ARETÆUS overlooked the moral treatment: Celsus had the greatest confidence in it. Physicians generally expect more from it than from the medical. The fatuous merely require protection. There should be different institutions for the curable and the incurable. There should be in an asylum one department for the patients under treatment, and another for convalescents. Proper airing-grounds : larger for melancholy. Cells for very fierce to be stronger than others. An opening from each cell into the gallery, and one into the open air. To be warmed by heated air : only a few cells unwarmed, and these to be paved with flag-stones merely; the cells of dirty patients to be also thus paved; their beds should have holes in the bottom, and the floor might be inclined to the door. Convalescents should be separated from the other patients, and occupations be especially provided for them. The most essential point is to put good rules into effect. I have often found that "what is the best administered is the best." I have seen abundant means, and very little use made of them; and sometimes much was done by small means. An inferior plan well executed, is more beneficial than a better system under negligent management. Physicians should attend particularly to cleanliness, air, light, and temperature. The diet should be modified in quality and quantity to suit the system of the patient, and the treatment adopted in his case ; and should not be the same in all the patients of an asylum. Dr. Hallaran censures justly a custom in Cork, of giving, in festival times, a corresponding diet to the patients.
When coercion is necessary, it must be applied without silly coaxing or vague insinuations : with humanity and firmness, and as little noise as possible. The most tender method generally produces the best effects. No stripes, no resentment, no return of injury. No deception, but confidentiul behaviour and firm authority. Sometimes necessary to confine a patient in a solitary cell : thus shown that he has a superior this fails sometimes; and then wristbands (invented by Dr. Hallaran) to be used in hot weather ; and the strait waistcoat admirable in cold. If a strong impetus of blood to the brain, confinement in a chair : this favours the application of cold water and ice to the head, warm water to the feet, and bleeding. Hallaran praises the swing as a means of coercion. Sometimes, in violent fits of young and powerful maniacs, chains are necessary. If mischief is committed in a moment of indulgence, no means should be used but those necessary to prevent the repetition. If the patient attempts to starve, Haslam's instrument to be employed. Suit your management and conversation to the character of the patient, and the character of his derangement. Deception hurtful. Everything exciting deranged feelings to be avoided, and other feelings to be excited. Rarely produce any influence by reasoning: much more power over intellectual states than feelings. Some few cases of cure, or at least change in the train of ideas : quotes the instance given by Cox (v. p. 27). Pinel relates the case of a watchmaker, who imagined that he had been guillotined, and a different head had been placed on his body; from this delusion he was cured by mentioning to a companion his belief in 95 the miracle of St. Denis, who carried his head under his arm, and kissed it as he went along. His companion burst into a laugh and said, "What a fool you are! how could St. Denis kiss his own head? was it with his heel ?" Regulation of the five senses and voluntary motion not to be neglected. In debility or inactivity of mind, exciting the smell may be useful. Colours. Music. These should always be, in their quality, opposite to the insane psychological faculty. It is essential to keep all the deranged faculties inactive, and to exercise the others. Occupations of all kinds. Instance of an insane person almost de. mented, a painter ; who, having his attention turned to painting, was finally cured.
Reprobates the expectant method of Pinel ; and the routine method of some practitioners. We must examine the cause, the history, and the various circumstances attending a disease ; and treat it accordingly.
For the curable fatuous: bowels kept open, without purging ; tonics ; generous diet; dry and warm abode ; pure air ; aromatic baths ; shower bath ; rubefacienta along the spine ; issues ; a prurient eruption on the shaved scalp, by lotion with a strong solution of antimonium tartarizatum, continued for a long time.
In insanity from mechanical causes: antiphlogistic system. Bleeding, ice and snow, or cold water to the head ; also aspersion of aether. Bowels to be kept open ; and things which carry blood to the head, avoided ; as liquors, indigestible aliments, costiveness, violent affections. Use those things which remove it, as an upright position, and low diet. Sometimes weakness of the bloodvessels remains ; then use the same general treatment : washing the head with a ether, cold water, cata.plasmata of aromatic herbs boiled in wine. Avoid walking in hot weather, dancing, riding on horseback, swimming, or stooping. Blisters and vomits improper.
Where there is a hypersthenic state of the brain ; either local, where the symptoms are obscure ; or general, as shown by the flushed face and glittering eyes of inflammation ; mostly in young, plethoric, well-nourished individuals ; preceded by stimulating, rather than weakening causes ; sudden, and of short duration. These, occurring in erotomania, require bleeding behind the ears, cold applications to the neck, and low diet. Pulse, deceitful ; sometimes suppressed and small, rising after venesection. Fury depends on the excitement of the organs of combativeness and destructiveness ; melancholy and despondency, of cautiousness. Whatever mental symptoms, use bleeding; opening the temporal artery, cupping at the temples, or behind the ears, at the neck ; leeches to these parts ; venesection at the arm ; shaving the head ; application of ice and cold water; aspersion with water, or vinegar and water; evacuants of the bowels ; frequent use of serum lactis ; decoctum hordei, altheæ, lemonade. If from refrigeration, use blisters : they do harm, if disease proceeds from too great application of the mind, or internal excitement. Avoid irritating things, as light, caloric, vomiting, camphor; and even be cautious in the use of opium and digitalis. Bleeding, &c., must be proportionate to the degree and nature of the inflammation.
