Diseases of the Nervous System
93 Akt. VIL? No. III.?INSANITY. :Author: ROBERT BOYD, M.D. Edin., F.R.C.P. Lond. President Medico-Psychological Association. 1K70; late Physician and Superintendent County Somerset Lunatic Asylum, formerly Resident Physician St. Marylebone Infirmary, anil Lecturer on Medicine.
The functional disorders of the Brain, Convulsions, Epilepsy, and Idiocy, all of which usually prevail before puberty, have previously been shown to be so closely allied as to justify their being included in a distinct class or natural order, and sepa- rated from a second class, including the various forms of insanity occurring almost exclusively in adults.
The cases of the first class were treated of in former papers.* The cases of the second class are now to be considered, and include nearly three-fourths of those that have come under my observation in the Somerset County Lunatic Asylum. A synopsis of the first twenty annual reports of that institution will be given, including a summary of the admissions and the results.
The general classification and description of the principal forms of insanity is that adopted bv the Metropolitan Com- missioners in Lunacy, being the one most likely to be followed and to be of practical utility.
A preliminary statement of the statutory regulations prior, to the confinement of a patient tinder certificates is affixed; also, observations on the diagnosis of insanity, and of feigned insanity.
In the Lunatic Asylum Act 1853, 16 & 17 Victoria, c. 97, the mode of sending pauper lunatics to an asylum is prescribed in clauses 67 and 68, the more important provisions of which are as follows: ?Under ordinary circumstances lunatics are sent to the asylum by an order of a Justice; or of the officiating clergyman of the parish and the relieving officer. The person who makes the order must see the lunatic and satisfy himself that he is a proper subject to send to an asylum, and must also obtain from a legally qualified medical man a certificate as provided by the Act.
The form of statement given by the Act comprises ques- tions which must be answered by the relieving officer. Every medical officer of a union must, within three days, give notice to the relieving officer of any person deemed to be lunatic; and thereupon the relieving officer must, within three days, apply to a Justice, in each case under a penalty of J10 (sec. 70). The Justice must order the person to be brought before him within three days, or he may act at once on his own knowledge, without requiring any of these preliminaries. If the patient cannot conveniently be taken before a Justice, then the officiating clergyman may examine the patient at his own abode or elsewhere; but there is no power to bring the patient before him given in the Act.
Wandering Lunatics are to be sent to an asylum by order of one Justice; and lunatics not under proper care and control, and those who are cruelly treated or neglected by any relative or other person having care or charge of them, by order of two Justices. In each case the medical certificate is the same. There are provisions that constables are to take wandering lunatics into custody, and bring them before a Justice; and that, upon information, due inquiries shall be made, either by a Justice, or by a medical practitioner by order of a Justice, into the cases of persons not under proper care, or cruelly treated, or neglected; and upon an unfavourable report, an order shall be made to bring the lunatic before two Justices.
There are penalties of ?10 for not taking wandering lunatics into custody, and for not giving information within three days of persons not under proper care or who are cruelly treated. Private Patients.?Sec. 74 enacts that no person not a pauper is to be received into an asylum, except under the pro- visions of this Act, without an order and two medical certi- ficates, according to the form and containing the particulars required in Schedule F annexed to this Act. Each person certifying shall be a registered medical practitioner, and the two shall not be in partnership nor one be assistant to the other, and they shall separately have examined the patient not more than seven days previously to the reception of such person into the asylum ; and every person who receives any person, not a pauper, into any asylum without such order and medical cer- tificate shall be guilty of a misdemeanour.
It may be as well to add a few remarks on the order, statement, and medical certificates. The directions on the printed form must be carefully attended to, or the form will be returned, to be completed or corrected, by the Commis- sioners in Lunacy, to whom copies are sent. If not amended within fourteen days, the Commissioners may make an order for the patient’s discharge. The medical practitioner has to certify, not only that the person is a lunatic, or idiot, or of unsound mind, but also that he is a proper subject to be taken charge of in an asylum ; and he must also give his reasons for coming to such a conclusion; first, from facts which he has observed himself; and secondly, from facts communicated to him by others, stating the name of his informant. The latter facts are usually those which have led to the inquiry into the person’s sanity. No confusion should be made between the two classes of facts. The circumstances which the medical practitioner should state, as having come under his own observation, must of course be such as to indicate some amount of unsoundness of mind. They need not be so complete as to form the entire basis of his opinion, either as to the existence of insanity or the expediency of sending the patient to the asylum. In one important class of cases, where there is danger of suicide, it is extremely unlikely that the medical man can have facts known to himself which indicate the extent of the danger. In such cases, relying chiefly upon hearsay evidence, which of course he will strictly scrutinise, he will not shrink from the responsibility which is attendant upon his signing a certificate. When he observes no indica- tion of insanity, and neither the family history nor the pre- vious acts and expressions of the patient furnish reasonable grounds for suspicion, he must refuse to sign the certificate. Diagnosis of Insanity and Delirium.?The diagnosis of insanity is often very difficult, both with respect to medical jurisprudence and in a practical point of view. Prichard considered monomania to be the most clearly defined of all the forms of insanity. Persons who labour under illusions are, for the most part, eccentric in their conduct in general, and also morally insane. The supervention of some illusory opinion on a previously existent derangement of the habits and moral feelings is the general chai-acteristic of monomania. The existence of moral insanity is more difficult to deter- mine, as may be inferred from the description of that disorder. It is defined by Prichard, in his treatise on Insanity, as ” a morbid perversion of the feelings, affections, and active powers, without illusion or erroneous conviction impressed upon the understanding.” It must be proved before any pro- ceedings against an alleged lunatic can be taken, and before he can be declared of unsound mind, not merely that he labours under a degree of moral insanity, but that his case is individually such as to render him incapable of managing his affairs and unfit to be entrusted even with the care of his own personal safety. The diagnosis of instinctive madness, or of insane impulse from crime, the object of moral punish- ment, is a most difficult and at the same time an important investigation. The diagnosis of mania, or of raving madness and delirium, is of the utmost importance. A delirious person should not be moved to an asylum. Such mistakes have been made, and to a medical practitioner might be ruinous. Delirium no doubt, when it occurs in fever or inflammation of the brain, often passes into insanity in persons hereditarily predisposed. Several writers have divided de- lirium into the acute and the chronic; the former consisting of various morbid states of the brain, attended by mental disturabnce and fever; the latter of mental alienation, un- attended by fever or active bodily disease. Chronic delirium therefore comprises the various forms of insanity. Some con- sider insanity the delirium of chronic disease.
