Diseases of the Nervous System
270 Art. IX.? T No. IV?Mania. :Author: ROBERT BOYD, M.D. Edix., F.R.C.P. Loot. Medico-Psychological Association, 1870; Late Physician and Superintendent County Somerset Lunatic Asylum; Formerly Resident Physician St. Marylebone Infirmary, and Lecturer on Medicine.
From the annual^ reports of the Somerset County Asylum for twenty years, mania, recurrent mania, monomania, and puerperal mania included nearly 53^ per cent, of the admissions of mental disorders; previously distinguished in the Journal, as belonging to the second class of cases of insanity.
The actual numbers under the above forms of mania were 595 males and 712 females; from ordinary mania, first attack, there weie 374 males and 418 females ; from recurrent or periodic mania, second and more frequent attacks, 174 males and 206 females; the numbers from monomania were 47 males and 41 females, and from puerperal mania 47.
The cases were distributed unequally over the different years as regards numbers. In the first year, 1848, upwards of 200 were transferred from licensed houses, in which they had been maintained, to the asylum, and 81 were sent directly from their unions and homes ; so a larger number were admitted in the first ten months than in any succeeding year. In the second year there was a diminution of a third, and in the following seven years the cases of mania averaged only a half, being about 1 instead of 3 in the week. In the following years the average numbers increased about one-fifth, mainly due to the reception of W elsh patients pievious to the opening of the Glamorgan County Asylum in 1865. & b
As regards age at the time of admission, the youngest (682) was a boy of 10 % years, who worked in a silk factory at Taunton. Two months pieviously he received a blow over the left parietal bone, and suffered fiom fever; there was a slight swelling at the part, no pain on pressure. Sometimes he was furious and violent towards his family, also incoherent. He turned out to be a very intelligent lad, and at the end of fifteen months left the asylum quite recovered.
A second boy (1013), aged 14, was also admitted in a similar state; his mother was at the time a maniac in the asylum ; the boy was very violent and destructive. His attack came on suddenly; he worked in a coal pit. He had an eruption and incrustations on the scalp. He also recovered, and was discharged in fifteen months after his admission.
A girl aged 16 became suddenly insane after the death of her mother, who had been a violent character; her father was transported, and subsequently her brother, for sheepstealing. The girl was so violent and so destructive, she became unman- ageable in the workhouse. Her disposition stubborn; sometimes she required to be fed, at other times she was orderly and assisted in the laundry. At the end of 4^ years she was still a patient, in declining bodily health.
The following shows, in decennial periods, the ages of the cases of mania at the time of admission:? Males Females Under 20 years …. 27 24 From 20 to 30 … . 87 92 30 to 40 . 40 to 50 . 50 to 60 . 60 to 70 . 70 to 80 . 80 upwards Total . . 92 115 . 78 94 . 44 53 . 31 33 . 14 6 ? 1 1 . ^74 418 These figures indicate the comparative frequency of mania in male and female patients, that it occurs most frequently at the age when the brain and mental faculties are developed, and at the earlier periods in females than in males. In advanced age, the males are more susceptible than the females.
With respect to the civil condition in cases of mania, the numbers were?of married males 196, of females 213; single males 173, females 204; widowed males 32, females 55. In recurrent mania?married males 93, females 80 ; single males 71, females 91. Civil state not ascertained in 30 males and 69 females. The married were in excess in the males, and the single only slightly so in the females. The widows considerably exceeded the widowers, being in about the proportion of five to three.
The bodily health of the majority of both males and females was indifferent on their admission, and some were brought into the asylum in a very unfit state?in the last stage of disease? in a moribund condition.
The causes in cases of mania admitted were as follows:?
Males Females Hereditary predisposition . . 85 95 Intemperance in drink Religious enthusiasm Grief, deaths in family, &c. Pecuniary losses &c. 54 15 24 23 17 25 9 5
Disappointment in love . Jealousy- Anxiety, excitement Remorse. From belief in witchcraft Hysteria, pride Previous bodily illness and after fever Accidents, and injuries to head &c. Sunstroke and heat in bakehouse Critical period and overwork . Found wandering, poverty and illness Causes not ascertained .
Males Females 4 15 4 6 5 2 1 8 1 3 5 10 48 75 13 2 3 2 8 3 18 12 75 127 374 418 Total
So many were chronic cases transferred from other in- stitutions, that the causes and previous history were not to be obtained. In the others?299 male and 291 female cases?in whom the causes are above enumerated, hereditary predisposi- tion was the principal one ; next in frequency came intemper- ance in males. These causes cannot strictly be classed either as moral or physical. In females, bodily illness occupied the second place, and the physical causes prevailed in them; the moral causes rather predominated in males.
One man (1546), aged 27, with hereditary predisposition on the father’s side, and of intemperate habits in drinking, violent to others, and destructive, fancies he sees witches and the devil. He assaulted a magistrate, and broke the cell at the police station. A fortnight after his attack he was brought to the asylum in a state of mania. At the end of six weeks he was discharged on probation, but was brought back in a few days very excited, having been riding about on his neighbours’ horses. At the end of five months he was discharged recovered, having been previously for two months employed at agricultural work. A man (1010), aged 41, an albino, fancied that spirits visited him at night; his conversation was about spirits; his disposition was to wander from home. He also inherited the disorder. His mother died in the asylum; his sister was also a patient in the asylum, and recovered. At the end of seven months he was discharged recovered, having been for four months employed at agricultural work, and for the last month in a convalescent state.
A male (530), aged 20, was admitted in a restless state of one month’s duration, with suicidal propensities. He fancied that he had an interview with our Saviour, who told him that he was to die the following Thursday; that his soul was lost. After the first week he worked at his trade in the tailors’ shop, and at the end of five months was discharged recovered. A mason and railway sub-contractor (483), aged 41, became insane from loss of money, and dangerous to others. He fancied he had written the clergyman’s sermon, and accused him of committing errors in the delivery of it, and went up to lay hold of him in the pulpit. His expression was wild ; he looked up and talked to the clouds, and heard voices in the wind. He worked with the mason attendant, and after six months was recommended for discharge on probation, but behaved so oddly before the visitors that they deferred then allowing his dis- charge. He told them that he still found the spirits within, but that he had secured them by a couple of handkerchiefs tied round his waist. In another month he returned home to work.
A schoolmaster (1,109), aged 24, whose disorder was attri- buted to mental overwork, had been under treatment at home for three years previous to his admission to the asylum. He was excited and suspicious, and fancied that he was Prince Albert. He remained in the asylum six months, and was discharged not improved, by his father’s desire, to be removed to an asylum in France, where, being a Roman Catholic, he could attend to his religious duties.
A railway labourer (785), aged 32, who fancied himself a king, was admitted in a state of mania, violent and destructive. He recovered after six months, and was discharged, having been out at work in a convalescent state for two months.
