_Bleeding._
Where the patient is strong, and of a plethoric habit, and where the
disorder has not been of any long continuance, bleeding has been found of
considerable advantage, and as far as I have yet observed, is the most
beneficial remedy that has been employed. The melancholic cases have been
equally relieved with the maniacal by this mode of treatment. Venesection
by the arm is, however, inferior in its good effects to blood taken from
the head by cupping. This operation, performed in the manner to which I
have been accustomed, consists in having the head previously shaven, and
six or eight cupping glasses applied on the scalp. By these means any
quantity of blood may be taken, and in as short a time, as by an orifice
made in a vein by the lancet. When the raving paroxysm has continued for a
considerable time, and the scalp has become unusually flaccid; or where a
stupid state has succeeded to violence of considerable duration, no
benefit has been derived from bleeding: indeed these states are generally
attended by a degree of bodily weakness, sufficient to prohibit such
practice independently of other considerations.
The quantity of blood to be taken, must be left to the discretion of the
practitioner: from eight to sixteen ounces may be drawn, and the
operation occasionally repeated, as circumstances may require.
In some cases where blood was drawn at the commencement of the disease
from the arm, and from patients who were extremely furious and
ungovernable, it was covered with a buffy coat; but in other cases it has
seldom or never such an appearance. In more than two hundred patients,
male and female, who were let blood by venesection, there were only six
whose blood could be termed sizy.
In some few instances hemoptysis has preceded convalescence, as has also a
bleeding from the hemorrhoidal veins. Epistaxis has not, to my knowledge,
ever occurred.
Before particular remedies, to be employed for the cure of mania and
melancholia, are recommended, it may be necessary to give some directions
concerning the means to be used for their certain administration.
Maniacs in general feel a great aversion to become benefited from those
medicinal preparations which practitioners employ for their relief; and on
many occasions they refuse them altogether. Presuming that some good is to
be procured by the operation of medicines on persons so affected, and
aware of their propensity to reject them, it becomes a proper object of
enquiry how such salutary agents may most securely, and with the least
disadvantage, be conveyed into the stomachs of these refractory subjects.
For the attainment of this end various instruments have been contrived,
but that which has been more frequently employed, and is the most
destructive and devilish engine of this set of apparatus, is termed a
_spouting_ boat. It will not be necessary to fatigue the reader with a
particular description of this coarse tool, except to remark, that it is
constructed somewhat like a child's pap boat; and is intended to force an
entrance into the mouth through the barriers of the teeth.[35]
In those cases, where patients have been obstinately bent on starving
themselves, or where they have become determined to resist the
introduction of remedies calculated for their relief, I have always been
enabled to convey both into their stomachs, at any time, and in any
quantity that might be necessary, by the employment of an instrument, of
which the figure and dimensions are here given.
[Illustration]
Since the use of this very simple and efficient instrument, which I
constructed about twelve years ago, I can truly affirm, that no patient
has ever been deprived of a tooth, and that the food or remedy has always
been conveyed into the stomach of the patient.
The manner in which this compulsory operation is performed, consists in
placing the head of the patient between the knees of the person who is to
use the instrument: a second assistant secures the hands, (if the
straight-waistcoat be not employed) and a third keeps down the legs. As
soon as the mouth is opened, the instrument may be introduced; it presses
down the tongue, and keeps the jaws sufficiently asunder to admit of the
introduction of the medicine, which should be contained in a vial, or tin
pot with a spout, to allow it to run in a small stream. The nose of the
patient being held by the left hand of the person who uses the
instrument, a small quantity of the medicine is to be poured into the
mouth, and when deglutition has commenced, is to be repeated, so as to
continue the act of swallowing until the whole be taken.
