INSANITY; 
ITS ETIOLOGY, DIAGNOSIS, PATHOLOGY, AND 
TREATMENT, WITH CASES ILLUSTRATING 
PATHOLOGY, MORBID HISTOLOGY, 
AND TREATMENT. 
1IY 
EDWARD C. MANN, M. D., 
MEDICAL SUPERINTENDENT OF STATE EMIGRANT INSANE ASYLUM, 
WARD’S ISLAND, NEW YORK. 
(REPRINTED FROM THE N. Y. MEDICAL JOURNAL, DEC., 1874.] 
With Additions kt the Author. 
NEW YORK: ; 
G. P. PUTNAM’S SONS, 
Fourth Ave. and 23D St. 
1875. INSANITY; 
ITS ETIOLOGY, DIAGNOSIS, PATHOLOGY, AND 
TREATMENT, WITH CASES ILLUSTRATING 
PATHOLOGY, MORBID ' HISTOLOGY, 
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.] 
With Additions by the Author 
NEW YORK: 
G. P. PUTNAM’S SONS, 
Fourth Ave. and 23D St. 
1875. IN S AN IT Y ; 
ITS ETIOLOGY, DIAGNOSIS, PATHOLOGY, AND 
TREATMENT. 
From the earliest period in the history of medicine, mental 
diseases have been recognized, more or less classified and 
treated, as a rule, as worthy of the utmost attention that 
science and humanity could dictate. As far back as the days 
of Hippocrates, 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 
Roman laws divided the insane into two classes : furiosi. 
those who were violent and maniacal; and mente capti, those 
who were suffering from dementia, or weakness of intellect. 
The ancient writers, although very crude in their ideas of 
insanity, recognized, as a rule, the different mental states 
accompanying mania, 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 suc- 
ceeding writers have reared their modern systems of classifica- 
tion. The classification just alluded to includes the four great 
primary mental states or conditions of insanity, namely: 
mania, melancholia, dementia, and idiocy. As most writers 
on insanity prefer to enlarge on such 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. 4 
INSANITY; ITS ETIOLOGY, 
The etiology, or causes of insanity, has been made the basis 
of two very excellent classifications ; the first, by Dr. Morel, 
in his “Traitedes Maladies Mentales,” published in i860; 
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 In- 
sanity; 2. Epileptic Insanity; 3. Paralytic 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 clas- 
sification. They have divided it under five heads, or divis- 
ions, 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 the states in which marked delusions are present ; melan- 
cholia, with delusions; monomania, with delusions; and 
homicidal and suicidal insanity, with delusions. 
IV. Emotional Insanity, or morbid states of the emotions, 
without delusion, whether attended by melancholia or excite- 
ment. 
V. 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,—Insanity grows out of a violation of those 
physical, mental, and moral laws, which, properly under- 
stood and observed, result not only in the highest develop- 
ment of the race, but in the highest type of civilization. 
During the past twenty years there has been a decided in- 
crease of insanity in our country, disproportionate to the 
increase of population. In the foreign element this is due to DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
5 
marked changes in habits of living, the changes in food, in- 
creased intemperance, working more in-doors, living in badly- 
ventilated tenements, and disappointments at not succeeding 
at business, etc., as they had expected to do in America, 
which are causes, all of which combined, tend to impairhealth, 
break down the nervous'system, and tend insensibly toward 
insanity in the offspring. The increase of insanity among 
our own population is due largely to a change from a vigorous 
well-balanced organization to an undue predominence of the 
nervous temperament, which is gradually taking place in suc- 
cessive generations. The educational pressure on the young 
to the neglect of physical exercise, the increasing artificial 
and unnatural habits of living, the great excitement and 
competition in business, are all tending to induce and multi- 
ply nervous diseases, many of which must terminate in insan- 
ity. These causes, and the evils resulting from them, are 
propagated by the laws of inheritance in an aggravated and 
intensified form. It is an interesting fact, which I have ob- 
served from an extended examination of the reports which 
have been sent to me from the various insane asylums of our 
country, many of which I have examined from the com- 
mencement of such institutions up to the present time, that 
insanity is appearing gradually at an earlier age than for- 
merly. These reports show that in former years the average 
period at which the greatest number became insane, ranged 
between the age of thirty and forty, but an analysis of statis- 
tics shows that this average age is coming on at an earlier pe- 
riod of life, generally appearing between the years of twenty 
and thirty. This is supposed, by the highest authorities, to 
be owing to hereditary influences, which have gradually be- 
come intensified by violation of physical laws in early life, 
want of proper training, or too high pressure in education. 
From these preliminary remarks, we proceed to the investi- 
gation of the predisposing and exciting causes of insanity 
The first and great predisposing cause is, hereditary predis- 
position. This has been noticed from the earliest history of 
the study of insanity. Esquirol observed and traced heredi- 
tary predisposition in about one-fourth of all his cases of in- 6 
INSANITY ; ITS ETIOLOGY, 
sanity. Guislain estimated hereditary predisposition at thirty 
per cent, of all cases of insanity. Mich6a 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 disposition was traced in thirty-one per cent, of 
all the admissions. With regard to hereditary predisposi- 
tion, it has been determined that, as a general rule, if the 
mother is insane, the disease is more frequently transmitted 
to the offspring than if the father be affected ; 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 ap- 
pear in male offspring, the father being affected, than in the 
female. There are, of course, many exceptions to this rule : 
but the laborious researches of M. Kaillarger have been ac- 
cepted by the best authorities as highly probable, if not con- 
clusive. It has also been proved that the lower forms of in- 
sanity, as imbecility, and also depression of mind, are in a 
marked degree hereditary. It has been remarked 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, at the periods of puberty, child- 
birth, climacteric period, etc. 
Most people ignore the law of progressive development, 
and find it difficult to believe that an attack of insanity, 
coming on in maturity, may have originated in the parent or 
grandparent, in whom it gave very little, if any, appreciable 
trace of its existence. Yet this is a fact, and insanity is often 
the result of a lowered vitality or abnormal organic develop- 
ment of the nervous system, that has descended from genera- 
tion to generation, gaining in intensity until it manifests itself 
by an outburst of insanity in children. One very important 
organic law, which should be universally understood, is, that 
morbid impulses and characteristics and insane traits may 
disappear in the second generation, and break out with re- DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
7 
newed intensity in the third. It is doubtless true, however, 
that a tendency or predisposition to mental disease may be 
transmitted to the offspring, and under good hygienic and 
other favorable conditions, die out, and fail to be transmitted 
any further. 
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 
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 1867, 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 8 
INSANITY; ITS ETIOLOGY, 
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. 
Intemperance.—It is impossible to estimate the complex in- 
fluences that intemperance exerts upon the production of in- 
sanity. All observers agree that it is intimately connected 
with, and is one of the main exciting causes of, insanity. 
Lord Shaftesbury, in his evidence before the Select Commit- 
tee on Lunatics, in 1859, expressed his opinion that fifty per 
cent, of the cases admitted into English asylums are due to 
drink. Many superintendents of foreign asylums have esti- 
mated the admissions from intemperance at twenty-five per 
cent, or higher, including not only the proximate, but remote 
cause of the disease. This percentage will be largely in- 
creased if we take into account the great number of cases in 
which the intemperance of parents causes the insanity or 
idiocy of their offspring. I have traced intemperance as a 
cause, in a great many cases of general paralysis that have 
come under my care, and other superintendents of insane 
asylums have observed the same thing. M. Lunier estimates 
that fifty per cent, of all the idiots and imbeciles to be found 
in the large cities of Europe have had parents who were 
notorious drunkards. Of 350 insane patients admitted dur- 
ing two years at Charenton, in Europe, insanity was attrib- 
uted to drink in 102 instances. We have three forms of 
insanity resulting from the abuse of alcohol, either in the 
individual himself or his progenitors, and these should, I 
think, be all included under the general term of alcoholic in- 
sanity. As this term is, at present however, synonymous with 
alcoholism, we must find some more fitting term, 
I suppose, to include these three manifestations. They are 
as follows: First. Delirium tremens or mania a potu, which 
is the acute and temporary form of mental derangement 
caused by intemperance. Secondly. Dipsomania, which is 
characterized by an irresistible impulse to indulge in alcoholic 
stimulants—an impulse which the intellect seems powerless 
to control, being overborne by the superior force derived DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
9 
from disease. It becomes, therefore, properly speaking, a 
form of moral insanity. It appears under three forms— 
acute, periodic, and chronic. Third, and last, we find the 
condition known as chronic alcoholism, which is a peculiar 
form of chronic insanity. Excluding the symptoms of delir- 
ium tremens, which are too familiar to bear repetition, we 
have in the other two forms of insanity from intemperance, 
hallucinations of sight and hearing, confusion of thought, per- 
version of feelings, suicidal tendencies, tremor o'f the facial 
muscles and tongue, at times anaesthesia of the extremities, 
with paralytic symptoms, ending in general paralysis. It is 
a fact of importance that the children of habitually intem- 
perate parents often inherit a predisposition to mental 
diseases, which generally appear in the form of weakened 
mental faculties, as in dementia, or that they are entirely 
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, 
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 deter- 
mined 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 
present 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 ! Herbert Spencer, in speaking of the emotions, re- 
marks : “We know that emotional characteristics, in com- 
mon with all others, are hereditary; and the differences 
between civilized nations, descended from the common stock, 
show us the cumulative results of small modifications heredi- 10 
INSANITY ; ITS ETIOLOGY, 
tarily transmitted. And, when we see that between savage 
and civilized races, which diverged from each other in the 
remote past, 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 characterize civilized races 
are the organized results of certain daily repeated combina- 
tions of mental states which social life involves? Must we 
not say that habits not only modify emotions in the individ- 
ual, and not only beget tendencies to like habits and accom- 
panying emotions in descendants, but that, when the condi- 
tion 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 emotions, 
analytically considered, consist of aggregated and consolida- 
ted groups of these simpler feelings, which habitually occur 
together in experience ; that they result from combined ex- 
periences, and are constituted of them?” 
