Insanity (Lat. insanitas, from in, privative, and sanitas, health or soundness), unsoundness of mind. The term is usually applied to acquired unsoundness in contradistinction to that which is congenital, but treatises on the subject include the latter under the heads imbecility and idiocy. The legal relations of insanity will be treated under the synonymous but mere technical legal term Lunacy. Locke says that " madmen do not appear to have lost the faculty of reasoning, but having joined together some ideas very wrongly, they mistake them for truths, and they err as men do that argue right from wrong principles." It will be seen however, from an examination of cases, that not only are madmen the subjects of delusions and hallucinations, but that their reasoning faculties are generally more or less deranged, and sometimes entirely perverted. The attempt to treat mental diseases from a purely psychological point of view has been the cause of much useless labor, and has resulted in many erroneous conclusions. - Insanity appears to have been of rarer occurrence in ancient than in later times, and it is also seldom met with among primitive people of the present day.
The occupations of both men and women in antiquity were not of a character calculated to excite cerebral disease, even if the predisposing causes had been present. It is, however, a matter of doubt whether insanity can be induced without a pathological basis, the tendency being to the opinion that it cannot. The earliest references to mental disease in antiquity are the madness of Saul, the feigned madness of David, and that of Ulysses immediately before the Trojan war. Although several instances of real or feigned madness are mentioned by the ancients, their writings contain no account of any institutions devoted to the care of the insane, nor any laws for their protection. The opinions expressed by Plato in the "Timaeus" and " Phaedrus," in regard to the prophetic power of madness, which he looked upon as a sacred disease and full of blessings, are well known. Ancient Greek authors, especially Euripides, abound with allu-' sions to the supposed power of Bacchus to produce madness. Lycurgus, king of the Edones in Thrace, refused divine worship to Bacchus, for which the god visited him with madness.
In this condition, and under the delusion that he was cutting down a vine, he killed, according to Apollodorus, his own son. The three daughters of Praetus became insane for neglecting the work of Bacchus, and ran about the fields believing themselves to be cows. It is worthy of remark that in the Mosaic law there is no provision for insane persons. In the 6th century B. 0. history records a remarkable example of insanity produced by epilepsy in the person of Cambyses, king of Persia and conqueror of Egypt. It is said that from his birth he was subject to fits of epilepsy, called the "sacred disease." The earliest medical writings which treat of insanity are those of Hippocrates. It is a remarkable fact that this earliest of observers should have, like those who are the most advanced in knowledge at the present day, regarded insanity as having a pathological basis, and that through all the intervening centuries the same sound opinion should have scarcely ever been thought of. He says: "And by the same organ (the brain) we become mad and delirious, and fears and terrors assail us, and dreams and untimely wanderings, and ignorance of present circumstances.
All these things we endure from the brain when it is not healthy." One of the most noted ancient writers on insanity was Asclepiades. He believed in stimulation, and applied it in the treatment of insanity. He therefore recommended wine and recreation, and that the patient should be placed in the light, and discouraged bleeding and the use of narcotic fomentations. Celsus exercised a powerful influence upon the treatment of the insane from his time even to the present century. He wrote the first independent treatise on the subject, entitled Be Tribus Insaniae Generibus, in which he gives a compend of all that had up to his time been found to be the most correct views. He has received much praise from many authors, but his treatment was harsh and such as would not be tolerated at the present day. Aretaeus of Cappa-docia, according to the notions of his age, attributed melancholia to black bile, but says that sometimes it arises from mental causes alone. He describes the passing of the disease into imbecility and bodily decline, and shows a good knowledge of the different forms of mania. He also carefully distinguishes between the delirium of fever and of intoxication or of poison and that of insanity.
Coelius Aurelianns, who is supposed to have flourished about the time of Galen, advised in mania the shaving of the head and the application of cups, first over the chest, then between the shoulders, and next to the head. As reason returned, he recommended moderate exercise, riding, walking, and reading aloud. Theatrical entertainments were prescribed for melancholies, the scenes being of a lively or sad character, according to the state of mind of the patient. Acquaintances were to be employed to converse with the patients and amuse them, and during the progress of recovery they were allowed to go and hear the disputations of the philosophers. The celebrated Galen, who flourished in the latter part of the 2d century, based his treatment on the humoral pathology which was in such high repute among the ancients. He recommends that should you be of opinion that the whole of the patient's body contains melancholy blood, you should bleed, especially from the median cephalic vein. Should the blood not appear of a melancholy quality, the vein is to be immediately closed. Thick and black wine is to be avoided, "as from it the melancholy humor is made." After Aurelianus and Galen no medical writer of any eminence appears until the dawn which followed the middle ages.
The practice of mental medicine during this period was based upon mystical theories, and cannot be said to have had a system. "That man is sick in mind," says Paracelsus, "in whom the mortal and the immortal, the sane and the insane spirit, do not appear in due proportion and strength." "Mania is a change in the reason, but not in the senses." And he gives for causes over exercise of the reason, the elements, influences, constellations, conjunctions, microcosm, macrocosm, etc. As to remedies he says: " What avails in mania except opening a vein? Then the patient will recover. This is the arcanum; not camphor, not sage and marjoram, not clysters, not this, not that, but phlebotomy." The first institution for the insane was established in the East. It is said that one existed at Jerusalem in the year 491. In the 12th century the traveller Benjamin of Tudela says there was a large edifice at Bagdad, called " house of grace," in which the insane were received in summer and kept confined in chains until they recovered or died. It was visited by the magistrates every month, and those who had recovered were discharged.
In the same century hospitals for the insane were founded in the Byzantine empire, and asylums for them are said to have been common among the Moors. - The amelioration of the condition of the insane is not difficult to trace, as it had its commencement in modern times. Bucknill and Tuke remark: " It must be a matter of surprise that the principles of treatment so well laid down by one or two of the ancient medical writers should have been so entirely forgotten or disregarded. It is indeed to be presumed that the directions of Celsus have exercised a most prejudicial influence, even till within a very recent period; and it is not difficult to recognize them in the writings of the classical Cullen, who did not omit to recommend the employment of 'stripes' in the treatment of the maniacal." The pursuit of mental philosophy by the metaphysicians of the 18th century was not accompanied or immediately followed by any corresponding advance in the study or treatment of mental diseases. This was brought about by the investigations of physicians and the efforts of philanthropists.