Agent for Morrison’s pills (448), aged 60, in bad health, of intemperate habits, ill two weeks, rather dangerous, his conver- sation unconnected, about paying off the National Debt and the electric telegraph. Had a pustule on his upper lip, and asked permission to wear a moustache, observing that as he was going to practise as a quack doctor, a moustache was as necessary to him as a diploma to me. He talked of the British College of Health, where there were neither fellows nor students, but about a dozen great strapping fellows making pills in the back, in the front handsome rooms and good cheer for friends and agents. He had known, from New York, one order for ?5,000 worth of pills. When hygeist at Exeter he was consulted respecting a patient then in the asylum, and he had undertaken to cure him in three weeks for ?10, no cure, no pay. Not being a pauper, and having property, he was removed in six weeks, not im- proved, to be placed under care, which was not done, and he subsequently cut his throat.
A female (786), aged 25, a servant, became maniacal from disappointed love; she had religious delusions, and her con- versation was varied, about spirits, devils, and witches. She soon became tranquil and industrious, discharged recovered three months after admission.
One female (1503), aged 39, in bad health, had religious delusions, and held similar views to those of the Princeites. Her condition remained unchanged.
A female (295), aged 27, described as always being a nervous person, but no disposition to insanity in her family. She dreamt that the world was about to come to an end ; next day there was a thunder storm ; she believed her dream was about being fulfilled, and she became at once insane and violent; said her soul was lost, and prayed fervently. She recovered in eighteen months, but after seven years had a relapse, and remained nine years without any mental improve- ment.
A man (868), aged 39, found wandering, incoherent, and in indifferent health; was a patient for six years, and died suddenly of rupture of an aneurism of the aorta. The following extra- vagant description of himself is from an advertisement in the New York Sun of January 16, 1855 :
William Ber, currier, late of the City of Dublin, the Poet of Nature, can be seen in the City of New York by the following persons namely: Victoria or Albert; the Duke or Duchess of Sutherland, so called; or the Duke of Wellington, so called; or the Earl Elles- ?e?e’ S0T galled; or Col. James Sibthorp, M.P.; James Whiteside, M-?.-! ‘^Napier, M.P; the Eight Hon. Henry Goulbaum, MP. or Sir Moses Montifiore, banker of London, England; or by William Bergan, cock-fighter of the liberty of the City of Dublin, who reared the said William Ber, the Poet of Nature, he being the supposed only heir of Charies Stuart, of Scotland, and the supposed heir, legitimate born, of the so-called George the Fourth, of England, by Caroline Charlotte, consort to said George the Fourth of England, so called, by marriage, lives; and a challenge to Victoria and Albert,*and to the rest of the family, to disapprove the statement. So help me God, to wit: being born the 24th of May 1819. William Ber.
A female (793), aged 32, a vagrant, abusive and quarrelsome, transferred from a licensed house; was very troublesome, but soon improved and was industrious, in good bodily health, and was to have been discharged on probation; meanwhile she made her escape.
An Escaped Lunatic. During the very boisterous weather on Saturday evening, while in the Channel, the attention of the passengers on board the Avon, plying between this city and Newport, was attracted to a person apparently in great distress of mind, lying upon the deck, despairingly clinging to the side of the vessel, and praying earnestly in broken English, ” 0 God preserve me only this once, and I’ll never ask’ee any more,” and frantically inquiring if they should not all be drowned. By the coarse dress worn he appeared to be a navvy. Hearing his Welsh accent, a young man addressed him in that language, and endeavoured to consule him, but he refused to be comforted, saying he had been very wicked. To the surprise of the passengers, when asked rather abruptly for his name, he (or rather she) said it was Sarah Evans. It was further elicited that she had escaped the previous day from Wells Asylum through a small window, and had possessed herself of the man’s apparel she then wore, and was then making her way to Carmarthen, of which place she was a native. On arrival at Newport, Captain Howe judiciously handed her over to the care of Sergeant Curtis, of the Newport police, until inquiries could be made respecting her.?Bristol Daily Post, February 12,1861. The previous history could rarely be obtained of any patients who had been transferred from other institutions. Of the more recent cases it was reported that the conduct of 93 males and 108 females was violent; of 81 males and 54 females, dangerous ; in 33 males and 36 females, suicidal; 1 male and 1 female, homicidal; in 29 males and 26 females, destructive in various ways; restless and excited in 15 males and 28 females; of filthy habits, 6 males and 19 females; noisy, 34 males and 48 females ; obscene and indecent, 4 males and 20 females ; obstinate and irritable, 5 males and 6 females ; idle, 11 males and 11 females.
Moral Treatment.?As soon as possible after their admis- sion, 97 males and 158 females of these cases of acute mania, first attack, were usefully employed at their trades, assisting the attendants inside, on the farm garden, in quarrying, attend- ing masons &c. out of doors, and the females in the laundry, at needlework, and in the dining ball. Employment was found to be most conducive to quietude and mental restoration, and as a test of the fitness for discharge. Every inducement and encouragement was therefore given to accomplish this most desirable object.
It was found that the cultivation of the land afforded a healthful occupation to the patients, and a most important assis- tance to the recovery of the curable cases ; it had also a tran- quillising effect on many of the noisy and incurable cases, by producing natural sleep. The employment of the insane cannot be too strongly enforced, whether regarded with reference to their disorder or as a means of reducing the cost of main- tenance, and thereby extending the benefits of the institution to a greater number of poor lunatics, the expense too frequently operating as an objection to the removal of patients to the asylum. Besides those occupied on the land, several were em- ployed in the workshops. All the shoes were made and repaired on the premises, and much of the clothing and bedding; also assistance was afforded to painters, carpenters, blacksmiths, and engineer. Many of ^the female patients were regularly engaged in the laundry, kitclien, dairy, and in house work. Although so many of them had the unrestricted use of the various imple- ments necessary for their employment, not the slightest accident occurred.
Recreations, too, may certainly be included as an important part of the moral treatment. How frequently has it happened that a patient, when first introduced to the weekly dance or the theatricals in the large hall, has been divested of the dread of the asylum and its inmates, and has at once entered into the present enjoyment. On other occasions there were frequent musical performances of the band in the hall, and excursions occasionally in the neighbourhood in summer; all of which had a most salutary tendency, and were heartily and grate- fully acknowledged. The meeting of both sexes at meal times in the dining hall relieved the monotony of their lives, and was a healthful measure; and the assembling of them daily in the chapel for morning prayers, and selected parties attending the parish church on Sundays, exercised a most beneficial moral control.
Medical Treatment.?Upon the generally acknowledged principle that mental disorder, if not dependent on, is at least aggravated by bodily disease, symptoms have invariably been attended to in chronic as well as in recent cases, and the general health improved and maintained as much as possible.
