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1847) Utility of Opiates in several Forms of Insanity.

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Chap. IV. On Mental Derangement, especially that form called Melancholia, or the alternation of melancholia with violence, termed Lypomania or Suicidal Madness, especially in reference to the treatment of this form of disease by the employment of Opiates, or of that class of medicines called Sedatives.

The following sentence from Esquirol is affixed to this chapter as a motto or epigraph : Every organic lesion, that has ever been found in the bodies of the insane, has been observed in those of persons who had never been affected with chronic. delirium : in many cases no abnormal change has been discoverable, although the insanity had existed for a number of years. Pathological Anatomy has shewn to us every part of the encephalon altered, suppurated, destroyed, without any chronic injury of the understanding."

The great object of Dr. Seymour in this chapter is to recommend and enforce the great utility of opiates and other sedative and hypnotic medi. cines in certain forms of mental alienation, where there is reason to believe that no organic lesion of the encephalon is present. The existence of such a lesion may be suspected whenever there is loss of power in any of the limbs, liability to epileptic fits, cephalalgia accompanied by dimness of sight and loss of memory, &c. In all cases of this sort, the prognosis must be most unfavourable.

Passing over the introductory remarks,* which are, it must be confessed, most loosely and carelessly written, we proceed at once to the consideration of the very important practical point that our author seeks to illustrate. His attention was first drawn to the benefit of the use of opiates, con. tinued for a length of time, in certain cases of insanity, about eighteen years ago, by Messrs. Berverly and Phillips the medical superintendents of Dr. Warburton's very extensive lunatic establishment at Bethnal Green. Their statement was to this effect :

* We have found the acetate of morphia useful both in the excited and the low form of insanity.

We have also found it useful in cases of fixed delusions, but not of any great standing, and more useful in the low than the excited form of the disease. "of five cases of melancholy, three got well; the remaining two are certainly improving under the use of this medicine. Of five cases of excitement, two were discharged cured; one remains much improved; two received no benefit. It is necessary to observe, that we have used this medicine in several cases without taking notes, and the result was similar to the two cases mentioned, that is, without benefit. It appeared to us, that morphia did not produce the same good effect in excited as in other cases, unless there was an occasional interval of reason. In the cases mentioned, we have commenced with a fourth, and have not found it necessary to exceed half a grain; at present we have a patient taking half a grain dose every night, with decided advantage, and we

• Many of the observations at the close too of this paper are scarcely intelligible, from sheer carelessness in the manner of their expression. For example :"The state of the memory, the principal function of the brain, which depends on the perfection of the organ, is to be carefully considered. In old people the deficiency appears traceable to ossification of the arteries, and the first failure often precedes it.” Are we to understand that the decay of the memory, "the principal function of the brain,” is owing to incipient ossification of the cerebral arteries? Where is the proof of this assertion?

think the case very interesting, and proving the extraordinary effect of the medicine in cases of melancholy.

“ A woman, of the age of thirty-six, the mother of four children, was attacked with depression of spirits while pregnant with her last child. She did not feel the attack before she quickened, but immediately after : she had a strong desire to destroy herself and children. This continued during pregnancy. After she was delivered she became worse, and attempted to commit suicide several times ; and described her feelings; which is not common in such cases. She continued in this state, not fit to be trusted without a strict watch. She was sent here about two years ago ; and what is extraordinary in her case is, that about noon all the feelings of the desire of self-destruction left her. This occurred within the last three months; from which time they have remained the whole of the day. Various means were tried, without effect. Our first idea, from the regularity of the attack, was to treat her disease as an intermittent; which failed. About a fortnight ago we gave her the morphia, beginning with the fourth of a grain, and gradually increasing it to half a grain. After taking the second dose, one-third of a grain, she slept all night; in the morning she was cheerful, without feeling the propensity to destroy herself. The third day she had a return, which lasted until noon; the dose was then increased to half a grain. The fourth morning she had not any return, and continued well until the fifth day after the half-grain dose was given, when she had a return from five o'clock in the morning until nine; a paroxysm three hours shorter than any of the preceding. She is now free from any desire to destroy herself.” P. 155.

Since then, Dr. Seymour has employed this practice in very numerous cases, and with most pleasing effects. "Upwards of 70 cases (of Melancholia and Hypochondriasis) have recovered ; and I consider no case to be called a recovery, unless two years at least of unabated health have elapsed since the treatment concluded. In nearly 20 cases, the treatment has failed, or only given temporary relief.” The preparation employed was the acetate of morphia ; the dose being, in mild cases, a quarter of a grain in the form of solution, and, in severe ones, half a grain increased speedily to one grain, every night at bed-time. The practice must be steadily continued, without the intermission of a single night, for several weeks in mild cases, and for three months at least in very severe ones. Sometimes indeed, at first, sleep is not induced ; but, almost always, rest and quietude are at once obtained. Slight nausea and disturbance of the head may be felt for the first few mornings ; after a short time, however, these unpleasant symptoms cease, the patient sleeps at night, and is free from pain and uneasiness during the day. In some cases, two, three, or four weeks pass

