The proportion of deaths to the admissions in males is 40 in 100. females is 45 in 100. The proportion of both sexes is 42 in 100. Contrasting the mortality of the two English and the French lunatic hospitals, it is worthy of serious reflection, why the rate of mortality should be greater in the former than in the latter. The accommodations and arrangements in the Bicêtre and La Salpetrière, which contain always a very large number of the imbecile, among whom the mortality is ever the most, are decidedly objectionable, and very inferior to those of Lancaster and Wakefield. So bad is this department of the French hospitals, that it is pointedly complained of in the report of the French commissioners.* The next French official report will probably shew a considerable reduction in the rate of mortality among the lunatics in these hospitals, in consequence of their meditated improvements. In the Senavra, at Milan, an institution which is admirably conducted, the proportion of mortality exceeds that in all other lunatic hospitals. But the cause is fully explained in the description of patients admitted into that hospital. Between the years 1798 and 1818, 1431 lunatics of all classes were admitted into the Cork asylum: the mortality was 429, or 30 in 100. The causes of this extraordinary mortality were too apparent: Ireland during that period was visited by rebellion and famine, and all their concomitant miseries. Added to these, the dreadful vice of habitual intoxication from drinking ardent spirits, in which the poorest, from the extreme cheapness of this liquid poison, indulge, • Compte Rendu, Tabl. No. 3. + Suprà cit. p. 28. PART IV. COMMENTARY I. PROGNOSTIC. NATURE, it is known, sometimes in her own way effects the cure of insanity. Sometimes, however, she confirms the malady, or closes the scene by death. These results are variously brought about, and we must become acquainted with them before any prognosis can be attempted. But of all disorders with which humanity is afflicted, there is none respecting the event of which it is so difficult to decide. Some allege that every form of mental disorder terminates by crises, such as spontaneous salivation, an abundant flow of tears, the hæmorrhoidal flux, &c. Again I say that I never met with an instance of insanity so terminating. If spontaneous ptyalism prove critical, recoveries would probably be more frequent; for it is a very common occurrence both in mania and melancholia. But I am strongly inclined to suspect that the cases reported to have recovered in this manner are rather coincidences, and not the specific effects of increased salivary secretion. The maniacal action often finds a solution in various hæmorrhagic, alvine, and suppurative discharges; also by hydropic depositions, cutaneous eruptions, and fever. But any of these incidents may occur without remission of insanity. I cannot, therefore, call these terminations crises. It is frequently also suspended by the intervention of acute disorders; as upon the accession of pulmonary inflammation, asthma, gout, hepatitis, &c. But when some of these affections resume their proper seats, the insanity generally returns. Neither are these crises, but substitutions of one morbid action for another. Yet when they happen, recovery frequently follows. I have seen insanity and asthma alternate for many years, the patient being always sane when asthma supervened, or insane when asthma was absent. Mere metastastic changes, however, cannot be ranked among the terminations of insanity. The greatest deliberation is necessary in investigating whether an attack of insanity be idiopathic, symptomatic, sympathetic, or transferred; for the remedies differ in each. The previous history of the case can alone guide the judgment and direct the practice. If we ascertain the natural temperament of a patient attacked with mania, it is not generally difficult to pronounce whether that form of insanity will continue, or melancholia supervene; the primary morbid action in either form being identical. In both the sensorium is affected, but in different ways; in one, all the internal and external senses, and nervous and muscular powers, are exalted; in the other, they are blunted. The effect of certain stimuli on different constitutions differs: wine makes one mad, another stupid; opium induces pervigilium in this, and sleep in that person. We must, therefore, consider mania and melancholia as modifications of the same disease. Each may end fatally. But in mania, the sensorium may be so violently acted upon as to extinguish vitality; in melancholia, life may suddenly end from the want of sufficient stimulus. Should mania supervene on other diseases, they are usually ameliorated, suspended, or sometimes entirely removed; and if mania continue, it prolongs life often to a good old age. On the contrary, when other diseases supervene, and terminate insanity, the patient either rapidly sinks, or is cured. Although insanity never ends by a natural crisis, but generally preserves a continued form, yet a visible decline of the symptoms takes place in most cases, and sometimes leads to a complete remission. Such remissions may continue for days, or weeks, or more. They, however, rarely leave the patient entirely free from some mental or physical lesion; reason is still partially deranged, or sleep is still disturbed by horrible dreams, or there are some uneasy sensations in the head, &c. The patient makes no progress, and by and by the malady re-assumes its primitive form. Intermissions are often so perfect, that the mind is capable of exercising its entire faculties. In this case there is no physical lesion. The access of delirium is regular or irregular, and the intervals are more or less protracted; sometimes it occurs every month, or six months, or yearly. When it observes nearly regular periods, it is termed periodical insanity, and is often introduced by all the stages of a primitive attack. This form is usually incurable; and by degrees the intervals diminish so much, that constant insanity at length is established. However, in many cases nothing but time can discover whether the chronic has succeeded the acute or active state of insanity. Long-continued insanity often terminates in demency; but I must positively deny Georget's dictum, that insanity, if not cured at all, always terminates in that condition, provided the patient live so long.* I have known patients insane many years, and * Suprà cit. who have lived to old age, the original character of whose malady persevered till death. This opinion of Georget's is derived from his observations on the insane women in La Salpetrière, mine from private practice. A close analogy in the results of private and hospital practice cannot, in the nature of things, exist; and this may account for the discrepancy in this author's conclusions and mine on this point. The intensity of fury which often ushers in mania commonly diminishes in a short time; and hence a prognostic favourable to convalescence is inferred. But when the accompanying delusions continue equally strong, although there be an abatement of physical violence, it is not an indication of returning reason, but leads rather to the expectation of a protracted case. Decrease of fury is on many accounts desirable. Sometimes, however, it only intermits, and the patient being refreshed by temporary quiescence, it is renewed with increased violence. A paroxysm of mania may continue only a few hours, or days, or weeks, or longer, and then remit or entirely vanish; or it may assume the form of melancholia, and persevere or alternate with mania to its termination. It is not possible to pronounce when the symptoms of either form of insanity will subside. The more furious the first paroxysm, the shorter, generally, but not always, is the duration of mania; and when a remission of violence is attended by an amelioration of other symptoms, it is a favourable sign. But when the malady has continued several weeks, and the whole system is evidently suffering, we may expect an obstinate attack. When tremors, or a sudden prostration of strength, or coma, or convulsions, supervene on a furious attack of mania, with violent raving, it has a fatal termination. The same result may be feared also when any of these morbid conditions supervene on melancholia. The appearance of moderate anasarca of the lower |