Systematic writers on the subject of insanity have usually dated the commencement of reform from the labors of Pinel, and to that great man too much credit cannot be well given. "The year 1792," say Bucknill and Tuke, " will ever be memorable in the history of the treatment of the insane. In that year the celebrated Pinel liberated 53 of the patients confined in the Bicetre from the chains by which it was thought necessary to restrain their fury." Pinel's labors were attended by great results, but he was not the pioneer in modern reformatory treatment of the insane. The subject had received the attention of Benjamin Franklin and others in this country as early as 1750. At the organization of the Pennsylvania hospital at Philadelphia a department for the care of the insane was established, in which the system afterward advocated by Pinel was successfully practised. An act was passed founding "a hospital for the reception and relief of lunatics, and other distempered and sick poor." (See annual address before the medical society of the state of New York, 1868, by Dr. John P. Gray.) The reform in the treatment of the insane in England, particularly in regard to restraint and punishments and mode of confinement, forms an interesting chapter in the history of institutions for the insane.
Bethlem hospital, or Bedlam, as it was commonly called, which on various occasions became notorious for the ill treatment of the insane, was founded and first provided for them with benevolent intentions. In 1547 Henry VIII. took possession of the monastery or hospital of St. Mary of Bethlem, and presented it to the city of London, with an order that it should be converted into a house for the reception of lunatics. This building, however, could accommodate only 50 or 60 patients, and therefore in 1675 a larger one was erected in Moor-fields, capable of receiving 150 patients, and which remained as a hospital till 1814. In 1734 additions were made to Bethlem, and it still proving too small, St. Luke's hospital was established in 1751 by voluntary subscription. The York asylum was founded also by general subscription in 1777. The management of the asylums had previously begun to retrograde, but not many complaints were made until the year 1791, when some members of the society of Friends sent one of their family to the York asylum.
The rules forbade any of her friends to see her; suspicion of something wrong was aroused, and a new establishment called "the Retreat" was founded by the society, chiefly through the influence of William Tuke, in the spring of 1792, the year in which Pinel caused the lunatics in the Bicetre to be liberated from their chains. At the retreat no chains, leg locks, or handcuffs were employed from the opening of the establishment. A patient who had been chained naked for 20 years was admitted; no restraint except the occasional use of arm straps was employed, and he was soon induced to wear clothes and adopt orderly habits; and there were many other cases of a like nature. Little was publicly known of the experiment till 1798, when De la Rive visited it, and was so delighted with what he saw that he published an account of it on his return to France. The publication of a " Description of the Retreat," by Samuel Tuke, in 1813, attracted still more attention to the institution. The physician of the York asylum took offence at some observations it contained, and a controversy arose which resulted in exposing a number of aggravated cases of bad management in the other asylums, and also in causing the house of commons in 1813 to appoint a committee to investigate the subject, who visited not only Bethlem and York asylums, but many private institutions, and brought a horrible condition of things to light.
Among the minutes of evidence taken before the committee are the following. One witness, Mr. Edward Wakefield, said: "In the year 1808 I heard a physician state to the Rt. Hon. John Foster, that of the insane persons who were sent up to Dublin the treatment of them was so little understood that the accustomed mode was tying them with a cord to the back of a car and forcing them to walk the distance they might have to come; and this gentleman's expression was, ' I give you my honor that of the insane persons sent up to Dublin almost one in five loses an arm from the tightness of the ligature producing mortification, which renders amputation necessary.' " Dr. Richard Salisbury, a general practising physician, testified: " In one house the number of patients confined is 23, 14 men and 9 women; 7 of the men and 7 of the women supported at their own expense. One room was on the ground floor, 21 by 16 ft. and 7 ft. high, divided into 6 cells, 9 ft. long and 5 ft. wide, with a passage 3 ft. wide between; not the least air or light admitted except when the doors are open. The principal door immediately opposite a pig sty and dung heap about 7 ft. distant. Three only of the cells floored with wood, the other three were on the bare earth.
A long box, 6 ft. by 2 1/2 ft., was used for a bedstead, to which the patient was chained. Some had blankets, some only coarse straw. They were taken out to air once a week, during which time clean straw was supplied when necessary. The patients were so dirty in their persons that on opening the door of the first cell the smell was so offensive as nearly to prevent further inspection." The medical treatment in most of the establishments was of the lowest empirical kind. The physician of Bethlem said: " Twice a year, with few exceptions, the patients are bled, and after that they take vomits once a week for a number of weeks, and after that we purge them. That has been the practice for years, long before my time." But it must be remembered that although much of the treatment arose from cruelty and negligence, the system was supposed by the more ignorant to be one of necessity. Lunatics were not looked upon then as unfortunate sufferers from disease, but rather as subjects of demoniacal possession, or as self-made victims of evil passions.
The exposure of the abuses aroused the public mind, and medical men not only felt called but were forced to pay more attention to the study of humane methods of treating the insane, and to emulate the example of the Tukes at the retreat. - Causes. The causes of insanity may be divided into predisposing and exciting. The more general predisposing causes are sex, age, social position, education. The question as to the influence of sex has not been definitely settled. Alienists are agreed that the existing statistical tables do not settle the question, and that asylum reports are apt to mislead, as the minority of female patients in asylums may be owing to the greater unwillingness of friends to send them from home than males. The statistics of Esquirol embrace about 70,000 patients of all countries, and show a small majority of females, and he and also Haslam thought insanity more frequent among women than men. It has been said that women are more liable than men to inherit insanity, and Dr. Maudsley is inclined to this conclusion. In regard to the influence of age, cases of insanity are rare in childhood. The greatest number become insane between 25 and 50. It is difficult from statistics to determine the effect of social position.
In England there are about 9,000 poor and 1,300 members of wealthy families in public and private asylums, and this is probably about the proportion of the poor to the rich; but it is probable that a state of poverty is more productive of mental disease than one of affluence. Insanity has been found more frequent among unmarried men and married women. Its greater frequency among married women is probably owing to care, anxiety, and over-exertion of body and mind, and difficulties in gestation, lactation, and menstruation. Of the more special predisposing causes, heredity plays a most important part. Jacobi in 220 cases of mania found hereditary predisposition in about one ninth. Hagen in 170 cases found it in about one third. Esquirol found it among the poor in more than one fourth; in the rich, about three fifths. Webster found at Bedlam, in 1,798 patients, hereditary predisposition in about one third, oftener in females. Skae of Edinburgh, in 248 admissions, found it in a little over one third. In a large number, from English and Irish asylums collected by Dr. Jar-vis of Massachusetts, it was found among 44,-417 men in the proportion of 1/25, and 43,093 women of among 1/23. At Bloomingdale asylum the proportion was found to be about one sixth.
It was advanced by Esquirol, and confirmed by Baillarger in the examination of 453 cases, that insanity is more frequently transmitted from the mother than from the father. It was found that the transmission from the mother to the sons was only about equal to that of the father; but the transmission to the daughters was twice as frequent. This would indicate that women inherit insanity oftener than men, a point previously alluded to. It is also found that children who inherit insanity sometimes manifest the disease before the parents do; but they are more likely to inherit it if born after its appearance in the parents. There is also a tendency in hereditary insanity to show itself in much the same way in the different individuals of the family; thus it has been observed that a whole family of brothers and sisters have become insane at about the same age, and committed suicide. The disposition may be removed by marriage with healthy stock, or may be increased by intermarriage. - The exciting causes of insanity may be divided into moral or psychical and physical.
