Case.-Placed in succession under several divines, that he might be educated with strict religious principles. Mind became thus bewildered, and at length thought constant attention to religious things a duty ; would kneel in any place whatever; soon his religious extravagances were many, became violent on interruptions, and positively insane. Æt. 15 ; brought to Dr. B.'s asylum. No notice taken of his religious enthusiasm. Innocent amusements. History. Belles-lettres. Recovered. In numerous cases of amenorrhoea, derangement of mind preceded by obstruction, and the discharge returns with mental health. Emmenagogues do, therefore, much mischief. On the Continent of Europe black and yellow bile still supposed, and hellebore considered to possess an antinianiacal effect. In a periodical case, originally from syphilis, in which there was great irregularity of the circulation; at first being very quick, and at. tended by great general excitement, displayed in the mental and physical symptoms, and then very much depressed, and with correspondent symptoms of depression in the mental and physical actions : no remedy or plan produced any amelioration. On the approach of one paroxysm, tried depletion by dividing the temporal artery, by section of the jugular vein, and by scarifying and cupping. Symptoms more exasperated from this, and debility protracted the time of return to the degree of health existing between the paroxysms. This exhaustion was overcome by generous diet, the shower bath, and tonics. Case.-A quiet and industrious tradesman ; æt. 30 ; subject to occasional fits of epilepsy, and lately much inclined to religious devotion. Sitting reading his Bible, when a fomale neighbour came in to ask for a little milk. Looked wildly at her, seized a knife and attacked her, his wife and daughter. Next day, countenance ferocious and hideous, complexion dusky red, eyes starting from their sockets, continually sighing deeply-, or extending his jaws, as if going to yawn. Pulsation of temporal and radial arteries full and laborious. Could make no reply to questions, although he attempted it, but occasionally exclaimed "Oh dear !" Appeared to be on the very verge of apoplexy. Depleted freely, by bloodletting and purging ; head shaved; refrigerating lotions and low diet. On third day intellect much improved, and was quiet. Soon quite recovered. A similar attack year before, but not then but slightly mischievous. Some years since occurrence of epilepsy or mental disturbance. A case of catalepsy, complicated with melancholia, in a young man, has recently come to his knowledge; lie was cured of both diseases in about six weeks by the carbonate of barytes. Case of cataleptic derangement, produced by violent mental emotion the catamenia being prematurely brought on, and suppressed by one and the same cause. At first in the highest state of excitement; when she was bled and purged copiously, afterwards was blistered, used the warm bath, and a strict antiphlogistic diet; leeches, also, to temples. In three weeks improved, but relapsed by too much society; milder mania supervened in a short time. chanuinri to melancholia. In a fortnight sent to my establishment. Symptoms of torpor and tendency to catalepsy. As 209 in all cases of mental derangement of which I have no personal knowledge, and when the symptoms do not demand prompt remedies, so in this, I delayed prescribing till I had time for observation. This is a precaution always to be remembered on the first view of a case of insanity ; for the history of such cases is rarely satisfactory. Preternatural heat about sinciput, whilst rest of body cold. Head shaved, bleeding from occiput by cupping, refrigerating applications, warm bath ; stomach and bowels fully acted on, salivation, but with no permanent change, and she became, finally, more decidedly cataleptic. During this condition twice cupped, leeches once to head, tartarized antimony, briskly purged, spine rubbed with stimulating embrocations, blisters to extremities and irritating clys ters; also warm bath. Head again shaved, and blister to whole scalp. Small blisters in succession along whole course of vertebral column; emetics twice a week: improved somewhat, but relapsed. After being with me two months and a half, she was removed, I urging a seton near the occiput. She then resided six months in lodgings, during which the seton was tried. From this she derived great benefit : the stupor and confusion of ideas left her as soon as the discharge from it was established. She then removed to the seaside, where she used both the cold and warm sea-bath, and took a great deal of exercise. At length the menses re appeared, very largely : up to this, slight returns of cataleptic symptoms. Cure complete, but kept seton open nearly a year. Ten years passed since, and no return of symptoms. Hufeland relates a case of a boy, between thirteen and fourteen, who suddenly began to talk in a very wild and incoherent way, and at length became ungovernable. Assuaged by soporifics, but paroxysm recurred whenever placed on his feet; symp toms vanished on removing a piece of glass from the foot. Old lunatics, when become feeble; are especially liable to an extreme constipation if an accumulated and hardened mass be found by inspection, nothing will relieve but the introduction of some instrument, as a spoon ; and such inspection should ever precede drastic purgatives, or even stimu lating clysters. If such remedies have been used before a discovery of the real state of the case, care should be taken to prevent too violent catharsis. Case.-Nymphomania. A young lady, æt. 15 ; hereditary taint; virtuously educated; manifested symptoms of insanity. Person and mental faculties of the highest order, fully developed at eleven years, when catamenia appeared. Violent and haughty ; memory remarkably strong, but devotion to a great variety of studies had tried her mental powers too much, and deranged her general health. Menses became obstructed ; great irregularity in circulation ; extremities always of marble coldness, though season warm ; at the same time heat of head unprecedented. Every means to equalize circulation. At length symptoms of nymphomania, unaccompanied by any indecency, and detected only by nurse. This not permanent, but intermittent. When preternatural heat of scalp and coldness of extremities, genital irritation ceased, and when head cool, irritation returned, as if by metastasis. Local a bstraction of blood from head, and refrigeration of shaven scalp; or any application restoring warmth to the extremities, as pediluvia of mustard infusion, or strong walking exercise, always relieved the cerebral excitation, and removed the other distressing symptoms. As the equilibrium of the circulation was restored, general health improved, and catamenia return. ed, Local irritation then disappeared, and in about four months she quite recovered. Gratification never cured satyriasis or nymphomania. 210 Castration has been advised : thinks little of it, on account of its often failure in cases of self emasculation. Case.-A French dragoon ; in. sane from coup de soleil. Drank a pint of boiling water at a draught, and then retired quietly to bed. Remained two days without eating or drinking, and without complaint, though his mouth was much inflamed, and eschars had formed. Six days after, an abundant ptyalism, which was succeeded by a copious diarrhoea, and in three or four days recovered health and intellect. Astonishing muscular power of the insane is not to be mistaken fbr real strength, and hence a depletory practice is to be avoided. Case.-An insane military officer; constantly walking up and down at the asylum; never speaking voluntarily, and rubbing his hands continually. By the use of the rotary chair, some improvement effected. All the most efficacious remedies, such as vomiting, purging, salivation, tonics, the bath, gestation, &c., operate by inducing a new and increased action in the circulatory vessels, co-essential with febrile action, and in this way supersede the maniacal action. As reason dawns, often an intense anxiety to be restored to friends. A very important, but painful duty, is then imposed on the physician ; for such solicitations are difficult to withstand, yet must be resisted till he is convinced that compliance is prudent.
Puerperal Insanity. Case.-Mrs. -----, æt. 24, delivered 6th May, 1798, of her first child. On fifth night, little or no sleep On sixth day, watchful and sullen ; on seventh, visibly, deranged. Called in : a gentle emetic, small doses of soluble tartar frequently repeated, keeping her perfectly quiet, and suffering no person but the nurse and one female servant to see her, she soon recovered, and I left, June 4th. Three children after this, at separate births, and no derangement. Succeeding 5th, lying in on beginning of September, 1804, when she had twins, again deranged. Called on tenth day. Using same means as formerly, soon materially better. On seventeenth day discontinued visits. Seven days after, sent for to her as dying. Found her perfectly senseless and comatose, with a thickness in her breathing, approaching to snorting ; pulse hard, though small, and at rate of lO2. Leeches, blisters, and evacuants, without success ; and she died in forty-eight hours. An instance of puerperal mania terminating in apoplexy. In treating a recent case of puerperal insanity, many circumstances admonish us against a depletory or reducing treat. ment. In most instances which he had met with, depletory treatment had been pushed to an unreasonable extent; hence the great mortality. Whenever mental aberration, however slight been manifested, during pregnancy, every kind of stimulus should be avoided, the bowels should be kept soluble, and moderate venesection, especially towards the end of that period, be practised ; and during parturition, the greatest precautions against irritation or alarm. Case.-A young woman, while single, had the menses often obstructed, and experienced attacks of furious mania. During her first pregnancy similarly affected. Repeated bleedings ineffectual, and derangement continued many months. Again became pregnant ; but, from its commencement, both her cheeks were covered with a pimply eruption, till near her lying in ; and she had not, during the whole period of this gestation, any symptom of insanity. Therefore, when developed during pregnancy, a fair experiment to produce an artificial eruption on the skin, or a derivative discharge. Generally in those cases where the delirium comes on after the secretion of milk is completed, and the lochia are flowing in due course, and both these secretions are 210 suspended, to restore them, offers the best chance of intellectual recovery. Whenever fully developed, first duty, to secure patient's safety, by placing her under the management of an attendant experienced in mental disaxders: Free evacuation of the bowels the next necessary measure: de. lirium has ceased in a few hours, simply from purging off an immense quantity of unnatural fmces. Bowels should be regularly, but not violently purged, by a dose of calomel, and the common purging mixture of salts and infusion of senna. As long as alvine evacuations black, tenacious, and very offensive, purging is indicated, due regard being had to patient's strength. If purging weakens, glysters must be employed. If the delirium be of more determinate character, other measures. If vascular excitement and determination to the head, as commonly, with a preter. natural heat of the scalp, redness of the eyes, pain or throbbing in the head (not always, however, complained of), and want of sleep: head should be immediately shaved, and blood abstracted by cupping, in pref. erence, or by leeches, on the occiput, vertex, temples, or behind the ears, according to the part wherever the uneasiness is felt. Quantity drawn to be regulated by the natural constitution and habits of patient. Symp. toms are commonly relieved by loss of blood, but are apt to recur ; when, if not weakened, the cupping or leeching, and moderate purging, may be repeated, and, with the same caution, so often as there may be occasion. If heat and pain of head not removed by abstraction of blood, evaporating and refrigerating lotions to be applied over the shaven head. Pulse and muscular movements equally fallacious as indices of strength. The. pulse rarely justifies bloodletting. Only admissible case, where the system is plethoric, and convulsion or apoplexy threatened. In those cases when the delirium is coincident with the fever attending the first secretion of milk, pulse is quick, and sometimes full : this is a temporary state, subsiding in a few days : bloodletting would only produce subsequent exhaustion and exasperation of the delirium. Nauseating doses of tartaremetic, with the saline mixture and digitalis, will aid in reducing the fury and violence of the patient : should recollect, however, that from whim, obstinacy, and, very often, suspicion of poison, the patient will not take sufficient nourishment ; and if so, evacuation must be more sparing ; and nausea tends to diminish vital power, and also to encourage distaste for food and medicine. With the excitement and determination to head, lower extremities will frequently be very cold : here after cupping, &c., and cold applications being to head, may be placed in a warm slip. per or hip bath ; or the legs and feet only may be immersed in a foot bath filled with a warm infusion of mustard or horseradish. Both these baths tend to equalize the circulation and relieve the cerebral irritation. If secretion of milk be suddenly suspended, means to restore it. If delirium developed with the accession of the milk, the secretion must be encouraged by inducing the child to suck, or by drawing off the milk artificially ; and even when the breasts have become empty, it will be useful to continue these means for some time, in order to determine the milk to its natural channel. Sometimes apathy towards child : putting it to the breast, if she will permit, often revives maternal feeling-a point of much importance. Renewal of the lochiae, if suppressed, desirable. Here French apply leeches to vulva. Has seen good effects from cups to sacrum. May be promoted by a warm bath, or even a hip bath, or ordinary washing-tub. Warm fomentations over the pubes, or to the pu. denda, or injecting gently stimulating glysters, serviceable. Opiates 212 and blisters favourite remedies generally. Repose important ; but without preliminraysteps, when obtained from opiates, unrefreshing. Where determination or congestion of the cerebral vessels denoted, or there is great excitation, opiates will never have the desired effect, till these ves. sels are in some degree emptied, and the bowels well evacuated. Of course, all narcotics inadmissible, where any degree of coma : best soporific, after thg above preliminaries, is the application of cold to the shaven head. Should the head feel quite cool, and there be no flushing of the face or throbbing of the arteries, or other indication of cerebral excite. went, cold applications to cranium not called for. Should above measure fail in procuring sleep and repressing other bad symptoms, has frequently found great advantage from an opiate : dose should be large ; costiveness must be guarded against by combining with an aperient, or using a clyster. Calomel with solid opium, taken at bedtime, often answers well; and has found Battley's liquor opii sedativus much superior to every other liquid form of opium. Head less affected, and confines bowels less. Extract. hyoscyami, gr. x.-xx., sometimes effective. Dr. Gooch recommends camphor with it, but has never seen benefit from it in the early stages, and whilst vascular excitement continued. Has little faith in blisters. Do harm when applied to head or contiguous parts during exacerbation. Only useful to thighs and legs. When coma, or torpidity of system, and particularly of the skin, or circulation in extremities is too languid, may be serviceable ; but when stimulating only, and not a discharge been indicated, has fund more benefit from sinapisms to the feet. Caution that they be not kept too long on the feet as soon as patient complains of pain, should be removed, and renewed at short intervals; has known them otherwise to carry delirium to fury. Great care that nutriment be got down in the incipient stage, on account of the liability of a sudden exhaustion. When cerebral excitement has subsided, mild tonics advantageous; and these, by degrees, to be changed for the cinchona, ferrum, and a more generous diet: air and exercise also essential. The shower bath will then be found very beneficial. In recent delivery, the patient cannot, under any circumstances, be safely removed from her home. So soon as this can be done, it should be, provided that the affections are alienated, and illusions exist with respect to home. The same principles apply to seclusions from relatives. Ignorant and boisterous persons should be removed from attendance on a patient, as they agitate and alarm.
