MORAL or empirical means are much more useful than the indirect or medical : always necessary, they act with a much more constant utility than the other class. Alone, they can cure many cases. The medical act ordinarily by dissipating sympathetic symptoms, and restoring the health of the general economy. The reason of the superiority of the moral is, that by these we act directly upon the part of the brain which is endued with mental functions and which is the seat of the disease ; whereas by medical means we can only affect directly that portion of the brain endued with the nervous influence ; and thus act but sympathetically upon that possessing psychological properties, and forming the object of curative endeavours. He divides the treatment, then, into direct or moral and intellectual, and indirect or rational.
I. Moral. The indications here are as follows :-1. To remove or lessen causes which, having originally brought on, tend afterwards to keep up and renew the disease. 2. Separation from the objects causing or connected with the derangement. 3. A location in which they cannot commit acts injurious to themselves or to others. 4. To rectify false sensations from which spring hallucinations, and a crowd of strange ideas and actions. 5. To fix the attention of the maniac upon a small number of objects ; to force him to think, to reflect upon what he says and does, to hinder his thoughts from wandering over all things without resting on any one. 6. To withdraw the attention of the monomaniacal from certain objects upon which it is riveted too strongly ; to cause oblivion of the false ideas which constantly possess, sadden, and alarm them, and to counteract feelings of too exalted a nature, by exciting those of an opposite character. 7. To arouse the thinking faculty in the torpid, with them almost inappreciable ; to dissipate their confusion of ideas, and give them the power of expressing them. 8. To restore their courage to the lypemaniacal, to draw them from the sadness and moral abasement which overwhelms them. 9. Finally, to lead all the insane to their ordinary feelings and affections. We can fulfil these indications in two ways : passively, by isolation ; and actively, by what I call medical education.
Separation from their friends, and the circumstances in which they are found, is almost indispensable in curing the insane. By such a Separation things connected with the disease are thus withdrawn from the notice of the patient ; moreover, strangers can manage them better ; and new objects attract their attention, and take it from their delusions, &c. There are three modes of isolation-travelling, a house prepared for the individual alone, and a building for a number of the insane. Travelling is suitable only in convalescence, and in some varieties of melancholy bordering on hypochondriasis. A house prepared for one individual 113 solely, is inferior to a general establishment. At Salpétrière, the female attendants are chosen from convalescent patients : this measure is very advantageous, from the greater interest taken by them in the patients ; and from the knowledge which they have of the causes of their agitation and mental suffering, which they are thus enabled the better to alleviate. The duty of repressing disputes among the patients should fall to a subordinate officer. The physician and chief supervisor should seek to be loved and confided in by all. The very habit of repression would, in this particular officer, create a great influence and power over the patients as to the point in question. The power of the physician should be absolute. Persons employed in the institution should never be publicly reprimanded for any fault ; for this leads the patients to disregard their directions. We should seek to gain the confidence of the patients by treating .them with kindness ; by persuading them that we wish them no evil, and that we have had no hand in confining them. It is very necessary to guard against deceiving them in the least degree. The only means of restraint at the Salpétrière is the strait waistcoat. The tranquillizer of Rush, however, seems to be very useful in some cases : to repress a furious maniac, a large number of persons should surround him simultaneously, without hesitation or the least fear, or even a doubt that he will be able to resist. At the Salpétrière, in such instances, a cloth is suddenly thrown around the head of the patient, which so confines him that he yields without resistance. Though we should employ kindness to calm and restrain the insane, when they do not wish to obey, it is necessary to use some measure of repression ; if they commit reprehensible acts, they should be punished immediately. There are some who act knowingly and wilfully ; a greater degree of rigour should be adopted with respect to these. For this purpose at present only humane means are employed. A change of habitation, a stay of some time in a grated court, the strait waistcoat, the douche, seclusion for many hours or a day in a lodge, are the only means used at the Salpétrière. No blows or bad treatment are ever admitted. The insane will yield more readily to those of an opposite sex than to their own ;this is essentially the case with female patients, arising principally from the fact that the idea of the opposite sex always affects an individual agreeably.
Medical Education.-The more simple the means of education are, and the more familiar to the insane person, and the less intellectual power they demand, the sooner can they be profitably employed. Manual labour, that of the field, and some objects of recreation, fulfil very nearly these conditions. The first principle here is, never to exercise the minds of the insane in the sense of their delirium. 2. Never to oppose directly their diseased ideas and feelings. It is not until reason has in a great measure returned, that we can with hopes of success seek to remove directly by reasoning the few false ideas which remain. 3. A consequence of the other two principles is, to fix their attention on objects foreign to their delusion, and to communicate to their minds new ideas and emotions by varied impressions. We have here as our endeavour-1. To occupy the mind of the patient with something else, and thus cause him to forget his irrational ideas. We produce this by manual and rural labour, objects of recreation, &c: 2. To counterbalance and dissipate, by the opposition of the new impressions, the ruling ideas : here is particularly referred to, the excitement of the passions. 114 3. To give means with which to combat the diseased fancies. Instead, for instance, of refusing a lunatic the character of kilt,, which he pretends to possess, prove to him that lie is without power ; that you, who are anything but a king, have the control of him. Do not say to those having hallucinations that they hear nothing ; but enter with theirs into the place whence proceed the voices ; and often renew this expedient ; though it does not often have, much effect. With a lunatic who believes himself surrounded by his enemies, and who is frightened at everything, place an attendant day and night, and his fears will be removed. 4. To excite the cerebral action of tile torpid, and of certain lypemaniacs, to move them powerfully, to break the chain of disordered ideas. Certain lively emotions sometimes act, thus. I have often sottgltt to make lunatics feel their situation, the quality- of the clothing, their culpable indifference towards their parents. Case.-Miss M-. Torpid nearly a year; in a state of complete inditlerence respecting her own condition and that of her family ; every morning, during about fifteen days, I excited her as referred to above with success, and convalesence declared itself in a short time. The means by which we attain tile effects proposed under the above four heads consist, very nearly, in the conversation and counsels of the physician, the society of the convalescent insane, manual and rural labour, objects of recreation, the sight of parents or friends, in the diminution arid then the cessation of isolation, and in travelling.
