Some Considerations on Insanity and its Thera- peutics. BY EDWARD C. MANN, M. D. REPRINT PROM Kcto York iWetucal Journal. June, 1881. This Paper is reprinted from The New York Medical Journal for June, 1881. The contents of that number are as follows: ©riginal Communications. PAGE A Case of Ovarian Tumor treated hy Incision Bos worth on the Throat and Nose 673 and Drainage. By T. Gail lard Thomas, Irvine on Relapse of Typhoid Fever 677 Wood on Fever 679 Case of Large-round-celled Sarcoma of the Testicle in a Unilateral Cryptorchis; Ex- tirpation; Cure. ByEdmnud C. Wendt, M. D., etc 626 M. D., etc 625 Hammond on Nervous Derangements 680 Masse’s Anatomical Plates .. 681 Duhring’s Atlas of Skin Diseases. Part YHI. 682 Beard and Rockwell on Electricity 683 Dickinson on Albuminuria 683 On the so-called Rupture of the Internal Lat- eral Ligament of the Knee Joint. By Charles A. Jersey, M. D 633 Books and Pamphlets received 683 Some Considerations on Insanity and its Ther- apeutics. By Edward C.Mann, M. D., Boston Dispensary 685 Clinical Reports. etc 638 New York Obstetrical Society 686 of Societies A Case of Exophthalmic Goitre; Recovery un- der Electrical Treatment. By A. D. Rockwell, M. D., etc 643 New York Clinical Society 698 Note on Surface Electrodes. By Frank P. Foster, M. D.,etc 644 Hepocts on tpe of f&emcme. Quarterly Report on General Medicine. By W. H. Katzenbach, M. D., etc 705 JEDitorials. Quarterly Report on Materia "Medica, Thera- peutics, and By Gaspar Griswold, M. D .a «. 717 Obstetrics and Gynaecology in the Journal— 647 Medical Lectxxrers and the Law of Copyright.. 648 The Alumni Association of the College of Phy- sicians and Surgeons 650 Quarterly Report on Venereal and Genito- urinary Diseases. By Edward B. Bron- Otis on Syphilis 653 3&cbictos anti 2Utn-ar;n Notes. son, M.D.,etc 726 .pUsrcllanj. Yan Buren on the Rectum 660 Guhler’s Therapeutics 664 Therapeutical Notes 729 Medico-Legal Notes 731 Agnew’s Surgery, Yol. II 669 Bryant’s Surgery 672 The Revision of the Pharmacopoeia 732 Army Intelligence 734 The New York Medical Journal is published monthly, and contains 112 closely printed octavo pages. It-is devoted to the general practice of medicine, and aims to meet the wants of the general practitioner. EDITED BY FRANK P. FOSTER, M. D., PHYSICIAN POE DISEASES OP WOMEN TO THE OUT-PATIENT DEPAETMENT OP THE NEW TOEK HOSPITAL. New York ; D. APPLETON & CO., Publishers, 1, 3, & 5 BOND STREET. Single Number, 40 Cents. Yearly Subscription, $4.00, SOME CONSIDERATIONS ON INSANITY AND ITS THERAPEUTICS; SUPERINTENDENT OP THE SUNNTSIDE RETREAT FOR MENTAL AND NERVOUS DISEASES. EDWARD 0. MANF, M. D., Insanity is a cerebral disease, in which the person affected is prevented from controlling his thoughts, his feelings, or his conduct. We must bear in mind that the pathology of the disease of the mind establishes the fact beyond dispute, that there are forms of mental disease in which, though the patient is quite aware he is about to do wrong, the will becomes overpowered by the force of irresistible impulse. The power of self-control, in these cases, is either destroyed or suspended by mental disease. Respecting these cases we may briefly state that homicide is not criminal if the person by whom it is committed is, at the time when he commits it, prevented by any disease affecting his mind from controlling his own conduct. Respecting the subject of testamen- tary capacity, about which the family physician is not unlikely at some time to be asked for his opinion, it is my conviction that the mental unsoundness of a man, if unconnected with the testamentary disposition, ought not to destroy testamentary capacity. If the will of a person is not affected by, or is not the product of, an insane delusion, it should be regarded as valid. Delusions per se should not, I think, render a will void. A person may be a monomaniac, and yet have sufficient mental capacity to make a valid will. In such a case the mental faculties are often unimpaired and undis- turbed. The most important point to be looked into is, whether the testator has ignored natural affection and the claims of near rela- tionship in the making of the will in question. The testator’s men- tal faculties must be so far normal that he shall understand the 4 nature of the act and also the consequences of it, and he must also have a clear idea as to the amount of property which he is dispos- ing of. There