Suicide.-When the mind is beginning to aberrate, very essential to prevent persons affected by moral causes or inclined to suicide, from reading newspapers, lest the disposition and the mode be sug-ested by something similar. Only in epidemic suicide, indignity threatened to corpse availing. Accompanying mania or melancholia, same remedies as in them : differing merely in preventing mischief to himself, instead of to others. Few have recommended particular remedies. Avenbrugger prescribes cold water as almost specific. A pint every hour; and if continuing pensive and taciturn, forehead, temples, and eyes sprinkled with it until more gay and communicative; feet being wrapped in warm flannel. Hufeland recommends it in mania ; this impracticable, and too inert if patients were willing. When symptoms of cerebral vascular excitement, same plan of shaving head, moderate cupping or leeches, refrigeration and purging, as when these symptoms present in pure insanity. Has seen more decided good effects from emetics, in incipient 213 cases, with propensity to suicide, than in any other variety of insanity; and where the biliary functions have been suddenly disturbed, and the excretions indicate a morbid action of the liver, calomel with or followed by some brisk cathartic, will sometimes at once remove the depression of spirits, and even mental aberration tending to suicide. Warm bathing daily, for an hour or more, with cold applications, or a slight douche, when signs of considerable cerebral excitation, are very useful. Narcotics, where little or no sleep, may be prescribed, with the precautions mentioned under puerperal insanity. Confidently pronounces, especially where from excessive grief, that timely abstraction of blood, either locally from the head, or generally from the system by a very moderate venesection, in a majority of incipient cases, not only relieves the urgent symptoms, but also suspends the propensity. Case.-A gentleman ; very irascible and impetuous ; had in a public meeting a rebuke which made him miserable. Instead of going to bed at night, roamed abroad, and at length found himself near a sheet of water, early in the morning; and the view of it urged him to suicide by drowning. Taken out insensible, and on returning animation became rather violent, eyes very wild, and ready to start from sockets ; face became flushed, vessels of forehead excessively distended, and all the symptoms of genuine delirium came on ; apostrophized me as Dr. Death, as if uniting two ideas. Regarding the violence to spring from reaction on account of the previous collapse, took sixteen ounces of blood by cupping, kept head cool, and cleansed bowels well out with an enema: soon became passive and disposed to sleep. Slept six hours, and awoke tolerably composed, but not quite coherent; took light nourishment, and at night. awoke perfectly collected, but exceedingly low ; next day well, but languid: an explanation was given him of the offensive part of the speech so affecting him, and he by degrees recovered his usual state of mind. From this case judges unfavourably of submersion to the suspension of animation, as recommended by some writers. Melancholy patients, it is said, have had delusions removed by some sudden and violent emotion being excited. Never had the temerity to try surprises or fright : and would recommend, before such were tried, that the absence of cerebral congestion should be evident, lest apoplexy close the scene. Accidents, however, have certainly occurred to persons about to commit suicide, which have prevented it, and reconciled them to life ; as, for instance, one such was attacked by robbers. Change of scene is important, and its frequency most beneficial. Whenever the morbid thought is for a short time averted by a fresh object, this is the moment for appropriate reasoning on the wickedness of the design, or the fallacy of the delusion. Occupation according to the patient's taste, education, or business. To this to be led by gentle, almost imperceptible endeavours. If circumstances prevent a varied residence, a well-regulated asylum best. His peculiar delusion should never be treated with contempt or rudeness by the physician or attendant. Impulse sometimes intermits ; this is the moment for consolation and reasoning. If too much susceptibility for direct reasoning, indirect observations, made in patient's presence, will often be effective. When once isolated, intercourse with relations subject to same rules as other cases of insanity. All means of self-destruction should be removed from the patient's room. Knives, forks, razors, scissors, pieces of glass, iron, or tin, garters, braces, sashes, neckcloths, have all been converted into implements of self-destruction, and should be taken away ; the windows 214 should be secured, fire guarded, lines from windows and bed-ticking, fireirons, and every possible instrument of self-injury be removed. No projection on which a cord could be fastened should present itself in the apartment. Even though an attendant sleep in the same room, the clothes of both should be locked up, and the key secured. Has known slips from sheets or blankets, and likewise handkerchiefs and cravats, made to form nooses for hanging or strangulation. When no other means offer, will attempt beating their brains out against a wall. Means so cunningly devised often, as impossible to detect them, and a volume might be filled with the stratagems and plans. Superintendent of St. Luke's Hospital states, froth thirty years' experience, that it will not be attempted in the presence of others ; has known several instances to the contrary; this is important, as a misguided confidence may ensue. A nice point when to put confidence in a suicidal patient; you may cause his death by trusting him too soon, and may cause him to relapse by a want of confidence when convalescent. In general, symptoms attending improvement of health or mind may be discovered by attention, which will guide our judgment how far we may enlarge his liberty, and how far we may confide in him. King George 111. of England desired one day to shave himself. Dr. Willis feared that hesitation might awaken the idea of suspicion in the king's mind, and turn his attention to the subject of suicide, before unthought of. He promptly sent for the razors. While being brought, he engaged his attention with papers on the table : the king became so occupied with them, that his physician felt assured he entertained no design of the kind. After shaving he returned them. The razors were not sent away immediately, lest he should think himself not trusted. Determination to starve generally succumbs to a few days' fasting, or perhaps the scent of savoury viands. Case.-From many mortifications, fell into a state of deep melancholy ; resolved to die of famine, and for forty-five days took no nourishment except water arid spirits of aniseed: no requests to break his resolution availed. At last, having by chance seen a child enter with a slice of bread and butter, it excited in him so violent an appetite, that he instantly asked for some soup; gave him every two hours some spoonfuls of rice bouillie, and, by degrees, more nourishing diet, and his health, though slowly, was re-established. When refusing to eat from some other delusion than a suicidal tendency, they are often either persuaded by kind entreaties, or induced by stratagem to do so. When not to be persuaded, tempting food should be placed within their reach, and left ; if patient partakes of it, no notice should be taken of the fact, but the same course should daily be pursued. This plan should be tried with every lunatic refusing food. Frequently they delight in stealing it, and will take it in no other way. If so, it is requisite to indulge this caprice. Gay spectacles damp, by contrast, the spirits of the melancholic arid suicidal, says Falret; and Burrows agrees to this. In truth, amusements or diversions, like religious consolation and instruction, must be selected to suit the various conditions of deranged intellect, or more harm than good may follow.
Senile Insanity.-Treatment must be generally purely palliative; but when not organic, proper treatment may much ameliorate the condition of the patient.; or even, when powers of life not too exhausted, effect a restoration of the mental faculties. The only remedies here prescribable, are those removing any inordinate action in the system without reducing the strength, regulating the natural functions, arid renovating them. 215
Hypochondriasis.-In the cure of hypochondriasis, is imperative to restore suppressed eruptions, &c. Topical bleeding from the head in all cases required where determination evident. Purging violently generally injurious, though the excretions are always dark and offensive Costiveness being a general accompaniment., must be obviated by aloetics and warm aperients. Small doses of the blue pill, combined with aloes and light tonics, seem best adapted to restore the digestive functions. The warm bath, or a tepid shower bath and friction, very serviceable in equalizing the circulation, and restoring the functions of the skin. Emetics borne better than purges, and they commonly evacuate much sahurra from the stomach, with evident relief. Exercise, occupation, and amusements, as far as can be borne without irritation, are powerful adjuvants in restoring health. Case.-An accountant: 45 ; regular habits ; very sedentary occupation; suffering most of the symptoms of genuine hypochondriasis. Every autumn had a pustular eruption on his neck, back, and arms, which he had missed the preceding autumn ; and soon after mental disease appeared. By the daily application of blisters, the size of a shilling, along the course of the spine, keeping up a constant irritation and discharge ; removing him from his occupations in the city to a purer air and more cheerful scenes, and regular attention to the chylopoetic functions, he soon amended, and in six weeks recovered. Following case contains an epitome of the practice which he has found very successful in hypochondriasis, if nor of very long standing. Case -A gentleman of fortune ; æt. 50, of the melancholic temperament and hereditary predisposition ; became very desponding, and, in consequence, unmanageable ; a married man, with a numerous family. Father was an eccentric and violent man, but of great talents as a statesman. Patient naturally of an amiable disposition, a highly cultivated mind, and deeply learned in various languages ; habits of literary men ; yet fond of field sports. Had lately experienced much anxiety and vexation, causing great depression of spirits, and a gradual change had been observed in his disposition and habits ; health, too, sensibly affected. At the commencement of symptoms, a sister, insane for many years, died ; this seriously affected him, and impressed him with the opinion that his own mind was becoming deranged. Complained of great pain and throbbing in the head, beating of the temporal arteries, flushing of the face, and general confusion of ideas, with sleepless nights, and if he had a short slumber, terrific dreams. His digestive powers were exceedingly impaired, and he was troubled with great flatulence, borborygmi, &c. Was bled, and took some medicine, and went to a friend's house in the country. Here, one night, became rather violent, and evinced a positive delusion of mind ; brought back to town, and Dr. B. was called in. Countenance betrayed great gloom, anxiety, and suspicion ; complexion very sallow ; tongue whitish, with a brown streak down the centre ; pulse quick, small, hurried ; bowels very constipated ; nights sleepless ; appetite moderate ; skin cool. Every evening the throbbing of the head and flushing of the face returned, and he was then very irascible, and almost unmanageable. Often shed tears, and always with relief, and repeatedly sighed. Was dreadfully apprehensive he should die, and stated many diseases to which he thought himself disposed, and was willing to submit to any remedies recommended ; his general timidity was indeed extreme. Expressed the warmest affection for his wife, and his fears of being separated from her. Spoke kindly of his children, but had no 216 wish to see them. Of his affairs generally, had a clear comprehension, but fancied himself in danger of arrest from debt. Without opposing impressions, endeavoured to inspire him with hopes of getting well. Told him he was not insane, but had experienced a paroxysm of delirious violence from temporary fever, and, as this might occur again, and lead to serious consequences, should place him under a respectable keeper, staying constantly with him : advised removal into another house with his wire, where he would be free from interruption by improper visiters. Retained his wife, because an accomplished lady, intelligent; and having still the best influence over her husband ; his unbounded affection and confidence. None of his old servants, however, attended him. The pain, throbbing, arid confusion, he thought much relieved by the application of eight leeches behind the ears. An emetic brought off an immense quantity of tough, viscid phlegm from his stomach arid a subsequent purge evacuated an abundance of black and very offensive faeces. Pediluvium every night. Afterwards slept better than for many previous weeks. Blue pill with aloes every night, and a saline bitter draught twice a day, and adopted a course of regular exercise, light diet, and early hours. At home amused himself with any light reading, and such games as he could be persuaded to engage in. Three days afterwards, leeches again, and with the same relief. Afterwards renewed, with intervals of a few days, till all the symptoms of cerebral determination ceased. Result beneficial, but riot immediately ; for the day after he always complained of weakness, arid on the second day invariably felt better. As he bore the emetic well, it was repeated twice or thrice, each time ejecting much viscid phlegm. The pulse returned to its natural standard, but was languid ; the tongue cleaner. Light tonics only were now exhibited. Still every day had paroxysms of despondency, with tears, but were diminished in force, arid his steep was more refreshing. Some difficulty to induce exertion and sufficient exercise, as he fancied himself exceedingly weak, and an indisposition to reading or any amusement. By degrees became a little more animated. One day surprised him by a challenge to a game of chess, of which, when well, he was very fond. Consented, after some hesitation ; commenced his usual play ; made a false move, arid was going to give up in despair. Purposely, however, avoided taking any advantage, which encouraged him, but had riot patience to finish the game. Effort had the good effect of rousing him ; and lie walked some miles that day, ate a good dinner, read the newspaper to his wife for the first time, and continued till bedtime cheerful. From this, daily gained a little confidence, asked to see one or two particular friends, took exercise regularly, arid engaged in some simple amusement every evening. Corporeal functions improved, and also his general appearance. Still occasionally a little fearful arid desponding ; and upon any unusual noise was suspicious of more being meant than met the eye. Leeches continued twice, arid then once a week, for two months ; arid the tepid shower bath, and more powerful tonics, were prescribed. He then went to the seaside, and his keeper was removed. At Dr. B's. request gave up, or, at least, relaxed his studious habits, arid devoted himself more to riding on horseback arid field sports. Spirits variable until the spring, when he quite recovered. Although has since lost his wife, and experienced many other trying domestic circurnstances, yet his hypochondriacal affection has never returned. Uninterrupted confidence of patient in his physician, one basis of success 217 in treatment. Hypochondriac details all his feelings and pains : physician must listen with great attention and apparent interest. Must never commit himself by fixing any limit to the disease, lest. the prognostic fail ; neither must he accord with patient's gloomy predictions. Should beware of giving a hypochondriac reason to think his mind is deranged, neither ridicule his predilection for adopting all sorts of remedies. Often advantageous to treat a fancied disease as if real ; but care should be taken that patients suspect not this state of things. He ought never to be suffered to read his prescriptions : after gaining his confidence, a sensible physician, being acquainted with his weaknesses, will know how to meet and combat them. He will sometimes reason, sometimes console, sometimes exercise a little firmness, especially in enforcing his prescriptions ; at others, to obtain consent, alarm him with the consequences of non-compliance. But lie should always speak and act with caution, quietness, and self-possession. A little society with agreeable persons and those he loves is not only admissible, but desirable. Consolations of friendship also advantageous. When his real ailments no longer require medical superintendence, he should take short journeys amidst pleasing and varied scenery. All kinds of exercise are to be recommended, since they promote the circulation and reaction, and improve all the secretions. Riding on horseback and driving a carriage best. Has not found music advantageous.
