Observations on Madness and Melancholy, &c. By John Haslam,
Member of the Royal College of Surgeons, and Apothecary to Bethlehem Hospital.
Second edition.
Management.-Thinks supposed controlling power of physiognomy, &c., in physician, merely imaginary ; at least has never observed it in any of the eminent practitioners of the present day, and ridicules the idea. Great object of superintendent to gain confiderrce of patient, and awaken in him respect and obedience ; but apparent that such is only to be procured by superiority of talents, discipline of temper, and dignity of manners. Imbecility, misconduct, and empty consequence, although enforced with most tyrannical severity, may excite fear, but it will be always mingled with contempt. Superintendent must first obtain an ascendency over them. When this once effected, will be enabled, on future occasions, to direct and regulate their conduct, according as better judgment may suggest. Should possess firmness, and when occasion may require, should exercise his authority in a peremptory manner. Should never threaten, but execute; and when patient has misbehaved, should confine him immediately. As example operates more forcibly than precept, has found it useful, to order the delinquent to be confined in presence of other patients. If patient powerful, two or more to assist keeper. Afterwards to be secured by strait waistcoat, or by manacles. Been recommended by high medical authority to inflict corporeal punishment. If patient so far deprived of understanding, as to be insensible why he is punished, such correction, besides its cruelty, is manifestly absurd ; and if conscious of impropriety of conduct, there are other methods more mild and effectual. No one in phrenitis would order scourging, and a morbid state of brain in insanity also. Should be our object to remove such disease, rather than irritate and torment the sufferer. Coercion should only be considered as a protecting and salutary restraint. In most violent state of disease, patient to be kept alone in a dark and quiet room, so that he may not be affected by the stimuli of light or sound, such abstraction more readily predisposing to sleep. As in this violent state a strong propensity to associate ideas, particularly important to prevent the accession of such as might be transmitted through medium of senses. Hands should be properly secured, and patient be confined by one leg ; this will prevent him from committing any violence. Metallic manacles best, for friction produces no excoriation, as from linen or cotton. Ligatures to be avoided. Strait waistcoat admirably calculated to prevent mischief, but in furious state, and particularly in warm weather, p71 it irritates, and increases that restlessness under which such patients usually labour. If sensible of restraint, a patient may be punished for improper behaviour, by confining him in his room, degrading him, aid not allowing him to associate with the convalescents, and by withholding certain indulgences he had been accustomed to enjoy. Objects strenuously to practice in some private receptacles for the insane, of half-stifling a noisy patient by placing a pillow before the mouth, and forcibly pressing upon it, so as to stop respiration. At Bethlehem, view these involuntary ejaculations as a symptom, or part of disorder ; and, if cause cannot be suppressed, effect should not be punished. As frequently entertain very high, and even romantic notions of honour, often rendered much more tractable by wounding their pride, than by severity of discipline. Can truly declare, that by gentleness of manner, and kindness of treatment, has seldom failed to obtain their confidence, and conciliate esteem, and has thus succeeded in procuring from them respect and obedience. Certainly some patients not to be trusted, and in whom malevolence forms prominent feature of character ; such persons should always be kept under a certain restraint, but this not incompatible with kindness and humanity. Speaking of the English secret of managing the insane, as discussed by M. Pinel, and his description of M. Pussin, the superintendent of the Bicêtre, he observes- Not being myself endowed with any of these rare qualities ; carrying no thunder in my voice, nor lightning in my eye, it has been requisite for me to have recourse to other expedients." In the first place, been thought proper to devote some time and attention to discover character of patients, and ascertain wherein, and on what points, insanity consists : also, important to learn history of disorder from relatives and friends, and to inquire particularly respecting any violence he may have attempted towards himself or others. In holding conferences with patients, in order to discover insanity, no advantage ever derived from assuming a magisterial importance, or by endeavouring to stare them out of countenance : a mildness of manner and expression, an attention to their narrative, and seeming acquiescence in its truth, succeed much better. By such conduct, acquire confidence in practitioner ; and if be will have patience, and not too frequently interrupt them, they will soon satisfy his mind as to derangement. When a patient admitted at Bethlehem, if