A little address will obviate the determination of the patient to keep his
teeth closed: he may be blindfolded at the commencement, which never fails
to alarm him, and urges him to enquire 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 are wanting,
the 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, I have usually performed the business of
forcing, more especially amongst the females, and it has, in some degree,
rewarded my trouble; it has ascertained the practicability of
administering remedies; and it has also afforded the consolation, that,
where the means employed have produced no good, the patient has sustained
no injury.
_Purging._
An opinion has long prevailed, that mad people are particularly
constipated, and likewise extremely difficult to be purged. From all the
observations I have been able to make, insane patients, on the contrary,
are of very delicate and irritable bowels, and are well, and copiously
purged, by a common cathartic draught. That, which has been commonly
employed at the hospital, was prepared agreeably to the following formula:
[Precsription] Infusi sennae [ounce] iss ad [ounce] ij
Tincturae sennae [dram] i ad [dram] ij
Syrupi spinae cervinae, [dram] i ad [dram] ij.
but, within the last seven years, the tinctura jalapij has been
substituted for the tinctura sennae. It is so far an improvement, that it
operates more speedily, and produces less griping.
This medicine seldom fails of procuring four or five stools, and
frequently a greater number.
In confirmation of what I have advanced, respecting the irritable state of
the intestines in mad people, it may be mentioned, that the ordinary
complaints, with which they are affected, are diarrhoea and dysentery:
these have heretofore been very violent and obstinate.
Perhaps it may be attributed to superior care that the occurrence of these
complaints has, of late years, been comparatively rare, contrasted with
the numbers who were formerly attacked with such diseases; and, when they
do happen, an improved method of treatment has rendered these intestinal
affections no longer formidable or fatal.
In those very violent diarrhoeas, which ordinarily terminate in
dysentery, from five to ten grains of the pilula hydrargyri have been
given according to the sex, constitution, and nature of the complaint,
once or twice a day, and with general success.
It may be necessary to add, that it is proper, during the course of this
mercurial remedy, which shortly arrests the disease, to keep the bowels
in an open state, by some of the milder purgatives employed every third or
fourth day.
Diarrhoea very often proves a natural cure of insanity; at least, there
is sufficient reason to suppose, that such evacuation has very much
contributed to it. The number of cases, which might be adduced in
confirmation of this remark, is considerable; and the speedy
convalescence, after such evacuation, is still more remarkable.
In many cases of insanity there prevails a great degree of insensibility,
so that patients have scarcely appeared to feel the passing of setons, the
drawing of blisters, or the punctures of cupping. On many occasions, I
have known the urine retained for a considerable time, without complaint
from the patient, although it is well ascertained, that there is no
affection more painful and distressing than distension of the bladder.
Of this general insensibility the intestinal canal may be supposed to
partake; but this is not commonly the case; and, if it should frequently
prevail, would be widely different from a particular and exclusive torpor
of the primae viae.
But, sometimes, there arises a state of disease in maniacs, where the
stomach and intestines are particularly inert. The patient refuses to take
food, and is obstinately constipated: the tongue is foul, and the skin is
tinged with a yellowish hue: the eyes assume a glossy lustre, and exhibit
a peculiar wildness. In this state, I have given two drachms of the pulvis
jalapij for a dose, and which, on some occasions, has procured but one
stool, so that it has been necessary several times to repeat the same
quantity. After the bowels have been sufficiently evacuated, the appetite
commonly returns, and the patient takes food as usual.
Much mischief may be produced, if it be attempted to force food into the
stomach in such a case, which the ignorance of keepers may attempt,
supposing it to originate in the obstinacy of the patient. In order to
continue the bowels in a relaxed state, after they have been sufficiently
emptied of their contents, the following formula has been employed with
advantage:
[Precsription] Infusi sennae, [ounce] vijss
Kali Tartarizati, [ounce] ss
Antimonij Tartarizati, gr 1ss
Tincturae jalapij, [dram] ij
From two to three table spoonsful may be given once or twice a day, as
occasion may require.