The principal psychical causes are grief, fright, anxiety, care, or an excited state of any passion, particularly if recurring often or prolonged; the emotions aroused by disappointment, by unfortunate love, by jealousy, by reflecting on misfortunes that have ruined the prospects of life; excessive or prolonged employment of the intellectual faculties, particularly when connected with the emotions, as the composition of poetry or romance, or the prolonged excitement attending the management of difficult legal cases. Anything which will produce a hyperemia of a portion or of the whole of the brain, by which the nutrition and consequently the normal function is interfered with, may become an exciting cause. From the number of cases of insanity in men of business, who have broken "down in the struggle to amass fortunes, it is fair to assume that the prominence given by Maudsley to the eager desire to get rich as a cause of insanity is amply justified. He says: "The occupation which a man is entirely engaged in does not fail to modify his character, and the reaction upon the individual's nature of a life which is being spent with the sole aim of becoming rich is most baneful.
If one conviction has been fixed in my mind more distinctly than another by observation of instances, it is that it is extremely unlikely that such a man will beget healthy children; that, in fact, it is extremely likely that the deterioration of nature which he has acquired will be transmitted as an evil heritage to his children. In several instances in which the father has toiled upward from poverty to vast wealth, with the aim and hope of founding a family, I have witnessed the result in a degeneracy, mental and physical, of his offspring, which has sometimes gone as far as extinction of the family in the third or fourth generation." The principal physical causes are drunkenness and the use of narcotic or poisonous drugs; want of food; want of sleep and over-exertion; other nervous diseases, such as epilepsy, chorea, and hysteria, particularly the first; severe injuries to the head, particularly from blows, causing fracture of the skull or concussion of the brain; sunstroke, and tumors in the brain. Acute febrile diseases, as typhoid, typhus, and malarial fevers, are also causes of insanity; and it may occur during the course of pneumonia, generally in the form of acute mania.
The poison of Asiatic cholera may so interfere with the nutrition of the brain as to produce not only transient delirium, but mania, which may continue for several days or weeks. Acute rheumatism is sometimes a cause of insanity; and it is an interesting fact that the mental symptoms follow the apparent disappearance of the rheumatic symptoms, and pass away upon the reappearance of the disease. Chronic constitutional diseases are frequent causes, and among the most formidable probably of these is constitutional syphilis. Its effects are produced in a variety of ways. The skull may be the seat of exostosis or of caries; the membranes may be affected and cause mal-nutrition of the cerebral substance; or tumors of the brain may arise directly from the effects of the syphilitic poison; or the nutrition of the whole body may be so interfered with that all the plastic material furnished by the food is vitiated and incapable of forming sound nervous tissue. The syphilitic affections of the nervous system have recently been the subject of careful examination by Drs. Wilks and Moxon. According to Dr. Wilks, there is in syphilis a disposition to a low form of lymph in nearly every tissue of the body, which does not readily form tissue, never that which is perfectly normal.
According to Dr. Moxon, syphilis attacks the surface of the brain and its membranes in limited spots, spreading slowly. The lymph which exudes from the membranes destroys the gray matter of the convolutions, and syphilitic deposits may form fleshy tumors which contain a certain gummy characteristic substance; or the brain and spinal cord may be invaded by gummatous tumors springing from the dura mater or the bones. Paralysis of various degrees of intensity and extent, and also mental diseases, are the results. (See lectures of Dr. Broadbent, "London Lancet," 1874; also an illustrative case, with plates of pathological changes, "American Journal of Insanity," July, 1874.) Tuberculosis, particularly by inducing a state of exhaustion or degenerated tissue development, is sometimes an exciting cause of mental disease; and, as will be noticed further on, there are apparently intimate relations between tuberculosis and insanity and certain other forms of nervous disease. Diseases of the heart have been assigned as causes of insanity, and as far as they operate in exhausting the strength of the patient, they may be considered as such; but more often the heart disease is, along with the mental affection itself, the effect of other changes, such as disease of the arteries or capillaries, or of the vaso-motor system of nerves.
Disease of the genital organs sometimes exerts an important influence in producing insanity. During the period of sexual development, particularly when any morbid condition is present, resulting from secret vice or from any cause, insanity in some form, mania, melancholia, or dementia, is liable to occur. Disorders of menstruation at any period of life may bring on attacks of mental disease; as also may diseases of the uterus or ovaries, such as tumors, cysts, or displacements. Pregnancy, the puerperal state, and lactation are not infrequent causes of mania and melancholia. A state of melancholy during pregnancy is often the precursor of an attack of puerperal mania. Insanity from lactation is generally in consequence of the exhaustive effect of the function superinduced upon a hereditary predisposition. Sexual excess and unnatural vice, from inducing a perverted condition of the mind and nervous system, as well as from their weakening effects, are not uncommon exciting causes of insanity. But among all the causes of mental disease, it is acknowledged by most authorities that the excessive use of intoxicating drinks is the greatest.
Of 1,428 cases admitted into Bethlem hospital, 12 per cent. were found to be caused by intemperance'. The report of the commissioners in lunacy in England in 1844 gives, out of 9,868 cases, 1,792, or more than 18 per cent., as the proportion attributable to the effects of alcoholic liquors. Of 748 cases, Halloran found drunkenness a cause in more than one fifth. Prichard and Esquirol attribute half of the cases of insanity in England to intemperance. Dr. Rush gave it as the cause in one third of the cases in America, and more recent statistics of some asylums show a larger proportion. Blandford and other modern writers ascribe to it a potent influence. Dr. Dickson, late superintendent of St. Luke's hospital, London, takes a somewhat different though not opposite view. He says: " Although it is true that drunkenness is very frequently the exciting cause of an attack of insanity, yet the incentive to drunkenness is the result rather than the cause of brain deterioration in the first instance; a potentiality of insanity is often discovered on examining the history of the persons who complain of a constant sense of depression, and who seek to relieve that depression with stimulants." The continued use of intoxicating drinks and narcotic poisons, in the opinion of Dr. Carpenter (" Mental Physiology," 1874), destroys or weakens the will so that it loses its control over the emotions.
The experiences given by De Quincey as to the weakening of the will in his own case, so that he became unable to perform what he had planned, not from want of brain power, but of volition, is instanced by Dr. Carpenter as an example; and he also points to the excessive use of tobacco in creating a mental state which manifests itself in deferring the performance of pressing duties. The effect of alcohol he regards as more potent in weakening the will and arousing the more violent passions than that of any other agent; and it is not improbable that the excessive and habitrial use of alcoholic beverages, which are produced in such great quantities by civilized countries, has had much to do in inducing a hereditary tendency to insanity, and causing the spread of mental maladies to a greater extent among civilized than among other nations. The researches of Morel on the cause of the formation of degenerate varieties of the human race are interesting as explaining the continuance of morbid action through succeeding generations, and the final extinction of families.