In cases of ordinary mania, characterised by habitual rest- lessness and a constipated habit of body, belladonna and cam- phor have been employed, after purgatives, and followed in some instances by marked benefit. In a few patients, who beat their heads continually, belladonna, veratria, or aconite, applied ender- mically after a blister, procured a temporary cessation of the violence. Purgatives were freely administered, and in violent fits of mania the shower-bath was found useful, and also tartrate of antimony, digitalis, and sedatives, iodide and bromide of potas., tonics, nitric and sulphuric acids, stimulants, cod liver oil, astringents, the exhausting apparatus to the lower extremi- ties, all these have been used when circumstances seemed to require them. In a few cases, where patients had obstinately re- fused food, the stomach tube was employed; other patients were constantly obliged to be fed by attendants, some required a more generous diet than others; all under medical treatment had their meals regulated from day to day.
Restraint and Seclusion.?The use of mechanical restraint was sometimes required for surgical reasons, to prevent patients from injuring themselves, as from removing bandages or dress- ing, or from picking sores on their skin, by means of gloves, securely fastened at the wrists, or by a handkerchief. Coercion was sometimes required in cases of continued obsti- nacy in refusing food or medicine, to be dressed or undressed, or to go into a bath… .
Seclusion, which is the improved substitute tor restraint, inasmuch as it does not subject patients to the same degree of mortification and exposure, and is therefore much less likely to keep alive angry and vindictive feelings, was found necessary. Noisy, destructive patients, and those with disgusting habits, were removed from the others, as well as the violent ones, and placed in seclusion, occasionally in their own single, or in padded rooms.
Many patients were brought to the asylum m strait waist- coats, and it was stated that of those transferred from other institutions at the opening of the asylum, about twenty males and forty females had been subjected to personal restraint; it should be remembered, however, that some of these were epileptics, whom it was the custom formerly to fasten to their beds at night. All these were at once freed from mechanical restraint. Results were:
Males. Females. Recovered . ? ? .175 199 Not recovered . ? .36 56 Died 105 87 Remaining . ? ? .58 76 Total 374 418
The recoveries in mania were therefore nearly 47 per cent, in males, and 47’6 in females; the mortality 28 per cent, in males, and 20-8 per cent, in females. The much greater mortality in the male sex in insanity has been generally observed. Post-mortem examinations were made in 110 males and 99 females.* Of these 12 males and 8 females were from 20 to 30 years of age; 9 males and 4 females were single ; 3 males and 3 females “single ; and 1 widow. Duration of illness varied in the males from one month to four years, and in the females from three months to six years. The assigned cause of death in the males : meningitis, 1 ; spinal arachnitis, 1 ; pulmonary phthisis, 4; gangrene of lungs, 2 ; pleuro-pneumonia, 1 ; peri- tonitis,’l ; ulcer of stomach, 1 ; dysentery, 1. In females: arachnitis, 1 ; cerebral apoplexy, 1 ; pulmonary phthisis, 4 ; pneumonia, 2.
Circumference of the skull varied in the males from 2Of to 23 inches, the average being 22*3, and in the females 20*6 inches; the antero-posterior measurements varied in the males from 101 to 141, the average 13-2, and in the females 12*3 * The examinations in cases of monomania are included in these numbers. inches. The transverse measurement varied in the males from 10? to 14|, average 13, and in the females 12*2 inches. Condition of the Brain and Membranes.?The dura mater preternaturally adherent in 1 male and 1 female; opacity of arachnoid in 1 male, and 2 ounces of fluid in arachnoid in 1 female ; congestion of blood in cerebral veins in 4 males and 1 female ; the brain appeared natural in 4 males and 4 females ; brain soft in 1 male, pale in 1, and firm in 1 female. Weight.?The right cerebral hemisphere varied in weight from 12i to in males, and from 13| to 23f ounces ; average, 21 in males and 18 in females; the left cerebral hemisphere varied in males from 17^ to 25^, and in females from 13? to 23f; the average weight in the male was 21-4, and 18*1 in females. The encephalon varied in males from 45 to 58? ounces, and in females from 31 to 53^- ounces, average weight 48*8 in males, and 41*1 ounces in females. Spinal Cord,? there was more fluid than natural in the spinal canal in 3 males, and the veins were turgid in 1 male and 1 female, soft at centre m 1 female, natural in the remainder. Average weight 1*1 ounce in males, and I ounce in females. Lungs natural and healthy in 4 males and 1 female ; tubercles in 4, and cavities in 1 male, and tubercles in 3 females; pneu- monia in 1 male, and 1 female, pleuro-pneumonia in 2 males, gangrene in right lung in 1, pleuritic adhesions in 3 females! Weight of right lung varied in males from 13? to 411, and in females from 10 to 28^-, average in males 28, and in females 20 ounces ; left lung varied in weight in the males from llf to 42, and in females from 6 to 26? ounces ; average weight in males 22*2, and in females 18 ounces. Heart small in 2 males and 2 females. Much fluid in the pericardium, in 1 male it varied in weight from 6 to llf, and in females from 5 to 9f ounces; average in males 8*2, and in females 7 ounces.
Intestines natural in 6 males and in 2 females, peritonitis in 1 male, tubercular peritoneum in 1 female, enteritis in 1 male, fatty omentum in 1 female, ulceration in 4 males and in 3 females, mesenteric glands enlarged in 1 female; average weight of the stomach 5*8 in males, and 4*4 in females. Liver, peritoneal adhesions in 2 males, average weight 51*8, fatty in two females, varied in weight from 31 to 75 ounces. Spleen varied in weight in females from 3f to 12 ounces, average weight 5*1. Pancreas in males, average weight 3*3, in females 2*6 ounces. Right kidney 5*4 in males, 3*7 in females; left kidney 5 in males, and 4 ounces in females; renal capsules 7 in males, *6 in females ; uterus 1*3. Average height in males 5 feet 6^ inches, in females 5 feet 3-- inches. Average weight of the body 94 pounds in males, and 74 pounds in females. At the decennial period, from 30 to 40, there were 24 males, 16 married and 8 single, and 19 females, 10 married and 9 single, examined. It seems unnecessary here again to go so fully into detail respecting each of the organs. The assigned causes of death were meningitis in 3 males and 3 females, apoplexy in one of each sex, cerebritis 1 male, cerebral softening in 2 females; pulmonary disease in 14 males, 5 of these tubercular, and in 10 females, 6 of these from phthisis; abdominal diseases in 5 males and 3 females. Average circumference of skull 22*2 in males, and 21 in females; antero-posterior measurement 12*6 in males, and 12-3 in females; transverse measurement 12*1 in males, and 11*9 in females; brain appeared natural in 8 males and 4 females, soft in 1 of each sex, firm in 1 male and 2 females. The right cerebral hemisphere varied in weight in males from 18? to 24^ ounces, average 21 ounces; in females from 16 to 23 ounces, average 18*6; the left cerebral hemi- sphere varied in males from 16 to 24|, average 20’8 ; in females 15f to 23, average 18*7; the average weight of the cerebellum in males 5’5, medulla and pons 1*1 ; in females 4-8, medulla and pons *9; the average weight of the encephalon in males 48*4, in females 43 ounces.