There are some circumstances unconnected with disease of mind, which might
dispose insane persons to costiveness. I now speak of such as are
confined, and who come more directly under our observation. When they are
mischievously disposed they require a greater degree of restraint, and are
consequently deprived of that air and exercise which so much contribute to
regularity of bowels. It is well known that those who have been in the
habits of free living, and who come suddenly to a more temperate diet, are
very much disposed to costiveness. But to adduce the fairest proof of what
has been advanced, I can truly state, that incurable patients, who have
for many years been confined in the Hospital, are subject to no
inconveniences from constipation. Many patients are averse to food, and
where little is taken in, the egesta must be inconsiderable.
To return from this digression: it is concluded, from very ample
experience, that cathartic medicines are of the greatest service, and
ought to be considered as an indispensable remedy in cases of insanity.
The good sense and experience of every practitioner must direct him as to
the dose, and frequency with which these means are to be employed, and of
the occasions where they would be prejudicial.
_Vomiting._
However strongly this practice may have been recommended, and how much
soever it may at present prevail, I am sorry that it is not in my power to
speak of it favourably. In many instances, and in some where blood-letting
had been previously employed, paralytic affections have within a few hours
supervened on the exhibition of an emetic, more especially where the
patient has been of a full habit, and has had the appearance of an
increased determination to the head.
It has been for many years the practice of Bethlem Hospital to administer
to the curable patients four or five emetics in the spring of the year;
but, on consulting my book of cases, I have not found that such patients
have been particularly benefited by the use of this remedy. From one grain
and half to two grains of tartarized antimony has been the usual dose,
which has hardly ever failed of procuring full vomiting. In the few
instances where the plan of exhibiting this medicine in nauseating doses
was pursued for a considerable time, it by no means answered the
expectations which had been raised in its favour by very high authority.
Where the tartarized antimony, given with this intention, operated as a
purgative, it generally produced beneficial effects.
Ten years have elapsed since the former edition of this work appeared; but
this length of time, and subsequent observation, have not enabled me to
place any greater confidence in the operation of emetics, as a cure for
insanity.
An author[36] who has lately published a work, entitled "_Practical
Observations on Insanity_," is however a determined fautor of emetics in
maniacal cases. In his skilful hands they have worked marvellous cures;
nor have any prejudicial effects ever resulted from their employment.
Perhaps no one has enjoyed a fairer opportunity of witnessing the effects
of remedies for insane persons than myself; and when emetics are employed
in Bethlem Hospital they have the best chance of effecting all the relief
they are competent to afford, as they are given by themselves, without the
intervention of other medicines; and this course of emetics usually
continues six weeks. Had Dr. Cox confined himself to the relation of his
own victories in combating madness with vomits, it would have been
sufficient; but he endeavours to raise the levee en masse of medical
opinion to co-operate with his sentiments. He says, page 78, "Yet _every_
physician, who has devoted his attention to this branch of the profession,
_must_ differ from him when he treats of vomiting." It was never my
intention to deny, in a disordered state of the stomach, that the madman
would be equally benefited with one in his senses by the operation of a
vomit: but I have asserted, that after the administration of many thousand
emetics to persons who were insane, but otherwise in good health, that I
never saw any benefit derived from their use. It will also be granted,
that some ascendancy may be gained over a furious maniac by forcing him to
take a vomit, or any other medicine, but this is widely different from any
positive advantage resulting from the act of vomiting. Sir John Colebatch,
in his "_Dissertation concerning Misletoe_," says, _p._ 35, "But I have
been for some years afraid of giving vomits, even of the gentlest sort, in
convulsive distempers, from some terrible accidents, that have been likely
to ensue, from moderate doses of Ipecacuanha itself."
In St. Luke's hospital, the largest public receptacle for insane persons,
where the medical treatment is directed by a physician of the highest
character and eminence, and whose experience is, at least, equal to that
of any professional man in this country, vomits are by no means considered
as the order of the day; they may be employed to remove symptoms
concomitant with madness, but are not held as specifics for this disease.