From his previous knowledge of a patient's past history, a physician may often at his first visit succeed in gaining great ascendency over him, by talking in a prophetic tone as to the conduct of the individual ; saying, for instance, " You have wicked designs, you seek to destroy yourself," &c. He will be astonished at these predictions, will ordinarily confess himself sick, which familiarizes him to the idea of being treated, and his confidence will be gained. I have seen the happiest results from acting upon their imagination. Case.-A young female ; discharged well from the Salpétrière, after a month returned with heavy heart, for a consultation respecting certain symptoms which she feared to be the prelude of a relapse ; it was, in truth, thus that the disease had first come on. After having consoled her, M. Esquirol wrote down, "I answer for the cure of Miss -." Convinced that lie would not compromise his reputation, by so positive an assurance of that respecting which lie was not certain, she regained hope, and from that time all the symptoms disappeared. The physician should not content himself with seeing the insane at one visit in the morning, but he ought to be constantly among them, to study the motives of their actions, the variations of their character, to reprove, to see that they executed the promises which they had made, to eat, to be tranquil, to labour, &c. Nothing is more favourable to accelerate a cure than reunions of the patients who are more or less convalescent ; by reason of their having the interest in common of entering again the bosom of their families, &c. It happens not unfrequently, too, that one in a better state of mind will take pains with another, giving him hope and conversing with him ; and this assistance is of such remarkable utility, that we ought, I think, in great part to attribute the little success which is met with from particular isolation merely to the fact that it is impossible to replace this aid in such a situation. The very melancholy, the despairing, those with a suicidal propensity, should never be placed together ; they would seriously injure 115 each other ; they should be separated, and confided to others who are more gay.
A labour more corporeal than intellectual has been advised by all authors, and particularly by M. Pinel, as one of the principal means, of treatment. This turns away the too fixed attention of a certain class of the insane ; it fixes, on the contrary, that of others, habituates the mind to form combinations, in the first instance simple. ones, and thus combats the delusions without violence. At the Salpétrière, the females knit and sew, they seek by every possible means to occupy them ; it is a condition imposed for obtaining favours, for being placed among the convalescents, to see the family, to go from tie house, &c. ; very good effects are obtained from it. The men are furnished with means of labour, analogous to their previous mode of life. The cultivation of land and the exercise of certain trades fulfil perfectly the same object. Similar measures impossible with the higher classes, as they are unwilling to engage in them : it is necessary, then, to obviate this circumstance by occupations more analogous to their condition, such as games of skill, billiards, the ring, the exercise of acquired accomplishments, as singing, painting, playing on musical instruments. M. Esquirol has not obtained any good effects from plays and concerts, as means of abstraction (distraction). The first have often increased the delusions, and the second conveyed the idea that. their misfortunes were made a matter of sport. I think, however, that in an advanced stage of convalescence, they agreeably recreate the mind and operate as a useful diversion. Reading should not be permitted until very late, arid also requires discernment. We should take care that the patient should not find therein opinions and circumstances which may disquiet him and augment his delusions. We can sometimes permit the study of some branch of natural history; for example, of botany. Every asylum should contain large gardens for promenading, that those who do not wish or are not able to labour, may at least walk about : the furious even, restrained with the strait waistcoat, ought to be permitted to go about freely, in separate enclosures ; nothing so much augments fury as forced repose. Now the body being thus fatigued and the mind more or less abstracted, repose for the night is induced. The rich find a powerful means of abstraction in travelling : I would counsel every person who is able, thus to consolidate his cure. The cessation of isolation by the visits of parents or friends offers, at the same time, a fit occasion for the production of very important impressions upon the patient. In general, we ought not to grant interviews unless the patients themselves desire it, and have requested it for some time. It is necessary, in order to guard against all hazard, to announce beforehand to the patient the day of the first visit, and the name of the persons whom he is to see. If he is rational, and is pleased without wishing to accompany them on their departure, they may make subsequent visits. These visits revive old feelings and hasten convalescence : but if patients do not ask to see their relations, an interview is not desirable. But in certain cases of protracted indifference, of moral insensibility, we can awaken by those means a lively feeling of surprise ; it is necessary, then, that the visit should be unexpected. In convalescence, we should never expose the patient to any sudden or lively emotions, his mind should not be fatigued by any very profound psychological combinations, or by an action too long kept up. When the faculties have been perfectly restored, a relapse should be guarded 116
II. Medical. The general principles of the expectant mode of practice, apply to the treatment of insanity. With the exception of a small number of cases, in which their salutary effects are indisputable, medicines serve but. feebly to change or sensibly modify the succession of phenomena in disease ; and the physician, playing the part of spectator, does much towards the cure, in removing the influences which have caused the disease, and the circumstances calculated to aggravate it, and he is fortunate if he succeeds in removing the obstacles which oppose its procedure to a favourable termination. According as the malady is uncomplicated, and regular in its progress, or the reverse, will be the indications. If its nature and course are changed and impeded through the agency of age, sex, idiosyncracy, or some other modifying circumstance, it will be necessary to restore its proper characteristics, in order to obtain a cure. Sympathetic symptoms may also be presented, affecting the general economy, of sufficient importance to merit the attention of the physician. But in general, it is less by embarrassing the natural progress of the disease through the importune employment of medicines, more or less energetic, that we conduct most patients to recovery, than by the avoidance of all unfavourable influences, and by preventing the occurrence of things having a prejudicial tendency with respect to the disease. Above all, when there is no danger present, and no apprehension of its approach, we should carefully refrain from violently disturb, ing the succession of the periods which characterizes the disease. We ought then to make our practice expectant : by letting the whole system rest, and causing every function to cease which has any important connexion with the diseased organ, as, for instance, digestion and the operations of the mind ; by satisfying pressing wants, as the thirst ; by favouring the natural alvine, urinary, and transpiratory secretions, we give rise to the circumstances the most favourable to recovery, when often active remedies would but destroy.
