INSANITY; 
ITS NATURE, PATHOLOGY, AND TREATMENT. 
BY 
►EDWARD C. MANN, M. D., 
MEDICAL SUPERINTENDENT OF STATE EMIGRANT LUNATIC ASYLUM, WARD’S ISLAND. 
NEW YORK. 
[.REPRINTED FROM THE N. Y. MEDICAL .JOURNAL, DEC., 1874 ] 
NEW YORK : 
D. APPLETON AND COMPANY, 
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1874. APPLE I ONS’ JOURNAL, 
FOE 1875. 
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D. APPLETON & CO., Publishers, New York. IN' 8AN'ITYr; 
ITS NATURE, PATHOLOGY, AND TREATMENT. 
I3Y 
EDWARD C. MANN, M. D., 
MEDICAL SUPERINTENDENT OP STATE EMIGRANT LUNATIC ASYLUM, WARD*3 ISLAND, 
NEW YORK. 
[.REPRINTED FROM 1UE N. Y. MEDICAL JOURNAL, DEC., J3T4 } 
NEW YORK: 
D. APPLETON AND COMPANY, 
549 & 551 BROADWAY. 
1874. INSANITY; 
ITS NATURE, PATHOLOGY, AND TREATMENT. 
From the earliest period in the history of medicine, mental 
diseases have been recognized, more or less classified and treat- 
ed, as a rule, as worthy of the utmost attention that science and 
humanity could dictate. As far back as the days of Hippoc- 
rates, insanity was recognized as appearing under different 
forms and conditions of mind. Hippocrates, in writing of 
insanity, mentioned three states in which mental disease was 
manifested: mania, melancholia, and dementia. Celsus also 
recognized three kinds of insanity. The old Homan laws di- 
vided the insane into two classes: furiosi, those who were 
violent and maniacal; and mente capti, those who were suf- 
fering from dementia, or weakness of intellect. The ancient 
writers, although very crude in their ideas of insanity, recog- 
nized, as a rule, the different mental states accompanying ma- 
nia, melancholia, and dementia. Different writers, in modern 
times, have attempted various methods of classification; but the 
simple and yet comprehensive one of Pinel has really been the 
foundation-stone on which all succeeding writers have reared 
their modern systems of classification. The classification just 
alluded to includes the four great primary mental states or 
conditions of insanity, namely: mania, melancholia, demen- 
tia, and idiocy. As most writers on insanity prefer to enlarge 4 
INSANITY. 
on sucli simple classifications, and elaborate them somewhat, 
the question arises, What are the best grounds on which to 
found our classification ? This question has been ably answered 
by many writers. The etiology, or causes of insanity, has 
been made the basis of two very excellent classifications; the 
first, by Dr. Morel, in his “ Traite des Maladies Mentales,” 
published in 18G0 ; and the second, a later and more elaborate 
one, by Dr. Skae. The International Congress of Alienists, 
at their meeting in Paris, in 1867, adopted a combination of 
the etiological and symptomatological methods under seven 
heads: 1. Simple Insanity; 2. Epileptic Insanity; 3. Para- 
lytic Insanity; 4. Senile Dementia; 5. Organic Dementia; 
6. Idiocy; 7. Cretinism. Drs. Bucknill and Tuke, in their 
“Manual of Psychological Medicine,” third edition, 1874, 
have adopted a combination of the symptomatological and 
psychological method of classification. They have divided it 
under five heads, or divisions, as follows: 
I. Idiocy, Imbecility, and Cretinism; states of undevel- 
oped intellectual power. 
II. Dementia ; a state in which the intellectual power has 
been destroyed. 
III. Delusional Insanity; under which head they embrace 
all states in which marked delusions are present: melancholia, 
with delusions; monomania, with delusions; and homicidal 
and suicidal insanity, with delusions. 
1Y. Emotional Insanity, or morbid states of the emotions, 
without delusion, whether attended by melancholia or excite- 
ment. 
Y. Mania. In conclusion, it is remarked that “all these 
forms or varieties of insanity are liable to complication with 
epilepsy, or, if acquired, with general paralysis.” 
These classifications are for the most part excellent for 
study; but, for actual practice, the simpler the classification 
the better for the general practitioner. 
Etiology.—In the study of mental diseases, the first great 
question that naturally presents itself to the mind is, "VVhat are 
the causes of insanity ? As in all other diseases, we find them 
to be both predisposing and exciting. The first and great pre- INSANITY. 
5 
disposing cause is, hereditary predisposition. This lias been 
noticed from the earliest history of the study of insanity. 
