The Pulse in Insanity. 
Original Study of Cases. 
HY 
THEO H. KELEOGG, M. D. 
Superintendent of Willard State Hospital, former Physician in Charge of New 
York City Asylum for the Insane, and of Saudford Hall; member of the 
American Medicopsychological Association ; fellow of the 
New York Academy of Medicine ; member of the 
American Neurological Association ; of 
Medico-legal Society; of the 
New York Neurolog- 
ical Society, etc. 
Read before the American Neurological Association, Boston, June 5th, 1895. 
GENEVA, N. Y. 
W. F. Humphrey, Publisher. 
1895- THE PULSE IN INSANITY--ORIGINAL STUDY 
OF CASES. 
The circulation of the blood in the human system is a simple 
matter as explained by the application of definite mechanical laws, 
but it is a most complex biological problem when considered as 
completely controlled by vital forces generated in the cerebro-spinal 
and sympathetic nervous centres. 
The older medical authors discoursed voluminously and not 
altogether impractically about the characters of the pulse in various 
diseases, and since the introduction of the sphygmograph modern 
writers have described at length the diagnostic and prognostic value 
of the pulse and its variations in pathological states of the body. 
Several contributions have been made to the study of the Pulse 
in Insanity, but the literature of the subject is not very large and 
it is repetitious, to a considerable degree of conclusions arrived at 
by Wolff in an article published in Germany many years ago. The 
general opinion of these writers is that mania, melancholia and de- 
mentia, and each of the other common forms of insanity, has a 
characteristic kind of pulse and pulse tracings and that as the men- 
tal disease becomes chronic the pulse is dicrotic and then monocrotic 
in the terminal stages. 
After making efforts to confirm the chief conclusions just men- 
tioned the writer by much study of his cases is forced to believe in 
a decidedly more complicated state of pulse phenomena in insanity. 
Not only do different stages of the same form of insanity present 
different kinds of pulse, but different individuals passing through 
the same phase of mental disorder furnish different pulse records. 
In fact, if all previous observers of pulse-phenomena had taken in- 
dividuals as physically constituted, rather than forms of insanity, 
as a basis for classification, the conclusions arrived at would have 
been more reliable. Reasoning a priori, is it for a moment to be 
concluded that because suffering from melancholia, for instance, a 
young man would furnish a pulse like an old one, or a fat person 
like a lean one, or a patient of powerful muscular development like 4 
one emaciated, or that a plethoric, melancholic woman would yield 
a sphygmographic tracing like one depleted of her fluids in puerperal 
melancholia ? 
It is upon the physical constitution of the patient, the etiology 
of the case, and the stadium of the mental disorder rather than upon 
the form of the insanity, that the kind of pulse is to be predicated. 
Time and space will not permit a further mention of the views 
of others about the pulse in insanity. The conclusions of this arti- 
cle, based on a study continued interruptedly through a series of 
years in a large number of cases, will be given somewhat summarily 
under two heads, as follows : 
• First, the frequency of the pulse. Second, the sphymographic 
characters of the pulse. 
The study of the pulse rate here given consisted in the registra- 
tion of its frequency in twenty-one hundred and seventy-two cases. 
Eleven hundred and thirty-two of these cases were females, and ten 
hundred and forty were males, and they were of all ages and forms 
of mental disorder. The pulse was taken before the midday meal 
and in the sitting posture, and was verified a second time in doubt- 
ful cases; and in every instance the pulse was counted throughout 
an entire minute. These individual records were then, for the sake 
of analysis, arranged by decades of frequency beginning with that 
from 40 to 50 and ending with that from 130 to 140, showing the 
number of men and women respectively and the total number of 
patients whose pulse rate fell by count within the various decades 
from 40 to 140. 
This analysis is here shown in tabular form : 
Table No. I. 
Pulse frequency by decades in 217a patients. 
40 
5o 
60 
70 
80 
90 
100 
no 
120 130 
Decades 
to 
to 
to 
to 
to 
to 
to 
to 
to to 
Totals 
50 
60 
70 
80 
90 
100 
no 
120 
130 140 
Number 
women 
9 
96 
307 
344 
217 
103 
33 
21 2 
I‘32 
Number men. 
3 
14 
120 
365 
294 
150 
70 
12 
12 
1040 
Grand totals... 