Demency or Fatuity. Case-Æ. 24 ; scrofulous habit; fair complexion ; a very cheerful and lively disposition ; suddenly attacked with pain in the head and slight fever ; bowels having been previously much constipated, and menstruation irregular in quantity. The pupils of the eyes were contracted ; there was great susceptibility of light, and the pulse was quick. Little other constitutional disorder. Cerebral symptoms did not yield to the means used, and in a few- days slight delirium followed. Fever subsided in about a fortnight, and the pulse became slow and unequal. Pupils of eyes now became excessively dilated, fixed, and insensible to the rays even of the sun. A complete state of fatuity rapidly followed. Powers of sensation and volition suspended ; insensible to the calls of nature ; if solid food was put into her mouth, she did not masticate or retain it. All nutriment, therefore, in a liquid form; of which she would swallow a part from a spoon far in her mouth. Neither spoke nor walked except when led. After four months thus, suddenly amended. First symptom an instant return of sight ; consciousness soon followed ; and in full possession of all faculties fourteen days after return of sight. Eleven years since and no return. Must acknowledge, no perceptible effect from treatment. This was local abstraction of blood, by alternately cupping on the occiput and by leeches behind the ears, which were repeated six times, with intervals of eight or ten days ; blisters to nape bf neck, and afterwards a seton introduced and continued. Warm bath ; purged briskly twice or thrice a week ; mercury as an alterative for two months, gradually increasing the dose, and tincture of digitalis thric.e daily, commencing with fifteen and ending with forty minims. At the same time abundant nourishment. Case.-Miss ----- possessed youth, fortune, accomplishments, and a very amiable disposition ; but from excessive indulgence and an illregulated education, had very little command over her feelings. Constitutionally one of the most nervous and sensitive of beings. Good health, but catamenia been scanty and irregular, and obstructed for some 218 months. No moral cause, except some little perplexity on one subject, about which worried for some days, and just before, a great fright, rendering her more than usually susceptible. Felt her spirits discomposed and unequal, with frequent fits of abstraction-a habit not unusual with her. In a few days some incolrerency, and oftener absorbed in reverie. In two or three days slight symptoms of violence. A week after brought to town. Received me politely, and answered all questions readily ; but immediately, in a childish and peevish tone, and in a rapid way, reiteratedly asked for a friend, dearer, she said, than all the world-as an infant for a favourite nurse ; and when the lady came she fondled her in a childish manner. At other times absolutely abstracted, and when roused, would cry for her friend in a whining tone, although perhaps present, arid when she made.any request it was in the same tone, or in an impatient way. Had all the terrors, too, of a nursery child fancying she saw ghosts and demons, and heard terrible noises, and at night would bury herself, if not prevented, under the bedclothes, as if to avoid them. Countenance neither maniacal nor melancholy, but very silly. Head very hot, arid, when asked, complained of a great noise in it - face flushed, eyes red, tongue white, pulse quick, arid slight pyrexia. Placed under a judicious nurse. Head shaved; twelve ounces of blood from scalp ; air evaporating lotion constantly applied ; a brisk purgative and saline draught, with ten minims of tincture of digitalis every six hours, and as her extremities were cold, pediltrvium. Diet to be very simple. All the symptoms next day relieved ; more sensible arid composed, and had slept without expressing her usual alarms. Evident in a short time that the presence of her friend always excited her; therefore, denied her intercourse. For a few days, Miss ----- very importunate for her, but this wore off livery two or three days the symptoms of a cerebral excitation returned, and were generally relieved by the means described. Evaporating lotions, and cold of any kind to head, always particularly agreeable to patient. Eight ounces of blood from head, repeated thrice in first fortnight, and continued with longer or shorter intervals, according to the urgency of the symptoms, till the external marks of cerebral irritation ceased. Purgatives repeated once or twice a week. In about six weeks many boils, but with no benefit, to mind. Sleep now a good deal disturbed, and when so, mind crowded with all sorts of phantasies. Tried large doses of extract of lrenhane : at first produced sleep, but phantasies then continued while awake in the day : all narcotics therefore abandoned. After three months, great improvement ; infinitely more rational ; took interest in many things, and that without being roused to do so. Although had interdicted friends, yet permitted, as an experiment, the visit of a very sensible old friend. Much gratified, and bore an interview, several times, very well, but always more abstracted afterwards. In a few days relapsed, and worse than ever. Now expressed the same foolish and morbid affection for her maid, an old servant, as at first for her friend, arid it their became necessary also to remove her. Alternately, completely unconscious of .her wants, and everything around her, or would exhibit all the pettish waywardness of a child; yet., if medical attendants came in, it aroused and steadied her, and while we conversed, she would answer correctly, arid ask questions, evincing an unimpaired memory ; but if the conversation were discontinued, relapsed into thoughtfulness. Since the first attack, never exhibited violence or vindictive feeling, but submitted to every remedy, took 219 medicines with readiness, and was content with very little, and the plainest food. Totally indifferent to dress and appearance ; indeed, if at liberty, would unwittingly strip off her clothes, and commit acts betraying total want of reflection. The same trivial punishments, as of a naughty child, as tying hands together with a riband, or slightly fastening her to a chair, or the gentlest scolding, always produced momentary attention and amendment. In about a month, paroxysm abated, and she more quickly- than before arrived at the former point of convalescence. Now asked for her drawing and painting materials ; could not, however, trace a figure or a flower, but amused herself by colouring little prints. Attempting to write, letters would be unconnected scrawls, and in books she only looked for the prints. Been now on one floor nearly five months, for every attempt to change her apartment, or even the sight of any passing object in the street, always revived the hallucination, and she fancied she saw friends long since dead, or something horrible. At len„•th tried a thorough change of scene, and took her to ride in my carriage on a quiet road. Quite passive arid abstracted, yet answered simply when asked a question ; but expressed no gratification. Next time carried her into the Regent's Park, a new scene to her, but. nothing arrested attention except when pointed out. Now came in drawingroom, but always felt alarm, and would not for a moment be left alone ; and when evening came, sought her chamber as the securest place. At this period, could read fluently, but remembered little of it a few moments afterwards ; and when she wrote a letter began properly, but presently betrayed her incapacity by repeating the same phrases, and leaving the sentences unfinished ; yet, at this time, when roused, could converse quite sensibly. Cerebral excitation having apparently ceased, had been for some time taking tonics, and using the shower bath. By degrees gained a little more courage, and as I had quite obtained her confidence, I encouraged her to draw, write, arid read travels ; arid set her little tasks. She made progress. At length made two requests, to have a piano, and to read a certain moral work. Latter allowed, former deferred, as music in the streets had agitated her and increased the abstraction : read many passages of the work to me, and understood it. Soon after, piano being given to her, played with correctness arid without notes, pieces formerly practised ; but, from it, became more and more abstracted. All her illusions returned, and unconsciousness, but without external signs of cerebral excitation. Ridiculous attachments, as formerly, but this state soon subsided. Seclusion to her room, quietude, a purgative every third day, and continuing the chalybeate, in a fortnight, nearly restored her ; but perfect consciousness still wanting. Bore an interview with a near relation without any ill effect, and being roused, evinced the excellence of her memory and affectionate feelings by the kindest inquiries. Now removed to a house in the environs of town. Accompanied her, and she imagined she saw friends on the road, who were either dead or far away. Here took abundant exercise in a good garden, without observation from strangers, a circumstance which always excited her suspicion and apprehension. Walked sometimes in the garden with her for half an hour: on these occasions more confidence seemed attained, for she expressed great delight, and would converse with perfect'sense and her usual freedom. By degrees thought herself secure when walking with her nurse only. An unknown young lady now came to stay with her, and manage the house ; soon reconciled to her, but sight of old 220 friends always disturbed her. Here three months ; still fits of abstraction frequently, when she neither recollected meals, nor any other natural wants ; yet at times would read, draw, work, walk, arid skip with a rope, or play at battledoor and shuttlecock, for the sake of exercise, or enter into any amusement with her companion and nurse. Every night, however, phantasms, and every passer-by appeared a spectre. Yet when consulted on a necessary point with respect to her property, clearly comprehended and directed. Confessed a great dislike to present abode, as whenever she went tip stairs her imagination was haunted. Another tried, and removal to it a source of great satisfaction. Several weeks before any material change in mind or body. Tonics, air occasional aloetic purge; the bath; exercise, and every species of amusement. to rouse her, were persevered in. Up to this time forgetful of things immediately precedent. First symptoms of returning corporeal health a slight appearance of catamenia. At the next period, feelings denoted its return, but it failed. Ten ounces of blood from sacrum by cupping; at the next period occurred, and afterwards continued. :Mind now sensibly improved. Interest in affairs ; before indifferent, and resumed music with much pleasure arid good effect. Letters perfectly correct, yet brief. But absent fits still intervened, though not, as before, unconsciousness. Now permitted services of maid, and bearing this well, of friend first mentioned. This proved a lasting gratification. Ventured on short airings in her own carriage. At first timid and confused, and sometimes imagination wandered a little, but she always became composed before the ride finished. Then allowed to see whom she pleased, and led to look forward to being freed from all restraints. Thus a year from access before convalescence. Remained where she was a few days longer by way of probation, and paid her occasional visits rather to watch any deviation than prescribe. Although recovered, some degree of mental weakness ; and as a vivid sense of all the degrading circumstances of her illness was left, advised her not to go immediately among her friends ; but where there was variety to divert and where she might occasionally see them. Continued the shower bath, and every species of exercise that could conduce to invigorate the system arid strengthen the mind. In about six months, fortitude enough to return to native place, without unpleasant feelings. Have been thus long, because progress and event of a rare case, and treatment in similar cases illustrated. So decided is the effect of fever in suspending and often in curing deniency, that could we as readily inoculate fever, and define the limit of its operation, as we do that of the variolous infection, it might be applied as a remedy in the treatment of this form of mental derangement. When idiopathic, last case a specimen of mode of treatment; each one being managed of course according to circumstances. If symptomatic, and complicated with mania and melancholia, should not be considered as hopeless. Except when clearest proofs of increased action in brain, as heat of head, flushing of face, and quicker action of cerebral vessels, all depletory and exhausting remedies must be avoided. Even in acute dementia, caution in their use. Unless above train of symptoms of excitation, tonics, the bath, and good diet rather than otherwise. Where consecutive to fever, hemorrhages, or evacuations, or any debilitating causes, all means to repair without too much stimulating, the sources of supply and nourishment. In chronic and senile dementia, vital energies must be adequately sustained; and should reside in a pure, warm, and dry air. Dr. John 221 Monro coincides with Mead in thinking, that the danger of relapse being always great, everything prescribed for the cure, as medicines, diet, exercise, &c., should, when it is effected, be continued at intervals for a considerable time after recovery. Burrows thinks this judicious, but that it will be very difficult to persuade the patient and his friends that it is so. Danger of a relapse or recurrence is announced by a train of nearly the same corporeal symptoms as before the first access, only perhaps in a less degree. If there be obtuse pain in the head, a sense of weight, confusion of ideas, disturbed sleep, with rushing of blood to the head, or throbbing of the cerebral vessels, and a great heat of the scalp, suspicion ought to awaken. Moderate bleeding, or cupping or leeches to the head: purging, vomiting, pediluvium, an issue or seton, or producing an artificial eruption on the skin by the tartarized antimonial ointment, prophylactic. If menses diminished, or obstructed, loss of a little blood particularly advisable. Cupping on the sacrum in such case relieves the uterine vessels. The French, as usual, recommend in a female leeches to the vulva, and in the male to the anus.