Esquirol observed and traced hereditary predisposition in 
about one-fourtli of all his cases of insanity. Guislain esti- 
mated hereditary predisposition at thirty per cent, of all cases 
of insanity. Micliea gave the opinion that at least one-half 
if not three-fourths of all the insane have either had at some 
past time, or have at the present time, some cases of insanity 
in their families. At the York Asylum, during twenty-seven 
years, from 1846 to 1872, hereditary predisposition was traced 
in thirty-one per cent, of all the admissions. With regard to 
hereditary predisposition, it has been determined that, as a 
general rule, if the mother is insane, the disease is more fre- 
quently transmitted to the offspring than if the father be affect- 
ed ; and also, the mother’s influence in transmitting insanity 
to girls is much more to be dreaded than if the offspring be 
a boy; likewise, as regards the father, insanity being much 
more certain to appear in male offspring, the father being 
affected, than in the female. There are, of course, many ex- 
ceptions to this rule; but the laborious researches of M. Ilail- 
larger have been accepted by the best authorities as highly 
probable, if not conclusive. It has also been proved that the 
lower forms of insanity, as imbecility, and also depression of 
mind, are in a marked degree hereditary. It has been re- 
marked that the outbreaks of insanity, in persons who inherit 
a predisposition to it, generally make their appearance, and 
seem to be in some manner connected with, the growth and 
processes of evolution of the individual, as the periods of pu- 
berty, childbirth, climacteric period, etc. 
Insanity also may appear either in the same form in suc- 
ceeding generations, or it may assume an entirely different 
form of insanity, or even of nervous disease. Thus, it is com- 
mon to see cases in which, the parent suffering from mania, 
the offspring may develop symptoms of epilepsy or chorea. 
Some authors have held that nothing -was transmissible to the 
offspring but an aptitude, or predisposition, to some disease 
of the nervous system, and that the development of any par- 
ticular type or form of nervous disease was largely the result 6 
INSANITY, 
of circumstances subsequent to birth. The diseases most fre- 
quently presenting themselves as the result of hereditary pre- 
disposition have been found to be, aside from the typical forms 
of insanity, hypochondriasis, apoplexy, paralysis, epilepsy, 
convulsions, chorea, hysteria, and neuralgia. Undoubtedly, 
next to hereditary predisposition, may be ranked, in the pres- 
ent day, as a predisposing cause of insanity, the great mental 
activity and strain upon the nervous system that appertain 
to the present age and state of civilization. The same fever- 
ish haste and unrest which characterize us as a nation to-day, 
and the want of proper recreation and sleep, tend to a rapid 
decay of the nervous system, and, sooner or later, the most 
overworked and overstrained minds stagger beneath the ex- 
cessive burden ; and, one by one, brilliant intellects and ster- 
ling men are lost to the world, who, if they had exercised mod- 
eration in their respective pursuits, might have been spared for 
years to enjoy the fruits of their industry. Among other pre- 
disposing causes may be mentioned those included by the In- 
ternational Congress of 18GT, namely, great difference of age 
between parents; influence of sex ; of surroundings ; convul- 
sions, or emotions of the mother during gestation ; epilepsy; 
other nervous diseases; pregnancy; lactation; menstrual pe- 
riod ; critical age ; puberty ; intemperance ; venereal excess ; 
and onanism. Among the exciting causes of insanity may be 
mentioned—trouble, and excessive grief; intemperance; ex- 
cessive excitement, of whatever kind ; epilepsy; disordered 
functions of menstruation ; pregnancy ; parturition ; lacta- 
tion ; fevers ; injuries to the head or spine, and overwork. 
With regard to intemperance, it has been calculated that from 
twelve to twenty per cent, of most admissions to asylums are 
from this cause. It is a fact of importance that the children 
of habitually intemperate parents often inherit a predisposi- 
tion to mental diseases, which generally appear in the form of 
weakened mental faculties, as in dementia, or that they are en- 
tirely wanting, as in idiocy. Domestic troubles and griefs are 
a frequent cause; and it is roughly estimated that from twelve 
to fifteen per cent, of admissions are from this cause. Under 
the head of exciting causes are also included physical causes, INSANITY. 
7 
as artificial deformities of the cranium, organic disease of the 
brain, etc. 