sufficiently rational to profit by such tuition, is explained to him, by keepers and convalescents, that he is to be obedient to the officers of house, and especially to Mr. H., with whom will have daily intercourse : they point out to him, that all proper indulgences will be allowed to good behaviour, and that seclusion and coercion instantly succeed to disobedience and revolt. No one from a state of tranquillity becomes furiously mad: precursory symptoms manifold and successive, and allow of sufficient time to secure patient, before mischief' ensues : principally by taking these precautions that his patients are observed to be so orderly and obedient. Examples of those under strict coercion being constantly in view, operate more forcibly on their minds than wisest precepts. In this moral management, co-operation of convalescents particularly serviceable ; consider themselves in a state of probation, and, in order to be liberated, anxious, by every attention and assistance, to convince superintendents of restoration to sanity. From mildness of treatment and confidence reposed in them, become attached, and always disposed to give information concerning any projected mischief As we are creatures of habit, experience justifies expectation, p72 that madmen might be benefited by bringing their actions into a system of regularity. llioltt be supposed, that as thonwht precedes action, that whenever ideas are incoherent actions will also he irregular. I;ncontrolled, would probably be so, but custom prevents. Here a number of patients, whose ideas are in the most disordered state, who yet act, upon ordinary occasions, with great steadiness and propriety, and are capable of being trusted to a considerable extent : this might lead its to hope, that by superinducing different habits of thinking, irrcgttlar associations would be corrected. Impossible to efect this by reasoning, for madmen can never be wholly convinced of folly of their opinions. More frequently these opinions recurred to, under a conviction of their truth, deeper they subside in the mind, and become more obstinately entangled tinder a conviction of their truth : object, therefore, should be to prevent such recurrence by occupying the mind on different subjects, and thus diverting it from the favourite and accustomed traits of ideas. As patient should be taught to view medical superintendent as a superior person, latter should be particularly cautious never to deceive him. Maddmen generally more burt at deception than punishment ; and whenever they detect the imposition, never fail to lose that confidence and respect which they ought to entertain for the person who governs them. Late Dr. John Monro expressly says, physician should never deceive them in anything, but more especially with regard to their distemper ; for as generally conscious of it, acquire a kind of reverence for those; who know it ; and, by letting them see that he is thoroughly acquainted with complaint, may often gain such an ascendant, that they will readily follow his directions. Disagrees with Cox as to pious frauds, &. Of great service to establish a system of regularity in actions. Rising, exercise, and food, at stated times. Independently of health, rendered more easily manageable. Diet to be light, and easy of digestion. Proper duantity to be directed by good sense of superintendent, according to age and vigour of patient, and proportioned to degree of habitual bodily exercise. As Dr. John Monro says, should never be suffered to live low, especially while under a course of physic. Dict of Bethlern hospital allows animal food three times a weed:, and on other days, bread with cheese, or occasionally butter, toglether with milk pottage, rice millk, &c. Those regarded as incurable ought certainly to be indulged in a greater latitude of diet, but never intemperate. Wine in moderation, if circumstances will afford, and criterion of quantity, that it does not affect temper of lunatic, does not exasperate his aversions, or render his philosophy obtrusive. Objects to tire recommendation by Cox, of intoxication in certain cases. Confinement always necessary in cases of insanity, and should be enforced as early in the disease as possible-removal from home, as otherwise few have recovered, and often happens that those said to be violent and ferocious at horne, become suddenly calm and tractable when placed in the hospital ; so, many who have for a length of time conducted themselves, under confinement, in a very orderly manner, have a recurrence of disorder on return to families. When convalescent, visits of friends attended with manifest advantage, as imparting consolation, &c. But certain restrictions necessary ; ignorant people often supposing patient well, after a few minutes' conversation, acquaint him with this opinion, induce him to think so too, and he frequently becomes impatient of confinement and restraint. From this, known many to relapse ; and in two instances, has a well-founded suspicion p73 that it excited attempts at suicide. -Many patients have received considerable benefit by change of situation, which occupies the mind with new objects, and this sometimes takes place very shortly after the removal.