The evil influences which produce disease, such as the poisonous air of a malarious district, or a badly drained and cleaned city, overcrowding and privation in large towns, persistent intemperance and sexual excess, and intermarriage in families, unless counteracted, appear to tend to increase through generations, until continuance of the species is impossible. He regards insanity in any form, whether mania, melancholia, or dementia, as a stage in the descent toward sterile idiocy, as sometimes shown by the consequences of frequent intermarriages in foolish families. He relates the history of one family in which the progress of degeneration may be briefly stated as follows: first generation - immorality, alcoholic excess, brutal degradation; second generation - hereditary drunkenness, maniacal attacks, general paralysis; third generation - sobriety, hypochondriasis, lypemania, systematic mania, homicidal tendencies; fourth generation - feeble intelligence, stupidity, first attack of mania at 16, transition to complete idiocy, and probable extinction of the family. - General Symptoms of Insanity. The earliest symptoms of coming insanity are depressed manner, unusual excitement, anger, and rashness; and even these may be preceded by an altered manner, if careful notice has been taken.
An abnormal condition of brain exists, including a want of nervous energy which creates a consciousness that there is something wrong; a want of coordination of the faculties produces false reasonings and conclusions as to the nature of the difficulty, and so as the disease progresses delusions and hallucinations make their appearance. An important symptom in all forms of insanity is impairment of the faculty of attention, as might be expected from the loss of will which directs the attention. The inconsistency of the beliefs of the insane is one of the earliest noticeable symptoms, and they are conveniently classified as "delusions" and "hallucinations." It is important that a clear conception of the meaning of these terms should be had. A delusion is a false belief in regard to some fact which generally concerns the patient, and which is so strongly rooted that all attempts to reason him out of it are futile. Thus, he may believe that a certain occurrence took place at a certain time, or that he is a certain person, as a saint, or a prince, or the Saviour, or that his head is made of metal. The delusions of the insane may be of a gloomy or of an exalted nature.
A man who believes poverty to be the greatest evil may, in consequence of false reasoning as to the state of his affairs, imagine himself to be ruined, and that his family will be turned out of doors. When the patient has exalted delusions he is apt to imagine himself immensely wealthy, or that the asylum in which he is confined is a palace and himself a monarch. A hallucination is a false perception of one of the senses; the patient may fancy that he sees a spirit, or a person who does not exist; such hallucinations are common in the temporary insanity of delirium tremens, when the patient may imagine that he sees serpents, or frogs, or insects, or that people, generally those whom he dislikes, come into the room. Hallucinations affect the different senses; thus the insane have hallucinations of sight, of hearing, of taste, of smell, and of touch. Hallucinations of sight are more liable to occur when the brain is in the greatest state of exhaustion, and to accompany the acute stages. They may be simply flashes of light or colors, or they may be objects like those in the state of exhaustion called delirium tremens. The hallucinations are oftentimes visions of the supernatural. Epilepsy in the insane is constantly accompanied by hallucinations of sight.
Hallucinations of hearing occur in acute, but are more frequent in chronic cases, and are unfavorable symptoms; and those who are subject to them are often the most dangerous patients. They are liable to hear voices commanding them to perform certain acts, which they are blindly impelled to attempt, however absurd or destructive. Hallucinations of smell are generally not persistent, and belong to the acute stages; and those who have them are apt to imagine that their own persons have an intolerable stench. Hallucinations of taste are rather uncommon, and are generally associated with disordered digestion. Those of feeling are not uncommon, and patients often declare that they feel themselves touched, or that they feel snakes or other animals in their bodies. The acts of the insane are prominent symptoms. There is a proneness among them to strip off their clothes, arising from various causes. They often experience a feeling of uneasiness, often of heat from the pressure of their clothes, or they imagine that they are foul or poisoned. Sometimes in mania there is a desire to destroy them, and in other cases to expose the person. The desire to dress in a fantastic garb is common among the insane.
In states of exaltation, whether of mania or of melancholia, the patient will often desire to assume a dress of authority, and the dejected melancholic will assume the most careless appearance. In some forms of insanity there is often a disposition to commit acts of violence and destruction. Sometimes these acts will be directed against inanimate objects, sometimes against other persons, and sometimes against the patient's own person. In the two latter instances it has received the names of homicidal and suicidal insanity. Some authorities contend that such a classification should not be made; but there are too many cases furnished by insane asylums, and which have occurred under the notice of intelligent physicians, where lunatics have shown morbid impulses to commit wrong acts which they had not sufficient will to resist, to leave much room for doubt that such states of the mind do occur. Patients have under some circumstances committed deeds of violence under the influence of impulses, and have at other times, in anticipation of the coming on of those impulses, asked to be restrained, saying that they feared they would not be able to resist them.
Considering the morbid perversion of the nervous system and the unhappy condition of the mind in some instances, it is not strange that the combined effects of these and of insane delusions and hallucinations should result in such acts, nor that the disposition to commit violence should under the circumstances take these forms. - Classification. There have been many classifications of insanity, but they have not thrown much light upon its nature, and in many cases have rather been hindrances to the discovery of the most important conditions (pathological) of the patient. The older writers divided insanity principally into mania and melancholia. Thomas Arnold in 1802 made a general division into ideal and notional insanity. The ideal he subdivided into: 1, phrenetic, or raving; 2, incoherent; 3, maniacal; 4, sensitive. Notional insanity he divided into: 5, delusive; 6, whimsical; 7, fanciful; 8, impulsive; 9, scheming; 10, vain or self-important; 11, hypochondriacal; 12, pathetic; 13, appetitive. The pathetic he subdivided into 16 varieties: 1, amorous; 2, jealous; 3, avaricious; 4, misanthropic; 5, arrogant; 6, irascible; 7, abhorrent; 8, suspicious; 9, bashful; 10, timid; 11, sorrowful; 12, distrustful; 13, nostalgic; 14, superstitious; 15, enthusiastic; 16, desponding.
Pinel made four divisions, viz.: mania, melancholia, dementia, and idiocy. Esquirol added to these another, monomania. Dr. Prichard, whose work, published in 1835, was for a long time high authority, made two general divisions, moral and intellectual insanity, subdividing the latter into three, monomania, mania, and dementia. The existence of such a disease as moral insanity is not recognized by a majority of modern alienists, and it is contended that the moral sentiments are often wanting in persons who are considered sane, as well as in the subjects of mental disease. Dr. Daniel Tuke divides insanity according as it affects - 1, the intellect; 2, the moral sentiments; 3, the propensities. Maudsley classifies insanity into two great divisions, which are subdivided into varieties as follows: I. Affective or pathetic insanity, including: 1, maniacal perversion of the affective life, mania sine delirio; 2, melancholic depression without delusion, simple melancholia; 3, moral alienation proper. Approaching this, but not reaching the degree of positive insanity, is the "insane temperament." II. Ideational insanity, subdivided into: 1, general (a, mania, acute and chronic; b, melancholia, acute and chronic); 2, partial (a, monomania; b, melancholia); 3, dementia, primary and secondary; 4, general paralysis; 5, idiocy, including imbecility.
