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.