When we see how readily and inevitably the future mental 
state and characteristics of the next generation are determined 
by the health and proper mode of living of the present one, 
it behooves all physicians, who, perhaps, more than any 
class of men, are placed in the closest and most confidential 
relations to their fellow-men, to endeavor to promote such 
modes of living and thinking, that the descendants of the pres- 
ent generation may be the gainers, and not the losers, by their 
advice. The very mental states and emotions of a pregnant 
woman are indelibly impressed upon the offspring; and how 
important it is that the condition of such a woman should be 
expressed by the old motto, Mens sana in corpore sano ! Her- 
bert Spencer, in speaking of the emotions, remarks: “ We know 
that emotional characteristics, in common with all others, are 
hereditary; and the differences between civilized nations, 
descended from the common stock, show us the cumulative 
results of small modifications hereditarily transmitted. And, 
when we see that between savage and civilized races, which 
diverged from each other in the remote pa.st, and have for 
a hundred generations followed modes of life becoming ever 
more unlike, there exist still greater emotional contrasts, may 
we not infer that the more or less distinct emotions which char- 
acterize civilized races are the organized results of certain daily 
repeated combinations of mental states which social life in- 
volves? Must we not say that habits not only modify emo- 
tions in the individual, and not only beget tendencies to like 
habits and accompanying emotions in descendants, but that, 
when the condition of the race makes the habits persistent, this 
progressive modification may go on to the extent of producing 
emotions so far distinct as to become new ; and if so, we may 
suspect that such new emotions, and by implication all emo- 
tions, analytically considered, consist of aggregated and con- 
solidated groups of these simpler feelings, which habitually 
occur together in experience; that they result from combined 
experiences, and are constituted of them ? ” 
Diagnosis.—The next question which engages our attention 8 
INSANITY. 
is the diagnosis of insanity, and here not only the astute and 
experienced physician is needed, but he must also bring to 
bear upon the case all his knowledge of human nature, and 
must be a good physiognomist, as very often he will be com- 
pelled to make up his mind as to the sanity of his patient by 
his own unaided resources, depending entirely upon the con- 
duct, conversation, and appearance of the individual. It is 
often extremely difficult to obtain any thing like a complete 
or satisfactory history of the patient; as the friends, disliking 
to acknowledge a taint of insanity in their family, considering 
it a disgrace, will deny the fact of hereditary predisposition, 
which is one of the most important facts relating to both diag- 
nosis and prognosis. The question relating to the existence of 
previous attacks is also one of the most important points to 
the physician, and it has been remarked that the two facts 
as to hereditary predisposition and previous attacks are to the 
diagnosis of insanity what the fact of haemoptysis is to the 
diagnosis of consumption. There is often an entire change, in 
persons becoming insane, as to habits and disposition. One 
marked case of a young girl, who is at the present time under 
our charge, may serve to illustrate the diagnostic value of such 
changes. The young person just alluded to belonged to a 
healthy family, but her grandfather had suffered from acute 
melancholia. Her father and mother were both perfectly 
healthy. She was religiously inclined, never omitted prayers, 
and was regarded by her friends as in every respect a model 
young girl. About six months ago, she exhibited an utter 
change in her habits and actions, from no assignable reason. 
She talked and acted very strangely, and once or twice un- 
dressed herself and persisted in remaining in this condition. 
She refused to attend church, and, from being a quiet and well- 
behaved young lady, became precisely the reverse. Upon 
being called upon to give an opinion in the case, after care- 
fully watching and conversing with her, and finding that her 
grandfather had been insane, and noting the symptoms above 
alluded to in her behavior, we pronounced her insane, an opinion 
which an attack of acute mania, within a week from the time 
of examination, fully confirmed. There are sometimes marked 
peculiarities of dress, manner, and gesture, in the insane, which INSANITY, 
9 
are important when taken in connection with hereditary pre- 
disposition, as diagnostic symptoms. As regards the bodily 
health of the patient, it is important to discover whether there 
are symptoms of gastric, hepatic, or uterine disease; for, al- 
though the mere existence of these difficulties would by no 
means indicate that a person suspected was really insane, yet, 
as they are sometimes the remote causes of cerebral disturb- 
ance, a proper attention should be paid to them as aids to 
diagnosis. Regarding the insane physiognomy, it has been 
noticed that there is oftentimes a marked want of accord in 
the expression of the different features. To a practised eye, 
the facial expression in cases of acute melancholia and demen- 
tia is easily recognizable. In dementia all lines of expression 
disappear, and the meaningless laugh and stare, and vacant 
expression, indicate clearly the nature of the disease. On the 
other hand, mental disease in some instances leaves no imprint 
whatever on the features, by which to distinguish the mental 
state. It is generally easy to recognize acute mania by the 
symptoms accompanying it: loss of sleep, incoherence of 
speech, violence of action, hallucinations and delusions, being 
the most prominent symptoms. In melancholia, the symp- 
toms most frequently met with are sadness, depression of 
mind, and fear. The expression, too, is very characteristic in 
this form of insanity. The sadness of countenance, dry and 
harsh skin, want of clearness in the complexion, and in some 
instances the terrible expression of fear and dread, which 
spreads over the patient’s face, are perfectly diagnostic marks 
of melancholia, which are not to be mistaken. In the general 
paralysis of the insane, the slurring speech, peculiar gait, mus- 
cular tremor and trembling of the lips while speaking, are all 
signs not to be mistaken when once seen. 