In the first division the intellect may be comparatively unaffected, but there is insanity of feeling and action. In the second there is insanity of thought, or delusion. The "insane temperament" is a kind of potential insanity introduced by Maudsley to characterize a condition of mind in which great eccentricity of thought, feeling, and action, proceeding from a morbid nervous organization, does not make the person actually mad, but queer and morbidly eccentric. Individuals having this temperament have certain marks of genius, though never of the highest order. Griesenger, one of the highest modern authorities, says: " A classification of mental diseases according to their nature, that is, according to the anatomical changes of the brain which lie at the foundation, is at the present time impossible." He therefore classifies insanity according to the nature of the psychical symptoms, and says " that while it is the aim of clinical instruction to render conspicuous and to analyze the multiplicity of mental disorders in the concrete, nosology must content itself with establishing fewer principal groups, fewer abnormal states to which all the varieties of individual cases may be referred." He divides mental diseases into two grand groups.
In one there is a morbid condition of the emotions, affecting, according to its nature, the whole mental life of the patient. In the other group insanity consists in disorders of the intellect and will, which exhibit, "without profound emotional excitement, an independent, tranquil, and false mode of thought and of will, usually with the predominant character of mental weakness." In most cases the conditions found in the first group precede those in the second, the latter generally being consequences and terminations of the former. The different forms of insanity may be conveniently considered under the following divisions: 1, melancholia; 2, mania; 3, general paralysis of the insane; 4, dementia; 5, imbecility; 6, idiocy. - Melancholia. This may be acute or chronic. The great majority of cases of insanity commence with a state of emotional perversion of a depressing and sorrowful character, which has been called the stadium melancholicum, or initiatory period of mental disease, or the period of incubation. The first stages of melancholia are generally preceded by a condition called hypochondriasis, which may be considered as the mildest form of insanity. There is a feeling of bodily illness at this time more than at any other, or in any other form of insanity.
It is often vague, and depends upon irritation of the nervous centres arising from disorders, sometimes obscure, of the viscera. The patient becomes peevish and suspicious, is easily fatigued, a mental apathy takes possession of him, and he becomes weary of life; or he passes into a state of extreme anxiety. The mention of a disease will often cause him to fancy that he is afflicted with it, and he is constantly feeling his pulse and examining his tongue and excretions. He often changes his physician, and also his opinion of the nature of his ailment. His feelings are not all imaginary; there is frequently indigestion, sometimes of an aggravated character, accompanied with great evolution of gas, which by its distention of the intestinal canal occasions uneasiness. The tongue is foul, the appetite irregular, the bowels constipated, and the skin in an unhealthy condition. Moral treatment is often beneficial, but should always be accompanied by therapeutical measures calculated to remove pathological conditions. This state is very often accompanied by an inherited tendency to mental disease, and when not relieved passes into that condition more definitely styled melancholia. His delusions take a more decided character, and he fancies himself a criminal.
He is now evidently to all observers an insane man, and becomes the subject, not only of delusions, but of hallucinations; he imagines that he is beggared, and that his family are to be thrown helpless on the world; that he is destroyed by odious diseases; that he has leprosy, and that a loathsome smell emanates from his body. His countenance expresses intense woe, and he stands for hours in one place and in one posture, either in solitude or in the street; or he may be impelled to constantly wander about. He sleeps badly, and generally eats but little; the bowels are obstinately constipated, the breath offensive, and the pulse slow and weak. The age at which persons are liable to melancholia is often the prime of life, or when the vigor is beginning to fail, at 40, 50, or 60 years. Of 338 cases of melancholia admitted into St. Luke's hospital, London, only 9 were under 20 years of age. Women who have been weakened by parturition are sometimes the subjects, when it generally assumes an acute form, with sleeplessness and obstinate refusal of food. In this state there is almost always a disposition to commit suicide, which may manifest itself suddenly; sometimes it appears earlier in the disease, even before the other symptoms have been observed.
The treatment of a case of chronic or sub-acute melancholia will vary with its history and symptoms. An asylum is not indispensable if the patient's means are sufficient to provide him with proper care. He may be benefited by travel and change of scene; but when his condition will not admit of this, a proper place, either a private house or an asylum, should be selected, and an attempt made by therapeutical and hygienic measures to restore the cerebral defect by sleep and nourishment of the body. In many cases recovery will be observed to rapidly follow medical treatment alone, some bad cases getting well in a couple of months. There are three conditions which require constant attention: want of sleep, rejection of food, and constipation. To remedy the first, chloral is much used by some; others prefer the effects of morphine or Dover's powder, believing that chloral is better suited to the more violent condition of mania. Wine and brandy are also used to give temporary strength, and have been observed to be of practical benefit, inducing sleep in some forms of insanity.
As to whether the dyspepsia and other visceral disorders are the cause of the melancholia, or whether they are in common with it, the result of a primary nervous disorder, is one of those disputed matters about which physicians will probably never be perfectly agreed. The practical aim is, however, to produce regularity of the evacuations by laxative medicines, and to sustain the strength with nourishing food and wine. The prognosis in cases of melancholia is generally good. Some have recovered after having been a long time in asylums, and subject to suicidal impulse and delusions and hallucinations. If the melancholy becomes paroxysmal, or runs into mania, the prognosis is not so favorable, as pathological cerebral changes of a permanent character are liable to occur. The symptoms are intensified; there is now no longer mere depression or silent stupor or anxiety, but the patient becomes frenzied. He will hardly sit or lie in one position for a moment, and has to be placed in restraint, either mechanical or manual. He is extremely suicidal, and will not only try to put an end to his life, but will attempt to iniure his person by gouging out his eyes, or swallowing nails or pieces of glass or corrosive liquids.
He is not liable, like a subject of general paralysis or an epileptic maniac, to make homicidal attacks; but he will resist with violence the assistance of his attendants. He will not take food, will not be washed or remain in bed, and will strip himself of clothing. There is an increased weakening of the will, indicating great deficiency in cerebral nutrition. There is a great tendency to sink rapidly from exhaustion, and therefore the patient has generally to be forcibly fed, or, as is said, to be fed "mechanically." This is accomplished by forcibly opening the jaws and putting nourishing food into the pharynx with a spoon, or by introducing it with the oesophageal tube, which is generally preferred. Gentleness, however, will sometimes succeed in prevailing on the patient to swallow his food voluntarily, and must of course be tried until found of no avail. One great danger is death from starvation, and therefore food must be given, and in considerable quantities. Chloral is considered appropriate, and may be given alone, or in combination with conium, hyoscy-amus, etc. If the patient refuses, it may be given by the rectum. Morphine is also of service, particularly in the form of subcutaneous injections. Constipation is to be relieved by laxatives and clysters.
