Traumatic Insanity and Other Effects of Head Injuries. By S. V. CLEVENGER, M. D., Chicago, Ills. Reprint from The Alienist and Neurologist, St. Louis, July, 1888. [Reprint from The Alienist and Neurologist, July, 1888, St. Louis.] Traumatic Insanity and Other Effects of Head Injuries. By S. V. Clevenger, TyI. D., Chicago, Ill., Consulting Physician for Nervous and Mental Diseases to the Michael Reese and A'exian Brothers' Hospitals; late Pathologist County Insane Asylum, Chicago; Member of the American Neurological, American Microscopical, American Electrical Societies; Author of * ' Comparative Physiology and Psychology," etc. T TEAD injuries do not invariably produce mental dis- ease, but when insanity results there are, in most cases, peculiar symptoms constant enough to justify the designation of Skae,1 traumatic insanity, which has been adopted by Krafft-Ebing,2 Spitzka3 and the other leading psychiatrical authors. There are important medico-legal bearings that should induce the scientific physician to accord the trau- matic aetiology a just consideration even where the malady did not, upon superficial observation, appear to otherwise differ from the ordinary epilepsies, paranoias, paretic dementias, etc., which, as sequelae, are often prominent, but which are, as a rule, modified by the traumatism markedly. Closer attention to such cases will reveal the impure nature of insanity improperly classified under other than the traumatic name when head injury figures as the cause. Many of the perplexing " mixed cases " in asylums can thus be satisfactorily accounted for : such as present first one fairly defined psychosis and then another, or blend two or more forms, aside from katatonia and circular insanity. The mental ailment being apt to develop long after the receipt of the injury, surgeons do not ordinarily 1. London Journal of Mental Science, Vol. XX. 2. Lehrbuch der Psychiatric. 3. Insanity, Its Diagnosis and Treatment. 1 2 S. V. Clevenger. encounter or recognize the disorder, as is evident in the bare mention by Agnew4 and Bryant5 that insanity may follow head injury and there be no external evidence, upon the head, of the injury. In hospitals and private practice cranial injuries are seldom followed, from lack of opportunity ; even military surgeons are debarred from a satisfactory study, for in the field such cases are sent to the rear, discharged as dis- abled, or otherwise escape observation, after the wound, if any, has healed. From various causes even insane asylums differ widely in their statistical records. Thus Clouston6 encountered but 12 cases in 9 years at the Royal Edinburgh Asylum and infers that: " Accidents to the head do not loom largely therefore in the production of the insanity of the world.' On the other hand Schlager' found 49 out of 500 cases of insanity, to be traumatic. Sankey is silent on the subject as his cases were females in the Hanwell Asylum, princi- pally. Pritchard8 quotes from Esquirol9 traumatic cases in private practice: 8 in 120, Salpctriere 26 in 361, Charen- ton 11 in 256, total 45 in 737; of which 22 were from head blows or falls, and 23 coup de sohel. Worcester10 cites (J. Crichton Browne's West Riding Asylum Reports) that from April 1st, 1870 to the same date in 1872 there were admitted 42 such cases, fifteen times more numerous annually than in Edinburgh. Kiernan11 found 45 in 2200 at Ward's Island Asylum, New York. While pathologist at the Chicago county asylum I ascertained 49 cases wherein traumatism was operative among 610 patients, and my report12 divides them as follows : Causes ascertained 357, unascertained 253 ; of these 24 males, 3 females, had head injuries; 3 males, I female were sunstruck; 3 males 4. Agnew's Surgery, p. 304. 5 Bryant's Surgery, p. 200, 6 Mental Diseases, p. 300. 7. Zeitschrift der K. K. gesellschaft der Aerzte zu Wien, XIII, 1857, p. 451. 8. Insanity, p. 186 et seq. 9. Art. Folie, Diet, deeSci. Med. 10. Insanity and Its Treatment, p. 90. 11. Detroit Lancet, June, 1883, p. 539. 12. Chicago Med. Journ. and Examiner, April, 1884, p. 388.. Traumatic Insanity. 3 had been subjected to intense heat, I male had become insane after a lightning stroke upon the head. In these the traumatism appeared to be the only cause, but in 2 male cases typhoid fever, in I male a fright, in I male and I female a tendency to hebephrenia, and in 2 males and 3 females heredity were associated; 3 males were epileptic, 1 male had been sunstruck in addition to having a head injury. Mickle13 states that in 1221 cases of paretic dementia, tabulated in the 1878 Lunacy Blue Book for England and Wales, 3.1 per cent, was caused by sun-stroke and 4.6 per cent, by cranial injury. The proportion of insanity due to blows and falls upon the head, overheating and sunstroke, from various authors, approximate from among all other forms of mental dis- ease : 6. per cent. Bucknill & Tuke {Psych Med. p. 97.) 10. " Schlager {Wien Zeitschrift, loc. citi) 6. " Esquirol {Diet, des Sci. Med.'} .33 " Clouston {Mental Diseases, p. 300.) 2. " Kiernan {Journ. Nerv. and Mental Dis- ease, July, 1881.) 8. " Clevenger {Med. Jottrn. and Exam., loc. cit.} The average proportion of traumatically caused to other forms of insanity is thus 5.4 per cent., ranging with different asylums from less than 1 up to 10 per cent, of the admissions. But for reasons to appear this is not the proportion of Trarimatic Insanity. It is in many cases difficult, if not impossible to deter- mine whether the traumatism acts as the predisposing or the exciting cause of insanity. Heredity would undoubt- edly precipitate matters after an injury and, we would think, subject such predisposed persons to a greater lia- bility to injury where the neurotic or mental taint had developed enough to lead them into danger; but the recorded cases show that heredity is not necessary to the 13. General Paralysis of the Insane. 4 S. V. Clevenger. establishment of this form of insanity, and, a priori, a maimed brain would be quite sufficient to institute a men- tal ailment without preceding causes. Kiernan14 found inherited taint in 28 of his 45 cases. My records furnish 5 males and 3 females predisposed by heredity in 59 cases. Ten of the total were in private practice after leaving the asylum four years ago. Bucknill and Tuke15 report a case resembling paretic dementia, whose father died insane. Verity16 a similar instance with an insane maternal grandmother and uncle, Brower17 gives three cases in two of which there was hered- ity; a paternal uncle, three paternal cousins and a brother insane in one of the instances, and a grandmother, two uncles and two cousins, all paternal, in the other case. About the best deduction we can make from the cases cited is that while heredity renders the individual with a head injury more liable to insanity than one with the same injury would be without the heredity, and while this predisposition plays a very important part in a large but undetermined number of traumatic cases, the psychosis may exist without any previous insane tendency, inherited or acquired. Plainly any constitutional vice, however obtained, that would enfeeble the resisting powers could act as a pre- disposing cause in this as in other divisions of mental derangement. Winslow18 believes " that the importance of head injury as a cause of insanity cannot be exaggerated," and further states : " In some instances accidents of the kind may not be followed by serious results, but in cer- tain temperaments, or conditions of bodily health, and in particular predispositions, we may safely predicate the development of chronic disease of the brain as the result of neglected blows on the head. Injuries of this charac- ter occurring to persons of a strumous habit, or suffering long-continued debilitating diseases, impaired nutrition, 14. Journ. Nerv. and Mental Dis., July, 1881, p. 450, Table 11 15. Psychological Medicine, p. 311. 