this city. She was then in a state of great exaltation, and the choreic movements were at their height. Two persons were necessary to keep her in bed, as, on the least relaxation of their vigilance, she would attempt to leave the room, and once had tried to get out of the window. She was talking at the top of her voice, but this was not high, as exhaustion was rapidly advancing, and she was then very weak, but, though she spoke distinctly enough, there was nothing but a string of disconnected words without the slightest relation to each other. At times she would close her eyes, as if about to sleep, but instantly would start up, frightened, and would begin to talk apparently with the object of saying something in regard to her hallucinations, but with the same utterance of unrelated words.

Conceiving the case to be one requiring prompt treatment, I put her under the anæsthetic influence of ether, with the effect of quieting both her mental and physical manifestations, and procuring for her the first good sleep she had had for several days. By means of the hypodermic administration of morphia and arsenic, she made a good recovery in about three weeks.

In another case, occurring in a young lady of this city, whom I saw in consultation with the late Dr. Henschel, violent chorea, with maniacal manifestations similar to those of the case just cited, was developed by the excitement consequent on a visit to the dentist. In this instance, a like means was successful in immediately quieting the patient, who ultimately recovered under the use of arsenic and bromide of sodium.

In connection with choreic insanity, there are very generally pain in the head, frequent attacks of vertigo, acceleration of pulse, and increased bodily temperature.

There are other alleged constitutional forms of insanity, but they are not included here, for the reason given on page 292. It is very well to speak of alcoholic insanity, malarial insanity, syphilitic insanity, and so on for a dozen or so more, but all these are simply instances of insanity of different types produced by alcohol, malaria, etc. It would be just as proper to regard traumatic insanity as a separate form of mental alienation, though it is well known that any of the varieties of insanity may have wounds and injuries for. its exciting causes.

CHAPTER IX.

THE CAUSES OF INSANITY.

PREDISPOSING CAUSES.-The causes of insanity have been to a great extent considered in the earlier chapters of this work, so that it will not be necessary to do more in the present connection than to apply the principles there laid down, and to bring forward such other factors as are proper in illustration of the subject. Thus, under the heads of Habit, Temperament, Idiosyncrasy, Constitution, Sex, Race, Age, the influence of these agencies in producing mental derangement have been sufficiently dwelt upon, but there are a few others of what may be called the predisposing causes that require some consideration at this time.

Civil Condition. The civil condition, as regards marriage or celibacy, is important in its etiological relations to insanity. The statistics of all civilized countries show a larger proportion of lunatics among those who are unmarried than among those who are married. In France, according to Dagonet,' there is one insane person to every 528 celibates over the age of fifteen, while among those who are married the proportion falls to one in 1,523. In large cities, the proportion of single women who become lunatics is greater than in single men. In the widowed, the proportion is one to 942.

Of 1,426 patients admitted into the Colney Hatch Asylum, England, during four years, the proportion was about equal,' but then, as the married persons in England and Wales, according to the census of 1871, are more than twice as numerous as the single persons, it follows that the proportion of lunatics existing among single persons is about double that among the married.

Most of the asylum reports of this country show like results. Taking one of the latest, that of the Illinois Eastern Hospital for the Insane at Kankakee, we find that of 424 patients admitted during the years 1881-'83, 209 were single, 152 married, 29 were widowed, 17 divorced or separated, and of 17 the civil condition was unknown.

Upon this point there is a general accord among writers on psychological medicine.

Bucknill and Tukes's "Manual of Psychological Medicine," London, 1879,

Civilization. It is the generally received opinion that insanity is much more common among civilized nations than among those who are lower in the scale of enlightenment. It is difficult to arrive at any very exact conclusion in regard to this point. In the first place, as nations advance in intelligence and refinement, the insane are more readily recognized than they are among barbarous and savage peoples, or even than they were among ourselves a few years ago. Not long since no one was regarded as insane who was not either a jabbering idiot or a raving maniac. The individual who, under the influence of a morbid impulse which he could not resist, killed some one, was held to be responsible, and was punished accordingly. Such forms as morbid impulses, and many others, were not known. The individual who acted in accordance with them was supposed to have been "moved and instigated by the devil," and in all probability went to the stake for allowing himself to be subdued by satanic power. To say, therefore, that the number of the insane has increased with the advance of civilization is in reality only alleging that more insane are known to exist than formerly; and another factor in adding to the number is the increased facility for discovering instances of mental derangement, owing to the development of the means for intercommunication.