Gives from his son, Dr. George Burrows, an account of several asylums. In the Senavra of Milan, majority of the patients of the poorest class, chiefly inhabitants of the low and swampy grounds near Milan, who from marsh miasma and the very worst species of food become affected with the pelagra, which induces insanity. Pure air, wholesome lodging, and a good diet, recover, with little or no medical aid, a very large proportion. Larger airing grounds allotted to the convalescent and quiet ; and the others, which are much smaller, to the noisy and furious. Noisy on ground floor, and convalescent and imbecile upon the upper floors. Each patient at all furious has a separate cell, with a window looking out into the gardens, and a door communicating with the corridor. Convalescent women generally spin ; and men, independent of domestic work, labour, in fine weather, in a kitchen-garden, completely supplying the establishment with vegetables. A certain quantity of snuff allowed, and distributed occasionally as a favour. Bath of surprise given up because fatal in two or three cases. Exercise in the airing grounds and labour in garden only employment. Hand-organ, which, in the fine evenings of summer, is taken to the airing grounds, and there some of the patients amuse themselves with it. Also swing occasionally. Dr. Antonini, physician to the Villa Antonini, says he has found swings of great utility as a diversion; a common swing and one revolving in a horizontal direction ; latter had answered the purpose of the rotary chair, now interdicted by the medical commissioners. If patients have any fear of the water, let it in from the bottom. In one of the bath-rooms an apparatus for directing a steady and powerful stream of water upon any part of the patient's body, and the physician said he had found great benefit from it. In the hospital at Aversa, the bath of surprise in the floor of a moderate-sized room. Patient blindfolded and led across the room, when he unexpectedly falls into the bath, the sides of which are well guarded with cushions. Cold to the head while in hot bath, a common remedy. Numerous methods of amusement. A theatre, many musical instruments, billiard-table, &c. All not outrageous attend the church twice every day. At the hospital at Pirna, in Saxony, saw a very well-contrived tin machine, made to fit the hollow of the thigh, with straps, for those incapable of retaining their urine. There is a species of tread-mill, something like a revolving squirrel's cage, in which patients are compelled to take some 222 exercise. Evening winter-room extremely well fitted up with piano-fortes, violins, flutes, three or four backgammon and draft-boards, and a very good book-case. Allowed to remain here until ten o'clock, and music and these games encouraged as much as possible. The proportion of recoveries exhibited in his work, and in Minutes of Evidence before a Select Committee of the House of Peers in the present Session of Parliament, testify beyond doubt, that wherever curative means and judicious management are employed, ratio of cures will correspond and increase. Not only this, but the number relapsing is considerably lessened ; for the cure from medical treatment is always more permanent than that from nature. Remedies must vary with the constitution and peculiar features of each case ; consequently no fixed rules of treatment. Practice of the ancients generally judicious, and feels more indebted to them than the moderns for what success may have attended his efforts. Inductive evidence, aided by experience and reflection, and exemption from preconceived theories, form the basis of his views and practice. Moral discipline is requisite, throughout insanity : medicine is so no longer than the hope of a cure is entertained. When consulted in a case, our first duty to ascertain, as clearly as we can, the causes, moral or physical, nature, duration, peculiarities of patient's constitution, circumstances, &c. Should attentively consider character of delirium, whether idiopathic, from cerebral or meningeal inflammation ; symptomatic, and simply indicative of mental derangement ; or sympathetic from a remote organ or texture. If history unsatisfactory, and no symptom threaten serious consequences, always better to wait three or four days, keeping the patient separate and quiet, and having regard only to the due performance of the natural functions. By this simple precaution, a furious, vociferous patient, in an apparent state of high excitation, often becomes calm and compliant. By the contrary, prescribing remedies on first view, which his condition appears to demand, proved wrong by subsequent observation, much injury is perhaps inflicted ; thus a case is rendered intractable, and of long duration, which might have otherwise speedily recovered. Cælius Aurelianus and Paulus Ægineta teach that the mode of cure in both mania and melancholia is nearly the same, except that depletion in the latter must be more moderate, and that local remedies, as well as moral treatment, must suit. the modifications which present themselves. Satyriasis and nymphomania, if sympathetic, should be treated as in the case referred to (p. 209). If from local irritation of the genitals from extraneous causes, as leucorrhaea, prurigo, pediculi, &c., treatment obvious ; if from determination to those parts, leeches and cooling applications to them, bloodletting if the habit be plethoric, saline purgatives, and abstemious diet. As functions of vascular and nervous system, in all cases of insanity, are disturbed, should endeavour to diminish the action of either system which may preponderate, so as to restore the lost balance. When the cause is evidently in a structural or functional lesion of some remote organ, affecting the brain by sympathy, it is obvious that attention must be first directed to the organ so affected. History of case will inform us of the constitution, idiosyncrasies, &c. Reflection will teach us, that the aged and the young, the vigorous and debilitated, a recent and long-standing malady, cannot be treated on the same principle. In the incipient stages of mania and melancholia, the medical treatment. can differ but little. This a period for prompt measures, and in the active or confirmed stage, while a chance of cure offers, 223 these measures should not be relaxed, though they must be adapted to suit the carious modifications during disease's progress. The declining or convalescent stage, though requiring great experience and tact., belongs more strictly to moral treatment. In the incipient stage, the great vascular excitation and cerebral irritation must be met by repeated topical abstractions of blood from the head or contiguous to it, shaving the head arid refrigeration so long as preternatural heat of scalp, cautious general bloodletting even in the plethoric and robust, very moderate in the delicate though young, puraing, vomiting after he vessels of the head are unloaded and the bowels evacuated, nauseating doses of tartar emetic to moderate the circulation arid excessive violence, digitalis in gradually augmenting doses, till the pulse intimates reducing the dose, saline draughts, and moderate diet. Wren the incipient symptoms of excitement recur, must be treated as in the first. instance, except that neither depletion by local or general bleeding, nor by any evactiants, should be so active or copious. System will not in this stage bear them so well ; on the contrary, light tonics and the shower bath of great use, even when moderate topical bleeding and purging indicated ; and when exacerbation of paroxysm ceases, more powerful tonics, as chalybeates, cinchona, cold bathing, arid a better diet. In melancholia, also antinervines useful adjuvants. In the convalescent stage, if symptoms still of cerebral congestion, gastric irritation or uneasiness, or intestinal irregularities, should be attended to until removed. Formulas and doses of remedies vary according to the constitution and peculiarities of the patient, and symptoms of the case. In some hereditary cases, no symptoms of corporeal disorder, and no alteration in the external appearance, except, perhaps, a little more vivacity in the look, and a slight peculiarity in the eyes. Moral rather than medical remedies appear here to be indicated. Nevertheless, remedies which diminish inordinate cerebral action, provided they be not violent, will be found useful, and will often prevent a positive paroxysm of mania.
1. Abstractions of Blood. Copious abstractions of blood almost universally adopted in cases of insanity, with symptoms of violence and sometimes where patient is tranquil. The practice has received the sanction of ancient authority, arid at present very universal. Many eminent characters among the moderns have doubted its efficacy ; his experience, that, except in a very restricted sense, it is fraught generally with michievous effects. Tried depletion, by bloodletting, for several years ; but discovering his error, more cautious now ; has scarcely ordered venesection in six cases of simple mania or melancholia in as many years. Since changing his practice, more have recovered, and the cases have been less tedious and intractable. In the young, or the gross and plethoric, the determination to the brain in mania may be so strong as to threaten sangumeous apoplexy. In this case, prompt and copious general depletion may save the patient's life. If copious abstraction urgently impelled in mania and melancholia, most prudent to effect it with the greatest celerity. Condemns, with the moderns, and Ctwlius Aurelianus, the old practice, of abstracting blood from the head, by puncturing the frontal, nasal, or orbicular veins, or venx raninx under the tongue. Latter mode knew to relieve engorgement, in a case where those veins were so distended as to hinder the flexible movements of the tongue, and protrude the point of it between the teeth. Condemns, also, that from feet and ankles, as inferior to more direct means. Arteriotomy 224 often the readiest and best course ; and to divide either branch of the external carotid passing before or behind the ear, more advantageous than dividing that of the temple. If syncope desired, one large, or even two, orifices, or bleeding from both arms at once, been advised, as taking least blood and vis vitce. Only where a real state of plethora exists, or apoplexy is pending, that general bloodletting can be justified. Cerebral irritation, and perhaps the maniacal action from congestion of the brain, produced by simple determination of blood, not relieved by venesection. Inadmissible in the cachectic state. Venesection cannot be justified in any case of pure insanity; whether upon the principle of febrile or inflammatory action accompanying it, or of local determination. Writers who believe in febrile and inflammatory action in the early- stages both of mania and melancholia, do not all advise general bloodletting, or that it must be with great caution ; others object both to general and topical bleeding, although admitting febrile action ; and others, again, consider it, in the strong and plethoric, highly beneficial, without reference to the existence of either fever or inflammation. Regrets the sweeping condemnation both of the lancet and cupping by Dr. F. Willis ; because one may possibly be required, and the other, or leeching, seldom to be dispensed with in any recent case. As to obtaining by it quiescence and reduction of violence, as much opposed to the idea as any one. Should always first inquire whether quiescence cannot be obtained by any other means ; and next, whether consequences may not follow depletion, not to be compensated by present advantages. Agrees with Ferriar and others as to the sudden giving way of the strength on general bleeding. Bloodletting should not, therefore, be decided on, except upon a most mature consideration of the constitution, and all the symptoms of the case. Bloodletting inadmissible in long-standing insanity, except a temporary attack has come on, with symptoms of active cerebral excitement. Does not allude to those periodical or intermitting paroxysms sometimes attending ; for these, bloodletting is certainly not indicated ; nor in chronic demency or fatuity ; nor in any form of insanity from some extenuating disease. Rarely permanent ill effects, relative to diminution of vital energy, from leeches or cupping. From primary symptoms, both of mania and melancholia, may be inferred, that although venesection is not indicated, yet, that topical or local bleeding may be very useful. In every recent case he has seen, local abstraction from the head itself, or contiguous, as the nape of the neck, or between the shoulders, has been indicated. Mode been cupping or leeches. Cupping on the occiput preferable. Celsus says this lessens the malady, and brings on sleep. Leeches a substitute, when too great a terror of cupping, or a prejudice. Neither weaken like general bleeding, and therefore preferable. Shaving the scalp should generally be premised in all recent attacks. Head kept cool thus, and facility made for applying cupping-glasses or leeches. If pain or throbbing in a precise spot, much relief often from the glasses or leeches. If no particular part, he orders them behind the ears, or across the occiput, and sometimes on the temples. Quantity of blood regulated by circumstances of case : one may require sixteen or twenty ounces ; another only ten, eight, six, or even a smaller quantity. Hallaran says, that the superficial heat is reduced by placing leeches behind each ear, on a limited space, and afterwards by cupping-glasses over the orifices. Where more blood than the leeches take is wanted in any case, this is a good mode. An excellent rule, that as many glasses or leeches should 225 be applied at once, if possible, as are capable of abstracting as much blood as may be desired: effect more certain, and operation curtailed in length, an object of importance with impetuous and unruly patients. Diversity of opinion as to propriety of repetition, &c. : holds dangerous the practice of repeating, through exacerbation and remission, even into the continuous form. His practice to repeat cupping or leeches so long as symptoms of great cerebral excitation, especially whilst a preternatural heat of scalp ; but when they remit, to desist from drawing away blood, and repeat it only with the renewal of these symptoms. If premonitory symptoms announce an attack, local depletion will often prevent it. Mere raving and fury not from cerebral excitation, consequent on vascular excitement, and would inevitably be exasperated by depletion. The degree of mental anguish and disturbance impelling suicide, finds relief in the sudden loss of blood. In cases of nymphomania, all characteristic symptoms been removed by leeches to vulva. In like manner, improvement of the mental faculties, dependant on menstrual obstruction, follows cupping on the sacrum. Cases occur, where topical bloodletting has been required to relieve local congestion, and, at the same time, stimulants to support the general tone of the system. Has no hesitation in continuing abstractions by cupping or leeches, so often as symptoms denote fresh excitation. Advisable to pursue this plan, even when tonics are indicated to support the patient's strength ; for local determination as frequent in the weak as the strong; of course quantity taken smaller. Should faintness or marks of exhaustion come on during the abstraction, the patient must be supported by good broths or a little wine. The melancholic, though having less vital force than the maniacal, whether despondent or excited, may require topical bleeding; and as symptoms in this form of insanity persevere longer without remission, moderate local depletion may be repeated for a greater length of time than in an attack of mania. The ancients advised it in this form : Willis says that it finds a place in all cases, and sometimes is to be often repeated. Practice on the Continent of leeches to anus, as a general principle, should be declined. But where disease from sympathy, with some abdominal viscus morbidly affected, the loss of blood from that part may do good ; and more especially, if accustomed to hemorrhoidal flux, and that has been suppressed.
2. Dry Cupping. Useful where determination and congestion of brain, and debility too great for bloodletting. Have seen such cases ; and found sensible advantage from the repeated application of several glasses to the head, without scarification or loss of any blood. Friction on the pericranium after dry cupping, and pediluvium, greatly tend to determine blood from the head to the general circulation.
3. Refrigeration. Its utility where preternatural heat of head, confessed in all cases of cerebral disorder. Shaving the head, not only a necessary preliminary, but deserves regard and adoption, as itself refrigerating. Celsus sometimes advised clipping off the hair, sometimes shaving the head. Clipping the hair close does not suffice ; for, besides that it does not produce the soothing effect. of denuding, the process of evaporation, which abstracts caloric, never goes on so rapidly as when a naked surface presents itself; nor is effect on sensoriurn so effective. Abstraction of heat much more rapid and complete by evaporation than by cold applications, as ice, or any of the frigorific mixtures. Head, when divested of hair, should be kept so as long as symptoms of active 226 cerebral excitation, and local applications to the surface are deemed necessary. When such symptoms subside, and the brain may be suspected to be in a state of collapse, refrigeration must cease, and the hair may be suffered to grow. As a general rule, recommends that the heads of all insane persons should be kept cool. For this reason, permitting them to have their heads covered when indoors, is injurious. Observed this in several asylums. Will produce in many cerebral excitement arid sleepless nights, and consequent irritation to all the patients. If having a determination to the head, should lie with their heads cool, and also raised. A substance like feathers invites the blood. Cold to the scalp, in cases with great cerebral excitement, though agreeable, yet its effects neither so complete nor permanent as when topical bleeding and purging have preceded. Intense cold to the head, in a chronic state, when patient is noisy and violent, never induces quiescence and sleep. On the contrary, it is irritating. Dr. Busser, of Wohlau, relates the case of a lady, attacked with mania on the seventh day after delivery, and who was cured by ice in a bladder to the shaven head, for six or eight minutes, several times a day. But in a man, six months in a state of mania, tried twice a day for half an hour, for eight days, produced loss of sleep, previously obtained by belladonna. Agrees with Dr. Newbek, that in cases of turgescence of cerebral vessels, and at the commencement of attack only, that benefit follows the application of ice, and use of antiphlogistic means. Cold applications should not be continued longer than the preternatural heat of the scalp lasts. Georget says, that cold applications ought. not to be employed during the period of excitation : differs totally with him, provided the previous evacuations. Means immaterial evaporation produces the most intense cold. Æther dropped on the shaven crown, and alcohol diluted, used by some ; former, however, troublesome and very expensive ; latter answers extremely well. Liquid should be unpalatable, to prevent attendants drinking it, Prescribes a lotion of one fourth alcohol and three fourths camphorated mixture ; or spirits, vinegar, and water, of equal parts ; or with liquor ammoniæ acetatis, instead of vinegar. But refrigerating mixtures of the London Dispensatory, also, are useful. A napkin, folded several times, and put over and around the head, well saturated with any of these lotions, and wetted again as often as dry, best way of keeping head cool. Ice pounded and applied in a bladder good ; or even a clay cap, often renewed, where expense is an object, is not a bad substitute. The surface may be kept cool, also, by sponging the head with a tepid mixture of vinegar and water. Knows nothing, by experience, of the douche. Cold douche represented to act sometimes as a sedative, sometimes as a tonic. But seems declining in reputation, as often injurious. Even in France now much reprobated. Now used only with the greatest caution ; and more as a means of repression and moral agent in furious cases, than with an expectation of sleep or tone. Death followed its abuse, in one case, at Charenton ; and other serious accidents have happened. Disorganization of the brain and incurability have followed submitting patients to the operation for an hour together, as formerly practised. Still, when used with judgment, a remedy of importance.