3 
23 
216 
672 
638 
367 
‘73 
45 
ssj * 
2172 5 
It appears from this table that out of twenty-one hundred and 
seventy-two patients, three had a pulse from forty to fifty per min- 
ute, twenty-three from fifty to sixty, two hundred and sixteen from 
sixty to seventy, six hundred and seventy-two from seventy to 
eighty, six hundred and thirty-eight from eighty to ninety, three 
hundred and sixty-seven from ninety to one hundred, one hundred 
and seventy-three from one hundred to one hundred and ten, forty- 
five from one hundred and ten to one hundred and twenty, thirty- 
three from one hundred and twenty to one hundred and thirty, and 
two from one hundred and thirty to one hundred and forty per 
minute. 
It is also obvious, from a glance at this table, that a majority of 
the female patients and a very much larger proportion of women 
than men had a pulse in the decades above eighty. 
The following table, No. II, will also show the separate and 
total percentages of the sexes in the various decades of pulse fre- 
quency : 
Table No. II. 
Percentages of pulse frequency by decades. 
40 
50 
60 
70 80 
90 
IOO 
iro 
120 
130 
Decades.. 
to 
to 
to 
to to 
to 
to 
to 
to 
to 
50 
60 
70 
80 90 
100 
110 
120 
130 
140 
Per cent. 
women 
.008 
.085 
•27 .30 
• 19 
.09 
.029 
.0185 
.0017 
Per cent. 
men .... 
.003 
.0134 
.115 
•35 -28 
•145 
.067 
.0115 
.0115 
Total 
Per ct... 
.0014 
.0106 
.10 
.30 ; .293 
.14 
.08 
.02 
.015 
.001 
It becomes at once evident by this table that there are contained 
in the decade of frequency 70 to 8o, thirty-five per cent, of the men 
and only twenty-seven per cent, of the women, while on the con- 
trary in the decade 80 to 90 there are thirty per cent, of the women 
and only twenty-eight per cent, of the men. It also appears that 
the percentages were relatively larger in the four decades immediately 
above eighty than in the four consecutively below it. 
The salient feature of this diagram is that the male pulse curve 
reaches its highest numerical point at 70, and the female curve not 
until one decade later at 80, while the total pulse curve attains its 6 
maximum height at the decade of frequency beginning with seventy 
beats per minute. 
Finally to complete the study of pulse frequency, a table of 
average rates in the two sexes and also for the total 2172 patients, is 
here given. 
Table of averages of pulse rate in 117a Insane patients. 
Average pulse rate in 113a women 
84.8 
Average pulse rate in 1040 men 
80.8 
General average pulse rate in the 117a patients 
8a.8 
Table No. III. 
Admitting the average pulse in adult males to be seventy-two, 
and that of females seventy-eight per minute, the tabular information 
above given leads to the conclusion that there is a marked average 
increase of pulse rate in insanity. The actual increase over the 
physiological norm mentioned would be 6.8 beats per minute for the 
females and 8.8 for the males. 
The statistical figures here given are derived from such a large 
number of cases that it may be safely admitted that in established 
cases of insanity there is, on the average, a decided increase in pulse 
rate. 
To what degree pulse variations in the insane are due to pneu- 
mogastric disorder has already been described by the wiiter in an 
article read last year before the American Medico Phychological 
Association, and entitled “ Frequent Disorder of Pneumogastric 
Functions in Insanity.” Both quantitative and qualitative pulse 
variations are often to be attributed to this source in case of mental 
disorder. 
The sphygmographic characters of the pulse in insanity will now 
be considered. 
For convenience of comparison of our own conclusions with 
those arrived at by other writers, this part of the subject will be 
divided according to the chief forms of insanity, though, as already 
intimated, there is nothing inherent in the clinical findings which 
demands such a division. 
To begin with then, let the sphygmographic tracings of the 
pulse in mania receive attention. 7 
The division which is most widely applicable here is into two 
classes of cases having totally different pulse tracings. 
The first class of maniacal patients has active cutaneous circula- 
tion with warmth and color of skin and the pulse about normal or 
slightly increased in frequency. The sphygmogram in these cases 
has a vertical ascent, a sharp apical angle, the predicrotic wave and 
notch almost disappear and the aortic notch and dicrotic wave are 
strongly marked. 
The second class of maniacal patients has pallor and coolness of 
the cutaneous surfaces and a pulse of much higher tension. The 
percussion wave has a less sudden ascent, a less acute angle, and the 
descent is more gradual, with a distinct tidal wave and an obscure 
aortic notch and a scarcely perceptible dicrotic wave. Even these 
two types of pulse are not often permanent throughout an attack of 
mania, and they may follow each other, or, in rare instances, be 
interchangeable in the same case. 
