together only with purging. I used in turn every substance in the materia medica possessing emetic properties, and marked with attention the effect of each; but I must conscientiously declare, that, after several years' perseverance, my confidence in emetics alone in cases of insanity has been entirely dissipated. Ferriar asserts, that he has known dangerous debility in this malady brought on by a single vomit of emetic tartar. A vomit is sometimes given to refractory patients as a punishment. This is very inconsiderate, for no lunatic is at all times in such a state that vomiting may be excited without risk. Besides which, a prejudice against all medicines is raised, that nothing afterwards may be able to subdue. Still, I have occasionally recourse to emetics, but only as I would in other diseases, to free the stomach from troublesome ingesta, accumulated phlegm, or morbid bile; and sometimes to give activity to torpid viscera, and rouse and emulge the general system. In melancholia, vomiting is decidedly more useful than in mania; for in the former the stomach is more apt to be loaded with saburra, and the viscera to perform their functions languidly. Then the action of an emetic, while it clears away the cause of offence, invigorates the powers of digestion and assimilation, and conduces to corporeal and mental health. Emetics are occasionally useful, too, by interrupting intense abstractions, and morbid hallucinations, and capricious resolutions. Where the urine has been retained from obstinacy, the operation of an emetic will generally evacuate the bladder. In like manner, it sometimes will act on the rectum when the fæces are withheld. In the apoplectic and hemiplegiac diatheses, it has been remarked, that powerful doses of emetic tartar are TT required to induce vomiting. The same may be generally observed in all diseases, as well as in insanity, where there is cerebral congestion. I have given to the extent of a scruple of it at a dose without the least nausea, in cases of mania where, as soon as the congestion was relieved by the abstraction of blood from the head, a grain or two has vomited. So, likewise, where the object has been merely to induce nausea to abate symptoms of great excitation. Till the vessels of the head are unloaded and the lower intestines well evacuated, a large dose is required; afterwards, a smaller will produce the effect. These, however, are general remarks, not without exceptions; for sometimes, though rarely, the insane experience much gastric irritation, and then the slightest dose of any nauseating medicine cannot be borne on the stomach. 13. Nausea. The action of nausea and vomiting is very opposite : the former diminishes the power of the heart, and retards the circulation; the latter increases the action, and determines the circulation to the surface. Emetics, therefore, exciting vomiting, or only nausea, may in the one event be of great service, in the other do infinite mischief. This observation especially applies in the treatment of insanity, and ought particularly to be regarded. Nausea exercises a powerful control in mania. To the sensation it creates, the whole attention of a maniac is often directed. In this respect it acts like any thing that excites local pain. While nausea lasts, hallucinations of long adherence will be suspended, and sometimes be perfectly removed, or perhaps exchanged for others; and the most furious will become tranquil and obedient. In mania furibunda it is an excellent auxiliary, not only because it subdues violence, but because of its controlling power over the circulation. Indeed, it is far safer to reduce the patient by nauseating than by depleting him. The effect of the former, when artificially produced, we can check and counteract when we please; the effect of the latter is not within our control, and often leaves lasting proofs that it has been injudiciously practised. Doses of emetic tartar at such intervals as will keep up the nausea, rarely fail to reduce the most stubborn to subjection. Sleep, also, which in these cases is so desirable, will sometimes occur while in this state. This plan should be continued so long as it is positively useful, and no longer. I have known it pursued for a fortnight, and the hallucinations by degrees dispersed, or so weakened that the cure has been quickly accomplished. But in melancholia, nausea never ought to be excited intentionally as a remedy. The hallucinations in this case are generally full of suspicion, and especially of poison; therefore, any thing that disturbs the stomach the patients are apt to suspect is given with an evil intent, and it prejudices them against all other remedies, and, what is more material, against their food. The operation of an emetic they understand; and though very disagreeable to them, it excites no false alarms; but the terrors they endure in protracted nausea, is to many a realisation of their worst apprehensions. Besides, in melancholia, where the vital powers are apt so suddenly and unaccountably to give way, exciting nausea, which is itself a state of collapse, and enfeebles the system, may have dangerous consequences. 14. Salivation. Mercury has been recommended in the treatment of insanity, both from its peculiar qualities as a cathartic and a sialagogue. As a purgative, in the form of calomel, it is certainly highly useful, either by itself or in combination with other cathartics; but it possesses no antimaniacal properties. I prefer it in most cases, either in combination with, or followed by other purgatives. It then acts better on the liver, which is often in fault both in mania and melancholia; and those slight deliria frequently consequent on the accumulations of morbid bile which so peculiarly influence the nervous system, are oftener dispersed by this mode of purging. Mercury is likewise extremely useful in combination with opium, emetic tartar, digitalis, squill, &c., when particular effects are desired, as in other diseases. As a sialagogue to produce salivation, I think it probable mercury may have been first prescribed from observing that ptyalism was a symptom often attendant on insanity; and likewise that recovery had succeeded mercurial salivation. Hitherto I have viewed the efflux of saliva in maniacal persons as purely symptomatic, and occasioned by irritation from local determination to the salivary glands; for it generally appears on the access of or during the paroxysm, and not on the decline of it. Mercury, by its acknowledged power of equalising the circulation, may restore the balance between the vascular and nervous systems, and thereby remove that morbid condition of the brain, which, perhaps, originates intellectual derangement, while no such effect would arise from spontaneous salivation. Analogy, too, supports this inference; for the excitement from mercurial action very closely resembles febrile excitation; and those conversant with insanity know, that a smart attack of fever, from whatever cause, often effects a perfect cure of the mental disorder. Yet, expectation of such an effect proving critical in disorders of the mind, ought not to be sanguine; since we know how easily a copious flow of saliva is excited, through the medium of the mind, on the anticipation or odour of savoury viands, and that this is a frequent symptom in hysteria and many other maladies, without occasioning any abatement whatever of the disease. Ptyalism is also incited by chewing certain substances. Cælius Aurelianus notices it as a symptom characteristic of cerebral affections.* Although it was known to Theodoric, the friar, in the thirteenth century, that mercury would produce salivation, yet it was not much employed till the sixteenth by Paracelsus. Nor is mercurial ptyalism mentioned, I believe, as a remedy for insanity till the following century. Thomas Willis, who makes little difference between madness from the bite of a rabid animal and mania, advises salivation among other chirurgical remedies.+ As the effect of mercury is obviously stimulating and calculated to rouse the circulation, salivation might, à fortiori, be considered a useful adjunct in those cases where there is an evident torpidity in the vascular system. I had, however, never prescribed it with a view to salivate in any case of insanity, when my attention was aroused by the sudden recovery of an insane patient from accidental mercurial salivation. I shall quote an abstract of the original case: Miss C. was a very respectable woman, aged forty, of a leuco-phlegmatic temperament, gray eyes, darkbrown hair, and very corpulent. Her disposition was equable, though rather melancholic. She had for several years conducted a prosperous business; but her occupation was sedentary, and admitted of little variety. In the spring of 1817 she became very dyspeptic, * De Lethargo, cap. ii. Lond. Med. Repos. vol. xiv. † Omnia Oper. de Maniâ. |