The causes which give origin to delirium are often them- selves sufficient to distinguish it from insanity. In the ad- vanced stage of acute, and also in chronic, diseases, when the powers of life become exhausted, and acute febrile action has set in, delirium, although considered an accidental, is especially a characteristic symptom. The insane patient retains his senses, as well as his digestive, assimilative, and locomotive powers, but little or not at all impaired. His mental faculties and intelligence are but partially deranged. There are, how- ever, some instances of acute raving mania in which, from long continued and violent agitation, febrile symptoms supervene. ” Maniacs see, hear, and perceive correctly, although they talk incoherently; their senses are not obscured as are those of a patient in febrile delirium; and they have not the tremulous agi- tation and muscular weakness which generally exists in the latter diseases.” There are instances in which perception and the muscular power are unimpaired in delirium. A case is related of a patient in the Bristol Infirmary ” who once jumped sud- denly from his bed, being alarmed by a clap of thunder, and sprang up with astonishing strength and agility over the beds to a window nearly eighteen feet high. He held himself up on the outside by the sill of the window, and was taken down from a great height. He afterwards recovered from his fever without any sign of mania.” An instance occurred of a young female, in the fever ward of the St. Marylebone Infirmary who sprang from her bed, leaped through the window on the third story, fractured her skull, and was killed on the spot. Another case occurred, in the same institution, of a man in the fever ward with pneumonia, who, a few hours before his death, got out of bed suddenly, and commenced shouting and raving; his face flushed, and pulse rapid and small. Patients in fever often rave in a way which indicates that they are under illusion as to where they are, and mistake the persons who surround them. Fatal surgical operations are sometimes attended with delirium, and it occasionally appears towards the termination of pneu- monia, hepatitis, splenitis, and phrenitis. Also in chronic diseases, such as phthisis, cancer, dropsy; the mind wanders towards the last. The delirium is generally preceded by pain and throbbing of the head, heat of the scalp, and flushing. A case of pulmonary phthisis combined with delirium (547) occurred in the St. Marylebone Infirmary?No. 159 Edin. Med. and Surg. Journal. A stableman, aged 25, became delirious and weak before his death, and so violent that he had to be removed to a separate ward; in addition to tubercles in the lungs, liver, &c., a scrofulous tumour was found between the falx and the right cerebral hemisphere. The mental disorder gradually increases, and the delirium usually passes into coma. Occasionally it disappears, especially in chronic diseases, and leaves the mind clear before death.
The diagnosis of mania and delirium tremens is impor- tant, and sometimes more difficult than that of madness and febrile delirium. The history of the case must be taken into consideration ; but, the same habits of drunkenness leading to both disorders, this is not always sufficient. Patients in deli- rium tremens have seldom or never clear and accurate percep- tions ; their organs of sense are affected by the disorder; they fancy themselves to be surrounded by fiends or spectres, or gnawed by rats; their muscular power is greatly impaired; they are weak and tremulous; while even in the most violent paroxysms of mania the person affected sees and hears distinctly, and is strong and active in his limbs.
The various distinguishing marks of delirium have been thus summed up by Georget:?
1. Acute delirium is not an essential symptom of that disease in which it occurs, since that disease may exist without it. Insane delirium is the essential, and often the most pro- minent, symptom, for there may be little or no disturbance in the constitution. The voluntary motions may not suffer, and the patient may be able to walk, and to eat and drink as usual. 2. In acute delirium the intellectual functions appear to be suspended rather than prevented. The patient can scarcely utter a few unintelligible and unconnected words, and those, as well as his actions, are without any relation to the surrounding objects. The senses, too, perform their functions very imper- fectly, or not at all, and the natural affections do not exist. In insane delirium the intellect is seldom totally overpowered, some of its affections only being affected. It is exce s of action, deviation, and want of harmony of these faculties, or prepon- derance of some fixed and assumed idea, that characterises general or partial insanity. By the partially insane a connected discourse is often kept up, and they are frequently capable of maintaining the discussion of an argument. The senses also perform their functions, perception exists, although it may not be just, and the mind is awake to objects which are present. 3. In acute delirium the mind is wholly absorbed, as in a dream, with its own creations, and preserves the power, when strongly roused to momentary recollection, of directing itself to its situation. In insane delirium truth and error are mixed up and not distinguishable by the patient.
4. In acute delirium volition as well as consciousness is suspended, the patient being for the most part in a state of stupor; and when he does attempt an intellectual effort, he appears as if he were in a dream. In insane delirium volition is often powerfully exerted and influenced by motives in the action it produces.
5. In the course of acute delirium, circumstances that have occurred are on recovery but faintly remembered. In insane delirium a full recollection is frequently retained of all that has passed.
6. Acute delirium is not hereditary, any more than is the disease in which it may occur, nor is it announced by signs of predisposition, nor of imperfection. Insane delirium is very frequently hereditary. The greater number of the insane, or of those destined to become so, exhibit traces of it in the general character of the mind, their manner of life, and of study, &c. 7. Acute delirium being only the symptom of another disease, its duration is dependent on that of the primary one; and this does not remain long in such a state of violence as to keep up the delirium; which therefore may last a few hours or days, and rarely extends beyond one or two weeks. In insane delirium the duration is very indeterminate. Not being a mortal disease, the patient may live a great many years; indeed, for the most part, he is not restored to reason until some months, or a year, or even longer time has elapsed. 8. Acute delirium occurs in acute diseases common to childhood. Insane delirium is scarcely known before the age of puberty.
