TJ0dfNS^(/j. CjfugL, S v From the Maryland Medical and Surgical Journal, Volume I. REPORT OF CASES OF I DELIRIUM TREMENS occurring in the HOSPITAL Baltimore ^VJma fjouse, UBS E 11 V A T 1 t) N S TO WHICH rs ADDED AN APPENDIX CONTAINING AN Appeal iii Bdjalfof tfje ^iijiiik Poor of . 1840.] By Alexander C. Robinson, M.D. 9 when interrupted, again and again showing himself the sport of a disordered imagination. He recogniz2s his friends, returning ra- tional answers to their questions and is generally quite manageable by soothing treatment, but rendered impatient by any opposition to his movements. From phrenitis it may be known by tha above features, the absence of the hot and dry skin, tense, inflammatory pulse, impatience of light and the injection of the eyes, accompa- nying a phrenitic attack. Cases presented in females recently delivered, are with difficulty distinguished from puerperal mania. The known habits of the patient, and the evidences of greater constitutional exhaustion will assist the diagnosis. From the delirium of fever, we can distinguish it by our familiarity with its peculiar features, assisted by the history of the case. The delirium of fever is of a low mut- tering character; the .vital depression is extreme, and has been gradually advancing; instead of tremor, there is subsultus, unac- companied by the loquacity, incessant quick motion, wild timidity and anxiety of manner seen in Delirium Tremens. After a first attack recovery generally takes place, if the con- stitution be strong, but its frequent recurrence diminishes the chances of recovery, particularly if accompanied by evidences of vascular irritation of the encephalon. Any want of correspond- ence of the pupils, a softer and more frequent pulse, the persist- ence of restlessness, the supervention of short unrefrcshing naps, from which the patient starts with increased tremors or con- vulsions, are alarming symptoms. This state is. said to be more dangerous if caused by opium, as the powers of the consti- tution are so wasted by that drug. The mitigation of the symp- toms, a less frequent pulse, a more natural condition of the skin, accompanied by evidences of sleepiness, are favorable, since they are the natural precursors of a deep refreshing sleep, the only salutary termination of the disease. The autopsic appearances furnish no positive information as to its nature. In a few cases the membranes of the brain show no change, but in the great majority, more or less opacity of the arachnoid, especially at the base of the brain, is found. This same thickening and lymphatic effusion we have, noticed in every case we have examined of confirmed drunkard's dying of other acute diseases. The pia-mater may be injected, with slight serous 2 10 Baltimore Alms House Hospital Report. [October, effusion into the ventricles. These appearances are more marked and manifestly inflammatory in those cases directly following in- toxication; the vessels, particularly of the velum interpositum, are much congested, and the serous effusion abundant, or even sanguineous. The lesions of the stomach and the liver, which are found in the uncomplicated cases, are dependent upon the habits of the indivi- dual. The stomach presents evidences of chronic gastritis, the mucous membrane thickened, mammillated, sometimes softened, and of a dark slaty color; the liver is generally enlarged and gran- ulated, the yellow substance being hypertrophied, or there is a fatty degeneration of the organ, as noticed by many writers. The want of positive information from the appearances on dis- section, has permitted great diversity of opinion as to the nature of Delirium Tremens,—some, regarding gastritis, others, meningitis, as the pathological state essential to the disease, while a third class admit, that these local inflammations are sometimes attend- ants, but do not believe them to be essential, regarding nervous exhaustion and sensorial irritability as a more important ingre- dient. It will go far to accommodate these differences of opinion, if we recollect the distinction insisted on above, between the two forms of the disease; the one connected with vital nervous ex- haustion, the other with excited circulation in the brain. The treatment has been the subject of more discussion than even the nature of Delirium Tremens, and the most opposite means have been advocated by different writers. While some, viewing the disease as dependent upon gastric and inflammatory irritation, use leeches to the head and anus, with ice to the scalp, administer- ing calomel with purgatives, and subsequently hydrocyanic acid* others recommend venesection, followed by sedative doses of tart. antim, or infus. of digitalis; another class advise emetics and the cold douche; and a fourth set the various preparations of opium in the most opposite doses, to which some add stimulants, and others depressing agents. This want of uniformity is attributable to the contrasted fea- tures of different cases; some giving evidence of local vascular excitement; others of nervous or constitutional exhaustion, while these two pathological conditions apparently co-exist in a third class, either predominating more or less. 1840.] By Alexander C. Robinson, M.D. 11 The practitioner may be led into error by the acknowledged difficulty of distinguishing between the morbid phenomena flow- ing from vascular excitement of the brain and its dependencies, and such as arise, in a great measure, if not altogether from nerv- ous exhaustion. He should be mindful of this difficulty, and minutely enquire into the history of each case, closely watching its morbid manifestations in order to arrive at correct views of the pathological condition determining the phenomena; and having resolved upon the most advisable treatment in each of the class of cases referred to, he will recognize the remedial means suited to the predominating character of the symptoms, and best calculated to afford relief in the particular case;—ever recollect- ing that an easy, natural, refreshing sleep is the object to be ob- tained, and that he has only to prepare the way for this by "lulling the disturbed vascular and nervous systems, and whether this be aimed at, by an antifebrile or antiphlogistic, an exciting or sedat- ive mode of cure, we make the selection with this one object in view." We seldom observe a spontaneous sleep, accompanied by re- covery from a well marked attack; yet it sometimes occurs, as shown by the instances of cure by "animal magnetism," reported in the American Intelligencer, and the twenty-two cases treated by "quiet," reported by Dr. Hoegh Guldbebg. (No. xii. British and Foreign Review, page 324.) If Delirium Tremens presents itself after recent excesses in the young and strong, possessed of constitutions unbroken by dissipation, it is apt to assume the garb of a species of arachnitis; the full and tense pulse, hot skin with evidences of cerebral con- gestion, calling for the loss of blood, which is succeeded by great relief. We have to use general blood-letting, however, with great caution, in consequence of the tendency to constitutional prostra- tion observed in almost every instance. One case only has presented itself in our practice requiring the use of the lancet; in that instance, occurring in an individual of unusual vigor and firmness of fibre, it was necessary to assist the lancet by free cupping over the epigastrium, and the repeated cold shower bath. Local depletion may be employed with less hesitation, even late in the attack, whenever indications of local congestion, or undue 12 Baltimore Alms House Hospital Report. [October, vascular action appear. This will be found a most important means of relief in the management of numerous cases. One was presented to our notice, in which the cerebral engorgement implicated even the vessels of the orbits, giving an unnatural prominence to the eyeballs, accompanied by a heavy, unmeaning stare, expressive of the great mental stupidity, which was further shown by the patient's very slow movements and imperfect com- prehension of what was said to him; a condition from which he aroused as from a heavy sleep, to consciousness and recognition before the cups were removed from his neck and temples. Early in such cases the cold affusion will also be found most advantageous. It not only subdues the morbid heat of the scalp and surface generally, but relieves the congestion of the brain, and dissipates the -hallucinations of the patient. Its beneficial influence, manifested in many cases within our observation, was displayed in a very marked manner some years ago, where the subject was a hale, handsome young sailor, who presented him- self for treatment, fresh from recent excesses, which had produced a condition of general nervous agitation, with high delirium; great tremor of the hands; head and surface hot, yet covered with perspiration; pulse frequent, but neither tense nor full; eyes in- jected; constant restlessness; the wildest fancies crowding upon his mind, and leading him to flee from point to point. With the aid of several assistants he was stripped, and placed under the cold shower bath, by which he was so quieted that he composedly dressed himself and retired to bed; his hallucinations controlled, and his hands steadied. In order to secure this benefit, opium was then administered; but failing to effect the object, it became necessary again to resort to the douche, which once more, seconded by anodynes, induced a refreshing sleep, from which the patient awoke, composed and sane. A profuse perspiration, if the surface be warm, as it frequently is found to be, and there exists sufficient evidences of general tone of the system to ensure reaction, does not forbid the use of cold affusions. We have observed the skin hot, dry and husky in cases of extreme constitutional exhaustion, and in those of an op- posite character, covered with perspiration, evidently not the result of a mere passive exudation, but rather of a great activity of the exhalants of the surface. 