On the other hand, when the malady follows a course incompatible with a cure, when it is encumbered by accidental circumstances, when there is too much or too little excitement, when a fatal termination announces itself, when the duration of the disease has passed its ordinary limits, and a chronic and incurable state is feared, then the physician should act, to establish order-to prevent fatal results. Maladies also which announce themselves from the commencement as very dangerous or mortal, permit the immediate employment of medical means (perturbateurs), guided always by reason and experience. Sympathetic symptoms may, too, by their intensity or locality, become prejudicial to the organ primitively affected and to the general economy, and thus sustain or even augment the principal disease ; and though usually disappearing simultaneously with their cause, yet here they merit regard. The same affection will offer species or varieties, which may require a peculiar or even very different treatment.
Ths simple and favourable course of insanity has been described; we shall see this course disturbed or arrested by-particular conditions of the diseased organ : some symptoms will call for special attention ; finally, 117 many varieties will merit separate consideration. W e shall establish the rules of treatment agreeable to this order.
The same general principles of hygiene apply to the insane, which hold good with respect to those affected by other diseases. I proceed to glance at a few things in which there is a difference. If a patient does not wish to eat, without being prompted to this feeling by the condition of his organs, but from the influence of erroneous moral motives, as the fear of being poisoned, not being able to swallow, or the intention of starving, persuasion, menaces, or punishment should be employed to induce him. If a furious patient, who has been shut up in a dark lodge, persists in wishing to go out, he should not be hindered for a long time ; for he will become otherwise more indocile and violent. Experience proves that to the demented throwing off their clothing, on account, as they say, of their being stifled by the heat, it is better not to oppose ; nevertheless, they should not be thus exposed to the winter's cold.
The Simple and Regular Course of Insanity.-The disease here runs, without obstacles, through its different periods successively, even to convalescence and recovery. The functions, more or less disturbed in their action, return by degrees to their previous condition. Nature calls for no succour from us, except, so to speak, that of a passive character, suitable to place the organism in a state to re-establish itself through its own powers alone, by removing the circumstances which would hinder this, by favouring the happy tendencies which are naturally in preparation, and, above all, not interrupting the repairing power by disturbing means.
In the period of incubation we can effectually combat the slow causes of insanity, which have not as yet disturbed the reason. It will suffice, in fact, mostly to cause their action to cease, from which the brain, as yet little altered, easily returns to its ordinary state. If you withdraw immediately a foreign substance which irritates the conjunctiva, you prevent ophthalmia, and the eye has scarcely been affected at all. Unite two lovers who cannot live separate, give peace to a female harassed in her household, repair injustice, restrain your wives and daughters, already too much inclined to fanaticism, from attending the discourses of violent preachers, and you will often prevent the development of madness, although the reason has already been somewhat affected.
Period of Excitement.-The heat, the muscular agitation-oftentimes even convulsive, here so frequent-clearly demonstrate nervous excitement. All the means employed, which tend to calm the disorder, are those entitled cooling and emollient. We should see that the patients do not receive too strong a light, which always agitates them. On this account it is advantageous to place them in summer towards the north. They should walk in the open air, but through umbrageous avenues. If we can, without too much compulsion, retain the furious in dark lodges, many hours of the day, they will experience good effects from it. The melancholy and the torpid should remain as long as possible out of their habitations, in order to be influenced by external objects, which would but too much excite the maniacal, but which arouse the torpid, and prevent the melancholy from brooding over their delusive ideas.
The hair, especially that of females, should be cut short: heat is thus lessened, applications to the head become more convenient ; nutritive action is decreased and the vital action of the skin of the part; the hair, also, would otherwise become tangled, and give pain on being combed. 118 Patients who do not wish to keep on their bonnets or hats, ought not to be constrained to do so ; they wish to expose the head to the fresh air.
The thirst is usually very intense : and patients should be given, in abundance, cooling and acidulated or mucilaginous drinks, according to their taste and their constitution, such as orgeat, lemonade, emulsion, all sorts of cooling syrups, or a decoction of barley, either simple, acidulated, or tartarized, gum-water, &c. Those who fear being poisoned, desire water merely, and will not refuse it; it may be sweetened and a little vinegar added. It is necessary to see that the insane have drink at night ; at the Salpétrière, persons go many times during the night to be satisfied on this head. In the summer they should be given a profusion of aqueous and acidulous fruits, as gooseberries, cherries, grapes ; these satisfy both the palate and stomach. At this period, they should not partake of wine or strong beer ; they can be given only, at meal-time, water reddened with a little wine.
