left frontal eminence. He had occasionally had temporary right hemiplegia. I decided to trephine him, and on the 28th of February, 1882, I performed the operation before the class. There was no fracture, but the dura mater was thickened at that spot. The result of the operation, as regards the insanity, is yet to be seen. At this date (March 2d) he is doing well, and is quiet.

Sunstroke, though not so common a cause of insanity as is popularly supposed, produces nevertheless a tolerably large number of cases during every summer season, especially in this country. Of four hundred and twenty four cases admitted into the Illinois Eastern Hospital for the Insane during the years 1881 to 1883, thirteen were from this cause; like traumatism, the full action of the factor may be postponed for several years. Such, at least, has been my experience. I constantly see cases in which pain in the head, inability to exert the mind, vertigo, insomnia, and disturbances of the sight exist as the consequences of sunstroke or of heat-fever for several years, and in which insanity is the ultimate result. The form in which it generally appears is that of acute mania. Occasionally it ensues immediately on the reception of the injury.

Cerebral Hæmorrhage and other diseases of the brain are also occasional causes. The influence of epilepsy and chorea has already been sufficiently considered.

Of other diseases, a long list might be made out, each of which is recognized as having an occasional causative relation to insanity. Among them are phthisis, gout, rheumatism, the various fevers, diseases of the heart, intestinal worms, and other causes of reflex irritations from the abdominal organs, uterine and ovarian disorders, and syphilis. In regard to this latter, the attempt has been made to make a distinct form of mental derangement under the designation of syphilitic insanity, but, as I think, without sufficient reason. I have never seen anything sufficiently characteristic in the insanity following syphilis to warrant such a differentiation. It is true that, as regards treatment, there are characterizations; but, if we are to classify the forms of insanity according to the manner in which they should be treated, we would do very little toward a scientific nosology, and would, moreover, be acting in regard to mental diseases in a way not followed with other affections.

Masturbation and sexual excesses are also to be placed among the etiological factors of insanity. In young persons, their influence is often decidedly manifested. Persons of mature age do not appear to incur, except as regards paralysis, any noticeable liability to mental derangement, unless they are practiced to an inordinate extent, and then they are probably the symptoms of an already existing mental disease. In youth, acute mania, melancholia with stupor, or more generally hebephrenia, are produced. Sexual excesses are, however, among the most common causes of general paralysis. On this point there is no difference of opinion among writers. In my own experience I have abundant evidence of its power as a factor in producing this disease.

The occupation followed by the individual may be an exciting cause of insanity, but it is exceedingly difficult to arrive at any conclusion on this point from an examination of the tables given in the lunatic asylum reports. The mere fact that a greater number of the members of one profession than of another are reported is of no value, unless the numbers following each profession in the district from which the insane come are also given. This is an almost impossible task.

For instance, the following table is given in the report of the Illinois Eastern Hospital for the Insane for 1882:

If we judged solely from these data without regard to the point referred to, we should be forced to arrive at the conclusion that "disreputable" occupations are less conducive to

insanity than any other, for there is no male patient who owes his insanity to such a factor, and only one female patient.

The influence, however, of certain occupations which are in themselves of a specially unsanitary character is more distinctly recognized. Thus, workers in lead are liable to insanity from the absorption of the metal into the system. The forms of insanity most apt to be produced are acute mania, or some one of the varieties of melancholia. In either case there are illusions, hallucinations, and delusions, or the toxic influence may result in epileptic seizures; or these may be combined with either of the forms of insanity mentioned.

Workers in mercury are very apt to suffer from insanity as a consequence of the absorption of mercury into the body. Several cases of the kind have come under my observation, occurring in manufacturers of looking-glasses and workers in fire-gilding. The mental symptoms are generally well marked. There are hallucinations and delusions, accompanied with a high degree of maniacal excitement. As in lead-insanity, epileptic convulsions may be associated with the mental derangement. Other occupations, which require exposure to the direct rays of the sun, and consequently induce a liability to sunstroke, are also exciting causes of insanity.

Exposure to morbific emanations from the earth, such as malaria, may also conduce to the promotion of insanity. For reasons given I cannot admit the existence of any distinctive features about the mental derangement caused by malaria, but that it does produce aberration of mind is beyond question.