Prognosis.—The prognosis of insanity is a question of much 
interest, and is often a very difficult point to determine. The 
cases most unlikely to recover are those in which the insane 
temperament or diathesis is clearly manifested, and who in- 
herit a predisposition to disease. Such patients, although they 
may have lucid intervals, rarely if ever entirely recover. The 
other types of insanity in which we rarely see cures are imbe- 
cility and idiocy, dementia, general paralysis (which is one of 10 
INSANITY, 
the varieties least amenable to treatment) and epileptic in- 
sanity. On the other hand, acute mania, acute melancholia, 
hysterical insanity, and puerperal insanity, not unfrequently 
completely recover. The first symptoms of recovery are the 
return of natural tastes, inclinations, and affections, in the pa- 
tient. Drs. Bucknill and Tuke, in speaking of symptoms of 
recovery, lay down the following as evidences of restoration of 
the mind: 1. A natural and healthy state of the emotions ; 2. 
The absence of insane ideas or delusions; 3. The possession 
of sufficient powers of attention, memory, and judgment, to 
enable the individual to take his part as a free member of so- 
ciety ; 4. Tranquil and reasonable conduct, and say regarding 
them, “ When these four symptoms of recovery coexist, there 
can he no doubt that recovery has taken place.” 
Pathology of Insanity.—Owing to the great difficulty and 
labor incident upon making a thorough examination of the 
brain in cases of insanity, the pathology of insanity is as 
yet in its infancy; but already valuable information has been 
obtained by microscopical investigations, and much more will 
doubtless be discovered in a few years of microscopical re- 
search. Regarding the existence of morbid changes in the 
brain accompanying mental disease, Portal wrote as follows : 
“ Morbid alteration in the brain and spinal marrow has been 
so constantly observed, that I should greatly prefer to doubt 
the sufficiency of my senses, if I should not at any time dis- 
cover any morbid changes in the brain, than to believe that 
mental disease could exist without any physical disorder in 
this viscus, or in one or other of its appurtenances.” M. 
Parchappe, the Inspector-General of Asylums in France, has 
made very careful and thorough investigations regarding the 
pathology of insanity, and published the following conclusions: 
That the pathological changes met with in insanity may be 
divided into three classes : those which may be considered ac- 
cidental ; those which are found in other diseases, yet appear to 
be concerned in the production of insanity; and, lastly, those 
which he considers as essential to mental disease. Among the 
first he mentions cerebral haemorrhages, softening of the white 
substance, and disease of the cerebral arteries. Among the 
second, thickening and opacity of the arachnoid, hypersemia INSANITY. 
11 
of the pia mater and of the brain, serous infiltration of the pia 
mater, and collections of fluid in the arachnoid cavity. Under 
the last head, or the changes considered essential to mental 
disease, he mentions subarachnoid ecchymosis, and a partial 
punctiform injection of the cortical surface, with or without 
softening, extended softening of the middle portion of the corti- 
cal substance, adherence of the pia mater to the surface of the 
brain ; rose, lilac, and violet-colored discoloration of the corti- 
cal substance, loss of color of the cortical substance, atrophy 
of the convolutions and induration of the brain. In conclu- 
sion, M. Parchappe remarks that in acute insanity the promi- 
nent alterations are hypersemic conditions, with arachnoid ec- 
chymoses and injection and softening of the cortical substance; 
while in chronic insanity the predominant alterations are atro- 
phy of the convolutions and induration of the two substances. 
Griesinger, the eminent Berlin pathologist, gives, as the result 
of his labor in the pathology of insanity, the following morbid 
conditions: hypersemia of the brain and membranes, thicken- 
ing and opacity of the membranes, softening of the cortical 
substance, and pigmentation of the cortical gray substance in 
acute insanity; while in chronic insanity the principal lesions 
he noticed were opacity and thickening of the membrane, 
atrophy of the brain, particularly of the convolutions, chronic 
hydrocephalus, effusions into the subarachnoid space, pigmen- 
tation of the cortical substance, and extended and profound 
sclerosis of the brain. lie remarks that in chronic insanity 
softening is not so frequently met with in the superficial layer 
as pigmentation, superficial induration and adhesion of the 
pia mater. 
Histology.—The microscopical investigations of the histol- 
ogists of the present day have done a great deal in revealing 
the morbid histological changes which take place in insanity. 