1840.] By Alexander C. Robinson, M.D. IS After the energies of the system have become measurably ex- hausted, so that full reaction cannot be promptly re-established; universal tremors, resembling paralysis agitans, are liable to be induced by the cold shower bath, and stimulating cordials become necessary to invite reaction, and thus remove passive, visceral en- gorgement. When constitutional debility is combined with great mobility of nervous system, violent convulsions may be induced by the indiscriminate use of the cold shower bath, as we once wit- nessed in a female to whom we were hastily called. Her constitution had been impaired by protracted habits of disJ sipation, and upon enquiry we found that the bath had been unre- flectingly ordered during her catameuial discharge, for the relief of a wild delirium, arising from the abuse of alcoholic stimulus, and accompanied by apparent evidences of high vascular excitement. Her nervous excitement and delirium promptly disappeared; but a universal tremulousness came on—the catamenial discharge ceased, and in about thirty minutes, violent spasms of the abdominal mus- cles, with excruciating pain of the back and head succeeded; while her countenance, attitudes and screams, expressed unutterable mental horror. This condition lasted two hours in defiance of the active measures for relief we at once adopted. When the cold douche has been successfully used, it should be repeated every two hours, or as often as may be necessary to con- trol the returning symptoms, frequently repeated moderate doses of opium or laudanum being administered as soon as the evidences of cerebral vascular excitement are sufficiently subdued, in order to continue the favorable impression made upon the perturbed nervous system. The opium may be combined with grain doses of tart, antim. if the additional sedative influence of this import- ant drug be demanded; a combination from which we have derived very important aid, and which is so highly esteemed by Dr. Stokes of Dublin, and other writers. We particularly remember an instance in which the Delirium finally yielded to the combined influence of opium and tart, antim. repeated every two hours,—although it had previously resisted for some days, all our best directed remedial means, manifesting unusual violence; the patient for much of the time refusing to take medicine, and successfully opposing all efforts to cup him. We have never found it necessary to use the antimony in the 14 Baltimore Alms House Hospital Report. [October, large sedative doses recommended by some writers. It is said to have been given in doses of iv. vi. viii. and even xxx. grs. repeated every hour or half hour, with the effect as stated, of im- mediate lassitude; slight vomiting and diarrhoea; tranquillity of body and mind, followed by the critical sleep. Yet a case is mentioned by Dr. Eberle, in which xv. grains produced neither vomiting nor purging, but an immediate power- ful sedative operation; the pulse becoming small and extremely feeble, the extremities icy cold, and a profuse, cold, clammy sweat breaking out over the whole body, the patient dying in about four hours. Such possible depression from tart, antim. should suggest caution in its use. Some of the French writers object to it in large doses, upon the ground that it is liable to produce inflamma- tion and ulceration of the mucous membranes of the alimentary canal. We have never witnessed this effect upon the mucous coat, although we have repeatedly administered large sedative doses of tart, antim. in cases of Pneumonia,—with a single excep- tion, in which distinct tart, emetic pustules were seen studding the fauces. In that instance the medicine having been admin- istered in a thick mucilage of gum-arabic, particles of the undis- solved antimony had adhered to the surface of the membrane about the throat. There is, frequently, a relaxed state of bowels in those laboring under the effects of protracted stimulation. Yet the accumulated vitiated secretions, generally found lodged upon the gastroente- ric mucous membrane, should be removed by purgatives calculated at the same time to invite the gorged ducts of the liver__long stimulated to excessive secretion—to pour out their morbid con- tents; thus taking away a source of irritation to the whole system. If there exist general or local nervous debility, stimulants and cordial stomachics should be united with the purgatives. The same may be said of Enemas—so useful in every case by their revulsive influence in stimulating and unloading the larger bowels In the management of cases at an early period, we have found emetics an important remedial mean—few having been presented in which we have not endeavored to induce free emesis. Some cases occur in which we require the sedative combined with the emetic effect of tart, antim.; others, again, in which habitual stimulation seems to have so wasted the susceptibility of the gas- 1840.] By Alexander C. Robinson, M.D. 15 trie membrane, that, to produce emesis, it becomes necessary to administer active and repeated emetics—combined, perhaps, with stimulants—as ipecacuanha with camphor. But with such excep- tions, we have found a strong solution of the muriate of soda, freely administered, a prompt, safe, and generally applicable emetic,— a statement corroborated by the experience of several practi- tioners of our city, one of whom we have been informed, seldom finds it necessary to do more than give repeated saline emetics, to control the development of Del. Tremens. We learned the value of this saline emetic during the preva- lence of-.the Cholera in 1834—when we found that, in many cases, and especially one in our own family, it allayed gastric irritability, even when existing to an excessive degree; a single glassful allaying the retching and nausea—acting as an agreeable anodyne upon the stomach, and allowing the exhausted patient intervals of relief. We have found the tepid solution of muriate of soda, particularly beneficial in the class of cases referred to by Dr. Wright, who remarks: "Our confidence in the final and permanent efficacy of emetics, is abated by the fact, that it is not uncommon to find some of the worst forms of Delirium Tremens, complicated with and aggravated under almost constant vomiting." In all instances of nausea and vomiting, not connected with evidences of decided gastric inflammation, we have found the irritability greatly alleviated, if not dissipated, by tepid saline emetics. When they proved merely palliative, we have assisted their action by the use of Rubefacients,—Tinct. opii in effervesc- ing draughts,—cupping over the epigastrium, with or without the scarificator, allowing milk and aqua calcis as diet. The saline draughts are particularly applicable in cases of "Temulentia.'1 By their use we have frequently seen the early symptoms of the forming disease at once interrupted, the gastric distress relieved, the general nervous agitation quieted, and sleep induced. We generally direct the patient to gorge his stomach, if necessary for emesis, with the tepid saline solution, following each glassful of salt and water with one of pure water, and assisting its operation by titillating the fauces with his finger. He seldom refuses to try this remedy when assured that the effect is prompt,—little or no nausea preceding or following the dose. This emetic is of course inapplicable, where the patient has lost his consciousness, and in 16 Baltimore Alms House Hospital Report. [October, the wildness of his delirium refuses to swallow any remedy unless concealed in his food or drink. If the stage of vascular excitement be subdued, the vigilance and delirium persisting, with advancing evidences of nervous prostration—or, if the attack have occurred in a constitution broken by exposure, want, and exhausting stimulations, presenting ab initio the sensorial irritability and vital depression which belong to the second type—the true Delirium Tremens of some—we are to regard opium as our "sheet anchor." But as our object is to "lull and soothe the disturbed state of the nervous system without disabling it, to calm the tumultuary movements of the irritated nervous and vascular systems without expense of power," we will guard against the too energetic use of narcotics—recollecting, that in some the vital power has sunk so low, that, like a flicker- ing taper, an incautious movement may extinguish it, and that "vigor is lost while tumult remains, if evacuants exhaust or sti- mulants excite unduly." In many cases of this form of the disease, there is much more real constitutional prostration than is apparent to the inexperienced,—the exertions of the patients to effect their purposes being vigorously continued, with well feign- ed energy, even to the hour of death—tempting us to forget that "Their hearts, though stout and brave, St.11 like muffled drums arc beating Funeral marches to.the grave." The accession of death, if not arrested, being so sudden, and in the midst of some renewed muscular effort, as to take the very attendants by surprise. It is, therefore, most important to re- member this tendency to collapse, and studying the degree of vital power in every case, guardedly avoid "extinguishing the remains of sensorial energy," in the effort to calm by opiates. Before making this effort it is important to subdue any disco- vered gastric or other local inflammation by a treatment conduct- ed upon general principles. If an acute gastritis display itself it is to be met by cupping pro re nata, assisted by blisters over the epigastrium if necessary, while ice is allowed ad libitum, and small doses of hydrocyanic acid are administered at proper inter- vals. In order to soothe general nervous irritation, and thus 1840.] By Alexander C. Robinson, M.D. \7 economize the resources of the system, we may be obliged to asso- ciate opiates with these means; if the opiates be rejected by the stomach, they may be given per enema. When we have succeeded in our aim to bring the system into a proper state for the use of opium, we should carefully deter- mine the quantity to be given at each dose. Upon this point the recorus of medical experience show us that practitioners widely differ. Some of them regarding opium as the "remedium magnum-"" in Delirium Tremens, direct it in immense doses, expecting to stimulate the nervous system, while its excitability is at first blunt- ed and then exhausted; contending that as no bad effects have been witnessed from the opiate treatment, and as sleep must be induced, "cofite qui coute," opium should be given till sleep occurs, in doses of two, four, ten, or if necessary, fifteen, and even tv/enty grains, repeated every two hours. Others fearing that the sleep thus induced might too often prove the "sleep of death," and not judging it advisable or proper thus to decide the alternative of "sleep or death," even in the most protracted instances of vigilant Delirium, guard us against thus abusing this invaluable remedy; yet admit that the quantity of opium necessary to produce a re- freshing sleep with all the assistance of the best directed adjuvant means, is sometimes enormous; thirty or eighty grains, in divided doses of two or four grains, repeated every hour or two, having been given with the best effects, in the course of a day. The importance of the cautious use of opium in the class of cases now referred to, and the value of Dr. Wright's observa- tion that "the effects of excessive doses of this drug, nearly resemble the phenomena of the last stage of the disease, particu- larly