The asthenic state (approaching to congestion) occurs generally in patients who are weak and delicate, of a nervous, irritable temperament, and florid complexion; or Haslam observes, after raving paroxysms have continued some time, leaving the scalp flaccid. This state may take up any form-pride, liberality, &c. Bloodletting will not remove it, but 96 may be used in great exacerbations. Things to be avoided which determine blood to the brain, as spirituous liquors, artificial heat, hot weather, affections of the mind. Treatment to be tonic and nourishing without stimulating. Shave the head, asperse it with cold water, or wash it, and apply ice to it; mild evacuation of the bowels. Internal remedies to be tonic without stimulating; amara, decoctum cinchorus, cinnamomum, acidum sulphuricum, and with the greatest caution opium and digitalis. Diet to be light, digestive, neither lowering nor stimulating, but nourishing. Good hopped beer, milk if digested, soft eggs, good broth; more animal than vegetable diet ; aliments causing acidity and flatulence to be avoided.
The nervous state arises from violent or long-continued disagreeable affection, as jealousy, disappointed love, &c., in irritable, delicate (called nervous) temperaments, exhausting the bodily strength. Apparent inflammations and crudities in the digestive organs more often effects than causes. Not the antiphlogistic plan is here required, but tonics and antispasmodics. In the commencement, opium and other anodynes. In anger, a draught of cold water, or thrown on the body, and silence. If necessary to keep bowels open, hyoscyamus, musk, and castor, preferable to opium. Camphor in small doses often useful here. The antispasmodics rank first; then tonics, as chamomile, columbo, quassia, gentian, Peruvian bark, martialia. External and dietetic plan the same as in the last variety ; so of things carrying the blood towards the brain. The failure in remedies is owing to the states of the brain being various, to the manner of using them, and not attending to all the circumstances of the patient.
The above three forms of insanity are idiopathic: then follow those from sympathetic causes. From inanition, where there are symptoms of bodily exhaustion and mental inaction, same treatment as in the fatuous. From repelled eruptions, &c., similar treatment, as when other diseases are induced by the same cause. From piles, by leeches and vapour bath to the part. When cutaneous, by blisters, issues, or setons. He coincides with Dr. Hallaran, that blisters in the early stages of insanity, when the determination to the head is perceptible, are improper: they are also apt to be rubbed off or swallowed by the patient. Dr. Hallaran says, that in cases where there is a want of energy, applied to the lower part of the neck, they are occasionally good. If from pregnancy, we must only palliate until delivery. The largest number of sympathetic cases occur from deranged digestive organs : hysteria, hypochondriasis, and melancholy, often found here ; these forms often alternate. Plan of treatment to be enlivening, animating, and tonic. No bleeding. Behaviour to be kind. Ridicule to be prohibited. Change of situation and mental occupation highly important. If the cause is removable, as a drunken husband, should be removed. Mild aperients first ; then tonics, as amara, bark, martialia, and antispasmodics. Reject irritating things, as strong wines, spirituous liquors, spicy dishes. Rub the skin with rough linen or flesh-brushes. Tepid baths often beneficial. Practitioners disagree with respect to the utility of bathing in insanity : he thinks that in a plethoric state of the brain, in which there is great determination to the head, the shower bath or warm bath is hurtful, increasing the delirium and headache; in inactivity of the brain, dryness of the skin, rigidity or spasmodic contraction of the muscular system, tepid bathing is useful: in warm weather for cleanliness. The partial cold bath, or the 97 application of ice or cold water to the head, is admissible only in too great excitement of the brain, both in the inflammatory state, and in congestion of blood. If there is general apathy, or if the faculties are oppressed by saburra in the stomach, vomiting is indicated; to be rejected, if the bloodvessels of the brain are supposed to be affected. Melancholia with symptoms of hysteria, or hypochondriasis, or propensity to suicide, is to be treated then in the same manner. Young, sanguineous, and very irritable patients cannot bear digitalis. Dr. Hallaran employs it after evacuants : he prefers it to opium as an anodyne and soporific, procuring refreshing sleep without the bad effects of opium ; if its effects are too strong in causing vertigo, nausea, vomiting, and too slow a pulse, suspends it and gives purges ; he recommends table beer as a vehicle. Dr. Hallaran approves of Cox's swing, as giving supreme authority over the unruly, and procuring sleep : it lowers the circulation, and the temperature of the body. It is contraindicated in young, plethoric patients, in an inflammatory or congestive state of the bloodvessels.
DR. JOHN MASON GOOD places little faith in anything but purgatives and moderate bleeding : and says that "after all, we have chiefly to depend on moral treatment"-firmness, amusements, &c.