Bleeding. -Where strong and plethoric, and where disorder not of any long continuance, found of considerable advantage, and as far as yet observed, most beneficial remedy that has been employed. Melancholic cases been equally relieved with maniacal: treatment generally, which he has observed most successful in melancholia, not different from that employed in mania. Venesection by the arm inferior in its good effects to blood taken from head by cupping. Head previously shaved, and six or eight cupping glasses then applied. Any quantity of blood may be taken, and in as short a time as with lancet. When raving paroxysm has continued for a considerable time, and scalp has become unusually flaccid ; or where a stupid state has succeeded to violence of considerable duration, no benefit from bleeding: indeed, too much weakness. Quantity dependant on discretion of practitioner : from 8 to 16 ounces may be drawn, and the operation occasionally repeated, as circumstances may require. flood seldom buffy, unless in commencement of disease, when patients extremely furious and ungovernable. In more than 200 patients only six thus. Many instruments been contrived to give medicines when refused; most abominable, spouting-boat-constructed somewhat like a child's pap-boat ; and intended to force an entrance into the mouth through the barriers of the teeth. Seen many patients who had been temporarily deranged, restored to friends without a front tooth in either jaw; this duty of forcing food should always be performed by master or mistress of madhouse instead of a servant. When thus bent on starving, or refusing all medicines, he has always succeeded by means of the key. Since use of this, which he constructed about twelve years ago, no patient been deprived of a tooth, and food or remedy been always conveyed into stomach. Head of patient between knees of person who is to use instrument : a second assistant secures hands (if strait waistcoat not employed), and a third keeps down legs. As soon as mouth opened, instrument may be introduced ; it presses down the tongue, and keeps the jaws sufficiently asunder to admit of introduction of medicine, contained in a vial, or tin pot with a spout, to allow it to run in a small stream. Nose of patient being held by left hand of person who uses instrument, a small quantity of medicine to be poured into mouth, and when deglutition has commenced, to be repeated, so as to continue act of swallowing until whole be taken. A little address will obviate determination of patient to keep teeth closed ; may be blindfolded at commencement, which never fails to alarm him, and urges him to inquire what the persons around him are about: causing him to sneeze, by a pinch of snuff, always opens the mouth previously to that convulsion, or tickling the nose with a feather commonly produces the same effect With delicate females, where one or more of the. grinder teeth wanting, finger may be introduced on the inside of the cheek, which being strongly pressed outwards, will prevent the patient from biting, and form a sufficient cavity to pour in the liquid. With a wish of speaking confidently on this subject, has usually performed the business of forcing, more especially amongst the females.

Purging.-An opinion has long prevailed, that mad people are particularly constipated, and likewise extremely difficult to be purged. On the 74 contrary, finds them of very irritable and delicate bowels, and well, and copiously purged, by a common cathartic draught. That commonly employed in Bethlehem-Rx Infusi sennæ, Ounce iss.-Jij. ; tincturæ sennæ, 3i.-3ij. ; syrupi spinæ cerrinæ, 3i.-3ij. ; but within last seven years tinctura jalapae substituted for tinctura sennw : operates more speedily and with less griping. This medicine seldom fails of procuring four or five stools, and frequently a greater number. Occurrence of diarrhoea and dysentery more rarely of late years in Bethlehem attributed, perhaps, to superior care ; and an improved method of treatment has rendered them no longer formidable or fatal. In those very violent diarrhoeas, which ordinarily terminate in dysentery, from 5 to 10 grains of the pilula hydrargyri have been given, according to the sex, constitution, and nature of complaint, once or twice a day, and with general success. During course of mercurial remedy, which shortly arrests disease, to keep bowels in an open state, by some of the milder purgatives employed every third or fourth day. Sometimes a state of disease in maniacs, where stomach and intestines particularly inert. Patient refuses to take food, and is obstinately constipated: tongue foul, and skin tinged with a yellowish hue : eyes assume a glossy lustre, and a peculiar wildness. In this state has given two drachms of pulvis jalapae, which, on some occasions, has procured but one stool, so that it has been necessary several times to repeat same quantity. After bowels been sufficiently evacuated, appetite commonly returns, and patient takes food as usual. Much mischief may be produced from forcing food, on supposition that refusal is owing to obstinacy. To continue bowels in a relaxed state, after sufficient evacuation of contents, has employed with advantage, Rx Infusi sennæ, Ounce vijss. ; kali tartarizati, Ounce ss. ; antimonii tartarizati, gr. iss. ; tincturæ jalapæ, 3ij. From two to three tablespoonfuls once or twice a day, as occasion may require. From very ample experience it is concluded, that cathartic medicines are of the greatest service, and ought to be considered as an indispensable remedy in cases of insanity. Frequency, dose, and occasions where prejudicial, practitioner's good sense must determine.