towards its fatal close," was impressed upon our mind some years ago, by witnessing the unfortunate issue in two instances of ten grains of opium, repeated in twp hours, under the direction of a young medical gentleman, who had been convinced after an at- tentive perusal, of the truth of the views of an American writer of high authority, who conceives that sleep must be procured by opium in the protracted cases of this form of Delirium Tremens. Having the recollection of the fatal coma, which soon followed the unusual doses administered in these two cases, under the firm conviction that such a course alone could prevent the fatal ex- haustion of the patients; although disappointed in the anticipated 3 18 Baltimore Alms House Hospital Report. [October, effects of the contrasted doses of twenty, ten and even five drops of the tinct. opii, to be repeated every forty or thirty minutes, as recommended by Dr. Wright, we have never thought it advisa- ble, or found it necessary to venture upon the fearless use of opium, authorized by Drs. Coates and Jackson. The result of our experience in the treatment of a number of cases in the Baltimore Alms House since May, 1839, a large pro- portion of which have presented the type usually occurring after protracted stimulation, in subjects of impaired constitutions, is in favor of a combination of laudanum with the accustomed stimu- lus, in doses of a table-spoonful every two hours, of a mixture of half an ounce of laudanum, with seven and a half ounces of whiskey or brandy toddy, giving in the intervals, other stimuli, as wine- whey, &c, if symptoms of vital prostration progressed, and doub- ling the opiate if its influence were not manifested after the lapse of a certain period; depending of course upon the stage of the attack, and the condition of the patient. The adjuvant remedies upon which we relied, with confidence in their beneficial influence, were the saline emetics; stimulating purgative enemas; cupping, with or without the scarificator, about the head, between the scapulae, or over the epigastrium, and the immersion of the patient for twenty or thirty minutes in a warm bath at ninety degrees; first suggested to the profession, at least of this country, we believe, in the treatment of Delirium Tremens, by Dr. Wright of this city. We have been taught to appreciate this suggestion by witnessing the delightful effects of the warm bath in cases when the protracted Delirium and vigilance, with progressing exhaustion, had excited our serious apprehensions. The patient is usually alarmed, violently resisting the immer- sion, and requiring several attendants to place him in the bath; but after a few minutes remaining quiet, and acknowledging it to be very comforting, in some instances dozing or even sleeping before removed; if not, as soon as placed in bed, composing him- self for the purpose, and after a short period, if allowed to be per- fectly quiet in a dark room, sinking into a refreshing sleep, the harbinger of recovery. Instead of exhausting, the warm bath has appeared to soothe and revive the flagging energies of the system. The pulse is at first increase*1 in frequency, but also indistinctness; the gradually 1840.] .% Alexander C. Robinson, M.D. 19 improved force and diminished frequency of the arterial pulsation, while the patient continues in the water, showing its good effect. The beneficial results we have derived from this remedy, when the failure of our efforts to dissipate Delirium, and induce sleep by quieting- the nervous and vascular disturbance of our fast fail- ing patient had caused us anxiety, have strongly impressed upon our mind its value as an adjuvant mean for allaying nervous irrita- tion. But a few days since one of the intelligent resident medical gentlemen of the house, assured us that he had never been more agreeably surprised than by the beneficial effects of the warm bath, in cases when disheartened by failure, he had begun to despair of his flagging patients. Instead of wasting the small remains of constitutional power, as he dreaded, the effect was reviving and soothing. Every one of his fellow students have seen and ac- knowledged similar results. If the composing influence of the bath prove transient it should be repeated at the end of three or four hours, and a table-spoonful of the mixture of spirit and laudanum be administered as soon as the sufferer is placed in bed. If much prostrated, warm wine-whey, or a draught of brandy- toddy, may also be allowed. We were led to adopt the plan of allowing frequently repeated small portions of the accustomed stimulus, combined with opiates, from havin- seen two or three instances under the charge of others, where the patients were found moribund, instead of convalescent, as their medical attendants confidently anticipated from a sleep- regarded as critical and the sure forerunner of recovery—having occurred, although late, under the use of the opiate alone;—the patients apparently sinking from the want of something to sup- port them, worn out by the protracted absence of sleep, food, and their accustomed stimulus. As patients under this disease seldom desire food, their favorite beverage is the only thing they seem to relish; and if deprived of it entirely they are apt to sink, particularly when the nervous system is no longer protected by the unnatural augmentation of its vital phenomena, resulting from the prolonged vascular erethism within the head. Early in our own experience an instance occurred, which impressed upon our mind the importance of allowing small quantities, repeated at proper intervals, of the accustomed stimu- lus, to patients habituated to its use for years, and goaded into a 20 Baltimore Alms House Hospital Report. [October, condition of excessive vascular and nervous irritation oy its recent use in large quantities, as both "food and drink." The stomach in its weakness loathes solid food, and craves the stimulus to which it has long been accustomed, while it is incapa- ble of responding with sufficient promptness to the stimulant properties of the unassisted opiate, given in such quantities as can be endured by the nearly powerless nervous system. In a moral point of view, we acknowledge the importance of im- pressing the deluded victim of drunkenness with the conviction, that no real benefit can ever be derived from his favorite drink^ but as the preservation of the patient's life, should be the first ob- ject with the practitioner, and as the exclusion of the accustomed stimulus in the treatment of cases of Delirium Tremens, has never within our knowledge, had any agency in producing a reformation in the habits of the patient, we perceive no sufficient objection to its introduction. We at first excluded it, but experience has taught us its necessity in a large proportion of such cases as are presented for treatment in infirmaries designed for the subjects of public charity. Its use may be dispensed with in many more instances during some seasons than others—arising from the modifying influence of a certain atmospheric constitution, fre- quently acknowledged in other forms of disease subjected to its impression. As we learned from Dr. Wright's statement, that he had not found it necessary to use ardent spirits in the treatment of Delirium Tremens, and that he had yet been singularly successful, we ex- cluded them in the earliest cases under our direction, but were soon taught to acknowledge their necessity in the great majority of cases occurring in the Alms House Infirmary. We may have used the accustomed stimulus in some instances in which success would have crowned our efforts had it been dispensed with but seeing the instinctive greediness with which the poor patient would take it, and convinced of its safety, we have, of late, seldom treated a case without administering ardent spirits at some stao-e of it. If they are to be proscribed on the ground of morality we must also banish opium, the habitual use of which, in extraordinary quantities, is every day becoming more and more common in this country, particularly amongst females who lead irregular lives There are many other stimulants that may be used, as camphor 1840.] ity Alexander C. Robinson, M.D. 21 ammonia, capsicum, tinct. foetid, &c. Yet no one acts like that to which the patient has been accustomed, and in his delirium he will sometimes refuse to take any other. But, as his taste is blunted, he may now and then be deceived. In addition, we need not urge the evident advantages, if not posi- tive necessity of darkness and quietude, together with a pure atmos- phere, a comfortable bed, and sufficient covering when it is damp and cold. These, together with an experienced, capable nurse, are as important as any mere medicinal means to induce tran- quillity. This is particularly impressed upon all who have con- ducted the treatment amidst the inconveniences inseparable from a public institution—in a community where no distinct provision is made for that peculiarly unfortunate class of paupers, the insane.* The patient disposed to tranquillity, is, perhaps, ever and anon aroused by the noise and tumult of a maniac within hearing. It is no less important that he should be restrained from that ceaseless, unremitted, but exhausting muscular effort to which he is impelled by mental delusions, connected with a state of brain, rendering both mind and body "the sport of its power, seeming to impart superhuman ability to endure the unnatural privation of rest or relaxation." (Wright. Amer. Jour, of Med. Sciences, 1830.) To economize the resources of our patient's system, by quelling such unnatural muscular action is most desirable, but this seldom can be accomplished by the use of the "leg chain," the "leather muf- flers," the "strait waistcoat," or the "bed straps." By such personal hindrances we may prevent the patient from injuring himself, but we can scarcely gain any other advantage, for the mental condition which impels the poor patient to unintermitted muscular effort, continues, and banishes composure. The indignity of the restraint presents a new motive of action, while its discomfort never per- mits his attention to be distracted from it, and for hours he will work to free himself from his chain, or writhe in enforced recum- bency under the bed straps, until stimulated by fright or fired by indignation, he collects all the energies of his sinking frame, and breaks the strong fastenings of his chain, or bursts his leather bands, springing to obey the dictates of his frenzy—more discom- posed than ever. We have frequently found it soothing to remove all personal incumbrances; by doing so, in some instances, the * See Appendix. 