Again, though additional influences capable of causing insanity are probably furnished by a higher state of civilization, it must not be forgotten, on the other hand, that many influences due to a low degree of civilization have been eliminated. People are better fed, clothed, and housed than they were two or three hundred years ago. And, again, among barbarous or savage nations, or those persons among civilized peoples whose minds are not developed up to a high standard, slight causes which would be of no effect in persons of educated minds are often influential in causing insanity. An ignorant person will, therefore, become insane from the action of a cause that would scarcely ruffle the equanimity of an educated individual.

But, whatever value is to be attached to these suggestions, the fact remains undisputed that there are more known cases of insanity at the present day than there were, for instance, fifty years ago. According to Marcé, the proportion of lunaties to the population was in Europe, in 1836, one to 3,080, while, in 1851, fifteen years later, it was one to 1,676, not far

from double. Lunier states that the rate has in France progressively advanced. A part of this increase is undoubtedly due to increase of population, but, making all reasonable allowance for this circumstance, there is still a large margin left.

It has been stated, but I do not know whether or not on satisfactory evidence, that since the abolition of slavery in the United States the number of the insane among the negroes has very greatly increased.

Cities. Large collections of people in one place certainly tend to the increase in the number of the insane. The larger the city, and the more the inhabitants are crowded together, the greater, other things being equal, will be the number of the insane.

EXCITING CAUSES.-The exciting causes are those which stand to the disease as its immediate producers. They are very numerous, and the influence of some that are generally considered to be strong factors in giving rise to insanity is very questionable.

Emotional Causes.-These are undoubtedly the most efficient of all the exciting causes of insanity. Their action is generally prompt and easily recognizable. Chief among them is anxiety, which, however, is more frequently a secondary emotion than one of primary action. A person, for instance, becomes insane, it is supposed, from love, but it in reality is not love that is the causative emotion, but anxiety lest the passion felt is not reciprocated. As soon as all doubt on this point is removed, whether by a favorable or an unfavorable termination, the anxiety disappears, and the condition of the patient becomes much more tolerable.

Again, a man engaged in business, and having constant need for large sums of money to meet his engagements, suffers the keenest anxiety day after day, to a greater or less extent, throughout his life. He is never quite sure that he will obtain the funds he requires, and hence the strain upon his mind is so great that it is not at all singular that it often gives way and that insanity is the result. On the other hand, if he does not get the money he needs, and bankruptcy follows, there is at once a relief from the strain, and comparative mental repose follows. The uncertainty and anxiety are far more apt to lead to mental alienation than the assurance of disaster.

Almost all the domestic chagrins to which Esquirol attributes so great an influence in the causation of insanity are only forms of anxiety. The father of a family, feeling the responsibility that rests upon him, is anxious relative to his ability to clothe, feed, and house his wife and children. A son or a daughter gives evidence of vicious inclinations, and again anxiety to one or both parents is the result. I am acquainted with the particulars of a case in which both the father and mother became insane in consequence of the anxiety felt in regard to the guilt or innocence of a son accused of highway robbery, but upon whom the crime was never proved. They neither of them believed in his culpability, but the anxiety as to the result of his trial, the doubt and uncertainty, were more than their minds could endure.

Anxiety in regard to political success is in this country not an infrequent cause of mental derangement. The tenure by which fortunes are held is often so slight, the ways by which they are obtained are often so uncertain, the risks are so great, the profits so large, that those who plunge into the vortex of "business," as it is called, often come out perhaps with a million or more of money, but with a mind shattered past recovery.

Chagrin, or active corroding grief, is also a prolific cause of mental derangement scarcely second to anxiety in power. Here, again, family and business affairs stand pre-eminent as the producers of the emotion. With some people, those in whom the hereditary tendency is strong, very slight causes are sufficient to produce intense grief, and consequent insanity. The case of a lady is within my own experience in which intellectual subjective morbid impulses were produced by the grief resulting from a leak in the bath-room, which ruined a finely-painted ceiling. She became wakeful, had pains in her head, and kept constantly repeating the words she had uttered when she saw the wreck that had been caused: "My God, it will cost a thousand dollars to repair it!" Night and day these words were passing through her mind, as in the cases mentioned under their proper head.

In another case, from the chagrin and disappointment resulting from failure to receive an office from the Government, for which he had been an applicant, a gentleman became affected with acute mania. In another instance, from a like