The influence of malarial poisoning as a cause of insanity was pointed out by Sydenham, who refers to a particular kind of mania, which, so far from yielding to purgatives and blood-letting, is rendered worse by those agencies. It is consequent upon intermittent fevers which have lasted some time, especially those of a quartan type.

1

Baillarger cites several cases in which intermittent fever was followed by insanity, and in which cures were accomplished by the use of antiperiodic remedies.

Griesinger, in speaking of this cause of insanity, and stat

"Sur la folie à la suite des fievres intermittentes," Annales médico-psychologiques, 1843, t. iii, p. 372.

"Mental Pathology and Therapeutics," New Sydenham Society Translation, p. 183.

ing that it is not the intermittent fever which induces the mental disorder, but the endemic cause of the fever, says that the attacks of insanity may take the place of the paroxysm of fever. These consist of violent accessions of mania, with delirium, and there may be impulses to suicide. Eventually these forms may become chronic.

Again, the insanity may not be developed till after the cessation of the paroxysms of intermittent fever, and this he says is the most common mode of origin. As he declares:

"The mental disease frequently continues as a uniform persistent chronic affection, and the symptoms of the intermittent fever are no longer observed."

Other writers on psychological medicine, and perhaps the majority, entirely ignore the relation of cause and effect existing between the malarial poison and insanity, and some of them, as for instance Dagonet, express the opinion that there is no such connection.

Extensive experience in highly malarial regions in the Western and Southern parts of the United States have proved to me in the most indubitable manner that malaria is productive of insanity. Sometimes the form is that of acute mania; sometimes morbid impulses of various kinds are excited, and, again, morbid fears; or there may be melancholia, simple, with delirium or with stupor, or hypochondriacal or hysterical mania, and these may run into dementia. ported two or three years since an interesting case of acute mania passing into melancholia, which occurred in my experience in this city.'

I re

Emanations from sewers, dissecting-rooms, slaughterhouses, and other places where animal and vegetable decomposition is going on, are said to be among the causes of insanity.

CHAPTER X.

THE PROGNOSIS OF INSANITY.

Two chief questions are to be considered in the discussion of the subject of the prognosis of insanity. The first of

p. 55.

Insanity of Malarial Origin," Neurological Contributions, No. 1, 1879,

these relates to the life of the patient, the second to his mind.

In regard to the preservation of the life of the subject of mental alienation, the prognosis varies, other things being equal, according to the type of insanity from which the patient suffers.

Thus, uncomplicated perceptional insanities, whether consisting of illusions or hallucinations, are very seldom of fatal augury. If, however, they are accompanied by physical symptoms, indicating profound lesion of the optic thalamus, or other parts of the brain, such as paralysis, tremors, destruction or marked impairment of the sight, hearing, or other sense, severe pains in the head, vertigo, etc., the prognosis is much more unfavorable. But, in those cases so frequently met with, which depend upon temporary variations in the blood-supply of the perceptional ganglia, the prognosis is exceedingly favorable, provided that the patient is promptly submitted to proper medical treatment.

Intellectual Insanities.-None of these are of bad prognosis, so far as relates to the life of the affected individual. Relative to megalomania, under which name he describes intellectual monomania with exaltation, Dagonet' says: "Of all the forms of mental alienation, this is perhaps the one most compatible with the prolongation of existence. Examples of longevity in monomaniacs are not rare in lunatic asylums. It appears that the tranquil life which they lead there, removed as they are from every cause of excitation, and the perfect content which they have with themselves, are circumstances which favor the regular action of the organic functions."

Though of the opinion that this is too sweeping a statement, it is undeniably true that the form of insanity in question is entirely compatible with long life. Intellectual monomania, with depression, and the depressed form of chronic intellectual mania are of more unfavorable prognosis. The asthenic effect of the constant terrifying delusions under which the patient labors is prejudicial to the normal action of the organs of the body. The digestive system is very apt to suffer, and hence the basis for intercurrent diseases of the stomach, intestines, and liver is laid. Moreover, a depressed condition of the mind is not favorable to long life, the powers 1 Op. cit., p. 276.