9. Acute delirium does not present any directly curative indications; in particular, we never think of removing it by moral means, because (intellect being nearly suspended) no effect could be looked for from them. In insane delirium the treatment is very much directed to injured function; it being on this principle that moral means operate.
10. When once the health is established a relapse of acute delirium is not dreaded. In insane delirium the recovery is not always permanent, relapses are frequent, and the brain is easily disturbed by slight causes.
Lastly. The causes of acute delirium are either from remote diseases, or from different influences which give birth to cerebral affections, of which this is the symptom. Tlif causes of insane delirium act directly upon the intellects functions of the brain.
Simulated Insanity.?” The supposed difficulty,” says Dr. Kay, ” of distinguishing between feigned and real insanity has been the principal cause to bind the legal profession to the most rigid construction and application of the common law relative to this disorder. Nothing requires a severer exer- cise of a physician’s knowledge and tact than such a case. There is a prevalent but unfounded notion that insanity may be easily imitated.” A convalescent patient in the Somerset Asylum was heard to observe to a ” tramp ” who came to ask alms, ” What a fool you are to beg! Gro into the town and knock down the quietest looking and most respectably dressed gentleman you can find ; you will be taken up, made out mad, sent here, and be comfortably provided for.” The method that is in madness, the constant recurrence to the predominant idea, is one of those features in the disease which is generally overlooked. Greorget does not believe that a person who has not made insanity his study can deceive a physician well ac- quainted with the disorder. Haslam declares that ” to sustain the character of a paroxysm of active insanity would require a continuity of exertion beyond the power of a sane person.” Impostors generally overdo the character they assume, and present nothing but a clumsy caricature. The representa- tions of mania put forth in the works of novelists and poets, with a few such admirable exceptions as the Lear and Hamlet of Shakespeare, are, of all their attempts to copy nature, the least like their models. The really mad are, generally speaking, not readily recognised by a stranger, and they re- tain so much of the rational as to require an effort to detect the impairment of their faculties. In feigned cases all this is very different; the person is determined his derangement shall not be overlooked for want of numerous and obvious manifestations of its existence. A maniac has generally no difficulty in remembering his friends, places, names, dates, and events, and the occurrences of his life. His replies to ques- tions, though they may sometimes indicate delusion or extravagant notions, generally have some relation to the subject, and show that it has occupied his attention. Now, a criminal simulating mania, will frequently deny all know- ledge of men or things with which he has been always familiar, especially whenever he imagines that such ignorance, if believed, may be considered as a proof of his innocence.
There is also a certain hesitation and appearance of preme- ditation in the succession of ideas with which, in real madness, the train of thought is changed.
In the year 1849, a male prisoner, aged 27, described as a hawker, who was sentenced to fifteen years’ transportation for highway robbery, was sent to the Somerset County Asylum from the gaol. He had been a month in the infir- mary of the prison, on account of his health, which was bad. He had low fever after his admission, and was for several weeks in the infirmary of the asylum. He never would speak to any one, but chattered like a monkey, repeating the words, ” Jack, Jack, fifteen years for nothing.” If he saw a female he would run at her; and he had a dangerous pro- pensity of climbing and suspending himself by his legs, head downwards. Six months after his admission he had im- proved, went out to work, and was very expert in lifting weights; and from the manner in which he set about such things he impressed one with the idea that he had been a sailor. He sometimes spoke in Spanish and in French, and expressed a great dislike to English and French people. About this time his conduct changed; he never spoke Eng- lish to the attendants, and pretended not to understand it, although, when not observed, he spoke English to one of the patients. He slept well at night; gesticulated when he thought he was observed, or when he heard any one approach- ing, and not at other times; and the general impression was that he was feigning insanity. On one occasion he came behind the attendant when opening a cupboard, and snatched at a carving knife, but did not succeed in getting it, at which he was greatly enraged. A few hours afterwards he attempted to strangle the same attendant. An order was subsequently obtained from the Secretary of State, and he was removed to the criminal ward of Bethlehem Hospital, where, I was in- formed, he conducted himself like a rational person. On the journey to London, although handcuffed, he displayed his monkeyish tricks, and frightened passengers from the car- riage, and at Swindon station a remonstrance was made, and a strong desire expressed that he should be expelled from the train. The method of detecting insanity in England is left to individual sagacity. The French arrange their means under three general divisions : the interrogatory, the continued observation, and the inquest. The interrogatory embraces those means of information which are applicable in a personal interview. The continued observation has usually to be pursued for some time, and when the person supposes him- self to be unobserved; he should be led to speak of the motives of those who are anxious to prove his insanity, or to write to his friends and prepare statements of his wrongs. It has been observed that a forgetfulness of words and letters will be evinced by well-educated maniacs, whose mistakes are owing to their malady. The inquest consists in collecting- information respecting the patient’s condition before and after the presumed disorder, and the causes suspected to have impaired his mind; his writings are consulted, and the testimony of those who have been about and have conversed with him. Facts should be preferred to opinions, and it should be ascertained if madness be hereditary in his family, and whether any powerful cause, chagrin, severe crosses, reverse of fortune, or any change in his habits, tastes, or affections, have preceded the development. His business transactions, management of his family, and the state of his health are also subjects for inquiry. If the patient’s in- sanity be not evident, the conclusion ought to be that he is not a fit subject for legal interference. In the report of the Metropolitan Commissioners in Lunacy, made previous to the passing of the Lunacy Acts in 1845, a brief, but distinct, description is given of principal forms of insanity, which are classified under the following heads :?
I. Mania ; which is subdivided into^? 1. Acute mania, or raving madness. 2. Ordinary mania or chronic madness of a less acute form. 3. Periodical, or remittent mania, with compara- tively lucid intervals. II. Dementia, or decay and obliteration of the intel- lectual faculties. III. Melancholia. IV. Monomania. V. Moral Insanity. The three last-mentioned forms are sometimes compre- hended under the term partial insanity. VI. Congenital idiocy. VII. Congenital imbecility. VIII. General paralysis of the insane. IX. Epilepsy. X. Delirium tremens.
