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Medical Treatment of Insanity.
better for the cause of humanity. Would that we were able to say that the Courts of our times have entirely avoided this error, and studied the influence of insanity upon human conduct more by the light of Shakespeare and of Nature, than of metaphysical dogmas and legal maxims." P. 332.
DR. BRIGHAM ON THE MEDICAL TREATMENT OF INSANITY AT THE
New YORK STATE LUNATIC ASYLUM.
Dr. Brigham having been frequently questioned upon this subject supplies a short paper to the present volume of the “ Journal.” He observes that, as no specific treatment exists, each case is submitted to remedies appropriate to its stage, recent cases usually requiring a mild antiphlogistic treatment. Much depends upon the cause. Thus, if the disease arises from any direct phyeical injury to the head or violent mental commotion free bleeding and purging are indicated. Such cases, however, are seldom seen in lunatic asylums; and only four out of the 622 patients were bled during the last year, in one of whom only did benefit seem to accrue. Cerebral excitement is occasionally treated by local depletion ; but gcnerally by placing the feet in warm water, applying cold to the head and the administration of purgatives. One of the most certain means of subduing maniacal excitement is the pouring cold water from a height of four or five feet directly upon the head ; but it must be gently executed, only for a short period, under the immediate superintendence of the physician, and never when the bowels are confined or the stomach full. The warm bath, continued for half an hour or longer, cold being simultaneously very gently applied to the head, exerts also a very calming effect in many cases. In most cases of insanity warm bathing is beneficial; and cold bathing and the shower-bath might be resorted to more frequently, but that thie patients are apt to regard them as intended for punishment.
Emetics and cathartics having proved of little service are now seldom prescribed, guarding against constipation, however, by diet and laxatives. In some recent cases Croton oil has proved very efficacious, apparently effecting a cure. It is the easiest of all medicines in its administration and has led to no unpleasant results.
Blisters, issues, and especially setons in the neck, have been frequently tried, but rarely effected anything but incidental good by diverting the attention of the patient from imaginary sufferings and delusions.
Great success has frequently attended the use of opium. In some cases it appears useless and in a few injurious, especially when the skin is hot and dry, and the pulse full and hard. Although not perhaps frequently curative it is a valuable adjuvant, securing an advantageous calm not otherwise procurable. “In some cases, however, it seems of itself to effect a cure; of this we can have no doubt, after having seen many patients apparently recover while taking it freely, and immediately relapse on its being withheld, and again recover under its use, and finally, after continuing it for a considerable time and gradually diminishing the dose, recover and remain well for years without it.” Dr. Pritchard, who formerly spoke very disparagingly of this remedy, in a late edition highly commends it. The following formula is employed in many nervous, sleepless, and hysterical cases. Ro. Træ. Lupuli. ; Træ. Hyoscy. aa ziv.; Camphoræ 3j. ; Ol. Valerian. mxxxij. Dose 1 to 2 drachms. The following is also useful in some cases of violent mania, especially, as is often the case, when the secretion of urine is defective. R. Træ. Digital. ; Træ. Scilla, ää 3ss.; Vin. Ant. Tart., Spt. Nitra Dulc. āā zj. M. Dose 30 to 60 drops.
Many cases, particularly if they have been of long duration, require invigorating diet and tonics; and many patients are brought to the institution seriously injured by the depletion which their maniacal excitement and great muscular efforts have unfortunately given rise to. The usual tonics are prescribed ; but from none is a greater advantage derived than the following combination. Extract. Conii zvj.; Ferri Carb. Præcip. Jsij. ; Molasses, Wine, Warm Water, äā two quarts; 01. Sassafras zij. dissolved in Alcohol zviij. M. The usual dose is į oz. ad 1 oz. adding a little Tr. Aloes and Myrrh to each dose when a laxative is required. The foba lowing combination also has been found " quite serviceable” in many cases of debility and loss of appetite. R. Træ. Cinchon. Co. Zj.; Tre. Gentian. ziij.; Træ. Capsici zij. ; Sulph. Quin. 388.; Acid. Sulph. mxv.-M. A dram to be given in water or ginger tea.
Insanity is often complicated with other affections. Nocturnal emissions are not infrequent and are very injurious, for which large duses of the Tre. Ferri Muriatis seem the best remedy. So, tvo, Passive Menorrhagia, which is often ohstinate and seemingly sometimes a cause of the insanity, may be treated by the same, or better still by Tr. Cinnamom. and Tr. Aloes, of each from 20 to 30 drops.
“ It should ever be borne in mind that disease in the insane is very apt to be masked,--that serious disease of the lungs, or of some of the abdominal viscera may exist, but without being manifested by the usual symptoms, and may therefore be overlooked without careful examination. In other respects not particularized in these remarks, we are not aware that the diseases of ibe insane require different treatment from those of the sane."