Diagnosis of Insanity.—There is probably no disease which 
presents greater difficulties in the way of diagnosis, than in- 
sanity. In most diseases we examine physical signs and 
symptoms, and we determine by our senses the existence of 
such diseases. In insanity, on the contrary, we have to be 
guided chiefly by our knowledge of the normal functions of 
the mind, and in our examination we have to rely on our 
intellect rather than on our senses, although of course the 
latter are called in to assist us. It is, however, very often 
extremely difficult to decide with certainty, as we are ex- 
pected to do, as to the existence of mental disease, and we 
assume a great responsibility, whichever way our decision 
may be given. We either give the patient liberty to take his 
place in society, and thus expose society to the consequences 
if he prove to be insane, or we place him in confinement in 
some institution for the treatment of the insane, thus depriv- 
ing him of his liberty, and his family of his support. It 
becomes, then, a matter of great importance to decide rightly 
as to the existence of mental disease, for if this is not prop- DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
11 
erly done, we shall expose ourselves to the risk of great 
mortification, and also to the loss of professional reputation. 
Before going to see a patient who is to be examined for the 
existence of insanity, it is advisable to find out all one can 
from the friends and relatives ; but in accepting such state- 
ment, it is wise to allow a wide margin for their informa- 
tion in regard to hereditary predisposition, as most people, 
foolishly considering the existence of insanity in their family 
a disgrace, will pertinaciously conceal and deny this fact 
both from themselves and from their medical adviser. An- 
other reason for this concealment may be, that the members 
of such families are not infrequently odd and eccentric in 
their behavior, even when perfectly sane, and do not care to 
have their peculiarities attributed to hereditary taint of in- 
sanity, and therefore endeavor to mislead their physician on 
a point which is to him of the utmost diagnostic importance. 
Indeed, this and the question of previous attacks are perhaps 
the two most important points in the diagnosis of any given 
case. 
We should endeavor, when we are called to our patient, 
to gain his confidence, and from a general conversation lead 
him cautiously to his state of health and mental feeling. If 
we are abrupt and wanting in tact we shall probably defeat 
our object, and the patient, if displeased, will either refuse 
to listen to, or answer our questions, or will become very 
angry at our conspiring to deprive him of his liberty. If we 
are fortunate enough to get a history of the patient, we can 
generally determine easily the existence or non-existence of 
insanity, by the patient’s appearance and conversation. 
Many times, however, we have to rely alone on the conver- 
sation, general appearance, and conduct of the patient, un- 
aided by any other resources. After having gained our 
patient’s confidence, and having drawn him into a pleasant 
conversation, we should first inquire about previous attacks, 
then into his hereditary history, then into any predisposing 
causes, such as intemperance, vocation, habits, etc., which 
may have operated in the production of insanity. Also as 
to injuries to the head or spine which may have occurred, 12 
INSANITY; ITS ETIOLOGY, 
sunstroke, etc. We should then systematically, but carefully 
and cautiously, examine into the vegetative and reproductive 
functions, and then carefully examine the nervous system for 
the existence of any lesions such as paralysis, epilepsy, cata- 
lepsy, hysteria, and allied affections. We should next exam- 
ine the different senses, beginning with sight, and in this way 
we shall find out if our patient has good vision, if the retina 
is normal, and, what is more important, we may discover if 
he has hallucination or illusions pertaining to this sense. 
We may then proceed to the sense of hearing, examining for 
deafness and also to discover any hallucination or illusions 
of hearing. Proceeding to the sense of smell, we shall dis- 
cover if it is normal, and also if there are any hallucinations 
or illusions connected with it. Taking up the sense of taste, 
we may inquire as to the existence of hallucinations or 
illusions. Patients often complain of their food being 
poisoned, or that they are eating injurious and hurtful things 
with their food. The last of the senses, that of touch and 
nervous sensibility, may be examined for imaginary sense of 
pain, the existence of reflex action, hyperaesthesia, and last- 
ly, for hallucinations and illusions pertaining to this sense or 
referring to internal organs of the body. The mental symp- 
toms unconnected with the special senses and pertaining to 
the intellect, the emotions or the will, may finish the exam- 
ination. 
Whether the diagnosis of insanity presents itself to the 
physician in a purely medical or in a medico-legal point of 
view, the principles of diagnosis are the same, and we must 
pursue our examination in precisely the same manner. The 
first thing we are generally called upon to decide is, whether 
the patient can be treated at home or whether it is necessary 
to place him in an asylum, and we are also probably asked for 
a prognosis, which latter cannot be too guarded, whatever may 
be our own impression at the time about the patient. Let 
us consider for a moment the first question, that of the pro- 
priety of removing our patient to an asylum. Insane patients 
are, by the very nature of their disease, inclined to do mischief. 
The DIAGNOSIS, FATHOLOGY, AND TREATMENT. 
13 
them vivid realities, and no one knows what they may con- 
sider it right and proper to do, when they are under the 
influence of such delusions. 
Some of the most fearful crimes have been committed by 
those who had previously been regarded as harmless patients, 
and no one therefore should take upon himself the responsi- 
bility of advising that a patient whom he is called to see should 
be kept at home. The mere moral effect of a residence in a well- 
regulated asylum for a time, at the onset of insanity, has 
an immense effect on the mind of a patient, and may prevent, 
perhaps, consequences that might prove most disastrous, 
were he to be at home and exposed to the many causes of ex- 
citement from which he is sheltered in an asylum. We must 
also decide what form of insanity the patient is laboring 
under, and in a medico-legal case must give our diagnosis as to 
the insanity of the patient in its relation to his civil capacity, 
and responsibility for criminal actions, and also as to feigned 
and concealed insanity. In this latter class of cases, medico- 
legal cases, it is of the utmost importance for every physician to 
understand that a man is not irresponsible for crimes which he 
commits from the fact that some of his ancestors have been 
insane. The question to be determined here is whether the 
hereditary taint, by being transmitted to the individual in 
question, has influenced or determined at all his volitions, 
impulses, or acts. If on the one hand he has been noticed 
for displaying such peculiarities as usually proceed from he- 
reditary taint, and if the crime was apparently unaccompanied 
by any adequate incentive, doubts of his legal guilt are then 
to be carefully considered. On the other hand, if the crim- 
inal act appears to have been rationally performed, and with 
some adequate and usual incentive, and if the individual has 
previously been free from mental infirmities or peculiarities 
that might be attributed to hereditary transmission, then we 
cannot justly advance insanity as a plea for defense from 
the consequences of crime. The diagnosis of insanity is at 
times very easily made. Thus if we find our patient, from 
havipg been previously moral, affectionate, and industrious, 
has become immoral and dissolute, exhibits alienation of 14 
INSANITY ; ITS ETIOLOGY, 
affections, and neglects his business, all without adequate 
cause, it is of course easy to determine his insanity, al- 
though of course changes may take place in the character of 
individuals without any suspicion of insanity being excited. 
A great many cases, however, are on the border line which 
separates sanity from insanity, and it often requires the 
nicest discrimination to determine whether such a patient 
shall be placed under treatment or not. It now remains to 
consider the diagnosis of the different forms of insanity 
which we meet with. In mania the physiognomy is gener- 
ally distinctive. The countenance is furrowed, the eye wild 
and vacant, and there is generally a peculiar want of agree- 
ment in the expression of the features. The hair often 
becomes harsh and bristling, and the ears may become 
shriveled. The actions, demeanor, and dress of an insane 
patient are generally indicative of mental peculiarities, and 
oftentimes the latter may be indicative of the nature of the 
patient’s delusions, or, if not, it may display marked eccen- 
tricity. In acute mania it is generally easy to discern in the 
countenance the presence of some strong emotional charac- 
teristics, such as pride, hatred, or anger. It has been 
remarked that insanity anticipates the effects of years, and 
prematurely imprints upon the countenance the facial lines 
characteristic of habitual emotions, while in lunatics of ad- 
vanced age, these are observable in a greater degree, and are 
more deeply marked than they ever are in sane persons. In 
this form of insanity the bowels are generally constipated, 
the urine is loaded with phosphates, and the patient suffers 
from that protracted loss of sleep which is diagnostic of acute 
mania, and which is a symptom that cannot be feigned by an 
impostor. Patients of this class pass several days without 
sleep, and sometimes weeks with but a few hours of sleep in 
the course of the whole time. Hallucinations of sight and 
hearing are far more frequent in this than in any other form 
of insanity. There may be also rapidly changing delusions, 
and there is generally an intense muscular restlessness, which 
manifests itself either in destructive impulses, or in contin- 
ual motion, which rapidly induces dangerous exhaustion, DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
15 
if not properly treated. In melancholia, the most noticeable 
symptoms will be despondency, fear, and despair, and the 
expression of their mental states are depicted in an unnatural 
degree of intensity upon the countenance of the patient. 
