Of course, so far as this includes moral treatment and management, it has advanced in all civilized countries in a manner calculated, all will admit, to cause the liveliest feelings of satisfaction. Putting aside moral treatment, we cannot boast, it must be confessed, of the same unanimity of judgment. If, however, it must be admitted that as respects details, Tot capita, tot sensus, it will be allowed that, notwithstanding the so many heads, and the as many opinions, the general principles of treatment based upon a just view of the general pathology of insanity, are accepted by all. There were too many who, forty years ago, bled freely for mania, and I remember Conolly, at even a later period, complaining of the number of patients brought to him hopelessly demented in consequence of the heroic treatment to which, when maniacal, they had been subjected by men who, no doubt, still believed with Paracelsus when he said, "What avails in mania except opening a vein? Then the patient will recover. This is the arcanum. Not camphor, not sage and marjoram, not clysters, not this, not that, but phlebotomy." Well, this treatment by the Paracelsuses of 1841 has been supplanted by the more rational therapeutics which we witness in 1881.
Dr. Stokes, the highly respected superintendent of the Mount Hope Retreat, Baltimore, thus writes in his last annual report: "Forty years ago, when this institution was opened, large blood-lettings—in the standing, recumbent, or sitting posture, to the amount of thirty or forty ounces—were recommended in acute mania, followed up by local depletion, by leeches, to the number of twenty or thirty, to the temples. The moral treatment, hygienic measures, exercise, and suitable occupation were almost wholly ignored. Drastic purgatives, ... the shower bath, large and frequent doses of tartarized antimony, and mercury to the extent of producing ptyalism, were the most popular remedial agents in the treatment of insanity. This, in general terms, was the system advocated and practised when, forty years ago, this institution entered upon its godlike mission."
If the success of the treatment of insanity bore any considerable proportion to the number of the remedies which have been brought forward, it would be my easy and agreeable duty to record the triumphs of medicine in the distressing malady which they are employed to combat. But this, unhappily, is not the case. Hypodermic injections of morphia, the administration of the bromides, chloral hydrate, hyoscyamine, physostigma, cannabis indica, amyl nitrite, conium, digitalis, ergot, pilocarpine, the application of electricity, the use of the Turkish bath and the wet pack, and other remedies too numerous to mention, have had their strenuous advocates during late years. Each remedy, however, let us hope, leaves a certain residuum of usefulness behind it, though failing to fulfil all the hopes raised on its first trial.
Dr. Ramskill lately avowed his opinion in my hearing that the advent of the bromide has done infinite mischief. Others, attacking chloral, would maintain that while the bromide has slain its thousands, chloral hydrate has slain its tens of thousands. In spite of this, however, Dr. Ramskill, doubtless, continues to employ the bromide; and who would wish to be deprived of chloral, or any other drug, because of its abuse?
"For nought so vile that on the earth doth live,
But to the earth some special good doth give;
Nor aught so good, but strained from that fair use,
Revolts from true birth, stumbling on abuse."
Employed without discrimination, regarded as a talisman in insomnia and excitement—petted, in short, when it ought to have been restrained—chloral became for a time the spoilt child of psychological medicine, and, like other spoilt children, it has disappointed the fond hopes of its parents.
When it is possible for a physician in asylum practice to write as Dr. Pritchard Davies has written this year in our Journal, "On Chemical Restraint," to the effect that chloral, the bromides, and other sedatives are unnecessary, or even injurious; when, on the other hand, we have Dr. Hills replying that his experience at the Norfolk Asylum leads him to an entirely opposite conclusion; and Dr. Stokes, in America, writing thus in his report, after 7425 patients have been under treatment in his asylum, "without wishing to undervalue the great importance of an efficient system of moral treatment, great results can only be expected from a patient and persevering administration of powerful remedial agencies"—I say when such contrary opinions can be expressed by practical men, one feels how impossible it is to dogmatize upon the good effected by pharmaceutical remedies in insanity, and how far we are yet from witnessing a consensus of opinion in regard to their value.
It must be frankly granted that Psychological Medicine can boast, as yet, of no specifics, nor is it likely, perhaps, that such a boast will ever be made. It may be difficult to suppress the hope, but we cannot entertain the expectation, that some future Sydenham will discover an anti-psychosis which will as safely and speedily cut short an attack of mania or melancholia as bark an attack of ague.
Rather must we rest satisfied with the general advance in treatment in a scientific direction. Most of us know asylums where, within forty years and much less, tartarized antimony was in daily use in large doses as a quietus, and where croton oil was administered in addition to black draughts to a surprising extent, all these remedies being now employed only on the rarest occasions. Take an actual example, one of many, in a particular asylum. A few years ago a patient, who had been much excited and very troublesome, was treated in season and out of season with strong purgatives and sedatives. It so happened that he then fell under a new régime, which consisted in knocking off all these medicines and placing him under one attendant's entire supervision. The result was that he became as quiet and docile, though not cured, as any of the inmates of the asylum, and has remained so to the present time. But we may go further, and say that some cases of insanity are cured now which a few years ago would have remained uncured. Indeed, in relation to the associated bodily state, it may be said that specific treatment has been adopted. Remedies, like iodide of potassium, in large doses, are employed in cases in which, from the increased attention directed in recent years to the somatic ætiology of insanity, a causal relation between the physical and mental condition has been recognized, and the mental symptoms have disappeared in the most marked manner; and so again in gouty melancholia, relief has been obtained by appropriate remedies and diet. These are illustrations of the directly scientific application of medicine to medical psychology, and it is in this direction we must hope for a really satisfactory advance.
On the other hand, there are the successes obtained by the employment of drugs without our being able to say why or how they have exerted a curative agency; and it is obvious that as the number of drugs has so much increased during the period over which my survey extends, the chances of hitting on the right remedy are proportionately increased. How often we see one, two, or three drugs exhibited in mania without any result, while a fourth acts like a charm. Only by studying in detail the special characteristics of each case, can we hope to find a clue which will serve as a guide to the treatment of a subsequent one.