16. Amer. Jour. Neurology and Psychiatry, May, 1882. 17. Alienist and Neurologist, Oct., 1883. 18. On the Brain and Mind, p. 440. Traumatic Insanity. 5 overwrought and anxious minds, or a constitutional lia- bility to mental or cerebral disease, are frequently followed by serious and often fatal results." Before arriving at what traumatic insanity is, it will be as well to dwell upon what it is not, owing to the confused idea conveyed by almost all writers except Spitzka.19 He states that " it does not accurately correspond to the ordinary psychoses, has distinct clinical characters, and is always, when found, referable to traumatism or to analo- gous causes." He allots only two pages to the subject, but tersely and effectively. Directly, or by implication, in many works, every form, from melancholia to senile dementia, has been ambiguously included as traumatic; but Kiernan20 incautiously criticises Crichton Browne21 for this, when that observer merely noted that trauma- tism had preceded or complicated the development of cases of hypochondriacal melancholia 3, dementia 9, epi- leptic dementia 9, senile dementia 5, dementia with gen- eral paralysis 3, general mania 2, and one case each of acute, puerperal, recurrent and a potu mania, and a case of " amentia." The abominable classification of the English does not enable us to know whether delirium tremens or alcoholic insanity was meant, and as the trau- matism in the " amentia " case was doubtless post-natal the list may probably be translated into imbecility, alco- holic, puerperal, recurrent insanity one each, dementia 9, senile dementia 5, epileptic insanity 9, paretic dementia 3, mania 3, hy. melancholia (paranoia?) 3. I referred to two hebephrenia cases complicated by head injuries. These, with many in Browne's list, would be atypical, for aside from the fact that some psychoses may develop one upon another and an epileptic, puerperal or other case may be also traumatic, the traumatism may predispose to other forms, precisely as any other brain malady may. If the pubescent insane tendency pre-ex- isted the injury could be the exciting cause, the hebe- 19. Manual of Insanity, p. 370. 20. Op. cit. 21. West Riding Lunatic Asylum Reports, Vol. II. 6 S. V. Clevenger. phrenia could be modified or aggravated by the trauma, traumatic insanity might co-exist with or be overwhelmed by the hebephrenia, so that the case might be one of simple hebephrenia with traumatism, traumatic insanity with hebephrenia, one or the other or even both well- marked, according to the clinical symptoms. This is the advantage of Spitzka's classification ; there is something tangible about it; a prominent group of phenomena char- acterizes each mental disease. We cannot be bound to an aetiological ignis-fatuus. There is no justification for other than a clinical classification in the present unripe stage of mental science. The puerperal case might or might not have become such with or without the head injury: heredity has more to do with that trouble. A well-marked case of melan- cholia, mania or any other mind alienation should not be included as traumatic insanity, even though the injury were the cause, unless the clinical features of that disease are apparent. A cerebral malformation may induce epi- lepsy, idiocy or paranoia, according to circumstances. It would be absurd to neglect the palpable result for the obscure aetiology, so all insanity following a head wound is not traumatic insanity, and the conclusions may be made that: Traumatism may precede insanity and have no relation to the insanity, just as head injury is compatible zvith sanity. Traumatism may predispose to traumatic, or other forms of insanity, especially alcoholic and syphilitic. Traumatism may be the exciting cause of traumatic or other forms of insanity in the predisposed, as hebephrenia and paranoia. Iraumatism may modify, complicate or aggravate other forms zvithout the clinical symptoms of traumatic insanity appearing. The latter may co-exist zvith other forms of insanity. Traumatism may act as both predisposing and exciting cause, producing traumatic insanity by itself (Dickson, Luys and Schliiger), but hereditary or other taint causes greater lia- bility. Traumatic Insanity. 7 Instances of head injury during youth developing epi- lepsy at puberty and insanity at 50 are noted by Cal- med22 and Lasegue.23 Esquirol24 mentions a 3-year-old boy who fell upon his head and became insane at 17, with headaches in the interim. Rush25 one at 15, who fell from a horse, sustained contusion and died insane a few years later. Voisin28 and many others recite similar instances. Savage cites a slight head hurt in a lad caus- ing insanity, but he was strongly predisposed by hered- ity. From Kiernan's researches it appears that slight head injuries, from the insidious nature of the changes they set up, are as much to be dreaded, if not more, than the grave injuries. Winslow takes strong views as to the severity of apparently slight head injuries. Duret,27 Rush28 and others note the slowness with which cerebral injuries manifest themselves; some observers mention 4 to 10 years and later. Griesinger29 says that traumatism may produce insanity at once or several years afterward, that it predisposes even without visible cerebral lesion. Savage, Winslow and Krafft-Ebing call attention to the same fact, and the latter divides traumatic insanity into kinds produced immediately or later, sometimes many years. In 19 of Schlager's 49 cases, insanity began within a year of the accident, in the remainder in from 4 to 10 years afterwards. Insanity may develop at any interval after a head injury, biit usually several years intervene. Under head trauma that affect the brain, with or without demonstrable cranial or cerebral lesion, may be included contusions, compressions, incisions, punctures, concussions, the effects of transmitted or direct violence 22. La Paralysie chez les Alienes. 23. Paralysie Generale des Alienbs, Voisin. 24. Maladies Mentales. • 25. Medical Inquiries and Observations, p. 28. 26. Op. cit. 27. Etudes exp. et clin. sur les Tran. Cerebraux, p. 137. 28. Op. cit. 29. Mental Pathology and Therapeutics. S. V. Clevenger. 8 (such as could be imparted by a jar of the spinal col- umn), lightning stroke, sun-stroke, overheating, exposure to sudden alterations of intense heat and cold. Neck wounds through probable injury to the cervical sympa- thetic,80 and injuries to the limb or trunk may occasion insanity. Skae, Worcester, Dickson, Savage, Spitzka, Bucknill and Tuke, Clouston and the alienists of continental Europe uniformly include sun-stroke as a cause, and later works, such as Spitzka's " Manual," properly add general overheating, while Krafft-Ebing,31 Reich,3' Brush,33 Schwartzer34 report a transitory insanity from exposure to alternations of great temperature ranges. I treated one such case whose delusions were grandiose. There was considerable cerebral hyperaemia. He recovered promptly within two months of the inception. Schlager observes that the injuries were followed by immediate loss of consciousness, by dull pain in the head or by simple mental confusion, but these are the custo- mary accompaniments of all head hurts. Savage speaks of the nervous instability that sometimes follows with an increased liability to become affected by other exciting causes of insanity, and thinks that bone depression with membrane inflammation may often be the cause of the disorder, but acknowledges that altered conditions of brain nutrition may suffice. Duret's " Etudes " form a handsome contribution to the subject. He explains contrecoup and other effects of head injuries, especially concussion, by the sudden pro- pulsion of cerebro-spinal fluids from the point struck to opposite parts, often the fourth ventricle. This accords with Spitzka's idea that paretic dementia is a localized 30. Brower, Bannister and I published separately, and at several years' inter- vals, accounts of the progress of a case of this kind: one side of his face « as flushed and delusions of persecution and suspicion were prominent, in Jour. Nerv, and Men- tal Dis., 1879, and Med. Jour, and Exam., May, 1884. 