4. Gyration and Swinging. Each of three preceding remedies, by diminishing cerebral excitation, induces sleep in recent insanity, and hence greatly contributes to the cure of the malady. Any remedy inviting sleep acts more beneficially than narcotics, though producing that 227 effect. One of the means recommended by Celsus and Aurelianus, in mania, is motion in a suspended bed or moveable seat, or by swinging. Darwin advised gyration. Effect of sea-sickness on stomach and circulation analogous to rotary machine, and in olden times been prescribed in insanity. Darwin constructed a rotary machine, for obtaining two objects : first, quieting violent action of the heart and arteries, by gently compressing the brain, by having the patient's head distant from the centre of motion ; and, secondly, forcing the blood from the brain into the other circulating vessels, by reversing the position of the patient, and placing his head next the centre of motion. Dr. Cox first introduced it in treatment of insanity ; prescribed the oscillatory as well as the circulating movement. He and Dr. Hallaran speak well of it; the latter adopting it in the Cork Asylum. If stomach only acted on, a purge should be afterwards given. Erect machine best form for evacuations, and horizontal circular bed for sleep. Clear evacuation of the bowels should precede either ; nor should they be used at the commencement of the disease, until the violence of the paroxysm has subsided ; nor in young plethoric persons, nor where a positive determination of blood to head. Motions should be gradually carried to the degree of velocity desired. In the intermitting form, gyration been found of particular benefit in checking the approaching paroxysm. If great prostration from it, most advantageous. If we seek sleep, a slow and long-continued action to be kept up, if possible, without affecting the stomach to vomiting. Like all other remedies, acknowledged sometimes to fail. Either vertically or horizontally, strongly advised, as a moral as well as a medical agent in chronic cases ; for where no expectation of cure, a few trials have produced a wonderful improvement in manners and behaviour. Where violence been so great as to compel a rigid confinement, patient has become tractable, and even kind and gentle, from its operation. The morbid association of ideas has been interrupted, and even the monomaniac's delusion dissipated. In abstracted cases, Dr. Hallaran says he never saw any one instance of complete recovery from it, when disease had assumed the chronic and uninterrupted form. Now met with in most British public asylums ; but its results very. differently reported ;some speaking most favourably of it, some dubiously ; and with others it has fallen into disuse. Thinks these contradictions owing to want of selection in cases, and attention to rules of prescribing. Professor Horn, of La Charite, at Berlin, coincides with Cox and others : a fatal accident occurred from it to one of his patients. The government of Milan have suppressed it in the Senavra, from several fatal accidents attending a. Professes no personal experience ; but from analogy and pathology, believes it an efficacious remedy, and that no asylum should be without a complete apparatus of both kinds. Unquestionably a formidable remedy, and on no account should be tried, but under the superintendence of a competent judge.
5. There is commonly by far too great a solicitude to procure sleep. If the means used to obtain it be not indicated by the physical state of the patient, mischief follows its exhibition. But whatever diminishes the too great excitement and activity of the intellectual organ, will induce composure and sleep as a consequence ; hence abstraction of blood from the cerebral vessels, refrigeration and gyration, which promote the equalization of the circulation, produce that effect ; and from these means, it is comparatively a calm and desirable slumber, from which much good 228 is usually derived. Even if sleep do not follow, previous cupping and intestinal evacuations prepare the system for the safe and beneficial exhibition of a, narcotic; which would, without these evacuations, have probably had the opposite effect to composing. A hearty meal for supper has been found to produce refreshing rest in maniacs where every other means has failed. This kind of sleep, however, in those of a full habit, rather compresses the brain and confuses the intellect, than invigorates the mind. Tuke and other observers have noticed, that noisy maniacs, who scarcely ever sleep, by a change from a low to a fuller diet, especially after a full meal before going to bed, and with the addition of a moderate quantity of porter, or even with porter alone, have slept soundly, and ultimately recovered. From this testimony, must not conclude this to be a practice of universal application. The patients must be selected from a thorough knowledge of their cases. In the excited state of mania, Dr. Clutterbuck advises that the head should lie low in bed, to procure sleep: disagrees with him. Dr. Hallaran says that it is better to encourage the erect position, than to suffer-them to lie flat. Dr. B. generally orders all maniacal patients to lie with their heads raised, on a hard pillow, or, what is better, on a hard bolster, of considerable circumference, and as wide as the bed itself, as they are apt to slip their heads aside, or even hang them over the side of the bedstead. Asclepiades advised friction of the whole body of phrenitics to induce sleep. The gentlest friction or inunction of the head was recommended by all the ancients in other mental affections ; and also the sound of dropping water and murmuring streams to lull the patient to rest. Swinging is, by all, considered very conducive to sleep. All these innocent means should be tried, where sleep is desirable, before taking narcotics.
6. Narcotics. More diversity of opinion as to narcotics than any other remedy except bloodletting. Yalsalva and Morgagni condemned them as injurious. Regimen, labour, and exercise, some say, are the only remedies for sleeplessness. Many proscribe them altogether; others recornmend them in small, and others, again, in astounding doses. Effects variously described. All narcotics increase cerebral irritation, or a kind of sanguineous congestion of the brain, and thus force sleep. In very strong doses, produce vomiting, convulsions, and death. Maniacs will generally bear large quantities of opium and other sedatives, better than they will support remedies which weaken the vital powers. But opium, when the excitation is great in a full and strong habit, aggravates ; when moderated by previous depletion, or the habit reduced by long-continued mania, stimulants, like opium, wine, porter, &c., tranquillize and prove soporific. If, therefore, an opiate be given in the early stage of an attack of mania, it may force sleep ; but it will certainly excite and aggravate all the symptoms. In fact, the system must be emptied, and somewhat lowered, before opiates should be administered. In the advanced stage of the disease, when the vascular excitement is moderated by the antiphlogistic plan, an adequate opiate will often at once remove the delirium; so of sudden delirium from biliary derangements, sudden moral affections, &c. In mania from hepatic derangement, copious evacuation by the bowels ought to precede the opiate. In sudden maniacal delirium, calomel with opium. Caelius Aurelianus used the precaution, not to administer au opiate when the system was full. Ætius says, that after evacuation, sleep may be procured in any way; but if watchfulness succeed bleeding, it is the more aggravated, and if cold water, &c., be then applied 229 to the head, sleep will succeed. Burserius says, that opium is only efficacious in mania after necessary evacuations, and the patient's strength is reduced. Instances of mania ferox, where a large dose of opium, without previous evacuations, produced fatal apoplexy. Think if these hints are properly regarded, will be more uniformity of effect from anodynes. Weak opiates, through the medium of the stomach, decidedly mischievous in mania. Good only from a large dose, and repeating smaller till the end be attained. To fix maximum dose impossible. Constitution of patient and symptoms of disorder must regulate the quantity. Van Swieten has seen fifteen grains given at once to a maniac. Dr. Brandreth says Dr. Currie adopted alike practice, and that he himself gave four hundred drops of laudanum to a maniac in greatest possible furor; and in a few hours he became calm and rational. I have never ventured beyond five grains of purified opium as the first dose. In cases admitting an anodyne, I generally begin with three grains, and repeat one every two or three hours. Have never in this way exceeded twelve grains ; and if sleep has not then followed, have desisted. Burserius recommended the preparation of opium, of Bouquet. The wellknown black drop is said to affect the head less than laudanum ; but I have found no reason for preferring it in insanity. Have found no particular effects from morphine. Have, from numerous trials, found Battley's liquor opii sedativus to affect the head less, and constipate less than opium : opium, though in small quantities, taken by the stomach injurious, yet even in this form by the rectum, soothes and induces sleep.
Hyoscyamus niger ranks next to opium. Useful, however, chiefly in those cases of nervous irritation accompanying great despondency, where it is necessary to obtain a state of quietude on which sleep may be expected to supervene. As to sleep, therefore, indirect rather than direct. Advantage over opium in neither stupifying nor constipating. To obtain a decided soporific effect, extract must be given at bedtime, from fifteen to thirty grains, or ten or fifteen grains every six hours. If as a calmant merely, four or five grains at a dose ; and being bulky, better to dissolve it in some liquid than make it into pills. Hufeland and others say it acts by reducing the activity of the arterial system, and is a mediator for the introduction of remedies tending to allay nervous irritation and reaction. Therefore, an excellent remedy in cases denominated nervous irritability and morbid sensibility : given here with camphor. Frequently deteriorated. Has tried in mania and in melancholia, the extracts of stramonium, aconitum, and belladonna, as soporifics. One grain of the former in furious mania has procured several hours' sleep, when other narcotics, in considerable doses, have not succeeded ; but the patients, in all the cases, were infinitely more violent when they awoke. Nearly the same may be said of the two latter narcotics. Same rule obtains in the exhibition of all narcotics ; they are not admissible during great vascular action or congestion of the brain, or a constipated state of the bowels.
7. Blistering the head or nape of neck, another very favourite remedy in insanity. Reprobates the indiscriminate nature of their employment, &c. ; has frequently had occasion, upon visiting a patient, to order the removal of a blister from the head or shoulders, and in a few minutes have seen his fury abate, or cease altogether. Can never be serviceable in mania any more than opium, where cerebral vascular excitement or congestion exists, till local or general depletion has preceded. Where 230 admissible at all, it is in the more advanced stage of insanity, where vascular excitement is diminished and the nervous system requires stimulating. Vesication more beneficial in melancholia than in mania, because vital powers more torpid. But not a general rule, as melancholia often shows signs of violence and cerebral vascular action or congestion. When these symptoms, however, abate, blistering between the shoulders sometimes useful. As derivatives, blisters do more good when applied to the thighs and legs ; and then if the discharge be not kept up, they should be frequently removed. In some cases, have thought the benefit consisted in forcing the patient's attention to himself, rather than any other effect: the association of morbid ideas in melancholia, or the fixed delusion in monomania, may be thus broken and dispersed. Vesication dangerous, by patients eating blisters, or their being removed to some other part from where placed ; when constitution been much reduced, has known from them troublesome sores, and even mortification. Mead, John Monro, Haslam, Hallaran, and the most experienced practitioners, attach little faith to blisters. As derivatives or counter-irritants, warm stimulating cataplasmata on the soles of the feet, or to the legs, till the impatience of pain is expressed, are more efcacious. Still preferable to excite vesication, where indicated in mania, by a plaster composed of tartarized antimony and the common wax plaster. It soon occasions considerable heat, and a crop of pustules, from which a discharge may be kept up or checked at will. This might judiciously supersede cantharides in mania ; since it produces all their good, and none of their bad effects.
8. Setons and Issues. Inserted on the occiput, nape of the neck, &c., have been prescribed as derivants, to diminish cerebral irritation. Has rarely met with a case where he was quite satisfied that convalescence was the result of either of these applications : or at least other remedies had an equal or greater share in the result. lit two or three cases, however, where malady had continued for some months, and there was still evident cerebral commotion, with throbbing in the head, has certainly found these symptoms gradually decline after a discharge in this way has been established. Thinks that cases cured have been owing to retrocession, suppression, &c. ; drains in such cases decidedly useful. Whenever such causes suspected, a seton or issue should be introduced as near the head as is convenient..