Warm baths form one of the fundamental bases of treatment at the Salpetriere. All the females in whom there is no contra-indication take one many times weekly, or even every day, according to the necessity. They are a longer or shorter time in the bath on each occasion, according to the extent of the effects which it is wished to produce, and the capacity for bearing them. The vigorous, those very much agitated, of whatsoever class, whether maniacs, monomaniacs, or the torpid, take a bath every day, and are as long as possible in it, from half an hour to one or two hours or more. Those, on the contrarv, who are feeble, with a narrow chest, the apoplectic, are bathed more rarely and during a shorter time. Sometimes even baths cannot be employed without provoking suffocation, spitting blood, or the tendency to apoplexy ; they should then be left off entirely. They tend powerfully to diminish the general excitement, to calm the nervous organs, to dissipate the state of tension, the agitation, and the exaltation of the muscular power ; they restore freshness to the arid skins of certain melancholics ; also as a means of cleanliness they are very useful, often essential.
We must pay particular attention to guard against constipation ; and, as the insane do not easily give an account of their situation, the attendants should make themselves certain whether or not they have gone to stool; the physician may ascertain the position of the descending colon, by feeling the abdomen in the flank and in the left iliac fossa. If cooling and emollient drinks are not sufficient to prevent this intestinal state, we may cause a moderate looseness with tremor-tartar water, tamarinds, preserves, &c. We should make use, at the same time, of injections simply emollient. This is a secondary evil merely, and only requires palliation, as it disappears along with the principal.
It is with these simple, mild means, or others analogous to them, that we should treat the period of excitement in insanity, when its course is regular, and does not present special indications.
As reason is almost as precious as existence, we may attempt to conquer the disease by extreme or empirical means, but only after having vainly essayed others, and when our limited knowledge prevents us from comprehending the true nature of the disease. One of these means is bleeding. As to this remedy, there are many reasons for excluding its employment during the period of excitement. Even if the patient does not sleep, narcotics also should be excluded at this stage of the disease. There are often present in the commencement of insanity gastric symptoms, 119 such as want of appetite, furred tongue, &c. We should here not employ emetics or other disturbing means ; do not disturb the course of nature, calm the thirst with abundant drinks, diminish the cerebral irritation, and the alimentary canal will shortly regain the exercise of its functions. Purgatives are here not called for any more than emetics. With females, the menses are generally suppressed ; they will almost always be re-established with the return of the general health, and therefore we need not employ means for their restoration, except when obstinately suppressed, of which condition we shall hereafter treat. External excitants, such as vesicatories, setons, cauteries, sinapisms, &c., do not suit here. Later they are of great utility, but it is when we no longer fear to establish new centres of excitement, capable of augmenting the original source. Cold baths, cold applications to the head, and the douche should never be used in the period of excitement. I am entirely convinced that the douche should not. be used in any case, except as a means of repression, and to act morally. M. Pinel has already advised the reduction of the column of water to a thread, simply to sprinkle the head. At the Salpétrière few of the females receive it, and only during some seconds, or two or three minutes. Even M. Esquirol has been by degrees convinced that this means has never produced marked good effects. I have seen it administered during three quarters of an hour in a hospital of Provence ; and one patient there took it for nine hours, after which the disease was pronounced incurable. One died from it at Charenton, and two others scarcely escaped the same fate. The douche causes incurability in many cases by disorganizing the brain. It should be proscribed entirely as a medical means, to be replaced, where it tnight be suitabie, by lotions and affusions, which would at least be harmless. The bath of surprise and the rotary machine used at Berlin, are among those violent means which might possibly be sometimes advantageous, but whose use is attended with the hazard of rendering the patient worse or making him incurable. I shall not even treat of asphyxia from submersion or hanging, falls from a height, trepanning and castration, which have been proposed as remedies; for they are wholly ridiculous. I pass on to the consideration of the irregularities of madness. All the cases which I have been able to observe, which, deviating from the simple and regular course of the disease, call on this account for peculiar measures, in order to meet the indications, may be included under the physical states designated as follows :-1. General Plethora. 2. Debility--Atony, &c.
1. This condition is not rare in the insane : sometimes it occurs from the suppression of a hemorrhage, which is not renewed again. The young, vigorous, and naturally sanguineous, and females bordering upon the critical period of life, are more particularly disposed to it ;' patients, a~so, who are indifferent about their situation. It is recognised by a fulness and frequency of the pulse, by lassitude, and a feeling of weight in all parts ; the superficial veins are swollen and the capillary vessels injected. Sometimes nasal hemorrhages occur, oppressed breathing, or spitting of blood. The nervous energy and turbulence are diminished, and the patient is altogether sluggish in his deportment. The curative indication is evidently a diminution of the mass of the blood. The quantity drawn once or twice varies according to circumstances, which the physician easily appreciates. The stamina and the age must be considered ; and the advisableness of a second or third bleeding will be 120 judged by the effects of the first. The menstrual flow, if suppressed, must be substituted by small bleedings more or less frequent. In cases of suppressed hemorrhage, the bleeding should be of a nature to favour the flow of blood in that direction : thus, leeches to the thighs and opening the veins of the foot are most suitable in menstrual suppression. If, however, the patient is unruly, and does not relish this, we must resort to the arm. Warm baths during this state should be suspended, as occasioning difficulty of respiration and other bad symptoms. The diet of patients in whom much blood is easily formed should be of aliments which have little nourishment, with very aqueous vegetables. The bowels should be kept open by a plentiful supply of aqueous and slightly laxative drinks. Exercise and labour should replace a slothful demeanour.