In reading over the cases related by Dr. Cox, there is no one, where
emetics have been solely employed as agents of cure; they have been always
linked with other remedies; and it requires more sagacity than even the
doctor can exact, to pronounce, when different means of cure are combined,
to which the palm should be adjudged. In the relation of my own experience
concerning vomiting, as a remedy for insanity, I have had only in view the
communication of facts, for I entertain neither partiality nor aversion to
any remedies, beyond the fair claim which their operations possess. Had I
modestly ventured to state, after the example of the Doctor, "that I had
_devoted_ myself _exclusively_ and _assiduously_ for a _series of years_,
to the care of insane patients in an _establishment_, where persons of
_both sexes_ are received,"[37] it might be suspected, that the
superstructure of my philosophy had been reared on the basis of private
emolument.
_Camphor._
This remedy has been highly extolled, and doubtless with reason, by those
who have recommended it: my own experience merely extends to ten cases; a
number, from which no decisive inference of its utility ought to be drawn.
The dose was gradually increased, from five grains to two drachms, twice a
day; and, in nine cases, the use of this remedy was continued for the
space of two months. Of the patients, to whom the camphor was given, only
two recovered: one of these had no symptoms of convalescence for several
months after the use of this remedy had been abandoned: the other, a
melancholic patient, certainly mended during the time he was taking it;
but he was never able to bear more than ten grains thrice a day. He
complained that it made him feel as if he were intoxicated. Considering
the insoluble nature of camphor, and the impracticability of compelling a
lunatic to swallow a pill or bolus, it has been found convenient (when a
large quantity was required) to give this medicine in the form of an
emulsion, by dissolving the camphor in hot olive oil, and afterwards
adding a sufficient quantity of warm water and aqua ammoniae purae.
_Cold Bathing._
This remedy having for the most part been employed, in conjunction with
others, it becomes difficult to ascertain how far it may be exclusively
beneficial in this disease. The instances where it has been separately
used for the cure of insanity, are too few to enable me to draw any
satisfactory conclusions. I may, however, safely relate, that in many
instances, paralytic affections have in a few hours supervened on cold
bathing, especially where the patient has been 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. The shower-bath was employed some years ago in the
hospital, and many cases were selected in order to give a fair trial to
this remedy, but I am unable to say, that any considerable advantage was
derived to the patients from its use. If I might be permitted to give an
opinion on this subject, the principal benefit resulting from this remedy,
has been in the latter stages of the disease, and when the system had been
previously lowered by evacuations. As a remedy for insanity cold bathing
has been disregarded by a celebrated practitioner. To a question from a
select committee of the House of Commons to Doctor Willis, 9th March,
1807, the following answer was given.
_Question._ Are you of opinion that warm and cold baths are necessary for
lunatic patients?
_Answer._ I think warm baths may be very useful, but it _can seldom
happen_ that a cold bath will be required.[38]
_Blisters._
These have been in several cases applied to the head, and a very copious
discharge maintained for many days, but without any manifest advantage.
The late Dr. John Monro, who had, perhaps, seen more cases of this disease
than any other practitioner, and who, joined to his extensive experience,
possessed the talent of accurate observation, mentions, that he "never saw
the least good effect of blisters in madness, unless it was at the
beginning, while there was some degree of fever, or when they have been
applied to particular symptoms accompanying this complaint."[39] Dr. Mead
also concurs in this opinion. "Blistering plasters applied to the head
will possibly be thought to deserve a place among the remedies of this
disease, but I have often found them do more harm than good by their over
great irritation."--_Medical Precepts, page 94._ Although blisters
appear to be of little service, when put on the head, yet I have, in many
cases, seen much good result from applying them to the legs. In patients
who have continued for some time in a very furious state, and where
evacuations have been sufficiently employed, large blisters applied to the
inside of the legs, have often, and within a short time, mitigated the
violence of the disorder.