must be a clear, sound moral sense, and the human instincts and affections must be intact. There must be no insane suspicion or aversion, and no loss or impairment of reason and judg- ment. A person should not be considered capable of making a valid will if the act in question has been the product of, or has been actuated or influenced at all by: (1) hereditary taint which has influenced his volitions, impulses, or acts ; or (2) mental disease, or insanity, which has weakened, perverted, or destroyed the mental functions. In the study of disease of the mind, we, as physicians, are in- terested in the whole history of our patient and his ancestry, and we search for the causes of any bodily and mental changes that we find, and thus arrive at the true pathology of the disease, while the lawyer and jurist are mainly interested in the existence of mental disease, its degree, and its influence on conduct. There are some facts of equal interest to the physician and the jurist in diseases of the mind and nervous system. Thus, epileptics are to be classed in the most homicidal group of all insane criminals, or those likely to be- come so. Puerperal women and women at the climacteric period are subject at times to dangerous delusions ; and kleptomania is a peculiarity of a certain number of cases of general paralysis. These facts are classical, and should so he regarded by physicians and judges alike. The elementary disturbances of the cerebral functions which we meet with in our clinical studies in psychiatry involve processes in the emotional sphere; processes in the sphere of the conceptions, comprising the reason, memory, and phantasy; and, finally, pro- cesses in the psycho-motor sphere, the impulses and the will. Among emotional disturbances we find the two extremes of morbid depression and morbid exaltation, and also the conditions of abnor- mal excitability and abnormal absence of emotion. The morbid processes in the conceptional sphere involve and affect the duration, association, intensity, and reproduction of conceptions, and also comprise the delusions of the insane, or false conceptions. The morbid processes met with in the psycho-motor sphere cause the diseased propensities for food characterizing the insane, and the refusal of food by melancholiacs; affections of the sexual propensi- ties, either loss or abnormal excitation ; the various morbid im- pulses associated with insanity ; also disturbances in speech. We have elementary disturbances of consciousness in diseases of the mind, such as epileptic states, ecstasy, somnambulism, vari- ous states of altered consciousness, and the bewildered state of mind in paralytic dementia. We Lave also sensory disturbances, as anses- thesia and hyperaesthesia; motor disturbances ; vaso-motor disturb- ances, such as cerebral anaemia, cerebral hypersemia, venous stasis, and oedema of the cortex, and a great many changes in arterial ten- sion, resulting in sudden cardiac disturbances in the insane. We have also trophic disturbances, such as the herpes and rhagades of melancholiacs and patients with dementia; abnormal pigmenta- tions, etc. We find also many anomalies of the vital functions— the animal heat, the pulse, digestion, assimilation, respiration, gen- eral nutrition, and sleep. I do not consider that women are more liable to diseases of the mind than men. It is apparently so, from the fact that there are more females than males in our asylums; but females who are in- sane exhibit a lesser mortality than the male insane, and they there- fore accumulate in large numbers. Respecting the cause of insanity among Americans to-day, I do not hesitate to say that inheriting a delicate nervous organization, far in excess of physique as a rule, gives rise in modern society to a great increase of the neuropathic constitution. I have found over- strain of the brain and excessive use of stimulants to be the two principal causes of insanity and also of diseases of the nervous sys- tem generally. For a moral cause to produce insanity seems to me to necessitate an organic predisposition to it, although no doubt sometimes a nutritive disturbance of the brain may be produced by shocks to the nervous system, which may result in mental disorder in a previously healthy person. This, I think, however, is a rare occurrence. As forms of insanity of a curable nature, I would mention mel- ancholia, mania, and primary dementia, while