The patient generally wishes to be alone, is gloomy and de- 
pressed, has delusions of fear and persecution, imagines he 
has committed unpardonable sins, and in the acute cases of 
melancholia no more pitiable spectacle can be imagined, and 
the expression of terrible apprehension and fear which occu- 
pies the countenance is not easily forgotten. The skin is 
generally dry, harsh, and muddy, and the bowels constipated. 
It is such cases as these which have to be carefully watched, 
lest they give way to the suicidal tendencies which are gen- 
erally present. In dementia, the lines of expression are more 
or less obliterated, and the vacant, meaningless expression 
and smile or laugh are indicative of this form of insanity. 
When the mind is tested, the power of memory, attention, 
and comparison will be found to be partially or entirely 
wanting. It is only in primary dementia that the practitioner 
will find difficulty in reaching a decision, and sometimes these 
cases are very difficult to determine. In such cases, one of 
the most valuable symptoms is loss of memory. The patient 
may, in his conduct and conversation, exhibit no marked 
peculiarities, but when the powers of his mind are tested as 
to the recollection of past events, or even as to the conversa- 
tion of a few minutes previous, it will be found that he has 
entirely forgotten these things. This form of insanity is 
generally unaccompanied by hallucinations or delusions, and 
is nearly always due to some exciting cause, such as injuries 
to the head, and attacks of apoplexy, and strong emotional 
disturbances. There is another variety of dementia which is 
secondary to acute attacks of insanity, and which differs 
somewhat from primary dementia. In this form of dementia 
we meet with the remains of the delusions of acute mania, 
and we also find an exaggerated state of emotional feeling 
which remains after the storms of acute mania have blown 
over, and the functions of the mind are beginning to suffer 
decay. 16 
INSANITY ; ITS ETIOLOGY, 
The diagnosis of general paralysis is very easy, after we 
have become acquainted with the disease. 
In the early stage, the most marked symptom is a thick- 
ness of articulation particularly noticeable when the words 
articulated by the patient are composed of several conso- 
nants, when these will be shuffled over in a very character- 
istic manner. The lips of the patient while he is speaking 
will be seen to tremble, and likewise the tongue, if it is pro- 
truded from the mouth. The gait of these patients is very 
peculiar and characteristic of paresis. They shuffle along in 
a manner that denotes at once the want of co-ordination in 
the muscles of the limbs. Later in this form of insanity the 
power over the sphincters is lost, the patient has to be cared 
for like an infant, and becomes a great trouble to his attend- 
ants. There is another class of patients whose only mani- 
festation of insanity consists in an abnormal condition of the 
moral power, and who exhibit no obvious intellectual aber- 
ration or impairment. The symptoms of the mental disease 
in these cases are limited to the exhibition of morbid impulses, 
which the intellect seems powerless to control. These cases 
of moral insanity are sometimes difficult to distinguish, and 
the laity generally attribute such manifestations to total de- 
pravity. In such cases, we must compare the patient with 
himself when in a state of health, and not with any imagina- 
ry standard of sanity or insanity. We should bear in mind 
in this class of cases the excellent definition of Dr. Combe, 
who says: “It is the prolonged departure, without any 
adequate external cause, from the state of feeling and modes 
of thinking usual to the individual when in health, that is the 
true feature of disorder of mind.” 
We have thus far considered the diagnosis of insanity only 
in its relation to the existence of the disease. Let us finally 
look at the diagnosis of recovery, which oftentimes becomes 
a very delicate and difficult task for the examiner. We are 
to determine whether the patient has recovered so far as to 
leave no trace of insane ideas and delusions. We must com- 
pare the man with his former self in a measure, and see if 
his natural tastes, affections, impulses, and mental powers DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
17 
have been restored. Of course, we must make an allowance 
for a certain amount of weakness in his intellectual func- 
tions, just as we expect to find a man weak bodily, after an 
attack of typhoid fever or other severe disease. We must 
determine whether the man’s intellectual faculties, his mem- 
ory, reason, and judgment, are in a state to enable him to 
take his place and position in active life. We must observe 
also whether his conduct is reasonable and quiet. In homi- 
cidal or suicidal cases we must assure ourselves of the dis- 
appearance of the propensity. There are many patients who, 
although not recovered, are in such possession of their intel- 
lectual faculties as to become very impatient of restraint and 
confinement, and no amount of reasoning can make them 
appreciate the necessity for further detention in an asylum. 
A marked case of this characters at the present time under 
our care, and illustrates forcibly this class of cases, who, were 
they to be exposed to the excitement of society, before a 
thorough cure has been effected, would almost inevitably 
have a relapse. 
This patient will argue for an hour at a time very sensibly 
and forcibly upon the injustice and oppression of keeping 
him longer in an asylum, and will challenge any proof of his 
insanity, and probably nine out of ten physicians not ac- 
quainted with him would say the man was sane.- He will 
converse rationally upon all topics of conversation until the 
subject of religion is introduced, when he immediately re- 
veals gross delusions, and maintains with the utmost sincerity 
that he can perform miracles, and that he is frequently the 
subject of them. This shows the importance of examining 
a patient upon all conceivable topics before pronouncing him 
cured. These are the cases that generally make their friends 
and relatives, and particularly strangers, feel that they are 
unjustly detained, and are the ones who, if they obtain their 
release in any way, publish their wrongs, and create in this 
way ill-founded prejudices against institutions for the care 
of the insane. Generally speaking, if a person who has been 
insane expresses himself as having been unjustly treated and 
detained, and denies the fact of his insanity, we may be 18 
INSANITY; ITS ETIOLOGY, 
pretty sure that he has not fully recovered, as persons who 
are really convalescent are generally fully convinced that they 
have been insane and are generally very grateful for the care 
and attention that have been bestowed on them, and express 
themselves so. Such patients are nearly always willing to 
be guided by their physician’s opinion as to the proper time 
for their discharge, and do not, as a rule, exhibit that intense 
restlessness and desire to return home, which is so apt to 
characterize doubtful recoveries. 
The first symptoms of recovery are the return of natural 
tastes, inclinations, and affections in the patient. Drs. Buck- 
nill and Tuke, in speaking of symptoms of recovery, lay 
down the following as evidences of restoration of the mind : 
i. A natural and healthy state of the emotions; 2. The ab- 
sence of insane ideas or delusions ; 3. The possession of suf- 
ficient powers of attention, memory, and judgment, to enable 
the individual to take his part as a free member of society ; 
4. Tranquil and reasonable conduct, and say regarding them 
“ When these four symptoms of recovery coexist, there can 
be no doubt that recovery has taken place.” 
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 
imbecility and idiocy, dementia, general paralysis (which is 
•one of the varieties least amenable to treatment) and epilep- 
tic insanity. On the other hand, acute mania, acute melan- 
cholia, hysterical insanity, and puerperal insanity, not unfre- 
-.quently completely recover. 
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 DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
19 
research. 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 I"ranee, has 
made very careful and thorough investigations regarding the 
pathology of insanity, and published the following conclu- 
sions : That the pathological changes met with in insanity 
may be divided into three classes : those which may be con- 
sidered accidental; 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, hyperaemiaof 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 consid- 
ered 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 cortical substance ; adherence of the pia 
mater to the surface of the brain ; rose, lilac, and violet-col- 
ored discoloration of the cortical substance ; loss of color of 
the cortical substance ; atrophy of the convolutions and indu- 
ration of the brain. In conclusion, M. Parchappe remarks 
that in acute insanity the prominent alterations are hyperaemic 
conditions, with arachnoid ecchymoses and injection and sof- 
tening of the cortical substance ; while in chronic insanity the 
predominant alterations are atrophy of the convolutions and 
induration of the two substances. Griesinger, the eminent 
Berlin pathologist, gives, as the result of his labor in the pa- 
thology of insanity, the following morbid conditions : hyperae- 
mia of the brain and membranes, thickening and opacity of 20 
INSANITY; ITS ETIOLOGY, 
the membranes, softening of the cortical substance, and pig- 
mentation 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, effu- 
sions into the subarachnoid space, pigmentation of the cortical 
substance, and extended and profound sclerosis of the brain. 
He remarks that in chronic insanity softening is not so fre- 
quently met with in the superficial layer as pigmentation, 
superficial induration and adhesion of the pia mater. 
Histology.—The microscopical investigations of the histolo- 
gists 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 
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 insan- 
ity, in the possession of the writer, the thickening of the pia 
mater is very marked, and a cut vessel presents very beau- 
tifully the marked thickening of the coats. The brain-sub- 
stance 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 throughout 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 thickening of the membranes and sli gi>t 
subarachnoid effusion. DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
21 
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, 
miliary sclerosis, and colloid degeneration. The cells are 
the seat of atrophy, pigmentary, granular, or fuscous degen- 
eration, calcification, and hypertrophy. Microscopical exam- 
ination 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, commencing externally and extending inward. Dr. 
Tuke says that, in most cases of general paralysis which he 
examined, the cells 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. 
Cases Illustrating Pathology and Morbid Histology of Insanity. 
CASE I.—Melancholia with delusions. Death resulting 
from chronic meningitis. C. Me., male, aged 44 years, 
single; occupation, porter. Upon admission, May 5th, 1874, 
was noisy and maniacal. This state lasted but a few days, 
and he then became depressed and melancholy. He refused 
food for a few days, and had to be fed artificially. The 
melancholia assumed an acute form, and he had hallucina- 
tions of sight and hearing, causing at times great terror and 
mental excitement. At such times, when he imagined that 
he saw devils in the ward, his face would assume an aspect 
of the utmost fear and distress. He often expressed a 
wish to commit suicide. He died quite suddenly, August 
25th, 1874, having eaten and slept but little for some 
days previous. Post-mortem : Upon removing the calva- 
rium, the dura mater was found to be adherent to it ; the 22 
INSANITY ; ITS ETIOLOGY, 
pia mater was thickened, infiltrated, and hyperaemic ; the 
arachnoid was clouded and covered with granulations ; the 
brain was hyperaemic, and the cortical substance softened ; 
the lateral ventricles were filled with fluid ; the lungs re- 
vealed commencing tuberculosis ; the kidneys, spleen, and 
liver, normal. 