In the first class of cases,— when the excitement is very great, 
the pulse may become tricrotic, and in the second class of cases,— 
when exhaustion is very decided, the pulse becomes monocrotic. In 
all cases of mania the state of the emotions, as well as the physical 
condition, is to be taken into accouut. The etiology of the case is 
also of importance. Puerperal maniacs, having lost a considerable 
percentage of their vital fluids, may present the pulse of empty ar- 
teries and post-febrile maniacs may have subnormal temperature and 
an exaggerated tricrotic pulse. Mania with Grave’s disease may 
give anacrotic tracings, as shown here in one of our sphygmograms. 
Anacrotism is also found in alcoholic mania with atheromatous 
arteries. 
As a rule, all the toxicmanias have a high tension pulse, the 
tidal wave often rising to form a plateau with the apex of the pri- 
mary wave. In alcoholic cases the state of the liver and of the kid- 
neys exerts a modifying influence, as does the condition of the lungs 
in phthisical cases. In the latter instance there may be a typical 
pyrexial pulse tracing and the relation between pulse and tempera- 
ture may or may not be lost. In phthisis the mental disorder is 
often most active when the pulmonary disease is stationary and 
there is then a high tension pulse, and dicrotism only returns with 
an advance in the pulmonary lesions. The high innervation and 
muscular activity of maniacs favors easy circulation and dicrotism, 8 
but when excessive exertion leads to exhaustion the pulse l>ecomes 
monocrotic. Also when maniacal muscular effoits, continued for 
some months, have led to ventricular hypertrophy there is also a 
permanent secondary modification of the pulse tracings, which be- 
come still more complicated if, as is not unfrequently the case, car- 
diac valvular lesions develop in these cases of prolonged and intense 
stimulation of cortical motor centres. 
In mania and in all acute forms of insanity pathological states 
of the blood are of great importance in their relation to sphygmo- 
graphic studies. In all acute cases with foul secretions and excre- 
tions, and in all auto intoxications the pulse tracings are abnormal 
to the degree of the toxic condition. The rule in these toxic cases 
is a pulse of high tension, often with a sustained rectangular apex 
formed by the blending of the percussion and predicrotic waves, 
while the dicrotic wave disappears and the smaller diastolic elastic 
vibrations may be present. That qualitative and quantitative 
changes in the blood affect the pulse trace is well known, and the 
same patients will sometimes give different spygmograms according- 
ly as they are taking alkaline or acid remedies. Such a common 
remedy as phosphoric acid will came a variation in the pulse 
trace. The study of blood changes in insanity is rapidly advancing. 
In the light of future knowledge it will doubtless be possible to for- 
mulate some rules as to sphygmographic tracings in all toxic 
insanities. 
To turn now from states of exaltation to those of depression, let 
the sphygmographic character in some forms of melancholia next be 
considered. 
In the vast majority of cases of melancholia there is mental in- 
hibition, muscular contraction and vascular spasm, and as might 
readily be surmised, therefore, the average resulting pulse is one of 
high tension. The ascent is not high ; there is an early tidal wave, 
and the descent is gradual, with scarcely a perceptible trace of aortic 
notch or dicrotic wave. In great physical depression, with feeble 
systole, the percussion wave is small and the catacrotic elevations 
completely disappear. In senile melancholia the high tension pulse 
is due to atheromatous and other vascular changes rather than to 
spastic states of the arterioles, and in alcoholic melancholia likewise 
the sphygmographic signs of peripheral resistance arise more fre- 
quently from arterial degeneration than from angiospasm. 9 
The high tension pulse of the autointoxications deserves notice 
again in this connection and the relief afforded by diaphoretic diure- 
tic laxative and hydrotherapeutic measures which markedly modify 
the tracings. On the other hand there are whole classes of melan- 
choliacs with a low tension pulse. 
Melancholia originating directly from cerebral exhaustion, and 
indeed from all forms of neurasthenia gives signs of low arterial 
tension. 
Another kind of melancholia having a low tension pulse is that 
which originates directly from hypochondria as a neurosis. The 
same low tension is found at times in chlorotic and other diathetic 
states. In phthisical melancholia this is also true whenever there 
is pyrexia, which often yields a markedly dicrotic tracing which 
characterizes also tubercular melancholia with basal meningitis. 
Some of my hearers, like myself, may have studied with Meynert of 
Vienna and may well remember his demonstration of cases of melan- 
cholia with basal meningitis, which are less commonly found here. 
In general it may be affirmed that a continued low tension pulse 
in melancholia is of bad prognostic significance. The most marked 
changes in tension and in other graphic characters of the pulse are 
seen in the transition from the depressed to the elated state of circu- 
lar insanity and also in melancholia with maniacal exacerbrations 
and in cases of stupor with semi-maniacal recurrences. It is possi- 
ble, as a clinical experiment in melancholia attonita, to transform a 
monocrotic pulse of high tension into a dicrotic pulse by drugs and 
stimulants, or even by so simple a means as a prolonged hot bath. 