From 40 to 50 years there were 27 males and 18 females. Assigned causes of death were from meningitis in 2 males, from arachnitis in 2 males and 4 females, from cerebral congestion in 1 male, cerebritis in 2 males and 1 female ; from pulmonary diseases in 15 males, including 5 of phthisis, and in 7 females including 2 of phthisis ; from gastritis in 1 male, dysentery in 2 ; cancer in 3 females, purpura in 1, and fever in 1. Males. Females.
Average circumference of skull . 22*3 21*2 Antero-posterior measurement . 12*9 12*2 Transverse ditto . . 12’4 11*2
The right cerebral hemisphere varied in weight from 16^ to 25f ounces, and in females from 16|- to 21 ounces, average 21*1 in males, and 18*7 in females; the left cerebral hemisphere varied in weight from 17-fr to 25?, and in females from 161 to 21^ ounces, average weight in males 21-3, in females 18*8 ounces; the encephalon varied in weight from 39f to 57f ounces in males, and from 38f to 48^ ounces in females, the average weight in the males was 48-3, in females 42*7 ounces. The spinal cord appeared to be natural in 15 males and 11 females ; there was more fluid than natural in the spinal canal in 2 males and 2 females; blood effused in the canal in 2 males and 1 female, soft in 4 males and 3 females, firmer than usual in 2 males and 1 female, large in 2 males. Heart was hyper- trophied, over 10 ounces in weight in 13 males, varying from 10? to 16^ ounces, and below 10 ounces, varying from 7^ to 9 ounces in 11 males. In 7 females the heart was above the average, varying from 8^ to 11 ounces, and in 7 below the average, varying from 6^- to 5^ ounces.
In the next period, from 50 to 60 years, there were 18 males and 20 females : the assigned cause of death was from menin- gitis in 4 males and 2 females, cerebritis in 2 males and 3 females, and fluid in ventricles in 1, tumour in brain in 1 male, and hypertrophy of brain in 1 male. Pulmonary diseases in 7 males, phthisis in 3 of them, and in 8 females., and phthisis in 3; peritonitis in 1 male, enteritis in 1 female, dysentery in 1 male and 2 females, renal disease in 1 male, cancer of breast in 1 female. The average circumference of the skull was 22*6 in males, and 21 *2 in females; the average antero-posterior measurement 12 6 in males and 12*3 in females; the average transverse measurement 12-8 in males and 11-7 in females. The right cerebral hemisphere varied in weight from 18|- to 23? in males, and fiom 15-2 to 21-^- in females; the average weight in males was 20*9 and 18*4 in females; the left cerebral ^hemi- sphere varied in weight from 18| to 23 ounces in males, and from 15^ to 2If in females; the average weight in males was 20-9 and 18*9 in females ; the average weight of the cerebellum in males 5-3, and the pons and medulla oblongata 1*1 ounces. The encephalon varied in weight in females “from 36 to 505’ ounces; the average weight of the encephalon in males was 48-2, and in females 43*5 ounces. The spinal cord was natural in 10 males and 17 females, fluid in canal in 1 male, spots of softening in 6 males and 2 females, firm in 1 male and 1 female. The heart enlarged in 6 males, varying from 10^- to 19 ounces, small in 4 males, varying from 6 to 10 ounces, and small in 6 females, varying in weight from 5^ to 8 ounces.
From 60 to 70 the numbers were 13 males and 22 females. The assigned cause of death was from meningitis in 4 males, from cerebral disease in 5 females, including arachnitis in 1, fluid in ventricles in 2, and cerebritis in 1 ; pulmonary diseases in 7 males and 13 females, including 6 cases of phthisis ; cardiac dropsy in 1 male; enteritis in 1 male and 2 females ; gastritis in 1 female; abscess in peiinseum in 1 female, and carcinoma in 1 male. The average circumference of the skull was 22-3 inches in males and 21*2 in females; the antero-posterior measurement was 13*1 in males and 12*4 in females; and the transverse measurement 12*9 in males and 11 inches in females; the dura mater was preternaturally adherent to the skull in 8 males and 7 females, fluid in arachnoid in 1 male, and in ven- tricles in 5 females ; congestion of blood in cerebral veins in 3 males and 1 female; cerebritis in 1 female, and atrophy of brain in 1. The right cerebral hemisphere varied in weight from 17-t to 25? in males, and from 15^ to 20? in females; average weight in males 21*4 and in females 18*8 ounces; the left hemisphere varied from 181 to 26 in males, and from 16| to 21? in females; average in males 21-5, in females 19 ; average weight of the cerebellum 5*2 in males and 4*9 in females, and of the pons and medulla, 1*1 in males and 1 ounce in females; the encephalon varied in weight in males from 41? to 58f ounces, and in females from 35 ? to 48f ; average weight in males 49-3 and in females 43*7 ounces; the spinal cord disintegrated at the lower part in 1 male, rather soft in 3 males and 4 females; firm in 1 male and 2 females, pale in 1 male and 1 female; fluid in canal in 1 female, and natural in 4 males and 14 females; the spinal cord varied from f to 1 bounce, average weight 1 ounce, in each sex. Heart enlarged in 8 males and 3 females, small in 2 males and 3 females, fluid in pericardium in 1 male, valves thickened in 1 male, pericardium adherent in 1 male, fat in 1 female, flabby in 1 male and pale in 1; the weight of the heart varied in the males from 6^ to 19 ounces, and?in the females from 6 to 14 ounces; average weight in the males 13*3, and in the females 7*9 ounces. The amount of disease and size of the heart in males compared with females at this age is very remarkable.
From 70 to 80 there were 14 males and 9 females examined. Assigned cause of death, meningitis in 3 males and 3 females; cerebritis in 2 males and 1 female; pulmonary disease in 5 males and 3 females, phthisis in 2 of them; endocarditis, sudden death, 1 male; enlarged heart, 1 female; aneurism, 1 male; peritonitis, 1 female; Bright’s disease, 1 male; and 2 males suicide by hanging. Circumference of skull, 22-4 in males and 21-6 in females ; antero-posterior measurement 12*8 in males and 12*4 in females ; transverse, 11-8 in males, 11 in females; the right cerebral hemisphere varied in weight in males from 18 to 24 ounces, and in females from 16? to 20 ounces? the average weight in males was 20-9, and in females 17*8 ; the left cerebral hemisphere varied in weight from 18^ to 24, and in females from 15| to 20? ounces?the average weight in males 21 and in females 17*9 ounces; the cerebellum varied in weight from 4^ to 6 ounces in males, and from 4^ to 5 ounces in females?average weight in males, 5*2, and in females, 4*5 ; the pons and medulla varied in males from 1 to H, and in fe- males from | to 1?the average weight in males 1*2, and in females *9; the encephalon varied in weight from 42? to 55 ounces in males, and from 37 ? to 46 ounces in females?the average weight in the males was 48*4, and 41*2 in females. In the spinal canal there was more fluid than natural in 1 male, the cord soft in 1 male and 1 female, and natural in the remainder of both sexes; average weight, 1*1 in both sexes. Heart enlarged in 7 males and 4 females; endocarditis, 1 ; aneurism, 1 ; ossific deposits in 1 and flabby in 1 male; fatty in 1 female; the weight varied from 8 to 13f ounces, and in females from 7 to 12?; average weight in males 11-6, and in females 9*4 ounces. ?
