It is only intended, in this part of the subject, to speak of those
medicines which I have administered, by the direction of Dr. Monro, the
present celebrated and judicious physician to Bethlem Hospital, (to whom I
gratefully acknowledge many and serious obligations) without descending to
a minute detail of the hospital practice, or of the order in which they
are commonly exhibited. Of the effects of such remedies, I am able to
speak with considerable confidence, as they have come immediately under my
own observation.
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 goods 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 the few 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.
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 is commonly employed in
the hospital is prepared agreeably to the following formula.
[Prescription]. Infusi sennae [ounce] iss ad [ounce] ij.
Tincturae sennae [dram] i ad [dram] ij.
Syrupi spinae cervinae [dram] i ad [dram] ij.
This 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
intestines in mad people, it may be mentioned, that the ordinary
complaints with which they are affected, are diarrhoea and dysentery:
these are sometimes very violent and obstinate.
Diarrhoea very often proves a natural cure of insanity; at least there
is every reason to suppose that such evacuation has frequently very much
contributed to it. The number of cases which might be adduced in
confirmation of this observation 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 appeared hardly to feel the passing of setons, the
application of blisters, or the operation of cupping. On many occasions I
have known the urine retained for a considerable time, without the
patient complaining of any pain, though it is well known that there is no
affection more distressing than distention 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, would be widely different from a
particular and exclusive torpor of the primae viae.
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
contributes 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 spare
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 house, 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 degression: 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 remedies 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 has 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 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, by very high authority, had been raised in its favour. Where the
tartarized antimony, given with this intention, operated as a purgative,
it generally produced beneficial effects.
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 drams
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 melancholick 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 was intoxicated.
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: in some of these cases vertigo has been induced, and in
others a considerable degree of fever. If I might be permitted to give an
opinion on this subject, the benefit principally derived from this remedy
has been in the latter stages of the disease, and when the system had been
previously lowered by evacuations.
Blisters have in several cases been 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[10]."
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, awoke in a state of increased violence.