22 Baltimore Alms House Hospital Report. [October, patient has been induced to compose himself in bed with a satisfied manner, indicative of gratified feelings, gradually sinking into a refreshing sleep. But in the great majority of instances, some decided personal control cannot be dispensed with, in order to prevent the patient while fleeing in his alarm from some imaginary danger, from leaping out of a window, or otherwise injuring himself. The only mode of personal restraint at all calculated to promote the great object of the medical treatment and induce the patient to cease exertion, is such as can be exercised by a firm, judicious, kind, but watchful attendant, who is regarded by the invalid as a pro- tector and friend, and under whose persuasion he may often be induced to lie quiet, and disregard the ever recurring and ever varying phantoms of imagination, until at last the full effects of the anodynes become developed, and the excited mind, sinks into repose. We recollect one case in which the phantomic delirium had persisted, in spite of the bold use of anodynes, and every remedial means suggested by the condition of the patient, until the vital powers seemed fast ebbing, and we almost despaired of success, when the resident medical gentleman, having immediate charge of the patient seated himself, in the stillness of the closing evening, at the bed side, and without uttering a word, gently pressed his exhausted patient back upon the pillow, as often as he started up, under the influence of his morbidly active imagination. This in- terruption to his movements not being recognized by the sinkino- patient, did not irritate him, but gradually ceasing the fruitless effort to rise, he soon fell into a profound sleep of several hours, from which he awoke, refreshed and composed. Another instance presented in a vigorous, athletic man of thirty- eight years of age, whose condition gave strong evidences of increased vascular activity in the brain. He successfully op- posed all efforts to cup him, and became more and more violent under the bold opiates administered. Finally, refusing to swallow any medicine, and appearing provoked by the leg chain it had been necessary to use,—several times tearing its staple from the floor,—while his delirium increased in violence, he was persuaded by the entreaties of the same gentleman, who being wrapped in his long morning gown was mistaken by the delirious man for his wife, to rest his head upon his bosom and compose himself. He 1840.] By Alexander C. Robinson, M.D. 23 soon grew tranquil, and continued in this position for three hours, ever and anon muttering his surprise at such "unwonted kindness," and wondering "what could have wrought so sudden and so great a change in his wife's deportment towards him." Under the agreeable influence of this kindness the patient was gradually losing his consciousness in sleep, when a noisy lunatic in the next cell startled him, and the doctor found it impractica- ble to persuade him again to resume his position.* His vigilance and delirium continuing the next day, he was directed to have— R Pulv. Opii, grs. iv. Tart. Antim. i gr. repeated every two hours; and slept composedly after the third dose. As so much depends upon the comfort and personal manage- ment of a patient, an attentive experienced nurse is an invalu- able acquisition in conducting severe cases of Delirium Tre- mens. A case at first mild may unexpectedly become of the gravest form; a change which it is necessary should be at once re- cognized and mentioned by the nurse, or at the next regular visit the physician may find his patient beyond recovery. During covalescence the diet should be light and nourishing, and the opiates continued in diminishing doses, until the integrity of the nervous system be re-established. TABLE I. Slwwing the number of cases of Delirium Tremens and Temulentia, with the number of Medical and Surgical cases, admitted in the Baltimore Alms House Hospital from May 1st, 1832, to April 30th, 1839, inclusive. Date. S f o a = ° * o-0 p oa-i a.= v §&? ^ o a. ra " o' P*- EL So-CD **> 3 a 3 tr 3 3. w 3 2. 5' IS 0 a O 3 £ £ re 3 -5 ? — c a. pi a 3 S. 5' oq Do. do. 1834,...... Do. do. 1835,...... Do. do. 1836,...... Do. do. 1837,...... Do. do. 1838,...... Do. do. 1839,...... 1810 1960 2571 1968 1491 1223 1545 29 57 67 30 22 28 27 26 51 55 23 13 24 25 2 6 12 7 9 4 1 1 1 65 109 120 68 60 128 65 109 115 68 60 128 4 1 Total,..| 12568j 260 217 41 2| 550 545 4 1 * See Appendix. 24 Baltimore Alms House Hospital Report. [October, From the preceding Table it appears that the proportion of those suffering from the immediate effects of the abuse of ardent spirits is about one fifteenth of the number (12,568) admitted, in the period of seven years from 1st May, 1832, to 30th April, 1839, inclusive. TABLE II. Showing'the number of cases of Delirium Tremens and Temulentia, with the number of Medical and Surgical cases admitted in the Baltimore Alms House Hospital from May 1st, 1839, to December 31st, inclusive. o 2 8? P o re = ■ w p.- If "3 re 3 o c re g p. SI K > re 2 O > B o S S3 *3 1 p c a. i ptt" Ho 2 2,2 CD 3 2 O 2'« T* re £ 3 = a on; a- re as 3 OK) Date. re EL re S T re 8 1 j p' « May,............. 5 9 5 4 3 6 4 4 2 3 1 5 9 4 4 1 40 34 30 36 32 28 25; 20 19 18 14 9 15 10 q 11 4 8 5 20 19 IS 14 July,.............. 7 5 2 7 36 31; 17 8 9 17 4 6 4 3 5 2 1 1 2 4 6 1 1 37 32 63 27j 35 43 2 15 10 14 13 3 10 2 7 4 15 10 14 127 — Total,.. 1264 44 32 12 40 2 38 3l| 2 127 77 50 N.B. The oldest male referred to in the ahove table was J. M*****, ffit. 86. The youngest do. do. Aaron Simms, a negro, 19. --------------, aet. 46. The oldest female do. The youngest do. do. aet. 23. The above table shows the proportion of those sufferino- from the immediate effects of the abuse of ardent spirits to be about one seventh of the whole number admitted during eight months of the year 1839. The occupations of the males were as follows: 24 common laborers; 1 seaman; 1 bricklayer; J stonemason; 1 butcher; 1 printer- 1 merchant; 1 painter; 1 shoemaker. Among them were 15 Ameri- cans; 8 Irishmen; 2 Germans; 1 Englishman; 1 Frenchman, and 4 colored men. The females were generally women of ill fame; 5 of them were Americans; 4 Irishwomen; 1 Englishwoman; 2 colored women. 1840.] By Alexander C. Robinson, M.D. 25 TABLE III. Showing the number of cases of Delirium Tremens and Temulentia, with the number of Medical and Surgical cases admitted in the Baltimore Alms House Hospital from January 1st, to November 1st, 1840. January,... February,.. March,..... April,....., May,....... June,....., July,....... August, September,, October,... Total,. I/S.re 118 69 87 82 110 89 96 128 114 119 1012 ol g 3° 2 a 6 6 50 31 19 46 a era 40 33 101 51 50| 101 N.B. The oldest male referred to in the above Table was 68 years of age. The youngest do. do. do. 19 do. The oldest female do. do. 45 do. The youngest do. do. do. 18 do. The above Table shows the proportion of those suffering under the immediate effects of the abuse of ardent spirits to be less than one seventh of the whole number admitted into the wards during the first ten months of the year 1840. Among the males were 18 common laborers; 2 blacksmiths; 4 shoemakers; 2 seamen; 1 painter; 1 brewer; 1 farmer; 1 carpenter; 1 stonemason; 1 combmaker. 17 of them were Americans; 4 Germans; 8 Irishmen; 1 Scotchman; 1 negro. Of the females, (almost uniformly women of ill fame,) 13 were Americans; 2 Irish; 2 English; 1 Scotch; 1 negro. It may be proper to state that two of the four instances re- ported above as fatal, were in the last stages of the disease when received into the Hospital; their exhausted condition affording us little hope of success. They died in about thirty-six hours sub- sequent to their admission. The two remaining cases occurred in men of twenty-five and twenty-six years of age, respectively; their frames bloated, and their constitutions exhausted by protracted habits of excessive stimulation. One of them, E. T****, 26 years of age, a coach painter, entered 4 26 Baltimore Alms House Hospital Report. [October, on the 16th June, laboring under the highest grade of temulent agitation, complicated with epileptic convulsions, and an acute gastritis. Although the latter was alleviated by the treatment adopted, it continued unsubdued, until the afternoon of the 18th, when a violent convulsion was succeeded by a fatal stupefaction, soon terminating in death. The closing scene of this young man's life was a distressing comment upon his previous career. After his state of mental and physical suffering had yielded to the succeeding torpor, and a low, muttering delirium, his frequent allusions to persons and places, showed that he imagined himself to be still moving in his usual haunts of vice and sensuality. While the coarse jests, hoarse laughs and startling imprecations indulged, in deliriously address- ing his boon companions by name,—the cold sweat of death then upon him,—sadly told how ill calculated his recent life had been to prepare him for its end. The uneffaced melancholy impressions of that scene, need not be denied by one who fruitlessly watched in the silent darkened chamber, for some evidence of the sinking patient's earnestly desired improvement. Autopsy twelve hours after death.—The atmosphere cooled by a rain during the previous night. The superficial vessels of the brain were much engorged; the arachnoid thickened; two ounces of blood effused about the base. The cut surfaces of both cerebral hemispheres appearing somewhat softened, and presenting numerous red points of vascular injection. The thickened, mammillated, and in some parts, softened mucous membrane of the stomach and duodenum, presented evi- dences of recent high inflammation, while numerous patches of extravasated blood, mingled with tough mucus stained its surface. Some portion of the lining membrane was much injected, the dendritic appearance of the anastomosing vessels being increased by having their minute extremities fringed by small points of effused blood around their extremities. A chronic ulcer eight lines in diameter presented at the caput coli. The other fatal case, Vincent Mullikin's, was complicated with inflammation of the brain, as displayed by the marked injection of its membranes and substance, as well as by the effusion beneatl the arachnoid, at the base of the brain, and in the lateral ventricles Being unable to find our notes of the autopsy, we cannot g;iv * the appearances more in detail. 