Other medicines, as bromide of potassium and digitalis, according to Blandford, are not worth the trouble of administering. Warm baths will be of great benefit, and the room should be kept warmer than usual. The patient wastes rapidly, and it is often impossible to give him enough food. Another form of melancholia of a chronic character often follows an attack of mania. It is attended with less mental excitement, resembling more a state of dementia, but recovery from it sometimes takes place. - Mania. This is usually classified, in a general way, as acute and chronic, and Blandford adds a variety which he calls acute delirious mania. Mania, particularly where there is hereditary taint, may be brought on by grief, misfortune, or disappointment; but peculiar forms of it accompany epilepsy and general paralysis of the insane. Acute mania may come on suddenly, or it may be preceded by melancholy lasting for some time. The symptoms of acute mania are by no means obscure; there is almost always manifested extreme mischievousness, filthiness in person, and obscenity in language. One distinction between mania and melancholia is in the manner the mental state affects the acts.
There may be delusions in mania, but they are of a more confused kind and the acts are more purposeless, while in melancholia there is the evidence of some plan. The conversation is more incoherent. Maniacs will heap abuse on all around them, and are inclined to use violence. They commit self-abuse, and may become shameless in the exposure of the person. The bodily health often does not suffer greatly, and they seldom die unless their health is broken at the commencement of the attack, in which case they may wear themselves out. They eat heartily, but generally grow thin, although not very rapidly. There is want of sleep. Sometimes they will pass a good night, getting several hours of sleep, and then may go several days with only two or three hours' sleep, shouting, laughing, and singing. The tongue is often clean, and the bowels are not generally constipated; hence maniacal cases do not yield to medical treatment as readily as some cases of melancholia. Chloral may be of benefit to procure sleep. The doses should be large, from 40 to 60 grains. Opiates are given by some and condemned by others. The prognosis, when acute mania is not complicated with other disease, is on the whole favorable. Much, however, will depend on the time which has elapsed since the commencement of the attack.
If this has been long, recovery will be doubtful because of the changes which have taken place in the brain, a continued state of hyper-semia producing chronic thickening of the cerebral membranes and changes in the brain substance. The patient may recover, or die with a hyperaemic state of the brain, or gradually sink into a state of hopeless chronic mania or dementia, or become melancholic. From this he may recover, and again become maniacal. Acute delirious mania, as described by Dr. Blandford, differs from the preceding in being accompanied with more delirium and with more bodily disorder. The tongue is often coated, sometimes brown and dry, and as the patient becomes exhausted a typhoid condition ensues. The urine is scanty and high-colored, and the bowels rarely act without laxatives. The treatment consists in regulating the bodily functions, giving food freely, combined with plenty of drink, and also wine, and in the judicious use of hydrate of chloral. Opium should not be given, as it obstructs the secretions and is liable to increase the delirium. Rest is of the highest importance, and baths of warm water, in which mustard may be stirred, are of great benefit, the head to be kept cool during the operation.
Purgatives at the outset of the attack may be of use, as aiding to arrest it. The termination is almost always recovery or death, melancholia or dementia rarely following. "Where an acute case of mania is neglected or badly treated, or is of a violent and persistent kind, it may pass into a chronic state in which there is either constant excitement of a less violent kind, or a fixed delusion. The patient gradually becomes feebler in intellect, although his bodily health may improve, and with variable degrees of rapidity sinks into a state of dementia. - General Paralysis of the Insane. The peculiar form of disease accompanied by insanity to which this name has been given is of the most formidable character, no instance of recovery in a well marked case having been recorded. The French physicians are entitled to the credit of having first recognized and described it. Esquirol was aware of the complications of insanity with paralysis, but did not recognize the whole as a distinct disease. Bayle in 1822 attributed the cause to chronic inflammation of the arachnoid, and named the disease arachnitis chronique. M. Calmeil in 1826 gave a complete account of it, and for that reason he is often called its discoverer.
It has received several names, as folie paralytique, paralysie generale progressive, and Geisterkrankheit mit Paralyse. In England and America it has usually been called general paralysis of the insane, or paralytic insanity, and lately it is often called simply "paresis." It is generally regarded as presenting three stages: 1, the period of incubation; 2, the acute maniacal period; 3, the period of chronic mania, lapsing into dementia, with utter prostration of both mind and body. At the commencement of the disease an alteration in the manner of the patient may be observed, similar to that which is noticed in other forms of insanity, although there are commonly other symptoms which are of importance in forming a diagnosis, such as excessive extravagance in the spending of money. A general paralytic is liable to commit outrageous and immodest acts, such as exposure of person and foolish assaults upon women; he is easily aroused into a passion, which often rises to uncontrollable fury; he neglects his business, fails to keep appointments, and exhibits a general weakening of the mind similar to that in the commencement of senile dementia. This, occurring in a vigorous man, cannot but be regarded as a remarkable symptom, and of alarming import.
These symptoms increase rapidly, so that the disease will have greatly advanced in a few weeks. He sleeps badly, eats and drinks irregularly and often voraciously, spilling his food on his dress, of which he takes but little care. He is for a time sullen and morose, but as the disease advances grows more and more excitable; and it soon becomes evident that he needs restraint. A maniacal condition ensues, in which he assumes airs of great importance, imagines himself possessed of unbounded riches, and the owner of studs of the fleetest horses. An ordinary maniac may imagine himself a duke and the possessor of vast wealth, but he will show some consistency in adhering to the same delusion; while the general paralytic will style himself a duke, a prince, and a king almost in the same sentence, and will announce his intention of doing a hundred impossible things on the next day. He has extravagant notions of his intellectual, and particularly of his physical strength, and when in the last stages of bodily weakness will maintain that he can perform the most wonderful feats. He nearly always says that he feels well, even when not able to feed himself. In consequence of these peculiar symptoms, the French have called the disease manie des grandeurs.
His speech generally shows the first effects of paralysis, although it sometimes commences in the lower extremities. The articulation becomes obstructed, somewhat like that of a drunken man. It is not a true stammer, but shows a want of power over the vocal organs. There is often a peculiar tremulousness of the lips, such as is seen in grief. The defect in speech varies from time to time, sometimes not being noticeable except to the practised physician, and at others rendering the patient unintelligible. The subjects of the disease are almost always men in the prime of life. It does not attack boys or old men, and rarely women. The violence of the mania attending general paralysis is of the most dangerous character; its subjects become possessed with a blind fury, and know not what they are about. In this stage they are not paralyzed sufficiently in their limbs to prevent them from doing serious harm; therefore the restraints of an asylum are almost absolutely necessary. Other symptoms appear in time. Fits resembling apoplexy or epilepsy occur from time to time, dividing the disease into stages.
