in constant requisition, and are used with great advantage. Calomel, jalap, salts, rhubarb, tartar-emetic, colocynth, and croton and castor oils are in general use. The grand principle of moral treatment consists in directing the mind of the patient from the subject or subjects on which it is deranged to those on which it is not. As reason is disordered, it is obvious that all attempts to restore it by merely discussing with the insane the subjects on which it is disordered must fail. No appeal to fact versus fiction proves useful; a self-evident proposition frequently, or rather generally, appears to them to be absurd. It requires, therefore, much firmness, much caution, and a clear judgment, as well as quick perception, in conjunction with the best feelings of our nature, to bring moral treatment to bear successfully on the mind of the lunatic. Occupation offers many advantages; and idleness to the insane, as well as to those of sound mind, is itself a punishment; and to that portion of the monomaniacs who converse rationally on ordinary subjects, and generally conduct themselves with propriety, occupation is both an amusement and a powerful agent in recovery. Perhaps the good effects of this plan are best seen in the violent lunatic immediately after he has been subjected to the necessary medical treatment. To the ordinary maniac it has been of great service; to those bordering on fatuity it has also done good; and we may indeed add, in all cases where tried it has proved in some degree beneficial. The very bustle, excitement, and change, that our manufacturing and other works create in the House do good; which is also in some measure felt by those lunatics whose high rank and education prevent them from joining in these healthful exercises. It must, however, be admitted that medical as well as moral treatment succeeds in a much greater degree in the recent than in the old cases. No accident whatever has occurred, since the introduction of this plan of moral treatment in 1830, notwithstanding all kinds of tools and implements are daily used by the patients. In addition to the healthful exercises in which the ladies and gentlemen engage, such as music, dancing, and walking into the town and neighbourhood, and—which have been alluded to before-they are permitted to go into the country for several hours, in open or close carriages, according as the weather, &c. permits. In regard to restraint, moral treatment may itself be considered as a means of restraint, for it has generally superseded the other articles used for that purpose. To apply restraint properly is a most difficult and most painful, though in some cases an absolutely necessary task; and no one can execute this delicate business well who has not been accustomed to the treatment of the insane. It requires great humanity, great experience, and decided skill in the application of it. We have seen it have the most extraordinary good effect, owing in a great measure to the way it was applied."

The following is an interesting case.

In the Spring of last year a cabinetmaker was admitted labouring under deeprooted melancholy, who had been nearly twelve months affected. We tried all kinds of treatment, and at last by our perseverance have been entirely successful. In September he asked for his tools, they were immediately procured-a bench was got-and wood purchased; he shed tears-always said he was just going to begin to work, but something mental always prevented him, and he continued in this state till last April, when his depression almost left him, and he began to work in earnest. Since that time he has made handsome chests of drawers, &c., and has been cured, not more to the delight of his relatives than of us. This case is instructive, and shows how much can be done by a persevering plan of treatment, even with patients whose malady is of long duration. Another lunatic who was bred a flesher, after he became convalescent, made himself generally useful, and slaughtered and cut up the pigs for the use of the Institution.

5. Public Worship." In this country the first institution which gave to its

inmates the benefit of religious instruction was the Glasgow Royal Lunatic Asylum, and this was done, on the recommendation of its physician, nineteen years ago. In 1831, divine service was introduced here, the members of the Presbytery taking the duty Sabbath about, until a regular chaplain was appointed. Every succeeding Report has truly stated that nothing but good has resulted from its introduction, and that it has been and is highly appreciated by the lunatics in this Asylum, and to these statements we gladly bear testimony; and it is gratifying to learn that the other private and public asylums which have followed the good example set by the Glasgow one, confirm what is here stated thus showing not only the great utility, but the safety, of public as well as private worship, to those labouring under lunacy."

Such are the main features of the Report, which we may observe emanates from Dr. Nimmo and Dr. Mackintosh. We trust that they will endeavour to render the Institution as beneficial to the profession and to science as possible. Careful reports are of immense service.

EXPERIENCE OF MR. PORTER IN PUNCTURING THE DURA MATER AFTER

TREPHINING.

The following remarks are extracted from a Lecture on the Trepan, by Professor Porter, in our clever contemporary, the Dublin Medical Press.

Suppose, he says, that the trepan has been applied, and neither blood nor matter found-shall the dura mater be opened to search for the cause of mischief? Setting aside reasoning and other authority, Mr. Porter states, and we quote the facts with which he is actually acquainted.