31. Lehrbuch der Psychiatrie, 32. Berliner Klin. Wochenschrift, No. 8, 1881. 33. Amer. Jour, of Insanity, 1882-3. 34. Die Transitorisehe Tobsucht. Traumatic Insanity. 9 lesion in the floor of that portion, accounting for trauma- tism so frequently inducing a form of that malady. The strain upon ventricles and blood-vessels could cause effu- sion and extravasation. As a valuable addition to cerebral pathology Duret's work has not had even decent treat- ment by the English writers. The pathology of the subject cannot be simplified, for the results will vary widely between post-mortem findings and ante-mortem symptoms according to skull and brain structure, vascular peculiarities, age, habit, education, environment, nationality (the Irish develop greatest iras- cibility after head injury), and especially, what has been least considered, the location of the injury. To facilitate study of these cases the record should note the seat of the hurt, the manner in which it was sustained and other information likely to impart clues as to the portion of the brain injured. The statement " head injury" is too broad to enable judgment of cause and effect relation. My observation leads me to believe that frontal head wounds are apt to induce the paranoia form of traumatic insanity ; more diffused injuries, such as con- cussions, insolation, overheating, the paretic dementia. Among the troubles which Spitzka, Clouston, Marce33 and others describe as sometimes occurring are speech dif- ficulties, vertigo, irregular alternations of stupor, agitation and imperfect lucidity, tinnitus aurium, photopsia, eye scotoma and scintillation, paresis of muscular groups, par- ticularly those of the eyeball, anaesthesias and hyper- aesthesias. These are probably the least constant but some are usual accompaniments of different forms of brain derangement and hence need not be dwelt upon in con- nection with the typical cases except as subsidiary evi- dences. Epilepsy may supervene either in the form of petit or grand mal, with or without epileptic insanity, and as Kiernan says, not differing from the ordinary except that some ended in paretic dementia (a traumatic modification). He 35. Maladies Mentales. 10 S. V. Clevenger. had a larger percentage of epileptics from traumatism than other observers, who do not note so many. Ecchevaria3' states that 35 in 321 epileptic insane were such from trau- matism, and Gowers37 found 92 epileptic cases in 1450 due to head injury. One of the most violent and dangerous epileptic maniacs I ever knew had a fractured skull. Mania from traumatism is likely to be the recurrent furious phase characteristic of the occasional outbreak of traumatic insanity. Hebephrenia has been disposed of, supra. Melancholia admittedly rarely complicates or succeeds traumatism. Kiernan had but one case, the attonita form. This horrible derangement we can readily imagine could be caused by head injury. Katatonia. I found one case with a head injury, but doubt its relationship beyond its having caused alcohol addiction. Kiernan found four head injuries among 30 kata- toniacs. Stuporous insanity being a recoverable form, dementia would more properly include cases of traumatism resembl- ing it. Senile dementia. Traumatism could have but a prob- lematical association. It never could cause the disease unless it precipitated impending senile brain involution. Syphilitic dementia could occur through the injured brain or membranes affording a nidus for the post or pre- syphilitic poison. Alcoholic insanity may co-exist with, precede or follow upon traumatism and be associated with it in every con- ceivable manner, for reasons given infra, under alcoholic complications. Imbecility may result from traumatism, for obvious reasons Recurrent mania. A case was reported by Crichton Browne, but the attacks may have been only the episodi- cal furies of traumatic insanity. I observed one, a German 36. Epilepsy. 37. Epilepsy, p. 26. Traumatic Insanity. 11 aged 40, with a large scaphoid depression of the top of his skull from a fracture. When overheated he became volubly maniacal, but at other times appeared to be rational. (The " boodler gang" of county commissioners, part of which is now in the penitentiary, interfered with my means of studying this and other cases-a side com- ment to indicate the difficulties of the American non- political alienist). The prognosis of traumatic ally induced insanity is unfavor- able. Schlager attests this. Spitzka says: " as a rule progressive deterioration sets in and dementia terminates the history of the case." Marce also states that " the patient becomes progressively demented." All writers coincide in this. Where dementia follows swiftly, death does also; but other terminal dements from traumatism may linger an ordinary life-time. To this point in the subject we have regarded many phenomena (but not all) that could be included as occur- ring in traumatically induced insanity or that have some association with traumatism, leaving the insanity of trau- matism for separate inspection. Owing to authors not having fully differentiated this from other head injury forms, we have but little data for percentage calculation. It is probably related to other insanity in the proportion of 1 to 2 per cent. About one-fifth of all head injury insane cases. I would designate as traumatic insanity that which exhibited the constant phases that characterize it. The pathological term traumatic being used in a clinical sense and justified by the sufficient invariability of symptoms following demonstrable brain injury; nor would it be unreasonable to include under that head all cases pre- senting the characteristics whether head injury could be demonstrated or not. It would be as correct to infer the trauma or its equivalent from the symptoms as it would be to assert cerebral deficiency in idiocy regardless of the external cranial appearance. Skae held that the symptoms, progress and termination 12 S. V. Clevenger. are sufficiently 'distinctive and characteristic to enable it to be considered as a distinct type of disease. Spitzka fully recognizes this, but places it, nevertheless, among his second or complicating, when it should be under the first or pure insanities. Proper acknowledgment that the brain changes are not always demonstrable would assign it to sub-group A, class first; but supposing this to be debatable, then it may properly fall into the second class as associated with demonstrable changes in the brain, especially where the form was that of paretic dementia, paranoia or dementia. But that author solves its location for his third class, sub-group B (constitutional insanity, essentially the expression of a continuous neurotic con- dition) by stating (p. 371) that it developed upon the " traumatic neurosis." The objection to including traumatic in the pure group, when it manifests paretic dementia symptoms, can be met by the further observation that such forms are impure and were we to absorb a case under, say, paretic demen- tia, there would likely develop other co-existing symp- toms, or the paresis would be too feebly marked, while the peculiarities due to traumatism were strongly marked. Traumatic insanity is pure in the impurity of the psychoses it simulates. The maniacal excitement with which Skae stated that it usually began is most likely the fury which often calls attention to the disease which may have been previously apparent to an expert, for Schlager and others do not mention this kind of onset. Skae's further observations are well sustained: " A chronic condition, often lasting many years, when the patient is irritable, suspicious and dangerous to others; in many such cases distinct homi- cidal impulses exist ; this form is rarely recovered from and has a tendency to pass into dementia and terminate fatally by brain disease." The " characteristic delusions," he additionally enumerated, as " those of pride, self- esteem and suspicion " are best separated into those allied to paranoia and paretic dementia. Traumatic Insanity. 