From 80 upwards, 1 male aged 88, and 3 females, 2 of 80 and 1 of 82 years of age. The cause of death in the male was softening of the brain, hydrothorax, and Bright’s disease; and m the females, hydrothorax in 1, meningitis and the cerebral ventricles distended with fluid in the other 2 The right cerebral was the heaviest in the male (which is unusual) weighing 211 the left 20f ounces, the cerebellum 6, medulla and pons 12, encephalon 49f ounces, which is l1 ounce above the average. The average circumference of the skull in the females was 21-8, antero-posterior measurement 12-3, and the transverse 12 inches; average weight of right and left cerebral hemispheres the same, 19-3, and encephalon 45 ounces ; spinal cord rather soft m 1, and the heart small (6 ounces) m 1. The average weight of the body in the females 88 pounds, and the height 5 feet 2 inches very nearly. ? Te?Thi uG hl f V?6 remarkable fact may be observed, viz., that the left cerebral hemisphere preponderated in weight at the various ages in both sexes. & REcuRRENr Mania.
The analysis of cases under this head includes 174 males and 206 females. It is so difficult to draw an exact line, that most probably amongst these are included cases of what is defined as intermittent mama, attended with lucid intervals, which mav continue for weeks, and during which time patients might be discharged as recovered and capable of making a will or other- wise disposing of property; such cases probably have led to litigation. They have no delusions, but are subject to paroxysms of raving madness, often of uncertain duration. The ages at the time of admission of the cases of recurrent mania were as follows :?
? , Males. Females. Under 20 years 7 g From 20 to 30 26 57 3? ? 40 38 48 40 ? 50 . . # 43 43 50 ? 60 . . # 32 29 60 ? 70 … 18 14 70 ? 80 … 5 7 80 upwards ? . . 0 0 Total 174 20G At the earlier ages, up to 40 years, the females exceeded the males in number, after 40 the males predominated; the greatest number of females before their thirtieth year, and of males after their fortieth year.
With respect to their civil state, there were 86 males and 90 females married, 76 males and 97 females single, and 12 males and 19 females widowed.
The number of the attack on their first admission to the asylum is here shown ; but many of these patients were admitted on several occasions afterwards, which is not shown. There were admitted from a second attack,86 males and 111 females; from a third, 48 males and 53 females ; from- a fourth, 17 males and 21 females; from a fifth or more frequent attack, 5 males and 11 females; and in 18 males and 10 females no particulars as to number could be ascertained.
The causes so far as ascertained were, hereditary in 38 males and 39 females, from intemperance in drink in 22 males and 3 females, from previous bodily illness in 16 males and 25 females, from injuries in 7 males and i female, religious en- thusiasm in 8 males and 8 females, grief in 6 males and 18 females, from poverty in 3 males and 6 females, over-exertion in 2 males and 3 females, fright in 1 male and 4 females, super- stition in 2 males and 3 females, jealousy in 1 male and 3 females, love in 1 male and 8 females, causes not ascertained in 65 males and 88 females.
The duration of illness previous to admission varied from a few days to many years, so many chronic cases were trans- ferred from other establishments.
The prominent symptoms of the patients as reported on admission were violence in 30 males and 31 females, irritability in 6 males and 9 females, dangerous in 30 males and 35 females stubborn in 7 males and 8 females, suicidal in 15 males and’ 20 females, destructive in 20 males and 20 females, noisy in 6 males and 21 females, filthy in 10 males and 15 females, idle abusive, and troublesome in 20 males and 31 females; 30males and 15 females were ill and generally quiet.
Of these cases 56 males and 77 females were working patients, employed in various ways in the establishment. A male (216), aged 34, was admitted, having had three previous attacks within six years ; was ten months in recovering from the last attack; the present one was of two weeks duration! Hereditary predisposition (his father died insane); a mason by trade ; violent and dangerous to others; general health good ; sullen in his manner; when taken out would sometimes lie down and ask the working men to wheel a barrow over him.
At the end of three months he had improved so much that he worked at his trade with the masons, and continued to do so regularly for six months, at the end of which time he one day left his work and went a short distance up the hill on the turn- pike road and precipitated himself in front of the wheels of a coal wagon containing four tons of coal, the front wheel of which went over the left side, breaking the clavicle and all the ribs on that side. There was some ecchymosis of the skin, and emphysema behind, at the upper part of the chest; his pulse was very feeble; he was conscious, but did not speak. He tried to loosen the bandages which were applied to chest, over soap plaster; his wrists were fastened. He required an anodyne first night, afterwards antimonial mixture and digitalis, and was once bled to 12 ounces. He recovered from the accident and worked for years at his trade, although his mind never recovered. A man (588), aged 39, furious from drink, was admitted twice; he fancied he saw the devil; he was a powerful man, and in his fuiy would destroy everything he could lay his hands on. He lecoveied, and was discharged in five months. After his second admission he soon became well, but was very reluctant to leave the asylum, where he made himself very useful assisting the attendants.
Another mason (647), aged 48, very violent; hereditary predisposition from his mother. He fancied he had property, that he was the Saviour of mankind. This was the third or fourth attack. In about six weeks he went out and worked at his trade, and in four months was discharged recovered. A bookbinder (717), aged 42, had two previous attacks, violent sometimes; the first attack seventeen years before the present one; his idea, that lie was Jesus Christ’s vicegerent on earth, and in order to prove himself so and to fulfil the prophecy, ” that a bone of Him should not be broken,” he jumped out of the express train from Exeter and escaped with only a bruise on his shoulder. He was very excited, broke the reading desk in the chapel; he wished to occupy the Chaplain’s place, and had to be expelled by force. He was subsequently transferred to his proper asylum, being a native of Devonshire.
A male (731), aged 55 ; in bad health from hepatic and renal disorder; suicidal, attempted to drown himself, and was also dangerous towards his wife and family. In about five months he was mentally recovered. Four years afterwards the same symptoms of self-distraction and dangerous propensities re- turned. In six months he was again discharged recovered. A third attack occurred after seven years, which lasted five months, when his miud appeared to be restored, and he was discharged recovered.
A farmer (1422), aged 44, was reported as dangerous to others only ; hereditary predisposition on mother’s side. He threatened to kill his wife. Health indifferent; three months ill previous to admission. At the end of three months he was quiet, and was taken home by his friends. Within two years he was readmitted low-spirited, but became excited soon after admission, and had to be moved from the infirmary. He remained in indifferent health, irritable and excitable for nearly eleven months, when he committed suicide by hanging himself with his stockings to a gas pipe in a large dormitory during breakfast time. There was congestion of blood in the cerebral vessels, also in the lungs.