Case II.—M. H., male, aged 31, single, and by occupa- 
tion a laborer. Admitted to asylum Jan. 17th, 1874, with 
melancholia. Had delusions of fear and persecution, and 
had suicidal impulses. Often refused food, saying he wished 
to die. The mental faculties were very feeble, and the en- 
feeblement gradually increased. The bladder became para- 
lyzed, and the health gradually failed up to September 25th, 
1874, when he died from exhaustion. Post-mortem : The 
membranes were found to be adherent to each other, and 
the pia mater was thickened and adherent to the surface of 
the brain. Throughout the brain were small miliary tuber- 
cles; the substance of the brain was softened near the base; 
there was also considerable effusion about the base of the 
brain, and effusion in the lateral ventricles ; lungs normal, 
kidneys congested, spleen, liver, and heart normal. 
CASE III.—Melancholia, with religious delusions and hal- 
lucinations of sight and hearing. Death resulting from acute 
tuberculosis and rupture of pulmonary artery. J. S., male, 
aged 20, single ; occupation, laborer. Admitted to asylum 
June 20th, 1874. Upon admission, was in poor physical 
condition, having never regained his strength since an attack 
of pneumonia some months previous. There was dullness 
at the apices of both lungs, and a prolonged expiratory mur- 
mur, with difficult respiration. Pie was very depressed and 
melancholy, and said that he had committed unpardonable 
sins, and should be eternally lost. At night he imagined he 
was visited by evil spirits, who tormented him. He died 
suddenly, October 14th, 1874. Post-mortem : Dura mater 
firmly adherent to skull; meninges congested, and vessels en- 
larged ; brain revealed softening of cortical substance and 
effusion of fluid in lateral ventricles. Examination of lungs 
revealed the existence of miliary tuberculosis. The upper DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
23 
and middle lobes of the right lung were partially destroyed, 
and the sudden death was found to be the result of rupture 
of the upper branch of the right pulmonary artery in the 
middle lobe of the right lung. 
CASE IV.—Dementia and paresis. Death resulting from 
pulmonary hemorrhage. T. A., male, aged 22, single; 
occupation, wagon-maker. Admitted to asylum June 24th, 
1874. Upon admission, was demented, with symptoms of 
paresis. Laughed vacantly when addressed, and stared un- 
meaningly about him. No appreciation of condition or sur- 
roundings. His gait was staggering, and lips and tongue 
were affected with muscular tremors. Never spoke but once, 
and that was upon the occasion of a visit from his brother. 
His speech at that time was hesitating and trembling. He 
had an attack of sub-acute meningitis in October, and died 
in January, from an exhausting hemorrhage from the lungs. 
Post-mortem : Membranes adherent to skull; subarachnoid 
effusion ; large effusion between pia mater and brain ; pia 
mater was thickened in patches. There was effusion at the 
base of the brain ; fluid in spinal canal, and spinal cord atro- 
phied. Miliary tuberculosis throughout the brain. LTpon 
making an examination of the chest, the left lung was found 
to be partially destroyed by the breaking down of the 
caseous products of pneumonia, as a result of which, large 
cavities were formed. The heart gave evidence of recent 
endocarditis. The surface of the heart and endocardium 
were covered with miliary tubercles. The walls of the heart 
were atrophied, and exhibited traces of fatty degeneration ; 
kidneys, spleen, and liver normal. Upon hardening the spinal 
cord, and making thin sections, and employing carmine 
staining, there was found to be, upon microscopical examina- 
tion, atrophy and degeneration of the nerve elements of the 
posterior columns, with increase of connective-tissue. Sec- 
tions of hardened brain-tissue being made, there was observ- 
able in the cerebral cells of the frontal convolutions, a 
diffused granular degeneration. No change could be dis- 
covered in the cells of the cervical sympathetic, which was 
carefully examined. 24 
INSANITY ; ITS ETIOLOGY, 
Case V.—M. A. R., female, aged 29, single; occupation, 
servant. Admitted to asylum December 29th, 1873. Form 
of mental disease, dementia, ending in paresis. Speech was 
slurring and hesitating, and her gait was staggering, and 
mental faculties very much enfeebled. Would become very 
angry at trifling incidents, and then would relapse into 
silence, which lasted sometimes for weeks. She suffered 
from gradually progressing paralysis, which involved the 
sphincters of the rectum and bladder. The cutaneous and 
muscular sensibility was impaired, and'likewise there was 
less of electro-muscular contractility, so that disease of the 
antero-latcral and posterior columns of the spinal cord was 
diagnosticated before death. The paresis was attributed to 
spinal injury received when quite young. She died from ex- 
haustion, March 24th, 1874. Post-mortem: The dura mater 
was firmly adherent to the cranium ; the pia mater was 
thickened and infiltrated, and the arachnoid thickened and 
opaque. The convolutions of the brain were atrophied, and 
the brain-substance indurated. There was fluid in the 
spinal canal, and the cord was slightly atrophied and soft- 
ened in patches. The heart was small and flabby, spleen 
atrophied, stomach, liver, and kidneys normal. The uterus 
was in a rudimentary condition, apparently having never 
been developed properly. The spinal cord, after being 
hardened, and sections being made, revealed, upon micros- 
copical examination, loss of neuroglia and connective-tissue, 
and degeneration of posterior columns, and loss of nerve 
tubules of white substance. The ganglion cells of both an- 
terior and posterior cornua were disintegrated and atrophied, 
and granular and fatty matter occupied their place. 
,CASE VI.—Acute mania passing into dementia, with pa- 
ralysis; death resulting from apoplexy. J. W., male, aged 
27 ; occupation, student. Admitted to asylum April 30th, 
1873, with acute mania. Upon admission was violent, re- 
quiring the restraint of a camisole. As soon as he became 
quiet, showed signs of dementia, and gradually became 
paralyzed. His mental faculties seemed entirely lost. He 
did not speak, required to be dressed and undressed, and put DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
25 
to bed like a child, and led to the table for his meals, which 
he took from a spoon, which had to be put in his mouth by 
an attendant. On the morning of March 27th, 1875, he be- 
came suddenly comatose, and died in a short time. Post- 
mortem : The dura mater adherent to skull; arachnoid 
opaque and thickened ; pia mater thickened and infiltrated, 
and the blood-vessels enlarged and varicose. A varicose 
vessel had ruptured, giving rise to extensive hemorrhage, 
which pressed upon both hemispheres, causing death. Brain 
atrophied and indurated ; effusion at base of brain and in 
lateral ventricles. Upon examining the lungs there was 
found to exist a large cavity at the apex of the left lung ; 
stomach, liver, heart, and spleen were normal. The kidneys 
were hypertrophied, and undergoing fatty'degeneration. 
CASE VII.—Dementia and epilepsy. Death taking place 
during a succession of paroxysms. O. M. S., male, aged 19, 
single; occupation, gardener. Admitted to asylum Sept. 
29th, 1874, with epilepsy associated with mania, which pre- 
ceded and followed the paroxysms, requiring, sometimes, 
mechanical restraint. Dementia soon resulted from the 
mental deterioration. Patient had epileptic fits nearly every 
day, which condition had been going on for years. Patient 
inherited a predisposition to epilepsy. During the mania he 
imagined himself to be the Emperor of Germany. The 
paroxysms increased in frequency and intensity until April 
25th, 1875, in spite of all medication, when he had a succes- 
sion of fits lasting thirty-six hours, in one of which parox- 
ysms he died. Post-mortem : Membranes of brain thick- 
ened ; arachnoid opaque ; pia mater thickened; brain 
atrophied and indurated ; lateral ventricles filled with fluid ; 
spinal cord normal. Upon hardening the brain-tissue and 
medulla oblongata and examining microscopically, there was 
seen to be some vascularity in the fourth ventricle, which 
extended through the medulla, the capillary vessels of which 
were somewhat thickened and enlarged. The cervical sym- 
pathetic was carefully examined microscopically, but without 
satisfactory results. 
CASE VIII.—Paresis and chronic meningitis. Death 26 
INSANITY ; ITS ETIOLOGY, 
resulting from exhaustion. R. B., male, aged 51; occupa- 
tion, music teacher. Admitted to asylum January 26th, 
1874. Upon admission was gloomy and depressed, with 
exalted delusions, at times alternating with the deepest 
melancholia. He gradually became more cheerful, but pre- 
sented the symptoms of paresis ; hesitating speech, slurring 
all the consonants ; staggering gait, muscular tremblings, etc. 
Had been a hard drinker. Died May 20th, 1875, of exhaus- 
tion. Post-mortem : The calvarium being removed, the dura 
mater was adherent, the arachnoid opaque, and pia mater 
thickened and infiltrated ; with enlarged and tortuous vessels. 