1840.] By Alexander C. Robinson, M.D. 27 The limited data supplied by the preceding tables, may assist us in deciding upon the relative influence of age, sex, and season. Some have decided, that Delirium Tremens occurs most fre- quently between the ages of thirty and fifty, while others limit the period of its greatest frequency between the ages of forty and fifty; but within our observation a large proportion of cases in both sexes have occurred, between the ages of thirty and forty. The average age of the males being thirty-eight, and of the females thirty-one, for 1839, and forty for the males, and thirty- three for the females in 1840. The oldest male being eighty-six, the youngest nineteen; the oldest female forty-six, the youngest eighteen. Are the sexes equally liable to attacks of Delirium Tremens? In one hundred and twenty-seven cases of Temu- lentia in 1839, fifty occurred in males, while only twelve out of forty cases of Delirium Tremens occurred in females. In fifty cases of Delirium Tremens reported for 1840, there were nineteen females, and thirty-one males, while in one hundred and one cases of Temulentia fifty occurred in females. In drawing any con- clusions from these statements, it must be recollected, that the average proportion of women in the house from year to year is much larger than of men, as will be seen by Table IV. Medical statistics arranged by physicians in the north of Europe show, that cases of Delirium Tremens in women are very rare in that part of the continent, but in England the sexes are pronounced to be equally liable to attacks of the disease.* With regard to atmospheric influences, it appears that in 1836-7, in 1492 patients received, 22 were cases of Del. Tremens. 1837-8, " 1223 do. 28 do. do. 1839, " 1264 do. 44 do. do. 1840, " 1012 do. 50 do. do. \ *"Dr. Rayer observed it in seven women out of one hundred and seventy-six cases. Bang states, that in four hundred and fifty-six cases which he treated, only ten were females. Dr. Hoeg-Guldberg found but one case out of one hundred and seventy- three occurring in a female. Kruger-Hanson in sixteen cases, and the chief physi- cian of the hospital Christiana in eleven cases, met with no instance in a female. These statements differ very much from the accounts given in England, for we find both Dr. Ryan and Dr. Roots state, that the sexes are equally obnoxious to its influ- ence. This discrepancy can only be explained, by supposing that the indulging in intoxicating drinks amongst females, is carried to a greater extent in England, than in the north of Europe." 28 Baltimore Alms House Hospital Report. [October, The month of May is generally stated to be the time when attacks are most frequent. By the foregoing tables, July 1840, afforded the largest number of cases, half as many being reported for the same month in 1839; and for June of the same year, nearly double as many are given, as for that month in 1840; while eight are stated to have occurred in May of the current year, and only five in May, 1839. In connection with this point, we may remark, in conclusion, that it is the habit of many of our male paupers to resort, at the allotted period to the neighbouring fish- eries, where they are allowed to indulge in intoxicating drinks to great excess; at the conclusion of the season, in May or June, usually returning to the alms-house in the initiatory stage of an attack of Delirium Tremens. This circumstance should be considered in judging of the influence of season from the preceding tables. TABLE IV. Showing the average of Men and Women in the Alms House, from May, 1836. WHITE. COLORED. Date. 2 S 3 o 3 n 3 3 o S a a 1714 1596 1621 1159 2144 2194 2072 1331 412 411 412 221 738 764 785 Do. do. 1838,............. Do. do. 1839,............ For eight months, from May 1st, 1839, to Decem- 548 Total,.. 6090 7741 1456 2835 No report has yet been prepared for 1840. From this statement it appears that the average number of women in the house from year to year is much larger than of men* yet the number of cases of Delirium Tremens occurring in females in 1839, scarcely exceeds one-third of the number in men, while something more than one-half of the cases presented during the first ten months of the year 1840, occurred in females. The Temulentia cases occurring within the same periods are equally divided between the males and females. 1840.] By Alexander C. Robinson, M.D. 29 APPENDIX. The gentlemen of the Board of Trustees of the Baltimore Alms House, anxious to ameliorate the condition of the lunatic inmates and convinced of the impracticability of instituting such a moral and physical treatment as is best calculated to restore them to health, unless in an asylum exclusively devoted to the Insane, have already called the attention of the city and county authorities to the necessity of some more appropriate disposition of them, and have directed a few additional apartments to be prepared for their present accommodation. We are pained to acknowledge the inevi- table necessity we have sometimes experienced from the crowded condition of the cells and the large number of lunatics, of treating our Delirium Tremens patients in the immediate vicinity of, if not in the same apartment with, insane patients. Seventy lunatics are now confined in this Alms House alone. Twenty white males; thirty white females; seven black males; thirteen black females, besides twelve idiots. A portion of these are foreigners; some are individuals from other states, and some from other counties of this state, who find their way, or are sent to Baltimore totally unprovided for, and consequently have no other asylum but the Alms House. The whole number in the state of Maryland, including those confined at private houses, and such as continue immured in the county poor houses and jails, will soon be reported by the mar- shal. If the proportion to the entire population approximate that in other states, the new census will show a large class of in- digent beings, afflicted with a malady now known to be curable in the proportion of ninety per cent, of recent cases, under an early and judiciously directed physical and moral treatment. Yet the sufferers, whose only crime is their poverty and disease, are treated as if unworthy of sympathy; forgotten in their prison houses, where they are allowed little beside "the poor privilege to breathe," chained like convicts or associated with vagrants, as was formerly the case in all parts of Europe, as well as in every portion of the United States, when under the errors of a false phi- losophy and the force of prejudice, insanity was viewed as an 30 Baltimore Alms House Hospital Report. [October, infliction, the attempted removal of which was deemed idle if not presumptuous. When will Maryland arouse to the necessity of following the benevolent example of most of her sister states, in providing some suitable asylum for her Insane Poor,—where they may enjoy those comforts and conveniences, those occupations and amuse- ments, which are acknowledged to be indispensable to alleviate, if not to cure? In such an asylum how many would be restored to "mental existence" and usefulness, whose hallucinations are now aggravated,—the disordered functions of their brains goaded to excess, resulting in organic change and permanent fatuity, by being uncomfortably kept in crowded apartments, subjected, per- haps to some form of personal restraint to protect them from each other; deprived of the benefits of exercise, amusement and occupa- tion; a condition as well calculated to induce insanity in a healthy individual, as to render it perpetual when once manifested. Science and philosophy have triumphantly proved the curability of insanity if attended to early; and the people of Maryland can- not continue deaf to the claims of this most unfortunate class of her citizens, and refuse to aid their escape from the justly dreaded deprivations of permanent insanity, and consequent confinement in the comparatively comfortless apartments of Poor Houses, and the ill-ventilated, grated and cheerless cells of county jails, identified with felons and vagrants. Will Maryland allow herself to be longer,—now almost half a century,—behind France, Italy and England; indeed nearly all Europe, and many years behind Maine, Massachusetts, N. Hamp- shire, Vermont, Connecticut, New York, Virginia, South Carolina, Tennessee, Kentucky and Ohio, in the good work of providing for her pauper lunatics? Will she still allow them to remain shut up, two, three, four or more together, without even the poor con- solation of being alone in their misery? The destitute condition of the insane poor of our state is in truth, a dark blot upon her otherwise fair escutcheon, which we trust, will soon be removed. Instructed by the experience of her sister states, that on the score of economy it is her interest we hope she will follow the clear dictates of policy, if not of pity, and no longer refuse to make proper provision for this class of her citizens. 1840.] By Alexander C. Robinson, M.D. 31 Bountifully providing for the destitute widow, orphan and in- valid, for the mute and the blind, can she permit her soil to con- tinue one of the few spots where the poor lunatic is forgotten amidst her public charities, and left destitute of the comforts of existence, and every means of mental tranquillity! We hope not. But regarding the very partial provision made two years since in 1837-8, by the appropriation of $30,000 to the Maryland Hospital* as an earnest of her future disposition and efficient action, we fer- vently pray that at an early day an asylum and a home may be given by the state to every destitute subject of mental disease within her limits. An eloquent appeal has again been made in behalf of the insane poor of our sister state, Pennsylvania, which we doubt not will prove effective, so well is it calculated to re-enlist the active sympathies of her enlightened philanthropists in behalf of those * On the 3d of April, 1838, a resolution, offered by Dr. Stephen Collins, a Dele- gate from Baltimore city, passed the Legislature of Maryland, in favor of the Maryland Hospital, by which $30,000 were appropriated for its completion,—distinct reference being had in making the improvements, to its exclusive use as a Lunatic Asylum. This resolution contains the following clauses: "Provided, that one half of said institu- tion shall hereafter be appropriated to the accommodation of pauper lunatics of this state, who shall there be accommodated and treated at the expense of the county so sending such lunatic paupers; provided the same shall not exceed one hundred dollars for each pauper lunatic so sent." This appropriation has proved totally insufficient to supply the necessities of the pauper lunatics of the state. Their number is estimated at not less than two hundred and fifty. The sum of one hundred dollars, to be paid by the counties to the Hospital, is too small to bear expenses. It has been stated by Dr. Steuart, President of the Maryland Hospital Board,—a statement corroborated by the reports of the most econom- ically conducted institutions at the north,—that the food, nurse-hire, medical attendance and medicines of each patient costs one hundred dollars; and that clothing and fuel would cost twenty-five dollars additional. This loss the institution bears out of the small profits derived from the private patients. It seems, however, that the counties very seldom avail themselves of this provision, preferring to continue their unfortunate lunatics in their poor houses or jails, at an expense calculated not to exceed fifty dollars, with scarcely a chance afforded of recovery,—rather than incur the additional expense imposed by placing them at a hos- pital appropriated to the Insane; where alone, if not restored to health, their condition may be so improved by a judicious course of moral government, seconded .by cheerful exercise and healthful occupation, as to render them once more comparatively contented and useful. By this ill-judged economy, insanity is aggravated, and the sufferers con- tinue during life, totally helpless and dependent. Whilst had their home been at a lunatic asylum, their moral, mental and physical capacities would be so directed as to be conducive to their individual support, simultaneously with the improvement of their health and condition. 