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110 INSANITY of the disease which are not amenable to remedial agents in the present state of medical knowledge. Medicine, whether hygienic or therapeutic, cannot touch general paralysis, the insanity produced by adventitious products, or senile insanity, except in the reduction of intensity of symptoms. Traumatic insanity is for the most part hope less ; it is probable that sufficient attention has not been directed to surgical measures in such cases. In the insanities due to morbid conditions of the general system, in those associated with other neuroses, and in toxic insanity, the physician attacks the head symptoms through treatment of the causating factor. It is true that in these forms symptoms have to be attacked directly, but ultimate cure is to be looked for through treatment of the diathetic condition. It is rare, and then only in the earlier stages of the initial symptoms, that the progress of these diseases is cut short by therapeutic measures, inasmuch as they seldom come under the cognizance of the physician at that period. The exception to this statement is to be found in the case of puerperal insanity, where the patient is very generally under immediate medical supervision ; in her case, therefore, the prodromal indications are often observed, and the disease arrested by the timely administration of drugs. But in the great mass of cases the last idea which occurs to the minds of friends is the possibility of impend ing insanity, and it is not till the disease has considerably advanced that the fact is recognized and the physician called in. When he has the opportunity of applying his art during the initial stages, he directs his attention to the procuring of sleep by means of opium and other narcotics, the bromides of potash and ammonium and chloral hydrate, and by rectifying the disorders of the digestive system. But when the disease has reached the congestive stage the treat ment becomes for the most part expectant, as it does in analogous complaints of other systems. " Change of scene " is often adopted, and properly so in the very earliest stages ; but when the disease is confirmed it is much more apt to aggravate the condition, fatigue and excitement only fan ning the flame ; it is much the same as if a man with a congested lung were asked to walk a mile uphill, in the hope that he would breathe more freely at the top. Till within the last few years treatment by bleeding, cupping, and blistering, shaving the head, and cold applications, was much in vogue. In asylums of the present day a shaved head is never seen. It was likewise the custom to administer large doses of sedatives. The system of treat ment which now generally obtains is almost purely hygienic. Opiates are much less used, and are to be deprecated in those forms characterized by excitement ; in idiopathic and climacteric melancholia, however, they often produce good results. General constitutional treatment is what is usually adopted. In such forms as idiopathic mania and melan cholia, the mania of adolescence, puerperal mania, and climacteric melancholia, the disease, like many others, runs its course, not very materially affected by remedial agents apart from those applied to the maintenance of the system, and its cure is similarly dependent on rest and nursing. And the main question concerning treatment is, Where are these best to be obtained r In the case of the poor there is no alternative, even in comparatively mild cases, but to send the patient to an asylum. In the case of the rich it resolves itself very much into a question of convenience, for, with plenty of money at command, the physician can convert any house into an asylum. But under ordinary circumstances, when the patient is violent, noisy, suicidal, homicidal, or offensive to society, it becomes necessary to seclude him, both for the purposes of cure and for the safety and comfort of the family. Except amongst the very affluent, treatment at home is for the most part unsatisfactory ; it is very generally tried, but breaks down under the constant strain to which the friends arc sub jected. In a well-ordered hospital for the insane there is every possible appliance for treatment, with trained nurses who are under constant supervision; and it therefore affords the best chance of recovery. History. The history of the treatment of insanity has been stated to be divisible into three epochs the barbaric, the humane, and the remedial. But this does not take into account the very highly humane and probably highly remedial system of treatment which obtained in very ancient times. In Egypt the temples of Saturn, and in Greece the Asclepia, were resorted to by lunatics, and the treatment there adopted was identical in principle with that of the present day. The directions given by all the classical medical authors, and especially Hippocrates and Galen, are of the soundest character. How long their influence existed it is difficult to say, but in the Middle Ages, and up to the middle of the last century, little attention was paid to the care or cure of the insane. A small proportion were received into monastic houses or immured in common jails. In 1537 a house in Bishopsgate Street, London, fell into the possession of the corporation, and was appropriated for the reception of fifty lunatics. This, the first Bethlehem Hospital or Bedlam, was removed in 1675 to Moorfields, and in 1814 the present hospital in St George s Fields was erected. St Luke s was instituted in 1751. Bedlams or houses of detention for lunatics appear to have existed in other cities, but, with these ex ceptions, no provision was made for the insane, who were allowed to wander at large. There is good reason for believing that many were executed as criminals or witches. About 1750 the condition of the insane at tracted some amount of public attention, and the incar ceration in madhouses of a considerably larger number than formerly followed, not on account of any philanthropic sympathy with their condition, but as a measure demanded for the public safety and comfort. But this measure by no means brought about the termination of the barbaric, period. The houses, misnamed asylums, were in the hands of private parties, under little or no supervision, and were in fact merely prisons of the very worst description. The unhappy inmates were immured in cells, chained to the walls, flogged, starved, and not unfrequently killed. It is almost impossible to believe that this condition of matters existed far on into the present century. According to Conolly, " there is clear proof of the continued existence of these abuses in 1827 ; and it cannot be denied that not a few of them survived in some public and private asylums in 1850." Matters were no better in France when Pinel was appointed in 1792 to the charge of the Bicetre, the great hospital of Paris for male lunatics. In that establish ment, and in the Salpetritre, the condition of the inmates was as degraded as in the British madhouses. This great philanthropist adopted the bold step of striking off the chains and other engines of restraint from those under his care. About the same time, the most gross abuses having been brought to light in connexion with the management of the city of York asylum, William Tuke, a member of the Society of Friends, was mainly active in instituting the York Retreat for the care and cure of insane members of that sect. This real asylum was conducted on non-restraint principles. The names of Pinel and Tuke are indissolubly connected with the history of the humane treatment of the insane, and to their efforts must be ascribed the awakening not only of the public but of the medical profession to the true principles of management. It took, however, many years before the principles laid down by these men were universally adopted. In 1815 a committee of the House of Commons brought to light many gross abuses in Bethlehem Hospital, and it was not till 1836 that mechanical restraint