There was an effusion of lymph between the pia mater and 
brain, which had become organized. The brain was atro- 
phied and indurated, and the gray matter of the convo- 
lutions much atrophied. There was considerable pigmenta- 
tion of the cortical substance. The spinal cord was atrophied, 
and there was some fluid in spinal canal. The cord being 
hardened and examined microscopically, there was found 
atrophy and granular degeneration of the nerve-elements of 
the posterior columns, and a new formation of connective 
tissue. The membranes of the cord were thickened. The 
heart, liver, and kidneys, presented, at the autopsy, exten- 
sive fatty degeneration. 
Case IX.—Dementia, paresis, and tuberculosis. Death 
resulting from exhaustion. M. P., female, aged 23, servant. 
Admitted to asylum Sept. 30, 1873. Upon admission was 
depressed and melancholy, and in a delicate state of health. 
Became gradually demented and paralyzed. Physical ex- 
ploration of the chest revealed pulmonary tuberculosis, with 
cavities at apices of both lungs. Patient died from exhaus- 
tion from paresis and tuberculosis, July 18th, 1875. Post- 
mortem: Brain anaemic, atrophied, and indurated. The spi- 
nal cord was about of a normal size, its membranes were 
thickened, and the pia mater opaque and thickened. The 
lungs presented extensive disease, the heart was small and 
flabby, and the kidneys atrophied and anaemic. Upon hard- 
ening the cord, the posterior and posterior section of the lat- 
eral column were found to be affected. The posterior col- DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
27 
umns presented atrophy and disintegration of nerve elements 
and plates of connective-tissue in different places. In the 
postero-lateral column were granular and fatty corpuscles, 
and new bands of connective-tissue. It will be noticed 
that, in five out of the nine cases, there was pulmonary dis- 
ease, and, as I remarked in the New York Medical Record of 
September 18, 1875, *n an article on Consumption: 
“ It has been noticed that in a great many cases there 
exists a very close relation between tuberculosis and insanity. 
Esquirol was the first to note this fact, and it has since been 
commented upon by Schroeder van der Kolk and Dr. Clous- 
ton. In some cases phthisis has preceded insanity, and in 
other cases, and probably in the majority of those in which 
a close relation seems to exist, the development of the two 
diseases has been nearly contemporaneous. It has been 
noticed that the forms of insanity complicated with phthisis, 
exhibit a decided tendency to pass into dementia. Dr. 
Clouston, in the Journal of Mental Science, for April, 1863, 
gives a table showing the form of insanity in 282 patients 
who died of tubercular disease at the Royal Edinburgh 
Asylum. Acute mania, 12; mania, 15; monomania, 39; 
melancholia, 18; dementia, 153; general paralysis, 34. It 
will be noticed by the foregoing table that more than one- 
half of these cases passed into dementia, while, on compari- 
son of the tubercular with non-tubercular cases, it is shown 
that only one-quarter of the latter class of cases were 
demented at death. It was noticed, in all these cases, that 
the acute stage of the insanity was of very short duration, 
and that the patients all manifested a decided tendency to 
pass rapidly into subacute mania and dementia. It has also 
been noticed that the prognosis as regards recovery of men- 
tal health is very unfavorable, and that apparent recoveries 
generally prove to be only remissions.” 
Treatment of In sanity. it is not generally so 
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 28 
INSANITY ; ITS ETIOLOGY, 
insanity, 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 were 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 Ee Copelands 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, while 
if insane he has but an average life of 21.31 years if not restored 
to health. Dj\ 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 apply 
for treatment upon the early symptoms of disease is twenty- 
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 
hospital, etc., for six months, making an average cost of $134 
for restoration to health. If not restored to health, the family 
or State must be at an expense of $156 a year for 21.31 years. DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
29 
and must also lose the patient’s earnings for the 39.4.8 years 
which he would have made if well. The cost of the patient’s 
support is estimated at $2,121, while the loss of his future 
labor, if he becomes insane at twenty years of age, is estimated 
at $2,665.37, making a total loss of $4,786.37 if not cured ; 
while, if cured in the average time of twenty-six weeks at a 
cost of $134, there will be a gain to the family or to the State 
of $4,652. 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 
fo-und 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 cla'ssify 
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- 
ous wards of the institution, and noticing the women quietly 
sewing or reading, while many of the male patients were en- 30 
INSANITY ; ITS ETIOLOGY, 
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 expected to see. We took this astonishment as the high- 
est compliment 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 illus- 
tration of what triumphs kindness and moral and hygienic 
treatment have achieved over the cruel, harsh, and unsym- 
pathizing 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 
consfderation. Their peculiarities 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 pa- 
tient 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 us. 
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 sur- 
roundings, and good food, are of great importance. The 
mind, to be normal, must be associated with a healthy phy- 
sical 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 DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
31 
him, he is much better taken care of. This is a very mis- 
taken 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 be so called ; or, more prop- 
erly 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 concerns 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 prisoner, in his own home, than when 
allowred 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 center of observation and remark, and 
is treated and noticed precisely in the same way as are the 
thirty or forty other patients who are occupants of the same 
ward. A very striking instance of this kind occurred in a 
patient of good education who, upon becoming insane, fan- 
cied himself the Supreme Being, and insisted upon exercising 
all the fancied prerogatives of such a being. He became 
very troublesome and dangerous to those about him, and 
was entirely absorbed in the contemplation of his own great- 
ness, which idea was fostered by the attention he received 
and the private room that he occupied. He was accordingly re- 
moved 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 per- 
ceived, and at first angrily remonstrated against, the want of 
attention paid to his whims and caprices, but soon under- 
stood 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. Find- 
ing his endeavors to exercise his authority fruitless, he gave up 
his imperious and unrestrained demeanor, 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 32 
INSANITY ; ITS ETIOLOGY, 
treatment of the insane, the physician’s attributes have been 
well defined by Drs. Bucknill and Tube, 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 opinions he has on 
sound and sufficient reasons formed of his patient, and the 
treatment needed to be pursued toward him. With self-re- 
liance for a foundation to his character, it requires widely 
different manifestations to repress excitement, to stimulate 
inertia, to direct the erring, to support the weak, to supplant 
every variety of erroneous impression, to resist every kind of 
perverted feeling, and to check every form of pernicious con- 
duct.” 
In treating the insane, the great necessity is for better 
food ; more amusements ; which dravv off the mind from the 
delusions which occupy it, and combat depression of mind, by 
bringing before it new scenes and objects; and, lastly, more 
freedom. We have improved the condition of the insane 
materially during the past few years, and have rendered a 
residence in an asylum less irksome and more beneficial for 
those who are obliged to resort to such institutions. We 
have abolished mechanical restraint, except in rare cases ; 
have abolished all forms of punishments, and have improved 
the quality of food and clothing. The insane should be en- 
couraged and urged to go outside of the walls of the insti- 
tution of which they are inmates, as far as is practicable, 
when their behavior justifies this measure, for work or pleas- 
ure. In this way they are put on their honor and good 
behavior, and where one will occasionally escape, doing but 
little injury, thousands will be essentially benefited, and, in 
some cases, cured for life. 
Out-of-door work is very valuable for patients in promot- 
ing assimilation and digestion, and strengthening the muscu- 
lar system, and should be employed whenever practicable. 
Light work gives the patient something to think about, and DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
33 
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 possi- 
ble. As it is impossible 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 workshops is so great, that in 
most instances it is not considered a sufficiently valuable 
adjunct to justify the necessary outlay. They may be taught, 
however, to do light work, such as cane-seating chairs, etc., 
and in such ways occupy their mind and afford 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 Rouen, do a great deal of work in all 
the trades. Recreation is also more indulged in than in our 
asylums. At the Fisherton Asylum, near Salisbury, England, 
which is a private institution, accommodating about six hun- 
dred patients, a separate brick building was erected for the 
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 fitted up with all the accessories for private theat- 
ricals. At the Prestwick Asylum, near Manchester, is a very- 
large and handsomely-painted room, which is devoted to- 
musical and theatrical entertainments. At the Lunatic: 
Asylum at Ghent, the Hospice de Guislain, are four hun- 
dred and seventy male patients, who are variously employed, 
in shoemaking, book-binding, combing flax, making twine,, 
weaving cloth, and in carpenter-work and work out-of-doors.. 
There are also rooms for music and smoking. At the asylum, 
at Clarendon, 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 facilities for amusements as the foreign 
ones, if not on so extended a scale; while the condition of. 34 
INSANITY ; ITS ETIOLOGY, 
the patients, and their care and treatment are, as a general 
rule, superior to those of the foreign asylums. The medi- 
cinal treatment of insanity consists in removing, 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 hyperaemia 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 paralysis, 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 required. Drs. Bucknill and Tuke 
relate the case of a carpenter’s wife who was affected with 
suicidal melancholia, and was cured by the administration 
of large doses of morphia, and who was obliged to take eight 
grains of the muriate of morphia daily. When taking this 
enormous dose, she was cheerful and enjoyed good health, 
her tongue being clean and the pulse good, but when the 
• dose was diminished she again became 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 
restlessness, in doses of from thirty to sixty grains. The 
great advantages that it possesses are, that it does not con- 
stipate the bowels, does not disturb digestion, the doses do DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
35 
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 From our own ex- 
perience, we would decidedly 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 morphia has produced a long, nat- 
ural, healthy sleep, from which the patient has awakened 
refreshed and invigorated, and, after a few repetitions of the 
dose on successive nights, the symptoms 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 hyoscyamus have been admin- 
istered 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 
continued for some days and then gradually decreased. 
Stimulants are necessary to ward off the dangerous stage of 
exhaustion which accompanies or follows acute maniacal 
excitement, and are contraindicated only when there is exces- 
sive plethora. 
