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Full text of "Types of insanity, an illustrated guide in the physical diagnosis of mental disease [with manuscript notes]"



PLEASE DO NOT REMOVE 
CARDS OR SLIPS FROM THIS POCKET 

UNIVERSITY OF TORONTO LIBRARY 



MI Hamilton, Allan M. 

H Types of insanity 



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PLEASE DO NOT REMOVE 
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UNIVERSITY OF TORONTO LIBRARY 



M, Hamilton, Allan M. 

H Types of insanity 



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TYPES OF INSANITY 



AN 



ILLUSTRATED GUIDE 



IX THK 



PHYSICAL DIAGNOSIS OF MENTAL DISEASE 



I IV 



ALLAN MrLANK HAMILTON, M.I). 

"KK CITT, ** TBK HUDSON 

'" K,,H Tin 



N KW YO I:K 

WILLIAM \VOOI) A COMPANY 

! 58 I. UAYKTTK I' 

1888 



TYPES OF INSANITY 



ILLUSTBATED GUIDE 



IN THE 



PHYSICAL DIAGNOSIS OF MENTAL DISEASE 



BY 

ALLAN McLANE HAMILTON, M.D., 

ONE OF TOE CONSULTING PHYSICIANS TO THE INSANE ASYLUMS OF NEW YO11K CITY, AND TUB HCD8ON 

KIVElt STATE I10STITAL FOB THE INSANE, ETC. 






NEW YORK 
WILLIAM WOOD & COMPANY 

56 AND 58 LAFAYETTE PLACE 
1883 




COPTEIOHT BI 

WILLIAM WOOD & COMPANY 
1S83 



TROW'S 

PRINTING AND HOOKHINDING COMPANY 
201-213 l'- il st T-vclJtk Street 

NEW YUKK 



INTRODUCTION. 



As we progress in our study of insanity, we are constantly reminded 
of the physical changes that take place in the patients committed to our 
charge. Disease of the brain makes itself known by well-marked bodily 
symptoms, that are in themselves almost as important as the many varia- 
tions of disordered mental action. In the present work it has been my 
aim to put into simple form a few suggestions that may prove useful to 
medical men who, from time to time, meet with cases of insanity in their 
practice. The plates are drawn by Mr. T. J. Mauley 'from instantaneous 
photographs; the subjects were selected from many hundreds of patients, 
ami I believe them to be typical. 

I wish to express my obligation to Drs. A. E. Macdonald and 
Kranklin, as well as the gentlemen of the medical staffs of the male and 
female insane asylums of the city of New York, and to the various 
superintendents of asylums throughout the country who kindly sent me 
al>-traets of State laws. I am especially indebted to Dr. A. Trautmann, 
of the Ward'- island Asylum. f'"i- the accurate sphygmographic plates, 
and to Dr. (jr. D. Smith, of New York, for valuable assistance.' 



CONTENTS 



FHTRODUOBOV page 



111 



CHAPTER I. 

I i:\I. AlM'KAKANCE OF TIIK INSANE PHYSIOGNOMY, PoSTDRE, CONFOR- 
MATION OF THE HEAD, ETC pages 1-6 

CHAFfER II. 

< "vmnoN m- SPECIAL ORGANS: THE EYKS, THE EARS, THE MOUTH AND 

,111. mi. TONGUE, THE NOSE, ETC pages 7-11 

CHAPTER III. 

CONDITION OF THE BODILY FUNCTIONS : THE CIRCULATION, TEMPERATURE, 
AND PII.-K VARIATIONS OF THE SKIN AND ITS APPENDAGES MUS- 
CULAR To.vrs TIIK RKFI.KXES, SENSIBILITY THE URINARY SECRE- 
TION, MENSTRUATION, ETC pages 12-17 

CHAPTER IV. 

K.VAMINATION OF PATIENT CHANGES IN DltESS AND PERSONAL HABITS, ETC. 

-THE HANDWRITING OF THE INSANE pages 18-22 

CHAPTER V. 

TIIK COMMITMENT OF THE INSANE ABSTRACT OF THE LAWS OF THE VARIOUS 

STATES pages 23-36 



PLATES WITH TEXT. 



IIJIOCY PLATK I. 

IMBECILITY " II. 

MELANCHOLIA ATTONITA li III. 

CHRONIC MKLANCHOLIA " IV. 

Si i: \iTTi: MANIA " V. 

CHRONIC MANIA " VI. 

I >l MKNTIA " VII. 

DKMKMIA VIII. 

. KBAL PARESIS " IX. 

Aim i IONS OF THE EAU AND CONDITION OF THE TKETH IN TUB 

INSANE . " X. 



TYPES OF INSANITY. 



CHAPTER I. 

GENERAL APPEARANCE OF THE INSANE PHYSIOGNOMY, POSTURE, 
CONFORMATION OF THE HEAD, ETC. . 

THKRK are various changes in the appearance of the insane that are almost as 
important in their way as the evidences of mental trouble displayed in conversation. 
Not only is the unbalanced mind evinced by alterations in faeial expression, and by 
departures from former habits in the matter of gesticulation, postures, and dress, but 
physical alterations as well are presented, which are the outcome of disease of the 
brain, and are sometimes so trivial as to escape ordinary observation, but nevertheless 
should be always looked for. Especially is such the case in those examples of 
insanity which are masked or concealed. 

When one walks through the wards of any asylum for the insane, he will be 
immediately impressed with the repulsiv'eness of the faces about him, for the general 
appearance of the insane patient is in no sense prepossessing, and this is especially 
the case in the female. Women of beauty, as writers upon insanity have observed, 
rapidly lose their good looks with the establishment of mental disease, and plainness 
or downright homeliness is the rule among asylum patients, whether of high or low 
social station. What with slovenliness in dress, filthiness in habits, changes in the 
color of the skin, and the condition of the hair, much of the romance that is supposed 
to belong to insanity disappears. There are few I/ears, and fewer Ophelias. 

The physiognomy of the insane consists not only in the portrayal of inharmoni- 
ous types of expression, but in transitory and intensified manifestations of dominant 



2 TYPES OF INSANITY. 

feelings. The latter is often the case in commencing insanity, and in forms of mental 
disorder that have stopped short of dementia. It is well in all cases to systematically 
study the condition of the organs of expression themselves, and ascertain if there be 
functional derangements as well as general structural changes which may be the 
result of defective innervation. Such study should be careful and continued, and not 
only the manifestation or absence of expression should be taken into account, but the 
possible existence of paresis of certain facial muscles, the condition of the eyes and 
hair, the coloring and appearance of the skin, and the general muscular tonus should 
be noted as well. Relaxation and rigidity of the muscles are conspicuous factors in 
the expression of insanity, and in states manifested by lowered emotional activity we 
find the former to be nearly always present. Such is the case in melancholia and 
dementia, and in the atonic stages of other forms of asthenic disease. Rigidity, on 
the other hand, is the rule in mania and in conditions attended by excitement, as well 
as in certain sthenic forms of melancholia. The melancholic patient dramatically 
expresses mental distress by the position assumed, which is the embodiment of 
utter resignation to the worst ; the facial muscles are relaxed, the mouth sags at 
the corners, and the eyelids droop, leaving exposed a small portion of dirty white 
sclerotic. The color of the skin is muddy, and in appearance greasy, as the sebace- 
ous secretion is abundant; the nose and ears may be red or else livid, and the lips 
swollen and ill-defined. It is not rare to find spots of acne upon the forehead or 
back, or herpetic patches about the mouth. When the patient raises the head, which 
is usually bowed, it is to look wearily into vacancy (Plate III.), and a position 
of this kind may be assumed and kept for hours at a time. The hands hang list- 
lessly in the lap, are dusky and swollen, and the fingers are intertwined or engaged 
in picking imaginary particles from the clothing. When the back of the hand is 
pressed, a white mark remains, slowly disappearing however as the sluggish capil- 
laries refill. The nails are pale, or have a bluish tinge, and often there are hang-nails 
which are idly picked. These latter, in association with acne upon the forehead, 
are very common in sexual insanity, especially among masturbators. Such melan- 
cholies are not disposed to pay much .attention to what goes on about them, and beyond 
an occasional deep-drawn sigh they give little indication of their feelings, but seek to 
avoid interference or notice of any kind. In lighter grades of melancholia the ex- 
pression is of a much more sthenic and active character, and this is especially the 
case in forms of depression alternating with excitement. The patient is loquacious 
and communicative, as well as restless. His anxiety and anguish are evinced by 
certain forcible actions, such as pressing his hands over the face or head, by appealing 
gestures, a supplicating expression, or one of fear or remorse, by rolling up of the 
eyeballs; by bending the body usually forward, the patient assuming a crouching at- 
titude, and by other evidences of an intense play of the more active of the depressing 
emotions. 

In melancholia, when there is a complicating hysterical element, it is not rare 
to find libidinous gestures and postures, which are, however, more marked in mania 
of an hysterical form. 



TYPES OF INSANITY. 3 

In mania everything indicates the play of ambitious feeling. Under the sway 
of pride, self-satisfaction, inordinate vanity, rage, hate, and certain dominant and all- 
absorbing passions, the bearing and demeanor of the patient suggests only excitement, 
restlessness, and irregularly expended energy. Muscular rigidity succeeds relaxation, 
but there is an exhibition of power which is entirely disproportionate to that needed 
for the performance of any special act. The movements made by the patient are rapid, 
cumulative, and startling. He paces to and fro, and his emotions are of a kind that 
must find vent in muscular action. The elated sense of importance is shown by his 
pompous deportment; his smile is supercilious and constantly plays about the mouth, 
the upper lip being raised to expose his teeth. As he rapidly strides through the ward 
>r room in which he may be placed, his body erect, and lii.s face turned upward and 
usually to one side, he presents a striking picture. The maniac gesticulates in a way 
that is not to be forgotten: he pat* his In-east, smoothes down his clothing with both 
hands, strokes one hand with the other, points to himself, raises both hands with their 
palms toward the visitor, and he does all this in a rigid and puppet-like manner. In 
the midst of his rapid walk he commonly turns and strikes an attitude (Plate VI.). 
The same patient at another time manifests an extravagant expression of rage, which 
is no less actively displayed, the brows being corrugated, the teeth covered by com- 
pressed lips, the eyes widely opened and the balls fixed, but it is rare for such a 
patient to look a person squarely in the face, and the intense expression may be 
rapidly succeeded by one entirely different 

In i:hr<>ni<- mania we find that the dominant features of the patient s insanity have 
left indelibly marked traces. The suspicious, violent maniac (Plate V.) glares at the 
passer-by, with averted head and sinister expression, while the brow is contracted and 
the lines about the mouth are deep and sharply drawn. Such a patient suddenly 
starts up to swear and curse, and shake her fist violently in the face of the spec- 
tator, while her scowl may be succeeded in a moment by a contemptuous sneer or a 
malicious grin. For dajs together tin-re mav in such cases lie little variation in the 
play of expression. 

Certain sub-varieties of insanity are manifested by peculiarities in the behavior 
and appearance of patients which have more than passing interest. In hysterical 
mania, during the attacks the patient of ten presents the appearance of transfiguration 
alluded (o by Chan-ot in his writings upon hystero-epilepsy, there being a condition 
of ecstacy, the excitement displaying iisc-ir in fixed attitudes, in which she remains for 
several hours. Varieties of moral insanity of sexual outgrowth in young people 
of both sexes, but especially in males, are expressed by great shyness, timidity of 
manner, or an effeminate appearance which is highly suggestive. In certain young 
women with sexual insanity a restless manner and the existence of a morbid self- 
consrioiiMiess and vanity are constantly present. 