A few brief descriptions of the disorders to which these terms are appropriated may be deemed requisite by way of explanation.
I. General Definition of Mania.?Mania.?This term is used to designate a particular kind of madness, as affecting all the operations of the mind. Hence the term total or general insanity is used as synonymous with mania. Maniacs are incapable of carrying on, in a calm and collected manner, any process of thought; their disorder for the most part betraying itself whenever they attempt to enter into conversation. It likewise affects their conduct, gesture, and behaviour, which are absurd and irrational; their actions being characterised by great restlessness, appearing to be the result of momentary impulses and without obvious motives. Mania is also accom- panied by hurry and confusion of ideas, and by more or less excitement and vehemence of feeling and expression. When these last symptoms exist in an excessive degree, the disorder is termed aoute mania or raving madness.
1. Acute Mania.?Acute mania or raving madness is the first stage of the disease, which often becomes gradually milder in its character, and is then termed chronic mania or simply mania. In other cases the disposition to high excite- ment or raving continues throughout the whole course of the disease, which sometimes becomes fatal through the exhaustion occasioned by perpetual agitation and want of rest. It is also generally attended with considerable disturbance of the vital functions.
2. Chronic Mania.?The chronic form of madness is attended with less excitement of the passions, less rapidity of utterance, and less violence of action. In this stage the disorder of the mind is not always immediately perceptible ; but it soon becomes apparent that the patient is incapable of continued rational conversation or self-control, and that his acts are the result of momentary caprice, and not governed by rational motives. A great proportion labour under illusions and hallucinations, or false impressions as to matters of fact; but in these illusive notions there is no consistency or permanence. Patients labouring under this chronic form of mania are often tolerably tranquil and harmless. Many of them are capable of being employed in agricultural and other active pursuits, and of amusing themselves by reading, music, and various entertaining games. A great proportion of the inmates of lunatic asylums belong to this class. However quiet and manageable they may appear to be under the authority and supervision to which they are subjected in an asylum, they are quite unfit, to be at large and to mix with ordinary society, 3. Intermittent Mania.?Intermittent mania, or madness attended with lucid intervals, is by no means so frequent as might be inferred from the writings of authors on medical jurisprudence. Some medical writers of considerable note have denied the existence of lucid intervals altogether. The fact is, that in large asylums there are patients subject to occasional paroxysms of raving madness, but who have in- tervals of comparative tranquillity and rest. It generally happens that after the alternations of raving fits and periods of tranquillity have occurred for some time, the intervals become less clearly marked and the mind is found to be weakened, the temper more irritable, and both the feelings and the intellectual faculties more and more disordered. Distinction between Recurrent Insanity and Intermittent Mania.?Recurrent insanity differs from intermittent mania, though often confounded with it. In intermittent mania paroxysms occur either after regular or irregular periods, and this is the ordinary character of the disease. Recurrent in- sanity is a name applied to any form of mental disorder, when the patient recovers perfectly, but suffers from relapses after considerable periods of time.
II. Dementia.?Chronic and protracted mania is frequently the prelude to a decay and final obliteration of the mental faculties, which is termed dementia.
Dementia differs from all other forms of insanity. It differs from mania, in which the intellectual powers still exist, though they are exercised in a confused and disordered manner. It differs from idiocy, in which the powers of mind have never been developed, while in dementia they have been lost. Dementia is, in some instances, the primary form of mental derangement, and its phenomena make their appearance in the first onset of the disease. Cases of this kind are chiefly from causes of a depressing nature, such as deep and overwhelming grief, extreme poverty, destitution, and old age. In those instances in which dementia is the sequel of protracted mania, it is not easy to determine the point at which mania ends and dementia begins. It is sometimes, also, the sequel of epilepsy, apoplexy, paralysis, and other affections of the brain. III. Melancholia.?A considerable proportion of the in- mates of all extensive lunatic asylums are the melancholies, among whom there are several degrees and varieties. Some patients display merely lowness of spirits, with a distaste for the pleasures of life and a total indifference to its concerns. These have no disorder of the understanding or defect in the intellectual powers, and, however closely examined, manifest no delusion or hallucination. This state often alternates with an opposite condition of the mind, namely, one of buoyancy ot spirits and morbid activity. It is thus very frequently difficult to determine in what degree melancholy, when it exists without delusions, constitutes insanity. A great number of persons whose disorder is precisely that which is above described, and who betray no particular error of judgment or hallucination, are confined in lunatic asylums as a precaution against suicide, to which they are prone, in many instances, from a disgust of life.
Another class of melancholies derive their grief and despon- dency from some unreal misfortune which they imagine to have befallen them. Many are convinced that they have com- mitted unpardonable sins, and are doomed to eternal perdition. Others believe themselves to be accused or suspected of some heinous crime, of which they are destined to undergo the punishment; and of this they live in continual dread. Some fancy that they have sustained great pecuniary losses, and are utterly and irretrievably ruined. A numerous class of melan- choly patients live under the impression that they labour under some terrible bodily disease. Many of them have, in reality, some complaint of which they magnify the symptoms; they fancy every trifling sensation of a painful kind to be certain indications of their incurable distemper, which they often attribute to some fantastic cause.
IV. Monomania.?Monomania, properly so termed, is a form of insanity which, from the attention given to it, might be supposed to be of more frequent occurrence than it really is. The term is professedly given to cases in which the intellectual faculties are unimpaired, except with relation to some particular topics. Instances, indeed, are continually occurring in which some particular impression of a delusive and insane kind occupies the attention of the patient, and is uppermost in his mind; but unless the power of reasoning correctly on subjects unconnected with the illusion is retained, the disorder is not a case of monomania or ” partial insanity.” A frequent illusion of monomaniacs is that that they hold conversation with super- natural beings.
In most instances of partial insanity, melancholy connects itself with the subject of delusion. These cases properly belong to melancholia.