32 Baltimore Alms House Hospital Report. [October. who are no longer regarded, and should be no longer treated as outcasts. Her chief magistrate, as her organ, in withholding his sanction, (the necessity of which he deplored, but thought impe- rious, from the exhausted condition of the treasury) from a bill making provision for the numerous Insane Poor of that extensive commonwealth, which was passed by the Legislature two years ago, has avowed it to be her religious duty to provide, at her earliest ability, for the removal of so manifest an evil from amidst her people. And it being now shown to be her interest on the score of economy* alone, Pennsylvania, we are sure, will not neglect this "Second Appeal." And for the sake of the character of our native state we hope that Maryland will not be behind her in the benevolent undertaking and christian duty. To induce union and efficient action in order to effect so necessary and de- sirable an object, we earnestly appeal to the state and city authori- ties, as well as to every philanthropist, and every Marylander. For who, in this enlightened period, so characterized by wisely bestowed and extended charities, will acknowledge himself with- out sympathy for, and consent longer to forget the Insane Poor. "Who that bears A human bosom hath not often felt How dear are all those ties which bind our race In gentleness together, and how sweet Their force, let Fortune's wayward hand the while, Be kind or cruel." * See a second appeal to the people of Pennsylvania, on the subject of an asylum for the Insane Poor of the commonwealth. Philadelphia, 1840. [Reported by a sub-com- mittee, through their chairman, Dr. Dunglison.] REPORT OF THE LUNATIC DEPARTMENT OF THE BALTIMORE ALMS-HOUSE: Presented to the Board of Trustees, December 1840, by A. C. Robinson, M.D. one of the attending physicians. Gentlemen: The arrival of the period appointed for your annual Report of the Condition and Conduct of this Institution—benevolently designed for the accom- modation of the poor of our city and county—has suggested the propriety of presenting the accompanying statement relating to the insane inmates. To its various particulars your attention is solicited. This communication is laid before you, in full confidence that you will regard it as entirely consistent with our relations to you in your official capacity, and as alone dictated by a sense of duty to that unfortunate class of our fellow beings whose mental wants should command public sympathy and care, at the same time, that their bodily necessities are supplied at the public expense. You will all probably coincide in the opinion, that the insane department is the only portion of this institution calculated to produce other than grateful impres- sions upon benevolent minds. From the want of a more suitable place for the accommodation of pauper lunatics, they are necessarily transferred into the alms house—consequently, we have here presented to us the melancholy specta- cle of cases of nearly all the varied forms of mental disease crowded in unclassified confusion. Yet most of the sufferers give some evidence, that high mental and moral attributes still linger about them, penetrating the gloom—"beams of original light, of which the mind amidst its thickest darkness is never shorn," which seem to dwell even in "the dark grandeur of the soul" of the raving maniac. It is a well known fact, that the insane are often possessed of astonishing strength. This they are neither able properly to direct or control. It therefore becomes necessary that they should be deprived of facilities for escape, or oppor- tunities of injuring themselves or others. Moreover, although medical skill is very important in the management of the peculiar disorder of their nervous sys- tems, it is no less necessary that, when confined, their apartments should be well warmed, lighted and ventilated;—their persoaal comforts studiously regarded, and their morbidly sensitive minds gently checked and soothed by experienced, intelli- gent attendants, whose "considerations of convenience" should always be subserv- ient to the probabilities of cure. The architectural unfitness of this building for the accommodation of lunatics need not be argued. It was not originally designed for their habitation, and does not now afford the means of either secluding or classifying them, according to the intensity or peculiar features assumed by their This Report is made with the hope, that you will agree as to the necessity and propriety of again urging upon the city and county the cruelty of that false economy, which still refuses to take measures to place our insane poor where the architectural arrangements are so suited to the accommodation of lunatics, as to permit any advisable classification of the patients—while its internal arrangements afford humane, watchful, and capable nurses, with such appropriate amusements and occupations for the insane, as when aided by medical skill may prove pro- motive of their comfort and cure. 5 TABLE I SHOWING THE NUMBER, WITH THE AGES, PERIOD OF ADMISSION AND CONFINEMENT, PRESENT CONDITION, &c. INSANE WOMEN. ADMISSION. 1 Aug. 2 Sept. S.Aug. 4|May 5 Dec. 6l " t7|May 8'Oct. »i.J;in. 1 O.Dec. lliNov. i2;oci. I3]Aug. 14 Jaii. 1.) June lo'Jan. 17 Aug. !IS May 1839 1840 a 1326 1836 1831 183JI 1837 1838 39 26 47 25 28 39 50 44 77 34 1840|63 SO 47, 39j 1S38|32| 46 36 Widow Single Single Married Single SUPPOSED CAUSES. Single Disappointed affection Married Loss of property Single Intemperance... Masturbation.................. do and domestic unhappiness Indulgence of passion and pride. Epilepsy and do do Intemperance and opium....... Marriedl Domestic unhappiness......... Poverty and grief............. Indulgence of passion.......... Religious perplexity........... do do ........... Domestic trouble.............. Religious perplexity........... Domestic unhappiness......... do do Puerperal Disappointed affection......... recent or chronic; when rec'd Recent Chronic Recent Chronic Recent Dev. sub't Chronic Recent Chronic Recent Chronic PERIOD Of CONFINE MENT. 1 2 4 6 11 4 7 CONDITION 4.T PRESENT. Increased.... Not improved. HEREDITARY, PERIODICAL, PAROXYSMAL; WITH REHIRE! Not improved Paroxysms of excitement; suspicious; harmless; allowed to exercise Do noisy; inoffensive; confined to cell.* [in the yard.* Incessant raving; destructive; abusive; defying coercion; chained.* Periodical; harmless; escaping, if permitted; confined to cell.* Do do do do do cheerful.* Hereditary; chained in cell; paroxysms of ungovernable violence.* Do periodical; inoffensive; confined.* Increased..... Incessant raving; abusive; defying coercion; chained in cell.* Not improved. Inoffensive; silent; quiet; confined.* Violent only during her paroxysms of excitement; confined.* Do do do do do cheerful; confined to cells. Do do do do do dissatisfied; confined.* Inoffensive; quiet; escaping, if allowed; confined.* * Parox's of excitement; generally quiet; inoffensive; melancholy; in- Do of ungovernable passion; chained in her cell.* [firm. Do of violence; usually harmless; noisy.* Period.; mother 5 children; in parox's noisy, ungovernable; chained I Inoffensive; quiet; confined to her cell.* [in cell.* May 1835 57 J 1 } :S 7 '3 9 0 1 2 [33 |34 J35 |3ti 37 38 39 4^ exertion. We have done th- witfi fte viewof ^^S^J™* tl^uZZuli have been so far cured or ameliorated, that a large proportion of them mSM^eVg^^^^ S We also estelm it proper to remark, in ex Potion of ^e ^«9 °* P^£.™J^^ the temporary inmates of the house-few of whom can be expected building present few barriers to the escape of Pa^?^J " ^J^J ^Sation of their arduous ana peculiar duties, which combine to form an accomplished to nosslss those qualities of mind and manner, with that e*Pe"e™e a™ ^ of treatment can be pursued, except in an Institution exclusively 38 report—continued. SUMMARY NUMBER OF PATIENTS. Males......................36 Recent when admitted..........38 Females....................40 Chronic when admitted.......• -33 — Developed subsequent to admission I Total...........76 Unknown................. 3—76 DURATION OF THEIR CONFINEMENT IN THE ALMS HOUSE .31 Less than one year................................................. From one to five years............................................. g From five to ten years..............................................„___„ From ten to twenty years............................................ OCCUPATIONS OF THE MEN. Tanner.................... 1 Sailor......................1 Brushmaker................ 1 Tinner..................... 1 Stage actor................. 1 Shoemaker................. 1 Plasterer................... 1 Farmers................... 2 Artists..................... 2 Merchants................. 4 Carpenters.................5 Laborers...................16—36 FOREIGNERS. Irish.......................10 Germans...................6 Italians.................... 2 Swiss....................... 1 English.................... 1—20 Citizens of other States......11 " of Baltimore county ..13 " of Baltimore city.... 9 Other parts of Maryland......21 Unknown.................. 2—56 Total. .76 AGES OF LUNATICS, DEC. 1840. Under 20 years.............. 1 From 20 to 30 years........17 " 30 to 40 « ........27 " 40 to 50 " ........16 « 50 to 60 " ........7 » 60 to 70 " ........ 5 " 70 to 80 " ........3—76 The youngest male is 19; oldest male 70. The youngest female is 22; the oldest female 80. Single, forty-seven; married, twen- ty-six; widows, three; widowers, — SUPPOSED CAUSES. Intemperance...............23 Domestic afflictions.......... 4 Epilepsy and ill health....... 6 Religious fanaticism, perplex- ity, &,c___(all females)___6 Disappointment, or loss of pro- perty.................... 