Regarding the condition of the membranes, it has been found 
that, while the dura mater is rarely thickened, its vessels 
are dilated and irregular, and that the coats of the vessels are 
much hypertrophied. The arachnoid has been found by 
Meyer to be often covered with fine granulations on its sur- 
face, and it has also been found to be the seat of haemorrhage, 
and also thickened. The pia mater has often been found 12 
INSANITY, 
thickened, and a hyaline appearance has been noticed around 
the vessels, which has been attributed in part to the action of 
reagents. Dilatation of the vessels has also been noticed. In 
a microscopical preparation, from a case of chronic insanity, in 
the possession of the writer, the thickening of the pia mater is 
very marked, and a cut vessel presents very beautifully the 
marked thickening of the coats. The brain-substance in the 
same specimen is seen to be dilated where it surrounds the 
vessels. In another preparation, from a case of chronic mania, 
the only abnormal appearance is a deposit, scattered through- 
out the brain-substance, of newly-formed cells containing a 
nucleus and nucleolus, which show very clearly when viewed 
with a quarter-inch objective, carmine staining having been 
employed. The pathological changes observable at the post- 
mortem examination of this case were atrophy of the brain 
and convolutions, and partial sclerosis of the brain, with thick- 
ening of the membranes and slight subarachnoid effusion. 
The blood-vessels of the brain have been found to present 
thickening of the coats, thickening of the sheath or hyaline 
membrane, deposits between the adventitia and sheath, and 
proliferation of nuclei. The neuroglia has been found to be 
the seat of various lesions in insanity, the principal of which 
are disseminated sclerosis or gray degeneration, atrophy, mili- 
ary sclerosis, and colloid degeneration. The cells are the seat 
of atrophy, pigmentary, granular, or fuscous degeneration, cal- 
cification, and hypertrophy. Microscopical examination of 
the spinal cord in the insane has not revealed any particular 
lesion except in general paresis. Dr. Westphal describes an 
atrophied condition of the cells of the posterior columns in 
general paresis and an increase of the connective tissue, com- 
mencing externally and extending inward. Dr. Tuke says 
that, in most cases of general paralysis which he examined, the 
C3lls of the cord were found undergoing the fuscous, granular 
degeneration before alluded to as affecting the cells of the 
hemispheres and corpora striata. The cells of the cervical 
sympathetic have also been found undergoing pigmentary 
granulation in general paralysis, and also in other forms of 
insanity. 
Treatment of Insanity.—Although it is not generally so INSANITY. 
13 
regarded, insanity is one of the most curable of serious dis- 
eases if promptly cared for and treated. The mistake which 
is committed every day by foolish friends and relatives, of 
keeping secret as long as possible the fact of the patient’s in- 
sanity, thereby depriving him of the necessary care and treat- 
ment at the outset of the disease, is often fatal to the pros- 
pects of recovery of the unfortunate patient, who is only sent 
to an asylum when he has become perfectly unmanageable, 
and the disease has become deeply seated. It has been stated 
by eminent authority that if persons who wrere attacked by 
this disease were cared for as promptly as if they were suffer- 
ing from an attack of dysentery or fever, eighty or ninety 
per cent, could be restored to health and usefulness. There 
is no disease, however, which develops more rapidly if not 
treated, and tends to induce organic degeneration which ren- 
ders it incurable. From a financial point of view it pays well 
to restore the insane as soon as possible to usefulness and 
health, and thereby save the Commonwealth the cost entailed 
by the loss of his labor, and also the amount that has to be 
paid for his board and clothing, which at the lowest estimate 
amounts to not less than $156 a year, or $3 per week. Dr. 
Edward Jarvis, of Dorchester, Mass., who has made very 
laborious investigations upon the subject, in a paper entitled 
“ The Political Economy of Health,” presents the following 
view of the gain or loss entailed upon the State or family of 
an insane man by his cure, or by his remaining a lunatic for 
the period of life left to him after his attack. According to Mr. 
John Le Copelain’s table, showing the average longevity of the 
insane from any given age, it is seen that a man of twenty 
years of age, if sane, has an average life of 39.48 years, wdiile 
if insane he has but an average life of 21.31 years if not restored 
to health. Dr. Jarvis has estimated that, leaving out of sight 
the ten or twenty per cent, of the insane who are incurable, 
the average time for restoring to health the insane who ap- 
ply for treatment upon the early symptoms of disease is twen- 
ty-six weeks. At $4 per week, which was the average cost 
in the three State Lunatic Asylums in Massachusetts for the 
past year, this amounts to $104, to which is added $30 for each 
patient, for the cost of rent or interest on the value of the 14 
INSANITY, 
hospital, etc., for six months, making an average cost of 8134 
for restoration to health. If not restored to health, the family 
or State must he at an expense of $156 a year for 21.31 years, 
and must also lose the patient’s earnings for the 39.48 years 
which he would have made if well. The cost of the patient’s 
support is estimated at 82,121, while the loss of his future 
labor, if he becomes insane at twenty years of age, is estimated 
at 82,605.37, making a total loss of 84,786.37 if not cured; 
while, if cured in the average time of twenty-six weeks at a 
cost of 8134, there will be a gain to the family or to the State 
of 84,652. The foregoing is an admirable argument for send- 
ing insane patients to be treated in the early and curable 
state of the disease, and, if acted upon, would reduce by a 
large percentage the incurable cases which are now to be 
found in such great numbers. 