In il'ini nti<i the facial change consists in an absence of expression of any kind, 
and the muscular atony often gives to the countenance a mask-like vacancy and im- 
mobility. Under stimulation a meaningless smile may be brought to the lips, but it 
is not the reflex of any intelligent mental action. The lower lip is often relaxed and 



4 TYPES OF INSANITY. 

dependent, and from the corners of the mouth drools a stream of saliva which the 
patient makes no attempt to arrest (Plate VII.). The eyes are cold, fishy, suffused, 
and expressionless, and in advanced cases betray no indication of intelligence. Par- 
ticles of food collect in the interstices of the teeth and the breath is offensive and 
peculiar. The demented patient ordinarily is slow in his movements, remains in fixed 
attitudes, and his circulation is defective, the extremities being cold and livid; the 
lids are red, and sometimes there is a tendency to lachrymation, the person crying 
without apparent provocation. 

In many of these cases there are exacerbations of feeble excitement, usually 
short-lived and accompanied, in old people, by restless movement and incoherent 
loquaciousness and irritability. Loss of memory being one of the most important 
mental defects in dementia, we frequently find that the dement does not recognize 
any one with whom lie may have come in contact since the development of his 
condition, although in cases not far advanced he may be able to remember old 
friends, but cannot call them by name. 

A form of dementia which is rare is known as primary dementia, and 
affects young people, as a rule under the age of thirty, is manifested by a self- 
absorbed stupid manner, and by what Browne describes as "a perplexed vacant 
expression." The movements of the patient are slow, and, like older dements, he 
assumes a position of utter dejection and rarely changes it. He may make move- 
ments of an automatic character when such are suggested to him. When his hands 
or feet are placed in a certain position they maintain that position with a sort of 
cataleptic fixation, though there is little or no rigidity. His hands are cold, and 
the heart's action is weak. When he does talk it is in a garrulous manner, and like 
the echolalic idiot he repeats the last phrase he may have heard, or one word over 
and over. 

The imbecile usually presents changes in appearance which are very marked. 
As possessors of inherited taint and the victims of early cerebral disease, we find 
defective development of various parts of the body, such as misshapen, though not 
necessarily atypical heads, evidences of early hydrocephalus, distorted and con- 
tracted limbs, the result of infantile paralysis, and secondary degeneration and 
atrophy. In many of these cases there are ocular defects and various errors of 
nutrition. The expression of the imbecile is repulsive in the extreme, and we find 
varying indications of intellectual change (Plate II.). As a rule, the countenance 
indicates a low order of brutality, the eyes are small, furtive, and cunning, and the 
movements are quick and cat-like. Imbeciles are often deaf and dumb, and panto- 
mime may be a striking feature. Tne facial asymmetry which often exists in the 
imbecile, and is due to early unilateral disease of the brain, is detected by drooping 
of one corner of the mouth, absence of one nasal fold, flatness of the nostril on the 
same side, and unevenness of the palpebral openings. It will be found also in 
many cases that the tongue is not protruded in a straight line, or is the seat of 
hemiatrophy, and there may be in connection with this a drooping of one arch 
of the palate, and a deviation of the uvula. Many imbeciles are epileptic, and 



TYPES OF IK SANITY. 5 

during examination may have attacks of petit mal, or localized spasms of various 
kinds. 

The appearance of the idiot is so familiar, even to the lay observer, that not 
much need be said on this subject. Nevertheless a word of caution may be given 
to those who are liable to confuse imbecility with a congenital condition of non- 
development, which is idiocy (Plate I.). The physical defects of the idiot are sym- 
metrical, and the defective development is always of a type which can be duplicated. 
The body is generally undersized, the arms are sometimes long and there is a general 
tendency to flexion. In low grades the head is, as a rule, much smaller than normal, 
and out of proportion to the size of the body ; the facial angle is often very great 
and the upper jaw has an advancing alveolar process, and may contain irregular and 
carious teeth, which usually protrude, presenting a rodent-like appearance. Cleft 
palate and other osseous defects are often suggestive accompaniments of deeper 
errors of development. The mouth of the idiot is usually large, the lips are thick, 
the eyes prominent and surmounted by bushy br>\vs; the hair is coarse and bristling 
and inclined in the centre to grow well over the forehead. The physiognomy of the 
idiot betrays a slight degree of intellectual activity, but usually emotional excite- 
ment of an inconstant kind is all that we find. The grimaces and facial contortions 
are exaggerated and, as a rule, are suggestive of pleasurable feelings ; or, on the 
contrary, we find passing express!, , us of rage or sorrow, which follow the most 
trivial provocations. So monkey-like is he in his behavior and motions that the 
diagnosis should never be dith'cult. In other cases of idiocy, not so pronounced, there 
i- little to indicate the mental condition except certain vacuity, which shows how 
inconsiderable is the interest, taken by the patient in things about him. Such 
patients are amiable and tractable, and the cranial atypy may be very slight. 

Among certain idiots there are certain physical peculiarities which are the 
reMilt of defective development of the lateral and posterior column of the spinal 
cord. Among them is spastic paralysis. The feet may present various deformities, 
there being talipes valgus, varus, or equinus. In cases of idiocy it is not rare to 
find supplementary fingers or toes. 

The iji in ral paretic manifests his disease more in disorders of motility than by 
any alteration in facial expression, if we may except the appearance of elation which 
accompanies the delusions of grandeur, or the flatness and immobility of the facial 
muscles, or the local pareses, which are "features of the stage of dementia. In the 
early stages we are furnished with tremulousness of the lips and tongue, and fibrillary 
tremor of the facial muscles, difference in the size of the pupils, drooping of the eye- 
brows, a staggering walk which does not exactly resemble that of any other form of 
spinal or cerebral disease, and which indicates rather an uneven expenditure of power 
than a loss of muscular strength. There may possibly be incoodination of the upper 
extremities in advanced cases. The patient, when lie attempts to speak, uses his lips 
and tongue in a way that is peculiar, and his speech is explosive; or shuffling, and 
this is especially noticeable when he uses words which contain many consonants. The 
manner of the paretic is especially pronounced, and he is fond of attracting the atten- 



6 TYPES OF INSANITY. 

tion of any one who will listen to his extravagant delusions, and rarely misses any 
opportunity of seeking notoriety. At a later stage of the disease he loses all his 
energy, and may present the appearance of an ordinary dement, there being, how- 
ever, in addition, the special motor troubles and the pupillary alteration. 

In the physical diagnosis of insanity it is well, especially in cases with well- 
marked history of heredity, previous mental trouble, or cerebral disease, to carefully 
examine the configuration of the head, to determine as nearly as possible the capacity 
of the cranium, the existence of evidences of premature closure of the fontanelles, 
and to look for marks of injuries, or syphilitic bone or aural disease. Measurements 
of the head may be taken by means of a flexible lead pipe or tape, which should be 
of sufficient thickness not to lose its shape when removed. When such moulds are 
made they should be fastened to a smooth board and carefully measured. 

For the purpose of measuring the facial angle we may avail ourselves of either 
of the instruments described by Broca in his work upon craniometry, or more simply 
by the use of "three ordinary rulers which may be joined by adjustable screws. 

Records should be kept of the bi-aural or transverse, circumferential, and 
antero-posterior measurements. If, however, there is reason to suspect irregularities, 
moulds may be taken in different regions and measurements compared. 

The head of the insane is more often abnormally long (dolio-ceplialic), but 
occasionally a short (or Iracliy-ceplialic) configuration is found. With one-sided 
atrophy it is not rare to find imbecility, and lead moulds should be taken at several 
points in such cases to determine the inequality. In cases of hemiatrophy of the 
brain dependent upon disease of early origin, unilateral bone atrophy frequently 
results. 

In our observations and craniometric investigations, we are to avoid the mistake 
of attaching too much importance to simple irregularity and distortion, for every 
hatter's collection will show that men of brightest intellect are possessors of heads 
of decidedly irregular shape. After all, we are to look for atypical crania, which 
are either disproportionate in size, or present facial angles so great as to suggest at 
once a small or undeveloped brain. 



CHAPTER II. 

CONDITION OF SPECIAL ORGANS: THE EYES, THE EARS, THE MOUTH 
AN'D TEETH, THE TONGUE, THE NOSE, ETC. 

THK eyes of tin* insane undergo changes which are often of the greatest importance, 
and should never be di>regarded in making an examination. We should take into 
ftOOOtmt, first, the condition f tlie pupils; second, the mobility of the eyeball ; and 
third, the condition of the fiindns by means of the ophthalmoscope. In melan- 
cholia, as a rule, tin? pupils are dilated and sluggish, while in mania, except in the 
active stages, they ar<- moderately contracted, or present no apparent change, and 
ivpond readily to tin- light. In epileptic insanity they are mobile and usually 
dilated, but this is by no means invariably the case. If both pupils are found to be 
much reduced in si/..-, and local reflex action is abolished or impaired, the condition 
is highly suggestive of the lir~t -tage of general paresis, or of complicating disease of 
the pons ; but care ..hould be taken not to mistake the contraction that is the result 
of opium, and which may !> a iVaturo of the insanity. Unequal dilatation of the 
pupils is of great significance, a< it is so common a feature of general paresis. Such 
unequal dilatation is by no means always confined to one side. Mickle found that 
pupil variation bear- a dceided relation to the changes in mental symptoms. In 
patients present ing alti-rnatin^ depression and elation, the condition of the pupils 
is alike in the two mental conditions. In several cases he saw they were dilated 
and sluggish, but differed slightly in size. He noted in the confirmed disease, in 
the stage following excitement and expansive delirium, that there was always a dif- 
ference ; at first the left pupil was usually the larger, and afterward the right. 
They were always irregular and sin . iiilt! in the quiet stage preceding extreme 

dementia the pupils were commonly small. He, as well as others, has noticed that 
after unilateral convulsions there is temporary dilation of one pupil. It would 
seem that the left pupil is more frequently dilated than the right, the pupillary 
changes, however, are not constant in their method of appearance. In cases of 
insanity of syphilitic origin we commonly find changes in the color of the iris and 
irregularity of the pupil, that suggest old iriti-. 

In cases of insanity directly traceable to coarse disease of the brain, there are to 
be discovered, as a result of paralysis of the various muscles moving the eyeball, a 
variety of visual defects, the most important of which is diplopia or double vision. 



TYPES OF INSANITY. 

Paralysis of the third nerve results in ptosis, dilatation of the pupil, immobility 
of the eye, except in the outward direction, followed by divergent squint, and crossed 
diplopia, which is produced when the patient is directed to look at an object held 
in front, above, or on the side opposite the affected eye ; he will then see two images, 
one above, below, or at the side of the other. If the patient be directed to hold 
his hand over the sound eye, and he is told to touch a specified object in front 
of him, he is utterly unable to do so and is apt to become dizzy. Of course, it is 
rare to find complete paralysis of all the fibres of the third nerve and the appear- 
ance of all these symptoms conjointly. Paresis of the internal rectus causes 
the patient to look toward the other side, in order to overcome the diplopia ; a 
divergent squint results with crossed diplopia, the lateral distance between the 
true and false image widening as the object is moved in the direction of the sound 
side, away from the affected eye. With this form of paresis, when the object is 
held obliquely upward and inward, the images will be divergent above, that of the 
affected eye inclining to the opposite side. With the reverse position the images 
will converge above, that perceived by the affected eye inclining toward the im- 
paired side. Paresis of the external rectus is symptomatized by homonymous diplopia. 
When the object is placed directly in front of the affected eye, at a distance perhaps 
of five feet, no diplopia exists ; but when moved laterally so that the paralyzed 
muscle cannot be exerted to bring the eyeball to follow it, homonymous diplopia 
results the patient turning his head toward the affected side. 