2. This state is characterized by general feebleness, pallor, and lean ness, the pulse being feeble, or small and frequent. In spite of these, there may exist more or less violent raving. In most cases there is a complete stupidity, or a loquacity which approaches dementia. It arises under two different circumstances. Sometimes it dates from the commencement of insanity, and even precedes it. This is the disease of those becoming deranged from want of food. Austere and long-continued fasting produces the same result. At other times it is secondary, and proceeds from bad treatment, or the abuse of debilitating means, as bleeding or purgatives, or from obstinacy in the refusal of nourishment, or from excessive masturbation. The custom in some of the provincial hospitals, of immuring the furious in damp and noisome dungeons, causes them soon to lose their health. The indications are, plainly, to give tone to the organs, to strengthen and nourish the general economy, and to remove the causes. Above all, we should pay strict attention to the re-establishment of the digestive functions. When, from exhaustion, at the Salpétrière, they take a bath for cleanliness, of short duration, on account of their feebleness ; they then give them acidulated ptisans. In a few days the appetite returns, they eat of food much more nourishing than that to which they have been accustomed, and by degrees their health is restored. Cases from too much bleeding are restored with difficulty. They should partake, as much as their stomach will bear, of a nourishing and abundant regimen. Tonics should be given : the oxyde of iron and chalybeate waters are of great utility. Those addicted to masturbation are with difficulty corrected of the habit, being but little alive to moral influences. The strait waistcoat serves usefully for men, but females (who, especially, deliver themselves up to it with incredible fury) are not thus prevented. The irritation of the genitalia should be calmed by warm baths, aqueous drinks, mild regimen, &c. Above all, they should be made to promenade, and should be never left alone, or with some odious accomplice. When a patient weakens from the obstinate refusal of food, and after every moral influence has been fruitlessly employed, we should force him to take aliment. They can easily be made to open the mouth by pressing on the parotids, on account of the consequent pain. If he still refuses to swallow, a gum-elastic sound should be introduced into the oesophagus, by which broth, milk, wine, &c., may be injected. At the same time similar clysters may be given, and even baths, if his fortune permits this.
3. Active Cerebral Congestion.-It is the continuation of this state of the brain for many months after the commencement of the insanity, to 121 which reference is here made. It is characterized by the injection of the capillaries of the face, the eyes, and even the skin of the head ; by the enlargement of the veins of the neck ; by very strong pulsation of the carotids ; this being much stronger than that at the wrist. With these symptoms, they eat and go about perfectly well ; only they do not sleep. This state manifests itself equally in both monomaniacs, lypemaniacs, the maniacal and the torpid. It may remain for months and years, and may even pass into dementia. The indication here is, to combat the too great determination of blood to the head. The curative means consist of derivatives combined with refrigerant applications to the head. The full warm bath, at least for a time, should be given up, as favouring the symptoms. When, by the use of proper means, the cerebral irritation is diminished, we can resume them, taking care to apply simultaneously to the head compresses or sponges soaked in cold water; also of equal utility is the rose douche. Many patients, to lessen the heat, hold their head in water, or under the open spout of the fountain. The alimentary canal should be irritated with repeated purgatives, during ten, fifteen, or twenty days ; not by drastics, but carthartics. One or two grains of tartar-emetic in a vehicle of barley-water, or whey, is very suitable ; it acts at first upon the stomach as a nauseant, and continues its action upon the rest of the canal. Calomel has the advantage of acting at the same time as a vermifuge ; but it has the inconvenience of sometimes very powerfully exciting salivation. Hip baths are preferable to the entire : sinapised pediluvia are also very useful. Whilst the patient has half his body or his feet in the warm water, cold applications should be made to his head. These means should be continued some time, as the malady is of long duration. If the subject is young and strong, we may draw blood from the inferior parts, either by opening a vein of the foot, or by applying leeches to the legs, to the thighs, or to the anus in men, or to the vulva in women whose menses are supressed. In some cases they may be placed on the neck. The diet must be mild and aqueous. If the cerebral irritation persists after these means have been employed some tune, one or more vesicatories should be applied to the arms or legs, more rarely to the nucha.
4. Inflammatory State of the Brain.-This condition is not inflammation exactly, but something approaching to it ; it seems, indeed, but a degree of the form of the disease last treated of. Besides the symptoms of cerebral congestion, the following are also presented : a feeling of tension in the external or interior parts of the head, sometimes pain; an eruption of pimples, of erysipelatous spots, erosions, sweating behind the ears, on the temples, and on the forehead. The eyes are sparkling, injected, fixed or convulsive, and wandering. The patient suffers, which, if not evinced by complaint, is sufficiently indicated by the countenance, and the sometimes contracted features. The pulse is harder and more compressed than in cerebral congestion, there is ordinarily much thirst, and often constipation. All these symptoms are rarely found in union in the same individual; the physician will judge of their value, whether isolated or united in the same person in a greater or less number, being, indeed, rarely found all present. The curative indications are the same as those of cerebral congestion, but the brain demands more special care. Moreover, repellents do not suit ; they may augment the evil, or make it take a bad direction. It is necessary to unload the cerebral vessels by leeches and cups to the neck, behind the ears, to the temples or 122 the nucha ; bleeding from the temporal artery or jugular vein, if not opposed too much by the patient, promises to be extremely useful. Derivative bleedings from the lower limbs will also be advantageous. General tepid baths, hip baths, and sinapised pediluvia, will be employed according to the necessity. Instead of cold applications to the head, those of an emollient nature will be suitable, to calm the inflammatory irritation, and diminish the painful sensation of the parts ; laxative or purgative drinks will be given to excite the intestinal secretions, and act revulsively. Finally, in view of the same end, external excitants should be applied.