Vomiting.-However strongly recommended, not in his power to speak of this favourably. In many instances, and in some where bloodletting had been previously employed, paralytic affections have within a few hours supervened on exhibition of an emetic, more especially where patient of full habit, and with appearance of an increased determination to the head. Been for many years practice of Bethlehem Hospital to administer to the curable patients four or five emetics in spring of year ; on consulting book of cases, has not found that such patients have been particularly benefited. From one grain and a half to two grains of tartarized antimony been the usual dose, which has hardly ever failed of procuring full vomiting. In the few instances of nauseating doses for a considerable time, expectations from very high authority not answered. Where the tartarized antimony, given with this intention, operated as a purgative, it generally produced beneficial effects. Ten years since former edition of work, but still no greater confidence in emetics. No one ever had better opportunity of observing their effects than himself, as at Bethlehem, given without intervention of other medicines, for six weeks. After administration of many thousand emetics to persons who were insane, but otherwise in good health, can assert that he never saw any benefit from them. True, that some ascendency may be gained over a furious maniac by forcing him to take a vomit, or any other medicine, 75 but this widely different from any positive advantage resulting from act of vomiting. In St. Luke's Hospital, the largest public receptacle for the insane, where medical treatment is directed by a physician of character and eminence, and whose experience is, at least, equal to that of any professional man in this country, vomits by no means considered as the order of the day; may be employed to remove symptoms concomitant with madness, but not held as specifics for disease. In cases given by Dr. Cox, emetics always linked with other medicines, and therefore doubtful to which of these cure due.

Camphor been highly extolled, and doubtless with reason, by those who have recommended it: own experience merely extends to ten cases; from which no conclusion to be drawn. Dose was gradually increased, from five grains to two drachms, twice a day ; and, in nine cases, remedy continued two months. Only two recovered: one had symptoms of convalescence for several months after use of remedy been abandoned other, a melancholic, certainly mended during time of taking it; but was never able to bear more than ten grains thrice daily. Complained of its intoxicating him. From insoluble nature, &c., given in emulsion, by dissolving in hot olive oil, and afterwards adding a sufficient quantity of warm water and aqua ammoniæ puræ.

Cold Bathing.-Instances too few wherein employed separately to deduce any satisfactory conclusion. In many instances, however, paralytic affections have in a few hours supervened on cold bathing especially where patient in a furious state, and of a plethoric habit. That this is not unlikely to happen, may be supposed from the difficulty of compelling the patient to go head-foremost into the bath. In some cases vertigo, and in others a considerable degree of fever ensued after immersion. Shower-bath employed some years ago in hospital, and many cases selected in order to give a fair trial to this remedy, but unable to say that any considerable advantage was derived. If permitted to give an opinion on subject, principal benefit, in latter stages of disease, and when system had been previously lowered by evacuations. To a question from House of Commons, 9th March, 1807, Dr. Willis answered "I think warm baths may be very useful, but it can seldom happen that a cold bath will be required."

Blisters.-These been in several cases applied to the head, and a very copious discharge maintained for many days, but without any manifest advantage. Late Dr. John Monro, who had, perhaps, seen more cases of this disease than any other practitioner, and who, joined to his experience, possessed the talent of accurate observation, mentions, that he "never saw least good effect from them, unless at beginning, while some degree of fever, or when applied to partimlar symptoms accompanying complaint." Dr. Mead concurs in this opinion. Although they appear to be of little service when put on the head, yet I have, in many cases, seen much good from applying them to the legs. In patients who have continued for some time in a very furious state, and where evacuations been sufficiently employed, large blisters to inside of legs have often, and within a short time, mitigated violence of disorder. In a few cases setons have been employed, but no benefit from their use, although discharge continued above two months. Whenever opium been exhibited, during a violent paroxysm, it has hardly ever procured sleep : but, on the contrary, has rendered those who have taken it much more furious : and, where it has for a short time produced rest, the patient has, 76 after its operation, awaked in a state of increased violence. Many of narcotic poisons been recommended ; but his experience here very limited, nor is it his intention to make further trials. Ridicules ideas of Cox, as to swing, music, &c.