Ergot in the Treatment of Insanity.—It was proved, years ago, 
by the researches of Brown-Sequard and others, that ergot 
possessed the power of producing contraction in the vessels 
of the spinal cord, and accordingly it occurred to Dr. Browne 
that it might possess a similar control over the vessels of the 
brain, and might thus be made to modify or remove the 
active cerebral congestion, which is an attendant upon so 36 
INSANITY ; ITS ETIOLOGY, 
many phases of insanity. Upon thorough investigation, he 
found that there were three varieties of insanity in which it 
was eminently useful, jiamely, recurrent mania, chronic mania 
with lucid intervals, and lastly, epileptic mania. Dr. Browne, 
and other observers who have adopted the use of ergot in 
the treatment of insanity, have found that in the varieties 
above mentioned, it was almost uniformly successful in 
reducing excitement, in shortening the attacks, in widening 
the intervals between them, and sometimes in preventing 
their recurrence entirely, and in warding off the dangerous 
stage of exhaustion by which maniacal excitement is so often 
succeeded. The way in which ergot operates upon the con- 
tractile coats of the vessels has been proved to be by its 
influence upon the non-striated muscular fibers and cells con- 
tained in their coats, thereby exercising a controlling power 
over the caliber of the intracranial vessels. In the three 
varieties of insanity before referred to—in recurrent mania, 
in chronic mania with lucid intervals, and in epileptic mania 
—we find that the lesion consists essentially in cerebral hyper- 
mmia. We find, although the symptoms differ in these three 
forms of mental disease in which ergot is useful, that there 
is present in each form increased arterial pulsation, flushing 
of the face, suffusion of the eyes, dryness of the mouth, and 
cephalalgia. The disappearance of these phenomena in the 
intervals of the paroxysms, proves that they are dependent 
upon functional and not organic changes in the brain, in 
which latter case we should not expect to find any marked 
efficacy from the use of ergot, and indeed we often meet with 
instances in which the controlling power of ergot is, after a 
time, lost, as organic degeneration gradually follows as a 
sequence upon repeated attacks of mania. In epileptic 
mania, it will be found that a combination of bromide of 
sodium with ergot will materially aid the action of the latter 
in widening the intervals between the fits, and in modifying 
the attacks when they occur. This combination will also 
often arrest paroxysms in the incipient stage. The stage of 
•excitement which often precedes and ushers in the attack, 
and which sometimes succeeds it, is markedly diminished by DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
37 
the combination of the bromide of sodium and ergot. The 
bromide of sodium will be found to be preferable to the 
bromide of potassium, as it is pleasanter to the taste and 
causes less constitutional disturbance than the latter when 
given in large doses. Dr. Browne remarks that “ it is in 
epileptic mania that ergot has been found pre-eminently val- 
uable in allaying and abolishing excitement, and in conducing 
to a healthier tone of mental action. In the outbursts of 
violent agitation, which precede or follow a fit or group of fits, 
which occasionally take their place, and which have been 
pronounced by all authorities to be of so dangerous a charac- 
ter, it exerts a prompt and energetic effect. We may presume 
that these outbursts are dependent upon a want of equilib- 
rium in the intracranial circulation, primarily disturbed by 
the epileptic seizure or condition. The distention of the 
vessels, which succeeds their spasmodic contraction and pro- 
duces coma, subsides so far as to allow the resumption of 
activity by the higher centers, but only in an irregular and 
distorted way. And we may presume, further, that the 
soothing and rectifying effects of ergot are due to its power 
of re-establishing that disturbed equilibrium.” 
A thorough trial of the ergot treatment has satisfied the 
writer of its efficacy in asylum practice, and the following 
clinical cases will serve to illustrate its beneficial action. The 
doses of ergot used in the following cases have been from 
3 ss. to 3 i. of Squibbs’ fluid extract, three times a day, and 
in cases in which ergotine has been employed, from 5 to 10 
gr. have been given. No unpleasant effects have ever fol- 
lowed even prolonged administration of the ergot, and from 
our experience with it, it would seem that the danger of in- 
jurious effects from the continued use of ergot has been 
greatly overrated by the majority of the profession. Dr. 
Browne, who has used the ergot treatment for many years 
in many hundreds of cases, says : “ Indeed, so little have 
injurious effects of any kind followed even the prolonged 
exhibition of what might be termed enormous doses of ergot, 
that doubts might have arisen as to whether it were possible 
to produce that train of symptoms described as ergotism, 38 
INSANITY ; ITS ETIOLOGY, 
by means of the medicinal preparations of secale cornu- 
tum.” 
Case I.—Miss E. K , with recurrent mania, admitted 
to the asylum Jan. nth, 1873, aged 22 years; occupation 
servant, native of Ireland. Was very noisy and maniacal 
when admitted. Was very incoherent in speech and boister- 
ous ; had no realization of her condition or surroundings. 
She entertained the idea that people were trying to kill her 
and get her property. She destroyed her clothing, broke 
the windows, did much damage to the furniture, and 
imagined that she saw snakes and devils in her room at 
night. She required restraint very often, and continued in 
this excited state for over a year, with no mental improve- 
ment. She commenced to take the fluid extract of ergot 
in 3 i. doses three times a day, on the 15th of June, 1874, and 
had only taken a few doses before beneficial results were very 
apparent. The excitement subsided, and she became quiet 
and peaceable. The congestion of the head and face, which 
was very marked, has nearly entirely disappeared. Her 
pulse was reduced from 145 to 90. The temperature in the 
axilla from 99TV° to 98°, and her tongue, which was thickly 
furred, presents a normal appearance. At the present time 
she assists in the washing, and is very polite and quite cheerful. 
Miss M. K , a native of Ireland, aged 28 years, was 
admitted to the asylum June nth, 1874. Form of mental 
disease, chronic mania with lucid intervals. On admission, 
was very violent and abusive, requiring restraint; would 
strike and bite the attendants if not restrained. Her face 
was deeply congested, eyes injected, tongue coated with a 
thick white fur, pulse 130, and temperature 990. Having 
continued in this excitable state for some days, with no 
evidence of improvement, was ordered 3 i. of the fluid extract 
of ergot three times a day. By the 24th of June, she began 
to show decided signs of improvement, and in place of being 
filthy and abusive in language and conduct, was polite and 
neat in her habits. She also began to sleep at night, which 
she had not done before, although medicine had been given 
for that purpose. DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
39 
Her pulse was lowered to 85. Her temperature decreased, 
the suffusion of the eyes disappeared, and at the present 
time, April 28th, she has had no relapse of maniacal excite- 
ment. 
E. Z , a native of Germany, aged 27, a mechanic, was 
admitted to the asylum June 12, 1874, suffering from an 
attack of acute mania, caused by overwork and mental 
anxiety. Had always been a healthy man, and no trace of 
insanity in the family history. Upon admission, was very 
noisy and maniacal, and his great strength rendered restraint 
necessary, as he endeavored to injure every one about him. 
He was ordered a warm bath, which relieved him for about 
half an hour, when he again became maniacal and dangerous. 
Was given chloral and hyoscyamus, and passed a restless 
night. In the morning, he presented very much the same 
appearance as on the preceding evening. Face and eyes suf- 
fused and congested, pulse ioo; and temperature heightened; 
tongue thickly coated and mouth dry; was put on 3 i. of the 
fluid extract of ergot three times a day, and chloral and 
hyoscyamus at night. In a few days, the excitement began 
to subside, and, August 1st, was comparatively quiet. Aug. 
15 th, pulse 80, temperature 97TV°, appearance of tongue nor- 
mal. Has remained quiet up to the present time. Appe- 
tite good, sleeps well, and is cheerful, although anxious to 
get back to his family. 
Miss S. H , native of Ireland, aged 25 years, was ad- 
mitted to the asylum Sept. 2, 1872, with epileptic mania. 
From the time of admission to June, 1874, had a great many 
epileptic seizures, which were preceded and followed by 
attacks of maniacal excitement, which rendered her a dan- 
gerous patient. Had been under restraint many times. July 
24, 1874, became very noisy and excited, as is her habit 
before her fits, threatening to kill the patients and attend- 
ants. The eyes were suffused, mouth dry, pulse 140, and 
tongue furred. Was put on 3 i. doses of fluid extract of ergot 
three times a day. After taking the ergot for two days, she 
became quiet, and the epileptic seizure which followed was 
very mild as compared with preceding ones. The ergot was 40 
INSANITY ; ITS ETIOLOGY, 
continued, and since that time she has had no return of the 
maniacal excitement. The fits have decreased in frequency 
and intensity, and are not followed, as formerly, by any 
mental excitement. Her physical condition has also been 
markedly improved since she has taken the ergot. The pulse 
is now 75, and the temperature in the axilla 98° ; eats and 
sleeps well, and assists in the work. 
M. C , native of Ireland, aged 30, was admitted to the 
asylum about two years ago, with epileptic mania. He was 
a strong, muscular man, and had been subject to epileptic 
fits for some years. For a period of from a week to two or 
three days preceding the fits, was entirely unmanageable and 
a very dangerous man to deal with. Required to be re- 
strained. He was also accustomed to have a period of 
maniacal excitement following the epileptic seizures, which 
lasted for a variable period, during which time his pulse 
would range from 100 to 120, and the face would be deeply 
congested. Was put on 3 i. doses of fluid extract ergot 
three times a day, and this dose continued for a period of 
two months, sometimes omitting the medicine for a week, 
and then resuming it. The fits immediately decreased in 
frequency and intensity, and the maniacal excitement entirely 
disappeared. Pulse and temperature became normal. He 
expressed a desire to work, and, a short time ago, returned 
in comparatively good health to Ireland. 