5. Torpor.-When torpor is very slight, it goes through its periods regularly, and proceeds in a few months to convalescence. The means alone indicated for the period of excitement suffice in aiding the salutary operations, unless signs of congestion or other symptoms should be present calling for measures suitable to their removal. But when the disease is of a worse nature, when it persists unchanged for the better, after four or five months, without energetic means, incurability would be the inevitable result. The curative indication consists in creating a strong excitation to re-establish the vital forces, and recall their energy. The means which I have employed with most success are external excitants, applied to the seat of the disease, especially to the nucha. We should commence by a vesicatory or a seton, and if they produce no good effects, we should resort to the deep application of a moxa : if good effects result, there will be perceptible in a few clays the manifestation of a sort of general fever, and in fifteen or twenty days convalescence will be established. A second or third application should be tried if necessary, and the cranium should be more nearly approached. I have seen such good effects from this measure, that I do not hesitate to recommend it in the most hopeless cases. Vomits repeated many times, at some days' interval, may be employed as auxiliaries. The douche has sometimes aroused for an instant, but only during the time of its action.
6. Irritability. Nervous Susceptibility. -In this variety of disease, there are no signs of congestion or inflammation: the patients are, in general, meagre. The skin loses its freshness ; that of the visage is dry, pale, yellowish, or as though tanned. They are very sensible to the action of external excitants, of cold, for instance ; the least uneasiness is sensibly felt, and thus sad ideas, despair, and the fear of never being cured, are easily produced. The alimentary canal often exhibits disorders, such as want of appetite, colic, heat of stomach, and obstinate constipation. The patients do not know what position to take, nor in what place to go; everything causes them pain and suffering. Sleeplessness is obstinate. This condition is most common in lypemaniacs, individuals impelled by suicidal feelings, and those affected with the spleen of the English. After having vainly tried the means indicated for the period of excitement in general, the best treatment consists in determining a brisk intestinal irritation, and above all to the large intestines, at the same time that., by the administration of sedatives, we endeavour to prevent the consequences of local action, and diminish the excess of cerebral sensibility. The first part of this method formed the medical treatment almost exclusively of the ancients, in melancholy. They sent their patients to take hellebore at Anticyra. But the circumstances which accompanied the administration of the remedy were far more efficacious than the remedy itself ; the voyage, the different new objects, 123 the confidence with which the name of the place inspired the patient, all these were well calculated to ensure the success of the one means. Among purgatives we 'should choose drastics, such as the resin of jalap, aloes, hellebore, colocynth ; they should be given in the form most suitable to the patient ; with the resin of jalap a most agreeable emulsion may be formed ; castor oil may also be given, in the dose of one or two ounces, in a similar preparation. They use with much advantage at the Salpétrière the purgative of Weisse in whey. They continue it every morning during ten, fifteen, twenty days or more, ceasing, however, from time to time, many days, if too much uneasiness is produced. Abundant serous evacuations are caused, which soon enfeeble the whole economy and diminish the cerebral action. The patients, from their attention being strongly fixed on the operations in the abdomen, forget their other sufferings. Every evening they are made to take sedatives ; the extract of hyoscyantus appears to me preferable to the preparations of opium, as being less provocative of cerebral congestion. The water of orange flowers, in the dose of many ounces with an equal quantity of water, and with sugar, produces excellent effects ; as a ptisan, and at the same time a purgative, should be given a laxative drink, and the rest of the day art infusion of linden flowers, of orange leaves, &c. Tepid baths should be more rare. External excitants augment the irritable state, and only act revulsively by occupying the attention of the patient. The effects of this treatment, when successful, are more or less prompt. The following is an instance illustrating the practice in point. Case.-Mrs. G., aged 37 years, entered the Salpétrière 1819, in a state of melancholy, with a suicidal propensity, the consequence of violent grief. For three months the means indicated for the period of excitement were employed with little resulting change. At this period the patient was in the following condition : meagre, with contracted features, a dark complexion, pains in the head, colic of the stomach, and obstinate constipation ; very sensible to cold ; always complaining at the least uneasiness or inconvenience. A blister was applied to the neck: she felt severe pain in the neck, head, and shoulders, and was so much affected by it, that it had to be left off. She then took every morning for some days castor oil, and afterwards in whey the purgative of Weisse, and in the evening a potion rendered sedative by the syrup of poppies or simply orange flower water in a large dose. In the space of thirty-five days, during which this treatment continued, her health was re-established completely.
7. Tendency to Incurability -When all the curative indications have been fulfilled, with or without success, or all diseased action consists merely in delusions and watchfulness, there are no positive rules of treatment. We can then act empirically, being the less circumspect, as the chance of cure is small ; and the douche, baths of surprise, and similar disturbing means, may be employed empirically, provided that life is not. compromised.
8. Tendency to Dementia.-I go to treat here of acute rather than chronic dementia. And I allude more particularly to two modes of alteration,, which appear to me to coincide with dementia. Sometimes feebleness of the functions, which are more or less under the immediete influence of the brain, results in a sort of nervous collapse ; the patients are then pale, indolent, and sleepy ; the pupils often dilated, more or less fixed and motionless ; at other times, this condition is accompanied by 124 cerebral irritation ; the patient appears tranquil, but does not sleep ; the throbbing of the carotids is frequent and hard; there occurs sometimes in the evening heat and redness of the cheeks and scalp. These patients are rarely cured. In the collapsed state, it is requisite to aid the vital forces, and at the same time to stimulate strongly the action of the brain by tonics and external excitants, and to leave off all debilitating means, as tepid baths, aqueous drinks, &c. In the other mode of alteration, particular recourse should be had to derivatives, whether they act upon the skin or upon the digestive canal ; it also sometimes answers to make use of local bleeding by leeches. In the first kind of cases strengthening or exciting substances should be given internally, such as bark, aromatics, bitters ; musk united with the extract of bark, and the preparations of the oxyde of iron, produce sometimes sufficiently good effects. Blisters or moxas to the nucha, or even to the scalp. The patient should be placed in the fresh air and in the sunshine. He should be rubbed and made to lie upon aromatic plants ; the regimen should be of a tonic nature. In the second order of cases, external excitants are to be applied, but in order to act revulsively upon the cerebral irritation, and not to stimulate the organ ; at the same time the alimentary canal is to be irritated by purgatives. Sinapised pediluvia may be useful. I have seen few good results from the above treatment, however, and we are to regard it rather as theoretical than practical.
