Precious as they are on the right occasion, their employment should be subject always to the careful and judicious supervision of the physician.

Another feature of their physiological action to be borne in mind is their power to induce dreadful hallucinations in a well person—a fact which emphasizes the need of care in administering them to an individual whose mind is trembling in the balance. Long-continued use of these alkaloids interferes with nutrition.

From what has been said of the action of these drugs, it will be seen that their effectiveness is most manifest in conditions of motor excitement, in mania, agitated melancholia (combined with morphin), in agitated dementia, and in the motor excitement of epilepsy or paresis. I have often been able to feed excited patients who refused food, immediately after the injection of the alkaloid, during the few minutes that elapse before the advent of sleep.

The bromids, aside from their particular value in epileptic psychoses, are often useful in other forms of mental disease, owing to their effect in diminishing cerebral activity and reflex irritability. In epileptic insanities the combination of the bromids and opium is especially effective. They are of use in any mental excitement which is conjoined with some reflex irritability (illusions and organic sensations, uterine and genital disorders). As an anti-aphrodisiac they are employed in insanity with erotic manifestations. In large doses, sixty to ninety grains and over, they act well as a safe and innocuous hypnotic.

Chloral hydrate is not so much used as formerly, though its hypnotic effect resembles very closely natural sleep. It is applicable to acute hallucinatory conditions, insanities associated with chorea, and in the epileptic psychoses. In status epilepticus, per rectum it is one of the most valuable remedial agents. In some conditions, combinations of chloral with morphin are of much utility. Chloral is a heart poison, and its use is contraindicated in cardiac and vascular disease. Chloralamid is of little value.

Paraldehyd is a simple hypnotic whose utility is not sufficiently appreciated. Naturally, its bad taste and the rather disagreeable odor left upon the breath have limited its sphere of usefulness; but it has no bad influence upon the heart or nutrition. It can be given in heart disease, and patients seem to thrive and grow fat upon it. The dose is from one-half to two drams, but increasing doses are necessary, and I have had patients who have taken four or more drams at a dose. It is especially useful in conditions of inanition and in insanities founded upon hysteria or neurasthenia. The taste and odor of the drug can be concealed in orange-water or weak brandy. Amylene hydrate is of less value; it stands between chloral and paraldehyd.

Trional and sulphonal, as simple sleep-producing agents, are preêminent where nothing but sleep is the object to be attained. Trional acts quickly, sulphonal slowly; hence a combination of the two in equal doses is particularly fortunate in its results, inducing, as it does, rapid and prolonged slumber. Five to ten grains each, or more if indicated, may be given at bedtime with a glass of hot milk. The tastelessness of these drugs affords the possibility of administering them without the knowledge

of the patient, mixed with salt or sugar, or spread with butter upon bread. Sulphonal used for a long period produces muscular weakness and incoördination. Both of these agents may, after a time, give rise to some disorder of the alimentary canal. They are said to occasionally increase the intensity of auditory hallucinations.

Moral Treatment.-Psychotherapy is among the most important means of treatment of insanity. The general practitioner is especially concerned with it in the early stages of mental disorder; later, if the patient is turned over to the care of the asylum, it is still of the utmost importance, and the physicians in institutions know well the necessity and utility of moral agencies in effecting a cure or in at least ameliorating the condition of their charges. Physicians who have much to do with ordinary functional nervous disorders-hysteria, neurasthenia, mild depression, and hypochondriasis—are familiar with the wonderful influence they are able to exert over the mental attitude of patients thus afflicted, by kindness, patience, firmness, interest, and sympathy. Everything they say or do, if rightly said or done, conveys a suggestion, inspires hopefulness, increases the efficacy of their prescriptions, points out the way to health and a new lease of life. The insane also are in the same way dominated by the personality of the physician and of those chosen to carry out his instructions. Some physicians are fortunate enough to possess peculiar gifts in this way, and their influence is potent for incalculable good. Aside from this personal influence, the physician is called upon to direct and regulate the entire disposition of the time of the patient and to make for him the environment suitable to his malady. He prescribes isolation from friends, the care of strangers, the rest-cure, the periods and kinds of exercise, the mental and manual occupations, the amusements, all of which go to make up psychotherapy. Some of the principles of this moral treatment we will now briefly touch upon.