V. Moral Insanity.?This term was first used by Dr. Prichard to designate a form of mental disease in which the affections, sentiments, habits, and, generally speaking, the moral feelings of the mind, rather than the intellectual facul- ties, are in an unsound and disordered state. The common distinctive character of all these cases is of a negative kind; viz. the faculties of the understanding remain apparently unimpaired, and no delusive impression can be detected in the mind of the patient which may account for the perver- sion of his moral dispositions, affections, and inclinations. Cases of this description were formerly looked upon as un- accountable phenomena. They are, however, now recognised as a distinct’ form of mental disorder in nearly all the public asylums. They are characterised by a total want of self- control, with an inordinate propensity to excesses of various kinds, among others habitual intoxication. This is often followed by an attack of mania, which, however, speedily subsides when the patient is confined; but is generally re- produced, by the same exciting cause, soon after he is dis- charged. Among the female inmates of asylums, there are many whose disorder principally consists in a moral perversion connected with hysterical or sexual excitement. VI. and VII. Congenital Idiocy and Congenital Imbe- cility.?Congenital idiots are persons whose intellectual facul- ties have never been developed.
Congenital Imbecility is the result of some original defect, which renders the mind feeble in all its operations, though not altogether incapable of exercising them within a limited sphere. There are many degrees of imbecility, but the examples chiefly found in lunatic asylums are persons labouring under this weakness in an extreme degree. It is evident that more discrimination ought to be used than has hitherto been practised in selecting from persons of this class proper objects for confinement.
VIII. General Paralysis of the Insane, and other forms of Paralysis complicated with Insanity.?Paralysis is not unfrequently complicated with insanity, and is almost an in- variable indication that the case is incurable and hopeless, marking the existence of organic disease of the brain or spinal cord.
In some instances insanity is the consequence of an attack of apoplexy or of hemiplegia. This happens more especially in aged persons. In others apoplexy or paralysis supervenes on protracted mania or dementia.
The most strongly marked case of the complication of paralytic symptoms with those of mental disorder is the disease termed general paralysis of the insane. This is more properly to be considered as an affection distinct both from ordinary paralysis and from insanity. The paralytic symp- toms in this affection are, in some cases, observed to precede those of mental disturbance, whilst in others they follow. General paralysis of the insane seldom occurs in females, but mostly in men, and is the result almost uniformly of a de- bauched and intemperate life. Its duration is scarcely ever longer than two, or at most three, years, when it generally brings its victim to the grave. The onset of the disease is distinguished by an impediment in the articulation ; an effort is required in speaking, and the words are uttered with a sort of mumbling and stammering. At this period there is no perceptible sign of paralysis, and the mobility of the limbs is not impaired. In a second stage the patient is ob- served to have a tottering gait; the limbs are weaker than in health, especially the lower extremities ; while the func- tions of the organs of sense are likewise enfeebled. In the progress of time a third stage appears, during which the victim of the malady loses not only the power of locomotion, but can neither feed himself nor answer the calls of nature. He becomes more and more weak and emaciated, but generally perishes under some secondary disease, such as gangrene, sloughing of the surface of the body, or diarrhoea, unless he be cut off at an earlier period by an apoplectic or epileptic attack, to which these patients are very liable. The disorder of the mind is peculiar in this affection. It is generally a species of monomania, in which the individual affected fancies himself possessed of vast riches and power. IX. Epilepsy.?In most of the lunatic asylums there are some, and in the large asylums many, persons confined among the insane who are subject to epilepsy; for this disease, un- fortunately, is often complicated with insanity. There are, however, some epileptics in these asylums who are not insane, or in any way disordered in mind during the intervals of their paroxysms.
Epilepsy is complicated with disorders or defects of the mind in various ways.
1. Epileptic Idiots.?Persons whose intellectual faculties have never been developed. They are not materially different as regards their mental deficiency from idiots not subject to epilepsy; but they require greater care, on account of the accidents to which this disease renders them liable. 2. Epileptics who are Imbecile or Demented.?When pa- roxysms of epilepsy are very frequent and severe, and the disease is of long duration, it generally impairs the intellectual faculties. Torpor, weakness, and imbecility come on, which, if the patient survives under his disease for many years, termi- nate in fatuity, similar in every respect to the fatuity which ensues in protracted mania.
3. Epileptic Mania.?Some persons subject to severe paroxysms of epilepsy without suffering obliteration of their intellectual faculties, and even without obvious disorder of the mind during the intervals of their paroxysms, are never- theless subject to occasional fits of a maniacal character. It is an observation frequently made by the attendants of asylums that, when the epileptic fits are coming on, such persons are irritable, morose, malicious, and sometimes exceedingly dan- gerous. During these periods epileptics are prone to violence, and sometimes perpetrate the most atrocious acts. Many instances are upon record of such persons, at a time when their disorder had been in abeyance, or even supposed to have ceased altogether, having been seized with a sudden impulse to commit homicide, infanticide, suicide, or to set fire to houses. In other instances, the mental disorder of epileptics; has the form of acute mania, or rather of raving delirium. The patient, generally a day or two after the attack of epilepsy, sometimes immediately after it has ceased, is seized with a sudden fury, during which he sings, roars, shrieks, or resembles a man in a violent fit of intoxication. The species of mad- ness which is complicated with epilepsy is one of the most mischievous and dangerous forms of the disease. But the instances of this affection bear a very small proportion to the cases of epilepsy in general.
Epileptics whose Intellects are Unimpaired. A great number of instances of epilepsy, however, are well known to exist without any disorder of the mind. Persons subject to occasional paroxysms, or those of infrequent occurrence^ only, are, during the intervals, in a tolerably perfect possession of their intellectual faculties, and are capable of following their ordinary pursuits.
Adult persons of this description are scarcely to be found in lunatic asylums ; but boys and girls, when they have become a source of anxiety and trouble to their parents, as well as dangerous to themselves, have sometimes been sent by boards of guardians to asylums for protection. This, however, is not a sufficient reason for associating this class of epileptics with the insane. Where a proper classification exists, the epileptics are placed in wards by themselves, or are separated from the insane ; but there are many lunatic asylums where this regula- tion is entirely neglected.