"I must say that both my reason and experience are directly opposed to the operation. I have seen it performed, and performed it myself. In one instance of compression, the trepan was applied over the seat of the injury, or rather on the spot that had received the blow. Immediately on the piece of bone being taken out, the dura mater and brain rose into the vacant space, as if suddenly relieved from some compressing force, and (what seemed to decide the operator on puncturing the dura mater,) the brain did not exhibit the usual phenomenon of pulsation. The membrane was cautiously divided, but nothing found; and dissection shewed afterwards, that the extravasated blood was situated at the base of the brain. In the month of December, 1836, I trepanned a man for symptoms of compression, the result of inflammation, and apparently produced by matter. On removing the bone, I found that a scale had been broken from the internal table, and wounded the dura mater, and on this being taken away a small quantity of pus pumped up through the little aperture. I thought that if there ever was a case to justify proceeding farther, it was this one; the membrane had already been wounded, and I had ocular demonstration of the existence of matter underneath. I, accordingly, enlarged the opening, but I took nothing for my pains, no more matter was evacuated, and it was found, after death, that it could not have been, for it was smeared over the surface of the dura mater, closely adherent to it, and by no possibility capable of being removed. In a former lecture I stated that there was no circumstance to justify a surgeon in cutting through the dura mater, and I am strongly disposed to repeat the precept here."

Dublin Medical Press, Feb. 13th, 1839.

CLINICAL OBSERVATIONS ON THE STATE OF THE HEART AND ON THE USE OF WINE IN TYPHOUS FEVER. BY WILLIAM STOKES, M.D. &c.* The object of Dr. Stokes is to determine with precision the symptoms or circumstances which indicate the exhibition of wine in typhous fever. We may observe, in limine, that Dr. Stokes repudiates the doctrine of exclusive solidism, the modern theory that fever is but the symptom or effect of some local lesion.

"There can be no doubt," he says, "that the typhus of Great Britain and Ireland is a disease of the whole system, not symptomatic of any particular local lesion; shewing on the one hand a tendency to a favourable termination, after a period which varies indefinitely; and on the other, being capable of destroying life with various lesions, or without any appreciable change in the solids. It is a disease on which anatomy sheds but a negative light, not telling us what it is but rather what it is not.

With respect to the organic lesions, I consider them as much secondary to the general disease, as the pustule in small-pox is to the disease of variola. Their not unfrequent absence in the worst cases of the disease proves that they are not the cause of typhus, while in cases where they do occur, we observe a signal want of proportion between their amount, and the severity of the symptoms. They are in the fullest sense inconstant in their seat and extent, incompetent to the explanation of symptoms, and unnecessary to the characteristic phenomena of the disease."

After some remarks on the greater frequency of intestinal ulceration in the fevers of the Continent and those of Great Britain and Ireland, Dr. Stokes proceeds to observe :

"If we compare the inexperienced man with him who has had a long continued practice in fever, we may often observe that the former employs a too vigorous antiphlogistic treatment in the commencement of the disease, and delays the exhibition of stimulants until the powers of life are sunk too low, while the latter is much more cautious in husbanding the strength of his patient, and shews much less fear of resorting to wine and other stimulants. It is in determining on the use of wine in fever that the junior or inexperienced man feels the greatest difficulty; it is in its exhibition that he betrays the greatest uncertainty and fear. This is to be explained by referring to the general character of the doctrines which have prevailed within the last quarter of a century, and which are only now beginning to yield to a more rational pathology. The doctrine of an exclusive or almost exclusive solidism, which referred all diseases to visible changes of organs, which taught that inflammation was the first and principal morbid phenomenon, and that fevers were always the result of-or accompanied with-some local inflammation, was, however disguised under various denominations, the doctrine taught to the majority of our students. Their ideas were thus exclusively anatomical; inflammation formed the basis of their limited pathology, and thus instructed, they entered on the wide field of practice, most of them having never even attended a fever hospital; utterly ignorant of the nature of essential fevers, they applied, in the diseases of debility, the treatment of acute local inflammation, and delayed stimulation until nature could not be stimulated."

But the question comes-" what distinctive symptoms call for wine-how shall the inexperienced practitioner know when it is required?" Dr. Stokes thinks that to the want of wine the loss of many lives may be ascribed, and the very object of his paper is to endeavour to furnish some signs by which we may learn to give or to withhold stimulants.

* Dublin Journal, March, 1839.