9. Artificial Eruptions. Derivation may also be accomplished by producing a crop of pustules. Tartarized antimony best means : by rubbing it into the skin, a local irritation succeeds, and pustules are raised which contain, and discharge most copiously, well-formed pus. Friction of an unguent with this preparation on the shaven scalp, or neck, or between the shoulders, or on the inside of the fore-arms, till distinct pustules are produced, has been highly recommended. When gastric affections have preceded the alienation, pustules raised thus on the epigastric region have, it is said, removed the mental affection. Success of this treatment been variously reported before Dr. Jenner forcibly recommended it in 1822. Of eighteen cases, five were insanity, and three of hypochondriasis nearly approaching to it. Two or three recovered in a few days ; and he mentions no case where it was tried that it did not succeed in curing. This is his formula-Rx. Antim. Tart. (subtil. pulv.), 3ij. ; Ung. Cetacei, 3ix. ; Sacchari albi, 3i. ; Hydr. Sulph. Rub., gr. v. M. Fiat unguenturn. Where a prompt effect required, advises the 231 quantity of the tartarized antimony to be increased. To be rubbed into the inside of the arms night and morning, for several weeks. Dr. Burrows has been far less successful with this remedy than Jenner. When insanity has been connected with much gastric pain or irritation, and when retrocessent eruptions have been the cause, has seen the symptoms ameliorated, but never saw the mental disorder recede so rapidly as he has described. Not different effects with him even, dropping two last ingredients of ointment, and substituting five grains of carbonate of ammonia. Has frequently had the ointment rubbed on the shaven scalp, where he wished to stimulate and has been afraid of cantharides. Case.-A young gentleman ; had lived intemperately and been troubled with dyspepsia ; was attacked by furious mania. Been very largely depleted by bloodletting, &c., before I saw him. In a very weakened state, inclining to fatuity. Pulse very small and appetite bad. Plenty of nourishment and tonics, and a little wine. In a few days an appearance of mortification of the extremities. Cinchona, opium, and wine administered. A warm plaster, with tartarized antimony intermixed, applied over the shaven scalp. Complained in a day or two of great itching of the head ; but plaster not removed. Got well very soon, and without extremities sloughing. But whether general treatment or plaster most effectual, will not determine. When counter-irritation desired, has frequently recourse to this remedy ;for it has none of the objections to vesication by cantharides, and yields all the good from them. Owns, however, that there are few cases in which he should venture to rub it in for weeks together, as recommended by Dr. Jenner, for it sometimes occasions very deep sloughs, which are not lightly to be treated in cases of insanity.
10. Bathing. Good effect of the bath in the treatment of insanity been fully appreciated in all ages. But mode of application and degree of temperature, equally been matter of discussion ; some recommending it to be hot, others tepid or cold. Cclsus advised beginning with hot, then tepid, and lastly to pour cold water over the head and whole body for some time, and then to dry it and anoint. And says expressly-, that it is very beneficial for one who has a weak head to hold it where a strong stream of water may fall on it. Hence we trace the douche to be of great antiquity. Caelius Aurelianus ordered warm fomentations to the eyelids, and injecting warm infusions through the ears ; with false views. Immersion in a bath at 90° F. considered generally as the most useful. Time of continuance must be regulated by the constitution. Commonly, half an hour the extent, keeping up carefully the temperature of the bath. But when the patient is spare, highly nervous, and irritable, he may be kept so immersed for many hours. If any disposition to determination of blood, refrigerating the head while in the bath is not only a safe, but beneficial practice. According to Poggius, the Florentine, in his time the insane were placed in baths to the knees, waist, or higher, as the state of the disease required. Pomme treated maniacal patients by employing the warm bath for eight hours every day, and by applying cloths constantly wet with cold water to the head during the whole time. He even kept them in the bath twenty-four hours. Pinel more generally introduced Pomme's plan ; but he ordered that the cold water should descend on the head in a column, varying in height according to effect. wished ; sometimes limiting it. to a mere sprinkling (douche en arrosoir) on the cranium. Intention to drive circulation towards 232 the surface, and diminish, by refrigeration, the energy of the brain. The douche was carried to excess in the French hospitals, for it was used almost indiscriminately. Much more circumspection now. From Esquirol's opinion hazardous, but in judicious hands may prove very efficacious. As of gyration, so of the douche, much is said in favour of it as a means of repression, of calming violence breaking dangerous associations of ideas, and conquering obedience. The cold bath has had, perhaps, more advocates than the warm. Two modes were principally followed : first, simple immersion, by plunging voluntarily and openly ; and second, by surprise. Whenever a tonic plan becomes requisite, can be no doubt that cold bathing in the ordinary way, by plunging, is efficacious. Mode at the Senavra Hospital, at Milan, of placing timid patients first in the bath, and then letting in the water by degrees through holes in the bottom, changes entirely the expected reaction into collapse. Van Helmont regarded the bath of surprise as the best means of curing insanity ; and Baglivi, Boerhaave, &c., adopted this opinion. Latter goes farther to recommend submersion till animation had almost ceased. Bath of surprise, reported in some instances, which can credit, to have produced recovery. No personal experience ; but thinks mania so nearly- allied to apoplexy, that experiment must be dangerous. A just apprehension of this remedy now predominates, and therefore it is little used in those lunatic establishments where heretofore it was often resorted to. In some foreign hospitals has been wholly interdicted by the government. Provided the necessary precaution of evacuation in the plethoric, or those with a manifest determination of blood to the head, either warm or cold bathing may prove equally beneficial. In using the warm bath, conjoint application of cold to head may prevent the ill effects of determination, even when evacuation had not been premised ; but the safer practice in such cases is, to prepare for its use by local bleeding and proper alvine evacuations. Ferriar advises the warm bath for mania, and the cold for melancholia. Half an hour in the former, he says, will make a man who required six to put him into the bath, so passive, that one may take him out. Generally, however, the reverse obtains ; and author has found more good in melancholia from the warm than the cold bath ; though, in certain constitutions, the cold is useful. It will very soon be discovered whether the warm produces quiet in the furious, and reaction and vigour in the melancholic ; and if these expectations are disappointed, the temperature for each should be reversed. If cold bathing in melancholia produce reaction or a universal glow on the surface, it acts as a tonic ; and is peculiarly adapted to that physical and mental state of debility which succeeds the active stage of insanity, and is then an inestimable remedy. For delicate and timid persons, and for those to whom a plunging bath is inaccessible, the shower bath, either tepid or cold, is an admirable and convenient application. Those who can obtain neither, will find simple affusion of water over the head and body a good expedient. Same precautions here as in other diseases. Bathing in sea-water, not superior in itself.
11. Purging. For two thousand years, faith in the virtues of hellebore was maintained. In the middle ages Trallianus says it had grown into disuse, and was superseded by the famous Armenian stone ; and according to Nouns, a Greek physician of the tenth century, the latter was still preferred. The Arabian physicians feared the too great activity of the plant; Avenzoar recommends the flowers of nymphæa to be mixed 233 with it, to correct its effects. Its reputation revived, but many fatal, from it. Cophon, an Italian physician of the twelfth century, directed a chicken to be fed with white hellebore, and after eight days killed and made into broth, as a gentle purge. Morgagni lost a patient in melancholia from half a drachm of the extract of black hellebore, and he ascribes his death to his not having taken whey after it, as he always prescribed. Both species, black and white, were commonly administered. Black to cause defections in melancholia; and white vomit. ing, when the patient was too high and merry in mania. This remedy is still held in high estimation in many parts of the Continent, particularly in Germany. Has tried extract of both black and white. Operation always been very uncertain, and never found any difference of action from other purgatives or emetics. Has therefore long since discarded hellebore. Keeping the bowels in free action indispensable in all cases of insanity, but absolute purging in the incipient and active stages especially necessary ; on account of depraved nature of secretions. Montanus inveighs against half purges as irritating. Thomas Willis's formula in melancholia: calomel and extract of black hellebore, each a scruple, and extract of jalap, six grains ; such a dose at present would be dangerous, whatever it might have been. Author observes no stated days, but is governed by the circumstances of the case. And when the evacuations have become natural, endeavour to keep them so by exercise, diet, and means best calculated to preserve the functions of the body in health. Drastics may be indicated in the first instance, not only for torpidity of bowels, but for large quantities of morbid bile or scybala in the colon and large intestines, the evacuation of which sometimes at once greatly diminishes cerebral irritation and delirium. For this the sixth or fourth of a grain of elaterium has proved very beneficial. Calomel with other cathartics, very useful. When evacuations of this description, strong pur`res must be interposed ; but the bowels in the interim should be kept regular by milder cathartics. If vomiting and purging desired at the same time, gives a solution of Epsom salts, with one grain of tartar emetic to each ounce of the solution, and of this a tablespoonful or two every half hour, till both or one of these effects he produced. If great activity of the bowels required, two grains of emetic tartar, with six ounces of the common senna mixture, and three or four tablespoonfuls of it to be repeated every two; three, or four hours, till it freely operates. A dangerous error that bowels difficult to move always, for often free, and sometimes very irritable. Caution, therefore, necessary. He begins with moderate doses, and continues purging at intervals so long as the excretions bear an unhealthy appearance, and remits as they improve, always having regard to the constitution of the patient. As men of studious and seden. tary habits are often affected with melancholia and hypochondriasis, it should be remembered that they, especially, can never bear violent purging.
Where system, with costiveness, is much exhausted, either by longcontinued violence, or for want of a proper quantity of nutrition, or disability of assimilation, all of which are frequently met with, drastic purgatives out of the question. Glysters then the only resource. When resistance made, purgatives to be employed, which, from their bulk and insipidity, can be best disguised. A dose of calomel, with a grain or two of tartar emetic to give it activity, a convenient form. Has often sue. ceeded in getting this down, by putting it between two pieces of buttered 234 bread. Croton oil may be sometimes given, rubbed down with a little sugar, in table beer. Elaterium excellent as to bulk and certainty ; but too nauseous except in pill. Both these medicines sometimes cause intense nausea and vornitin; : an objection to them. In one case, former created nausea for a week : elaterium never failed to purge when expected, but sometimes operated alarmingly : should therefore, before such remedies, know well the strength of the patient. Galvanism has been successfully applied to remove obstinate costiveness. Purgatives in a case had little effect; but galvanism, twice a day for half an hour, always produced a stool, preceded by a rumbling in the bowels. Has not tried it, but conceives it very useful in constipation, connected with cerebral affections. Various devices used to overcome both involuntary and voluntary retention of the f%aelig;ces ; and any means accomplishing the object better than drastics. Suppositories, as a piece of common soap or a twist of tobacco, or irritating the sphincter ani with a feather, will often answer the intent. When all other means have failed, and the necessity of evacuation urgent, surprise will relax sphincter muscle. In La Salpétrière saw a strong arm-chair, like a night-chair, fixed to the ground, in which, when the patient is firmly seated, a stream of cold water is suddenly propelled from a douche ascendante, full on the anus. The shock generally produces the wished-for effect. This, however, might fail on a second trial, with a cunning lunatic. A vibratory chair, at the Glasgow Asylum, thinks would produce the effect. Thinks lunatics would, generally, acquire a regular instinctive action of the bowels, if forced to go, to the water-closet daily, at the stated time when nature makes the call in health. Has tried this plan with many where an opposition or disinclination has shown itself, and have thus imperceptibly conquered it. Filthy habits could in the same way be avoided, if the movements of those unconscious of the calls of nature were carefully watched.
12. Vomiting. No remedy that has been more generally or strongly recommended. Evacuation, says the elder Monro, the best cure, and vomiting preferable to all others ; and if not carried beyond the patient's strength, nor crowded too fast upon him, his bodily health improves so long as vomits are continued. Prodigious quantity of phlegm not otherwise to be got rid of: purges do not operate so well till after vomits. Hallaran advises that purging should precede vomiting. Monro's opinions certainly strengthened by the practice of many, before and since his day. Dr. B. has given them a fair trial; and in several cases relied upon their operation, together only with purging. Used in turn every emetic, and marked with attention effect of each ; and confidence, after several years' experience, in emetics alone been entirely dissipated. Ferriar asserts, that he has known dangerous debility brought on by a single vomit of emetic tartar. A vomit sometimes given to refractory patients as a punishment ; condemns this as attended with risk, and exciting a prejudice against medicines, afterwards irremovable. He has occasionally recourse to emetics, but only as in other diseases-to cleanse the stomach, excite activity of torpid viscera, and rouse and emulge general system. Decidedly more useful in melancholia than mania. Oc. casionally useful too, by interrupting intense abstractions, and morbid hallucinations, and capricious resolutions. When the urine has been retained from obstinacy, an emetic will generally evacuate the bladder. In like manner, it sometimes will act on the rectum when the fæces are 235 withheld. Where cerebral congestion, powerful doses of tartar emetic required to induce vomiting : has given a scruple at a dose without the least nausea, in cases of mania, where, as soon as the congestion was relieved by blood from head, a grain or two has vomited. So likewise as to nausea, until vessels of head unloaded and lower intestines well evacuated. These, however, general remarks, not without exceptions ; for sometimes, though rarely, much gastric irritation, and then the slightest dose of any nauseating medicine cannot be borne on the stomach.
13. Nausea. While it lasts, hallucinations of long adherence are suspended, and sometimes perfectly removed, or perhaps exchanged for others ; and the most furious become tranquil and obedient. In mania, furibunda an excellent auxiliary, not only because it subdues violence, but because of its controlling power over the circulation. Indeed, safer by far to reduce the patient thus, than by depletion. Doses of emetic tartar, at such intervals as will keep up the nausea, rarely fail to reduce the most stubborn to subjection. Sleep, also, in these cases so desirable, sometimes occurs in this state. Should be continued so long as positively useful, and no longer. Have known it pursued for a fortnight, and the hallucinations by degrees dispersed, or so weakened that the cure has been quickly accomplished. In melancholia, nausea never ought to be excited as a remedy ; for various reasons.
