the heart and arteries. In many cases it acts like a charm, subduing the excitement and violence of the patient, and sometimes an alteration of the symptoms for the better commences with its administration. If, however, the doses are large and repeated, great prostration of strength may be produced.

Narcotics.-Much difference of opinion exists with regard to the benefit to be derived from their administration. Dr. Sutherland's experience leads him to the conclusion, that opiates are of essential service in those cases of insanity which border closely upon delirium tremens; in cases of puerperal mania; in the first breaking out of an attack of madness, before congestion has taken place; in cases where there is great nervous irritability, from poverty of blood; and in cases of cachexia from starvation, and other causes: they are contra-indicated wherever there is the least sign of general paralysis or congestion about the head. Hyoscyamus and conium may be employed as well as opium and morphia. Hyoscyamus often agrees better with the stomach, and it does not constipate the bowels; it also increases the secretion of the kidneys and of the skin. It is often serviceable, combined with tartar emetic, in paroxysms of furor.

Combined with camphor, opium allays the irritability of those suffering under madness, either accompanied with some degree of delirium tremens, or preceded by it. Stramonium, belladonna, and aconite are not, in general, of very much importance.

Hydrocyanic acid is useful as a sedative in those cases where there is pain and a sense of weight about the præcordia. If acid eructations are present, it may be combined with soda, or, if there be much action of the heart and arteries, with digitalis.

Diuretics. The urine of insane patients is very often, at the commencement of the attack of mania, scanty and high-coloured, with a lateritious sediment. Sometimes no water is secreted for a day, sometimes for two days. In these cases nitric æther, with nitrate of potash, infusion of digitalis, or the compound decoction of scoparius may be given with advantage. The more powerful diuretics are seldom of much service; even where you suspect effusion, or in incipient paralysis, the bichloride of mercury is generally to be preferred to cantharides.

Tonics. Since the insane have been better fed, there have been, on an average, more recoveries and fewer deaths. Even in acute mania it is necessary to have reference to the future condition in our treatment. Light bitters, mineral tonics, the preparations of iron, the sulphate of zinc, and the salts of copper, are often valuable medicines in nervous disorders.

Blood-letting. This practice fortunately does not prevail in England as it formerly did. Even in acute mania with symptoms of plethora, local abstraction of blood by means of leeches is a much more safe means of proceeding.

Counter-irritants.-These are much employed in the treatment of insanity. They should not, however, be used in the acute stage of mania, certainly not till the heat of skin and general irritation from the loaded vessels have subsided. The acetum instead of the emplastrum lytte ought generally to be employed.

In some cases of insanity which run their course sluggishly, or where there is a healed ulcer, or a suppressed discharge, setons are of great service. Esquirol says they act as if by enchantment. The ung. antim. pot. tart. proves beneficial in some cases of suppressed eruptions, and as a counter-irritant.

Strychnine has proved serviceable in catalepsy; it is also useful in cases of insanity accompanied with paralysis. Where patients have illusions of hearing, cotton, on which laudanum has been dropped, may be put in their ears: it is also useful to have the cars syringed, or to place small blisters behind each ear, to

divert the attention of the patient from the noises and whisperings on which his imagination dwells.

The function of the skin is often disordered in insanity, to remedy which state baths of every description have been, very properly, recommended. The tepid bath is of great service in subduing irritability and excitement. It is sometimes necessary that the patient should remain in it for an hour and a half or two hours. Ice or cold lotions to the head should be applied at the same time: it may be necessary to repeat it every day, sometimes twice daily, till some effect is produced.

If the irritation is not subdued, a blister may be applied to the nape of the neck, immediately the patient leaves the bath. In acute dementia, much benefit may be derived from the douche, but this is a remedy which requires caution, and is not by any means to be ordered for those patients who are liable to congestion of the head, or have any tendency to paralysis.

The shower bath, with antispasmodics, is a valuable means of subduing the symptoms of madness with hysteria and hypochondriasis.

When a patient has passed into what is termed the chronic stage of the complaint it by no means follows that nothing is to be done for him; something can be effected by medicine even here, in shortening the paroxysms of furor, in procuring sleep for the restless, and improving the general health of the debilitated.

ST. GEORGE'S HOSPITAL.

REPORT OF CASES OCCURRING IN THE PRACTICE OF MR. HENRY JAMES JOHNSON, Assistant-Surgeon to the Hospital.

The following are selected from amongst the many of a miscellaneous character, which have been under treatment lately.

1. CHRONIC ABSCESS IN THE SUBSTANCE OF THE TONGUE.

Case. Thos. Adams, aged 17, a vendor of cat's-meat, came under my care on the 10th of May of this year.

In the substance of the tongue, on the right side of its median line, and about three quarters of an inch from the tip, is a hard, globular tumor, of about the dimensions of a small marble. There is occasionally some shooting pain in it, and it is rather tender upon pressure. The speech is rendered indistinct by it. No enlargement of lymphatic glands. Face somewhat puffy, but health reported good.