Paresis of the superior rectus is manifested by a diplopia shown in the upper 
half of the visual field. The patient holds his head backward so that the objects 
may be brought into the lower half of the field. If the sound eye is covered and the 
patient is told to place his finger upon a certain object, he will invariably shoot above 
the mark. Paresis of the inferior rectus gives rise to diplopia opposite to that of 
the last named variety. Paresis of the superior oblique, is difficult to diagnose, 
because of its slight character. Objects below the horizontal median line appear to 
be double and irregular, while above no diplopia whatever is produced. In the 
double vision that occurs with this form of paresis the images appear at different 
distances from the patient, that seen by the affected eye being nearer to him. 

Limited space will not permit me to go into this subject as fully as I could wish, 
and I will refer the reader to Avorks on ophthalmology, where he will find much that 
relates to the mechanical defects of the motor apparatus of the eyeball. Tests 
should be applied in all cases of organic insanity, especially when there are visual 
hallucinations. In syphilitic insanity ocular paralyses are common and early 
manifestations, and in idiocy and imbecility various motor defects of this kind are 
to be found. 

The ophthalmoscope has been used extensively as a diagnostic agent in deter- 
mining the existence of organic insanity, but, so far, the appearances found differ 
widely. 

Optic neuritis with atrophy of both kinds have been discovered in the eyes of 
general paretics, dements, and the subjects of epileptic insanity. In general paresis 



TYPES OF INSANITY. 9 

t lu-re is a progressive neuritis, which passes into a peculiar atrophic condition, 
observed by Loring and others. 

Enlarged veins, shrivelled arteries, and choked disk may be detected in one or 
both eyes of the insane, and it is not rare to find atrophy of the disk associated with 
mcoordination, pains of the lower extremities, and other symptoms of associated 
spinal trouble. 

In many cases of mental disease no impairment of the visual power is associated 
with neuritis. Ophthalmoscopic appearances have been found in acute and chronic 
dementia, idiocy, imbecility, and syphilitic insanity, but rarely, if ever, in simple mel- 
ancholia or mania. One of the first symptoms of atrophy of the optic nerve is im- 
pairment of the color sense. The failure is met with most frequently in dementia, 
hysterical insanity, and general paresis, and,' among men, more often in the latter dis- 
ease. The power of seeing red and green is lost first, as a rule, and afterward the 
other colors. To apply the color test, the examiner should supply himself with a 
number of skeins of different-colored worsted, which the patient? are asked to match. 
Hemiopia is an occasional feature of insanity, depending on gross cerebral disease ; 
consequently it is more common in secondary dementia, general paresis, and syphilitic 
insanity than in other psychoses. In addition to the defects mentioned, we. may find 
clonic spasms of the orbicular muscles (nystagmus), diseases of the lids, and a ten- 
dency to lachrymation; and this latter is a very common accompaniment of dementia. 
In examining the eyes of the insane we are furnished with diagnostic suggestions of 
the greatest value. Especially true is this with regard to expression. Buckuill and 
Tuke lay strips upon the absence of expression of the eyes in the delirium of fevers, 
in contradistinction to the intensity which exists in mania ; and they call attention, 
on the other hand, to the prominence of the eyeball and the bloodshot appearance 
which characterizes the excitement dependent upon cerebral meningitis. In mania 
there is simply an intensification of emotional expression. 

The " insane ear" or otlieotoma, which has been described by a number of 
observers, is probably the result primarily of trophic disorder, and may arise from a 
slight injury or some such trivial exciting cause. The auricles become the seat of 
violent inflammatory process, which goes on to suppuration and may entail a con- 
siderable destruction of tissue. 

The appearance of the ear in the acute stages of such inflammation is quite 
striking. It becomes hot, engorged with blood, and swollen to an extraordinary 
degree, so that the normal folds and indentations are lost in the general tumefaction, 
and there is closure of the external meatus. The affected ear is exquisitely painful, 
the patient shrinking from the slightest touch. It is not long before there is an in- 
crease in the violence of the inflammatory process and the formation of one or more 
abscesses, which, if not opened, burst and discharge a large quantity of bloody pus 
(Fig. 1, Plate X.). An abscess may sometimes form behind the ear. Extensive 
separation of the cartilage from the other tissues often occurs from burrowing of the 
pus, and when reparative process takes place a conspicuous deformity remains, due 
to contraction, so that the affected ear is shrivelled, creuated, and often flattened 



10 TYPES OF INSANITY. 

(Fig. 2, Plate X.). The " insane ear " may be of slow origin, and the result of a 
low inflammatory process, or it may arise in a single night. It is common in cold 
weather, and may follow exposure to cold or pressure. This condition is sometimes 
met with in people who are not insane, and is considered by some authors to be very 
rare and a different affection, but I can see no difference, considering the pathologi- 
cal condition in both to be a perichondritis. 

An appearance of the ear is occasionally met with which is misleading, and 
should not be confounded with that of the disease under consideration. I allude to 
the deformity produced by insane patients who constantly pull their ears (Fig. 3, 
Plate X.). Not only do we find elongation of the lobule, but ulceration and diffused 
redness as well. In certain cases of congenital insanity the auricles may be either 
abnormally large, pointed at their extremities, and stand out prominently, or else 
they are unusually small and flat. 

The mouth undergoes changes in configuration which have much to do with the 
insane physiognomy, and is perhaps the most expressive organ, with the exception of 
the eyes, in the portrayal of mental variations. Its appearance in repose and in ex- 
citement should be noted, and the coloring and formation of the lips should be like- 
wise. In certain forms of insanity the latter are tumefied and often dry and cracked. 
The buccal mucous membrane is pale and sometimes insensitive. The tonicity of the 
oral muscles undergoes considerable diminution, especially in such forms of chronic 
insanity as dementia and general paresis. In the former it is common to find a 
drooping of the lower lip, and in advanced cases, there is inability to prevent the 
escape of saliva, entirely independent of the patient's mental disregard of its accu- 
mulation. There may be a paretic condition, which manifests itself in unevenness of 
the mouth. In general paresis there is tremor of the lips, which is especially notice- 
able when they are slightly parted, or when the attempt is made to speak, and seems 
to be increased by the effort of the patient to control it. 

The tongue also trembles in general paresis, and when protruded is not only 
agitated by vermicular movements but is suddenly retracted. We also find this 
tremor in chronic alcoholism, but it is coarser and is not associated with the pecu- 
liar speech defects of the former disease. In varieties of insanity due to organic dis- 
ease it is not unusual to find that the tongue, when protruded, points to one or the 
other side, or that it is impossible for the patient to bring the tip in contact with the 
roof of the mouth. The tongues of certain idiots and cretins are unusually large and 
swollen, of pale color and decidedly flabby. The appearance of the tongue in insan- 
ity as an index of various bodily states is also of great importance, as melancholia 
and diseases of like character are connected with digestive disorders, especially of an 
hepatic nature, and it will be found that this organ is iisually coated with a heavy 
white or brown fur, and the breath is foul. In acute mania we may expect to find a 
red and glazed tongue. Various peculiarities in the appearance of the teeth are found 
among idiots, as well sometimes as among those who are of the " insane neurosis " or 
temperament. Figs. 4, 5, 6, Plate X., show these abnormalities quite fully. The two 
upper drawings show the teeth of idiot boys, the lower those of the lower jaw of 



TYPES OF INSANITY. 11 

an imbecile with inherited syphilis. It will be seen in many of these cases that the 
iiu-isors and canines are of a peculiar shape. They are sharp, cracked at the corners, 
crowded together, and irregular. In certain rare cases it is possible to find two rows 
of teeth in each jaw, one set being the permanent and the other the milk teeth, 
which emerge at different points. A tusk-like development is frequently found (Fig. 
4, Plate X.), and it is not rare to find a large canine or incisor jutting out from the 
anterior surface of the alveolar process. 

The nose, according to Honing, in shape and appearance undergoes noteworthy 
changes, which he regards as important. We should therefore note the condition of 
the nostrils, whether they are distended or compressed, together or singly, and their 
mobility. 

Evidence of general malnutrition is .the rule in the early steps of all forms of 
mental disease, and may arise from insufficient food, many patients refusing to eat, or 
from the constant wear and tear incident to excessive excitement. When dementia 
follows chronic insanity it is quite usual for the patient to become much improved 
in apj>earance. In fact, the sudden increase in si/.e and improvement in the color 
of the skin of ten h-ads the friends of patients to believe in a great improvement, while, 
011 the contrary, this change is one that makes the prognosis bad. 



CHAPTER III. 

CONDITION OF THE BODILY FUNCTIONS: THE CIRCULATION, TEMPERA- 
TURE, AND PULSE VARIATIONS OF THE SKIN AND ITS APPEND- 
AGESMUSCULAR TONUS THE REFLEXES, SENSIBILITY THE URIN- 
ARY SECRETION, MENSTRUATION, ETC. 

THERE are temperature and pulse variations in insanity which are valuable evidences 
of structural changes. These should be studied in every case if possible by means 
of surface and deep thermometers, and by the sphygmograph. The asthenic mental 
disorders which are grouped under the head of melancholia are usually attended by 
lowered surface and deep temperature, and in dementia the same condition of affairs 
is found to exist. In all forms of insanity attended by slowness of muscular move- 
ment this diminution of temperature is notable. The surface circiilation is extremely 
sluggish, and it is with difficulty that the extremities are flushed or made warmer by 
energetic rubbing. When bulbar symptoms are present, a unilateral lowering is by 
no means uncommon. In alternating insanity (folie circulaire), or melancholia at- 
tended by transitory attacks of excitement, there is often a sudden rise of temperature 
with the beginning of the irritability. In general paresis the elevation is constant and 
important, even in the melancholic stage toward the latter part of the day, and is 
most decided during the first and last stage of the disease. In the first stage, how- 
ever, the increase is connected with the maniacal attacks, in the second stage it is 
lowered, but rises again in the third stage. The increase in temperature continues 
with the excitement, and a very great and sudden increase of the body-heat is a fore- 
runner of death. In mania the elevation is very conspicuous, and bears a direct rela- 
tion to the muscular irritability and restlessness. In the mania of debility, the tem- 
perature may continue two or three degrees higher than normal for some days. In 
phthisical insanity there is an evening rise, which is attended by flushing and disten- 
tion of the temporal vessels. 

In puerperal insanity there is a primary elevation with quite small pulse. In 
patients suffering from insomnia, and who are violent, there is often a rise of two 
degrees at night. Macleod believes this to be the rule in all cases where there are 
destructive tendencies. As in various other diseases, an important point to have in 
mind is the difference between the morning and evening temperature. 

In all forms of insanity the intercurrent complications are marked by sudden 



TYPES OF INSANITY. 



13 



and conspicuous variations of temperature ; bed-sores and typhoid states are evinced 
b\ increased body heat, and in convulsive seizures, which may occur from time to 
time, the temperature is higher. After an attack of hemiplegia, whether following 
an epileptiform discharge or not, we find an increase of heat upon the paralyzed 
side. The surface-temperature is increased in mania, and the head, especially, is 
hot, while in some cases it is possible to detect local elevation of temperature. The 
sphyginograph in atonic conditions shows indications of lowered arterial tension. 
The tracings in melancholia vary, but are usually of an asthenic character. In 
complicated cases with cardiac hypertrophy the pulse is rapid, hard, and gives a 
tracing in which the first event is exaggerated and the diastolic line is marked by 
the absence of valvular breaks. In other forms of melancholia the heart impulse is 
\\i-ak, the tracing is almost straight, broken, only by a feeble systolic elevation and 
tremulous valvular indentation. 

