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of the brain, but the pain is aggravated when inflammation and softening occur in the immediate vicinity of the tumour. The headache that accompanies cancerous affections of the brain is generally acute and lancinating in its character. In abscess of the brain it is generally paroxysmal.

I have previously referred to the intimate sympathy existing between the brain and the stomach, and to the frequent presence of nausea, gastric irritability, and actual vomiting, in many cases of obscure organic disease of the brain. Romberg has, with his usual perspicuity and accuracy, described the characteristic diagnostic symptoms, by means of which we are enabled to distinguish cerebral from idiopathic sickness of the stomach. They are as follows:

1. "The influence of the position of the head; the vomiting is arrested in the horizontal, and recurs, and is frequently repeated in the erect position. It is also easily induced by movements of the head, by swinging, shaking, or stooping, or suddenly rising. 2. The prevailing absence of premonitory nausea. 3. The peculiar character of the act of vomiting; the contents of the stomach are ejected without fatigue or retching, as the milk is ejected by babies at the breast. 4. The complication with other phenomena, the more frequent of which are pain in the head, constipation, and the irregularity of the cardiac and radial pulse, which is increased during, and subsequent to the act of vomiting. The duration of the vomiting is limited in the inflammatory affections of the brain, meningitis, encephalitis, and acute hydrocephalus to the first stages of the disease; and the prevailing rule is, that as the paralytic and comatose symptoms increase the vomiting remits and ceases."

TREATMENT AND PROPHYLAXIS.-In all acute affections of the brain and disorders of the mind the cure and life

of the patient depend, 1. Upon the speedy detection of incipient symptoms; 2. Upon the accuracy of the diagnosis formed as to the nature of the cerebral affection; 3. Upon the immediate application of remedial treatment.

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 suspicions 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.

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, necessary 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

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 high 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 douche 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. When 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 hellebore. 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.

Anticyras 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,

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Drink hellebore, my boy-drink deep, and purge thy brain.”

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