In ancient times the insane were regarded as possessed 
with devils, and were accordingly fastened with chains, hand- 
cuffs, and fetters, and confined in cages or dungeons, to drag 
out their miserable lives as best they could. 
As, in the commencement of this paper, we have seen that 
Pinel was one of the first to properly recognize and classify 
insanity, so in speaking of treatment we would refer to him, 
in his humane endeavors and successful efforts to do away 
with the beating and cruel treatment of the insane, as he has 
elsewhere aptly been termed, “The Father of the Modern 
Treatment of Insanity".” His pupil, Esquirol, also was the 
most successful of his immediate successors in carrying out 
Pinel’s ideas in treating insanity and in advancing the scien- 
tific knowledge regarding it. The treatment of insanity" has 
improved up to the present day, and the success which has 
been reached, in abridging maniacal attacks and warding off* 
dangerous excitement, gives us to-day a much different class 
of patients both in behavior and appearance than could have 
been found fifty years ago. This change, which has taken 
place gradually, as the natural result of improved modes of 
treatment, has not been fully recognized by the profession at 
large, as the following may serve to illustrate: A physician of 
large practice visited the asylum under our charge, a short 
time ago, and, after having been conducted through the vari- INSANITY, 
15 
ous wards of the institution, and noticing the women quietly 
sewing or reading, while many of the male patients were en- 
gaged in out-of-door employments, supposing that only the 
quiet and convalescent patients had been shown, as is some- 
times the case, desired to see the “raving and dangerous pa- 
tients,” and was exceedingly astonished upon being informed 
that the ward we had just left was the excited ward of the 
asylum, as the patients had been quiet and polite, and did not 
show the maniacal glare and ferocity of manner which he ex- 
pected to see. Me took this astonishment as the highest com- 
pliment which the gentleman could have possibly paid us, as 
our patients as a rule come from the lowest class of society, and 
are not accustomed to a great degree of self-control even when 
sane. The foregoing is a very simple illustration of what tri- 
umphs kindness and moral and hygienic treatment have achiev- 
ed over the cruel, harsh, and unsympathizing methods which 
characterized former times. One great rule to be observed 
in the management of the insane is, that they are invariably 
to be treated with kindness and consideration. Their peculi- 
arities should never be lost sight of, but should never be made 
the topic of conversation or ridicule. In the excited state of the 
nervous system in the insane, a careless or an unkind word is 
often deeply felt, and all efforts toward a cure may be rendered 
futile by the patient perceiving in his physician the want of 
sympathy and kindness of heart which he, above all others, has 
a right to expect and demand from ns. 
The insane are as amenable to kindness, as a rule, as sane 
people, and will almost invariably repay it by good behavior, 
while the opposite course is quite as sure to counteract all 
our efforts in their behalf. As in all other diseases, hygienic 
influences must be insisted on, and pure air, pleasant surround- 
ings, and good food, are of great importance. The mind, to be 
normal, must be associated with a healthy physical state, and we 
must in the treatment of the insane attend primarily to these 
things, and not by any means regard them as beneath our 
notice. Many people question the propriety of confining a 
patient in an asylum, private or otherwise, maintaining that, 
if they can afford to keep the patient at home and provide 
medical attendance and an attendant for him, he is much bet- 16 
INSANITY, 
ter taken care of. This is a very mistaken idea, and one very 
injurious to the patient himself. One of the most marked 
characteristics of the insane man is his intense egotism, if it 
may he so called; or, more properly speaking, it consists, in the 
language of Dr. Blandford, in an “ extreme concentration of 
the whole thought and ideas on self, and on all that con- 
cerns self.” At home he is more or less the master of the 
house, and regards himself, when restrained, as a deeply- 
injured man, and chafes much more, and is more truly a pris- 
oner, in his own home, than when allowed the comparative 
liberty of a well-regulated asylum. When in an asylum he 
loses or merges his identity more or less with his companions, 
which is an excellent thing for him, as he ceases to be the 
centre of observation and remark, and is treated and noticed 
precisely in the same way as are the thirty or forty other pa- 
tients who are occupants of the same ward. A very strik- 
ing instance of this kind occurred in a patient of good edu- 
cation who, upon becoming insane, fancied himself the Supremo 
Being, and insisted upon exercising all the fancied prerogatives 
of such a being. lie became very troublesome and danger- 
ous to those about him, and was entirely absorbed in the con- 
templation of his own greatness, which idea was fostered by 
the attention he received and the private room that he occu- 
pied. He was accordingly removed from his room to a ward 
in the asylum containing twenty or thirty other patients, and 
was given to understand that the amount of his liberty and 
the privileges which he enjoyed would depend entirely upon his 
behavior. He at once perceived, and at first angrily remon- 
strated against, the want of attention paid to his whims and 
caprices, but soon understood that he was not regarded by the 
attendants as in any -way superior to the other patients, and 
in their treatment of him was manifested no attention at all 
to his delusion. Finding his endeavors to exercise his au- 
thority fruitless, he gave up his imperious and unrestrained de- 
meanor, and soon submitted quietly to the order and discipline 
of the institution, and at the present time is one of the best- 
behaved patients in the ward, rarely recurring to his delusion* 
Regarding the moral treatment of the insane, the physician’s 
attributes have been well defined by Drs. Bucknill and Tuke, INSANITY. 