The following are tracings taken by Pond's sphygmograph at the New York 
City Asylum for the Male Insane : 



General Paresis. Hiirht Radial Pulse; 78. 
(Most common.) 



ral Paresis. Right Radial Pulse; 70. 



General Paresis. Right Radial Pulse; 76, 



General Paresis. Right Radial Pulse; 96, 



Acute Melancholia. Right Radial Pulse; 
84. 



General Paresis, Maniacal Stage. Right 
Radial Pulse; 128. 




TYPES OF INSANITY. 



Acute Mania. Right Radial Pulse; 82. 





General Paresis, Maniacal Stage; 78. 



Absolute indications cannot be relied upon as the result of sphygmographic 
examination. There are general characteristics that are of great significance, and 
for this reason a number of tracings should always be taken. 

In chrome and advanced insanity, the pulse is soft and compressible, and especi- 
ally is this the case in melancholia. In diseases of this kind, circulation is exceed- 
ino-ly defective, and we find venous stasis in distal parts. As a result, it is found 
that inconsiderable injuries or exposure to cold, which in ordinary persons would 
have little effect, are apt to give rise to slowly healing wounds and sloughing. 
Chilblains are common, among demented patients especially, and dry gangrene is by 
no means uncommon, not only in old but in young people as well. 

In some cases of asthenic insanity the pulse is found to be abnormally slow. 

Heart disease has been found to exist in connection with nearly every form of 
insanity, and Berman has found that thirty-six per cent, of five hundred patients 
who died at the West Riding Asylum presented evidences of cardiac disease. We 
should, therefore, be on the outlook not only for cardiac murmurs, but for the signs 
of hypertrophy of the left ventricle. The cases in which we find heart- com plications 
most frequently are those of melancholia, impulsive insanity, and among patients 
who are sullen, morose, and suspicious. In general paresis the second aortic sound is 
accentuated, which is also the case in mania. In both of these diseases we find 
increased arterial tension, and it is advisable always to use the sphygmograph. In 
many cases of secondary dementia obstruction murmurs are to be detected. 

The condition of the akin and its appendages is worthy of study. The cutaneous 
surface is usually dry, harsh, and presents evidences of malnutrition. In rare instances 
there is profuse sweating, notably in acute mania, but the action of the sweat, 
glands is feeble. In some forms of disease, acne, herpes, and certain bullous eruptions 
play a crisogenic part and disappear after each exacerbation. Moles and staining are 
frequently a feature of chronic insanity, especially among women, and changes in the 
hair are also found, and have been commented on by various authors. In mania the 
hair is peculiarly coarse and bristling and with every attack of excitement it becomes 
erect or crinkly. In some patients I have looked upon this as a prodromic sign of a 
developing attack of violence, and I have found such to be the case. In melancholia 
it is in appearance sodden and limp, and rarely curls. In many insane people prema- 
ture or uneven blanching of hair occurs. In cases of hysterical insanity and in chronic 



TYPES OF INSANITY. 15 

infinity in women, there is a tendency to the appearance of hair upon the face upon 
the upper lip and chin especially, the growth amounting to a beard in some cases. 

There is occasionally found among children of weak mind a puffing or pseudo- 
' edema of the skin, which is associated with atrophy of the thyroid gland, and spots of 
staining. The face, in particular, is swollen and the lips and tongue are thick and 
enlarged. The voice is munled and harsh and speech is slow. This condition is known 
as orttintfm, and is quite rare in England and in this country. Of several hundred 
idiots I have examined, I have found but one case. 

The electric eaooitabiUty of muscles is not often affected. In a series of carefully 
made experiments, Lowe was unable to find any diminution in mania, but in general 
paresis and organic forms of disease, there was much loss of excitability. In even 
the tir>t and second stages of general pan-si* no lowered reaction was found, but in 
the last stage he. found that both in the arms and legs the muscular response to fara- 

dlC excitement was considerably lowered. 

The activity of the ten Jin >"'- r< fJ> ./ depends very much upon the form and stage 
of insanity. In uncomplicated mania and melancholia it is rarely affected, but in all 
affections where there are symptoms indicative of affection of the posterior columns 
of the spinal cord it will be found to lie diminished. In secondary degeneration of 
the lateral column, the patellar reflex is ..)' coiir>e exaggerated. In general paresis it 
may be normal or alent, depending of course upon the lesion. 

I Norder> of m.itility an- occasionally present among the insane. The existence 
of tine tibrillary tremor is a common indication, especially in chroni< insanity. It 
may t.e noticed in the face particularly, and a vermicular contraction may be detected 
up'.n close examination or by lightly striking the face. Allusion has already been 
made to the di-ordcrs of motilitv so conspicuous in general paresis. The tremor of 
alcoholism is of a different character, effecting the hands and lower extremities as 
well, and is ii-nally connected \\ith anesthesia ; besides, it is more active in the 
early part of the day. In organic disease with mental symptoms we find various 
irrades of tremor and paralysis, which depend upon the region of cerebral substance 
involved. The gait of the insane is sometimes a valuable indication of the form of 
insanity. In general paresis the walk of the patient is uncertain and unsteady, and a 
true defect of coordination causes him to advance with widely spread feet and 
a tottering method of propulsion. In various forms of dementia there is a shuffling 
gait due to loss of power, and in second.^ \ dementia we find quite often an old hemi- 
ple^'ia and its embarrassments. 

8tH9Ofy *i/iiij>tninx are usually of an uunthettc character, and vary greatly. In 
melancholia tin-re is sometimes ; i general cutaneous anaesthesia of a profound nature, and 
in general pare>is the same- state of affairs is found, but most marked in the last stage 
of the disease, when, besides diffused loss of sensibility, there may be anaesthesia of 
the fauces and larynx. It is often difficult to determine the state of sensibility, owing 
to the mental obtuseness of the patient and his perverted perception. In rare forms 
of hysterical insanity there is pronounced hemiamesthesia, with color-blindness upon 
one side. In dementia the loss of cutaneous .sensibility is markedly lowered, and 



16 TYPES OF INSANITY. 

severe injuries or burns give rise to little complaint. The electric sensibility is occa- 
sionally increased in general paresis. 

.Loss of smell and taste are met with in general paresis, during the last stage. 

In chronic alcoholism, hemiamesthesia, with anaesthesia of mucous membranes has 
been pointed out. With this there is color-blindness in the anaesthetic eye. In this 
organ the cornea is insensitive and may be touched without annoyance to the patient. 

Invohmtary discharges of urine and f wees may occur at various times in the course 
of mental disease. In mania the patient is so occupied with his delusions that he is 
apt to void the contents of his bowels and bladder, while in melancholia, according 
to Luys, there is a certain anaesthesia of the lining membrane of the intestines which 
prevents the patient from perceiving the distention of the lower gut by substances 
accumulating therein, and finally there is a mechanical escape. In dementia and 
advanced insanity, actual paresis of the sphincter prevents retention of the contents 
of the rectum -and bladder. 

In many cases of commencing insanity I have observed that it is common for 
female patients to void their urine, even though they are perfectly conscious of their 
weakness. In early melancholia and in hypochondriasis constipation is the rule. 

Examination of the urine of the insane shows that there are great variations 
both in the amount and in the component parts. In melancholia, and in conditions 
attended by slow organic changes, the quantity of urine is greatly diminished and 
the proportion of urea and chlorides excreted is diminished. 

In conditions of excitement in mania, in the expansive stages of general paresis, 
the reverse is true, and in melancholia with excitement it is not rare to find abun- 
dant urine. In mania the quantity of urine may be very small. 

Merson, Beale, Sutherland, and Lindsay have found that there is a plus amount 
of the phosphates in the urine in acute mania, while, in the stage of exhaustion in 
mania, the third stage of general paresis, and in the feeble stage of acute dementia 
they are reduced. The presence of albumen in the urine of the insane is occasionally 
found, especially in puerperal insanity, when the mental excitement often appears 
and disappears with the presence or absence of this substance. In the urine of gen- 
eral paretics it is often found, and in epileptic insanity it may be detected after the 
paroxysm. 

The appearance of sugar in the urine may be determined sometimes in cases 
in which excessive thirst is a feature, and in which slight maniacal outbreaks follow 
inconsiderable excitation. I have frequently found it in the urine of paretics. 1 

In certain general paretics the urine presents an excess of alkaline carbonates. 

In all cases of insanity it is well to inquire into the condition of the menstrual 
functions. Not only is insanity, as Falret and Esquirol have pointed out, very 
often caused by uterine and ovarian disorders, but there is a very important variation 
in the function of menstruation. Idiots and cretins menstruate very scantily or not 

1 In the light of Magrian's theory of the origin of the disease in the fourth ventricle, this circum- 
stance is an additional confirmation of the pathological and experimental production of diabetes. 



TYPES OF INSANITY. 17 

at all, and puberty is delayed. In disorders of the asthenic type there may be 
amenorrhoea, though, so far as my experience goes, the development of the insanity 
has been preceded by excessive, protracted, and debilitating flowing. In mania and 
other conditions of excitement there is greater mental disturbance at the catanienial 
period ; and attacks of epilepsy, when they have been a feature of the insanity, are 
apt to be more numerous and violent at this time. It is a well-known fact that forms 
of sexual mental disorder are much aggravated by menstrual disorder, and with any 
abnormality the patient is inclined to indulge in disgusting practices and foul con- 
versation. 

Sutherland holds that general paralytics undergo change of life much earlier 
than other women. 

In certain varieties of insanity, especially in the early stage of general paresis, 
there is an excitement of the genital function, which manifests itself, besides lewd 
behavior, in frequent erections, masturkitiun, and ungovernable lust. Luys reports 
the case of a young man who indulged during the day in masturbation whenever lie 
recounted his hallucination of the women who followed him, soliciting him to have 
intercourse with them during the night. In dementia the tendency to masturbation 
is often constant, and it is found necessary to provide tight-fitting clothing in one 
piece, with sleeves sewed down to the sides, but even then the patient often manages 
to gratify his ilrsire. 

In nymphomania the behavior of the patient is perhaps more conspicuous than 
in the satyriasis of the male patient. 

The salivary secretion is commonly increased, and in dementia very decidedly 
so. With accumulation the patient is apt to make what Luys calls " automatic 
attempts " to eject it, expectorating forcibly, with some degree of regularity (Plate 
VII.). 

The breath and bodily odor of the insane are often very unpleasant, and by 
some authors the former is supposed to be aa characteristic in its way as that eman- 
ating from the small-pox patient. 



CHAPTER IV. 

EXAMINATION OF PATIENT CHANGES IN DRESS AND PERSONAL 
HABITS, ETC. THE HANDWRITING OF THE INSANE. 