Several other cases have exhibited as marked improvement 
under the ergot treatment as the foregoing, but want of 
space forbids their insertion. 
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 promoting sleep, is often wonderful, after 
all other means have failed. Patients with excessive mania- 
cal excitement, hot head, dilated pupils, tongue thickly 
furred, and a high temperature in the axilla, have repeatedly 
passed a comfortable night, after having remained for half 
an hour in a warm bath at a temperature of ioo°. This, in 
connection with a dose of chloral and morphia or hyoscya- DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
41 
mus, 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 treatment 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 apparently hopeless cases restored 
to society, and families rendered happy which had been 
broken up by the visitation of this fearful disease. 
A microscopical examination of blood from insane patients, 
as compared with an examination of blood from the same 
number of healthy individuals, revealed in the blood of the 
insane a condition of leucocythaemia, or a marked increase of 
the number of white corpuscles. This condition has also 
been remarked by other observers, and Dr. Charlton Bastain 
and Dr. Blandford have described a plugging or stopping up 
of the cerebral vessels by small embolic masses composed of 
collections of white corpuscles, in cases of acute mania and 
delirium. It has also been found that during the period of 
maniacal excitement, that there is a marked diminution of 
fibrine in the blood, and that during convalescence the 
amount of fibrine is increased to the normal standard. These 
results have been confirmed by the recent researches of Hit- 
torf, Erlenmayer, Michea, and Dr. Marcet. Examination of 
the urine of the insane has shown that in acute mania there 
is an excessive elimination of the phosphates as a rule, while 
in dementia, general paralysis, and chronic mania, the amount 
of phosphates eliminated is generally below the average. 
There has been some difference of opinion in different ob- 
servers as to the reaction of the urine in insanity, Erlenmayer 
claiming that it is generally alkaline in recent cases of mania, 
while Dr. Sutherland, who has paid great attention to the 
condition of the urine in insanity, found that in 125 cases of 
recent mania, the urine was acid 101 times and alkaline 13 
times, and gave a neutral reaction once. In our investigations, 
we have found the reaction to be acid in the majority of cases 
of those affected with acute and chronic mania and dementia. 42 
INSANITY ; ITS ETIOLOGY, 
The small amount of time at the disposal of a physician in 
charge of an asylum, and the difficulty of making an extended 
course of investigation in the analysis of blood and urine, 
which is so desirable in the study of insanity, and also the 
difficulty of making microscopical researches, are causes 
which have combined heretofore to deter the superintendents 
of asylums in this country from giving to the profession the 
results of their valuable experience, and it is, therefore, to 
be hoped that the time is not far distant when every asy- 
lum shall possess the services of a skilled pathologist and 
chemist. 
Cases Illustrating the Treatment of Insanity. 
Case I.—T. B., male, aged 30, married, a native of Eng- 
land, and by occupation a photographer. Admitted to 
asylum with acute mania, resulting from abuse of alcohol. 
No insane relations. Upon admission, said he left England to 
get rid of his wife, who tormented him. Said he knew he was 
insane when he left, but that destitution and hard drinking 
had made him worse. Toward night, became acutely mani- 
acal, and very boisterous. Tore up everything within reach, 
and was incoherent and vulgar in speech. Had no apprecia- 
tion of his condition or surroundings. Quoted continually 
from Shakspeare, and showed that he had received a liberal 
education. Said he burned Spurgeon’s Tabernacle. Eyes 
suffused and pulse full and bounding. Was ordered warm 
baths every night, lasting half an hour, with chloral and 
morphine at bed-time, the dose of chloral being twenty 
grains, combined with one- fourth grain of morphine. He 
was fed liberally, and, as he was always quiet in the morn- 
ing, was ordered fl. ext. of ergot, in 3 i. doses, twice every 
afternoon when he became excited. Under this treatment, 
he quieted down, and he soon began to appreciate his condi- 
tion, and take an interest in his surroundings. He improved 
gradually, and was discharged recovered, and sailed for Lon- 
don, August 3, 1874. 
Case II.—M. B., female, aged 39, single, native of Ger- DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
43 
many. Admitted to asylum May 24, 1874, with melan- 
cholia, resulting from syphilis. Upon admission, was uneasy 
and restless at night, and would get out of bed, suspicious of 
injury from unseen persons, who, she said, were anxious to 
kill her. Was depressed, melancholy, and very suspicious of 
all about her. Imagined her food was poisoned, complained 
of great pain in the head, and was pale and anaemic ; ate and 
slept but little. Was put on a nourishing diet, with milk 
punch, and was given the iodide of pot., fifteen grs. three times 
a day, and twenty grs. of chloral, with tinct. hyoscyamus, at 
bed-time. Upon this treatment, her general health improved 
very much. She began to eat and sleep, but would sit 
alone all day and cry over imaginary troubles. After a few 
months began to evince a desire to work, and was sent to the 
sewing-room, where she sewed well, but still retained her 
delusions. She improved slowly, but surely ; her delusions 
gradually disappeared, she became more cheerful and happy, 
and was discharged recovered, April 18, 1875, and soon after 
sailed for Bremen, in good physical and mental health. This 
is a very interesting and unusual case, as syphilitic insanity 
is a very rare disease, not more than one or two per cent, of 
all cases of insanity presenting this complication. The most 
frequent form of syphilitic insanity is dementia. The above- 
mentioned case was probably the result of a simple irritation 
of the central nervous system, due to cerebral anaunia. The 
only remaining case of syphilitic insanity, where a clear syphi- 
litic history was obtained, which the writer has met with, was 
a woman aged twenty-nine, a native of France, with no insane 
relations. This patient’s limbs were covered with secondary 
syphilitic sores, and the head was affected with gummy 
tumors. She soon passed into profound dementia, asso- 
ciated with epileptiform convulsions. She was treated with 
a combination of mercury and the iodide of potassium, but 
remains a case of chronic dementia. 
Case III.—T. C., male, aged 25 years, single, a native 
of Ireland. Admitted to asylum March 21, 1874, with 
melancholia, bordering on dementia, caused by intemper- 
ance and vicious indulgences. Upon admission, denied 44 
INSANITY ; ITS ETIOLOGY, 
insanity in the most positive manner, but complained of 
severe pain in the back of his head, and over the frontal 
region. The faculties of the mind were much enfeebled. 
Would burst out laughing, and laugh incessantly for some 
minutes, and upon being questioned subsequently, had no 
remembrance of doing any such thing. Had a delusion that 
he had been reduced to half his size by divine assistance. Saw 
visions at night. Was feeble and anaemic. Had attacks of 
mental excitement about once a fortnight, in which the bod- 
ily temperature would be much increased, and the eyes 
suffused. At such times was very homicidal in his im- 
pulses, requiring, often, seclusion in his room Was put 
on nourishing diet and tonics, with fl. ext. ergot, 3i. 
three times a day, and warm baths at bed-time, when he 
could not sleep. There was no perceptible mental improve- 
ment for some months, but the general health was much im- 
proved, and he slept much better. The attacks of cerebral 
congestion decreased in frequency and intensity and finally 
ceased altogether. He began to work in the hall, and his 
sleep ceased to be disturbed by visions. His appetite became 
good, his mental faculties began to be restored to their 
normal state, and his delusions disappeared. He was dis- 
charged recovered, September 17, 1875, with no trace of 
insane ideas or delusions, his conduct for some months pre- 
vious to his discharge having been reasonable and quiet. 
It is proper to mention that the ergot in this and other cases 
was never continued for more than two or three weeks with- 
out suspending its use for a week or two, and using it in this 
way, no injurious effects have ever followed its employment. 
Case IV.—J. C., male, aged 26 years, single ; occupation, 
farmer, nativity, Ireland. Admitted to asylum April 2d, 
1874, with acute mania, the result of ill-health and overwork, 
associated with intemperance. Upon admission was thin 
and anaemic, and was incoherent and rambling in speech. 
Said he was married to the Queen of Heaven. Was sleep- 
less, ate but little, and was very destructive in his impulses, 
tearing up clothing, etc. The eyes were injected, and the 
pupils widely dilated. Was given bromide of sodium in fifteen DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
45 
grain doses, three times a day, which was increased to twenty 
grains, with full doses of chloral and tinct. hyoscyamus at 
bed-time. Full nourishing diet. Soon became quiet and 
polite, and with the increased health and strength his mind 
became normal, and his delusions disappeared. He worked 
well on the grounds of the asylum, and was discharged re- 
covered, December 28th, 1874. He obtained a good situa- 
tion on a farm, and has had no return of his insanity. 
Case V.—M. F., male, aged 23 years, single; occupation, 
blacksmith, native of Ireland. Was admitted to asylum 
September 24th, 1874, with recurrent mania. Upon admis- 
sion was depressed and sullen, would not answer questions. 
His tongue was thickly furred and bowels constipated ; was 
ordered a laxative and warm baths at bed-time, as he said he 
did not sleep well. In a few days the eyes became injected, 
the pupils dilated, head hot and speech wild and incoherent, 
and movements restless and excited. Said he had a worm 
inside of him that was eating him up. Thought the food 
was poisoned, and refused to eat. Was ordered warm baths, fl. 
ext. ergot 3 i. three times a day, and chloral twenty grs., with 
one quarter grain of morphine combined, at bed-time. In a 
few days the cerebral congestion abated, and he went on until 
the next month, when he had a recurrence of the mania, 
which was preceded a few hours, as before, by melancholia and 
constipation. The same treatment was employed, and the 
maniacal attack lasted but twenty-four hours. The ergot 
was continued through the lucid interval, and was discon- 
tinued at the end of four weeks, as he had no symptoms of 
another attack. He went until January, 1875, when he had 
a recurrence of the mania, which was treated as before, with 
the addition of bromide of sodium, in twenty grain doses three 
times a day. This was his last attack. He improved steadily 
in health and strength, his delusions disappeared, he began 
to show an interest in his surroundings, and worked on the 
grounds of the asylum until the latter part of July, 1875, 
when he was discharged recovered. 