He states that he first perceived the swelling, accidentally, nine months ago. It was then very small, and has increased gradually since. Painless at first, it has become tender within the last three weeks. He can assign no satisfactory

cause for it.

The tumor felt as hard as a scirrhous tubercle, but the age and appearance of the lad combined to render that idea improbable. The globular form and firm resistance conveyed to me the impression, that there was either a cyst with thickened walls, or chronic abscess. I therefore introduced the exploring needle, and was gratified to observe a drop or two of distinct, yellow pus escape along the groove. The size of the swelling was little reduced by the evacuation, and it was evident that the parietes of the abscess were so consolidated as to form the bulk of the tumor. I prescribed :

Pil. hyd. chlor. comp. gr. v, omni nocte;-Dec. sarsæ comp. 3ij. bis quotidie ;-Magnesiæ sulph. 3ss. p. r. n.

By the 15th of June, one month from the puncture, the tumor was reduced to

half its original size, but continued very hard. It was quite unattended with pain, but still occasioned difficulty of articulation.

By the 4th July no trace of the complaint could be detected, but, seemingly from habit, the speech was still thick and indistinct. It may be stated that the gums were never affected, and that the health improved.

A few days after this, he was attacked, without obvious cause, with inflammation of the globus major of the epididymis, on the right side. This speedily subsided under calomel and opium, leeches, saline purgatives, and the application of a belladonna plaister. On the first of August, he was discharged cured.

I apprehend that chronic abscess in the substance of the tongue is rare. Acute inflammation is more common, and cysts are occasionally seen in it. But perhaps the most frequent affections of it are cachectic tubercles and ulcerations on the one hand, and malignant growths, or alterations on the other.

A year or two ago I saw a case which had some little interest attached to it.

II. TUMOR AT THE SIDE OF THE TONGUE.

A gentleman between forty and fifty years of age, inclined to corpulency, of indolent habits, and rather a bon-vivant, had suffered much, at different times from dyspepsia. Between two and three years ago, he came to me one morning in a state of some alarm, on account of a swelling which he had discovered on the left side of his tongue. It was opposite the first large molar tooth-when the tongue was protruded, it was about the size of a horse-bean, when retracted it nearly disappeared-was of bluish colour, with one or two large veins on it— was little, if at all, painful or tender-and rather occasioned alarm than inconvenience.

On examining it carefully, I could not satisfy myself of the existence of any actual tumor, that is of decided increase of bulk, or hardness, or other modification of density. It conveyed to me the impression of mere hypertrophy of the substance of the tongue, palpable only when the organ was thrown into a state of tension by the action of the genio-hyo-glossus and lingualis.

This opinion I ventured to give, and endeavoured to relieve the gentleman's mind by assurances of freedom from danger. But the idea of cancer had taken hold of him, and quite weighed down his spirits.

I prescribed a mild aperient pill to regulate the bowels, and advised the least possible interference with the part. A tooth, which might press on it, was, by Mr. Bell's suggestion, taken out.

Actuated by his apprehensions, Mr. B. did not long follow my advice, but applied to an eminent surgeon. This gentleman conceived that the swelling was a cyst, and punctured it with a needle. Nothing, however, but blood issued. It was then touched at stated intervals with caustic, and medicines of an aperient and tonic character given. But, under this treatment, the swelling increased rather than otherwise, the tongue grew foul, and the general health, the effect, probably, of anxiety, deteriorated.

Under these circumstances, Mr. B. consulted Sir Astley Cooper. Sir Astley, after a hurried examination, pronounced the case one of malignant disease, and advised the employment of the ligature without delay. His worst anticipations being now realised, the patient returned to me, and in a state of extreme despondency informed me of Sir Astley Cooper's opinion. I was naturally staggered by this, and made another and a careful examination, without seeing cause to alter my own. I suggested an application to Sir Benjamin Brodie, whose judgment and candour are so worthy of reliance in every case of difficulty. I gave the patient a note to Sir Benjamin, stating what had occurred. He went into the case fully, and gave it as his opinion that there was no disease of any consequence, confirming by his high authority the view and the practice that I had adopted.

The relief to the patient's mind was, of course, extreme, but he could not altogether shake off his fears, and, even to this day, he occasionally becomes alarmed. Being let alone, the tumor has sensibly declined, and occasions no pain nor annoyance, yet a fulness is still there, or, rather was there, when I saw him last, which is now twelve months ago, but I believe he is quite well in his general health, and thinks or says little of his tongue. I have lately had a very similar case amongst the out-patients of the Hospital. The patient, a girl, was sent to me for collection of fluid in the sub-lingual gland. No such collection existed.

Perhaps the most common affections of the tongue are cachectic tubercle and ulceration on the one hand, and what is sometimes called psoriasis of the tongue, upon the other. A word or two on each may be excused.

III. CACHECTIC ULCERATION OF THE TONGUE.

Without going fully into its history, it may be observed that this affection sometimes accompanies rupia, ecthyma, or other forms of cachectic eruption or ulcer, and sometimes occurs independently of any other symptom. Whichever is the case, the patient, in most instances, is palpably below par in constitutional vigour, and, not unfrequently, has suffered from the effects of mercury. He is mostly pallid, and the digestive organs are, in many instances, deranged.

