THE PULSE OF THE INSANE. BY EDWARD R. HUN, M. D., SPECIAL PATHOLOGIST OF THE NEW YORK STATE LUNATIC ASYLUM, AT UTICA. [From the American Journal of Insanity, for January, 1870.] THE PULSE OF THE INSANE. THE PULSE OF THE INSANE. BY EDWARD R. HUN, M. D., SPECIAL PATHOLOGIST OF TIIE NEW YOKE STATE LUNATIC ASYLUM, AT UTICA. [From the American Journal of Insanity, for January, 1870.] Before examining the results of investigations made upon the pulse of the insane, it might be well to con- sider the physiological pulse as traced by the sphyg- mograpli, and also to determine some of the changes which it undergoes in consequence of morbid conditions not attended by psychical phenomena. The normal pulse trace as obtained by the sphygmo- graph of Marey, consists of an upright or vertical line terminating in a moderately sharp point, and followed by a gradual line of descent, which latter line is broken into waves or undulations at two points. Such a trace is Fig. 1. Normal pulse. Tricrotic. represented in figure 1, and in consequence of its having three apices it is termed tricrotic. If we discard the various forms of cardiac disease as foreign to this paper, we may state that the most fre- quent and interesting of the many metamorphoses which the pulse undergoes, are these which accompany febrile action, and one of the most important of these is an in- 4 creased rapidity. As the temperature of the body rises, the pulse becomes more frequent, and at the same time assumes a different form. In order to explain this change we will find it con- venient to give a name to the various portions of the trace, and therefore we call the apex formed by the upper extremity of the line of ascent, in the normal type, and the commencement of the line of descent, the great or primary wave and the two undulations which in- terrupt the line of descent, the first and second secondary waves respectively. Now as the pulse becomes more frequent we find the first secondary wave diminishing in size, and at a tem- perature of about 104°, when the pulse varies between 100 and 120 per minute there remain only two apices to each pulse curve, the first secondary wave having entirely disappeared, and in place of the tricrotic or normal pulse we have the dicrotic or characteristic fever pulse. Fig. 2. Fever pulse. Dicrotic. As the temperature and rate of the pulse increases we have yet another modification of the pulse curve. The second secondary wave diminishes and finally disappears at a temperature of 106Q and a pulse of 140 per minute, and the result is such a trace as is represented in figure 3, where both secondary waves have disappeared, and only a single apex is observed. This pulse is termed monocrotic. Between these marked metamorphoses we find intermediate types where the pulse trace is termed sub-dicrotic, (fig. 4,) and super-dicrotic, (fig. 5.) Fig. 3. Fever pulse. Monocrotic. 5 Fig. 4. Fever pulse. !5ub-dicrotic. Fig. 5. Fever pulse. Super-dicrotic. The principal modifications of the pulse curve there- fore consist in a deviation from the tricrotic to the di- crotic or monocrotic type in ordinary forms of disease, and such deviation from the normal standard is accompanied by an increase not only in the rate of the pulse but also in the temperature of the body. Hence, there exists a certain harmony between the temperature and the rapidity and form of the pulse. This harmony holds good in cases of depression as well as of exaltation of temperature, for in cases of algidity such as are some- times found during convalescence from acute fevers, where the temperature falls below the normal standard, the rate of the pulse is diminished and at the same time the sphygmographic curve becomes more decidedly tricrotic than in health. .Fig. 6. Algid pulse. It lias been found by Wolff, and is so stated by him, tliat “ when this harmony between the temperature and the pulse is so interfered with that an elevation or 6 depression of temperature is not accompanied by a cor- responding alteration of the pulse curve, we have a dis- ease or a period of a disease in which the central nerv- ous apparatus is implicated to an unusually great and dangerous extent. Thus we find in febrile diseases of the nervous system a loss of parallelism between the temperature and the pulse, as is often manifested by the rate of the latter.” The same author finds, and my own investigations fully confirm his statements, that in the insane this loss of parallelism between the pulse and temperature is destroyed, and furthermore, that the form of the pulse curve is fundamentally altered. The trace no longer presents a series of acute apices, as in the normal or febrile pulse, but each curve is surmounted by a hori- zontal line or flat top, and assumes the form described by Marey as the senile pulse. Before entering more minutely into the study of the pu!se trace of the insane, I may with propriety mention, that in persons who suffer from psychical derangement, the bodily temperature differs but little if any from the normal standard, except in cases where there is some intercurrent disease, and as a general rule an elevation of temperature above 100° indicates the existence of some complicating disease which does not directly de- pend upon the insanity. The temperature of intercur- rent febrile diseases in the insane runs the same course as in the same diseases in the sane, and under these circumstances the pulse undergoes such modifications that in some instances an insane patient who has when apparently in good physical health presented a path- ological pulse trace, may under the influence of febrile reaction produce a curve which closely resembles the normal tricrotic pulse of the sane. The pathological pulse of the insane always tends 7 toward the dicrotic or monocrotic type, being never tricrotic in uncomplicated cases. It becomes more characteristic as the mental condition degenerates, and assumes its typical form in the most profound state of dementia. The following traces which I obtained from patients in this Asylum, will serve to demonstrate the pulse curves so found in the different forms of insanity. Fig. 6. Melancholia. Female, aged 38 years. Fig, 7. Melancholia. Female, aged 28 years. Fig. 8. Melancholia. Male, aged 48 years. Fig. 9. Melancholia. Male, aged 51 years. Fig. 10. Acute mania. Male, aged 40 years. Fig. 11. Acute mania. Male, aged 28 years. Fig. 12. Sub-acute mania. Male, aged 26 years. Fig. 13. Paroxysmal mania. Female, aged 30 years. Subsequently died of apoplexy. 