In a few cases setons have been employed, but no benefit has been derived
from their use, although the discharge was continued above two months.
Respecting opium, it may be observed, that whenever it has 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, after its
operation, awaked in a state of increased violence.
Many of the tribe of narcotic poisons have been recommended for the cure
of madness; but, my own experience of those remedies is very limited, nor
is it my intention to make further trials. Other, and perhaps whimsical
modes of treating this disorder, have been mentioned: whirling,[40] or
spinning a madman round, on a pivot, has been gravely proposed; and, music
has been extolled, with a considerable glow of imagination, by the same
gentleman.--That the medical student may be fully aware of the manifold
agents which _practical physicians_ have suggested for the restoration of
reason, I shall conclude my volume with the following extract.[41]
"The medical philosopher, in his study of human nature, must have
observed, that _sympathetic correspondence of action_ between the mind and
body, which is _uniformly_ present in health and disease, though _varying_
with circumstances. The different passions, according to their nature, the
degree or intensity of application, and the sensibility of the party,
exhibit certain characteristic expressions of countenance, and produce
obvious _changes_, actions, or motions, in the animal economy. MUSIC has
been found to occasion _all_ these actions, changes, and movements, in
some sensible systems; and where one passion morbidly predominates, as
frequently happens in mania, those species of simple or combined sounds,
_capable of exciting an opposite passion_, may be _very usefully_
employed. _If_ then such effects _can_ be produced by such a power, acting
on a mind only endued with its healthy proportion of susceptibility, what
may we _not_ expect where the sensibility is morbidly increased, and where
the patient is alive to the most minute impressions? Cases frequently
occur where such acuteness of sensibility, and _extreme_ delicacy of
system exist, that most of the more common, _moral_, and medical means are
contra-indicated; _here_ relief may be often administered through the
medium of the _senses_; the _varied modulations, the lulling, soothing_
cords of even an Eoelian harp have _appeased_ contending passions,
_allayed_ miserable feeling, and afforded ease and tranquillity to the
bosom _tortured_ with real or fancied woe: and I can easily _imagine_,
that _jarring discord_, _grating harsh rending_ sounds, applied to an ear
_naturally_ musical, would uniformly excite great commotion. Under
circumstances calculated to assist this action, by producing unpleasant
impressions through the medium of the other senses, as when SCREECHES and
YELLS are made in an apartment painted _black_ and _red_, or _glaring
white_, every man must be painfully affected: the maniacal patient,
_however torpid_, _must_ be roused: or, on the contrary, where an opposite
state obtains, extreme sensibility and impatience of powerful impression,
there _much may be expected_ from placing the patient in an _airy room_,
surrounded with _flowers breathing odours_, the walls and furniture
_coloured green_, and the air agitated by undulations of the softest
harmony. _Much_ of this may appear FANCIFUL and RIDICULOUS, but the
_enquiring_ practitioner _will_ find, on making the experiment, it
deserves his _serious_ attention; and no mean is to be despised that is
capable of arresting the attention, changing the trains of thought,
interesting the affections, removing or diminishing painful sensations,
and ultimately rendering both mind and body sensible to impressions, and
_all this has been effected by music_. Every individual is not capable of
accurately estimating the _extensive powers_ of this agent; but I would
ask the _musical amateur_, or the _experienced professor_, if he have not
frequently felt sensations the most _exquisite_ and _indescribable_; if he
have not experienced the whole frame _trilling_ with _inexpressible
delight_, when the _tide_ of full harmony has FLOWN on his ear, and the
most _wretched miserable_ feeling, UNIVERSAL HORRIPILATIO and CUTIS
ANSERINA from the _grating crash_ of discord? All the varied sensations
from transport to disgust, have been occasioned by the different movements
in one piece of music. I might _amuse_ my readers with a great variety of
instances where persons have been very singularly affected by means of
music, and where its powers have extended to the _brute creation_, but
this I purposely avoid."