Sometimes the free extremity, most commonly one side of the organ is affected; the median line then, forming a barrier against its extension to the other. There is swelling, sometimes tubercular in form, and hard, or rather boggy to the feel -with ulceration, irregular in shape, and of dirty yellow colour, with picked, or imperfectly healing edges. The ulcers may be deep and fissured, or scooped, or almost superficial. It is not uncommon for a tubercular nodule to ulcerate, and disclose its substance permeated by a yellowish substance, which forms the basis of the ulcer. The analogy between this, and the cachectic subcutaneous tubercle of the skin, can scarcely fail to be perceived.

These ulcers may or may not be painful, they are, at all events, a source of inconvenience, interfering, more or less, both with speech and deglutition.

Slow in formation, tedious in progress, they in many instances last for a very long period, and, in most, are tardy in their disappearance. I have known them heal almost miraculously in a very short space of time, and I have also known them hang on for months and even years.

The treatment which seems to answer best, is such as is generally applicable to cachexia. Sarsaparilla, the iodide of potassium, the mineral acids with bitters, quina, the ammonio-citrate and the iodide of iron, &c. in partial combination, and succession, combined with attention to the digestive organs, and such regimen and diet as are calculated to give tone to the general health.

The effects which follow the exhibition of the iodide of potassium are occasionally as remarkable in this, as in other forms of cachexia.

A gentleman consulted me three or four years ago, with this condition of tongue. He had laboured under it for five years, and a source of great distress it had been to him. He had employed a variety of remedies, and its origin could be traced, in my opinion, to abuse of mercury. I prescribed sarsaparilla and the iodide of potassium, with a suitable course of living, and directed the occasional application of a solution of the nitrate of silver to the fissures, with the daily use of the honey of borax. This gentleman went back into the country, from which he had come to consult me, and I heard no more of him for many months, when he called on me to report the rapid cure which the remedies ordered had effected. In the course of six weeks from commencing them, the tongue appeared quite well. He has since had a slight relapse, but it was quickly arrested by the same measures.

The combinaion of the ammonio-citrate of iron with the iodide of potassium

has seemed, on more than one occasion, a highly serviceable one. The formula is this: B. Potassii iodidi

Potassæ bicarb.

Ferri-aminonio-cit. sing. 3ss.
Tinct. aurantii c. 3ss.

Aquæ dist. 3vss.

M. Capt. æger coch. ij magna bis quotidie, superbibendo (post semi-horam.) Extracti sarsæ concent. c. 3ss. ex aquæ poculo.

In cachectic ulcerations of the skin, resulting from abuse of mercury, this combination is at times peculiarly valuable.

A gentleman came to me, three years ago, from Lynn, with such ulceration in a severe form upon the leg. It had existed for four or five years, and he had exhausted the medical advice within his reach. He had taken an excessive quantity of mercury, to which, with justice, he attributed the ulceration, which was of serpiginous character, and commenced as soft tubercle. It had not been limited to the limb, but had left unhealthy cicatrices on various parts of the body.

I prescribed the iodine, with iron and sarsaparilla, in the manner above stated, and the result was surprising. In a very few weeks the ulcer healed, the general health was restored, and there has not since been any return of the disease.

I might mention several cases, of a similar description, but it would be tiresome and needless, the experience of other surgeons being capable, no doubt, of supplying many such. Yet it is not always that the issue is so flattering, these cachectic ulcerations, whether of the tongue or of the tegument, being, in too many instances, uncertain, tedious, and obstinate. Cunctando vincere must be our motto, and it is necessary to wear them out, and build the patient's constitution up, by ringing the changes on tonics and tonic alteratives, to the exclusion, most religiously, of mercury.

Some apology is due for these desultory observations, but their clinical character may excuse their being found in a mere Report of Cases.

IV. PSORIASIS OF THE TONGUE.

This frequently coincides with the exanthematous mercurial or venereal eruption, with psoriasis guttata of the same character, with condylomatous ulcers of the genitals, which may, however, have only preceded it and disappeared—and, it not unfrequently, exists or survives as an isolated symptom.

The appearance of the tongue varies, in no important degree, from some such standard as this. It has a patchy aspect-spots of the circumference of a pea, or much larger, are red, smooth, shiny, and evidently denuded of epithelium, or having the latter much attenuated. In other parts, there are opaque white patches, varying in number, disposed to be circular, and looking not unlike portions of wax, which had dropped on the tongue in a melted state, and coagulated. The tongue itself is generally sore, sometimes fissured, particularly in the median line, and occasionally swollen, indented by the teeth, reddish, irritablelooking and inflamed. But this latter condition is comparatively rare.

There may, withal, be whitish ulceration of the throat, such as I have described in connexion with ulcerated condyloma,*-or a similarly opaque condition of the epithelium of the palate, and, there may be the several cutaneous complications which I have already mentioned.

Vide Medico-Chirurgical Review-Cyclopædia of Practical Surgery, Art. Condyloma.