I. Baths.-Their utility has been recognized by the ancient physicians : thus, Galen says, he has cured many maniacs by this method. 83
Those most frequently- used are of the temperature of 21-25 degrees, and half cold at that of 15-20 degrees. Thev are taken usually every two davs. Warm baths are more generally employed when there is spasm and erethism, because they are more mild and sedative than the half cold, which suit more particularly when the maniac are vigorous, ardent, plethoric, or of a bilious temperament and strong constitution, when they are in great agitation, and when they complain of feeling internally a smart heat. Baths of surprise are oftener hurtful than useful. Although reconnmended by great physicians, they have occasioned frequent accidents, which has caused them to be abandoned.
II. Douches, which often occasion happy effects when administered with prudence and discernment, appear to have been known to the ancients. Celsus directs cold water to be turned on the head of the maniac before plunging him in water or oil. Aretwus says, that when a patient is maniacal, it is necessary- to sprinkle the head with cold water. The douche consists of a thread of water, made to fall from a height of three or four feet upon different parts of the head, so as to produce a sudden and strong impression. It is prescribed ordinarily in the first period of acute mania, and at the return of a paroxysm of periodical mania. It ought not to last but a few minutes, and it is administered usually towards the end of the bath. They serve also advantageously to repress the excessive violence, indocility, and fury of certain indomitable maniacs, and to conquer those refusing obstinately to take nourishment. In these instances, we let fall on a sudden and largely, a column of cold water upon the head.
III. To diminish the heat-producing circulation towards the head, it is advised to apply upon the part pounded ice or snow, enclosed in a bag. Pomme has used here a bladder filled with cold water. These applications are not without danger ; it is better to make lotions on the head with a sponge soaked in cold water or in oxycrate.
IV. Pediluvia.-These are prescribed with a view of diverting the raptus of blood frorn the head to the extremities. The feet are plunged in a bath of simple water, at first at the temperature of 24-26 degrees, adding successively cold water to produce a slight rubefaction. Or better to obtain an analogous revulsive effect, the water of the bath is ren. dered more active, and even irritating, by a solution of soap or salt, or adding muriatic acid.
V. Clysters.-These are given in the acute period of mania, or in a paroxysm of chronic mania, to remedy the constipation which often exists, or to diminish the spasm and irritation of the intestinal canal ; or to solicit an evacuation of the mucous, bilious or bloody matters, and favour critical efforts. They are also employed as a vehicle for soothing liquids, sedative or laxative, as the case may be.
VI. The idea formerly, and even vet, amongst many of our practitioners, that insanity is due to too violent an impulsion of blood to the head, has led to bleeding as a universal remedy, in its various forms, and in all cases together with low diet, without any attention to the circumstances of the case : they take symptomatic effects for the cause. But when we consider that insanity depends most generally upon the most intense nervous excitement, which it becomes us to direct and moderate, in order to remedy the state of feebleness and atony which most often results from it, we see how absurd and fatal it is to provoke this condition by debilitating means, And the greater number of cases from 84 repeated bleedings and a rigid diet, fall into a state of torpor, and the disease, which would have terminated happily, running regularly through its periods, takes up a chronic or periodical character, which often renders it incurable, or it degenerates into dementia or idiocy. It is particularly to the nervous system that we should direct therapeutic measures. We ought not to conclude, however, that bleedings should be absolutely excluded in the treatment; but they should be used with discretion. They are principally necessary where the subject is young, vigorous and plethoric, and especially when the disease proceeds from the suppression of an habitual hemorrhage, as the menses or hemorrhoids : in these last cases, local bleedings are preferable.