13 Schlager speaks of "self-conceit, prodigality, disquiet and restlessness." These and other aspects of the sub- ject may now be detailed seriatim. The first thing to occur as a symptom usually being Change of character. This is very often only ascer- tainable by a comparison of the behavior before and after the injury upon testimony of relatives and acquaintances. Commonly the traumatic lunatic is described as " not being the man he was." These changes are often radi- cal and consist of Lapses of memory, as in epilepsy, more prominently than a general failure of that faculty. The memory can- not be said to be as acute as previously, and forgetful- ness of names, persons, places and transactions are occa- sional to frequent, but the most notable are the memory gaps. As Spitzka says, entire periods of life may be obliterated from the mind, but in my cases these lacuna were, so far as I could determine, limited to the epilep- tic-like, automatic furies, and to other occasions when insane acts were committed, during a few minutes or extending sometimes over many hours or days. As in other insanities, juvenile or olden events are more readily remembered than the recent occurrences. Headaches and sleeplessness are noticeable, especially as preceding or accompanying the most troublesome periods of the disorder. Both conditions are apt to be hyperaemic and aggravated by constipation, liquor imbib- ing, business or domestic worry, etc. Irritability, varying from occasional irascibility pro- voked by trifling affairs, an explosion of anger, a pas- sionate manner, to the most violent outbursts of temper. Schlager found these to exist in 20 of his 49 cases. Usually the head is flushed at such periods, and there is a swagger and bullyism differing from the epileptic iras- cibility or petit mal intellectuel, which is attended with pallor, a cynical, sarcastic or sneering " hatefulness," rather than boisterousness. But the epileptic unconscious automatism, it is readily understood, may also appear, as 14 S. V. Clevenger. any peculiarity of epilepsy may develop from head injury. The usual sun-stroke or traumatic irascibility, to a lesser degree, can be observed in many cooks who are " hard to get along with." Its cause is in cerebral turgescence from heat. It would seem as though many peculiarities such as these were exactly epileptic, and this probability should be borne in mind and studied. Suspiciousness is a frequent feature, as in phthisical insanity. In the neck wound case, I reported with Brower and Bannister, every delusion the patient, Kelly, had was accusatory. Being a policeman he imagined everyone a thief. Meyer38 reports a case which manifested delusions of suspicion after being struck on the head by a large weight, later he becoming paretic. Long apparently lucid intervals. It is not best to omit the " apparently," for there is no telling at what moment the insanity may explode in an outrageous act, and while hallucinations and other features of insanity exist, even though the patient may talk and act rationally, the insanity is not absent. Personal inspection of the patient may reveal nothing beyond a slight peculiarity of manner, or not even this. The speech may or may not be affected, the pupils may be dilated, contracted or normal, and respond to accommodation tests and to light. There may or may not be paresis of muscles or other deter- minable physical impairment, and such cases in asylums are often capable of doing routine work in an intelligent manner, but they should be always looked upon as dan- gerous. Homicidal and suicidal impulses, as frequent and charac- teristic occurrences in traumatic cases are recorded by Spitzka39 and Clouston,40 who cite a case.41 Many of Bucknill and Tuke's42 descriptions of homicidal impulse read like 38. Archiv. fiir Pysctriatrie, band 2. 39. Manual of Insanity, p. 370. 40. Mental Diseases, p. 298. 41. Op. Clt.» p. 244. 42. Psychological Medicine, p. 254, et seq. Traumatic Insanity. 15 traumatic cases, but epilepsy (which may have had the traumatic origin) is discussed in their connection. Verity 43 narrates a case where the pain and heat appeared upon the side of the head opposite to the part struck, with mental degradation, drunkenness, hallucinations of hearing, disagreeable in character. Three years after the hurt he struck and threatened to kill his wife; at this time he was sober. Two days later he committed suicide by hanging. Brower44 observed three cases. One was an army captain, set. twenty-three, wounded in right parietal region, suffered from headaches and insomnia and four years later became irritable, resentful, quarrelsome and dissolute. His wife abandoned him on account of his conduct. He went to France and became conspicuous for his outrages as a leader of the Commune. He committed a murder and mail robbery. "The immorality was obviously pathological and the case has in it the evidences of logical perversion." The second case, with heredity, hurt in the army, upon the head, under- went character change, was quarrelsome and subject to fits of ungovern- able fury, suspected his family of a desire to poison him. After an attack of epileptic convulsions, his delusions of conspiracy and suicide increased. He carried a knife and pistol for self-defence. The Catholic Church and clergy, to which he had been devoted, he especially regarded as persecut- ing him. He had attacks of fury, in one of which he killed his wife and then attempted suicide. The Illinois prosecution claimed the man's irregularities to be due to whisky. The judge instructed that if the insan- ity was the result of inebriety it was no defence, which resulted in the following verdict: " We, the jury, find the defendant guilty in the manner and form charged in the indictment, and fix his punishment at death by hanging. We also tind the defendant insane at the present time?' The prisoner committed suicide the next day. The third case, act. fifty, strong insane heredity, known as "silly" and "crazy" among his companions, sustained a concussion at forty-two years of age and a year later another. He squandered his property, had paretic delusions of great wealth, boasted of being the third son of God, and in June, 1878, in a public place, in the presence of several persons, without warning or evidence of passion or excitement he shot and killed his wife. Upon examination by Drs. Brower and Lyman he had pupillary inequality, nystagmus, fibrillary twitchings of muscles of face, back, thorax and legs, the jail attendants stated that he slept scarcely at all, feared his food was poisoned and refused it. E. P. Weber, the prosecuting attorney, conscientiously abandoned the case and the jury found the prisoner insane. In fourteen of Schlager's forty-nine cases " There were suicidal attempts with loss of memory and confusion." Pritchard 45 declares " The propensity to suicide is very often combined with the impulse to homicide," and that "acts 43. Amer. Journal Neurology and Psychiatry, May, 1882, p. 196. 44. Alienist and Neurologist, Oct., 1883, p. 650. 45. On Insanity, p. 284. 