Case VI.—J. N., female, aged 20, single; occupation, 
servant, native of Germany. Admitted to asylum Janu- 46 
INSANITY ; ITS ETIOLOGY, 
ary 27th, 1875, with acute mania. Previous to this attack 
had been a remarkably well-behaved and quiet girl, and had 
been reasonably healthy. Upon admission, was acutely 
maniacal, with rapidly changing delusions. Saw devils, 
snakes, and angels in rapid succession, and said the Virgin 
Mary visited her every night in her room. Pulse rapid, 
tongue thickly furred, bowels constipated and eyes injected, 
with the pupils dilated. Destroyed everything within her 
reach, and tore up three of the strongest camisoles which 
were in the house, as soon as she was confined in them. The 
display of muscular strength which she exhibited was some- 
thing remarkable. She was put in warm baths, with chloral 
and morphine at night, but did not sleep. Refused food, 
and was so violent, that the attempt to feed her artificially 
was for the time abandoned. None of the usual remedies 
seemed to quiet her in the least, and she seemed likely to die 
of exhaustion from the violence of her mania, when she was 
ordered the bromide of camphor, in doses of four grains 
three times a day, in capsules. After the third day’s trial, 
the temperature in the axilla became reduced from 102° to 
99|°. The pulse was reduced in frequency, and the suffusion 
of the eyes disappeared. The pupils were reduced to their 
normal size. She began to sleep and eat, and at the end of 
ten days was quiet and tranquil. The doses were reduced 
to two grains three times a day, as the mania decreased, and 
were continued for about a month. The mental faculties im- 
proved, the appetite returned to its normal condition, she 
began to take exercise in the open air, and soon desired to 
go into the sewing-room. She worked well, and was dis- 
charged recovered, September 9th, 1875. From the writer’s 
experience with the use of bromide of camphor, he believes 
it to be an excellent sedative of the cerebral system, and at 
times a decided hypnotic. In epilepsy, and mania with hys- 
terical symptoms, it has acted as a nervous sedative and anti- 
spasmodic with good effect, in doses of from two to four 
grains three times a day. 
Case VII.—C. G., female, aged 18 years, single, servant, 
native of Ireland. Was admitted to asylum with acute DIAGNOSIS, TATHOLOGY, AND TREATMENT. 
47 
mania, was noisy and boisterous, and a dangerous patient. 
Was homicidal in her impulses, and required mechanical 
restraint to prevent her from injuring those about her. 
Pupils widely dilated, head hot, and complained of intense 
pain in frontal region at times. Was incoherent in speech, 
and had no appreciation of her condition and surroundings. 
Was thin, and ate and slept but little Was ordered warm 
baths at a temperature of ioo° every other afternoon, with 
cold compresses to the head at the same time, and chloral 
and morphine in full doses at bed-time. She was also given 
thirty grains of the bromide of sodium twicd a day. In a short 
time she became quiet, and remained so for three months, 
during which time she had various delusions, and retained 
her homicidal impulses. At the end of that time she became 
acutely maniacal, and was put on fluid ext. of ergot and 
warm baths, with cold applications to head, and chloral and 
hyoscyamus in full doses at bed-time. In a week she began 
to improve, and her appetite, which had been poor since her 
admission, became good. She realized her situation, and 
thanked the doctor and the attendants for their care of her. 
She no longer wished to injure those about her, and as she 
soon manifested a desire to work, was placed in the sewing- 
room, where she continued to improve daily. Her insane 
ideas disappeared, and she was discharged recovered, in Janu- 
ary, 1875. Up to the present time she has had no return of 
insanity, and is regarded as an excellent laundress at the 
place at which she is employed. 
Case VIII.—E. K., female, aged 24 years; single; 
occupation, servant ; native of Ireland. Admitted to asy- 
lum with suicidal melancholia, was trying continually to 
escape. Had a great many delusions of fear and persecution. 
Said everybody wanted to kill her, and so she had better kill 
herself. Got very angry at trifles, and swore at the patients, 
and struck them if not restrained. Had no appreciation of 
her mental condition. Said that the devil was inside her. 
Was very filthy and obscene. Was put on a full nourishing 
diet, with opium in gradually increasing doses, and warm 
baths with bromide of sodium, thirty grains at bed-time. She 48 
INSANITY ; ITS ETIOLOGY, 
was kept on this treatment for some weeks with gradual im- 
provement. The opium was carried to the extent of one 
drachm of laudanum, three times a day, with excellent effects. 
The appetite was stimulated, and she became cheerful and re- 
alized her condition and surroundings. She slept well, and the 
desire to commit suicide disappeared. The amount of opium 
was gradually decreased, as the mental condition improved, 
and was finally withdrawn altogether. She worked well in 
the ward, and was transferred to the sewing-room, where she 
was of great service. She was discharged recovered, January 
6th, 1875, and remains well, up to the present time. 
Case IX.—E. B. M., female, aged 24 years; single ; occu- 
pation, dressmaker; native of Germany. Admitted to 
asylum May 27th, 1874, with acute mania. Was very much 
excited, eyes injected and pupils widely dilated. Head hot 
and face flushed. Had slept none for a week, and had eaten 
nothing for the same length of time. Was given a warm 
bath and milk punch, and at bed-time, twenty grains of 
chloral with one-fourth grain of morphine. Slept part of the 
night. The next day was maniacal, and imagined all the food 
was poisoned. Was fed on milk punch, and warm bath, with 
chloral and morphine, was repeated. She slept better than 
on the preceding night. During the next three weeks the 
same treatment was persisted in, resulting in gradual im- 
provement. She retained the delusion respecting the food, 
and tried continually to escape. She had new attacks of 
mania, recurring about once in three days at night, when she 
would see visions of angels, etc. She was put on doses of 
fluid ext. ergot 3 i. three times daily, with decided im- 
provement. She improved rapidly. Began to eat all that 
was given her, slept quietly all night and as she soon evinced 
a desire to work, was transferred to the convalescent ward, and 
allowed to sew, which she did very well. She continued to 
improve, and was discharged recovered, November 21st, 
1874, when she sailed for Germany, with no trace of insanity 
remaining. She has been heard from since her arrival in 
Germany, and is doing very well at her trade of dressmak- 
ing. DIAGNOSIS, PATHOLOGY, AND TREATMENT. 
49 
Case X.—H. P., male, aged 36; single; occupation, 
architect ; native of England. Admitted to asylum with 
acute mania, which had followed repeated attacks of delirium 
tremens. Nervous system very much broken down. Thin 
and anaemic, appetite poor. Slept but little. Was put on 
nourishing diet, and pills of phosphide of zinc, with the ex- 
tract of nux vomica, the combination being one-tenth of a 
grain of the phosphide of zinc, with one-fourth grain of the 
extract of nux vomica. He took these pills three times a day, 
with pepsin and bismuth before meals, as the digestion was 
impaired. He had warm baths, and chloral and hyoscyamus 
in full doses at bed-time. He soon began to improve. The 
hallucinations of sight and hearing with which he had been 
affected, disappeared. The general health improved, and 
in two months from the time of admission, was discharged 
recovered, having gained very markedly in flesh while in the 
asylum. 
Case XI.—A. P., male, aged 16; native of England, ad- 
mitted to asylum in a state of exhaustion, from acute mania, 
threatening death. Tongue and lips dry and black; eyes 
deeply injected and pupils widely dilated. Had not eaten 
or slept for over a fortnight ; was acutely maniacal although 
so much exhausted ; was put to bed and given a full dose of 
brandy, which was followed by a dose of chloral and mor- 
phine. He slept part of the night. The next day he was 
freely stimulated, and fed with beef essence and eggs beaten 
up raw. This treatment was followed up for a week with 
chloral and morphine at bed-time with the happiest results. 
He became quiet, and slept well. The sordes disappeared 
from the teeth and tongue, and he asked to see his mother, 
and recognized her when she came to see him. Talked in- 
coherently for some time, but realized his condition and sur- 
roundings in his lucid intervals. Was put on phosphide of zinc 
in one-tenth grain doses three times a day with good results. 
The appetite increased, the mental faculties improved, and 
he continued to convalesce up to October 3d, when he was 
discharged recovered. The cause of the insanity was thought 
to be immoderate use o'f tobacco, which acted very injurious- 50 
INSANITY ; ITS ETIOLOGY, ETC. 
ly upon a defective organization and weakened nervous sys- 
tem, inherited from his father, who was an intemperate man, 
and died of phthisis. Many more cases might be noted, but 
want of space forbids their insertion. The foregoing cases 
illustrate the necessity of repressing cerebral excitement, in- 
ducing sleep, by means of which the brain cells are renovated, 
and restoring the functions of the body, which are often dis- 
ordered in mental disease. In addition to these measures, if 
we provide cheerful surroundings, new objects of attention 
and interest, and can induce a healthy train of thought, we 
shall very often have the pleasure of seeing our patients make 
a good recovery.