Delirium Tremens,?Instances of delirium tremens are occasionally, though not often, seen among inmates of lunatic asylums. The disorder is well known. It is the result of intemperance, and frequently supervenes on a fit of intoxica- tion. It is named from the muscular tremor and agitation which accompanies it, and the peculiar affection of the mind, resembling the delirium of fever rather than the phenomena of insanity. It is not a disease of long duration, but terminates for the most part in a short period, either in death or in recovery. Hence there are few cases of this description in lunatic asylums.
Folie Circulaire (circular insanity), in which there are alternations of mania and melancholy with lucid intervals, has no defined place in any classification, nor can it be referred to any form of insanity under any English system. It includes the acute varieties of the second natural order or class of the functional disorders of the brain, as here proposed. There were two very remarkable instances of these alternations in females, who had been for many years in the Somerset Asylum. One of them had a regular annual rotation, from a maniacal state, in which she was noisy, destructive, and of filthy habits for several weeks, till gradually she became rational, quiet, obliging, and industrious for months. Then for months she would be in a state of the deepest dejection, sitting apart from others, silent, slovenly, and sometimes requiring to be fed. In the older female there was less regularity in the periodical alternations, and the symptoms were more allied to dementia.
With respect to the subject of insanity. In the introduc- tion to Hermann’s Physiology,” by Gamgee, 1875, it is stated: ” The means of treating in a scientific manner the phenomena of mind are completely wanting, inasmuch as these phenomena cannot be brought into relation with any of our scientific con- ceptions. Physiology must here, therefore, provisionally limit herself to the investigation of the organs with which they are connected.”
PAUPER ASYLUMS. Dr Prichard states that insanity appears to fall in a greater proportion upon the lowest classes of society, since, in England, 78f per cent, were stated to be paupers. Hence it appears that mental derangement must be looked upon not merely as an individual calamity, but as a serious public burden, for such must be the permanent maintenance of so many paupers re- quiring more than ordinary care and expense.
On this important subject, Dr M. Lindsay, Superintendent of the Derby County Asylum, has collected, and recently pub- lished, some valuable and interesting information for his com- mittee and the ratepayers in general; the usual question having arisen at Derby, as elsewhere, of providing additional accommodation, so as to include the pauper patients of the borough in the county asylum, and thereby diminish the cost which a separate establishment would involve. In many asylums numerous additions have been made from time to time, and in several counties one or more new asylums have been built, as in Middlesex, Kent, Surrey, Lancashire, and York- shire.
County and BoRouan Lunatic Asylums. Table showing the Cost pek Bed, including Building, Land, Furniture, Bedding, and Clothing. Asylums Original Number of Beds Original Cost per Bed Present Number of Beds Present Cost per Bed Derby . Leicester (Borough) Stafford (Lichfield) South Yorkshire . Cheshire (Macclesfield) Warwick Northampton. Worcester Gloucester Oxford . Hereford Devon . Glamorgan Northumberland Cambridge Bristol (City and County) Newcastle (Borough) City of London Beds (Herts and Hunts] Wilts North and East Ridings East Lancashire Surrey (Wandsworth) East Middlesex Berkshire Surrey (Brookwood) Hants . Carmarthen . Somerset 300 282 501 450 540 400 323 200 250 200 260 250 505 296 160 456 370 1,258 285 400 212 350 ? 327 180 144 203 218 219 190 271 196 200 245 272 220 200 230 193 230 230 235 150 158 148 436 800 640 750 624 499 668 400 ? 275 210 150 122 200 170 172 177 1,050 638 165 115
It seems necessary here to explain the difference in the cost per bed in the Somerset Asylum, and the reason of its having become so much lower than in any other, in the above table. The situation on the side of the Mendip Hills was, in the first place, well chosen; the contractor found excellent building stone, also lime stone and brick clay, on the spot. 2udly, the year after opening the Asylum in 1849, a building fund was formed from the extra charge for patients from other counties, and from boroughs which had not contributed towards the erec- tion of the Asylum. ( Vide Fifth Annual Report of the Somer- set Asylum, 1852.) The Lunacy Acts Amendment Act of 1862, 25 & 26 Vict. c. 3, sec. 6, recognises the establishment of a ” Building and Repair Fund ” from the excess of payments for patients not belonging to the county or borough for which the Asylum is provided, and directs that a detailed statement of the manner in which such fund has been expended shall be annually submitted to the General or Quarter Sessions. The Chairman of the Somerset Asylum, in his Report for 1862, to tlie Quarter Sessions, in reference to the Act 25 & 26 Vict. c. 3, states: “The Court is aware that such a fund as this was established when the Asylum was opened, through the judicious care of Mr. Moody, and that all the money received on account of the extra charge has been employed to the enlargement and improvement of the Asylum.
” The Committee, therefore, have thought this the proper time to append to their Report as full an account of this fund as can now be rendered, with notes of the chief improvements from time to time made. In all about ?8,600 has been re- ceived, and nearly the same sum expended, since the house was opened in March 1848.
” During the first six years, about ?2,000 was spent in com- pleting the boundary wall and lodges, in levelling and quarrying, and getting the ground in order in front of the house, and com- pleting some of the outbuildings behind. During the next three years considerable improvements were made in the farm- yard, and a dormitory then built at an expense of about ?1,000, and the large dormitories formed in the house by taking down the wooden partitions. After that the kitchen and workshops were removed ; the laundry, after the fire, repaired; steam in- troduced instead of open fires for the boilers, and iron substi- tuted for wood in the roof; and, lastly, the large dining and recreation hall built. The house was built for 350 patients, and cost ?52,000. At the end of 1859 there was room for 440, and 520 can now be accommodated, at an expense of about ?8,000 for the additional 170 patients ; and no charge has been made on the county rate for repairs and alterations ; and it is right to add that land has been bought which cost rather more than ?3,000. ” It is satisfactory to add that so large an increase has been secured at so small a cost, and that much of what has been done has been conducive to the good of the patients; the masons, carpenters, &c., who happened to be in the Asylum, being employed in their proper work, and others made to assist them.” According to the Census, the population of Somersetshire Was nearly half a million, and did not materially change during the 20 years. The number of insane paupers was in the be- ginning 610 ; of these 173 were idiots kept at home, and many were in workhouses.