A dairy-woman (499), aged 59, hereditary predisposition; second admission of two weeks duration; health bad; first attack eight years before, not so violent as in the present one. She attempted suicide by hanging, and the mark of the cord remained. Noisy at night; she very soon improved ; had ano- dynes to procure sleep. She assisted in the laundry, and was discharged recovered in five and a half months. Nearly seven years afterwards she had a third attack of mania, having again attempted to destroy life by tying cords tightly round her neck ; she refused food, and required forcible feeding by the stomach tube; black under the eyes from knocking her head against the wall; she required anodynes to procure sleep. In five months she was again discharged recovered.
A female (514), aged 44, the third attack, was in an asylum for eighteen months ten years before, caused from a fright in a railway, seeing a child fall down an embankment in front of train; she attempted suicide by hanging in the work- house, and was just cut down in time to save her life. She was incoherent at first and quiet; she soon became rational, and was discharged at the expiration of three months recovered. A mason’s wife (605), aged 54, was in an asylum for sixteen years for first attack, which came on after a fever; she was violent and incoherent, noisy at night; she became rational, but had frequent relapses ; was very industrious, working occa- sionally in the laundry and in the kitchens; she remained under treatment in the asylum thirteen years.
A dressmaker (1390), aged 38, second attack, of three months’ duration; seven years before she received a blow on the head, which was the supposed cause. She was violent in her conduct and incoherent in conversation ; occasionally noisy and excited. Bromide of potassium, and half-grain solution of mor- phia injected endermically had a tranquillising effect; at the expiration of eighteen months she was discharged fro.m the sylum recovered.
The results in recurrent mania, in males, were recoveries in 93, in females 106; not recovered, males 28, females 23 ; died, males 27, females 35 ; remaining-, 26 males, 42 females. The assigned causes of death were, from cerebral meningitis, arach- nitis, cerebritis, and fluid in ventricles, 9 males and 6 females; from pulmonary diseases 12 males, including 6 of phthisis, and 14 females, including 9 of phthisis; cardiac diseases in 2 males, and cardiac dropsy in 1 female, and aneurism of the aorta in 1 female; abdominal diseases, 4 in males, viz. 1 of peritonitis, 2 of enteritis, and 1 of jaundice, and 13 abdominal, including 7 of enteritis, including 2 from obstruction, 3 from ulceration and dysentery, 2 from cancer, and 1 from dropsy. Post-mortem examinations were made in 17 males and 22 females, second attack; and in 5 males and 12 females, third attack and upwards. The circumference of skull in the males who died in the second attack varied from 21 to 23^ inches, and in temales from 2L to 231 inches, the average in the males being 22*4 and in the females 21*6; the average anteropos- terior measurement was in the males 12*8 and in females 12-5 inches; the average transverse measurement in males 12-2 and in females 11*7 inches. These measurements are at all ages, varying from 23 to 56 years in males, and from 23 to 56 years (the same) in females.
The cerebral membranes and brain varied more or less from the natural state in 13 males and 13 females, the dura mater was unusually adherent in 4 males and 2 females, the arachnoid opaque in 4 males and 1 female, and containing fluid in 2 males, congestion of blood in the vessels in 3 males and 2 females, cen- tral softening of brain in 1 male, the brain unusually pale and firm in 2 males and 3 females, tough in 1 male, fluid in ven- tricles in 4 females, the biain appeared natural in 4 males and 9 females.
The right cerebral hemisphere varied in weight from ] 6f to 24 ounces in males and from 16^ to 22 ounces in females; the average weight in males was 21*1 and in females 19*2. The left cerebral hemisphere varied from 14 to 24 ounces in males, and from 17^to22 in females; the average weight in males was 21*2, in females 19’8 ; the average weight of the cerebellum in males was 5*4 and in females 4*7 ounces, and of the pons and medulla 1*1 in males and 1 in females; the average weight of the ence- phalon was 49 in males and 44*8 ounces in females. The spinalcord was soft in 2 males and 1 female ; pale and firm in 1 male and 1 female, blood in the canal in 2 males and 2 females, and fluid in 2 of each sex ; the average weight in males was 1*2 and in females 1*1 ounce. There was pericarditis in 1 male, the heart flabby in 1 male, enlarged in 5 males and 3 females, small in 3 males and in 7 females; it varied in weight in males from 5f to 19^ ounces, and in females from 5? to 13? ounces; the average weight in males was 10*2 and in iemales 8 ounces.
In the 5 cases examined in males of recurrent mania, third attack and upwards, and in the 12 females, the ages varied in the males from 54 to 79 years, and in the females from 48 to 74 years. The assigned causes of death in the males were from meningitis and jaundice in 1, broncho-pneumonia in 2, phthisis 1, and valvular disease of heart in 1 male; in females from menin- gitis in 2, pleurisy and phthisis in 4, cardiac dropsy 1, enteritis 3, cancer of uterus 1, and dysentery 1. The average circum- ference of the head was 22*4 in males and 21-2 in females, the antero-posterior measurement 12*3 in males and 12*2 in females, the transverse 12*2 in males and 11 -5 in females. The average weight of the right cerebral hemisphere was 21*5 in males ana 20*4 in females, and the left cerebral hemisphere 21-8 in males and 20*5 in females; the average weight of the cerebellum was 5*3 in males and 4’9 in females, and of the pons and medulla *9 in both sexes ; encephalon 49*6 in males and 46*8 in females. The spinal cord was disintegrated in 1 male, softened at lower part in 1 male and 3 females, fluid in the canal in 2 females; average weight in males 1*2 and in females 1*1 ounce. The heart was enlarged in 2 males and 4 females, and small, below the average size, in 1 male and in 6 females ; the average weight in males was 11*2 and in females 9*2 ounces. Monomania.
In this form of insanity, in which the understanding is only partially deranged, the numbers were as follows:? Males. Females.
From 20 to 30 years of age .11 5 ? 30 to 40 ? . 11 10 ? 40 to 50 ? . . 10 14 ? 50 to 60 ? 8 7 ? 60 to 70 ? 6 3 ? 70 to 80 ? 1 2 Total 47 41
Of these, 16 males and 17 females were married, 18 males and 13 females single, 8 males and 11 females widowed, and in 5 males the civil state was unknown.
The supposed causes were?from hereditary predisposition in 3 males and 4 females, from drink in 2 males, from religious enthusiasm in 4 males and 4 females, previous illness in 4 males and 6 females, belief in witchcraft in 3 males and 5 females, love in 4 males and 4 females, exalted ideas about riches &c. 9 males and 3 females, grief and poverty in 4 males and 7 females, conspiracy to injure in 1 male and 2 females, fright in 1 male, injury in 1, and reading in 1 ; unknown causes, 10 males and 5 females.
The conduct at the time of admission was reported as being dangerous in 4 males and 2 females, violent in 4 males and 2 females, suicidal in 4 males and 2 females, irritable and stubborn in 2 females, noisy in 1, excited and mischievous in 4 males, absurd in 2, quiet in 4 males and 4 females, indus- trious in 12 males and 15 females, destructive in 2 males and 3 females, wandering in 2 males and 2 females, idle and listless in the remainder of both sexes.