17 
as follows : “ The physician who aims at success in the moral 
treatment of the insane, must be ready ‘ to be all things to 
all men, if by any means he might save some.’ He must, 
nevertheless, have a good backbone to his character, a strong 
will of his own, and with all his inflections be able to adhere 
with singleness of purpose and tenacious veracity to the opin- 
ions he has on sound and sufficient reasons formed of his pa- 
tient, and the treatment needed to be pursued toward him. 
With self-reliance for a foundation to his character, it requires 
widely-different manifestations to repress excitement, to stimu- 
late inertia, to direct the erring, to support the weak, to sup- 
plant every variety of erroneous impression, to resist every 
kind of perverted feeling, and to check every form of perni- 
cious conduct.” 
Out-of-door work is very valuable for patients in promoting 
assimilation and digestion, and strengthening the muscular sys- 
tem, and should be employed whenever practicable. Light 
work gives the patient something to think about, and occupies 
his mind in a healthful manner, while being shut up constantly 
in-doors tends to enfeeble the body, and the mind is occupied 
too often in revolving the delusions which it should be the aim 
of the physician to banish as far as possible. As it is impossi- 
ble for the majority of patients to be employed in this manner, 
it is desirable to find some light employment in-doors. While 
it is comparatively easy to find employment for women, such 
as sewing, knitting, washing, and making dresses, the men are 
not so favorably situated, as the expense of fitting up work- 
shops is so great, that in most instances it is not considered 
a sufficiently valuable adjunct to justify the necessary out- 
lay. They may be taught, however, to do light work, such as 
cane-seating chairs, etc., and in such ways occupy their mind 
and afi'ord them some muscular exercise, however slight. The 
foreign asylums have systematized manual labor to a much 
greater extent than in this country; and some of them, as the 
asylum of Quatre Mares, near Itouen, do a great deal of work 
in all the trades. Ilecreation is also more indulged in than in 
our asylums. At the Fisherton Asylum, near Salisbury, Eng- 
land, which is a private institution, accommodating about six 
hundred patients, a separate brick building was erected for the 18 
INSANITY, 
purposes of recreation. It is one hundred feet in length, by 
thirty in width. At one end of the interior of this building is 
a stage Htted up with all the accessories for private theatricals. 
At the Prestwick Asylum, near Manchester, is a very largo 
and handsomely-painted room, which is devoted to musical 
and theatrical entertainments. At the Lunatic Asylum at 
Ghent, the Hospice de Guislain, are four hundred and seventy 
male patients, who are variously employed in shoemaking, 
book-binding, combing flax, making twine, weaving cloth, 
and in car pen ter-work and work out-of-doors. There are 
also rooms for music and smoking. At the asylum at Claren- 
don, near Paris, are six hundred patients of the paying class, 
for whose amusement are provided a library and billiard-room. 
The best of our own asylums afford, however, as good facili- 
ties for amusements as the foreign ones, if not on so extended 
a scale; while the condition of the patients, and their care and 
treatment are, as a general rule, superior to those of the foreign 
asylums. The medicinal treatment of insanity consists in re- 
moving, as far as possible, all functional derangements of the* 
system which would retard a cure, and endeavoring, as far as 
possible, to keep up a healthy state of the system by attending 
to the proper fulfillment of the functions of the body. We must 
relieve anaemia and hvperaemia of the brain so far as we are 
able, and treat symptoms as they appear in the course of the 
disease. Among the most valuable remedies for use in the 
treatment of insanity may be mentioned opium, hydrate of 
chloral, hyoscyamus, digitalis, ergot, bromide of potassium, 
stimulants, and the use of warm-baths. Opium has been 
called “ the sheet-anchor of the alienist physician.” The doses 
of opium require to be large, as the nervous system is singularly 
tolerant to large doses in acute mania and in some forms of 
melancholia, while, in advanced dementia and in general paral- 
ysis, the experience of observers warns us to be careful in its 
employment. Dr. Pliny Earle commences with twenty minims 
of tincture of opium three times a day, and gradually increases 
the dose until one drachm or more is administered three times 
a day. Guislain recommends large doses, but commences with 
two grains, which he increases to ten or fifteen grains, as re- 
quired. Drs. Bucknill and Tuke relate the case of a carpen- INSANITY, 
19 
ter’s wife wlio was affected with suicidal melancholia, who was 
cured by the administration of large doses of morphia, and 
who was obliged to take eight grains of the muriate of mor- 
phia daily. When taking this enormous dose, she was cheer- 
ful and enjoyed good health, her tongue being clean and the 
pulse good, but when the dose was diminished she again be- 
came depressed. 