before marked or decided benefit to the disturbed state of the mind or feelings is experienced. Still, the dose should not be increased beyond-what has been already stated. Dr. S. assures us that, even when the treatment has not succeeded in curing the disease, he has never witnessed any ill effects from the use of the Morphia, provided it has been given in the manner which he directs; viz. not to increase the dose beyond that recommended, and to keep the bowels daily open. Occasion. ally, the application of cold (ice in a bladder) to the head has been employed at the same time; this remedy is chiefly useful when the melan. choly and mental depression alternate with paroxysms of violence. The regular employment of the tepid bath, every or every second day, is a most serviceable adjuvant in very many cases ; particularly in females, and more especially when the disease has arisen in the puerperal state.

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1847)

Opium in Puerperal, &c. Insanity.

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remedy,” says our author, " which could, some thirty years ago, be recommended as being of certain advantage at the Quaker's Retreat at York was the warm bath in melancholia ; and the same was stated to me at Charenton in the year 1819.*

There is no form of Insanity more amenable to the treatment, that has now been recommended, than that which arises immediately after Parturition. We give the report of one case :

" About nine years ago I was sent for to Islington to see a lady, who had been confined the day before. This lady had had, a short time before her expected time, a fright from an alarm of fire, and her labour, although some days after the fright, was believed to be on the whole premature: the child was living. The patient's state was dreadful; her screams and cries were under the apprehension that she was condemned, and in hell fire. The lochia had ceased to fow; the patient, young and always delicate, seemed to have almost superhuman force; but her expression and violence of fear were scarcely to be endured. The pulse was 130, or even quicker. I recommended a grain of the acetate of mor. phia in solution, and a warm bath, every evening; her bowels to be kept open. I did not visit her again for two or three days, and I well remember the astonishment with which the anxious friends assured me she was so much better.

“ The practice was continued, and I only saw her once afterwards; the further attendance of a physician being quite unnecessary.” P. 174.

When the Insanity has arisen during the early months of Pregnancy, it is usually much more troublesome and unmanageable. Its character is generally that of self-accusation, alarm or horror for the husband or children; scenes of future punishment often present themselves, and a peculiar dread of taking food for fear of adding to the evil by increasing the health, and thus perpetuating the wickedness of which the patient considers herself to be guilty, is constantly present.” There is often a very strong disposition in this unhappy state to commit suicide ; and it may require the greatest and most watchful care to prevent this dreadful occurrence. It is not unfrequently supposed that the mental derangement will cease after the labour ; but this, in Dr. Seymour's experience, has not been the case; nay rather, “ the birth of the child has been the signal for an increase of the disorder, and unless cured—and it may be cured by the means I mention-no alleviation has occurred until after another child has been born." Is this last condition, pray, necessary for the recovery of the patient ?

There is much truth in Dr. Seymour's remarks as to the utter inutility -in many cases the positive mischief-of travelling and frequent change of scene upon patients afflicted with this kind of insanity:

" In every case that this course has been pursued, it has been invariably hurtful in my experience. Nothing is so common as to say- Poor thing! give her or him a little variety; rouse them, change the scene.' In simple hysterical cases this may do, but in cases of real aberration of intellect in melancholy, two circumstances render it wrong. "First, presenting to a mind impaired a succession of objects too quickly.

Secondly, that the mind pre-occupied considers all this as an abomination : What do they drag me here for? I who am so wretched : ah! it is all very well : what a mockery in my state!'

* “ Se melancholiam incipientem solo aquæ dulcis balneo frequenter curasse. Galen de Locis Affect. c. 7.

“ Thus it is, and thus it has been forced on my mind, in a great number of examples, both of men and women, that change of place and variety is eminently injurious as a means of cure, until the melancholy hallucinations are completely at an end.

“ This is in great contrast with the good which does arise from such a plan in the deep and real affliction which results from loss of friends, simply severe bodily illness, or any great moral distress. In these, if the unhappy individual can be persuaded to travel, new life comes from the exertion.

“ The contemplation or the thought of what great changes occur on the face of the earth,-how many thousands have equally great or worse sorrows,-the very distraction of occupation,-works wonders.

"In the one example the mind constantly rebels against the change of scene; in the other, the mind borne down with affliction, still in right-minded people lends it assistance to recover.

“ To the really melancholic and hypochondriac it does most serious harın. I speak decidedly, for I have seen many cases retarded in their cure by the preva. lent and popular opinion that variety and change of scene will benefit cases of mental aberration, either in the incipient or confirmed stage.” P. 180.

The recovery is always much promoted by encouraging the patient to engage in some regular pleasing occupation. For women, Embroidering is one of the very best.