16 S. V. Clevenger. of suicide like those of homicide are generally preceded by a morbid change of character and habits. Individuals who have been cheerful, active, animated, taking a lively interest in the pursuits of life, in the society of their friends, in their families, become melancholy, torpid, morose and feel an aversion to their relatives or most intimate associates, become listless and indifferent. These appear- ances have often been observed to be the preludes of some attempts at suicide, and have sometimes put the rela- tives on their guard and have led to the prevention of the catastrophe." And Savage46 very justifiably writes : " I would say that in considering a murder, the first question to be asked is, What was the assigned cause for the crime? was it the natural development of surroundings and habits? To my mind certain crimes are themselves sufficient evidence of mental unsoundness. If a person, with or without a sud- den shock, become completely changed in his domestic relations-if a man who is a good husband and a kind father kills wife or child, without any established delusion, I think the crime itself is sufficient to cause a prima facie belief in the existence of mental unsoundness. The chief points, then, are the apparent causelessness of the crime, the utter want of relationship between the crime and the supposed end to be attained, the relationship between the crime and any delusions, the establishment of any insane or nervous inheritance, or the proof that the patient him- self at one time or another has been of unsound mind or epileptic. Next after the consideration of the causation of the crime itself and its surroundings, it is important to obtain evidence as to acts immediately preceding and immediately following the deed, as well as to find out the details." In many cases of traumatic insanity murders, the pre- vious insane predisposition is emphasized by a number of immediate relatives having been insane. Alcoholic complications are very numerous, and where 46. On Insanity, p. 469. Traumatic Insanity. 17 one exists, a murder, especially a wife murder, may be the result of this, as alcoholic lunatics influenced by their marital infidelity, delusions and hallucinations commit peculiarly horrible crimes of this kind. A drunken kata- toniac disemboweled his wife in Chicago, running into the street in his nightgown. He was sent to the penitentiary after puzzling the doctors with the alternations of that disease. (Periodically the daily papers recount the acts of an ordinary katatoniac as a " wonderful case baffling all the physicians "). Spitzka (p. 254), mentions Lennon, a New York alcoholic, who cut his wife up in regular checker board pattern. That both alcoholic and traumatic insanity are mur- derous might raise the quibble in court as to which the crime was attributable. As the head injury impels to the alcoholic lunacy it should not matter, but there is a psy- chological interest in the disentanglement. The delusion of the wife's unfaithfulness might shift the homicide upon the liquor lunacy. 1. Alcoholism may in the ancestry predispose through transmitted nervous or mental instability, so that trau- matism will more likely induce insanity in a descendant. 2. It renders the individual liable to accidents, despite the old saying that drunkards escape injury. 3. Previous alcoholic habit complicates and aggravates traumatic cases as it does pneumonia, and may be the determining factor of insanity, where the abstemious, with the same injury would survive and may remain sane. It retards recovery and alcohol after a head wound or sun- stroke readily congests the brain, a condition especially to be avoided. 4. A proneness to alcoholic addiction is observed as remarkably frequent after a head injury, sun-stroke or overheating. 5. Traumatic cases are quickly, readily and badly affected by small amounts of liquor which previous to the injury would have had little if any effect. " A little will 18 S. V. Clevenger. always make them maniacal and often very dangerous and homicidal," says Clouston/7 6. Alcoholic insanity may be superimposed upon trau- matic and many degrees of these two psychoses combined are observable. 7. The delusions peculiar to the alcoholic insane are sometimes found in traumatic cases complicated with alcohol, even though the alcoholic insanity may not fully exist. This is an important observation. 8. As a probable majority of head injury cases are addicted to liquor the relations of alcoholism to this insanity should be clearly understood as of medico-legal importance, for the law makes a distinction between acts done through insanity from liquor continuously used and those occasioned by liquor "voluntarily" taken. Fearing that advantage may be taken of the plea if drunkenness secured acquittal the legal fiction remains, to be swept away by further advance in civilization, that every drunk- ard is responsible for his crime. Since this is in the statutes there should be careful discrimination of the effects of alcohol in criminal cases. It should be known that injury predisposes to alcoholism and that one or the other psy- chosis may predominate in the same individual. Frequently we have to combat the error of an effect or product of insanity being mistaken for the cause; and nowhere is so much injustice exhibited as in these instances. I knew an officer of the regular army whose eye was shot out and fore-brain injured during the late war. He was jovial, but dissipated, and occasionally irascible, especially when marching. He was thrice court- martialed for acts committed under liquor influence and threatened with cashiering. He had no sympathy from bis brother officers, who were harsh in their condemnations. His previous brilliant record for bravery stood him in good stead, whereas the pathological condition should have been recognized in mitigation or excuse. A fireman is in an Illinois asy- lum with a battered head received in the course of duty. He was pre- viously temperate, and as he drank heavily afterwards, this was blamed as the cause of the insanity and his wife is refused the customary pension. 47. Op. cit., pp. 298, 299. Traumatic Insanity. 19 If we adopt the Earl of Shaftesbury's dictum (he was in a position to make such an affirmation, being the head of the English Lunacy Commission for fifty years), that fifty per cent, of all insanity is due to alcohol, I think that careful tabulation will show much of this alco- holism to be induced or precipitated by cranial injury, which latter becomes the real and the former the apparent cause. Decisions, illusions and hallucinations are those of being persecuted and are often hypochondriacal, as in paranoia; those of grandeur as in paretic dementia; those of poi- soning and marital infidelity as in alchoholic insanity. The divisions of traumatic insanity I would suggest, are as follows : Traumatic dementia, which usually runs a rapid course to death, and follows upon severe injuries. Traumatic paretic dementia. This is not the ordinary paresis, but a mixed form blending the peculiarities of the traumatic with those of a shifting, illy-defined pare- sis, and often linked to a prominent enough paranoia, but the latter is modified by the paresis which governs the prognosis. Mickle48 says: " In the cases which have come under my observation where cranial injury has con- duced to general paralysis, it has in the majority served to play the part of a predisposing rather than an exciting cause." Closer study of these with other traumatic patients would enable him to see the injury alone suffic- ient in the majority, for it is too frequent to be other- wise. Sankey49 tells of a patient injured by a fall, who was a week insensible, recovered and two years later paretic dementia set in. In Burman's statistics50 103 paretic dements were such through sun-stroke in 7, and head injury in 12 cases. In 1221 cases of paresis stated by the "English Lunacy Blue Book" for 1878, 3.1 per cent, were caused by sun-stroke, 4.6 per cent, by head 48. Jour, of Mental Science, Jan., 1883. 49. Lectures on Mental Disease, second ed., p. 287. 