14. Salivation. Mercury been recommended, both from its peculiar qualities as a cathartic and a sialogogue. As a purgative, in the form of calomel, certainly highly useful, either by itself or in combination with other cathartics ; but possesses no antimaniacal properties. Prefers it in most cases, either in combination with, or followed by other purgatives ; acting better on the liver, which is often in fault in both mania and melancholia. Extremely useful likewise with opium, emetic tartar, digitalis, squill, &c., when particular effects are desired, as in other dis. eases. Mercurial ptyalism unmentioned till seventeenth century, when Thomas Willis advises it. Dr. B.'s attention called to it by accidental salivation of a patient and recovery. Case.-Miss C. ; very respectable ; forty; leuco-phlegmatic temperament; gray eyes; dark brown hair, and very corpulent ; disposition equable, though rather melancholic. Had for several years conducted a prosperous business ; but occupation sedentary, and admitted of little variety. In spring of 1817 became very dyspeptic, nervous, and fanciful. Was unhappy, without any moral cause. From a friend's having been operated on for umbilical hernia, imagined she had one ; also other illusions, and suicidal propensities. Accidental salivation, but not excessive. Suffered to take its course. Concurrently, an instant amelioration of mental alienation. In two other cases sanity supervened to accidental salivation. Has subsequently made many trials of it ; and although ptyalism accomplished in several, yet never succeeded but in one case to cure. This also melancholia. Salivation might, à fortiori, be considered a useful adjunct, as a stimulant, in those cases where there is an evident torpidity in the vascular system. We may, however, fairly infer, that its success has been equivocal ; otherwise we should have heard more of its virtues. Thinks there are certain maniacal conditions in which mercury is efficacious, but we cannot precisely recognise them. A case of apoplexy is related by Ferriar, where recovery commenced on ulceration of the gums from calomel ; and the cure was completed by supporting a gentle ptyalism. Mania resists the action of mercury more obstinately than melancholia. 236 Notwithstanding the ill success which has attended his attempts, where other means fail, shall not hesitate making trial again, in obstinate cases, of mercurial salivation, always first prescribing evacuants. As an alterative, in cases attended with glandular or cutaneous affections, or where the chylopoietic functions are deranged, mercury is of undisputed utility.
15. Digitalis. Possibly the testimonies of British practitioners are more at present in favour of powers of digitalis in mania and melancholia, than of any other remedy. Indeed, some ascribe to it a specific an. timaniacal virtue. Dr. Cox ranks it next to emetics, &c. Dr. Hallaran strongly recommends it : says that the digitalis is not eligible in any case, unless previously reduced by proper evacuants ;and that its sedative action on the circulation cannot be usefully exerted under the pressure of high arterial action. As firmly expects recovery from it, when judiciously administered, as from mercury in syphilis ;that besides its action on the heart, possesses remarkable anodyne and soporific qualities, and none of the objections to opium in maniacal cases. Cautions against carrying too far, lest, by producing paralysis or eXtreme debility, the existence of the patient should be endangered; and advises its suspension when there is pallor, inability of retaining food, vertigo, dilated pupils, and slow, intermitting pulse, with cold extremities, which condition should be met by volatile stimuli and cordials. Moderate purging during the interval of suspension secures a safe return to its exhibition. Recommends beginning with five or ten drops of what he calls the saturated tincture thrice a day, and gradually increasing the dose. When arrived at one hundred and fifty drops daily, in three doses, he stops at that quantity for ten or twelve days ;then proceeds, to increase it to one hundred drops at a time, with safety and advantage. But when there has been occasion to suspend it, he always recommences with ten or twenty drops, adding one drop to each successive dose daily. I have never carried the dose beyond fifty drops of the tincture of digitalis of the London Pharmacopaeia. Even in that quantity, by gradual increment, have seen effects that have alarmed me for patient's safety; and therefore, if it has not answered in that dose, I have desisted from carrying it farther, or suspended it altogether. Besides premising depletion, and purgation with calouiel, Dr. Hallaran advises mercury internally, so as to produce moderate salivation, as preparatory to digitalis. Although not going so far as Dr. Hallaran, yet I concur with him as to its powerful influence, when properly administered, fn all stages of insanity, accompanied with great vascular excitement and a rapid pulse. Believe, also, that its operation would be more uniform, if the previous evacuations were constantly observed. Effects of these exactly corresponds with my own experience. In fact, it is obvious that none of the most efficacious internal remedies recommended in mania are admissible, unless anticipated by evacuants. It would seem, indeed, that the vascular system in this malady is at first so excited; that it resists the powers of all remedies which act on that system, till it be lowered, so as to be capable of producing reaction. Confess that I have not had the surprising success with it that Dr. Hallaran and his correspondents describe. May not have observed so strictly rules. At same time have seen sufficient of its powers to have much confidence in them. Dr. Ferriar has remarked, that when digitalis, camphor, and opium alone, have been found ineffective, each has proved 237 serviceable with cinchona. This contrary to my experience. Think difference of effects in digitalis owing to different specimens.
16. Prussic Acid. Tried a few years ago in various lunatic establishments, but the report of its operation singularly differs. The only person who spoke in its favour was Dr. Balmanno, physician to the Glasgow Asylum. Told me that in furious mania he gave from fifteen to thirty drops of a diluted solution of it, preparatory to exhibiting hyoscyamus or other narcotics. This produced diminution of the pulse, exhaustion, slight twitchings of the muscles of the face, and slight subsultus; and that it was when the patients were in this state that narcotics had a full and good effect. I strictly observed this plan, but never derived permanent benefit from it in any one case.
17. Camphor. Its antimaniacal virtues been highly extolled, and some marvellous cures ascribed to it. Modern physicians have little confidence in it. Dr. Haslam says, he gave it in doses as high as two drachms without any sensible effects. Neither Cox nor Hallaran attribute a cure to it. To counteract its heating properties, old practitioners combined with it the nitrate of potash. In a case of insanity, where two scruples were exhibited, it produced a fit, and a perfect cure followed. Upon a relapse two years afterwards, it had the same effect, even to an alarming degree ; but it required to be repeated afterwards in smaller doses of ten grains. Hence we learn how far it can be prescribed as a remedy. In rash hands may prove dangerous to life, and in the most dextrous, rarely can be used to advantage. If ever admissible by itself, it would be where, as in some long-standing cases, the system is exten. uated and feeble, and requires stimulating. In combination with certain sedatives, however, especially henbane, it has proved beneficial.
18. Dr. Edward Percival, of Dublin, has strongly recommended the rectified oil of turpentine in maniacal epilepsy. He tried it in long. standing cases which were deemed incurable; and although unable in a single instance to banish permanently the epileptic attacks, yet in every instance they became considerably milder, less frequent, and remarkably disengaged from the maniacal excitement which before attended them. Employed this remedy in twenty cases,-thirteen women and seven men, -and in each case persisted in its use four months. Formula of Dr. Percival, an emulsion, prepared by triturating an ounce of rectified oil of turpentine with as much loaf sugar, adding very gradually a pint of spearmint water. Of this mixture he gave an ounce thrice a day, as a full dose. Women bore the largest doses without catharsis, and to them it proved soporific, which was not observed in any of the men's cases. Tried this prescription in three cases, but producing no good effect, de. sisted from its use.
19. Tonics. Of all kinds, admirable adjuvants; but in recent cases, before vascular action and excitation are abated, may be decidedly injurious. Not enough to prepare for them by vomiting and purling, but accelerated circulation and cerebral irritation, must first be lessened by moderate local bleeding, refrigeration, and other remedies acting on the heart and arteries. This course seems to be now generally pursued by most ,judicious practitioners before tonics in maniacal cases. Even in the excited state the immediate exhibition of cinchona, and wine also, merely preceded by clearing the bowels, have been recommended by those reputed to have had great success in the treatment. Dr. F. Willis says, this was the principle of his grandfather's and uncle's plan, and he 238 himself, therefore, recommends in every stage of mania, a tonic and stimulating system. Danger in depletion to excess, protracting the case, when recent; if old, fatuity or premature death. Dr. F. Willis adduces a solitary, case in support of his stimulating and bracing practice, a young lady, who, for six days from the accession of mania, and before he saw her, was very violent, and had been bled by leeches to her forehead and temples, and by cupping-glasses to the back of her neck. Also a blister on her head, been purged, and only allowed barley-water with weak broth. She had ceased to rave, probably from exhaustion. Sleep. less, silent, and in perpetual motion ; pulse 130, and all the symptoms of cerebral excitation ; unconscious of evacuations ; tongue brown ; lips and teeth covered with sordes. Gave her two glasses of old Port wine ; and two hours afterwards, three ounces of decoction of bark, with some of the tincture. Vital powers quickly restored, and soon answered ques. tions correctly. Case.-An athletic gentleman in a state of violent mania. Been treated on the stimulant plan, and allowed Port wine and beef steaks for his diet. Grew furious, to a degree beyond any one I almost ever saw, and was in a perfect delirium. After the first visit solely under my care. Treatment reversed in every respect : was first removed from home, head shaved, sixteen ounces of blood from occiput and temples by cupping, refrigerating lotions, purging, and afterwards nauseating doses of antimony, and a spare diet. In a few days infinitely calmer. When symptoms of excitation gone off, a bitter infusion with aperients; finally bark, wine, and abundant nourishment. In about two months reason restored, and in three more went to Brighton, stopped there two months, and returned home quite well. In recent cases of mania, so long as there exists symptoms of determination of blood to head and cerebral congestion, with a flushed countenance, hot scalp, and shining and suffused eyes, would advise postponement of all tonics and stimulants. Quickness of pulse no criterion, as often temporary, and from transient causes or simple irritation. Hence its tone, rather than celerity, to be regarded. In melancholia, often find much cerebral excitation and occasional fits of violence. Even here do not advise powerful tonics whilst these symptoms continue. But as soon as the vascular excitement is subdued in either case, and the nervous system chiefly seems affected, I confidently commence tonics ; first, the lighter, as gentian, calumba, cascarilla; and then cinchona, combined often with nitric acid, sulphate of quinine, iron, &c., with cold plunging bath or shower bath, strong exercise, and a generous diet, and wine, ale, or porter, in mode. rate quantities, according to the patient's constitution, or original habits. When digestive organs much disordered, which they generally are in melancholia, I add two or three grains of blue pill, with one of ipecacuanha at bedtime. Never tried arsenic, as abundance of safer reliable tonics.
20. Tobacco. Most universally agreeable substance tobacco, in any form. Some whom it renders more tranquil ; and in lunatic establishments is often found to be a ready means of conciliating good-will and confidence. Melancholy and imbecile seem fondest of it. From close analogy of maniacal and apoplectic diathesis, as tobacco reckoned a cause of latter, should conclude its use in any form injurious to the insane. Esquirol encourages smoking and chewing in his private establishment, in the hope of advancing a favourable crisis by inducing ptyalism. That it is ever serviceable, I think very problematical ; except as a means of 239 keeping some patients more tranquil. Might be encouraed, if any instance of a crisis being produced by it ; but as I know of none, and see no utility to compensate positive inconveniences, I never encourage it. Where it has become a habit, and its interruption occasions great irascibility, some indulgence must be shown ; but the sooner broken off the better. A little management will accomplish this in those most inveterately addicted to snuff-taking and smoking.
21. Diet. A very material part of treatment. If recovery or even quiet be sought, the diet should be apportioned according to the nature of the case. Appetite of most is capricious: voracious,defective, depraved, &c. These different conditions always obvious, and manner of treating them equally so. When the case will not admit of stimulation, as in roost recent cases, must be light and spare. But when a strengthening system is indicated, it should still be light, but more nutritive. In melancholia and hypochondriasis, dyspepsia common, and then the diet should be the same as in any case unconnected with mental affection. Caution necessary that mere violence and vociferation be not mistaken for the excitation of active insanity. These oftener the concomitants of old and permanent, than recent madness ; and spare and scanty food would increase restlessness, fury, and raving. Many here, troubled with devouring hunger, which augments their rage. Good and substantial food, with a little wine or porter, especially satisfies this craving, causes a greater flow of blood to the brain, in such cases generally deficient, induces sleep, and renders their whole conduct more quiescent and tractable. Some deemed incurable have recovered by a change from a poor and insufficient to a generous diet.
If refusal of food be prompted by a suicidal resolution, or a fanatical determination to emulate martyrdom, or from fear of offending the Deity, nothing but force can make thorn take food. Dread of poison produces almost as firm a resolution ; but it will give way occasionally, if patient can procure food in a manner he thinks free from the suspicion of it. More easily yields if from a whimsical distaste; will then often make a compromise to have certain things, and in his own way ; and frequently he will consent rather than be forced. Should expedients before advised not induce eating, and fasting gone as far as allowable, no alternative but stratagem or some mechanical contrivance. Various instruments been devised. Have seen liquid nutriment introduced into the stomach most readily by stomach-pump ; passing tube through a nostril is a more ready mode than forcibly separating the jaws. Much nourishment may be conveyed by glysters. Conveying food to stomach should never be left to an ignorant person, as patients have been choked ; and even with the utmost care, some injury is often inflicted. Consequently such operations should never be executed, except in the presence of a superior and responsible person. Practice gives some attendants a wonderful dexterity in getting down food. They should be especially resorted to, when possible, for this particular purpose. Medicines should never be mixed with the food of an insane person : this naturally strengthens the suspicion of poison, or mere disgust of nutriment, and his resolution to resist taking any.
