_Medical Superintendent of the Sussex Lunatic Asylum, Hayward’s Heath._
In the first number of the _Practitioner_, July 1868, Dr. Anstie has
published a Paper on “The Hypodermic Injection of Remedies,” in which he
truly says, that despite the satisfactory working of the method and of
the greatly increased power in handling remedies which it gives us, it
is still very much unappreciated. Believing that this remark applies
even to the employment of the hypodermic injection of morphia in the
treatment of mental disease, I venture on this occasion to lay before
the Medico-Psychological Association in the half-hour we devote to
Clinical Discussion, a brief outline of three successful cases
illustrating the treatment by the hypodermic injection of morphia in
recent mania, chronic mania, and melancholia respectively.
In October 1861 Dr. W. C. Mackintosh published a Paper in the _Journal
of Mental Science_ on “The Subcutaneous Injection of Morphia in
Insanity,” which first drew my attention to this method of treatment. In
the Reports of the Somerset Asylum, Dr. Boyd has also recorded his
opinion of the value of this treatment in cases of maniacal excitement
with sleeplessness, and in that form of destructive mania accompanied
with dirty habits.[8]
The detail of the hypodermic method of treatment is carefully stated in
Dr. Anstie’s Paper, and to this I must refer those who desire farther
information regarding it. I use a solution of 6 gr. of the acetate of
morphia to the drachm; Dr. Anstie’s strength is 5 gr. I always commence
with ♏︎v of the solution (½ gr.), and in only one case out of many
hundred hypodermic injections of morphia has any injurious effects
followed the remedy thus used.
CASE I. _Recent Mania._—J. H. W., No. 1,563, female, aged 20, single;
domestic servant. Form of disease, acute asthenic mania.
_History._—Never had any previous attack. No history of insanity in her
family. Has been engaged for some years as a domestic servant. No reason
can be given for her illness. It is stated that for the last three or
four months she has been strange, and at times depressed, and that about
three weeks ago she suddenly became maniacal, and has remained in a
state of violent excitement ever since.
_Progress._—On admission at Hayward’s Heath, on the 22d of March last,
she was in a state of the most intense maniacal excitement, and very
incoherent. Physically, she was suffering from marked typhoidal
symptoms, her pulse was feeble and very rapid, her skin dry and harsh,
her lips and teeth covered with sordes, her tongue coated with a thick
creamy fur. She refused all food, and had had no sleep for several
nights.
Although she could not be prevailed on to take any solid food, she was
coaxed at times during the first two days after her admission to take ½
gr. of morphia in a little brandy, but she was almost invariably sick
after it; moreover, the excitement continued, and she could obtain no
sleep.
On the third day the hypodermic injection of ½ gr. of morphia was
commenced, and continued every four hours except during the middle of
the night. On the fifth day she was calm, although incoherent, and had
slept during the whole of the previous night, took her food well, and
had lost nearly all the typhoidal symptoms. Moreover, the irritability
of the stomach was completely allayed.
She has since then recovered without a bad symptom, and she is now
convalescent.
This case showed in a very marked manner the advantage of the hypodermic
injection of morphia over its administration by the mouth in cases,
which so frequently occur, of acute mania with marked asthenia and
irritability of the stomach, causing refusal of food.
CASE II. _Chronic Mania._—W. H., No. 950, aged 68, single, groom. Form
of disease, chronic mania, characterised by frequent recurrent attacks
of maniacal excitement.
_History._—Strong hereditary taint of insanity. Nearly all his brothers
and sisters are more or less insane or eccentric. Much given to habits
of intemperance, but, although often strange and eccentric, was never
sufficiently insane to warrant his being placed in a lunatic asylum
until he was 64 years of age, when he was attacked with acute mania and
removed to Hayward’s Heath.
_Progress._—During the attack of mania under which he was suffering when
admitted into the asylum he was treated with small doses (♏︎x) of
tincture of digitalis every four hours. The symptoms lasted for nearly
three months. He was then calm for many weeks. On the next outbreak of
mania, equal parts of liq. opii were added to the digitalis, and with a
beneficial effect, the attack not lasting so long.
He was thus treated for some two or three years. He generally suffered
from three or four attacks in each year.
In April 1868 he had an unusually severe attack of excitement, combined
with much noise and destruction of clothing. The usual medicines having
no effect, he was treated with the subcutaneous injection of morphia (½
gr.) three or four times in the twenty-four hours, and with marked
benefit.
On the recurrence of the next attack subcutaneous injection was had
recourse to at once, and the period of excitement was reduced to little
over a fortnight.
The next attack passed off in an equally satisfactory manner. In the
January of the present year an attack of recurrent mania being evidently
imminent, the old treatment of digitalis and opium was tried for fully a
fortnight, but without benefit. On February 8th ½ gr. of morphia was
injected, and the injection continued every six hours, and on February
10th (to quote from the case-book) he was decidedly improved and free
from excitement and noise.
Not only, therefore, is the duration of the attack of recurrent mania
diminished in this case, but during the attack the excitement is much
less intense under the hypodermic method of treatment.
CASE III. _Melancholia._—M. T., No. 1,397, female, aged 57, married,
domestic servant. Form of disease, acute recurrent melancholia.
_History._—No hereditary taint of insanity. Has been insane and confined
in asylums three or four times. She is temperate in her habits, and her
attacks of insanity appear to have followed on most occasions the
puerperal condition, but the present illness is stated to be due to
family troubles.
_Progress._—On admission she was suffering from the most acute type of
melancholia, combined with insomnia, refusal of food, and a strong
suicidal tendency. Moreover she was in a poor physical condition, having
lost much in weight, and being thin and anæmic.
In the first place she was treated with stimulants, sedatives, and a
nourishing diet, but she remained from May 14th, the day of admission,
until May 20th, without any improvement, and was becoming so reduced,
from want of sleep and constant worry, that her life was despaired of.
On the 20th May, 1868 (to quote from the case-book), “she passed a very
restless night, and is much exhausted this morning: injected acetate of
morphia gr. j, and she soon fell asleep; took her food well on awaking.”
On the 23d, “injected gr. j of morphia twice daily since the last entry,
and with decided benefit, and she is much less excited. Sleeps well, and
the suicidal tendency seems to have passed away.”
On July 15th the entry is as follows:—“Has improved uninterruptedly ever
since the last entry, and is now tolerably sane.”
She was discharged recovered on 7th December, 1868, and has continued
sane to this date, although in such a case another relapse is most
probable.