During that period there had been 3,284 admissions?1,649 of males and 1,635 of females. The Discharges (recoveries) 39*8 per cent, males; 45 per cent, females. Not recovered 13*7 do. 12-8 do. Died . . 32*9 do. 24kl do. Remaining . 13k6 do. 18*1 do. 100 100
These numbers include 181 male and 129 female epileptics, and 52 male and 34 female idiots, previously treated of in the ” Journals.” The relapses are also included?15*3 per cent, in males and 16 per cent, in females.
The slight excess in males is due to the greater number of male epileptics and idiots. In the ordinary cases of insanity included in the second class, the females predominate?1,220 males and 1,237 females.
These have been arranged under three heads in the table, showing the influence of age in relation to the different forms of insanity in both sexes, and percentage of results. Under the first head (Mania) are included cases of mania, puerperal and intermittent. Under the second head (Partial Insanity) are included cases of monomania, melancholia, moral insanity, and delirium tremens. Under the third head (Cases of De- mentia), general paralysis and fatuity. At all ages as set down on admission for a period of 20^ years, the percentage of Recoveries were . 36’5 in males and 38*8 in females. Not recovered . .12 do. 12*3 do. Died …31*5 do. 22*4 do. Remaining . . 20 do. 26*5 do. 100 100
Those cerebral disorders which usually prevail before puberty ?convulsions, idiocy, and epilepsy?amounted to above 16 per cent, of the cases admitted to the Somerset Asylum, the males being one-third more numerous than the females. It is now intended to show the influence of age in the second class, the ordinary cases of insanity which prevail at a later period of life.
It is stated by a distinguished medical writer that ado- lescence is one of the most important epochs of human existence. The practices which both sexes acquire at this period of life, when the physical and mental powers are in a state of active development, both the dictates of reason and moral restraint are required to control. The physical exhaustion and mental torpor due to indulging in them, the infliction in after life of many of the diseases which proceed from debility, of numerous nervous and convulsive disorders, as neuralgia, chorea, epilepsy, melancholia and mania, &c., are the sad results. The mental disorders of the second class have been placed under three heads, in the following table:?
Percentage of the Results in 2,457 Cases of Insanity at Decennial Periods of Life, distinguishing the Sexes and showing the Numbers of each Sex. Ago and No. of each Sex Form of the Disorder Recovered Not Recovered SI. F. 31. Remaining SI. Total number SI. Under 20 39 SI years? .; 44 F…1 ? ?{ ?1 ?I ?(
From 20 to 30? 204 SI.; 266 F, From 30 to 40? 288 SI.; 289 F. From 40 to 50- - 287 M.; 268 F. From 50 to 60? 186 SI.; 174 F. From 60 to 70? 132 SI.; 131 F. From 70 upwards? 84 SI.; 65 F. . Slania . Partial Insanity Dementia Slania Partial Insanity Dementia Slania … Partial Insanity Dementia Slania Partial Insanity Dementia . Slania . Partial Insanity Dementia Slania , Partial Insanity Dementia Slania Partial Insanity Dementia Totals . Slania Partial Insanity Dementia 93-1 60 0 55*5 36-5 5-5 44-6 51 13-9 36-5 44-7 0 58-3 51-5 0 44-6 47-4 0 38-4 44-4 0 79’3 73 0 54-2 56-6 0 51 48-3 42-3 40 50’7 0 36-6 43-8 0 21 36-3 0 22-3 33-3 0 0 20 0 11*5 17-5 22-2 11*7 8 4’6 9-3 9 5 9-6 5 121 18-7 7-1 12-7 63-2 7-7 0 19 69 0 0 12-8 11-4 43 8-4 3-8 10-8 5-5 9-5 9-4 56 10-5 106 58-4 11-1 0 50 2-3 0 0 11-5 21 44-4 247 17-4 76-9 31 29’5 21-5 24-3 73-1 32-2 34-5 29 38-4 22’2 52 49-6 47-6 3-7 46-4 49-2 7’6 11-2 19-8 10-1 8-5 38-7 23 24 65’7 0 9 0 9-8 8 28-5 15-7 10 43-2 16-2 16-5 90-5 24-2 25 24 36’9 31-8 166 38-9 33-3 43-4 16-8 16-6 393 4-6 20 0 21-5 25 27’9 19 236 4-6 23*2 16-3 1-6 15-2 12-1 8-2 16-1 5-4 7-8 15’5 333 29 18-4 17-2 108 138 18 0 23-2 23 28-5 25’3 33 3 11-6 33 27-3 0 306 218 20 31-6 21-3 25 27-7 33-4 6-6 26-7 25-7 14’4 31 8 0 134 52 18 151 72 65 150 74 63 83 66 37 50 50 32 28 9 47 603 349 268 1,220
Under the age of 20 years there were 83 cases; three- fourths of them came under the head of Mania, under which are included intermittent cases of mania ; the numbers of each sex were nearly equal; the recoveries in mania at this age amounted to 86 per cent.; there was but one death. Under the head of Partial Insanity are included those in a state of melancholia, monomania, and moral insanity, including delirium tremens. There were 17 cases under 20 years ; the recoveries 66 per cent., and one death. The third head, Dementia, in- cludes senile fatuity, and that most fatal form, general paralysis, of which there were altogether 145 cases in males and 27 in females, mostly occurring in persons of from 30 to 55 years; no case under 20 years.