9. Puerperal Madness.-It is here, in general, suitable to excite the cutaneous or intestinal secretions and to replace those which are suppressed, or which, being but transient, should cease by degrees to exist. This should be done in the commencement of the disease, instead of following the rules prescribed for the period of excitement. They should be given every day purgative and sudorific drinks, and purgative injections ; M. Esquirol employed, with much advantage, a clyster composed of milk and sugar ; from it result abundant stools without too much irritation of the large intestines. Tepid baths are suitable here, as promoting cleanliness. After twenty-five or thirty days, we should establish an exutory ; one or two blisters to the arm are preferable, or to the nucha and to the back, if there be no signs of cerebral congestion. Attention must be paid to the breasts ; if they are hard and painful, we should envelop them in emollient cataplasms ; and later, when they have become soft, and give rise to pain no longer, resolution should be accomplished by exciting frictions made with a flannel impregnated with the ammoniacal or other liniment. An abscess, if formed, should be opened according to the rules of art. These places are sometimes very painful ; they should then be spread with opiated cerate. But when the period of excitement has passed, and when, in spite of the employment of these means, the madness persists, regard should be paid to the indications which present themselves, and they are fulfilled as in other cases. Females who become mad each time that they make children, should abstain from this work, if they wish to prevent the certain consequences.
10. Intermittent and Remittent Madness.- It is only when the remissions are very marked, appearing at short intervals, that I have employed with success bark and some other tonics, bitter or aromatic, given in the interval of the attacks, and a little before the return of the symptoms ; they ought to be continued some time after the presumed period of return. We can try here most of the means advised to intermittent diseases in general. 125
11. Serious Symptoms.-The brain is often affected so as to offer severe symptoms, either in itself or in other organs, either in the first portion of the disease, or latterly. For instance, there may- be, as to the early symptoms alluded to, convulsions ; sometimes there are many appearances of a decided fever, as feebleness, loss of appetite, dry mouth, vomiting, &c. ; but in general, these occurrences are not dangerous, and disappear after many hours' or days' existence, by diet, repose, and the employment of diluting, aqueous drinks, or of some other means indicated by circumstances. The important symptoms occurring in the later period I proceed immediately to discuss.
We now consider the progress of madness towards convalescence, or in its decline. Frequently, with the termination of the disease of the brain, morbific symptoms cease throughout the system. But it sometimes happens that convalescence does not proceed thus ; in many instances it is slow ;the brain retains something of its previous condition, or presents new phenomena, or even sympathetic symptoms, as if by morbid habit or the force of inertia. We should here give aid according to the indication. In general, the symptoms are very different from the primary ones ; thus, the irritable will become plethoric, the torpid very irritable, &c. The principal derangements under this head which we have observed will now be discussed.
1. Atony, General or Special.-To the general state of tension, succeeds sometimes a depression, an extreme feebleness in the organs ; the patients are pale and bloated, presenting swelling of the legs and feet ; they like but to repose, they have no courage to do anything ; their limbs weaken at the least exercise ; their ideas, although sane, are rare and feeble, their answers slow ;there is, perhaps, a commencement of paralysis, announced by the embarrassment in speech and formication ; digestion is laborious, there is a want of appetite, colic of the stomach, sometimes looseness ; they sleep much. We should here cease the warm bath ; but should have recourse to tonics and aromatics. Red wine of Bourdeaux or Burgundy, bark, canella, orange leaves, ferruginous preparations, should be given in different forms. The antiscorbutic wine or syrup, and the wine of wormwood, are often useful. In cerebral atony, a vesicatory to the nucha may have the power of arousing the spent strength. If the patients are sent to breathe the fresh air of the country, or to make a journey, they will draw from this great advantage. We may also strengthen the nervous system by employing, in summer, sea-baths, or those of running water; aromatic baths produce also the same effect.
2. Sleeplessness. Irritability.-Sleeplessness is not unfrequently found as a symptom succeeding delusions, and persisting a long time after them visions hinder sleep, and causeless fears agitate the patients. Watchfulness is a more important symptom here than at any other period; the patients are themselves uneasy, fearing a relapse ; they become irritable, and have the headache. We must here force the brain to resume its ancient functions. Warm baths are useful. The muscular system should be fatigued by exercise. Sedative drinks should be employed, as water of orange flowers, preparations of opium and hyoscyamus. A vesicatory to the arm may be useful as a physical revulsive, and especially as occupying the restless disposition of the patient; of the headache I will treat directly.
3. It happens sometimes that the return of health is marked by excessive sanguification. The sudden calm gives rise to an excessive 126 sanguification, as great proportionably as it had been previously slight. These patients are in general sluggish, and sleep much : they complain of weight about the head, and of palpitations ; sometimes their sleep is troubled by disagreeable dreams, interrupted by sudden starts ; and the signs of general plethora are present. These patients should be placed on an aqueous and slightly nourishing diet ; we should recommend much exercise ; mild laxatives must be given to keep the bowels open. Cautious bloodletting, roust be employed: the plethora may be only temporary, being the mere result of the sudden calm ; and it is only when it persists and increases that blood must be drawn. If menstrual suppression persists, our first care should be to recall this secretion.