They are called "congestive," or "paralytic," or " epileptiform " attacks, and resemble sometimes the petit mal of epilepsy, at others the grand mal.. Again, they may not be attended by any convulsion, but by sudden collapse and paralysis, which slowly passes away. The epileptiform attacks have not the definiteness of epileptic fits, but may last an hour or two, or pass off so rapidly that the patient may continue standing. It is important to distinguish these fits from those of true epilepsy, as the latter are more benefited by treatment, even when accompanied by insanity. In fits of general paralysis patients seldom bite the tongue, while in epilepsy they almost always do. The pupils of the eyes will generally be found irregular, and when this symptom is present it is important. In 108 cases of general paralysis examined by Dr. Nasse of Siegburg, the irregularity was present in all but three. Dr. Austin found only two exceptions in 100 cases. Irregularity of the pupils may, however, exist in other forms of insanity, and also in the sane in other affections of the brain, but it is much more rare. "When accompanied with the other symptoms of general paralysis, it may be considered pathognomonic.
The course of general paralysis has an average duration of about two years; some few cases last only a few weeks, and some may run on for five or six years. The maniacal or second period may last from a week to two months, and generally yields to treatment, the patient getting better, so that he is able to go about and appear like a sane man for a while; or he passes into a state of dementia, and so on downward to extinction of mind and body. Sometimes after apparent recovery the subjects of this disease may attempt to reengage in business, but such attempts have always been found to fail. The last stage, that of dementia, is sad indeed, and it is fortunate that the disease is rapid in its progress. The patient can scarcely walk or feed himself, and there is constant tremor of the hands; a habit of grinding his teeth in a most horrible manner comes on at this time; and his appetite remains good, but the power of swallowing is greatly diminished, and he will often go on cramming food into his mouth until he becomes nearly suffocated. The cause of general paralysis is a subject of discussion. Some authorities have but little doubt that it is generally produced by fast living, excess in wine and in sexual intercourse, particularly the latter.
Others deny this, saying that it may arise from extreme mental exertion, greatly prolonged, and point to examples in men of a high order of intellect in which this was the only assignable cause. "Whenever it attacks women, which is but rarely, it is nearly always those who have led irregular lives. Dr. Dickson has observed that its subjects are almost invariably men who have had no children. If this be a rule, it may point to a hereditary origin, and also to a tendency to die out. He also inclines to the opinion that the excesses of the patients are more to be regarded as evidences of the disease than as causes. - The insanity which accompanies true epilepsy, and which is known as epileptic insanity, has of late years received much attention, and many remarkable relations have been established between it and other diseases and insanity, especially that form called impulsive insanity. The tendency to epilepsy is hereditary, although it may be produced by blows on the head and other injuries to the brain. It has been found to have strong relations to paralysis, to chorea, and also to phthisis, which are indicated by the fact that children of tuberculous parents may inherit epilepsy, chorea, or paralysis, and vice versa; or insanity in offspring may follow these diseases in parents.
These diseases may also follow each other in the same individual, an attack of mania appearing in place of epilepsy, the latter, however, being the primary disease. The investigations of Dr. Echeverria have aided in establishing many important facts in regard to the subject, which had previously received the attention of Delasiauve, Morel, Falret, Baillarger, Trousseau, and others. They comprised the examination of more than 700 epileptics, embracing a period of over 13 years. The recorded cases number 532, of which 267 were cases of epileptic insanity, comprising 141 males and 126 females. Out of these the causes were distinctly ascertained in 123 males and 104 females. Insanity, paralysis, or epilepsy occurred among the ancestors of 37 males and 46 females; among the ancestors of the 37 males there were 11 cases of phthisis, and among those of the 46 females there were 13 cases of phthisis. He found that epileptic insanity may have an intermittent, remittent, and a continuous form; the intermittent being characterized by periodical attacks of variable regularity, the remittent having only partial recovery of intellectual soundness between the epileptic paroxysms and maniacal attacks, and the continuous form presenting a permanent and unmodified condition of insanity.
Dr. Echeverria does not find that the petit mal and the grand mal of epilepsy exercise so different an influence upon the violence of the succeeding maniacal attacks as has by some been supposed. The acts of the epileptic insane are always sudden and instantaneous, and beyond the control of the will; but it must not be assumed that the mania which causes the acts is itself instantaneous. He thinks that most of the cases of mania transitoria are those of epilepsy or epileptic insanity. Epileptic insanity is of a violent and dangerous character, with strong homicidal tendencies, and is remarkable from the fact that the patient during his maniacal excitement, which may last for hours, and during which he may be wandering around, is wholly unconscious. (See also Maudsley, " Responsi-bility in Mental Disease," 1874.) - The aphasia which occurs in certain cases of insanity is believed by many to have found an explanation in the experiments of Dr. Ferrier of King's college, London, which are regarded as strong evidence of the localization of cerebral functions; but the correctness of this conclusion is denied by Dr. Brown-Sequard in a paper read before the national academy of science at Washington in April, 1874. - Dementia, or loss of mind, may be primary, or it may be secondary to other forms of insanity, as mania, general paralysis, epilepsy, and more rarely melancholia, and differs from idiocy and imbecility in not being congenital.
It is the inevitable stage into which degeneration of brain tissue, if continued long enough, always passes, and is of course incurable, the only treatment being that directed to the general health, and when possible ministering to the comfort of the sufferer. - Idiocy and Imbecility. The great difference between these conditions is, that though they are both congenital, the subjects of the former have badly shaped and deficiently developed brains, while those of the latter are usually well shaped, but fail in consequence of congenital pathological conditions similar to those found in dementia. This condition is to a certain though less extent also found in idiots, but many of them are more susceptible of mental cultivation than imbeciles, because the brain of the idiot may be somewhat developed by exercise. (See Idiocy.) - Pathology of Insanity in general. The subject of an attack of acute mania may die in a week from the commencement. A post-mortem examination shows the cerebral membranes congested; the sinuses and the veins of the pia mater may be full of blood, and there may be effusion of serum beneath the arachnoid and the serous membrane.
In those who have had previous attacks or who have been partially insane there is often thickening of the bones of the cranium, with adhesion and thickening of the dura mater, indications of a chronic inflammatory condition. The brain will present discolored patches of a pink or purple hue, and also softening. The cells, nerve tubes, and connective areolar tissue may also be found more or less changed. Blood cysts are often found in the cavity of the arachnoid, and extravasated blood on the surface of the convolutions and in the cerebral substance. In cases of chronic mania and dementia there are usually more definite changes. The nerve cells are altered in character, and the nerve tubes leading from them are shrunken and sometimes disconnected. The inferior tissues are increased, and abnormal tissues take the place of those that are healthy, interfering with the functions of that which remains. The wasting of the brain is an important pathological condition. There is a loss of substance, the brains of the insane weighing less in proportion to the cavity of the cranium than in other cases.
