Part 12
Concerning their diet, it is merely necessary to observe, that it should be light, and easy of digestion. The proper quantity must be directed by the good sense of the superintendant, according to the age and vigour of the patient, and proportioned to the degree of bodily exercise he may be in the habit of using; "but they should never be suffered to live too low, especially while they are under a course of physic."[33] To my knowledge, no experiments have yet been instituted respecting the diet of insane persons: they have never been compelled to live entirely on farinaceous substances. The diet of Bethlem Hospital allows animal food three times a week, and on the other days bread with cheese, or occasionally butter, together with milk pottage, rice milk, &c. Those who are regarded as incurable patients ought certainly to be indulged in a greater latitude of diet, but this should never be permitted to border on intemperance. To those who are in circumstances to afford such comforts, wine may be allowed in moderation, and the criterion of the proper quantity, will be that which does not affect the temper of the lunatic, that which does not exasperate his aversions, or render his philosophy obtrusive. Although it seems rational in all states of madness, that temperance should be strictly enjoined, yet an author of the present day[34] steps out of the trodden path, and seriously advises us, in difficult cases, to drown lunacy in intoxication; and, strange as it may appear, has taught us to await the feast of Reason from the orgies of Bacchus. "The conversion of religious melancholy into furious madness is a frequent occurrence, and is generally followed by recovery. This has suggested the _propriety_, in some cases that have resisted more common means, of producing a degree of excitement by means of stimuli, in fact, _keeping the patient for days in succession in a state of intoxication_, which has often occasioned an alleviation of symptoms, and sometimes _restored the sufferers to reason_."
Confinement is always necessary in cases of insanity, and should be enforced as early in the disease as possible. By confinement, it is to be understood that the patient should be removed from home. During his continuance at his own house he can never be kept in a tranquil state. The interruptions of his family, the loss of the accustomed obedience of his servants, and the idea of being under restraint, in a place where he considers himself the master, will be constant sources of irritation to his mind. It is also known, from considerable experience, that of those patients who have remained under the immediate care of their relatives and friends, very few have recovered. Even the visits of their friends, when they are violently disordered, are productive of great inconvenience, as they are always more unquiet and ungovernable for some time afterwards. It is a well-known fact, that they are less disposed to acquire a dislike to those who are strangers, than to those with whom they have been intimately acquainted; they become therefore less dangerous, and are more easily restrained. It ought to be understood that no interruption to this discipline should defeat its salutary operation. On this account more patients recover in a public hospital, than in a private house, appropriated for the reception of lunatics. In the former, the superintendants persist in a plan laid down, and seldom deviate from their established rules: such asylum being a place of charitable relief, they are indifferent about pleasing the friends and relatives of the patient, who cannot there intrude to visit them at their option. In a private receptacle emolument is the first object, and however wisely they may have formed their regulations, they soon feel themselves subordinate to the caprice and authority of those by whom they are paid.
It frequently happens, that patients who have been brought immediately from their families, and who were said to be in a violent and ferocious state at home, become suddenly calm and tractable when placed in the hospital. On the other hand it is equally certain, that there are many patients whose disorder speedily recurs after having been suffered to return to their families, although they have for a length of time conducted themselves, under confinement, in a very orderly manner. When they are in a convalescent state the occasional visits of their friends are attended with manifest advantage. Such an intercourse imparts consolation, and presents views of future happiness and comfort. But certain restrictions should be imposed on the visits of these friends; ignorant people often, after a few minutes conversation with the patient, will suppose him perfectly recovered, and acquaint him with their opinion: this induces him to suppose that he is well, and he frequently becomes impatient of confinement and restraint. From such improper intercourse I have known many patients relapse, and in two instances I have a well-founded suspicion that it excited attempts at suicide.
Many patients have received considerable benefit by change of situation, which occupies the mind with new objects, and this sometimes takes place very shortly after the removal.
"Haply the Seas and Countries different With variable objects, shall expell This something setled matter in his heart: Whereon his Braines still beating, puts him thus From fashion of himselfe."
In what particular cases, or stages of the disease, this may be recommended, I am not enabled, by sufficient experience, to determine.
CHAP. VIII.
REMEDIES FOR INSANITY.
_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.
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._