The hydrate of chloral has proved to be a very valuable 
remedy in the treatment of insanity, often procuring refresh- 
ing sleep when all preparations of opium fail. It has been 
shown to be most useful in mania with sleeplessness and rest- 
lessness, in doses of from thirty to sixty grains. The great ad- 
vantages that it possesses are, that it does not constipate the 
bowels, does not disturb digestion, the doses do not require to 
be increased, as is the case with opium, and the sleep produced 
by it resembles natural sleep more than that produced by most 
other narcotics. From our own experience, we would decided- 
ly recommend the combination of chloral with morphia, or 
chloral with hyoscyamus, as being preferable to either alone. 
In very violent cases of maniacal excitement with sleeplessness 
and dangerous exhaustion, and weak pulse, a dose of twenty 
grains of hydrate of chloral and one-quarter of a grain of mor- 
phia has produced a long, natural, healthy sleep, from which 
the patient has awakened refreshed and invigorated, and, after 
a few repetitions of the dose on successive nights, the symp- 
toms have disappeared, or have been greatly relieved. When 
the chloral has been given in connection with hyoscyamus in 
maniacal excitement and sleeplessness, fifteen grains of the 
hydrate of chloral and one drachm of the tincture of hyoscya- 
mus have been administered at night, and the dose repeated 
in two hours if sleep was not induced, and the results have 
always proved the success of the treatment. 
The use of digitalis has been advocated by Dr. Lockhart 
Robertson, and by Dr. Duckworth Williams, his successor, at 
Hayward’s Heath, England. They claim that digitalis is a 
valuable sedative in both recent and chronic mania, and also 
when these forms of insanity are complicated with general 
paresis and epilepsy. The dose they employ ranges from half 
a drachm to one drachm of the tincture, this dose being con- 20 
INSANITY, 
tinned for some days and then gradually decreased. Stimu- 
lants are necessary to ward oft' the dangerous stage of ex- 
haustion which accompanies or follows acute maniacal excite- 
ment, and is contraindicated only wdien there is excessive 
plethora. 
The fluid extract of ergot is used to overcome the cere- 
bral hypercemia, which is an attendant upon many phases 
of insanity, and acts by exercising a controlling influence upon 
the calibre of the intercranial vessels by virtue of its power 
over the non-striated muscular fibres and cells contained in 
the contractile coats of the vessels. It reduces excitement, 
shortens the attacks, and widens the interval between them. 
In epileptic mania it often prevents the recurrence of the at- 
tacks, and, in short, does all, and even more, than was first 
claimed for it by Dr. Browne, of the West Hiding Asylum, 
when he recommended its use in recurrent mania, in chronic 
mania, with lucid intervals, and in epileptic mania. The dose 
employed should range from one-half to one fluid-drachm of 
the fluid-extract of ergot, three times a day for as long a period 
as necessary to reduce the cerebral congestion. Last, but not 
least, may be mentioned the use of warm baths, which are of 
inestimable value in asylum practice. The tranquillizing effect 
of a warm bath in relieving cerebral irritation and in promot- 
ing sleep is often wonderful, after all other means have failed. 
Patients with excessive maniacal excitement, hot head, dilated 
pupils, tongue thickly furred, and a high temperature in the 
axilla, have repeatedly passed a comfortable night, after hav- 
ing remained for half an hour in a warm bath at a temperature 
of 100°. This, in connection with a dose of chloral and mor- 
phia or hyoscyamus, will often suffice for the relief of acute 
mania if repeated on successive nights, if good, refreshing 
sleep can be induced. Enough has been said, however, to 
show clearly that we can lay down no definite plan of treat- 
ment for any number of cases, but must, in every instance, if 
we expect to accomplish a cure, study the constitution and 
idiosyncrasies of our patient, and treat him accordingly. By 
so doing, we shall often have the satisfaction of seeing appar- 
ently hopeless cases restored to society, and families rendered 
happy which had been broken up by the visitation of this fear- 
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