In most of the cases of which we have just been speaking, the catamenial discharge is irregular or altogether deficient. When the mental malady is cured by the use of opiates, &c. the secretion often returns as one of the results of restored health ; but this is not always the case. By far the most efficient remedy for the re-establishment of this important function is, in our author's opinion, the direct application of leeches to the cervix uteri, two or three days before the expected period.

“ It appears to me,” says Dr. Seymour, " to be very desirable to impress upon the profession the great advantage of this practice; it is equally useful in the hysterical mania of young women, which is met with not unfrequently, and here the application of the remedy is still more difficult, and the careful manner of its application still more necessary. I have seen the most serious and alarming illness disappear under the regular adoption of this remedy, and I have every reason to believe that I have seen consequences of the most distressing nature, namely, the establishment of mental derangement, averted by it." P. 184.

Very true; but then the same result may often be obtained by simpler and less objectionable measures. The very case, quoted by our author as an example of its efficacy, shows this ; for the patient had recovered on a former occasion without its adoption. How comes it, too, that no chaly. beate was ordered in a case of " languid amenorrhæa?" Under such circumstances, the employment of Electricity-shocks passed through the pelvis-is often of the greatest utility.

In the morose and fretful crabbed Melancholy or Hypochondriasis of old age, which, alas! not unfrequently terminates in suicide, the treatment by sedatives, as already explained, will often be found to be most useful. It may be necessary to have recourse to bleeding or cupping, and the use of saline aperients, if there be any symptoms of cerebral congestion ; but it will be almost always useful to give from * to į of a grain of the morphia every night, at bed-time. There is unquestionably far too much dread of Opium in any form, among medical men generally, in cases where they suspect disordered cerebral circulation. As a matter of course, its ex1847]

Connection between Melancholiu & Phthisis.

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hibition requires caution and watchfulness; but this is no more than is necessary in respect of every potent remedy ;-potent either for evil or for good, according to the judgment with which it is employed. The case of the poet Crabbe, as related in his life, suggests some useful reflections :

“My father," (says Mr. Crabbe's son,)“ now in his forty-sixth year, was much more stout and healthy than when I first remember him. Soon after that early period he became subject to vertigo, which he thought indicative of a tendency to apoplexy, and was occasionally bled rather profusely, which only increased the symptoms. When he preached his first sermon at Muston in the Fear 1789, my mother foreboded, as she afterwards told us, that he would preach very few more ; but it was on one of his early journeys into Suffolk, in passing through Ipswich, that he had the most alarming attack. Having left my mother at the Sun, he walked into the town alone, and suddenly staggered in the streets, and fell. He was lifted up by the passengers, and overheard some one say significantly, “Let the gentleman alone, he will better by and by ;' for his fall was attributed to the bottle. He was assisted to his room, and the late Dr. Clubbe was sent for, who after a little examination, saw through the case with great judgment. There is nothing the matter with your head, he observed, ' nor any apoplectic tendency; let the digestive organs bear the whole blame ! you must take opiates.' From that time his health began to amend rapidly, and his constitution was renovated : a rare effect of opium, for that drug almost always inflicts some partial injury, even when it is necessary,* but to him it was only salutary, and to a constant but slightly increasing dose of it may be attributed his long and generally healthy life.” P. 163.

Dr. Seymour, we must not omit to remark, has been led by the results of his experience to the conclusion, that one of the most frequent causes of failure in the cure of uncomplicated-i. e. unattended with any organic lesion of the encephalon-Melancholy and Hypochondriasis, is the intimate connection between diseases of the mind and diseases of the lungs, especially Consumption. Esquirol has remarked that “les melancholiques succombent presque toujours à des maladies chroniques, particulierement aux affections de poitrine;" and he states that of 176 patients, who died affected by melancholy, 62 were carried off by phthisis. Of the 20 cases, alluded to above, in which the sedative treatment failed of producing decided benefit, a large proportion, 12, proved fatal from this disease. It becomes, therefore, the duty of the physician to have his attention drawn, every now and then, to the state of the thoracic organs in melancholic patients, whose cases are found to resist every method of treatment that can be devised.

Dr. Seymour promises us one or two more volumes of the same general character as the present. They will doubtless be acceptable to the profession ; for all his writings shew him to be the shrewd and experienced physician. But we must call upon him to bestow more labour upon their composition, and aim at giving them something better than a merely ephemeral reputation. We cannot admit the plea of “unceasing professional occu

“ This is the opinion of Mr. Crabbe, notwithstanding his father's recovery, not of Dr. Clubbe; and this, in spite of recovery, is the ordinary state of alarm in the minde of people ignorant of medicine—the same as to colchicum, and to many of our most important means of cure.

"Í have known at least twenty cases similar to the one related by Mr. Crabbe.” NEW SÉRIES, NO, XI.-VI.

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