The value of isolation in melancholia and of the rest-cure for both acute mania and melancholia has already been mentioned. There are cases of melancholia, however, in which a modified rest-cure is better than the complete rest-cure. In such cases, after recumbence in bed from six in the evening until noon the next day, much of the afternoon may be spent in simple exercise, such as walking slowly about out-ofdoors. It is best not to seek, by amusements, visits of friends, and other cheerful devices, to raise the melancholiac from his depression, for usually these attempts rather add to his misery by force of contrast. A neutral atmosphere, so far as the emotions are concerned, is best, though an occasional word of confident reassurance is useful.

In acute stages of insanity it is best not to discuss the hallucinations and delusions of the patient, although neither physician nor nurse should ever fall in with or act upon his erroneous ideas. Whenever good judgment suggests, a brief but positive denial of the truth of the imaginings of the patient should be made. Later on such correction may with advantage be made more frequently and constantly.

When the patient is not taking a rest-cure, occupation of some kind is essential to his progress toward recovery. Most useful are all forms

of muscular or manual employment, for labor of this kind keeps the attention more or less fixed upon what is being done, the flow of ideas is checked and limited to a considerable degree, and the mind is prevented from concentrating itself upon illusions, hallucinations, and delusions. Moreover, muscular exercise is an outlet for superfluous energy; motor excitement is reduced by it; tissue metabolism is accelerated; and when the work is over, the organism gains all the more readily a certain composure of mind and repose of body. Out-of-door occupation is best-garden and field work for men, garden work for women; walking, bicycling, etc., for either sex. Among indoor employments we have ordinary housework, drawing, knitting, sewing, embroidery, carpentry, wood-carving, etc., all of which employ the muscles methodically. In certain cases mental occupation is useful, though it should be of the simplest kind. For instance, during my practice at the Hudson River State Hospital for the Insane, we found much value in the establishment of a regular country school, attended by patients of all ages. We had "spelling bees," copying lessons, reading aloud, blackboard exercises, geography, simple arithmetic, singing, and so on.

A very important point in the management of the insane is never to practise deception upon them in any way. Be absolutely truthful in every statement to them. Never remove a patient to an asylum under the impression that it is a hotel or sanatorium. It is better to state exactly what is going to be done, and then use force in the removal, if

necessary.

Hypnotism has been frequently practised upon the insane, in the effort to modify hallucinations or delusions, rarely with any definite success, occasionally with ill results, and generally with no effect what

ever.

There are a few conditions among the insane which require particular treatment or management. Among them are :

Suicidal Tendencies.-Suicidal patients are among those who require constant watching and the removal of every means of selfinjury. This is often difficult in treating such patients in their own homes. How difficult, it may be conjectured from the fact that, even in asylums, with all their safeguards, suicide is by no means infrequent. Thus, forty-eight patients in the asylums of the State of New York committed suicide between October 1, 1888, and September 30, 1896.

Suicidal patients are to be watched night and day, and kept in bed, and even put in restraint, if desperate. I have known a patient to strangle herself with a cord while lying in bed under the eye of a nurse. Another, broke a small piece from a china plate and tried to cut her wrists under the bedclothes. While suicide is most common among melancholiacs, patients with general paresis, paranoia, epileptic psychoses, and toxic delirium sometimes attempt it. The physician attending such patients should see to the guarding of windows and the removal of keys, hooks, scissors, weapons, drugs, strings, long pins, matches-in fact, of all instruments and means which he may suspect to be utilizable for a suicidal purpose.

Refusal of Food. The acutely maniacal often can not be made to take sufficient nourishment, because they do not stop long enough in their ideomotor excitement to permit of eating. The watchful and persevering nurse can generally, by persistent effort, induce the patient to swallow a considerable quantity of liquid food (preferably in a metal or heavy china cup, because the patient frequently knocks the vessel from the hand of the nurse). Such patients can often be fed, as already stated, immediately after a hypodermatic injection of hyoscin or duboisin before the supervention of sleep.

Other patients refuse to eat because of delusions of poverty or poisoning, suicidal proclivity, or simply from absolute distaste.