3 Disappointed affection........5 Indulgence of temper and pride 3 Puerperal.................. 3 Produced or perpetuated by masturbation.............. 4 Absence from home........2 Imprisonment............... 2 Unknown..................11—76 REPORT. 39 We have thus displayed the present actual condition of the insane department of the alms house. We believe the preceding tables to be accurate. They have been hastily prepared, and with considerable labor; no distinct or similar record of the in- sane paupers having heretofore existed, it was necessary to collect the materiel from various sources. They have been added with the hope of lending interest to the subject, and affording tangible and legitimate data for prompt action. Heretofore, every practicable scheme to promote the comfort of these unfortunates—consistent with the purposes and arrange- ments of the house, as a general asylum for the poor, in which point of view it will bear comparison with any other in the country, has been cheerfully adopted. Some of the insane are employed on the farm; such as are inoffensive and manifest no dis- position to escape, are allowed in good weather, to exercise during the day in a small yard, designed for their exclusive use, under the late arrangement of the grounds, suggested by Mr. Maguire, the overseer. Another class, the furious, violent and ungovern- able, or such as take advantage of every chance to escape, are kept constantly in their small apartments, under the charge of temporary nurses, selected from among the inmates of the house. There are two sets of cells—those most recently erected being eight feet by ten; those first constructed, ten by twelve. From their limited number, (fourteen cells being appropriated to the female lunatics, and twelve to the male,) and from the circumstance, that persons committed as vagrants are sent from the city and county to the alms house, as a work house, it is impossible to afford each lunatic a separate room; two, three or more are con- fined together. The cells in the basement of the building now being erected as an hospital for the colored women, will some- what enlarge their accommodations; still they cannot be appro- priately lodged;—and their number is added to by frequent admissions. Among them almost "every form of insanity has a representative of its terrors;" yet how much less enviable must be the situation of the lunatics shut up in the alms houses and jails of the several counties of the state, or of such as remain chained in the hovels of poor relatives, who cannot be persuaded to entrust them to the charge of strangers! 40 REPORT. If a history of the mental sufferings, the medical treatment, and the present condition of the latter could be obtained, and tables similar to the preceding, of the insane in this institution had been annually prepared, what a melancholy record would be pre- sented of cases "not improved,"—most unpleasantly contrasted with the statistical reports of the lunatic asylums of this country, as well as of Europe! These incontestibly prove, that, if insanity do not yield with more promptness than ordinary diseases, at least as large a proportion of recoveries will occur in recent cases, under an appropriate medical, moral and intellectual treatment, as from any other acute diseases of equal severity;—something more than ninety per cent, of recent cases, and from fourteen to twenty-five per cent, of old cases having been cured. This en- couraging truth, together with the fact, that the chances of relief diminish nearly in a geometrical ratio with the period of duration of the attack, shows the importance of an early application for medical aid, and cannot be too generally known.* However, although time so rapidly diminishes the chances of recovery, and the difficulties of restoring reason, when once dethroned are very great, requiring all the curative means sugges- ted by science to benevolence—yet the recorded instances of res- toration in cases long pronounced incurable are sufficient to prevent us from despairing in any instance, unless organic change of the brain have occurred. "A case is stated by Pinel, of a lady who had been maniacal for twenty five years, suddenly recovering her reason." Satisfied of the easy curability of insanity if attended to early, of the important aid to be derived from medicinal means, assisted by a moral treatment, and an intellectual discipline judiciously directed by capable and devoted attendants—it becomes a point *"The ratio of curability of cases, which have existed less than three months, is nine in ten; and eight and a half in ten when it has existed under twelve months; on the other hand of three hundred and eighteen cases, which had fallen under the care of Sir William Ellis, at the York West Riding Asylum, and which had existed from one to thirty years, only twenty six were cured. M. Esquirol, one of the greatest living authorities on the subject of insanity, has asserted, that after the disease has passed the third year of duration, the probability of cure is scarcely more than one in thirty. Such, too, have been the general influences deduced from the results in several of the admirable insane establishments of our own country."—See second Appeal to the people of Pennsylvania, page 21. REPORT. 41 of anxious enquiry in every public receptacle of the insane— "what proportion of insane patients are restored to the full posses- sion of their reason?" and "what proportion are amended or re- lieved in cases where an entire restoration to reason has not been accomplished?" If the results of experience in the treatment of insanity during past years in this institution had been distinctly reported, we are sure, that the data supplied would only corrobo- rate the statements in other sections of our country, where it has been proved, that few or no instances of recovery occur to cheer us among the many subjected to confinement and idleness, and to all the unfavorable, irritating and provoking influences of the "coercive system"—which is so happily calculated to devel- ope "the mind's various and extensive capabilities of pain." The insane mind not recognising the justice or necessity of it, feels with morbid distinctness any form of personal restraint, and in the absence of occupation or amusement to relieve the irksome- ness of confinement, it grows unhappy, discontented and restless; unless soothed, its unfavorable influence is manifested by func- tional disorder; sleep and appetite are banished, the illusions are aggravated, the idea of outrage, indignity and privation engrosses the mind, till lashed into fury, its ravings only cease with physi- cal exhaustion. "To him whose mind is alienated, a prison is a tomb, and within its walls he must suffer as one who awakes to life in the solitude of the grave. Existence and the capacity of pain are alone left him. From every source of pleasure and contentment he is violently sequestered. Every former habit is abruptly broken off. He is alike removed from all the occupations of health, and from those delicate acceptable attentions so soothing in sickness. The monotony of his confined apartment, the uninvited compan- ionship of those who neither pity nor soothe him, the unavoidable recurrence of causes of annoyance and provocation, are but too well calculated to derange the vital functions of the body, and thus a"-s:ravate the derangement of his mind. On every side is raised up an insurmountable barrier against his recovery. Cut off from the charities of life, endued with quick sensibilities to pain, and perpetually stung by annoyances, which, though individ- ually small, rise by constant accumulation to agonies almost beyond the power of mortal sufferance; if his exiled mind in its 6 42 REPORT. devious wanderings ever approach the light by which it was once cheered and directed, it sees every thing unwelcoming, every thing repulsive and hostile, and is driven away into returnless banishment. From the absence of suitable institutions among us, the insane have been visited with a heavier doom than that inflicted upon the voluntary contemners of the law. They have been condemned as no criminal ever was condemned, and have suffered as no crim- inal ever has suffered. The code by which they have been judged, denounces against them the penalties due only to crime, while it is unmitigated by any of those merciful provisions, which, in our penal code attemper justice with humanity. Even when a criminal stands convicted of perpetrating the most atrocious crime, the benignity of the law accompanies him to the solitude . where he is to expiate his offence. He is not only comfortably clad and warmed, and fed at the expense of the state which in- flicts his punishment, but he is supplied with the means of moral renovation, and when those proofs of penitence and reformation are given, which it is in his own power to furnish, the laws relent and authorize the remission of his sentence. But though the in- sane have been made fellow prisoners with the criminal, they have suffered, if not from the privation of every comfort for the body, at least from the absence of every solace for the mind. Vet why should a man be treated even as a criminal, who, by univer- sal consent is incapable of crime? We understand what is sig- nified by retributions for guilt, but to speak of retributions for insanity, does violence to every feeling of humanity and dictate of conscience. Yet this wretched class of. our fellow beings whose only offence is what others justly regard as amongst the direst of calamities—as incapable of moral guilt as unhappily they are of moral consolation, have been regarded by our laws as though they were rather the objects of vengeance than of commiseration. And were a system now to be devised, whose express object it should be to drive every victim of insanity beyond the limits of hope, it would scarcely be within the power of a perverse inge- nuity to suggest one more infallible than that, which, for so many years has been in practical operation amongst us. That system could advance one paramount claim to preference. Its experi- ments have been numerous, and have scarcely ever failed in ren- REPORT. 43 dering the most favorable cases of insanity incurable. This practice reacts upon the community by which it is sanctioned. To say nothing of the amount of human suffering, it has caused, it cannot be doubted that, with appropriate treatment, one half at least of all the lunatics whose support must now continue to be a burden upon the state while they live, might have been restored, and this half might have added as much to the resources of the state, as the other would have subtracted from them."