Dr. Brigham's Report of the New York State Lunatic Asylum contains some interesting remarks on some of the physical characteristics of the insane.
Frequency of Pulse of the Insane.—Dr. Brigham has recorded the frequency of pulse in 1234 cases, giving the following results. From 40 to 50 in 8; 50 to 60 in 22; 60 to 70 in 183; 70 to 80 in 233; 80 to 90 in 466; 90 to 100 in 144; 100 to 110 in 124, and 110 to 120 in 54. Examining the pulse in 76 sane persons he found it from 60 to 70 in 6; from 70 to 80 in 47; and from 80 to 90 in 23. Both the sane and insane individuals were in a calm state and sitting posture. “Age seems not to have much influence upon the rapidity of the pulse, as a few of the most aged were found to have a rapid pulse. Those who have recently become in. bane, most generally have a frequent pulse, above 80 in a minute, though there are exceptions to this, as in some such cases the pulse is remarkably slow.”
Size and Shape of the Head.-Dr. Brigham instituted careful admeasurements of the heads of 1163 insane persons (604 men and 559 women) And of 82 kane persons (45 men and 37 women). They were measured
1817) Weight of the Insane-Hereditary Prediposition.
341 around in three directions : 1, around the head, its greatest circumference; 2, from the opening of one ear, over the head, to the other ; 3, from the root of the nose or lower part of the forehead, to the nape of the neck or occipital protuberance. These two last were found to be nearly alike in the same individuals; and, with few exceptions, the heads which were largest in one direction were so likewise in the other. In eight only of the 604 insane men did the largest circumference extend to 24 inches, and the other directions to from 14} to 152. In 314 the largest circum. ference was more than 22 inches, and in 282 from 21 to 22 inches. In 5 of the 45 sane men only did this extend to 23 inches, and in 18 of the number it was less than 22-so that no material difference was observed in the size of the sane and insane head. In both insane and sane women the highest figure reached by the largest circumference was 224 inches. In 350 of the former, and 19 of the latter, it was less than 22 inches.
Weight of the Insane.Dr. Brigham likewise presents us with tables of tbe weights of 1007 insane persons, and believes this point has been too much overlooked. We do not consider any importance is to be attached to any such account of the absolute weight of the insane--every possible latitude of this being perfectly consistent with complete health of body and mind; but we quite concur with him in the following observations upon the indications to be drawn from variations in the weight subsequent to admission.
“ We have practised weighing each patient upon admission and occasionally afterwards, and I think we have derived considerable advantage from this custom. It is sometimes a valuable guide in prognosis, and often affords amusement and encouragement to the insane themselves when they find, contrary to their strong convictions, that instead of losing, they are increasing in flesh.
.“ A majority of the insane, when committed to our care, are less fleshy than natural. They have become more or less emaciated by disease, or by their imaginary troubles. Usually they regain flesh when they begin to recover, and frequently weigh more after complete restoration than 'at any other period of their lives. Some in the course of a few months have gained from 30 to 40 pounds. In recent cases of insanity we usually predict recovery when patients begin to increase in flesh, especially if at the same time there is some improvement of the mind. On the contrary, where the digestion and sleep and appetite are natural, and the patient increases in flesh, without any diminution of insanity, there is little hope of recovery: also, if the appetite continues good and emaciation increases, there is reason to fear an unfavourable result."
We have often thought that practitioners are too neglectful of the information which statical data would furnish to them. Every one must have at times felt the great desirableness of being assured whether the patient is gaining or losing flesh ; while the indefinite and frequently inaccurate statements furnished upon this head (especially by women who are continually confounding mere distension with increase of substance) may often mislead. In all chronic cases, a correct register of the patients' weight, as ascertained at periodical intervals, should be kept, the timid or wavering not being necessarily made acquainted with the results.
Hereditary Predisposition.-This, Dr. Brigham believes, exerts more influence in the production of the disease than all other causes combined. “It does not of itself excite the disease, but when it strongly exists, a trivial cause will develop it. Thus, most of the supposed exciting causes in the foregoing table would, of themselves, be inoperative, if there was not an inherited constitutional tendency to insanity.” The children may escape, and the grand-children suffer. Careful enquiry has shewn that insanity is a little more likely to be transmitted by the mother than the father, and that the mothers are considerably more likely to transmit it to daughters than to sons; while the fathers most frequently transmit it to sons. Thus of 79 men, 42 had insane fathers and 35 insane mothers, and in two both parents were deranged ; and of 96 women, 37 had insane fathers and 56 insane mothers, three inheriting the predisposition from both parents.