VII. The medicines which we employ in the treatment of insanity should have the following intentions : 1. To depress the nervous excitement by diluent drinks, acidulated, impregnated with nitre or camphor, or antispasmodics. 2. To prevent constipation by laxatives, as neutral salts; and to relieve the small intestines, if saturra is indicated, by emetics and purgatives. Throughout all time, purgatives have formed the basis of the treatment, because insanity has been recognzied as often complicated with gastric or intestinal derangement; it is this which the ancients called atribilarious madness, and which they treated by energetic evacuants, particularly hellebore, which is a violent drastic. Professor Hallé (1786) has proved the advantages of the evacuant method in atribilarious insanity ; he has reported a complete cure of this malady by boluses composed of extract of black hellebore, extract of aloes, scammony and calomel. He remarks the great necessity of giving here purgatives in very large dose, on account of the unimpressibility of the intestines. It is according to a like indication that Sydenham makes frequent use of bryony root. M. Salmade mentions the use of frictions of colocynth on the abdomen ; this is very active and easy of employ, is worthy of trial, and is recognized as curative by Dr. Chrétien of Montpellier. 3. To subdue sleeplessness by sedative juleps, and opiated emulsions. 4. To remedy debility which may occur, by light tonics, bitters, cold baths, and dry frictions, when the state of agitation has been calmed, and when the disease is on the decline. These different medicines ought to be considered as general means applicable to different cases of insanity, with distinction as to their causes and their complications. _But there are other means whose employment is useful in particular cases. Thus, when insanity is due to the repercussion of an eruption, we make use of evacuants and exutories. When from retrocession of gout, we recall this to the lower extremities by the most energetic revulsives, vesicatories, sinapisms, and irritating pediluvia. When puerperal, experience has confirmed the efficacy of a vesicatory to the nucha. When it manifests itself after the suppression of a hemorrhage, of the menstrual or hemorrhoidal flow, general or local bleedings. When the disease depends on irritation of the genitalia, we moderate the orgasm by lotions rendered sedative by the acetate of lead, by mild drinks, and by baths. When from insolation, we remedy it by bleedings from the foot, cold lotions to the head, and refreshing drinks. When from the abuse of mercurial preparations in the treatment of syphilitic maladies, we employ baths, antiscorbutics combined with opium, and milk diet. When it is complicated by worms, convulsions, adynamic or ataxic fevers, etc., we administer different medicines according to the case. Finally, in certain periodical cases of recent insanity, successful use is made of bark combined 85 either with camphor, musk, opium, or valerian. We see, after these rapid indications, how important it is to ascend to causes, and to the complications of insanity, in order that the treatnIent may be rationally directed. Cullen has remarked that it is sometimes advantageous, in mania to frequently shave the head ; this means probably extinguishes the internal excitement, by favouring perspiration. In the periodical collection of the Society of Medicine of Paris, there is fact supporting this assertion-a case of mania cured by cutting the hair.
VIII. Hygienic Aids.-Insanity is not always an intense affection of the nervous system, characterized by excitement, &c. ; it is sometimes, when due to moral causes, but a mild delirium, which it is necessary to direct without contradicting, opposing simple means drawn from hygiene. It is often sufficient, to cure such patients, to make them change their situations, to transplant them in a pleasant country place, to make them engage in exercise, and to occupy their minds by pleasant employments and various amusements. These are the cases which have been cured in all past times, by travels, pilgrimages to temples, different religious ceremonies, and by the pure and peaceful delights of a rural life. Most maniacs are characterized by an extreme restlessness, gesticulation, &c. They should be made to wander in a spacious garden, apart from the tumultuous heart of cities, where the air is pure, to prevent their gesticulations and actions from being injurious to them. We often see maniacs have a voracious hunger. It is necessary to moderate this by diluent and mild drinks, and by an abundant but light nourishment. When they have an obstinate repugnance to take food, they should be constrained, when necessary, by fear and terror, through the douche of repression, or they should be made to swallow by the spout ; or restorative soups and strengthening pottages should be injected through a gum-elastic, cEsophagic sound ; or lastly, they may be nourished with clysters of milk or soup. It is very useful to encourage and even provoke the excretions in maniacs, especially the forces. Exercise is very necessary to maniacs, but it should be so directed as to moderate their too great muscular activity by a regular con. tinuance, and to break the chain of vicious ideas ; such employment are mechanical labours, gardening, and agriculture. The muscular and ner. vous systems are generally developed in inverse proportion ; we therefore seek here to lessen the force of the latter by increasing that of the former.