The results in cases of monomania were :? Males. Females. Recovered …19 12 Not recovered …14 12 Died …. 7 12 Remaining … 7 5 Total 47 41
Mental dejection is so frequent an accompaniment, that those cases were not formerly distinguished from those of melancholia; and the varieties of hallucinations are so great, that an endless subdivision might be made of the different forms of monomania. Amongst the males admitted several considered themselves the highest personages. One was King Solomon ; one the Prince of Wales ; another, a second Duke of Wellington ; another, a friend, in the habit of conversing with Her Majesty; some have fancied that they possessed immense riches, others that they had been deprived of property; some had religious hallucinations; some were bewitched, others visited by spirits; one was a descendant of the great Locke, from his name, and fancied he inherited his powers of mind. Of the females, one fancied herself Queen Elizabeth ; there were more than one representative of Her Majesty Queen Victoria; one fancied she held conversations with Captain Speke ; one fancies she has killed a number of children; others had religious despondency and misgivings, visitations from spirits; some from jealousy, and delusions about male admirers in more than one instance.
Puerperal Insanity.
This form of disorder has shown itself immediately on women becoming pregnant; more generally it comes on soon after delivery, and for this reason women ought to be kept quiet for two or three weeks. In some cases it has come on when the breasts have been inflamed, or an abscess has been formed at the time of the first suckling, or at the weaning of the child seven or eight months after delivery. There are in sucli cases the general symptoms of fever; the skin has often a yellow tinge.
Of 63 cases in the Somerset County Asylum, 6 came on a week after parturition, 11 before the fifteenth day, 28 before the sixtieth, and 15 within twelve months, and 3 upwards of fifteen months, transferred from other asylums. In only 2 cases did the mental derangement come on previous to childbirth ; in 22 within a few days after, in 34 at various periods later, the greater number being during lactation. There was a sinking feeling, great prostration, vertigo, headache, antemia, loss of appetite, restlessness, sleeplessness, and despondency after protracted lactation. In 14 of the 34 cases attempts at suicide had been made by hanging, drowning, poison, or precipitation from heights; 2 were violent to the infant, 7 had taken a dislike to their children and husband, 12 were dangerous to their family and others, 1 was suspicious, 1 fancied she was bewitched, 1 was hysterical, and 2 epileptic.
Causes.?Hereditary predisposition was found on the father’s side in 4, on the mother’s side in 5, and it existed in the family of 4 patients, but on which side was not ascertained. There were other predisposing causes in addition to the heredi- tary taint; in 2 previous attacks of insanity, in 1 epilepsy, in 1 hysteria, in 5 excessive irritability of temper, in 2 stubborn- ness, and in 1 fretfulness. Apart from these, the moral causes only include 2 instances of remorse, 2 of fright, 2 of poverty and desertion, and 8 of intemperance. The ‘physical causes were nearly equal in number to all the foregoing, includ- ing 15 cases of bodily illness, 8 of milk-fever, and 5 of debility and prostration from suckling.
Of the forms of puerperal insanity, mania was the most frequent, being 3 to 1 of the cases of melancholia; but they frequently alternated after the maniacal paroxysms; great de- pression and despondency succeeded and continued for some time. There were 7 of the 60 demented. In 10 cases insanity occurred after the birth of the first child; in 42 there were previous births, varying in number from 10 downwards; in 11 the number of previous confinements was not ascertained. There were 19 infants of each sex, two instances of twins, 2 miscarriages, and 2 in which the sex of the infant born is not stated. The greater number of cases were admitted in spring, in the second quarter of the year.
Any serious disturbance in the uterine functions speedily affects the brain?a fright during pregnancy has produced insanity. Sometimes the offspring is rendered idiotic by a mental shock to the mother, and I have known malformation to be attributed to the same cause, although the mother herself escaped insanity.
Cases have occurred in which the maniacal symptoms have subsided, and the patient become comparatively tranquil during’ utero-gestation, and after parturition a relapse into the previous state has taken place. In three instances in which both parents were insane, one infant died in a few months ; a second, unusually quick, died of acute disease and convulsions in childhood, and the third, which survived, was quick, active, and as capable of learning as any boy of his age at school, and with a fully developed head.
There is no end of the variety of symptoms in puerperal insanity. The symptoms gradually become exaggerated, the talking becomes incessant, and generally on a particular subject; she is dissatisfied with herself and full of anxiety, has a strong aversion to her infant and husband, displays explosions of anger, violent gesticulations, and obscene language. Illusions quickly succeed one another, or fixed monomania supervenes, often commencing with religion. Fear of poison, or of murder, hear- ing voices, and a suicidal tendency are common. 21 of the 63 cases were suicidal. The maniacal symptoms in some cases come on suddenly.
The physical symptoms were not always alike; the secretion of milk was not always diminished ; headache and constipation have taken place. The state of the tongue varied ; of the 63 cases it was white in 18, red in 4, clean in 23, not noted in 18. The skin was sometimes hot, with feverish symptoms and accelerated pulse. If the pulse was quick and feeble, above 100, combined with dark offensive dejections, offensive breath, sordes on lips and teeth, excitement and emaciation, danger of life was near. Of the 63 cases, on admission the pulse was from 64 to 70 and feeble in 5, from 70 to 80 in 16, from 80 to 90 in 19, from 90 to 100 in 8, upwards of 100 to 180 in 13, not noted in 2. The bodily health was good in 8 only, feeble and indifferent in 25, and bad in 30.
The age in quinquennial periods, number of cases, and the results in the 63 cases were : ?
Age 20 to 25 25 to 30 30 to 35 35 to 40 40 to 45 Total No. in each period 10 18 12 11 12 63 Results Recovered 9 15 10 6 45 Not recovered Died Remaining
As generally the case, the proportion of recoveries was greatest in the earlier periods of life, being 82 per cent, under 30 years ; the mortality 11 per cent. Recoveries in the whole number at all ages, 70 per cent.
Mortality.?7 cases; 2 of these were attended with uterine haemorrhage. In 1 case (810), aged 22, mental derangement appeared two weeks after confinement. She had been under medical treatment in the Union workhouse; had uterine haemorrhage, health bad, pulse 66, tongue clean, skin warm, appetite bad, wild expression, violent, incoherent, wandering, memory lost. After admission noisy and destructive; her appetite improved. She was treated in the Infirmary for three months; no mental improvement took place; her knees became contracted; and she died emaciated, her appetite remaining good to the last. The body only weighed 52 lbs. ; circumference of skull 20 inches, antero-posterior 12, and transverse measurement 12^ inches. The brain was unusually pale, 41^ ounces; the left cere- bral hemisphere was 1^ ounce heavier than the right. The spinal cord was paler and softer than natural, f ounce ; the lungs natural; heart small, only 5^ ounces ; liver dark coloured, 38 ounces ; the mucous membrane of the intestines thickened and red ; uterus If ounce. Cause of death, enteritis.