8 Fig. 14. Periodic mania. Male, aged 51 years. Taken while he was recovering from an attack. Fig. 15. Chronic mania. Male, aged 36 years. Fig. 16. Chronic mania. Male, aged 60 years. Fig. 17. Chronic mania. Male, aged 38 years. Fig. 18. Chronic mania. Aged 78 years. Fig. 19. Chronic mania. Aged 50 years. Fig. 20. Dementia. Aged 18 years. Fig. 21. Dementia. Aged 45 years. Fig. 22. Dementia. Aged 37 years. 9 Fig. 23. Dementia. Aged 34 years. Fig. 24. Dementia. Aged 40 years. An analysis of tlie above traces sliows two points of difference between them and the normal type: 1st, a loss of tricrotism with a marked tendency to the dicrotic and monocrotic form, and 2d, a flat top in place of the acute angle found in health and febrile diseases. The first of these changes we have already found to exist in cases of fever when the temperature of the body is elevated, but among the insane there is no increase of temperature, and we may therefore consider a dicrotic pulse unaccompanied by an abnormal rise of tempera- ture as one of the physical phenomena of insanity. The second deviation from the normal standard is still more characteristic of psychical disorder. This peculiar pulse curve with a flat summit has been de- scribed by Marey, and attributed by him to a patho- logical condition of the arterial walls, whereby their elasticity was diminished and an impediment offered to the free flow of blood. Now in the examples of this form of pulse which he figures in his work upon the circulation of the blood, Marey states that his patients were inmates of the Bicetre and Salpetriere, which asylums contain for the most part insane, demented and paralytic persons. Consequently, we are as fully justi- fied in considering the alteration of the pidse curve due to the condition of the nervous system, as we are in attributing it to a pathological state of the walls of the arteries. 10 Moreover, I am fortunately able to furnish pulse traces of two patients who have fallen under my observation, in which Marey’s results are directly contradicted. Fig. 25, represents the pulse of a patient aged 60 years, who presented upon physical examination all the characteristic symptoms of structural change in the heart and arteries. Angina pectoris, dyspnoea, and a condition of the radial arteries which communicated to the finger, a sensation as if they were firm, inelastic cords, were symptoms which I frequently had occasion to observe, Fig. 25. Male, aged 60 years. and yet the trace has an acute apex, and is distinctly tricrotic. Fig. 26, on the other hand, is the pulse of a patient who was hemiplegic, and presented symptoms of mental derangement resulting from an apoplectic attack, and in whom neither auscultation or palpation revealed any Fig. 26. abnormal condition of the heart or arteries, and yet we find a flat-topped monocrotic pulse curve.* * Note.—I do not intend to be understood as denying that an atheromatous condition of the arteries may not be accompanied by a pulse which gives a trace similar to that seen in fig. 26, but I think that in these cases the same defective nutrition which causes the change in the walls of the blood-vessels may also interfere with the proper reparation of nerve tissue, and thus influence the form of the pulse. In fact, a diseased condition of the nutrient vessels of the brain is one of the most frequently observed facts in cases of paralysis and mental disorders, and it may be that the alteration 11 If we examine tlie traces represented in tigs. 12, 15, 17 and 22, we find the well marked senile pulse of Marey, while the age of the patient contraindicates atheromatous degeneration, and we are therefore com- pelled to seek some other explanation of the phenomenon, the key to which, I think, can only be found in the sympathetic nervous system. The disordered condition of the ganglionic system in the insane, is evidenced by such marked symptoms that it would be indeed surprising if we did not find a path- ological condition of the pulse. The sluggish circula- tion through the peripheral capillaries is rendered evi- dent by the passive congestion of the hands and feet, and the white line bordering the edge of the lip, ob- served both in melancholia and mania, and attains its maximum when the patient relapses into the most pro- found dementia; the frequent attacks of local hyperaemia, which in some cases are sufficiently intense to result in rupture of the vessels, and to produce that remarkable appearance known as hcematoma auris, can only be at- tributed to the disordered action of the sympathetic system, while the altered condition of all the secretions, both cutaneous and intestinal, must be referred to the same agency. Again, the defective nutrition of the in- sane is but the index of some unknown cause, influenc- ing the functions of organic life through the medium of the sympathetic ganglia. Comparatively recent investigations of physiologists have demonstrated that the centres of the great sympa- thetic are situated in the crura cerebri, and pass down- ward along the central axis of the cord. From these centres fibres radiate toward the periphery of the body of the nervous tissue is due to the disease of the vessels, and that the pathological pulse is therefore the result of the combination of two elements, which are related to one another as cause and effect. 12 in close contact with tlie fibres of tlie cranial and cerebro- spinal nerves, which they accompany for a short distance, and then branch off to supply the walls of the blood vessels, over which it is their special functions to pre- side. Other fibres again pass into the gray matter of the hemispheres, and are intimately connected with the nerve cells occupying the cerebral convolutions. Hence, it results that the sympathetic nerves may be influenced not only by external agents acting upon their peripheral extremities, but also by emotional causes influencing their centripetal prolongations. In fact the experiences of daily life continually ofter examples of this mode of irritation, the emotions of fear, anger and shame all give rise to external phenomena with which we are familiar, as pallor of the countenance, blushing, &c.,