* The result would be far different if the insane paupers could be properly classed, and treated on the "non-restraining principle," at the same time subjected to a well devised medicinal course, calculated to preserve or restore bodily health, with the assistance of cleanliness, exercise, air, and suitable diet; while mercy and kindness characterize the deportment of their nurses, who should invariably be persons of respectability, with experience, benevolence, dignity, patience, anxious watchfulness, and posses- sed of a just conception of their peculiar duties. "As far as in any manner possible, all causes of mental disquietude should be excluded by substituting persuasion for force, by practising for- bearance, mildness and all the nameless offices of humanity, and by imbuing in every practicable way, the minds of the patients with a new set of pleasing, cheerful, grateful and benevolent emotions. In fine, the whole scheme of moral treatment is embraced in a single idea—humanity,—the law of love—that sym- pathy which appropriates another's consciousness of pain, and makes it a personal relief from suffering, whenever another's suf- ferings are relieved."! This cannot now be termed a novel mode of treating insanity. It was introduced into France upwards of fifty years ago, with triumphant success, superseding the coercive system, the standard remedies of which, industriously applied, "have precipitated thousands of intellects from a condition of temporary danger to one of irretrievable ruin." When the functions of the brain and general nervous system are disordered, resulting in irregularity *See Report of Commissioners appointed to superintend the erection of a Lunatic Asylum, at Worcester, January 4, 1832. tSee first Annual Report of Trustees of the State Lunatic Asylum, at Worces- ter, Mass., December, 1833. 44 REPORT. of action and chronic delirium—can fetters, cheerless confine- ment, absence of occupation, and unceasing tumult recall harmo- nious action, and assist the recuperative energies of the mind to restore "an immortal nature to the capacity of virtue, and the en- joyment of happiness?" Every enlightened mind—every humane heart will respond in the negative. Then why is our state so backward in providing a home for her destitute insane, where medical skill may unite with intelligent benevolence in the good work of allaying the morbid excitement of the brain, and regu- lating the disordered actions of a chaotic intellect, recalling reason, and re-awakening all its natural sympathies? To this class of her citizens she is in long arrears. "One of the strongest if not one of the first principles of social obligation arises from the ne- cessity of relief, and the ability to relieve. And when does a man so urgently require the light of others to direct his steps as when he wanders in darkness? When does he stand in such ex- tremity of need of the knowledge and guidance of his fellow men as when his own mind is a wild chaos, agitated by passions which he cannot quell, and haunted by forms of terror, which the living energy of his nature is perpetually calling into being, but cannot disperse? When does he so strenuously demand their succor, as when his own soul is like a living wound, and he has lost all power of distinguishing between the sources of healing and of torture? If the insane have done nothing to forfeit the claim which men who suffer have by the law of nature, upon men who are able to prevent that suffering, they should be treated not with a sole regard to the security of others, but with special refer- ence also to their own misfortunes, and in a manner adapted to shorten their duration, or where that is impossible, at least to miti- gate their severity. Even if the public good imperiously de- manded the coercion of the insane, it would not be just to cast them into hopeless imprisonment, thereby making the cause of their confinement remediless, and the confinement itself termina- ble only by the death of the sufferer. In its practical operation, such a system is a direct consignment of human beings to the long protracted and mysterious horrors of madness."—Idem. On the other hand what has been the practical operation of the treatment opposed to this system of coercion, and which in obedi- ence with the laws of humanity, substitutes mildness and patient REPORT. 45 persuasion for harshness and force—liberty, exercise, and occu- pation for confinement, inactivity and idleness? We believe we cannot better serve the class of lunatics, whose claims we wish to urge, in depicting the results which have been realized from this change, than by again quoting the language of one, whose eloquent pen has so vividly depicted the inevitable horrors of in- sanity, when neglected or deserted, and uttered such rich appeals in behalf of those whose feelings and emotions, at least, may be soothed and subdued, even when the integrity of their intellects cannot be restored. "However deeply all our better feelings may be moved by the reflection that so many of our fellow beings, under the auspicious influences of this institution, have already been restored to reason and returned to bless the families and friends, who, under the former coercive system of treatment, would have mourned their loss 'without hope;' yet the ameliorated condition of such as have not been recovered, we regard as a subject of equal con- gratulation among men, and gratitude to heaven. No one, who has not actually seen, from time to time, the inmates of the hos- pital, can comprehend the extent of the change which has taken place in every external indication that marks the physical and moral condition of a human being. Many who, in their paroxysms, used formerly to wound and lacerate their own persons to a degree that threatened life itself, now habitually exercise an or- dinary degree of prudence in avoiding the common causes of an- noyance and accident. Not less than one hundred of those brought to the hospital seemed to regard human beings as their enemies, and their first impulse was to assail them with open or disguised force. Now there are not more than twelve who offer violence. Of forty persons who formerly divested themselves of clothing, even in the most inclement seasons of the year, only eight do it now. Through all the galleries, there is far less sus- ceptibility to excitement, more quietude, more civility and kind- ness exercised towards each other. The wailings of the despond- ing, and the ravings of the frantic are dispelled. The internal change is legible upon the countenance. With the insane it is emphatically true, that the dark shadows of the mind are^visibly projected upon the face. Hence, from the alteration which has ia many instances occurred in the outward aspect, amounting 46 REPORT. almost to a change in identity, there may be inferred a corres- ponding alteration of the condition within. The deep lines of anguish have been obliterated or softened, whose sharp engravings were begun many years ago in despair. The wide circle and heart-sickening variety of horrors, exhibited by the inmates when first brought together, have been greatly reduced in extent, and mitigated in quality."* Among the means conducive to so favorable a result, no one is more important than the principle of never allowing a patient to ) continue idle, if at all in a condition of general health admitting his engaging in light or laborious occupations. The mental re- vulsion induced by labor, prevents the morbid illusions and the real or fancied sufferings from wholly engrossing the attention. Gardening, farming, or mechanical operations—particularly if the patient has been accustomed to them, encourages cheerfulness and contentment, promoting at the same time refreshing sleep and appetite—the health becomes improved, and the mind invigor- ated. The anticipation of the benefits of labor, or the contem- plation of its results is also effectual in awakening a feeling of satisfaction, and self respect, which greatly aids the patient in controlling any disposition to violence and indecency, and in banishing unpleasant impressions, and feelings of irritation and degradation. Of course, during the vascular and nervous excite- ment frequently existing in the early stages, rest, seclusion, and quiet will best allay diseased irritability of body and mind; but as this disappears, exercise and employment adapted to the condition of the patient, promotes convalescence and strengthens the mental and bodily powers, greatly aiding the medicinal treat- ment in removing the functional derangement in that portion of the physical system—the brain and nerves, which causes insanity. We might also quote evidence to show the beneficial influence of introducing sabbath services within the confines of an asylum, judiciously arranged and conducted; and that a large proportion of the patients, pleased if allowed to attend, behave with great propriety. But we have already far exceeded our prescribed limits, and must resign the subject to the charge of a more able and experienced advocate. *First Annual Report of the State Lunatic Asylum, Worcester, Mass., Dec. 1833. REPORT. 47 It cannot be necessary to dwell longer upon the uncharitableness of sending our insane paupers into alms houses, where it is im- practicable to command the varied and nicely adjusted means best calculated to recall, and re-establish physical and mental health. What inconceivable good might have resulted from the expendi- ture of a comparatively inconsiderable sum years ago, in the establishment of a state lunatic asylum!—a large proportion of those, who must now be a burden upon the community as long a3 they live, might have been restored to their families, to happiness and to usefulness. When insanity was scarcely looked upon as a legitimate subject for curative treatment, alms houses were selected as suitable places for the safe confinement of the unfortunate subjects of it. But are they to be so regarded now? We trust not.—Convinced that the want of a well endowed Pauper State Lunatic Asylum is a serious evil, the magnitude of which should be pressed upon the notice of our people and our government—we venture thus to entreat you earnestly to plead for its removal;—feeling assured, that the intelligent body of a people, whose enterprize and de- termination to do all in their power to promote the true and perma- nent interests of their state, and fellow-citizens at large, have induced the expenditure of millions in rail roads, canals, and various other internal improvements, will promptly respond to the cry for relief, and advocate the desired provision for their destitute insane, if made to comprehend its necessity. Such an institution, assuming a high rank among our state enterprizes, .would prove a blessing to a helpless, and heretofore neglected class of our people, and continue an admired monument of her benevolence.