Perhaps the greatest progress in the therapeutics of mental diseases within the past twenty years has been in our methods for the treatment of excitement.

By degrees, means of restraint, always useless, often barbarous, have disappeared from institutions.

The methods employed to-day in combating excitement may be grouped under four principal heads:

Rest in bed;

Hydrotherapy;

Isolation;

Medication.

Rest In Bed

First used in melancholia (Guislain, Griesinger, Ball), rest in bed has been only recently adopted in the treatment of excitement. Magnan has introduced its use into France, after having shown the excellence of its effects and the relative facility of its employment.

Rest in bed presents the triple advantage of saving the patient's strength, calming excitement, and facilitating supervision. It is indicated in most of the acute psychoses and in the periods of exacerbation of chronic psychoses. Rest in bed need not necessarily be constant to be efficacious, except in cases in which the gravity of the general condition requires it. It is well to allow patients to get up for two or three hours daily, using part of the time for outdoor walks, the duration of which is to be determined by the special indications in each case.

1 Pochon. These de Paris, 1899. - Wizel. Ann. med. psych., 1901 - Scrieux et Farnarier. Ann. med. psych., 1900.

Rest in bed produces the best effects when carried out collectively in small dormitories containing not more than ten beds. The example of patients who have already submitted to this mode of treatment exercises a salutary influence upon newcomers and helps to induce them also to accept it. Under favorable conditions two or three days generally suffice for even a very excited patient to become accustomed to staying in bed, and to become calmed to a certain extent.

Though he may still persist in restless movements, he rarely leaves his bed, and when he does, he will return without difficulty upon the simple injunction of the nurse.

Hydrotherapy

The cold douche, formerly much employed for calming excitement, has been abolished.

Of the various forms of hydrotherapy two are most frequently used: the wet pack and the continuous warm bath.

The wet pack is applied by means of a sheet soaked in cold water and closely wrapped around the entire body. Its duration varies from twenty minutes to several hours. If kept on too long it may cause attacks of syncope.

Continuous warm baths are of great service when rest in bed does not suffice to calm the patient. As generally used, their duration does not exceed five or six hours daily. Some physicians, however, have obtained good results from the permanent warm bath: the patient remains in the bath for days or weeks.1 The bath tubs used for this purpose are equipped with a device for supplying a continuous flow of water at an even temperature; also with a canvas cradle for the patient to lie on and a canvas sheet for a cover.

1 Serieux. Le traitement des etats d'agitation par le bain permanent. Revue de Psychiatrie, Feb., 1902.

Isolation

Much opposed of late, isolation presents, in fact, certain inconveniences, the greatest of which is leaving the patient by himself without constant supervision; it is absolutely contraindicated in patients with suicidal tendencies, and should not, as a rule, be employed until the other measures - rest in bed and prolonged baths - have been tried.

Nocturnal isolation consists in allowing the patient to sleep in a separate room, which should, of course, be conveniently accessible to the attendant; it is of great utility for certain chronic disturbed patients. Many a dement who makes a great deal of noise during the night in the dormitory will rest quietly when he is alone.

Medication

We shall limit ourselves to the mention of those drugs which are most frequently used in states of excitement, and give several formulae.

Opium and its derivatives are used in the psychoses; extract of opium in pills, aqueous solutions of morphine for subcutaneous injection, tincture of opium, etc.

The danger of forming the habit prevents their use in cases requiring prolonged treatment.

Chloral enjoys a merited reputation. It is administered in solution by the mouth in doses of from one to two grams, or per rectum in doses of from two to three grams.

Chloral hydrate..

1 or 2 grams

Syrup of currant-berries...

30 c.c.

Water,enough to make...

60 c.c.

To be administered in one or two doses by the mouth.

Chloral hydrate...

3 grams

Yolk of egg...

1

Milk..................................

120 c.c.

To be administered per rectum, preceded by a simple enema.

1 Mercklin. Ueber die Anwendung der Isolierung bei der Behand-lung Geisteskranken. Allg. Zeitschr. f. Psychiat., 1903, No. 6.

Chloral may be combined with bromides:

Chloral hvdrate.........................

1.5 grams

Potassium bromide......................

2 grams

Syrup of currant-berries.................

30 c.c.

Water, enough to make..................

80 c.c.

To be administered in one or two doses by the mouth.

Chloral should be absolutely prohibited in cases of heart disease.

Bromides may also be used alone in doses of from two to four grams.

Sulphonal, trional, and tetronal bring about calm and prolonged sleep in cases of moderate excitement, given in doses of one or two grams. They are usually administered in powders each containing one gram of any one of these hypnotics. One or two such powders, according to the case, is to be administered in the evening toward six o'clock the action of these drugs being slow.

Chloralose, hypnal, and somnal may also be of service.

Chloralose.............................20 to 60 centigrams

Given in a powder.

Hypnal................................

2 grams

Chloroform water.......................

100 c.c.

Syrup of peppermint....................

30 c.c.

To be administered in two or three doses by the mouth. (Debove and Gourin.)

Somnal...

2 grams

Syrup of currant-berries.................

40 c.c.

Water....

20 c.c.

To be administered like the preceding. (Debove and Gourin.)

Paraldehyde may be given by the mouth, by the rectum, or hypodermically in doses of from 2 to 5 grams. It is an excellent hypnotic. Its only inconvenience is the disagreeable and persistent odor which it imparts to the breath.

Paraldehyde...

2 to 5 grams

Rum..................................

20 c.c.

Lemon-juice............................

1.5 c.c.

Simple syrup...........................

30 c.c.

Distilled water.........................

40 c.c.

To be administered in one or two doses by the mouth. (Debove and Gourin.)

Paraldehyde............................

4 grams

Yolk of egg.............................

1

Milk..................................

120 c.c.

To be administered in one dose per rectum, preceded by a simple enema.

Hyoscine hydrobromate or hydrochlorate is a very active drug and must be used with great caution. It may be administered in solution, in pills, or by subcutaneous injection.

Hydrochlorate of hyoscine................

0.005 gram

Syrup of peppermint....................

30 c.c.

Water enough to make................

120 c.c.

A tablespoonful every ten minutes until four doses have been given.

Hyoscine hydrobromate.................

0.02 gram

Water...

20 grams

For subcutaneous injection. One ordinary hypodermic syringeful contains two milligrams of the drug. Half a syringeful is given at first; it is very rare that the sedative effect is not produced by a whole syringeful.