From 20 to 30 there were 204 males and 266 females?a great excess of the latter at this particular period; in the cases of mania an excess of 38, and in partial insanity of 35; whereas in cases of dementia, including general paralysis, the number of males exceeded the females by 11, as shown in the table. The percentage of recoveries in mania in each sex were nearly equal?55 per cent in males and 54 in females; the deaths 11^, and nearly 10 per cent, in females. In partial insanity at this age the recoveries in females were 20 per cent, greater than in males, and the deaths were very much fewer; also in the cases of dementia and general paralysis the mortality was greatly in excess, being 21 as compared with 8 per cent, in females.
From 30 to 40 years the numbers of each sex were more nearly equal?288 males and 289 females. There was still a preponderance of females under the head of Mania. There were 151 cases of mania in males and 182 in females, at this age ; the recoveries in males 44*6, and in females 51 per cent. ; and the mortality 24*7 in males?very much higher than in females, being in them 15*7 per cent. The cases of partial insanity were nearly in equal numbers in the sexes; the re- coveries were 51 per cent, in males and 48*3 per cent, in females; the mortality 17*4 in males and 10 per cent, in females. Under the head of Dementia, including general para- lysis, there was a considerable excess of males?more than double the number of females, of whom there were only 26, a large proportion?42 per cent.?of whom recovered; among the males, 65 in number, not 14 per cent, recovered, whilst the mortality amounted to nearly 77 per cent, in the males and 43 per cent, in females.
From 40 to 50 the males exceeded the females by 19; viz. 287 males and 268 females. As in the former period, the cases of mania in females were in excess of those of males 6.
The recoveries were 36*5 per cent, in males, and 40 per cent, in females, and the mortality as high as 31 per cent, in males compared with 16*2 per cent, in females. The second head (Partial Insanity) included 74 males and 91 females. The recoveries amounted to 44’7 in males and 50*7 per cent, in females; the mortality to 29*5 in males and 1 6*5 per cent, in females. The cases of dementia were three times as numerous in males, 63, to 21 in females; no recoveries ; mortality, 88*8 in males, and 90*5 in females.
From 50 to 60 the total numbers were 186 males and 174 females. The cases of mania, 83 males and 85 females. The recoveries were in these cases considerably greater in the males, being 58*3 compared with 36’6 in females. The mortality was lowest in the males, being 21*5 compared with 24*2 per cent, in females. Of partial insanity the numbers were nearly equal? 66 males and 64 females; the recoveries in males being greater, 51*5 compared with 43-8 per cent, in females; the mortality 24*3 in males and 25 per cent, in females. The cases of dementia, including general paralysis, were 37 in males, and 25 in females ; no recoveries; mortality 7 3 per cent, in males, and 24 only in females.
From 60 to 70 the numbers were 132 males and 131 females. Cases of mania, 50 males, 54 females ; recoveries, 44’6 males and 21 per cent, females; deaths, 32’2 males and 36’9 per cent, females ; leaving the large proportion of 31*6 females compared with 16*1 per cent, males remaining in the Asylum. The cases of partial insanity numbered 50 males and 44 females; the re- coveries 47*4 males and 36*3 females; the mortality 34*5 in males, and 31*8 in females. At this decennial period the cases of dementia were nearly equal; there was not that predominance of males as at all previous periods, owing principally to the cases of general paralysis not occurring so late in life. The numbers were 38 males and 36 females ; no recoveries; the mortality 29 per cent, males, and 16*6 per cent, females; remain- ing, 7*8 males and 25 per cent, females; being three times the number of females remaining compared with males.
From 70 years upwards the numbers were 84 males and 65 females; under each head the males in excess. The recoveries in mania 38*4 in males, and 22*3 per cent, in females ; the mor- tality 38 per cent, in each sex. In partial insanity, recoveries 44*4 in males, and 33*3 per cent, in females; the mortality 22*2 in males, and 33*3 per cent, in females, the same proportion of each sex remaining in the Asylum. The mortality in cases of dementia was 52 per cent, in males, and 43*4 per cent, in females, leaving 29 per cent, males, and only 6*6 per cent, females, remaining under care in the Asylum.
In the 2,457 cases of mental disorders, of the 2nd class, ad- mitted to the Somerset County Asylum in 20? years, from which idiots, epileptics, and recurrent cases or relapses are ex- cluded, the percentage of admissions were as follows :? From Mania, Males 24*5 Females 28*7 Partial Insanity, do 14*3 Do 15*7 Dementia 10*9 Do 5*9 49-7 50-3
In the decennial period from 30 to 40, there was in both sexes the largest number of admissions ; up to that age the females predominated, after that age the males. Admissions up to 40 years, 22 per cent, males, 24*8 per cent, females. After 40 years, 47*7 per cent, males, and 25*5 per cent, females. From an analysis of these cases at quinquennial periods, it appears that at the earliest ages, up to 35 years, the females were more prone to insanity than the males, the numbers being 382 males and 464 females, or nearly four females to three males. After 35 years of age the males were in excess, but in a minor degree; from 35 to 60 years of age the numbers were 622 males and 577 females, and from 60 years upwards 216 males and 196 females.
At the earlier ages, before 35 years, the recoveries were, in males 188, or 49*2 per cent, on the admissions, and in females 267, or 57*4 per cent., a difference of 8? per cent, in favour of the latter. From 35 to 60 years the percentage of recoveries was 38*4 in males and 37*4 in females. After 60 years of age the percentage of recoveries was in males 19*4 and in females 17*3 per cent.
The mortality at these ages, was: under 35 years, 24*5 in males and 13*3 only in females, a difference of 11 ? per cent.; from 35 to 60 years the mortality in males was 40 and in females 26 per cent.; after 60 years of age the mortality was in males 57 and in females 55 per cent. ii 2
Disclaimer
The historical material in this project falls into one of three categories for clearances and permissions:
Material currently under copyright, made available with a Creative Commons license chosen by the publisher.
Material that is in the public domain
Material identified by the Welcome Trust as an Orphan Work, made available with a Creative Commons Attribution-NonCommercial 4.0 International License.
While we are in the process of adding metadata to the articles, please check the article at its original source for specific copyrights.