50 and 55. Bucknill and Tuke, Psych. Med., p. 329. 20 S. V. Clevenger. injury.51 Mickle52 discusses the influence of cranial injuries and heat as predisposing and exciting causes. Calmed6* speaks of similar results from exposure to great furnace heat. Brierre de Boismont54 affirms that paretic dementia may be preceded two or three years by great irritability or menace of suicide or character change and memory failure. It would be useful to know whether such cases were not traumatic, but the author cited gives us no clue to this. Burman and Calmeil55 unite in calling attention to the frequency of paresis in the army and navy. The hypochondriacal, suicidal and homicidal paretics of Mickle, with delusions of persecution, it is noteworthy, were mil- itary, a class particularly subject to head hurts and heat exposure. Careful inspection of Mickle's cases show a likelihood of a much larger undiscovered number of trau- matic patients. While several of his soldiers were sun- struck and one was hit by a poker, the evident trau- matic symptoms detailed were not referred to as such, and these same symptoms existed in several other cases in which there was no mention as to whether there had or had not been head injury. The precedent eccentric- ity, suicidal attempts, irritability, passion, insomnia, alcohol addiction point to a probability of traumatism in his Cases X., XII., XIII., XV., and XVI. Case X,III. had early epileptic convulsions, and XV., epilepsy eight years before. While an idiopathic epilepsy may become paretic and neither ailment be attributable to trauma, the epileptiform seizures of paresis should be studied with regard to trau- matism, especially if the fits occurred early in the dis- ease or heralded it, as affording a possibility of trauma- tism. At least as traumatism causes epilepsy and paretic dementia, it would be well to determine to which of the three conditions the spasms were due, and whether in traumatic paretics the epileptiform phenomena, from petit 51. Mickle Gen., Paral. of Insane, p. 102. 52. Op. cit. pp. 98 and 108. 53. Mickle, loc. cit. 54. Annales d'Hygiene pub. et de Med. Legale, 1860. Traumatic Insanity. 21 to grand mal or their similitudes, did not occur more fre- quently or sooner than in other paretics. Parchappe56 and CalmeiP7 and Burlureaux53 assign epi- lepsy as a cause of paretic dementia. Let us next ascer- tain the cause of the epilepsy. I have observed loquacity, prodigality and expansive ideation develop in a case six months after a head injury without headaches, insomnia or intemperance, with decided petit mal about weekly. He fell thirty feet causing stellate fracture of right occipito-parietal and post-occipital regions. He "was maniacal immediately after the fall and semi-comatose two months. He was treated by Drs. A. J. Baxter, Otto Schmidt, J. C. Oswald and myself, during the year that has elapsed since the accident. Irritability does not occur often. His abstemious life has aided him greatly. Traumatic paranoia may occur with or without the par- etic symptoms simultaneously or successively thereto. I should judge from the accounts of the "American crow- bar case" that paranoia was the prominent, if not the sole, manifestation in that instance. Left frontal hurts or heredity appear to determine the appearance of this logical perversion. There are cases wherein paranoia, epilepsy and paretic dementia are united, where one predominates or persists to the exclusion of the other form. Analysis of Mickle's cases yields the remarkable fact that Cases X., XII., XIII., group 3, paranoia with paresis, post-mortem proved the left cerebrum most diseased; in case XV., group 4, with epilepsy, the paresis predominated, and in the paretic and alcoholic Case XVI., group 4, the right cerebrum was most diseased in both. Traumatic insanity 'without the paresis, paranoia or demen- tia might exist and be evident in furious outbreaks, but I have not seen a case nor can I find any record of the absence of features allied to the psychoses mentioned. The treatment is to avoid sun or other extreme heat, liquor, costiveness, irregularity of habits, irritating influ- ences, business aggravations or close application to any 66. Traite de la Folie. 57. Traits des Malad. In flam, du Cerveau. 58. Folie Paralytique. 22 6. V. Clevenger. pursuit, and to combat with ergot, bromides, antipyrine and derivatives generally, the insomnia and other prod- ucts of cerebral congestion. Massage from the shoulders downward and hot baths, to diffuse the circulation, prove useful. I. Traumatic dementia. W., set. forty, depressed contused wound left upper frontal region from a falling brick, in two years became crochety, irritable, intolerant to liquor, sleepless. Memory and business ability suf- fered impairment. Without warning one day broke up furniture and raved about his house. Mentally deteriorating. II. Traumatic dementia. L.,ret. forty-eight, mechanic, vigorous, cheer- ful and industrious, was struck by Hying stone in left parietal region and within a year was helpless, irritable, sleepless, easily affected by small draughts of liquor, "it went to his bead and made him crazy." Lost memory for recent events. Repeated questions he had asked but wa fe moments before, photophobia, hemiparesis upon same side as the scalp wound (contrecoup is notably frequent in these cases, but Duret's researches account for it). He lost all relish for music and reading, of which pre- viously he was very fond, and presented the appearance of advanced age. In a civil action for damages a physician stated that electricity, the dyna- mometer, thermometer and aesthesiometer were valueless as tests, and he had not used them, that bromism (without foul breath or eruptions) and drunkenness (it was proven that L. was temperate) were probably the causes of all the symptoms. Several ignorant doctors testified on both sides, with others who were well informed, and the issue of the mess was against the plaintiff'. Time will fully corrobate the position I took in the trial, for L. is growing more demented. HL Traumatic dementia. A railroad official named Murphy was brought to me three years ago, after being pounded upon the top of his head with a large rock. He soon after became stupid, could not describe his feelings or condition, had forgotten nearly all he knew, was sleepless and troublesome at home, but too demented to be furious. At an early stage of his insanity he had faint paretic ideas. He died, I was told, in an asylum last year. IV. Traumatic dementia. John G., American, machinist, lightning marks along forehead, neck and left side. Was struck in 18S0, suffered mainly pain in head and stomach, but was conscious and talked rationally till the third day when left hemiplegia occurred and lasted a year. The paralysis included facial with ptosis. Tongue and vocal organs first to recover in 1881, when insanity became evident. Irritable, homicidal, sui- cidal, destructive, noisy, suspicious, erotic, jealous of wife. In 1883, a terminal dement. V. Traumatic paretic dementia. D. S., negro, teamster, ret. fifty-four, scar on right forehead; arrested for larceny, but found to be insane, well behaved between furibund attacks, during which he had paretic delusions of great wealth. Hallucinations of sight and hearing. Saw God in a chariot Traumatic Insanity. 