The Turkish bath is especially effective, as some years ago described 
by the writer, in relieving venous stasis and various angiospastic 
conditions which accompany a high tension pulse in forms of melan- 
cholia. 
Acute attacks of precordial panic in melancholia have a pulse 
marked by frequency, small volume and intravascular pressure, giv- 
ing a low ascent and sustained descent and disappearance of catacro- 
tic elevations, except occasional elastic vibrations. In fact, depress- 
ive delusional states of acute mental anxiety, in women especially, 
with great frequency of pulse often give a monocrotic tracing with a 
slight percussion wave and entire obliteration of other sphygmo- 
graphic characters. In stuporous and cataleploid conditions a simi- 
lar tracing often appears, with loss of the diastolic features, and the 10 
substitution of a simple gradual line of descent. A similar tracing 
may appear in cases of slowed pulse from puermogastric irri- 
tation. A great variety of accidental features appear in the sphyg- 
raograms of melancholia, as in those of other forms of insanity, from 
intercurrent cardiac affections. 
The cardiac affections found in the twenty-one hundred and 
seventy-two cases of insanity may be briefly summarized as follows : 
Irregularities of heart’s action in five percent., intermittance in two 
per cent., heart murmurs and heart lesions in eight per cent. Mit- 
ral murmurs and lesions prevailed in the melancholia cases and 
brought a variety of corresponding pulse tracings, mitral regurgita- 
tion being the most frequent of these affections. 
In cases of heart disease in mental disorders the syhygmographic 
records are not as a rule as typical of the cardiac lesion as in cases 
uncomplicated with insanity. 
Attention must now be given to the pulse tracings in the secon- 
dary and terminal stages of mental disease embraced under the gen- 
eral term dementia. 
When patients have been swept by the violent storms of acute 
insanity and left permanent human wrecks, it will be found that 
their vital machinery has been damaged in various ways. Some 
have wasted brains, others disease of the great sympathetic system ; 
some are left with hypertrophy, dilitation or valvular disease of the 
heart and others with general vascular degenerations; some have 
chronic pulmonary complaints and others cirrhosed livers or gran- 
ular kidneys, while still others, escaping all these complications, 
appear simply to have lost the essential and harmonizing control of 
the intellectual and emotional centers over all the functions of the 
human economy. 
It is not to be expected, nor is it found to be a fact, that these 
widely varying and pathologically constituted dements should 
present any one characteristic pulse tracing. It is true that all 
departures from tricotism, as the normal standard of the radial pulse 
tracing, are apt to be in the direction of simplicity, and that some 
form of the dicrotic or monocrotic pulse naturally results in de- 
mentia. It is al*o true in this terminal stage that there is apt to be 
in-the circuit of the blood some obstruction by a diseased internal 
organ, or some peripheral resistance from vascular changes, which 
gives as a rule a pulse of high tension. The following description 11 
of a sphygmogram would apply to a considerable percentage of ter- 
minal dements. The ascent is gradual and below medium height, 
the apex is rounded or formed in variously sustained shapes by the 
help of an early and imperfectly developed tidal wave, the descent 
is gradual and shows some wavelets, but no distinct aortic notch or 
dicrotic wave. 
One cause of the gradual line of descent in the sphygmograms 
of many dements is permanent exhaustion of the sympathetic ner- 
vous system, and the resistance which arises from venous stasis, as 
is shown by the cyanotic extremities of these patients and sometimes 
by a bluish tint of the whole bodily surface. Lunatics as a rule are 
psychically indifferent, but physically very susceptible to the action 
of heat and cold. This is due to feeble vasomotor innervation and 
the sphygmographic tracings will vary exceedingly according to the 
state of the atmosphere and of the surrounding temperature. 
Immerse the arm of one of these patients in hot water and there 
will follow an alteration in the tracing, and a hot bath will have a 
still more decided effect. 
In alcoholic dementia the resistance which gives rise to the high 
tension pulse may be in cirrhosed liver or kidneys, or sclerosed ner- 
vous centers. In senile dementia on the contrary it is attributable 
to atheromatous vascular changes, and in syphilitic dementia to the 
resulting arterial degenerations. Primary dementia again gives a 
tracing ordinarily of high tension, which is due to vasomotor pare- 
sis : but in some cases there is a distinctly dicrotic pulse. 
In terminal dementia there is sometimes a species of restitution to 
a normal standard of the physical man, and there may be an appar- 
ently natural tricrotic pulse in these cases, and a dicrotic tracing is 
also not uncommon. It not infrequently happens also that some 
chronic cardiac complication in these terminal cases imparts its own 
peculiar character to the tracing. 
