effects of a sedative drug were thus obtained by using the bromide of potassium and the cannabis Indica in combination.

11. The bromide of potassium alone may be continued for months in doses of half a drachm three times a day, and the patients gain in weight and remain healthy in body.

12. Cannabis Indica being a diuretic, and the bromide of potassium being carried off by the kidneys, it is probable that the former in that way helps to prevent the cumulative action of the latter when given alone.

13. When the two are given together, the first symptoms developed are those of the cannabis Indica, but these soon merge into a state of drowsy calmness of the nervous system which is in all respects the opposite of nervous irritability.

14. Fifty-one cases of various forms of insanity were treated by bromide of potassium alone or along with Indian hemp, and the results were that eighty per cent. of these were benefited more or less in some way, and twenty-five per cent. were most decidedly benefited.

15. The milder cases of puerperal and climacteric insanity were sometimes remarkably benefited by drachm doses of the bromide of potassium given at night.

16. In some of the cases of acute mania the excitement was subdued in a few days by the bromide combined with Indian hemp in doses of from half a drachm to a drachm of each given three times a day.

17. In some cases of periodic mania and general paralysis all the worst symptoms of maniacal excitement were allayed by giving a mixture of bromide of potassium and cannabis indica in doses of from half a drachm to a drachm and a half of each three times a day. This was continued in one case for nine months with the best effect.

18. In three cases of periodic mania, attacks were cut short by a mixture of the two medicines, or by the bromide alone. In one of these complete recovery followed.

19. Fewer cases of simple melancholia were benefited by the bromide alone or along with Indian hemp than any other form of insanity. Some were made worse by them, but in one case of this disease where there was great excitement and hallucination of hearing and suspected organic disease of the brain, the combination gave immediate and complete relief of all the symptoms for four months.

20. One case of senile mania was successfully treated at home by a mixture of the bromide of potassium and tincture of cannabis Indica, when she was to have been sent to an asylum. It seems probable that some such cases, and also patients with short attacks of mania might be treated by the same medicines at home, when at present they have to be sent to lunatic asylums, on account of the want of such a safe and powerful sedative.

Reclamation of Dr. G. Hamilton.

To the Editor of the British and Foreign Medico-Chirurgical Review.' SIR,-In the number of your Journal for July, 1870, page 14, I notice some remarks on my obstetrical practice which are so confused and incorrect that I must ask you, both in justice to myself, and from the great importance of the subject, to give insertion in your next number to the following extracts from the Edinburgh Medical Journal' for October, 1861, in which a short summary of my practice is given, with its results on child and mother:

"I have long held that a more frequent use of the forceps than has been usual in tedious labours is called for, in order that the maximum of success should be attained in obstetric practice; and I attempted to support my views on this point in papers published in the Brit. and For. Med.-Chir. Rev.' for April, 1853, and in the 'Edin. Med. Jour.' for May, 1855. In the former of these I stated that by using the forceps on an average in between every seventh and eighth case, a ratio of mortality to the child had been attained of 1 in 317; and in the latter I stated that I had then delivered in succession 416 cases, in all of which the child was born alive. At that time the numbers were still being added to; and I now think it interesting, as connected with this practice, to state that the successful deliveries continued to go on, until the numbers attained were 731 children delivered successively, not one of which was stillborn. As far as I am aware, this result is altogether unprecedented in obstetrical history; and when I look at the ease with which my experience tells me the forceps can usually be applied, when resorted to in good time, I cannot but think that the prejudice against their more frequent use has been altogether without foundation. I explained my views on the management of tedious labours so fully in the papers referred to, that I need not repeat them here. I may, however, say, that all the experience I have since had confirms me in the soundness of the position I then maintained, that it is not generally in the early portion of tedious labours that danger is to be apprehended, and that the labour may go on frequently even for days without anything more serious than some inconvenience to the mother. I think that during this stage, and until the head has fairly entered the pelvis, meddlesome interference, in urging on the labour, is for the most part uncalled for and pernicious, and that usually, with the exception of rupturing the membranes, little more is required than the exercise of patience. When, however, the os uteri has become dilated, and the head has entered the pelvis, so that an

1 "I must repeat here what I formerly explained, that this series includes1st, only those labours that were under my own care from their commencement, and 2nd, that children that were not viable, or were dead when I took charge of the cases, are excluded." The same remarks apply to my subsequent practice, to which allusion will afterwards be made.

ear can be easily felt, I hold that the dangers to the child usually becomes imminent if it be allowed to remain undelivered more than two hours, especially where the pains are smart, or the compression is considerable. When mother and child have been much exhausted by a protracted or very severe labour, my rule is, when an ear comes within reach, not to wait more than a quarter or half an hour, or even, if the case is urgent, to deliver immediately. I always feel anxious, in such instances as I have mentioned, to get quickly over the latter half of the labour; for though no serious harm may yet have happened to mother or child, there can be no question that to the latter, at least, much additional delay would be fatal. If, therefore, nature is getting over this portion of the labour quickly, I am content; if not, I use the forceps and deliver."

"It seems almost self-evident, that a low rate of foetal mortality ought, cæteris paribus, to be equally favorable to the mother, for an easy delivery is certainly the first, though not the only condition for securing a good recovery. On the other hand, every one knows how, occasionally, an even frightful maternal mortality may attend labours of the most favorable kind. It is quite clear, therefore, that this circumstance vitiates statistics where the rate of mortality to the mother is used as a test of the comparative value of any line of practice. The true test, it appears to me, is the ratio of the foetal loss. If this be low, I think we are entitled to hold, that the maternal mortality ought to be low also. Of course, it is always satisfactory to find that the two co-exist. In the 731 cases I have referred to there were six maternal deaths, but in only three of these were the forceps used. Of the latter cases, one death took place from disease of the heart, and another from asthma. In one of the others, also, the patient was previously in the last stage of phthisis.'

The extracts which I have given will show how utterly incorrect the author of the article I have referred to is, when he says, " Dr. Hamilton recommends us to use the forceps within a quarter of an hour after an ear can be felt, if no progress is being made;" and also when he states that in my practice, I have "arrived at a fœtal mortality of about 1 in 317 cases." What is meant by the sentence "The more customary rule is to wait two hours or more, and not to interfere until spontaneous delivery seems hopeless," I do not exactly understand. I am aware that many very eminent obstetricians have advised us "not to interfere until spontaneous delivery seems hopeless," but that is a very different thing from waiting "two hours," as I have recommended. If it be now the "customary rule," as stated, to wait only two hours, I feel assured the forceps will be used much more frequently than what, in the article referred to, is said to be the practice of the "Dublin School," viz. 1 in 684, and also that the results will not be a fœtal mortality of "1 in 20 or 30," but will approach to the results which my practice has yielded.