In a second case (319), attended with flooding after miscar- riage, the wife of a policeman, aged 37 ; was transferred from a licensed house, and the flooding occurred five weeks previous to her admission. She attempted strangulation, refused food, was violent occasionally and inclined to strike persons, memory good and conversation connected, fretful and obstinate, health indifferent, pulse 90, tongue clean, weight 105 lbs., height 5 feet 2 inches. She continued in the asylum for eight years without any mental change, when she tell a victim to pulmonary phthisis, which, according to my experience, is the usual termi- nation of old residents in large institutions of the kind. The body was examined 23 hours after death. The circumference of the head 22 inches, antero-posterior 13 inches, and trans- verse measurement 14 inches ; brain large, 48^ ounces, in other respects it appeared natural, as did the spinal cord. Tubercles and cavities in the upper lobes of both lungs?the right weighed 261, and the left 21 ounces ; heart large, and cavities dilated, 12 ounces ; about one quart of serum in the abdomen; liver large, 60 ; kidneys large, right 5%, left 6^- ounces ; uterus 2^ ounces.
The third fatal case (869) occurred in a farmer’s wife, aged 27. She was admitted in a state of delirium, having attempted to injure her children and also herself; skin hot; pulse 120. The attack was of one week’s duration previous to admission, and four months after childbirth. Her health bad ; she had a carbuncle on her back ; mind wandering and incoherent; memory lost; destructive propensities. For the first week she refused food, and was fed by the stomach tube ; pulse fell to 80. She continued without mental improvement, and was restless. Her death occurred four weeks after admission. Weight of the body 91 lbs. ; circumference of head 21 inches, antero-posterior 13^, transverse measurement 14 inches ; dura mater adherent; right cerebral hemisphere 19, left 19-| ounces ; encephalon 44 ; cord natural; bronchitis ; spleen soft and large, 14-^ ounces ; uterus 2^ ounces.
Fourth case (344). The wife of a blacksmith, aged 38, was confined of her fourth child seven months before admission. She attempted to drown herself, and disowned her children. She was under the delusion that she had seen the Queen in Bath the previous day. She subsequently refused to take food, and wished to stay in bed to avoid her meals. She sank from dysentery and enteritis, about six months after admission. Body emaciated, 64 lbs.; circumference of head 20, antero- posterior 12, transvei se 12-2 inches. ihe cerebral vessels were congested with blood; about f ounce of clear fluid in the lateral ventricles ; the right cerebral hemisphere 17f, left 18, encephalon 41 ? ounces ; lungs natural; heart small, 6f ounces; mucous membrane of the intestines red, thickened, and coated with lymph.
1* iffch case (668), aged 38, second attack, duration one month, infant 9 weeks old ; reported as violent; in bad health; pulse 84, tongue white, skin moist, appetite bad, dejected, noisy at night, and destiuctive. She had a cough, lost flesh, and after a few weeks required to be fed by stomach tube. She died in six months after her admission. Weight 72 lbs.; cir- cumference of head 21^, antero-posterior 13-|-, transverse measurement 13 inches; cerebral vessels congested with blood ; brain of a pink colour, and unusually firm; the right cerebral hemisphere 19, the left 19encephalon 44-^ ounces; spinal cord natural; old pleuritic adhesions of lungs, and numerous tubercles in right lung, 20 ounces; an abscess in the left lung, in lower lobe, and gangrene in parts around it; heart small, 6^ ounces ; abdominal organs natural.
Sixth case (551), aged 40, epileptic; suckling her baby eight months old. Maniacal in workhouse, duration two weeks; health indifferent, pulse 84, tongue clean, skin cool, appetite good, silly; for many years subject to epileptic fits, which were most frequent by day, 48, and 15 by night in a year; violent when fits occur, at other times industrious. She was ten years in the asylum, and died of pulmonary phthisis. For the last two and a half years her health declined, and fits more frequent; she had a cough, but no expectoration. Body 85 lbs.; circumference of head 21?, antero-posterior 12^, transverse measurement, 11 inches. The brain pale and unusually firm, each cerebral hemisphere 2H; encephalon large, 48 ounces; spinal cord natural, 1^ ounce; pleuritic adhesions and tuberculous cavities in both lungs, the right 30, the left lung 36 ounces; heart 8 ounces, semilunar valves thickened ; abdominal organs natural.
Seventh case (964), aged 45, mother of ten children ; second attack ; in an asylum fourteen years before. The present attack of fourteen months’ duration, and came on a month after her confinement; disposed to be suicidal; noisy, occasionally violent; her bodily health improved at first, and she assisted the attendants. Three weeks before her death she became feverish ; there was dulness on the left side of the chest on percussion; breathing short and laboured ; she gradually sank. Weight of body 85 lbs.; height five feet three inches; circum- ference of head 20 inches, antero-posterior 12, transverve 11 inches ; brain pale, 44 ounces; spinal cord natural, 1 ounce ; two pints of fluid in the chest; a thick covering of recent lymph on left lung, which was compressed; heart small, 6 ounces ; abdominal organs natural.
Of these seven fatal cases, the cerebral membranes were adherent, with fluid in the ventricles, in one ; in a case of pul- monary phthisis the brain was of a pink colour, firm, and above the average weight. In one a great difference in weight between the cerebral hemispheres in favour of the left, which is generally slightly heavier than the right. The spinal cord was softened in one, and the knees were contracted. In a similar case of contraction the softening was from disintegra- tion in the spinal cord, which is different from the inflammatory softening of the cord, first noticed in the earliest annual reports of the County Somerset Asylum, for 1849 and subsequently, as a chief cause, and constantly to be found in general paralysis of the insane. There were three deaths from pulmonary phthisis, one from hydrothorax, and two from enteritis.
With respect to treatment, the success mainly depends on the patients being submitted to us without delay, which was not the case, as fifty-one of the women were ill, on an average, nine weeks before being brought to the asylum. Exhaustion is the principal source of danger, often from sleeplessness ; opium in any shape in such cases often only aggravates the restlessness. After the bowels have been freely opened by a suitable aperient, hyoscyamus, chloral hydrate, combined with bromide of potas. or ammonia, or with a stimulant, as ammonia or camphor, in full doses rather than small ones repeated, may be given. Chloroform vapour and the inhalation of sulphuric ether failed to procure sleep. The subcutaneous injection of morphia has been effectual; also packing in the wet sheet had a very tran- quillising effect. Tonics, as cod-liver oil, iron, bark, and quinine, were all found necessary in many of the cases. Forced alimentation was often required, especially in the suicidal cases, the refusal to take food being a very common occurrence ; this was most effectually done by means of an elastic tube passed down the mouth, or in some by a small one down the nostril where the teeth were perfect and firmly clenched, a half-pint feeding bowl being attached to the tube. Where the skin and extremities were cold, the portal system con- gested, and the liver torpid, warm stimulating aperients were given. The Turkish bath was often found very beneficial in such cases.
The great difference in the weights of the body is worthy of remark. In the first case (810) it was only 52 lbs., although the appetite for three months previous to death remained good to the last. Judging from the weight alone, it might have been set down as a case of starvation.
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