Some of the varieties of sphygograms in terminal dementia are 
here shown as taken from among my patients. The tracings were 
first made on enamelled paper and were then photographed and 
mounted as you here see them. The variety which characterizes the 
tracings of the acute stages of insanity is to a considerable degree 
still present in this terminal phase of the disease in which if ever, 
uniformity would be expected. 
It would not do to dismiss this subject of the pulse tracings of 12 
dementia without some notice of the spyhgmographic characters of 
paretic dementia. 
In the earliest stage of general paresis the pulse may be tricro- 
tic, and, if the expansion reaches a maniacal degree, dicrotic. There 
is usually, however, a decided failure of systolic force as the disease 
advances, and the general angioparesis progresses rapidly after the 
first stage, so that there are soon developed various forms of high 
tension pulse from peripheral obstruction. 
Endarteritis in the syhilitic and alcoholic cases often causes this 
resistance to the flow' of blood, giving tracings which vary consid- 
erably within the limits of high tension. The percussion wave is 
usually low with rounded apex, and the descent has numerous wave- 
lets and not infrequently vibrations due to tremors peculiar to the 
disease. 
The apex in other tracings is rectangular, the plateau being 
formed by help of the tidal wave and the aortic notch and dicrotic 
wave do not appear. Following a series of paretic convulsions, 
however, the tracings may be dicrotic, or even hyperdicrotic, if the 
temperature reaches a high degree. In the final stage the monocro- 
tic type of pulse prevails, though bed-ridden cases sometimes give 
anacrotic teachings. In this third stage it is also quite possible to 
find an ascent with an acute angle and a sudden descent. In fact, 
there is nothing more surprising than the sudden variations in the 
pulse tracings of general paretics, and this is perhaps due in part to 
the variety of ways in which the cortical vasomotor and pneumogas- 
tric centres become involved with the advance of the disease. 
In tabetic or ascending cases of general paresis the tracings 
from the first are those of high tension and usually so continue to 
the last stage. 
Finally, it cannot be denied that in the forms of paresis with 
continued depression there may be a pulse of low tension and that in 
rare instances paretics throughout nearly the whole of the first and 
second stages of the disease give pulse tracings that are apparently 
about normal. 
It would exceed the intended limit of this paper to study in de- 
tail the sphygmographic characters of circular and epileptic insanity, 
of katatonia, or paranoia and of all the special forms of mental dis- 
ease, including imbecility and idiocy. This will be done in a second 13 
article devoted to this subject, and haste is now made to summarize 
the main conclusions of this paper, which are as follows : 
There is a considerable increase in the frequency of the pulse 
in both sexes in confirmed cases of insanity. Intermittance and irre- 
gularity of the heart, cardiac murmurs and valvular lesions are 
found in about ten per cent, of all established cases of mental dis- 
orders. 
Abnormal sphygmographic tracings are to be found at some 
stage of the disease in the vast majority of cases of insanity. They 
are due to affections of the cortical and spinal motor and vasomotor 
centres, to various lesions of the sympathetic, to disorders of the 
pneumogastric, to peripheral and central vascular changes, to degen- 
erations of central organs, to toxic agents in the blood, to auto-in- 
toxications, to cachectic and diathetic conditions, to cardiac lesions 
and to a great variety of intercurrent causes. 
These abnormal pulse tracings vary much in different kinds of 
insanity, and in different individuals suffering from the same form 
of mental disorder, and they are best classified according to the ac- 
tual physical status of the patient, and the etiology and stage of the 
mental disorder. No one sphygmogram is pathognomic of any par- 
ticular form of insanity, but there are certain general types of trac- 
ings which are found in one form of mental disease and not in 
another. Sphygmographic studies, to be of special value, should 
be continued in the same patients throughout an attack of mental 
disorder, and tracings finally obtained in convalescence should be 
preserved for comparison. Unfortunately studies with the sphyg- 
mograph are laborious and time-consuming, but they are of such 
diagnostic and prognostic value in mental disorders that they have 
already become an indispensible part of alienistic science. 
If this study of the pulse in insanity, made in the odd moments 
of a busy life, shall encourage like clinical research on the part of 
others, it will have served its chief purpose. 
I desire in conclusion to acknowledge the valuable aid rendered 
in these pulse studies by members of my medical staff, by Dr. Mel- 
len.Dr. Currie, Dr. O’Hanlon, Dr. Bowlby, Dr. Sanborn, Dr. Doran 
and Dr. Wheeler, and in particular by Dr. Frost, my first assistant, 
in the preparations of the pulse tracings.