It has long been known that if, under the use of wine, the pulse diminishes in frequency, the prognosis is favourable-if, under the same circumstances it becomes more rapid, our anticipations grow more gloomy. Reflection on this point led Dr. Stokes to endeavour to ascertain, whether any appreciable condition of the heart, besides the frequency of its contractions, would furnish the indication that was wanted. This inquiry he pursues with great zeal and with much interest through his lengthened paper. We cannot follow him throughout his observations and his cases, but we must content ourselves with stating the results, and recommending our readers most earnestly to consult the original paper. The conclusions of Dr. Stokes are:

1. That the condition of the heart in typhous fever must be determined by the application of the hand and stethoscope, the pulse being an uncertain guide. 2. That a diminished impulse, or a complete absence of impulse occurs in certain cases of typhous fever.

3. That in such cases we may observe a diminished first sound, or even an absence of the first sound.

4. That both these characters may exist with a distinct pulse.

5. That although in most cases the diminution of the impulse and first sound coexists, yet that impulse may exist without corresponding first sound, and conversely, that the first sound may be heard although unaccompanied by impulse.

6. That these phenomena are most evident as connected with the left side of the heart.

7. That when the impulse and first sound are lessened or lost, the return to healthy character is observed first over the right cavities.

8. That in some cases both sounds are equally diminished.

9. That in few cases the first sound preponderates.

10. That these phenomena indicate a debilitated state of the heart.

II. That they may occur at an early period of the disease, and thus enable us accordingly to anticipate the symptoms of general debility.

12. That the existence of these phenomena, in a case of maculated adynamic fever, may be considered as pointing out a softened state of the heart. 13. That this softening of the heart seems to be one of the secondary local lesions of typhus.

14. That the diminution or cessation of impulse, the proportionate diminution of both sounds, or the preponderance of the second sound, are direct and nearly certain indications for the use of wine in fever.

Spirit of the Foreign Periodicals, &c.

ON VACCINATION AND SMALL-POX.

In the last number of this Journal (vide page 271) we commenced an article on the present state of Vaccination in different countries of Europe, and, as it was left unfinished, we promised to continue the subject at our next trimestral appearance.

We stated the prevailing doctrines and practice of the German physicians, more especially in reference to the question of Re-vaccination, which has been adopted so extensively in the armies of Prussia and of some other states. We now proceed to explain what has been done and observed elsewhere; and shall then close our remarks with a series of corollaries, embodying most of the important information which has hitherto been obtained.

In no country has vaccination been prosecuted with more enlightened and assiduous zeal than in Denmark. The reports from this, as well as from every other country where it has been introduced, concur in loudly proclaiming the benefits of the great discovery; and, as very exact tables of mortality seem to be kept in Copenhagen, we have been enabled to ascertain the following particulars, in reference to the question now under consideration.

From the year 1800 to 1804, not a single case of small-pox in a vaccinated person was observed in that city. In 1804, two cases only occurred; and in both of these the disease exhibited a modified or varioloid character. In 1805, five persons (vaccinated, we presume) died from small-pox. In 1806, three vaccinated persons died. In 1808, there were 46 deaths in all from small-pox; and, of this number, 13 occurred in persons who were reputed to have been regularly vaccinated. In 1819, the number of cases of small-pox among vaccinated as well as among unvaccinated persons had very considerably increased; and in 1823, there was a regular epidemic of the disease in most parts of the kingdom.

During the three subsequent years-from 1824 to 1827-there was an annual renewal of the epidemic; and the following particulars are derived from the reports of Dr. Mæhl, physician of the small-pox hospital at Copenhagen. From January 1824 to February 1825, there were admitted 412 cases of genuine and modified small-pox. Of these 412 cases, 257 occurred in persons who had been vaccinated, 58 in persons who had passed through small-pox before, and 97 in persons who had not had either the cow-pox or the small-pox.

The ages of the 257 patients it is important to attend to, as we are thus enabled to form some idea of the length of time that the protecting influence of vaccination may be supposed to last:

24 were under seven years of age.

42 were between seven and eleven years of age.

191 were between twelve and twenty-three years of age.

257

So much for the age of the patients; and now for the character and issue of the disease. Of the whole 257 cases, there were only 16 of genuine small-pox; in all the rest the disease was more or less decidedly modified. Of the 16 cases, only 3 proved fatal; and these three occurred among adults.

It is needless to point out to the reader's attention how these facts strongly bear out the idea, now generally received, that the protecting influence of vac