among the secon- dary, incurable conditions of mental disorder are chronic mania and terminal dementia. We have also to deal with moral insanity, folie raisonnante, the monomanias, epileptic insanity, hysterical insanity, which may be complicated with epileptoid states, mania and melan- cholia; hypochondriasis; periodical insanity, under which state dipsomania ranks, and also mania, melancholia, and circular insan- ity; and, finally, we meet with cerebral diseases with psychical symptoms predominating, such as paralytic dementia, or progres- sive paresis, cerebral syphilis, and chronic alcoholism, with its com- plications ; also senile dementia and acute delirium. Respecting the therapeutics of diseases of the mind, I regard it as good practice to give five to ten grains of calomel to begin treat- ment, followed by salines, which prepare the system for what- 6 ever after-treatment is indicated. For an overworked business man, on the verge of insanity, whose whole system is probably dis- ordered, in whom anxiety has caused loss of appetite and inability to sleep, and in whom the integrity of the nervous system has been gradually deteriorating for some time, as well as for patients wdiose conduct and conversation are beginning to attract attention, such an initial treatment as I have described, followed by the adimnis- tration of thirty grains of bromide of sodium and thirty drops of tincture of cannabis indica thrice daily, in combination with warm baths at bedtime, cold affusions to the head, and galvanization of the brain (which latter controls the cerebral congestion), will be found by the profession, as I find it in the treatment of such cases at my private retreat for mental and nervous diseases, to be fol- lowed by prompt and gratifying recoveries. Many such patients are far better in their own homes, treated by this plan, than when carried away from home to an asylum, where, instead of rest, which is one of the great therapeutic reliances in early mental disease, the patient is soon an asylum-made lunatic. I do. not at all underrate the good work done at our asylums by some able men, but I contend that I can cure a patient in his own home, in the inception of insanity, or by taking him into my own family, in a much shorter time than I could cure the same patient by the use of precisely the same means when that patient was sub- jected to the depressing idea that he was in an asylum, where there were patients, perhaps, in the same ward who had been and who would be there for years. Such surroundings can not tail to depress a patient coming from a home of luxury and comfort. In acute mania I am inclined to think that either opium or morphine increases excitement, and that hyoscyaraine is a great deal better. Where there is exhaustive mania, with high excite- ment and cerebral anaemia, wine or brandy I have always found to be the best calmative and soporific. I have often induced and kept up sleep for hours by the administration of half an ounce or an ounce of fine old whisky, but I always give the whisky with a car- minative, so that the patient may not know what he or she is taking. Food must be given regularly and systematically, to support strength and prevent exhaustion. A pulse of 150 will come down to 80 under this stimulative treatment in exhaustive mania, and a quiet, refreshing sleep and a good recovery will result. I think chloral hydrate should be used very carefully, and I never give more than fifteen grains at a dose, generally combining it with sodium bro- mide and hyoscyamus, repeating at intervals of two hours until I get the effect I desire. 7 Curses have to be very carefully watched, lest, in caring for patients suffering from melancholia, they neglect to prevent the refusal of such food as is really needed for the support of the pa- tient. Ido not believe in slops for food in mental disease, but want my patients to have positive food—milk, eggs, beefsteak, lamb, and well-cooked vegetables and fruits. Rest and nourishment are my two main reliances, and if we add to these two a third, namely, sleep, we can by judicious treatment cure any curable case of insan- ity. Restraint, I think, is grossly abused; and yet there are cases in which the camisole, a soft canvas jacket, which is all the restraint ever necessary in any case, is temporarily needed ; but this should never be intrusted to the option of a nurse. ■2B West Thirtieth Street.