Dr. Lockhart Clarke has pointed out peculiar and numerous cavities in the white substance of the convolutions and of the optic thalami of the brains of chronic maniacs and the demented, and also in those who have died of general paralysis. These cavities are generally regarded as widened perivascular spaces, formed by the dilatation of the perivascular canals which surround the blood vessels (probably the adventitious tunic of Vir-chow). They are called perivascular cavities, and present the appearance of holes seen in Gruyere cheese. They are generally empty, having smooth walls, without any lining membrane, but some of them containing the vestiges of blood vessels, with a few granules of haematoidine. Drs. Batty, Tuke, and Rutherford have also observed holes differing somewhat from these, which, from their ragged character, they regard as produced by a solution of continuity of brain tissue, or to extravasation and subsequent absorption of blood. The cells of the corpora striata and other nerve centres, and of the convolutions, are found in a state of pigmentary degeneration, and sometimes in place of this fatty degeneration.
Rind-fleisch, Rokitansky, Wedl, Tuke, and Rutherford have pointed out hypertrophy of the connective tissue in long standing cases of insanity, and particularly in the cortical layers of the brain in general paralysis. Increase of connective tissue was at one time thought to be peculiar to general paralysis, but it is now known to be common to dementia following chronic mania, as well as that which is consecutive to syphilis and in congenital idiocy. Schroeder van der Kolk found dark pigmentary degeneration in the ganglionic cells of the hypoglossal nerve, in a case of dementia after mania, where there was partial paralysis of the tongue. Pigmentary changes of a like nature have been found in the retina, in what is called retinitis pigmentosa; and it is an interesting fact that they occur in members of the same family and where there is common deficiency of development. A pathological condition has been found in general paralysis by Drs. Poincari and Henri Bonnet, which it is thought will throw much light on the nature of this peculiar disease. They have found brown pigmentary degeneration in the ganglionic cells of the whole chain of the great sympathetic nerve, to a degree far greater than in other cases.
In the cervical and thoracic ganglia they found a substitution of adipose cells for nerve cells, and they are led to believe that this is the starting point of the disease. A remarkable morbid appearance sometimes found, called the insane ear, or haematoma auris, caused by an effusion of blood between the perichondrium and cartilage, which without bursting shrinks away and leaves the ear shrivelled, is a peculiar and it is thought certain evidence that the person is or has at some time been insane. The subject received particular attention from Dr. E. R. Hun while special pathologist to the New York state lunatic asylum at Utica; and from his investigations, which were published in the "American Journal of Insanity" for July, 1870, he established the following general conditions. Preceding the appearance of the tumor, one (rarely both) of the ears becomes red and swollen, the face and eyes of the patient at the same time indicating strong determination of blood to the head. Sometimes, however, the redness is absent, while the tumefaction is caused by an cedematous state of the auricle.
In the course of a few hours, or it may be several days, an effusion of blood appears on the concave surface of the auricle, varying in size from a bean to a hen's egg, in the latter case obliterating the natural ridges and depressions. Although apparently hard and unyielding, a careful examination detects a feeling of fluctuation and sometimes slight crepitation, supposed to be owing to the breaking up of blood clots. The skin is smooth and distended, and of a purple color, except that of the lobe, which is unchanged. If the skin is ruptured, clotted blood escapes; and if let alone, the opening closes and the sac refills. If kept open, however, a sero-purulent discharge takes place, which may continue for a long time, exudation of plastic lymph occurring in the mean time, uniting the walls of the cavity, and by subsequent contraction of the cicatrix producing the peculiar shrivelled appearance which is the sequence of the acute affection. When the sac does not become ruptured, much less deformity results.
Examinations of the pulse of the insane have revealed some remarkable characteristics, which are described in the article Pulse. - Enumeration of the Insane. The following table of the insane in various countries, compiled from the report of Dr. E. T. Wilkins, commissioner in lunacy for the state of California, made in December, 1871, contains the most complete synopsis of information that can be procured at the present time:
Date of information.
No. of institutions.
No. of insane in institutions.
Total number of insane.
• • • ■
Other German states..
• • * ■
No. of patlenti at close of 1873.
Concord, N. H......
Providence, R. I....
* Including idiots. † In 1861.
Table of Institutions for the Insane - continued.
No. of patients at close of 1873.
Bloomingdale, N. Y..
Ward's Island, N. Y..
Ward's Island (emigrant),N.Y.......
Flushing, N. Y......
Flatbush, N. Y......
Troy, N. Y......
Utica, N. Y......
Willard, N. Y......
Auburn (crim'l), N.Y.
Canandaigua, N. Y...
Middletown, N. Y....
Trenton, N. J.....
Pennsylvania Hospital for Insano, Philadelophia.......
Friends' asylum, Phil adelphia......
Burn Brae, near Philadelphia......
Mount Hope, Md....
Washington, D. C...
Weston, W. Va......
Raleigh, N. C......
Columbia, S. C.....
Mil ledgeville, Ga......
Batavia, Bellevue pl. 111...............
Mount Pleasant, la..
St. Peter, Minn......
St. Louis co., Mo....
St. Vincent's (St louis),Mo.....
Steilacoom, W. T....
- See the works of Thomas Arnold, P. H. Pinel, James Cowles Prichard, E. Esquirol, J. Haslam, J. Conolly, Pliny Earle, J. Thurman, Brierre deBoismont, F. J. Broussais, Feuchters-leben, Georget, and Bucknill and Tuke; "Medical Jurisprudence of Insanity," by I. Ray (Boston, 1838, and later editions); "Medical Jurisprudence of Insanity," by I). Tilden Brown, in Beck's " Medical Jurisprudence;" " Mental Pathology and Therapeutics," by W. Grie-singer, translated from the German (London, 1867); "Insanity and its Treatment," by G. FieldingBlandford(Philadelphia, 1871); "Physiology and Pathology of the Mind," by Henry Maudsley (London, 1872); "Insanity and its Relation to Crime," by W. A. Hammond (New York, 1873); "Contributions to Mental Pathology," by I. Ray (Boston, 1874); "Medicine in Relation to Mind," by J. Thompson Dickson (London, 1874); " Responsibility in Mental Disease," by Henry Maudsley (New York, 1874); "Mental Physiology," by William B. Carpenter (London, 1874); '"West Riding Lunatic Asylum Reports;" "Journal of Mental Science " (London); " American Journal of Insanity " (Utica, N. Y.); and the Annales Medi-co-psychologiques (Paris).