Where ordinary means fail, the nasal tube should be resorted to,one of large caliber with rubber funnel attached, and through this, once or twice daily, a mixture of a pint of milk, two or three raw eggs, a little meat-juice, and, if needed, brandy, may be introduced.

Before resort to this means nutritive enemata may be employed (three raw eggs, a half-pint of milk, a half-pint of water, and a little meat-juice).

I have been in the habit of delaying the use of the nasal or stomachtube to the last moment of safety, even for several days, rather than subject the patient to the excitement of its employment. It is only in rare instances that feeding is not effected in some other way before the use of the tube becomes imperative.

Violence and Destructiveness.-Hypodermatic medication and hot wet-packs are indicated in periods of excitement with tendency to violence and destructiveness. It has already been intimated that active physical labor or exercise is a safety-valve for patients with proclivities of this kind. Isolation in an empty room with protected windows is sometimes resorted to in institutions, and abroad the padded room is a favorite place for patients whose violent jactitations may lead to serious injuries to himself. The padded room consists simply of a room lined as to walls and floor with cushions. Mechanical restraint is used in the last extremity, when chemical restraint and other means have failed. The camisole and safety-sheet are employed only in cases with desperate suicidal tendencies, proclivity to excessive masturbation, great violence and destructiveness, and where needed to keep in place surgical dressings, splints, etc. In asylums mechanical restraint has been nowadays almost entirely abandoned.

In

Masturbation.-Masturbation is more often the consequence and concomitant of insanity than its cause. It may be ameliorated occasionally by drugs like bromids, camphor, and lupulin. Cold baths and hard physical labor are more successful in combating this habit. excessive masturbation, constant watching day and night or the use of mechanical restraint is necessary. The use of blistering fluids on the genital organs is only of temporary service. There are instances in which the habit is so fixed and so uncontrollable-for example, among some imbeciles-that surgical interference would be quite justifiable (castration, clitoridectomy, ovariotomy, section of the pudic nerves, ligation of the vas deferens).

CHAPTER VI.

MANIA.

Definition.-Mania is a form of insanity characterized by emotional exaltation, acceleration of the flow of ideas, and motor agitation. It is probable that the elated mood and the hyperexcitation of intellectual processes are both primary and simultaneous in their development. The motor excitement results from the conversion of the swiftly flowing ideas into acts.

Etiology. There is no special etiology for mania-what has been said in the chapter on General Etiology has application to this form. It may be said, however, that mania is ordinarily a disorder arising between the twelfth and twenty-fifth years; that it is more common in females than in males; that individuals of sanguine temperament are most liable; and that it is, upon the whole, rather an infrequent type of insanity. Hereditary taint is found in seventy-five per cent. and degenerative stigmata in twenty per cent. of cases. The percentage is larger for the periodical form.

Mental Symptoms.-An outbreak of mania is preceded by a period of depression lasting from a few days to a few weeks, sometimes as long as two months. This prodromal stage is characterized by a general feeling of malaise, vague uneasiness, and hypochondriacal complaints, accompanied often by headaches, cephalic paresthesias, constipation, loss of appetite, sleeplessness, and some loss of flesh.

When the true mental disorder begins to manifest itself, the sorrowful mood begins to give way to an exalted condition, which the patient looks upon as a state of renewed health and well-being. He takes a renewed interest in everything, and becomes unusually cheerful and talkative. The degree of increasing exaltation varies much in different cases. In mild cases the patient begins to surprise his intimates by his loquacity, facetious remarks, jocularity, and by his rather immoderate actions and undertakings. He enters upon many new schemes; makes innumerable calls upon friends and acquaintances; writes numberless letters; purchases unnecessary articles; and is inclined to excessive indulgence in tobacco, wine, and venery. There is considerable mobility or lability of the emotions, so that the elation may readily pass into conditions of anger or tears over trifles. In more severe types all of these symptoms are aggravated. A veritable chaos of ideas throngs through his mind, and the effects upon movement of this crowding series of ideas amount to a constant motor agitation. The patient laughs, declaims, sings, shouts, makes grimaces, dances, runs about, and becomes destructive and filthy, all inhibitory idea-associations ceasing to have any influence over the rioting torrent of thought. In still severer grades we have the picture of an acute delirium, boisterous incoherence, a motor agitation attaining to violent jactitation, and an actual and considerable increase of temperature.