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TREATMENT or INCIPIENT INSANITY. 659

of the patient depend, 1. Upon the speedy deleclion of incipient spmp/oms ,- 2. Upon the accuracy of file diagnosis formed as 1’0 t/ie nalure of the cerebral afleclion ; 3. (Ivan t/ie immediate application of remedial lrealmenf.

I propose, in the first instance, to consider briefly the general principles that should guide the practitioner in the treatment of incipient insanity.

The treatment of the early stage of insanity requires great delicacy, discrimination, and judgment. Under these circumstances, where the brain is in a morbid state of irritation, and the mind struggling between sanity and insanity, the person being conscious that his “ wits" are beginning “to turn,” the medical attendant should proceed cautiously and discreetly in his examination. If the patient be led to believe, from the conduct of the physician or from anything which falls from him, that derangement of mind is suspected, the most painful and disastrous consequences in all probability will ensue. In the early stages of insanity the patient’s suspicions are morbidly excited. He has a dread of “ going mad ;” expresses a horror of such a calamity, and often most positively refuses to allow himself to be questioned on the subject of his mental health. Should the patient believe that he is imagined to be deranged, he will sometimes exhibit great violence and excitement.

If the practitioner proceeds judiciously in his inquiry, he may generally succeed in effecting his object without inducing the patient in the slightest degree to suspect the purport of his visit. In many cases the physician may administer remedial agents, and succeed in warding off an attack of acute insanity, without conveying to the mind of the patient an intimation of the suspicious which exist as to his state of mind. When a medical man is called in to a case of this description, it is his duty first to direct his observations to the state of the general health. He will almost invariably detect either hepatic, gastric, cardiac, renal, or intestinal disorder which may be irritating and sympathetically disordering the brain. By the timely use of appropriate remedies, these affections may speedily be removed.

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It may occasionally be necessary to relieve the overloaded condition of the vessels of the brain. The patient often complains of severe headache, attended with an increase of temperature, for the relief of which the application of a few leeches, cold evaporating lotions, and ice to the head may be recommended. Great caution is, however, neeessary in the use of depleting and antiphlogistic measures. Alas! how often have patients, who have been injudiciously treated by such means, sunk into incurable chronic melancholy. In recent attacks, occurring in young and plethoric subjects, when the symptoms are closely allied to inflammation of the brain, local bloodletting is often attended with the happiest results.

In considering the physical treatment of insanity, it is essentially necessary that we should clearly understand upon what pathological condition of brain the morbid state of the mind depends. I think it may be safely laid down, as a general principle, that the brain, in cases of mania, even of the most exalted kind, is not necessarily in a state of active congestion or inflammation. The character of insanity, the symptoms which usher it in, and mark its progress, all unequivocally establish that alienation of mind frequently arises from a cerebral disorder, unaccompanied with vascular activity or turgescence.

In obscure and doubtful cases tartrate of antimony will be found an excellent substitute for bleeding. Violent maniacal excitement, accompanied by every apparent indication of a high degree of cerebral congestion and inflammation, will often yield to the administration of this

BLEEDING IN INCIPIENT INSANITY. 661

drug. The physician should begin with small doses, and gradually increase them, until the patient is able to take two or three grains without exciting actual vomiting.

On the subject of depletion in insanity, Dr. Seymour observes—“ In the great majority of cases, the functions of the brain in mental derangement are increased in force, while the circulation is depressed, extremely quick and feeble, and the action of the heart gives way to the smallest abstraction of ' blood; and yet these are often attended by raving delirium, great increase of muscular force, and are, in fact, what are termed lnlyfi cases. The consequence of such practice is, either the more frequent return of the high stage, or the patient sinks into one approaching idiotcy.”