IT is never wise to gain access to your patient by means of any ruse, and it is prefer- 
able that the medical man should appear before him in his own true character. The 
object of an examining physician is not to extort communications from the patient 
by misrepresentation or deceit, for in such cases the avowals of the alleged insane per- 
son are falsely based, and his motives are declared under a false impression. If the 
examiner has not siifficient tact to draw out the person whose sanity is doubted, he 
had better deputize some one else to do the work. It is only in the rarest cases, when 
the patient is violent and threatens actual harm to every one, that subterfuge is to be 
resorted to. Go to your patient, then, as you would to any other, and engage him, if 
possible, in conversation. If the occasion offers itself, ask him in relation to his feel- 
ings regarding his immediate family, business associates, and friends. His religious 
beliefs, if any, should be inquired into, and the possibility of any change in sentiments 
discussed. If there are morbid ideas, which show themselves in a disregard of the 
present or a dread of the future, it will be well to follow up the line of examination 
and ascertain the possibility of suicide or contemplated violence. If he has imaginary 
enemies it may be well to inquire who they are. 

His business capacity and plans for the future are important considerations. He 
should be asked as to the extent of his holdings, both of personal property and real 
estate, and of his ability to perform certain duties. He should be put through certain 
tasks, regarding his competency to execute business instruments and deeds if occasion 
arises. His memory should be tested both as to recent and remote events, and any 
speech defects, aphasic or ataxic, noted. His handwriting should be examined and 
compared with specimens of older dates. Moral changes in the demeanor of the patient 
are important. With slight promptings the insane person will often indulge in 
salacious outbursts, and especially is this the case in hysterical insanity and general 
paresis of the insane. Peculiarities in dress, habit, and mode of life, as well as the 
changes already described, should be investigated. 

After getting as much as possible from the patient himself, his friends as many 
as possible should be interrogated regarding his behavior and the truth or falsity of 
certain communications he may have made. Hereditary disease, bad habits, and 



TYPES OF INSANITY. 19 

other factors of disease should be also noted. After due care, an'd repeated inter- 
views if necessary, the physician may safely state an opinion, but he should never do 
so hurriedly or without deliberation. 

A most important duty is the taking of memoranda, which should be kept for 
possible litigation that may arise. 

In entering the house or room of the suspected lunatic, the physician should 
observe any peculiar or eccentric arrangement of furniture or decoration, for the 
patient is apt to surround himself with unnecessary objects, or to cover his walls 
with gaudy trash. In itself this tendency may amount to nothing more than 
harmless eccentricity, which has always existed, but when it is a new thing, and in 
contrast to the person's previous tastes, it will be found to be the result commonly of 
some delusion. The person with a delusion of grandeur will provide himself with 
worthless imitations of royalty, the insane woman who believes herself to be the wife 
of the President will cover the walls of her room with woodcuts of that dignitary 
from illustrated papers, or the young woman who becomes a subject of melancholia 
is apt to surround herself by a multitude of pictures of saints and martyrs and by 
relics and religious emblems. 

An important indication of the deep-seated character of certain delusions in 
chronic insanity is manifested in laborious yet useless industry, shown in the manu- 
facture of certain peculiar objects with which the patient is surrounded. One man 
with whom I am familiar has spent several'years in the preparation of a curious 
astrological apparatus, constructed of refuse material and rags found about the 
a-ylum, while others have been diligently occupied in the manufacture of flying 
machine*, and other objects requiring great time and labor in their construction. We 
may often find in the books read by the subjects of impending insanity pencilled 
comments and additions which show the drift of their minds. The value of these 
methods of expression cannot be too highly eatiin&tecL 

An early and conspicuous indication of mental disorder is the change in per- 
sonal attire made by the patient Gaudy finery, " loud " colors, and peculiarly made 
clothing take the place of quiet dress. Bright and glittering gew-gaws are affixed to 
various parts of the hat, coat, or dress, and buttons, pieces of looking-glass, feathers, 
and gay pieces of colored rag are pressed into service (Plate VI.). This fondness 
for self-adornment is found among maniacs, dements, general paretics, melancholies, 
imbeciles, and idiots, and in such patients is connected with delusions of grandeur 
and excessive self-satisfaction. 

ft >.-./' 'jurtl of appearance an<l -untidiness in dress are early and suggestive 
-vmptoms of insanity, both of melancholia and mania. The ordinarily neat and 
well-dressed person may neglect his razor and comb, and become slovenly, dirty, 
and careless; on the other hand, we sometimes observe an extraordinary neatness 
and personal cleanliness quite at variance with the patient's former habits. Many 
insane believe that they are contaminated by some foul substance, and therefore 
will frequently wash their hands or cleanse themselves in different ways. 

It is not unusual for the insane person to remove all clothing either as a result 



20 



TYPES OF INSANITY. 



of the seeming discomfort which their contact produces, or as a result of some 
delusion. In violent cases, and in many subjects where chronicity is being estab- 
lished, we find great destructiveness. They will not only tear their ordinary cloth- 
ing into strips, but will destroy the coarsest and strongest fabrics. 

Much stress is laid upon the peculiarities which are found in the handwriting of 
the insane, and there can be no doubt that it possesses much that is interesting from 
a diagnostic point of view. In nearly every case a departure from the normal 
mental state is displayed by change, not only in the method of written expression, 
but in the chirography itself. This is especially noticeable in general paresis, and if 
a series of letters be compared, it will be found that the more recent present various 
irregularities. Certain words are imperfectly ended, their terminal letters being 



V 




absent, or they are extended in a scrawl, while at a later stage of the disease we find 
the omission not only of syllables, but of whole words ; and in the. letters of persons 
of precise habit before the development of mental trouble, it is rare to find an " i " 
dotted or a " t " crossed after the disease has made its appearance. At a later 
stage it is impossible to decipher anything that the patient may write. 

One of the peculiarities of the letters of the insane consists in the use of illus- 
trative diagrams, keys of explanation, and strangely coined words, and in forms of 
mental disease syrnptomatized by religious exaltation there are constant suggestions 
of the delusions of the individual, which are shown in maps and plans in which 
figure astronomical and theological symbols. In some cases there is a veritable 
cacoetlies scribendi, which is a feature in many maniacal patients. We find exacer- 
bations of this form of mental trouble are preceded by vigorous letter- writing. The 



TYPES OF INSANITY. 



21 






L>2 TYPES OF INSANITY. 

first example is a specimen of tbe handwriting of a young woman suffering from 
acute mania, who spent entire days in. scribbling like rubbish, and inditing numerous 
letters to persons she did not know. In her case, and in many others, it will be 
found that there is a disposition to use capital letters to an extraordinary degree and 
to cross-write, so much sometimes as to destroy legibility. In passing judgment 
upon the letters of doubtful cases of insanity, we must carefully read them through, 
bearing in mind that with the insane any sustained effort is impossible, and it is prob- 
able that in a long letter we shall find some manifestation of disordered mental action 
before the end is reached. The specimens xipon the preceding page are examples of 
penmanship written by three general paretics, in different stages of the disease. 

In some cases we have but little difficulty in making a diagnosis by the letter 
alone, because of the striking incoherency, which the individual may restrain in con- 
versation but which he indulges in when left to himself ; and in suspected cases, 
where patients are on their guard, it is well to ask them to write a letter. 

In medico-legal questions one should not be too ready to express an opinion 
upon any document or letter that may be put in evidence, for ordinary bodily weak- 
ness may give rise to a tremulousness in the handwriting, and it will not do to make 
a hasty diagnosis upon this feature of a document. In other cases legal instruments 
may be presented to the expert witness for his opinion where there are intermissions 
and interlineations. Care must therefore be exercised in taking into account the 
pertinency of the interlineations and the presence of marginal notes and corrections. 



CHAPTER V. 



THE COMMITMENT OF THE INSANE ABSTRACT OF THE LAWS OF THE 

VARIOUS STATES. 

TIIK laws of the different States regarding the commitment of lunatics vary greatly. 
In all cases, however, judicial endorsement is imperative, and iu the State of New 
York it is necessary that the certificate of the examining physicians shall be 
approved liy the judge of a court of record. In other parts of the country the 
formalities are more or less rigid, and in Canada a lunatic who is not dangerous may 
be received into an asylum by the approval of the superintendent Besides the legal 
-teps to !. taken by the friends of the insane person, there are various local regula- 
tions pertaining to the asylums themselves. It is always necessary to give bonds, or 
to show that the alleged lunatic is without means, and proper blanks are prepared 
for the pur|x>se. When such is the case, the pauper lunatic may be committed and 
eared for, after representation lias been made to ft local police magistrate or to the 
officers of the poor. In ,Y< //' York City the lunatic may lie placed under arrest, and 
he is then tran-fenvd to a jail for examination by the medical officers of the Depart- 
ment of Public Charities and Correction. 

It is necessary, when the patient is sent to a pay asylum, for two physicians to 
be appointed examining physicians. The JVew York laws are as follows: 

SECTION 1. No person shall be committed to or confined as a patient in any 
asylum, public or private, or in any institution, home, or retreat, for the care and 
treatment of the insane, except upon the certificate of two physicians, under oath, 
setting forth the insanity of such person. But no person shall be held in confine- 
ment in any such asylum, for more than five days, unless within that time such cer- 
tificate be approved by a judge or justice of a court of record of the county or dis- 
trict in which the alleged lunatic resides, and said judge or justice may institute 
inquiry and take proofs as to any alleged lunacy before approving or disapproving 
of such certificate, and said judge or justice may, in his discretion, call a jury in 
each case to determine the question of lunacy. 

SEC. 2. It shall not be lawful for any physician to certify to the insanity of any 
person for the purpose of securing his commitment to an asylum, unless said phy- 
sician be of reputable character, a graduate of some incorporated medical college, a 



21 TYPES OF INSANITY. 

permanent resident of the State, and shall have been in the actual practise of his pro- 
fession for at least three years, and such qualifications shall be certified to by a judge 
of any court of record. No certificate of insanity shall be made except after a per- 
sonal examination of the party alleged to be insane, and according to forms prescribed 
by the State Commissioner in Lunacy, and every such certificate shall bear date of 
not more than ten days prior to such commitment. 

SEC. 3. It shall not be lawful for any physician to certify to the insanity of 
any person for the purpose of committing him to an asylum of which the said phy- 
sician is either the superintendent, proprietor, an officer, or a regular professional 
attendant therein. 

In the State of Maine the certificates of at least two respectable physicians are 
necessary. Sections 16 and 17 of the revised statutes, 143, 11, 12. 

SECTION 16. Parents and guardians of insane minors, if of sufficient ability to 
support them there, within thirty days of an attack of insanity, without any legal 
examination, shall send them to the hospital, and give the treasurer thereof the bond 
required, or to some other hospital for the insane. 

SEC. 17. All insane persons, not thus sent to any hospital, shall be subject to 
examination as hereinafter provided. The municipal officers of towns shall consti- 
tute a board of examiners, and, on complaint in writing of any relative, or justice 
of the peace of their town, they shall immediately inquire into the condition of any 
insane person therein, call before them all testimony necessary for a full understand- 
ing of the case, and if they think such person is insane, and that his comfort 
and safety, and that of others interested, will be thereby promoted, they shall 
forthwith send him to the hospital with a certificate stating the fact of his insanity, 
and the town in which he resided, or was found at the time of examination, and 
directing the superintendent to receive and detain him till he is restored or discharged 
by law, or by the superintendent and trustees. And they shall keep a record of their 
doings, and furnish a copy to any interested person requesting and paying for it. 