23 once, who commanded him to escape. It required six men to subdue him, as he had unusual strength. Died of pneumonia a year after insanity began. Medulla small. Isthmus cerebri, left Rolandic, frontal parietal and temporal regions, arterial engorgement, extreme in occipital portion. Capillary extravasations in course of superior longitudinal sinus, streaking the dura with the rusty color often found in alcoholic insanity. Veins of left side cerebrum fuller than right. VI. Traumatic paretic dementia. M., set. thirty, machinist, struck in the forehead and top of head by conductor's lantern and soon after began drinking heavily, developed irritability, memory and business ability impairment, sleeplessness and prodigality, and is advancing to dementia. VII. Petit mat and paranoia following traumatism. B., set. twenty-five, clerk, paranoiac father beat him over the head repeatedly when he was young, had attacks of petit mat, was temperate, but irritable (except to wife and mother), suspicious, had memory lapses and delusions of persecution tor which a direction and basis was afforded by some abusive anonymous letters he claimed to have traced to two women in his office. He pur- chased a revolver and deliberately shot both of them in their heads, but they made fair recoveries. The extreme penalty would have been twenty- eight years, but he was sentenced to six years in the penitentary after the State and defence attorneys conferred with the judge. Public feeling ran high, and as I testified to the insanity I received some newspaper criticism, such as this: "The doctor testified that petit mal was more dangerous to the intel- lect than the convulsions of epilepsy. Petit means little: how can the less include the greater danger? " Why do not these experts prevent crime by timely warning instead of waiting till it is done?" That is precisely what every expert does when he can, and what I have repeatedly done when the opportunity presented, but people seldom seek'medical advice in such cases until crime is committed by their insane friends. VIII. Traumatic paranoia. F.,aet. twenty-eight, wounded on head in accident on railroad, from which he alone of all the passengers in his car escaped, some of whom were burned alive within a few feet of where he was pinioned by the debris. In a year he became a decided paranoiac, sus- picious, irritable, quarrelsome, so much so his attorneys found him unman- ageable and compromised damages with the company. IX. Traumatic paranoia. C., set. thirty, butcher, energetic, habits regular; was struck by locomotive, small scalp wound on head healed completely; unconscious, delirious and vomited several days. Within six months his memory became impaired, lost his business ability. Sleepless and restless at night, headaches persisted, suffered from dizziness, dimness of eyesight, photophobia, tinnitus aurium and defective hearing. Ex- tremely irritable and suspicious, feeble, stupid, sullen with lapses of memory, forgetful of faces and places, the least liquor " goes to his head " and makes him worse. His bed-fellow stated that he several times rose in the night with hallucinations of burglars breaking in. Twice he fired 24 5. V. Clevenger. through the door at imaginary persons he claimed to have heard. He married a girl whose language he did not understand and who could not understand his, while unable to provide for a wifte. Beyond a few frontal rugae, there was nothing in his appearance to indicate insanity. Dr. Edmund Andrews was called by the judge and I by the patient in a civil action against the railroad company. Dr. Andrews agreed with my state- ment of the case and C. was awarded $5,000 damages. X. Epilepsy and dementia from traumatism. Recovered. K., set. twenty- six, Irish, when thirteen was struck upon left side of head with a club. Epileptic convulsions every three to six weeks since; iiritable, stupid, could not learn to read or write, progressing to dementia. An osteal node protruded an inch behind top of left ear. At my request Dr. A. J. Baxter removed this exostosis by trephining and I kept the'patient under treat- ment thereafter to avert the headaches which gave warning of the attacks. Since this operation in 1885 he has fully recovered mentally and from the epilepsy. XL Occipital injury with optic hallucinations and without insanity. J. H., aet. forty-two, merchant, had fallen upon occiput when a boy of twelve and suffered frequent pain about the nuchal location, growing worse with age. He drank wine, but not excessively. No mental impair- ment evident aside from peculiar optic hallucinations, interesting from the cuneus gyrus in the occipital brain being the pyschic optic center. He had been treated for tremens, which he resented in passionate outbreaks I induced him to go to the Alexian Hospital and lessened the vascular stasis in the back of his head by derivatives, and he was soon attending to busi- ness after having lost several months' time. His room would be filled with apparitions of his friends and he repeatedly asked me how often I had called to see him during the day when it was ir.y first visit in the morning. He was annoyed by being unable to distinguish the hallucina- tions from the real personages. As he had no auditory hallucinations I taught him to compel all whom he saw in his room to speak and he was pleased with the result, for the apparitions would not answer him, and his reason aided this discrimination. XII. Traumatic predisposition to, but without insanity. A. W., aet. forty-five, builder, was sun-struck during late war, and often irritable and sleepless with headaches, but not insane. In 1881 was very much reduced by neglected remittent fever, and I gave him ten grains of quinine, which developed a maniacal attack; a second dose brought on a similar fury, but by combining with hydrobromic acid 1 was enabled to increase the qui- nine even more. Kiernan59 first called attention to insanity induced by quinine. This instance might explain it as occurring in persons with some abnormality of cerebral circulation to whom congestion would be dangerous. XIII. Paranoia with traumatic insanity a?id alcoholism. Peter Deegan, mt. sixty, farmer, had lived in Ozaukee county, Wisconsin about thirty years, an Irishman, surrounded by Luxemburgers with whom he was incessantly at war. He had been beaten over the head with a club and had 59. Alienist and Neurologist, 1883. Traiimatic Insanity. 25 fallen out of wagons upon his head during drunken bouts, and, to use his own words, "swam in whisky." He turned his family out of doors and was cruel to his children in many ways. There was evidence that his sister and himself were primary paranoiacs. She was hemiparetic and passing into dementia. Both of them saw and talked to the fairies or " good people," left food out of doors for them, and had delusions concerning the dead not compatible with their professed religion. Deegan, in a dis- pute over a trivial matter (a wagon load of straw) brought two guns from the house, one of which he discharged into the thigh of a neighbor, from the effects of which he died. On a change of venue he was tried at She- boygan, Wis. The evidence was overwhelming as to the traumatic and alcoholic nature of his insanity, but there was great popular prejudice against him, and he received a twenty years' sentence. A medical politican swore that there was no such thing as alcoholic insanity, it was only drunkenness, that there were no American authorities on insanity, that the Germans had never added to our knowledge of the subject, that he would not use deceit in examining a prisoner suspected of simulation, he would inform him that he was a physician and tell him what he expected to elicit by tests, that it whs unfair to spy upon a prisoner to this end. He defined insanity as a " disease of the brain affecting the mind, causing the person to act, think and feel diftei/ently from usual," and acknowledged, when asked, that insanity was not always a disease of the brain, but claimed, in answer to another question, that he would not " think, act and feel differently from usual" if he were set down unexpectedly in the middle of China, or were he to sit down upon an upright pin point. The trial lasted more than a week, one day of which 1 spent upon the stand detailing the essentials of traumatic and alcoholic insanity. 