“When children resemble in personal appearance the insane parent, and manifest the same peculiarities of feeling and temper, there is reason to apprehend they will be more or less disposed to the disorder of the parent they resemble.” Of 1181 patients (594 m., 587 w.), 315 were known to have insane relatives, and in 175 cases the parents were the relatives. Many others would probably evidence the same predisposition were their history more accurately known. Dr. Brigham has, however, contrary to the opinion of most, found the inherited form of insanity as curable as any other, but very liable to relapse from slight and various causes. Individuals so predisposed may have repeated attacks, each one from a different exciting cause. The education of individuals having this predisposition is of vast importance.
“ The early education of all such requires much attention. Great pains should be taken to form a character not so subject to strong emotions, to passion and caprice. Among the most frequent causes of insanity in those not predisposed to it, is the over-indulgence of the appetites and passions in early life; and to those who inherit a tendency to this disease, such a course is highly pernicious. The utmost attention should be given to the securing a good bodily constitution. Such children should be confined but little at school; they should be encouraged to run about the fields and take much exercise in the open air, and thus ensure the equal and proper development of all the organs of the body. They should not have the intellect unduly tasked. Very early cultivation of the mind, and the excitement of the feelings by the strife for the praise and the honour awarded to great efforts of mind and memory, are injurious to all children, and to those who inherit a tendency to nervous diseases or insanity, most pernicious.”
Suicidal Form of Insanity.–Of 1181 patients admitted into the New York Asylum, 156 (63 m. and 93 w.) were disposed to suicide. “It is however a consoling fact, that this alarming variety of insanity is quite often a curable one. Among the most complete and permanent recoveries we have ever known, are a considerable number who, for several months, were very strongly inclined to self-destruction."
Homicidal Insanity. The Report contains many interesting observations upon this all-important subject. Dr. Brigham believes the homicidal insane may be arranged into six classes, differing in their mental condition, as indicated by the motives which actuate them, or the circumstances which accompany the deed. So unsettled are the views of the public and of the legal and 1847)
medical professions upon this subject, that we are glad of the opportunity of recording any remarks of so acute and experienced an observer; and certainly the first step towards a more accurate comprehension of these cases would seem to be a more distinct apprehension of their distinguishing traits. The classes indicated by Dr. B. are as follow. 1. Those who take life in a paroxysm of insane passion or fury. Insanity so frequently induces excessive irritability of temper, that every asylum contains patients who are disposed to assault or kill. Most of the cases related in the newspapers of insane persons at large killing their relatives or friends during a gust of passion belong to this class. In general, other acts have previously indicated insanity on the part of the perpetrator ; although occasionally cases occur in which it is difficult to decide whether the act results from insanity or depravity and violent passion.
“ Usually, however, in these somewhat doubtful cases, it will be found that those who ought not to be considered responsible for their actions, by reason of insanity, have suffered from some severe illness, or from some great mental disturbance, since which time their temper and disposition have undergone a marked change. When no such facts are found to exist, nor any other evidence of mental disorder, we think the act itself committed during violent passion, is not proof of insanity, though it may have been committed under such aggravated provocation as to render it, in public opinion, justifiable homicide.”
In the second class are placed those who commit a homicide from delusion, who are deceived or misled by their hallucinations, illusions, or disordered imaginations; and this is the form of homicidal insanity which is more prevalent than any other; the actuating motive being often benevolence towards the victim sacrificed to the delusion.
The third class is made up of “those who kill indiscriminately and apparently from a love of taking life ; from a diseased propensity and conscious desire to destroy others, against which act neither reason or conscience remonstrates.” Some of those persons seem almost constantly desirous of injuring or killing others: they are conscious of this ; but are actuated by no motive, malice, or passion. In the fourth class we have persons
“ who kill without any apparent motive, from a sudden impulse, but of which they are not conscious, and who retain no recollection of anything that prompted them to the act. Those belonging to the third class, have an intense desire to kill, of which they are conscious, and are usually evidently insane in other respects ; but those belonging to the fourth class kill from a sudden impulse, without any desire or conscious feeling relating to the act, and not unfrequently the act itself is the first noticeable evidence of their mental derangement."
The fifth class is composed of persons who commit the crime without motive, from an irresistible impulse, of which they are conscious, and against which reason often remonstrates. Gall, in his work upon the brain, instanced several cases in which the insane implored that they might be protected against the effects of their propensities, and similar ones abound in works upon insanity.
To the sixth class belongs such as kill from imitation, or an insane love of notoriety.
After this analysis of the cases that have come under his notice, Dr. Brigham adverts to the difficult question of legal responsibility, concerning