When bleeding is clearly inadmissible, cold applied to the head will be found not only to diminish vascular excitement, but to lessen powerfully the morbid sensitiveness of the cerebral organs. Should there, however, exist a tendency to active plethora and apoplexy, cold lotions and ice should be used with great caution. The prolonged hot bath, in conjunction with the cold douche, will often be found most efficacious in subduing maniacal excitement. I have witnessed the mental perturbation of incipient insanity frequently yield to this potent remedy. The douc/ze is to be used when the patient is in the hot bath.

In the incipient, as well as in advanced stages of insanity, the generally overloaded and inactive state of the bowels should be relieved by means of purgatives. Much caution, however, must be observed in the use of aperient medicine. Very frequently the whole surface of the mucous membrane of the intestinal canal is in a state of sub-acute inflammation. This condition acts sympathetically upon the brain and nervous system, and aggravates the mental irritation. \thn this morbid state of the intestines is present, the use of

aperients should be preceded by the application of a few leeches (particularly if there be pain upon pressure), or counter-irritants, to the neighbourhood of the abdominal affection. In other cases of insanity, it will be necessary to exhibit drastic purgatives. Insanity has been known to yield to the steady and persevering use of cathartics. Hellebore had in ancient times the reputation of being a specific in cases of insanity. This drug was considered to operate powerfully in cleansing and invigorating the intellectual faculties. It is said that Carneades, the Academic, when preparing to refute the dogmas of the Stoics, went through a course of purgation by means of white hellebo're. So celebrated was this medicinal agent as a mental remedy that the poets of antiquity have sung its virtues. Horace, in allusion to the “happy madman,” says (I have quoted a portion of the original in a former part of this work)— “ He, when his friends, at much expense and pains,

Had amply purged with hellebore his brains.

Came to himself—' Ah cruel friends !‘ he cried,

‘ Is this to save me? Better far had died,

Than thus be robbed of pleasure so refined,
The dear delusion of a raptured mind.’ "

Persius also refers to the fame which this medicine had acquired in cases of disordered mind. In his fourth satire he tells Nero that, instead of taking upon himself the great and weighty task of government, which required much experience and sound judgment, he ought to take the most powerful medicine to clear his understanding.

—“ Aniicyras melior sorbere meracas."'

Melampus, the son of Amythaon, is said to have cured " The islands of Anticyra. were famous for producing hellebore. The above quotation from Persius has been thus translated by Dryden :—

“ Thou hast not strength such labours to sustain,
Drink hellebore, my boy—drink deep, and purge thy brain."

TREATMENT or msamrr BY orwm. 663

the daughters of Proetus, king of Argos, of melancholy, by purging them with hellebore. According to the traditionary fable, Melampus had observed that the goats who fed on this plant were purged; and having administered it to the king's daughters, who were wandering in the woods under the delusion that they were cows, he cured them, and received the hand of one of them in marriage, and a part of the kingdom of Argos as his reward.

In the treatment of incipient insanity, clearly unconnected with active head symptoms, there is no remedy which so effectually masters the disease as that of opium in one of its many formulae. I am satisfied that a vast amount of mental derangement may be successfully treated in its early stage by the continuous and persevering administration of sedatives. \Vhen insanity is clearly associated with a depressed condition of the vital powers, evidenced by a weak pulse, feeble action of the heart, and general anaemic state of the system, the exhibition of the hydrochlorate, acetate, or muriate of morphia, combined with iron and quinine, will, in a great majority of cases, be found to act like a charm in arresting the progress of the mental malady.

In some forms of insanity, belladonna, conium, hydrocyanic acid, chloroform, Indian hemp, henbane, stramonium, and hops, may be administered with advantage. It is obvious that no particular instructions can be given for the administration of these remedial agents. Much must necessarily be left to the judgment of the practitioner, who should be directed in the application of sedatives by the peculiar circumstances of each individual case presented for his consideration. It will be occasionally found necessary to administer opium by what is termed the cndermic method, as well as by enemata. In some cases of acute maniacal excitement, I have found great benefit from the careful use of chloroform by inhalation.

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