1 am indebted to the medical fraternity of Sheboygan county for a kind recep- tion. Nor is it for this that I affirm the high grade intelligence and educa- tion of these " country doctors." They are better equipped in this regard than the average city medical man. XLV. Traumatic paranoia with alcoholism. Mathias Busch, aet. thirty- two, German, brewery beer vender. Grandmother threw herself in a well while insane, father "eccentric," a paternal uncle John insane and confined in a cell in his own house. A son, Henry, of this uncle is in the Jacksonville Asylum, insane; another paternal uncle, Fritz, was insane, who had two daughters, one of whom died in epileptic convulsions and the other gave birth to two idiots. Busch bad been struck on the left forehead when a boy, the scar is still visible; had also a punctured wound in left temple at outer angle of eye from a pitchfork thrust. He had twice been sunstruck in addition. He had been industrious and kind to his family up to the date of his first sun- stroke, six years ago, when stupid and depressed attacks followed with occasional irritability, and drink affected him more than formerly. His occupation led him to drink considerably. He suspected his wife of being unfaithful at times. These troubles with headaches and sleeplessness increased after the second attack, but he transacted his business as usual with occasional moroseness and accusations against his wife. Three years ago he attempted to commit suicide with a pistol. 26 S. V. Clevenger. A week before the murder his insanity was noticed by Mr. McAvoy, the president, and Mr. Ortseifen, the manager of the brewery. Busch wildly told them that he was being persecuted by the brewer's union (of which he was not a member, but thought he was). He told others that his wife had tried him twelve times in the brewery and at other times in the lodge (an insurance organization, the benefits accruing only to his wife upon his death). These statements of trials were proven to be absurdly unfounded. He bungled the beer-books of his customers, refused to talk to anyone, as he had some hypochondriacal delusions concerning his throat, but occasionally forgot this and spoke. Customers complained to the brewery and an agent accompanied him on his rounds, after which he was suspended, but he refused to work anyway, as be said "every one is against me." February 2nd, 1888, he talked of committing suicide and accused his wife of "being in a corner with men before his eyes," and said that her hair was mussed and clothes disarranged; all of which was an hallucina- tion. His wife appealed to friends about this time, saying: "Mat is going crazy, he acts foolish and does not sle< p at all." His manner became more Insane until the afternoon of February 6th, when he came into the house helped his wife prepare dinner, kissed her and the baby, and arose from his chair, went to his wife, laid her head on his shoulder as though to caress her, and drew a butcher knife across her throat severing the carotid. Mrs. Schenk, an aunt of the wife,cried out to Busch: "Look out, the knife is sharp!" He answered as though surprised at her interference: "Let me!" Mrs. S. cut her fingers in trying to interpose her hand. When arrested he was bending over the corpse, looking into the gash in which he had his fingers. Some said he had thrust a handkerchief into the wound, and that he grinned when asked why be did the horrible deed. He did not sleep well in jail, talked and acted "queerly." Had an illusion of his cell mate being " Katy," his wife, and addressed him as such, trying to kiss him. Twice he attempted suicide in prison, once with his suspenders, and the second and nearly successful time with his bed sheet torn and knotted for the occasion. Artificial respiration and an hour's hard work restored him. He had tinnitus aurium and hallucina- tions of sight and hearing. He told me that some said his wife was dead, but that as he heard her talking and singing to him be was puzzled and did not know what to believe. Evidently at times he would accept the statements of others, for he wrote to a friend to bury him next to his wife. At one time in jail he complained of a bone in his throat, and, because there was none there the newspapers brandished this as evidence of his pretending to be insane. He talked rationally when spoken to and made no attempt to feign. Incarceration improved him, through cutting off his drink and regulating his habits. He was watchful of the court proceed- ings. and at times stolidity gave way to evident interest, just as any other traumatic or paranoiac might. He did not seem to be able to recall the events of bis crime. His pupils were dilated, but responded to the usual tests as normal. Hearing was not impaired. Heart sounds feeble and its action was sluggish. The fact that he was capable of being controlled to some extent in Traumatic Insanity. 27 jail by threats was urged as evidence of pretence on his part, when every asylum attendant, with or without warrant, uses this method effectually with troublesome patients, and some political asylum superintendents bluff their cases by swaggering through the corridors with jack boots, long hair and pistols. Busch was said not to be insane because he had not the appearance of an insane person (the lay idea of the genuine article, derived from nov- els, being one with bristling hair, protruding eyes and startling behavior) Apropos of this a grand juryman doubted the insanity of a quiet, sensible- spoken woman in the county asylum, but remodeled his opinion when she returned to him with tinsel crown and other gew-gaws, introducing herself as the queen of song and tragedy. A negress was being sympathized with by another visitor as unjustly incarcerated, owing to her modest and rational behavior, when she launched a murderous kick which nearly rup- tured his perineum. An "expert" for the State swore that Busch was feigning traumatic insanity, but could not describe how that was when the prisoner appeared to be rational. He was further unable to enumerate any of the different forms of insanity, and when asked the difference between monomania and mania said that the first was "off on one subject while the other was off on severalthat the maniac's memory was always impaired. He had never heard of katatonia or hebephrenia and claimed that the murder was the product of an ordinary beer drunk. This alienist defined an insane delusion as a faulty idea having no foundation in fact, and a hallucination was one that had such foundation. Furthman and Walker, former assist- ant States' attorneys, defended the case, and the latter asked, " If a child believes the moon to be made of green cheese is not that belief a faulty idea not founded on fact, and is the child therefore insane?" The trial lasted two weeks and was ably conducted by the attorneys, extraordinary diligence being used to procure testimony of Busch's ante- cedents and behavior before the murder. Less energetic and astute charge of the case would have left the insanity badly sustained. The jury found Busch guilty but sentenced him to the penitentiary for life, a most illogical verdict, for were he sane, under the law wording he should hang; and if insane, the asylum and not the penitentiary, is the proper place for him. He should not have been liberated under any cir- cumstances, if sent to an asylnm. It was doubtless the expectation that he might escape from an institution for insane that inspired the verdict. In some States there is provision made for insane criminals in special asylums. Juries usurp the functions of legislatures and perjure themselves when they endeavor to compromise between public clamor and their disincli- nation to condemn the insane to death. The abolition of the death penalty and provision for insane criminals will solve the question, as, except among savages, the intent of the law is not vengeance but the protection of society.