Moral Treatment.-If the moderns have any claims to pre-eminence in treatment, certainly from study and application of moral means. Tact, however, pivot of everything in a physician. Pinel the first in this de. partment : his suggestions have been successfully practised, not only by 240 his immediate pupils, Esquirol, Georget, and other eminent French physicians, but by those of Europe generally. Although no specific rules, yet a few general principles recognised. ( Georget.) First, never to exercise the mind in the sense of delirium. Second, never to openly oppose the morbid ideas, affections, or inclinations. Third, as a consequence of preceding, to give rise, by diversity of impressions, to new ideas and feelings, and thus, by exciting fresh moral emotions, revive the dormant faculties. Fourth, never to commit one's self by a promise; but if inadvertently a promise be given, faithfully to adhere to it, unless certain that the fulfilment will be attended with worse consequences than the breach of it. These not for the government solely of the physician, but of every one who has the charge, or is attending on, or visits casually, a lunatic. Great caution necessary during approach to convalescence, and from this state to recovery. A well-cultivated mind requires here great tact, &c. : the first glimmer of returning reason, when unfolded, will be cherished and encouraged : a contrary course prevents or procrastinates recovery. Physician has not only to exercise a sound judgment, to encourage every dawning sign of returning sense, and to reason with his patient (for reasoning now is highly useful in removing weakened and decaying illusions), but he must add the voice of friendship to calm the agony of reminiscence. Has also to repress patient's impatience to be freed from restraint. Approaching convalescence sometimes announced by the gradual revival of the moral affections. Such feelings should be encouraged gently. No errors of memory or speech ought to be noticed, lest, if exposed too suddenly, they shock and discourage him. If, in reasoning with him on any remaining delusion, a painful recollection is revived, the subject should be changed, and resumed at another time. Inquiries resulting from returning moral affections, must be frankly, but cautiously answered. If any domestic event have occurred during his abstraction, likely to excite a strong feeling, whether of joy or grief, it must be withheld, and not be imparted till the understanding is supposed to have acquired strength to bear it; and even then caution prudent. Where nothing extraordinary has happened, the anxiety dictating a question should be promptly satisfied, in order that it may be quickly removed ; but the answer should be limited to the simple solution of the question. Very flood of reminiscences tends to overcome mind. Very difficult, therefore, to preserve a due medium between gratifying and checking his eager importunities for information. Whatever be their impression, as to events of excited state, for this differs in different lunatics, our conversation must conform to it. To reason with a lunatic is folly ; to oppose or deny hallucinations worse, because it is sure to exasperate. To make an impression, it must be by talking at, not to him. Objects to attempts to break catenation of morbid ideas by fraud, trick, terror, or surprise, for several reasons. The confidence of his patients is the sure basis of the physician's success ; and among none is it more essential than with lunatics. A cheerful, encouraging, and friendly address ; kind, but firm manners ; patience in hearing, but cautiously prudent in answering ; never making a promise that cannot safely be performed, and when made, never to break it; vigilance and decision ; prompt to control when necessary, and willing, but cautious in removing it, when once imposed ;-these acquire the good-will and respect of lunatics, and a command over them that will accomplish what force can never attain. Active and passive states, requiring different 241 treatment. In one, moral remedies almost useless; restraint and medical discipline till violence subdued; in the other, restraint never necessary, except there be a suicidal propensity, or to injurious and improper habits. Vigilance necessary in all cases, for the passive in a moment sometimes changes to the active state ; and therefore, unless always on the guard, mischief is done before it can be prevented. If subject to intermitting or periodical insanity, he requires the more caution, lest a paroxysm suddenly occur. Secret vice requires peculiar and unwearied vigilance. Sexual intercourse does not always cure the propensity. If contracted during continuance of insanity, it ceases generally with a return to reason. To prevent it by restraint is extremely difficult, yet it is imperative. A thousand subtle expedients will be resorted to, to accomplish the purpose. To prevent it effectually, patient must never be left alone one instant ; and even though in a strait waistcoat, and hands secured, such confinement only will be unavailing when in bed. Constraint, so that he cannot turn himself, is necessary; and some mechanical contrivance must be applied to guard against friction.
Although indelibly impressed with the efficacy of religious communication in particular cases, I am equallv so, that in others it is highly inimical. With judicious selection of patients, and discourses suitable to their state, effect of religious services has been tried on the patients in Bethlehem Hospital, the Glasgow, Lancaster, and other lunatic asylums, and spoken of favourably. Governed by these rules, I have never experienced any ill, but, on the contrary, much good effect, by a proper attention to religious observances among the patients of my own establishment. Before religious instruction in any form be attempted, let it be a maxim, that an intimate knowledge of every patient's state of mind, and of his former and present religious opinions, should be ascertained and this is very difficult. No minister, except he have constant intercourse with the patients, and be well acquainted with each, ought to assume this office. What may be adapted to one lunatic, may be a source of irritation to another. Without, therefore, the utmost precaution, the introduction of spiritual subjects must be dangerous, and often injurious. If it were adapted to their peculiar case, religious instruction would be, doubtless, extremely useful to many lunatics, but other matters might also be heard, deranging some harmony of mind. It is plain, then, that religious instruction, when attempted, ought generally to be administered separately, through private communication. It results, that religious instruction must, in the first instance, be tried as an experiment. The only safe way in which it can be essayed, is by a previous personal examination of each patient's state of rnind and feelings, and if pronounced in a fit frame, there can be no question that the inculcating of the simple and benign precepts of Christianity will not only be found an efficacious auxiliary to the restoration of sanity, but to the subsequent preservation of it. The morbid tendency of Cowper to mental derangement was always counteracted by the consolatory influence of the principles of true religion. In the first paroxysm of his disease, prayer to God afforded a temporary solace to his distractions ; and, later in life, the sense of his obligations and duty to his Creator arrested him from suicide.
Cælius Aurelianus accuses the sect of medical philosophers designated methodists, with treating lunatics with great barbarity. Says they ordered them to be fed like wild beasts, covered with chains without any discretion, and to be whipped. Celsus's maxim, "Fame, vinculis, plagis 242 coercendus est," adding terror, fear, and mental perturbation. Celsean rather than Aurelian plan prevailed, even to our age; and although happily fast exploding, yet it is not quite extinct in every part of Europe. Thomas Willis advised, as the first indications in mania, manacles, fetters, and stripes, as equally necessary as medical remedies. Farther recommends slender and not over delicate food, rough clothing, hard bed, and severe and rigid treatment. Prescriptions, deceptions, allurements, rewards, and punishments, to be frequently varied. In melancholia, as in mania, Willis recommends practice of ancients. Here excellent advice: advising cheerful society, music, singing, dancing, hunting, fishing, pleasant exercise, sights, any light occupation, studying mathematics or chemistry, also travelling, changing the scene, and to abstract the mind by artificial means. In the course of another century (18th) good points of Willis's practice forgotten, and bad retained. In no species of lunacy, incapable of distinguishing between kindness and rigour. Rewards and punishments, as with children, have each responsive effects. As much difference between coercion and restraint, as between morality and immorality. Rotary chair, douche, a dark room, and personal confinement, often used as means of repression. These, and other expedients, so far as mere restraint of violence or malignancy extends, are justifiable and imperative on many occasions. Deprivation of an accustomed indulgence, also, will often check the repetition of a wilful offence. In such matters, constitution and condition of patient must always be remembered. All these expedients, apt to be construed by patient into punishments; and if enforced when no actual necessity, beget a dread and resistance, when necessary as remedies, and thus counteract any benefit from them. Restraint not to be hastily adopted, unless safety of patient or others demands it ; nor any punishment like measure to be imposed but by the direction of the physician or superintendent, as the lunatic distinguishes between. these and a keeper or servant. If coercion mean not what Celsus and Willis recommend, but merely simple restraint, to prevent a patient from injuring himself or others, or to enable his attendants to control him, maintains that such restraint is frequently called for, is generally highly useful, and cannot altogether be dispensed with. Reprobates Dr. Autenrieth's idea of a padded room in place of restraint. Solitary confinement best for the turbulent and vicious. Irritation thus avoided; and if dangerous propensities, proper precautions necessary. Darkness is a powerful auxiliary in obtaining quiet, and preventing the renewal of raving ; but should beware that terror is not created, and should observe that the patient is not naturally afraid in the dark. A bandage over the eyes has banished ocular illusions; if other illusions substituted, no advantage from this. With those having pride of birth, or suchlike quality, should be particularly circumspect that no control is attempted that can possibly be avoided. No rule as to degree of control, as cases and constitutions differ; must depend on judgment of the person to whom intrusted. Strait waistcoat most commonly used restraint ; and is a good safeguard, provided it fits the shape, and is properly put on ; is apt to be drawn so tight as to impede respiration. Strings, also, often fastened so tightly round arms, as to check the circulation; and sleeves sometimes tied in a knot behind, so as to gall exceedingly. These faults may be obviated by care. Glasgow muff ingenious and excellent. Attendants complain of difficulty of application, but thinks this prejudice. Now generally adopted in asylums on the Continent, 243 especially in Italy. Drs. Hallaran and Knight, in their works, give drawings of several very useful belts, sleeves, &c. Similarity of metal manacles to common handcuffs, by association of ideas, has raised a very unjust prejudice against the former: less friction and excoriation from them, than from rings of linen, leather, or any other substance ; neither does patient exhaust himself by attempting to gnaw or tear them. A belt of leather, fastened round the waist, with steel or leather manacles, in which the wrists are confined, useful. Some one should always be with patients in confinement, as the calls of nature cannot be easily attended to. Filthy habits often from want of watching. None should be coerced, unless intention to support life or promote a cure. Food and medicine, if refused, and no disguise or stratagem avail, must be forced on the insane. Would suggest trying, before absolute force is used in any case, what persuasion by one of the opposite sex will do. Has known, often, an insane man, outrageous as to another man, yield with the greatest complacency to a female. Delicacy and custom forbid attendance of men on women, but merely for such a purpose, experiment might be made with propriety. A keeper should possess a quick apprehension to discern the first approach of a paroxysm, decision, prudence, and the greatest humanity. All is unavailing in the physician, unless judiciously seconded by able assistants. No general maxim, wherein medical practitioners, ancient or modern, foreign or domestic, are so unanimous, as that of separating the patient from all customary associations, family, and home. Dr. Heberden, perhaps, goes too far, in re. marking, that if, the insane are taken away from their friends and servants at the beginning of the attack, and placed under the care of strangers, in a short time they recover without any remedies. Does not think that separation is indispensable. Only case, when the affections are not perverted, nor delusions associated with home, or any person or object about it. Even here, however, disadvantageous circumstances, as being more averse to control, &c.
First hospital read of, at Jerusalem, in the year 491. Benjamin of Tudela mentions, that in the twelfth century there was a large building at Bagdad, called Dal Almeraphtan, or House of Grace, in which the insane were received during the summer, and kept in chains until recovered. In the same century, hospitals were founded, according to Anna Commenes, lbr the sick and insane, by her father, the Emperor Alexis. Bethlehem founded in 1547, the oldest hospital. Among the Moors, asylums for the insane were common; now numerous in all countries. As to visits of friends, before I permit the visit of any individual, I examine the state of the patient's feelings and views to that person. Moreover, I always select the one who the least interests the patient's affections, for the first interview. If that is borne without ill effect, I next fix on one who is nearer, and reserve, as the last trial, communication with the object of warmest attachment. The question of admitting friends must be left to the discretion of the medical attendant; for the slightest intercourse, or even object exciting reminiscences, will have a bad effect in some cases; even the family physician.
Exercise peculiarly appropriate for the insane. Whenever the circulation is already excited to an extraordinary degree, as in most recent cases of mania, violent muscular exercise would only increase the mal. ady. Moderate exercise only is applicable in such cases ; while for those in whom the momentum is reduced, or is languid, or unequal, the more violent and brisk is required. Exercise, constant exercise, is advised 244 for the insane. But I must insist, that unless a judicious limitation be observed, the malady of some will be greatly aggravated by it. Exercise, therefore, ought to be varied according to the form of the malady. Thus for patients easily excited, swinging, riding in a carriage, or gently on horseback, or slowly walking in quiet, shady places, will, under certain restrictions and modifications, be sufficient and beneficial ; while for those in whom the circulation is languid and sluggish, active exercises, and every degree or kind of muscular exertion, will conduce more to their health. A due medium, therefore, should always be preserved ; for if carried to excess in either case, greater excitation, or so much fatigue and exhaustion is produced, that harm instead of good will result. It cannot be necessary to point out particular species of active exercise with the caution premised, none can be objectionable. Occupations and amusements equally essential as exercise to recovery: fortunate when they can be combined. Should each be suited as much as possible to the rank and taste of the patient. Must be varied : same course long continued becomes wearisome and disgusting ; a little thought and ingenuity can wonderfully diversify these auxiliaries. No public lunatic asylum, especially for paupers, should be without a garden or land annexed, proportionate to number of patients. In manufacturing districts, may be made to follow their several callings. In the Wakefield Asylum, they manufacture all the materials for their apparel, and the surplus is sold. In La Salpetriere, the insane women are permitted to sell a part of the produce of their needle, or other ingenious works, and to appropriate it towards the relief of their necessitous families. Most lunatics disinclined to work ; but kind entreaties, or the prospect of procuring themselves the means of extra comforts, frequently tempts them to do something. Greatest difficulty, to find occupation or amusement for the higher classes of lunatics. They sooner get tired of the same pursuit. Reading, billiards, chess, cards, and other games must be diversified for in-door-walking, bowls, gardening, and athletic exercises for out-door amusement. No fear of trusting with them working implements ; rarity of accidents proves any fear unfounded. Dangerous lunatics, of course, never allowed so much liberty. Sometimes patient likes study and sedentary pursuits; should be remembered, that the exercise of the mind is a stimulant, and must not be indulged to excess ; consequently, such employment should not be encouraged to the neglect of bodily exertion. Many would find ample amusement from their pen : but this can seldom be allowed, as too apt to run in the sense of their delirium or delusion. Music been highly extolled, not only as an amusement, but a powerful remedy: this, like other moral remedies, is applicable or not, according to disposition, nation, and peculiar delusion of patient.