The Vermont laws, approved November 28, 1882, are as follows : 

SECTION 1. Section 2906 of the revised laws is hereby amended so as to read 
as follows : 

No person, except as hereinafter provided, shall be admitted to, or detained in 
an insane asylum, as a patient or inmate, except upon the certificate of such person's 
insanity, stating their reasons for adjudging such person insane, made by two phy- 
sicians of unquestioned integrity and skill residing in the probate district in which 
such insane person resides, or, if such insane person is not a resident of the State, in 
the probate district in which the asylum is situated ; or, if such insane person is a 
convict in the State prison or House of Correction, such physicians may be residents 
of the probate district in which such place of confinement is situated. And the two 



TYPES OF INSANITY. 25 

physicians making such certificate shall not be members of the same firm and neither 
shall be an officer of an insane asylum in this State. 

SEC. 2. The next friend or relative of a person whose insanity is certified to, as 
above provided, may appeal from the decision of the physicians so certifying him to 
be insane to the supervisors of the insane, which appeal shall be noted on the certifi- 
cate. The supervisors shall, when such appeal is taken, forthwith examine the case, 
and if, in their opinion, there was not sufficient ground for making such certificate, they 
shall avoid the certificate, otherwise they shall endorse their approval upon it. Such 
examination by the supervisors shall be had in the town where the appellant resides. 

SEC. 3. When the next friend or relative of such a person takes an appeal, as 
above provided, he shall not be received in an insane asylum while the appeal is 
pending before the supervisors. And a trustee, or other officer, or employee of an 
iii-aii'- asylum who receives or detains a person in such asvlnm whose insanity is not 
attested by a legal certificate which has not been appealed from or by a certificate 
duly approved by the super visors on appeal, shall be imprisoned in the State prison 
not more than three years. 

SEC. 4. Idiots and persons no// <-r>tn/>x, who are not dangerous, shall not be 
confined in any asylum for the insane. And if any such persons are so confined, the 
supervisors of the insane shall cause them to be discharged. 

The Neio //< '////<.>// //r laws provide (Sees. 12, 13, 18) : 



SECTION 12. If any insane person is in such condition as to render it dangerous 
that he should be at large, the Judge of Probate upon petition by any person, and 
sueh notice to the selectmen of the town in which such insane person is, or to his 
guardian, or to any other person, as he may order, which petition may be filed, notice 
issued, and a hearing had in vacation or otherwise may commit such insane person 
to the asylum. 

8 . 13. If any insane person is confined in any jail, the Supreme Court may 
order him to be committed to the asylum, if they think it expedient. 

. 18. No person shall be committed to the asylum for the insane, except 
by order of the court, or the Judge of Probate, without the certificate of two reputa- 
ble physicians that such person is insane, given after a personal examination made 
within one week of committal ; and su< n certificate shall be accompanied by a certifi- 
cate from a judge of the Supreme Court, or Court of Probate, or mayor, or chairman 
of the selectmen, testifying to the genuineness of the signatures, and the respecta- 
bility of the signers. 

The more important laws regarding the commitment of the insane in Massa- 
chusetts, are appended : 

SECTION 11. A judge of the Supreme Judicial Court or Superior Court, in any 
county, where he may be, and a judge of the Probate Court, or of a Police, District, or 



26 TYPES OF INSANITY. 

Municipal Court, within his county, may commit to either of the State lunatic hos- 
pitals any insane person, then residing or being in said county, who in his opinion is 
a proper subject for its treatment or custody. 

SEC. 12. Except when otherwise specially provided, no person shall be com- 
mitted to a lunatic hospital, asylum, or other receptacle for the insane, public or 
private, without an order or certificate therefor, signed by one of the judges named 
in the preceding section, said person residing or being within the county as therein 
provided. Such order or certificate shall state that the judge finds the person com- 
mitted is insane, and is a fit person for treatment in an insane asylum. And the said 
judge shall see and examine the person alleged to be insane, or state in his final 
order the reason why it was not deemed necessary or advisable to do so. The hear- 
ing, except when a jury is summoned, shall be at such place as the judge shall 
appoint. In all cases, the judge shall certify in what place the lunatic resided at the 
time of his , commitment ; or if confinement is ordered by a court, the judge shall 
certify in what place the lunatic resided at the time of the arrest, in pursuance of 
which he was held to answer before such court ; and such certificate shall, for the 
preceding section, be conclusive evidence of his residence. 

SEC. 13. No person shall be so committed, unless in addition to the oral testi- 
mony there has been filed with the judge a certificate signed by two physicians, each 
of whom is a graduate of some legally organized medical college, and has practised 
three years in the State, and neither of whom is connected with any hospital or other 
establishment for treatment of the insane. Each must have personally examined the 
person alleged to be insane within five days of signing the certificate ; and each shall 
certify that in his opinion said person is insane and a proper subject for treatment in 
an insane hospital ; and shall specify the facts on which his opinion is founded. A 
copy of the certificate, attested by the judge, shall be delivered by the officer or other 
person making the commitment, to the superintendent of the hospital or other place 
of commitment, and shall be filed and kept with the order. 

SEC. 14. A person applying for the commitment or for the admission of a luna- 
tic to a State lunatic hospital, under the provisions of this chapter, shall first give 
notice in writing to the mayor, or one or more of the selectmen of the place where 
the lunatic resides, of his intention to make such application ; and satisfactory evi- 
dence that such notice has been given shall be produced to the judge in cases of 
commitment. 

SEC. 15. Upon every application for the commitment or admission of an insane 
person to a hospital or asylum for the insane, there shall be filed with the applica- 
tion, or within ten days after the commitment or admission, a statement in respect to 
such person, showing, as nearly as can be ascertained, his age, birthplace, civil condi- 
tion, and occupation ; the supposed cause and the duration and character of his 
disease, whether mild, violent, dangerous, homicidal, suicidal, paralytic, or epileptic ; 
the previous or present existence of insanity in the person or his family ; his habits 
in regard to temperance ; whether he has been in any lunatic hospital, and if so, what 
one, when, and how long ; and, if the patient is a woman, whether she has borne 



TYPES OF INSANITY. 27 

children, and, if so, what time has elapsed since the birth of the youngest; the names 
and address of his father, mother, children, brothers, sisters, or other next of kin, not 
exceeding ten in number, and over eighteen years of age, when the names and address 
of such relatives are known by the person or persons making such application, to- 
gether with any facts showing whether he has or has not a settlement, and if he has 
a settlement, in what place ; and if the applicant is unable to state any of the above 
particulars, he shall state his inability to do so. The statement, or a copy thereof, 
shall be transmitted to the superintendent of the hospital or asylum, to be filed with 
the order of commitment, or the application for admission. The superintendent shall, 
within two days from the time of the admission or commitment of an insane person, 
send, or cause to be sent, notice of said commitment in writing, by mail, postage pre- 
paid, to each of said relatives, and to any other two persons whom the person com- 
mitted shall designate. 

.16. After hearing such other evidence as he may deem proper, the judge 
niav issue a warrant for the apprehension and bringing before him of the alleged 
lunatic, if in his judgment the condition or conduct of such person renders it neces- 
sary or proper to do so. Such warrant may be directed to and be served by a private 
person named in said warrant, as well as by a qualified officer ; and pending examin- 
at ion and hearing, such order may be made concerning the care, custody, or confine- 
ment of such alleged lunatic as the judge shall see fit. 

SEC. 17. The judge may, in his discretion, issue a warrant to the sheriff, or his 
deputy, directing him to summon a jury of six lawful men, to hear and determine 
whether the alleged lunatic is insane. 

In the State of Rhode Island patients may be committed upon the order of a 
justice's court or one of the justices of the Supreme Court, or by a guardian, or by 
relatives and friends, upon the certificate of two practising physicians of good 
standing. 

All have unrestricted communication with two commissioners appointed by the 
Legislature and are visited weekly by a committee of the trustees. 

According to the Connecticut laws of 1869 : 

SECTION 1. Any lunatic or distracted person may be placed in a hospital, asylum, 
or retreat for the insane, or other suitable place of detention, either public or pri- 
vate, by his or her legal guardian, or relatives or friends in case of no guardian; 
but in no case without the certificate of one or more reputable physicians, after a 
personal examination made within one week of the date thereof, which certificate 
shall b<- duly acknowledged before some magistrate or other officer authorized to 
administer oaths, or to take the acknowledgment of deeds in the State where given, 
who shall certify to the genuineness of the signature, and to the respectability of the 
signer. 



28 TYPES OF INSANITY. 

\ 

The laws of New Jersey regulating the protection and admission of the insane 
to asylums are quite numerous. Section 17 of the laws of 1875-76 is as follows: 

And be it enacted, That no person shall be admitted into said asylum as a 
patient except upon an order of some court or judge authorized to send patients, 
without lodging with the superintendent first, a request, under the hand of the 
person by whose direction he is sent, stating his age and place of nativity, if known, 
his Christian name and surname, place of residence, occupation, and degree of rela- 
tionship or other circumstance of connection between him and the person requesting 
his admission ; and, second, a certificate dated within one month, under oath signed 
by a respectable physician, of the fact of his being insane ; each person signing such 
request or certificate shall annex his profession or occupation and the county and 
State of his residence, unless these facts appear on the face of the document. 

In Pennsylvania the laws of 18(59 thus provide for the incarceration of patients : 

Insane persons may be placed in a hospital for the insane by their legal guar- 
dians, or by their relatives or friends in case they have no guardians, but never with- 
out the certificate of two or more reputable physicians, after a personal examination 
made within one week of the date thereof, and this certificate to be duly acknowl- 
edged and sworn to, or affirmed before some magistrate or judicial officer, who shall 
certify to the genuineness of the signatures and to the responsibility of the signers. 

The law of Virginia requires, in order to commit a person to an asylum, that 
the suspected person must be brought before a commission in lunacy, called for the 
purpose, consisting of three (3) magistrates of the city or county in which he resides, 
and that they shall summon the family physician and other witnesses, to make a 
thorough examination of the case. If after a careful investigation the person is 
adjudged insane, he is sent to an asylum, with a record of the examination, and the 
superintendent is required to admit him, if there is a vacancy. The law does not 
contemplate the admission of the insane of other States. 

In Maryland a patient may be committed upon the certificate of one physician. 
At the Mount Hope Asylum two certificates are required. 

In North Carolina, sections 13 and 14 of the laws of 1881, thus provide : 

SECTION 13. The judges of the Superior Courts, in their respective districts, 
shall allow to be committed to the asylum, as a patient, any person who may be con- 
fined in jail on a criminal charge of any kind, or degree, or upon a peace warrant, 
whenever .the judge shall be satisfied, by a verdict of jury of inquisition, that the 
alleged criminal act was committed while such person was insane. 

SEC. 14. For admission into the asylum in other cases the following proceed- 



TYPES OF INSANITY. 29 

ings shall be had : Some respectable citizen, residing in the county of the alleged 
ill-am- j>erson, shall make before and file with a justice of the peace of the county 
an affidavit in writing. 

In Mississippi the insane person may be committed by a "lunacy inquiry," 
requiring six jurors, or, a-s is usually the case, he may be received in an asylum, upon 
the certificate of two physicians, who shall swear before a justice or a county clerk. 

\i\AlnlxiiiKi tli- indigent insane are received in the State Asylum on certificate 
<f the Probate Judges of their respective counties, attested by one respectable 
physician and other witnesses, with or without a jury, as the judge may decide. 

Paying patients are received on certificate of one respectable physician, accom- 
panied by tlir usual bond to secure payment of board. 

Tin- la\\s <>f (J/n'tt in relation to the care of the insane are quite voluminous. 
Th- Revised Statutes thus provide: 

i ION 7i)i>. Fur the admission of patients to any of the asylums for the insane, 
the following proceedings shall be had : Some resident citizen of the proper county 
shall tile with the Probate Judge of such county an affidavit as follows: 

Till B OK < MlIO, - -COUNTY, 88: 

, the undersigned, a citizen of - County, Ohio, being 

sworn, says that he belies is insane (or, that, in consequence of his 

in-anity. iiis l>eing at large is dangerous to the community). He has a legal settle- 
ment in - township, in this County. 

hat. .1 this - day of - , A. D. - . 