2. Moral Treatment.-All the preceding means of treatment are useless, if the physician be ignorant of the happy and difficult art of understanding and directing men according to their character, their ideas, and their passions. This great art should be profoundly studied and suitably placed into practice, by those having charge of the insane. This is moral treatment. The two indispensable means of cure are isolation and repression. In transporting a patient into a strange house, the change of place, persons, manner of living, habits, &c., make upon him the strongest impression, and gives to his extravagant ideas a new direction, capable very often of interrupting their disordered course, and of sometimes even leading him to reason by this means alone, as many examples daily prove, &c., &c. When Dr. Willis undertook the treatment of the Queen of Portugal, not being able to transport her from her palace, he had all the movables changed, all the domestics, and substituted new objects. Not less useful than isolating an individual, is the isolation, in establishments for the insane, of the furious maniacs from the calm and convalescent, 86 in order not to expose the latter to relapses. This is an essential precaution, which has been long foreseen and recommended. When maniacs have but a mild delirium, which does not urge them to extravagant actions, they may be suffered freely to abandon themselves to their petulance and their extreme mobility. But when by the intensity and violence of their delirium they are led on to acts of violence, and when they show themselves indifferent to mildness and benevolence, it is necessary to employ means of repression to prevent sad accidents, and to restrain an impetuous fury, whose too prolonged action can but irritate the patient, and aggravate his sad condition. But these means of repression ought not to be the offspring of animosity or an arbitrary rigour ; they should be demanded by necessity, and be proportioned to the degree of agitation, and the violence of the patient; thus we should be content, at first, to show them an imposing firmness, and to place there in a dark and silent place, in order to calm the extreme susceptibility of their sensations; afterwards we act on their imagination by a large force. If these manoeuvres are unsuccessful, we resort to means of restraint, by applying the strait waistcoat : it is thus that chains have been replaced by milder means. The strait waistcoat is a very useful means of restraint ; the patient may be fixed to a seat, or on his bed ; in the latter case, the head must be lifted to prevent congestion of blood in that direction. M. Pinel describes a still more energetic repression, by drawing back the shoulders, by means of girths fixed to the waistcoat ; but this should be employed with much discretion, and suits only the most indomitable. M. Girandy has given the description of a means of repression employed at Charenton : it consists of an osier cylinder cushioned within, which is applied by the aid of straps in the form of suspenders; this keeps the maniacs in a natural position, prevents contusions and wounds, and leaves them freedom of motion in walking. The other means of moral treatment consists in determining, with each patient, the means necessary to repress the sallies of their delirious excitement, to moderate the violence of their rage, to break through the train of their fastidious and extravagant ideas. This we propose to do in striking their imagination by surprise, fear, terror ; in influencing their sensibility by privations or acts of kindness, by punishments or recompenses ; in awakening their attention, and in directing it to objects capable of occupying and acting revulsively ; and in exciting in them pleasant and agreeable emotions. It is necessary to understand how to employ à propos, an affectionate kindness or an inflexible firmness, and to shun, as equally hurtful, a feeble mildness or an inexorable severity. It is very essential in insane establishments to prevent roughness on the part of the attend. ants, as this irritates, and tends greatly to hinder the cure. I have recommended incessantly to my domestics to be mild, humane, and compassionate and have considered the contrary as exceedingly culpable. To make an application of general precepts:-When a maniac is governed by violent paroxysms of anger or fury, we seek to appease this impetuous rage either by kind manners, or by means of fear and terror, or lastly by a severe repression. When he assumes airs of grandeur and superiority, when he commands imperiously, and when he wishes to be obeyed, instead of condescending complaisantly, which would but exasperate the more his fantastic ideas, we oppose to this excitement of pride a stoical firmness and cold reserve, suitable to make him feel his dependance and inferiority. It is, on the contrary, by attentive cares, by 87 affectionate attentions that we relieve a patient in a state of depression, and that we inspire self-confidence in a case caused by deep grief. It is by the edifying consolations of an enlightened piety, and the mild consolations of a compassionate morality, that we repress the violent exaggerations and dangerous sallies which may arise in insanity from religious fanaticism. The passions, though the most frequent causes of insanity, when directed with address and discernment, may be made to serve a useful purpose in the cure of the malady. Before terminating this article, I ought to speak of music, whose great influence may be employed with advantage towards the cure ? &c. Amongst the diseases cured by music, authors mention melancholia and mania. It has been often remarked that music calmed the agitation of maniacs, and suspended their delirious ideas by fixing their attention, and that sometimes it has even cured them. Bourdelot reports an example in his treatise on music. When the dawn of convalescence begins to appear, we should then endeavour to use profitably the lucid intervals presenting themselves, to confirm the cure in seeking to gain the confidence of the patient by affectionate cares, in engaging him in manual labours, which diminish the muscular action, induce calmness and sleep, and diminish also the nervous excitement; in recreating him by games requiring exercise. by agreeable occupations, by light reading, and by interesting conversation having reference to his occupation or inclinations. Although reason may have returned, yet precautions are necessary to insure the complete re-establishment of the intellectual faculties. The peculiar sensibility of the convalescent insane renders then very liable to relapse on any excess or sudden change : nothing has this tendency more than a premature return to their families. Before an insane convalescent goes from a hos. pital, it is necessary that he should submit to different tests to completely certify his cure ; that the hot season should have passed, which often occasions relapses ; that lie should receive frequent visits from his family; that he should occupy himself with his own affairs ; and that he should be familiarized in advance with all the impressions which he inay experience after he has re-entered into society.