4. Constipation.-This sometimes incommodes patients even during convalescence ; the large intestines, sluggish, and little excitable, retain a long time the fwcal matters, and, by absorbing their humidity, convert them into small balls more or less hard. From this there results uneasiness,. heat in the parts, and sharp pains at each stool. This condition is to be remedied by giving tone to the intestine by means of tonic injections, as cold water ; and by exciting its action by irritating or purgative clysters ; we may resort in some cases to drastics, employed in small doses. I have rarely seen constipation very obstinate.
5. Headache.-The passage to convalescence rarely takes place without this phenomenon. In most cases, it disappears spontaneously from repose, or by the aid of simple means, mild sedatives, as the infusion of linden flowers and that of galium verum, of water of orange flowers, of pediluvia, simple or sinapised, and of warm baths. But sometimes, when persistent, notwithstanding the entire re-establishment of all the functions, it should engage our attention. When external, leeches to the seat of the pain oftentimes causes it to disappear at once ; if the pains are renewed, the same means are to be used, simultaneously employing foot or hip baths, which exert a derivative influence. Internal headache is more dangerous, as occurring at the source of the disease. Besides the derivatives vvliicli 1 proceed to mention, if there be signs of congestion towards the head, leeches or cups should be applied to the temples, to the neck, or behind the ears ; the intestinal canal may be irritated by saline purgatives, and we may calm the pains by some preparation of opium. Finally, in case of no success, we should place a blister or even a seton in the neck. Periodical cephalalgia has been successfully combated with bark. Drs. Royster and Fowler, of England, have praised much, in like cases, arsenical preparations.
6. Suppression of the Menses.-Although the cause of menstrual suppression may have disappeared, yet the uterus seems sometimes to have got into the habit, as it were, of not performing the function in point. The excitants of the uterine system are to be used here, such as saffron, motherwort, &c. ; or derivatives, such as sinapised pediluvia, hip baths, bleeding from the foot; or better still, leeches to the vulva. These sanguineous evacuations ward off plethora, whilst they direct the blood into the proper direction. The methodical employment of these meaus should be thus : if the suppression does not date but a few month, back, we should learn the period of the expected flow ; in the contrary ease, we should act at hazard, or after some indication more or less pressing, and each month they are to be renewed until a reappearance. Pediluvia or hip baths should always precede six or eight days the application of leeches. 127
I proceed to describe the treatment of relapses, and the mode of guarding aoaittst them.
Persons who have been insane should particularly avoid the causes of the disease, or should be placed at least in a situation proper to attenuate their effects. Marriage has been proposed as a prophylactic ; it may do for those who have been deranged from love, as satisfying this passion. With respect to all other considerations, I do not think it useful, but it may be dangerous, as constituting a source of vexations; and childbirth is a predisposing circumstance with many females. We must con,ider, too, that the germ of madness may be given to a whole generation. In such persons the least physical sign of the return of the disease should claim the strictest attention, particularly if analogous to those preceding, the first invasion, such as weight, pains in the head, &c. Simple derivatives, sinapised pediluvia, entire, or hip baths, some laxatives, as the water of Seitz or Seidtitz, should be then made use of. An issue on the arm is an excellent means of establishing an irritation which preserves the brain from a similar condition. If the signs of cerebral congestion persist, we must not hesitate in drawing blood, especially if in females the menses become less abundant. In this case, leeches must be applied to the vulva immediately after the cessation of the flow. In men the same operation to the anus produces excellent effects. If we are called in time to prevent an imminent renewal of the disease, besides the means which have been indicated, vvc should try a strong deriva lion to the intestinal canal, by means of purgatives, with an impressive action on the stomach, by vomits repeated many times at slight intervals.
At the Salpétrière all the patients have a certain quantity of wine every day- ; to the feeble, many ounces of a tonic medicinal sort are given.
At Charenton, in winter, the paralytic sleep in long osier boxes, reaching to the neck and filled with straw.
In an article written by M. Georget for the Dictionary of Sciences, on the same subject, as the work which we have translated above, little difference is found as to the treatment given. We, however, cull from it a few sentences worthy, perhaps, of special notice.
In general, we must consider the insane as still possessing consciousness, conscience, and memory, and as being more or less accessible to impressions having some relation with the passions ; in one word, the thoughts of most of the insane. are false, but not extinguished.
Daquin, Pinel, and Esquirol are strongly opposed in their writings and practice to the use of empiric and barbarous means. Since the impulse gived by these physicians, lunatics have not been so much bled ; cold baths are rarely employed ; baths of surprise, submersion, and blows have been proscribed ; purgatives and douches are employed with discretion ; in one word, the disturbing method has been replaced by a wise expectation, especially in cases in which there is no indication fot acting. But perhaps another excess has been sometimes produced; perhaps the system has been often left to itself, and the natural progress of the disease depended on, so as to lead to a fatal termination, Has not the commencement of mania or of acute melancholy degenerated into an incurable state, which would have yielded, promptly to active treatment? Nevertheless, it must be acknowledged, in the actual state 128 of science, that the physician often meets with cases of alienation, without any precise therapeutic indication ; which obliges him either to do nothing, or to blindly employ some of the means advised by authors as sorts of specifics. -We observe many of the insane in whom the nutritive and generative functions are perfectly regular, in whom the circulation and heat of the head are in a natural state, who feel no pain ; they are irrational, and this is all of apparent disease. What is the nature of the cerebral affection ? and what indication to be fulfilled ? The physician who doubts the errors of empiricism looks almost always, in these cases, to time and the employment of moral means.