SBC. 703. When the affidavit is filled, the Probate Judge shall forthwith issue 
his warrant to some suitable person, commanding him to bring the person alleged to 
be insane before him, on >i day therein named, which shall not be more than five 
days after the affidavit has been filed, and shall immediately issue subpoenas for 
siieh witnesses as he deems necessary (one of whom shall be a respectable physician), 
commanding the persons in such subjm-iias named to appear before the judge on the 
return day of the warrant: and if any person disputes the insanity of the party 
charged, the Probate Judge shall issue subpoenas for such person or persons as are 
demanded <>n behalf of the person alleged to be insane; provided, that if, by reason 
of the character of the affliction or insanity of said person, it is deemed unsuitable or 
improper i" bring the ]>erson into such Probate Court, then the Probate Judge shall 

nally visit said ]>erson and certify that he has so ascertained the condition of 
the per-on by actual inspection, and all proceedings as herein required may then be 
had in the absence of such person. 

SEC. 704. At the time appointed (unless for good cause the investigation is 



30 TYPES OF INSANITY. 

adjourned) the judge shall proceed to examine the witnesses in attendance ; and if, 
upon the hearing of the testimony, he is satisfied that the person so charged is 
insane, he shall cause a certificate to be made out by the medical witness in attend- 
ance, which shall set forth the following. (Here follows a list of questions relating 
to the patient's symptoms which are to be found in the certificate.) 

SEC. 705. The Probate Judge, upon receiving the certificate of the medical 
witness, made out according to the provisions of the preceding section, shall forth- 
with apply to the superintendent of the asylum for the insane situated in the dis- 
trict in which such patient resides ; he shall, at the same time, transmit copies, under 
his official seal, of the certificate of the medical witness, and of his finding in the 
case ; upon receiving the application and certificate the superintendent shall imme- 
diately advise the Probate Judge whether the patient can be received, and, if so, at 
what time; the Probate Judge, when, advised that the patient will be received, shall 
forthwith issue his warrant to the sheriff, or any other suitable person, commanding 
him to forthwith take charge of and convey such insane person to the asylum; if the 
Probate Judge is satisfied from proof that an assistant is necessary he may appoint 
one person as such assistant. The warrant of the Probate Judge shall be substan- 
tially as follows: 



THE STATE OF OHIO, - - COUNTY, ss. 
OFFICE OF THE PROUATE JUDGE OF SAID COUNTY. 



To 



All the proceedings prescribed by law to entitle - to be admitted 

into the asylum for the insane having been had, you are commanded forthwith to 
take charge of and convey said - to the asylum for the insane at 

, and you are authorized to take - as assistant; after exe- 

cuting this warrant, you will make due return thereof to this office. 

Witness my hand and official seal this day of , A.D., . 



Prolate Judge. 

Upon receiving such patient the superintendent shall indorse upon the warrant 
a receipt substantially as follows : 

ASYLUM FOE THE INSANE, AT - , 

-, A.D., 



Received this day, of - , the patient named in the within warrant. 



Superintendent. 

This warrant, with the receipt of the superintendent thereon, shall be returned 
to the Probate Judge who issued it, and shall be filed by him with the other papers 
relating to the case. In all cases the relatives of the insane person shall have a right, 
if they choose, to convey such insane person to the asylum for the insane, and in such 
case the warrant shall be directed to one of such relatives, directing him to take 






TYPES OF INSANITY. 31 

another of the relatives as his assistant. If the medical witness does not state in his 
certificate that the patient is free from all infectious diseases and from vermin, the 
Probate Judge shall refuse to make the application to the superintendent, as herein 
provided, until such certificate is furnished. The relatives of any person charged 
with insanity, or who is found to be insane, shall, in all cases, have the right to take 
charge of and keep such insane person charged with insanity, if they desire so to do ; 
and in such case the Probate Judge before whom the inquest has been held shall 
deliver such insane person to them. 

The insane of Indiana are committed by two magistrates, who are required to 
visit the alleged lunatic in person and report to the clerk of County Court, who sub- 
poenas witnesses and sends a certified copy of proceedings to Superintendent of State 
Hospital, requesting admission. 

Chapter 85, Revised Statutes of 1874 of the State of Illinois, contains the fol- 
lowing provisions for the commitment of the insane : 

" That upon the petition of a near relative of the suspected person, or any re- 
spectable person in the county, made to a judge of the County Court, the latter may 
diivrt the clerk to issue a writ directed t<> tin- sheriff or person having in custody 
the alleged lunatic, to bring before him the person ; and the clerk is furthermore 
<liivc't-'l to issue the necessary subpn'iias for witnesses. A jury of six persons, one 
of whom shall be n physician, shall be empanelled to try the case. The case shall 
be tried in the presence of the alleged lunatic, who shall 1-c entitled to the benefit of 
counsel. The jury shall return a written and signed verdict. If it be that the 
person is declared insane a committal is to be made out by the clerk, who sluill 
confer with the superintendent, and a warrant shall be issued and directed to the 
sheriff, or in preference, the relatives of the insane person. The court may make an 
ord'-r to temporarily commit any person. 

The law of Michigan which concerns the commitment of the insane is ;is follows : 

SECTION 26. When a person in indigent circumstances, and not a pauper, becomes 
insane, application may be made in his behalf to the Probate Judge of the county 
where he resides ; and said Probate Judge shall call two respectable physicians, and 
other credible witnesses, and also immediately notify the prosecuting attorney of his 
county and the supervisor of the township or ward in which such insane person re- 
sides, of the time and place of meeting, whose duty it shall be to attend the examin- 
ation and act in behalf of said county ; and said Probate Judge shall fully investi- 
gate the facts in the case, and either with or without the verdict of a jury, at his 
lU'Tetion, as to question of insanity, shall decide the case as to his indigence, but the 
decision as to indi^etu-e shall not be conclusive in such county; and if the Probate 
Judge certifies that satisfactory proof has been adduced, showing him insane, and his 



32 TYPES OF INSANITY. 

estate is insufficient to support him and his family, or, if he has no family, himself, 
under the visitation of insanity, on his certificate, under the seal of the Probate 
Court of said county, he shall be admitted into the asylum and supported there at 
the expense of the county to which he belongs until he shall be restored to soundness 
of mind, if affected in two years, and until otherwise ordered. The Judge of Pro- 
bate in such cases shall have power to compel the attendance of Avitnesses and jurors, 
and shall file the certificates of physicians, taken under oath, and other papers, in his 
office, and enter the proper order in his (the) journal of the Probate Court in his 
office. ' The Judge of Probate shall report the result of his proceedings to the super- 
visors of his county, if such person belongs to that county, whose duty it shall be, at 
the next annual meeting thereafter, to raise money requisite to meet the expenses of 
support accordingly. 



In Kentucky the insane are committed by the inquest of a jury and by order of 
court, their presence in open court being required, unless, upon the affidavit of two 
respectable physicians, it is shown that it would be dangerous to bring the supposed 
lunatic into court. 

In Iowa, I am informed by Dr. Hill, the modus operandi of commitment is the 
following : 

A practising physician, a practising lawyer, appointed by the Circuit Judge, 
who usually continue in office during good behavior, and the clerk of the courts, 
constitute the commissioners of insanity. The physician on the commission, or the 
family physician, goes to the home of the patient, often without informing him why 
he is there, and obtains answers to questions in the " Return of Physician." Then 
the commissioners meet and decide whether the person is insane, and whether to send 
him to the hospital. " If they shall be of opinion, from such preliminary inquiries 
as .they may make . . . that such a course would probably be injurious to 
such person or attended with no advantage, they may dispense with such presence." 
Two blanks are filed with the superintendent and one with the clerk of the court. 

The insane has a right to appeal to court within ten days, a right to appeal 
to court once in six months thereafter, as well as the right to habeas corpus. They 
may be discharged from an asylum by the visiting committee. 

The laws relating to the care of the Insane in Wisconsin are quite simple. 
Lunatics are committed only by the County Judge. The alleged insane person, or any 
person acting in his behalf, can request a jury trial, in which case it must be accorded. 
If tried by jury, the judge is authorized to clear the court of all persons except those 
immediately interested. If the person is found insane, he is regularly committed by 
order of the court and under its seal. 

In this State, as well as in some others, the physicians who examine the patient 
are required to answer a long list of questions relating to the circumstances of the 
patient, the history of the disease, his habits, heredity, etc. 



TYPES OF INSANITY. 33 

In Minnesota, according to the laws of 1874, Sec. 134, and 1877, Sec, 75, p. 123 : 

Patients, how committed. The Probate Judge, or in his absence the court coin- 
misMoner of any county, upon information being filed before him that there is an in- 
sane person in his county needing care and treatment, shall thereupon make an order 
appointing some regular physician or physicians (not less than one or more than 
three) to examine the said person, t<> a-certain the fact of insanity, a certified copy of 
\vliich ordt-r shall be delivered to said physician or physicians, and shall proceed to the 
hearing of such information, and shall hear and examine the proofs of said informa- 
tion, and if the said person is found to be insane, he shall, upon the written certificate 
of the examining physician or physicians, "that the said person in his or their 
opinion is insane and a proper subject for hospital treatment," said certificate being 
verified by the oath of the phvsieianor physicians, issue duplicate warrants committing 
the |>er8on so found insane to the care of the superintendent of the hospital, and shall 
place the warrant in the hands of some friend or other suitable person, whom he 
shall authorize to convey the said insane per-oii to the hospital. 

In MiMOuri there is a State law, and in St. Louis then- is H separate local regu- 
lation governing the commitment of the insane. 

The municipal law of is*!' is thus worded: 

m 

SKCTION 1. Ordinance Dumber 11,668. It shall be the duty of the police of the 

of St Louis, if any lunatic, idiot, or person of unsound mind, who is a resident of 
tin- city of St. Loui-. be foiuid by them within the limits of the city of St. Louis, in 
such condition as to endanger the lives or property of themaelvee "i - "f others, or who 
are unprotected by guardians or friends and without means, to take Midi person into 
en-tody and <_'ive notice thereof forthwith to the Chief of Police, who shall immedi- 
ately notify the Health Commissioner that such person i-~ in his custody, and in said 
notice he shall give the Health CommiaMOlMr the name, a ire, place of residence, length 
of residence in the city, occupation when known, the locality where person was ar- 
rested, circumstances causing tlie ane-t, and all other information he may have or can 
obtain in relation to said person. The Health Commissioner, on receipt of such report 
from the Chief of Police, shall <-ani an examination to lie made of such person by 
one or more physicians of the Health Department. If upon such examination such 

in is found to l>e of unsound mind and an unfit person to be at large, the physi- 
cian making such examination ^\\- t \\\ certify >uch fact to the Health Commissioner, 
whose duty it shall then be to take charge of such lunatic, idiot, or insane person and 
place such person in the insane asylum of the city >{ St. Louis, and to report to the 

d of Health his action thereon, and all facts and information regarding Midi 
lunatic, idiot, or in-ane person in his possession, or that may come into his possession ; 
but if the physician making such examination shall certify to the Health Commis- 
sioner that the person or persons reported by the Chief of Police as lunatic, idiot, or 
insane person be not of unsound mind or an idiot, and in his opinion not a h\ subject 



34 TYPES OF INSANITY. 

for treatment ill an insane asylum, the Health Commissioner shall give notice of the 
fact to the Chief of Police, and shall not receive such person from his custody. If, 
however, the physician or physicians examining such person should certify to the 
Health Commissioner that such person be a fit subject for hospital treatment, then 
the Health Commissioner shall place such person in one of the hospitals of the city. 

Whenever any lunatic, idiot, or person of unsound mind may be arrested by the 
police of the city of St. Louis, and is found to be a non-resident of the City of St. 
Louis, the Health Commissioner shall report the facts to the Mayor, who shall, if lie 
thinks proper, order the Chief of Police to cause such persons to be returned to the 
locality to which they belong, and all expenses attending the return of such person 
shall be borne by the city of St. Louis, but if the Mayor is of the opinion that it is 
not practicable to return such person, then the person shall be disposed of as provided 
in Section 1 of this article." 

In Arkansas the recent laws for the commitment of the insane provide : 

" SECTION 2. Whenever it shall appear that any person entitled to admission to the 
State Lunatic Asylum is- insane, any reputable citizen of the State may file a written 
statement with the County and Probate Judge of the county in which such supposed 
insane person may reside. 

" SEC. 3. Any County and Probate Judge with whom a citizen's statement may 
have been filed, as set forth in Section 2 of this Act, shall appoint a time, as soon 
thereafter as may be practicable for hearing, and at such time appointed shall pro- 
ceed to hear the testimony of such competent witnesses as may be produced at such 
hearing, and in addition to the testimony of such witnesses, shall cause such alleged 
insane person to be examined by one or more regular practising physicians of good 
standing, who shall present in writing to such County and Probate Judge a sworn 
statement of the result of his or their examination, including the following interroga- 
tories, with their answers as part of the same." 

(Here folloAv a number of interrogatories relating to the patient's antecedents, 
present condition, etc., which may be found in the blank certificate.) 

In Texas the insane person is committed by a jury of six, a charge of lunacy 
having first been brought before the County Court. Witnesses are subpoenaed, and 
upon a verdict of lunacy the person is deprived of his liberty. 

The law of California necessitates that application shall be made to a Judge of 
the Supreme Court by the friends of the patient. That after the presentation of a 
certificate of examination, signed by at least two physicians of good standing, the 
judge shall sign an order of commitment, which also provides for the appointment of 
a guardian ; as in some other States, a number of interrogatories are included in the 
medical certificate. 



TYPES OF IXSAXITY. 35 

For the Napa State Asylum the following laws were passed in 1876 : 

SECTION 18. No case of idiocy, imbecility, harmless, chronic, mental unsoundness, 
or acute mania a potu, shall be committed to this asylum, and whenever in the opinion 
of the resident physician, after a careful examination of the case of any person com- 
mitted, it shall be satisfactorily ascertained by him that the party has been unlaw- 
fully committed, and that he or she comes under the rule of exemptions provided for 
in this section, he shall have the authority to discharge such person so unlawfully com- 
mitted, and return him or her to the county from which committed, at the expense of 
such county. 

SEC. 19. The judge shall inquire into the ability of insane persons committed by 
him to the asylum to bear the actual charges and expenses for the time that such per- 
son may remain in the asylum. In case an inline person, committed to the asylum 
under the provisions of this Act, shall !> pOBeeased of real or personal property suffi- 
cient to pay such charges and expenses, the judge shall appoint a guardian for such 
person, who shall be subject to all the provisions of the general laws of this State in 
relation to guardians, as far as the same are applicable ; and when there is not suffi- 
cient money in the hands of the guardian, the judge may order a sale of property of 
such insane person, or as much thereof as may be necessary, and from the proceeds of 
such sale the guardian shall pay to the Board of Trustees the sum fixed upon by them 
f.-idi month quarterly in advance for tlie maintenance of such ward ; and he also shall, 
out of the proceeds of such sale, or such other fund as he may have belonging to such 
ward, pav for -uch clothing as the resident physician shall, from time to time, furnish 
such in-ane pel-son; and he shall give a bond, with good and sufficient sureties, pay- 
able to the Board of Trustees, and approved by the judge, for the faithful perform- 
ance of tip- duties required df him by this Act, as long as the property of his insane 
ward is -iilHeient for the purpose. Indigent insane persons having kindred of degree 
(if husband or wife, father, mother, or children, living within this State of sufficient 
ability, said kindred shall support such insane persons to the extent prescribed for 
paying patients. 

SEC. 20. Non-residents of this State, conveyed or coming herein while insane, 
shall not be committed to or supported in the Napa State Asylum for the Insane; 
but this prohibition shall not prevent the commitment to and temporary care in said 
asylum of persons stricken with insanity while travelling or temporarily sojourning 
in the State ; or sailors attacked with insanity upon the high seas, and first arriving 
thereafter in some port within this State. 

In O/;-,/on a complaint must be made by two householders to the County Judge. 
The patient will be examined under supervision of the County Judge assisted by the 
District Attorney and two physicians, upon whose certificate (if found to be insane) 
the patient will be sent to the asylum. One copy of the commitment is sent to asy- 
lum, one copy retained in county from which patient is sent, and one copy transmit- 
to Secretary of State. 



36 TYPES OF INSANITY. 

I am indebted to Dr. J. M. Wallace for the following abstract of the Canadian 
laws: 

There are two methods of committing insane persons to an asylum in Ontario. 
The ordinary process, and by warrant of the Lieutenant-Governor of the province. 
The lunatic is committed to jail as a dangerous lunatic, and is kept there until he is 
examined by the County Judge and two physicians, who each certify that he is insane 
and dangerous to be at large. The certificates and other commitment papers are for- 
warded to the Provincial Secretary, who is a member of the Government ; he ad- 
vises the Lieutenant-Governor to issue a warrant for the transfer of the lunatic from 
the jail to an asylum. By the ordinary process, application for admission is made to 
the Medical Superintendent by the friends of the lunatic ; blank forms are sent out 
to be filled, and when returned and found satisfactory, the Medical Superintendent 
sends an order for the admission of the patient. 



PLATE I 

IDIOCY. 



J. R , aged forty-three, is a case well known in the literature of psychi- 
atry. He weighs 72 jKnmds, is of short stature (4 feet 7i inches), and his 
head is perhaps one of the smallest reported in this country. The circumference 
from a point in front one inch above the root of the nose, to one at the level of 
the occipital protuberance behind is 15 indie-. The bi-aural arc measurement is 
8 inches, and the antero-posterior arc is 8 inches. This is over a thick growth of 
short coarse hair, and at least an inch difference must exist between the true 
measurements and those made. His teeth are nearly all gone and he has a 
'louble cataract. His general health is good and he is well nourished. His 
intelligence is almost nil He has been taught to swear, and can say a few 
words without any idea of their import. He is good-tempered and easily 
amused. His left ear is the seat of old inflammatory contraction, and is much 
deformed. 



PLATE II. 

IMBECILITY. 



A. B , aged twenty-five. Received in the asylum two years before his 

death, which occurred last year (1882). 

!! had a very slirill voice, and was quite excitable, crying and laughing 
without cause. He was in the habit of collecting bits of paper and straw which 
In- chewed, and kept a supply in his shoes and socks. He was sometimes so 
violent as to need restraint and was quite offensive in his habits. For some 
months previous to death he suffered from Bright's disease, from which he 
ultimately died. 



PLATE III. 

MELANCHOLIA. ATTONITA. 



C. C- , aged thirty-seven. Duration of insanity seven months. Cause 
unknown. Auditory hallucinations. She hears voices commanding her not to 
eat, and it is often necessary to feed her with the tube. She has delusions of 
persecution. Her movements are sluggish, and she assumes fixed attitudes. 
There is rarely any play of facial expression and she takes no notice of those 
about her. 



PLATE IV. 

CHRONIC 



II.H been melancholic for some years, and the disease' is drifting 
into li-iin-ntia. 



PLATE V. 

SUB^CUTE MA.JSH.A.. 



1 E , aged twenty -eight Duration of insanity six years. Originally 

acnt.- mania of a violent type. Cause unknown. Auditory hallucinations. She 
ha- r,)iniiHinication with divine personages, and delusion*: of grandeur, believing 
that --he is Queen of Ireland, and is the kinswoman of every one about her. 
Sin- is remarkably obscene and alludes to her carnal relations, which are of a 
peculiar kind, and -lie i- incoherent and loquacious. Her hair is coarse and 
becomes l.ri-tling and erect when she is excited. 



PLATE VI 

CHRONIC 



J. B , aged fifty-one, lias been in the Ward's Island Asylum eleven 

years. No history of cause. lie is incoherent and excitable, but quite tractable. 
Di-< 'lainis his proper name, and has delusions that his bones are all broken and 
his head smashed. Is clownish in his behavior,, and sings at the top of his 
voice. !!' is f'i!nl i>f decorating himself with rubbish and dirty finery. 



PLATE VII. 

DEMENTIA. 



A. W , aged forty-tour. Duration of insanity four years. Cause intem- 
perance. Her dementia was tin- .-c<[iiel of acute melancholia, She has Lad 
visual hallucinations, and lias seen spectres ami other frightful things. She 
has had suicidal tendencies, and has heard voices which told her to destroy 
herself. Her violence has been remarkable. She has now (March, 1883) lapsed 
into a condition of dementia attended by ^n-at rotl.-ssness and violence. It. is 

ary to keep her strapped iu the chair. Her habits are of the filthiest 
kind, and she needs constant attention. There is a constant accumulation of 
saliva which she ejects with violenc-', there being the automatic expectoration 
alluded to by some writers. She betrays no indication of the mental operations 
except in her appearance. 



PLATE VIII. 

DEMENTIA. 



-, aged thirty-six. There is a strong family history of insanity, 
five of his uncles being insane. He is profoundly demented, and is dirty, stupid, 
and careless. His disease has lasted nineteen years, and followed melancholia. 



PLATE IX. 



J. McK , aged thirty-seven. He has been in the asylum two years. 
Tin-re is no known cause of the disease. He has had delusions of wealth, but 
is n<>\\ demented and stuj>id. 



PLATE X. 



Fig. 1. Acute otheotoma : a, the opening into an abscess. It will be 
notic<-<! tliat tliere are several small holes about the large opening, and from 
til-'---. ;t-i well as the latter, a quantity of sanious pus escapes. Fig. 2 sli<>\\* 
the result of a previous subacute inflammation. Fig. 3. Elongation after pulling. 

. 4, 5. Defective irregular teeth in i<li<>;--. I-'i-. (',. Syphilitic teeth. 



PLATE I. 





HAMILTON'S TYPES OF INSANITY. 



PLATE II 




V 



HAMILTON'S TYPES OF INSANITY. 



PLATE III. 




r". 




HAMILTON'S TYPES OF INSANITY. 



PLATE IV. 




. 















HAMILTON'S TYPES OF INSANITY. 



PLATE V, 




-'- . 














HAMILTON'S TYPES OF INSANITY. 



PLATE VI. 







HAMILTON'S TYPES OF INSANITY. 



PLATE VII. 





HAMILTON'S TYPES OF INSANITV. 



PLATE VIII. 










HAMILTON'S TYPES OF INSANITY. 



V 




PLATE IX. 












HAMILTON'S TYPES OF INSANITY. 



PLATE X. 

(See text for reference.) 



r.i* 









' ' 



I I. 




\ 



\ 






], ::. 




f 




i... ti. 






HAMILTON'S TYPES OF INSANITY.